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Eyre H, Alba PR, Gibson CJ, Gatsby E, Lynch KE, Patterson OV, DuVall SL. Bridging information gaps in menopause status classification through natural language processing. JAMIA Open 2024; 7:ooae013. [PMID: 38419670 PMCID: PMC10901606 DOI: 10.1093/jamiaopen/ooae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 01/22/2024] [Accepted: 02/06/2024] [Indexed: 03/02/2024] Open
Abstract
Objective To use natural language processing (NLP) of clinical notes to augment existing structured electronic health record (EHR) data for classification of a patient's menopausal status. Materials and methods A rule-based NLP system was designed to capture evidence of a patient's menopause status including dates of a patient's last menstrual period, reproductive surgeries, and postmenopause diagnosis as well as their use of birth control and menstrual interruptions. NLP-derived output was used in combination with structured EHR data to classify a patient's menopausal status. NLP processing and patient classification were performed on a cohort of 307 512 female Veterans receiving healthcare at the US Department of Veterans Affairs (VA). Results NLP was validated at 99.6% precision. Including the NLP-derived data into a menopause phenotype increased the number of patients with data relevant to their menopausal status by 118%. Using structured codes alone, 81 173 (27.0%) are able to be classified as postmenopausal or premenopausal. However, with the inclusion of NLP, this number increased 167 804 (54.6%) patients. The premenopausal category grew by 532.7% with the inclusion of NLP data. Discussion By employing NLP, it became possible to identify documented data elements that predate VA care, originate outside VA networks, or have no corresponding structured field in the VA EHR that would be otherwise inaccessible for further analysis. Conclusion NLP can be used to identify concepts relevant to a patient's menopausal status in clinical notes. Adding NLP-derived data to an algorithm classifying a patient's menopausal status significantly increases the number of patients classified using EHR data, ultimately enabling more detailed assessments of the impact of menopause on health outcomes.
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Affiliation(s)
- Hannah Eyre
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT 84113, United States
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84112, United States
| | - Patrick R Alba
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT 84113, United States
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84112, United States
| | - Carolyn J Gibson
- San Francisco VA Healthcare System, San Francisco, CA 94121, United States
- University of California, San Francisco, San Francisco, CA 94115, United States
| | - Elise Gatsby
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT 84113, United States
| | - Kristine E Lynch
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT 84113, United States
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84112, United States
| | - Olga V Patterson
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT 84113, United States
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84112, United States
| | - Scott L DuVall
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT 84113, United States
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84112, United States
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Travis KJ, Huang AJ, Maguen S, Inslicht S, Byers AL, Seal KH, Gibson CJ. Military Sexual Trauma and Menopause Symptoms Among Midlife Women Veterans. J Gen Intern Med 2024; 39:411-417. [PMID: 37957529 PMCID: PMC10897107 DOI: 10.1007/s11606-023-08493-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/13/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Sexual assault and/or sexual harassment during military service (military sexual trauma (MST)) can have medical and mental health consequences. Most MST research has focused on reproductive-aged women, and little is known about the long-term impact of MST on menopause and aging-related health. OBJECTIVE Examine associations of MST with menopause and mental health outcomes in midlife women Veterans. DESIGN Cross-sectional. PARTICIPANTS Women Veterans aged 45-64 enrolled in Department of Veterans Affairs (VA) healthcare in Northern California between March 2019 and May 2020. MAIN MEASURES Standardized VA screening questions assessed MST exposure. Structured-item questionnaires assessed vasomotor symptoms (VMS), vaginal symptoms, sleep difficulty, depressive symptoms, anxiety symptoms, and posttraumatic stress disorder (PTSD) symptoms. Multivariable logistic regression analyses examined associations between MST and outcomes based on clinically relevant menopause and mental health symptom thresholds. KEY RESULTS Of 232 participants (age = 55.95 ± 5.13), 73% reported MST, 66% reported VMS, 75% reported vaginal symptoms, 36% met criteria for moderate-to-severe insomnia, and almost half had clinically significant mental health symptoms (33% depressive symptoms, 49% anxiety, 27% probable PTSD). In multivariable analyses adjusted for age, race, ethnicity, education, body mass index, and menopause status, MST was associated with the presence of VMS (OR 2.44, 95% CI 1.26-4.72), vaginal symptoms (OR 2.23, 95% CI 1.08-4.62), clinically significant depressive symptoms (OR 3.21, 95% CI 1.45-7.10), anxiety (OR 4.78, 95% CI 2.25-10.17), and probable PTSD (OR 6.74, 95% CI 2.27-19.99). Results did not differ when military sexual assault and harassment were disaggregated, except that military sexual assault was additionally associated with moderate-to-severe insomnia (OR 3.18, 95% CI 1.72-5.88). CONCLUSIONS Exposure to MST is common among midlife women Veterans and shows strong and independent associations with clinically significant menopause and mental health symptoms. Findings highlight the importance of trauma-informed approaches to care that acknowledge the role of MST on Veteran women's health across the lifespan.
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Affiliation(s)
- Kate J Travis
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA
| | - Alison J Huang
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Shira Maguen
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA
- San Francisco Veteran Affairs Health Care System, San Francisco, CA, USA
| | - Sabra Inslicht
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA
- San Francisco Veteran Affairs Health Care System, San Francisco, CA, USA
| | - Amy L Byers
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veteran Affairs Health Care System, San Francisco, CA, USA
| | - Karen H Seal
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veteran Affairs Health Care System, San Francisco, CA, USA
| | - Carolyn J Gibson
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA.
- San Francisco Veteran Affairs Health Care System, San Francisco, CA, USA.
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Gibson CJ, Bahorik A, Xia F, Peltz C, Yaffe K. Intimate Partner Violence, Mental Health, and Aging-Related Health Among Men and Women Veterans Across the Lifespan. J Gen Intern Med 2023:10.1007/s11606-023-08466-z. [PMID: 37962725 DOI: 10.1007/s11606-023-08466-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/06/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND A growing body of evidence suggests adverse health outcomes related to intimate partner violence (IPV), including traumatic brain injury (TBI). However, most research in this area has focused on reproductive-aged women. OBJECTIVE To examine relationships between IPV (with and without TBI), mental health, and aging-related health outcomes among men and women Veterans across the lifespan. DESIGN Cross-sectional analysis of Department of Veterans Affairs (VA) administrative data from fiscal years 2000-2019. Descriptive statistics and chi-square analyses were used to compare key comorbidities in matched samples of Veterans with and without IPV (gender-stratified and matched 1:3 based on demographics and index date). Comparisons between those with IPV and TBI relative to IPV alone were also examined. SUBJECTS Veterans aged 18 + with and without documented IPV in Department of Veterans Affairs (VA) electronic health records (n = 4108 men, 2824 women). MAIN MEASURES ICD codes were used to identify IPV, TBI, and aging-related medical (sleep disorder, hypertension, diabetes, dementia) and common psychiatric (depression, posttraumatic stress disorder, alcohol use disorder, and substance use disorder) diagnoses. KEY RESULTS Demographic characteristics were reflective of VA-enrolled Veterans (men: mean age 66, SD 16; 72% non-Hispanic White; women: mean age 47, SD 13; 64% non-Hispanic White). Relative to Veterans without IPV, both men and women with IPV had higher rates of all examined medical (e.g., sleep disorders, men: 33% vs. 52%; women: 45% vs. 63%) and psychiatric diagnoses (e.g., depression, men 32% vs. 74%; women 59% vs. 91%; all ps < .001), with evidence of an additive effect of TBI on some psychiatric outcomes. CONCLUSIONS IPV is broadly associated with aging-related and mental health, and TBI is a common correlate that may further contribute to psychiatric outcomes. Findings highlight the importance of trauma-informed care and recognizing the potential role of these exposures on men and women Veterans' health across the lifespan.
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Affiliation(s)
- Carolyn J Gibson
- San Francisco VA Health Care System, San Francisco, CA, USA.
- Department of Psychiatry & Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA.
| | - Amber Bahorik
- Department of Psychiatry & Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Feng Xia
- NCIRE-The Veterans' Health Research Institute, San Francisco, CA, USA
| | - Carrie Peltz
- NCIRE-The Veterans' Health Research Institute, San Francisco, CA, USA
| | - Kristine Yaffe
- San Francisco VA Health Care System, San Francisco, CA, USA
- Department of Psychiatry & Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
- San Francisco Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology, University of California, San Francisco, San Francisco, CA, USA
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Hargrave AS, Danan ER, Than CT, Gibson CJ, Yano EM. Factors Associated with Military Sexual Trauma (MST) Disclosure During VA Screening Among Women Veterans. J Gen Intern Med 2023; 38:3188-3197. [PMID: 37291361 PMCID: PMC10651589 DOI: 10.1007/s11606-023-08257-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/24/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Capturing military sexual trauma (MST) exposure is critical for Veterans' health equity. For many, it improves access to VA services and allows for appropriate care. OBJECTIVE Identify factors associated with nondisclosure of MST in VA screening among women. DESIGN Cross-sectional telephone survey linked with VA electronic health record (EHR) data. PARTICIPANTS Women Veterans using primary care or women's health services at 12 VA facilities in nine states. MAIN MEASURES Survey self-reported MST (sexual assault and/or harassment during military service), socio-demographics and experiences with VA care, as well as EHR MST results. Responses were categorized as "no MST" (no survey or EHR MST), "MST captured by EHR and survey," and "MST not captured by EHR" (survey MST but no EHR MST). We used stepped multivariable logistic regression to examine "MST not captured by EHR" as a function of socio-demographics, patient experiences, and screening method (survey vs. EHR). KEY RESULTS Among 1287 women (mean age 50, SD 15), 35% were positive for MST by EHR and 61% were positive by survey. Approximately 38% had "no MST," 34% "MST captured by EHR and survey," and 26% "MST not captured by EHR". In fully adjusted models, odds of "MST not captured by EHR" were higher among Black and Latina women compared to white women (Black: OR = 1.6, 1.2-2.2; Latina: OR = 1.9, 1.0-3.6). Women who endorsed only sexual harassment in the survey (vs. sexual harassment and sexual assault) had fivefold higher odds of "MST not captured by EHR" (OR = 4.9, 3.2-7.3). Women who were screened for MST in the EHR more than once had lower odds of not being captured (OR = 0.3, 0.2-0.4). CONCLUSIONS VA screening for MST may disproportionately under capture patients from historically minoritized ethnic/racial groups, creating inequitable access to resources. Efforts to mitigate screening disparities could include re-screening and reinforcing that MST includes sexual harassment.
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Affiliation(s)
- Anita S Hargrave
- Department of Internal Medicine, University of California San Francisco (UCSF), San Francisco, CA, USA.
- San Francisco VA Health Care System, San Francisco, CA, USA.
| | - Elisheva R Danan
- Division of General Internal Medicine, Minneapolis VA Medical Center: Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Claire T Than
- Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Carolyn J Gibson
- San Francisco VA Health Care System, San Francisco, CA, USA
- Department of Psychiatry & Behavioral Sciences, San Francisco, CA, USA
| | - Elizabeth M Yano
- Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA, USA
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Huang AJ, Cummings SR, Ganz P, Schembri M, Raghunathan H, Vittinghoff E, Gibson CJ, Grady D. Efficacy of Continuous Transdermal Nitroglycerin for Treating Hot Flashes by Inducing Nitrate Cross-tolerance in Perimenopausal and Postmenopausal Women: A Randomized Clinical Trial. JAMA Intern Med 2023; 183:776-783. [PMID: 37273224 PMCID: PMC10242506 DOI: 10.1001/jamainternmed.2023.1977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/06/2023] [Indexed: 06/06/2023]
Abstract
Importance Due to the potential risks of long-term systemic estrogen therapy, many menopausal women are interested in nonhormonal treatments for vasomotor symptoms. Physiologic studies indicate that nitric oxide plays a key role in mediating hot flash-related vasodilation, suggesting that nonhormonal medications that induce nitrate tolerance in the vasculature may offer therapeutic benefit for vasomotor symptoms. Objective To determine whether uninterrupted administration of transdermal nitroglycerin (NTG) to induce nitrate cross-tolerance decreased the frequency or severity of menopause-related hot flashes. Design, Setting, and Participants This randomized, double-blinded, placebo-controlled clinical trial included perimenopausal or postmenopausal women reporting 7 or more hot flashes per day who were recruited from northern California by study personnel at a single academic center. Patients were randomized between July 2017 and December 2021, and the trial ended in April 2022 when the last randomized participant completed follow-up. Interventions Uninterrupted daily use of transdermal NTG (participant-directed dose titration from 0.2-0.6 mg/h) or identical placebo patches. Main Outcome Measures Validated symptom diaries assessing changes in any hot flash frequency (primary outcome) and moderate-to-severe hot flash frequency over 5 and 12 weeks. Results Among the 141 randomized participants (70 NTG [49.6%], 71 placebo [50.4%]; 12 [85.8%] Asian, 16 [11.3%] Black or African American, 15 [10.6%] Hispanic or Latina, 3 [2.1%] multiracial, 1 [0.7%] Native Hawaiian or Pacific Islander, and 100 [70.9%] White or Caucasian individuals), a mean (SD) of 10.8 (3.5) hot flashes and 8.4 (3.6) moderate-to-severe hot flashes daily was reported at baseline. Sixty-five participants assigned to NTG (92.9%) and 69 assigned to placebo (97.2%) completed 12-week follow-up (P = .27). Over 5 weeks, the estimated change in any hot flash frequency associated with NTG vs placebo was -0.9 (95% CI, -2.1 to 0.3) episodes per day (P = .10), and change in moderate-to-severe hot flash frequency with NTG vs placebo was -1.1 (95% CI, -2.2 to 0) episodes per day (P = .05). At 12 weeks, treatment with NTG did not significantly decrease the frequency of any hot flashes (-0.1 episodes per day; 95% CI, -1.2 to 0.4) or moderate-to-severe hot flashes (-0.5 episodes per day; 95% CI, -1.6 to 0.7) relative to placebo. In analyses combining 5-week and 12-week data, no significant differences in change in the frequency of any hot flashes (-0.5 episodes per day; 95% CI, -1.6 to 0.6; P = .25) or moderate-to-severe hot flashes (-0.8 episodes per day; 95% CI, -1.9 to 0.2; P = .12) were detected with NTG vs placebo. At 1 week, 47 NTG (67.1%) and 4 placebo participants (5.6%) reported headache (P < .001), but only 1 participant in each group reported headache at 12 weeks. Conclusions and Relevance This randomized clinical trial found that continuous use of NTG did not result in sustained improvements in hot flash frequency or severity relative to placebo and was associated with more early but not persistent headache. Trial Registration Clinicaltrials.gov Identifier: NCT02714205.
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Affiliation(s)
- Alison J. Huang
- Department of Medicine, University of California, San Francisco
| | - Steven R. Cummings
- Department of Medicine, University of California, San Francisco
- San Francisco Coordinating Center, California Pacific Medical Center Research Institute, San Francisco
| | - Peter Ganz
- Department of Medicine, University of California, San Francisco
| | - Michael Schembri
- Department of Obstetrics and Gynecology, University of California, San Francisco
| | | | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Carolyn J. Gibson
- San Francisco VA Health Care System, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Deborah Grady
- Department of Medicine, University of California, San Francisco
- Deputy Editor, JAMA Internal Medicine
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Gibson CJ, Shiozawa A, Epstein AJ, Han W, Mancuso S. Association between vasomotor symptom frequency and weight gain in the Study of Women's Health Across the Nation. Menopause 2023; 30:709-716. [PMID: 37314873 PMCID: PMC10309105 DOI: 10.1097/gme.0000000000002198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/13/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The menopause transition is associated with weight gain in women. We examined whether changes in vasomotor symptom (VMS) frequency precede weight changes. METHODS This longitudinal retrospective analysis included data from the multisite, multiethnic Study of Women's Health Across the Nation. Women in premenopause or perimenopause aged 42 to 52 years at baseline self-reported VMS frequency (hot flashes/night sweats) and sleep problems at up to 10 annual visits. Menopause status, weight, body mass index, and waist circumference were compared across visits. The primary objective was to measure the association between VMS frequency and weight gain using a lagged approach with first-difference regression models. Secondary objectives were to statistically quantify mediation by sleep problems and moderation by menopause status and explore the association between cumulative, 10-year VMS exposure and long-term weight gain. RESULTS The primary analysis sample included 2,361 participants (12,030 visits; 1995-2008). Increased VMS frequency across visits was associated with subsequently increased weight (0.24 kg), body mass index (0.08 kg/m 2 ), and waist circumference (0.20 cm). Cumulative exposure to a high frequency of VMS (≥6 d/2 wk) over 10 consecutive annual visits was associated with increases in weight measures, including a 3.0-cm increase in waist circumference. Contemporaneous sleep problems mediated no more than 27% of waist circumference increases. Menopause status was not a consistent moderator. CONCLUSIONS This study demonstrates that increases in VMS, onset of a high frequency of VMS, and persistent VMS symptoms over time may precede weight gain in women.
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Affiliation(s)
- Carolyn J. Gibson
- From the Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA
| | | | | | - Wei Han
- Astellas Pharma, Inc., Northbrook, IL
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Goldstein LA, Jakubowski KP, Huang AJ, Seal KH, Maguen S, Inslicht SS, Byers AL, Gibson CJ. Lifetime history of interpersonal partner violence is associated with insomnia among midlife women veterans. Menopause 2023; 30:370-375. [PMID: 36753121 PMCID: PMC10038868 DOI: 10.1097/gme.0000000000002152] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVE Over a third of women in the United States report a lifetime history of intimate partner violence. Although a recent review found that intimate partner violence is related to poor subjective sleep, the majority of studies involved reproductive-aged women and used suboptimal measures of interpersonal violence and/or insomnia. We examined the relationship between lifetime intimate partner violence and current clinical insomnia in a cross-sectional sample of midlife women veterans. METHODS Cross-sectional data were drawn from the Midlife Women Veterans Health Survey. Women Veterans (N = 232) aged 45 to 64 years enrolled in Department of Veterans Affairs health care in Northern California completed an adapted version of the Extended-Hurt, Insult, Threaten, Scream to assess lifetime history of intimate partner violence (screening threshold score and any physical, sexual, and psychological intimate partner violence) and the Insomnia Severity Index to assess current insomnia. RESULTS In multivariable analyses, lifetime history of intimate partner violence was associated with twofold to fourfold odds of current clinical insomnia, including overall intimate partner violence (odds ratio, 3.24; 95% confidence interval, 1.57-6.69), physical intimate partner violence (odds ratio, 2.01; 95% confidence interval, 1.09-3.70), psychological intimate partner violence (odds ratio, 3.98; 95% confidence interval, 2.06-7.71), and sexual intimate partner violence (odds ratio, 2.09; 95% confidence interval, 1.08-4.07). CONCLUSIONS Lifetime history of intimate partner violence is common and may be associated with clinical insomnia during midlife. Findings highlight the importance of screening midlife women for intimate partner violence and recognizing the potential role of this traumatic exposure on women's health.
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Gibson CJ, Li Y, Jasuja GK, Keyhani S, Byers AL. Long-term Psychoactive Medications, Polypharmacy, and Risk of Suicide and Unintended Overdose Death Among Midlife and Older Women Veterans. J Gen Intern Med 2022; 37:770-777. [PMID: 36042093 PMCID: PMC9481785 DOI: 10.1007/s11606-022-07592-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 04/01/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rates of suicide and unintended overdose death are high among midlife and older women, yet there is paucity of data identifying women at greatest risk. Psychoactive medications, commonly prescribed and co-prescribed in this population, may serve as salient indicators of risk for these outcomes. OBJECTIVE To determine whether long-term psychoactive medications and psychoactive polypharmacy predict risk of suicide and unintended overdose death among midlife and older women Veterans above and beyond other recognized factors. DESIGN Longitudinal cohort study PARTICIPANTS: Women Veterans aged ≥ 50 with at least one Veterans Health Administration (VHA) clinical encounter in FY2012-2013. MAIN MEASURES Long-term psychoactive medications (opioids, benzodiazepines, sedative-hypnotics, antidepressants, antipsychotics, and antiepileptics, prescribed for ≥ 90/180 days) and psychoactive polypharmacy (overlapping for ≥ 1 day) from VHA pharmacy records; suicide and unintended overdose death through December 31, 2018. KEY RESULTS In this national sample of 154,558 midlife and older women Veterans (mean age 63.4, SD 9.3 years), 130 died by suicide and 175 died from unintentional overdose over an average of 5.6 years. In fully adjusted models, long-term opioids (hazard ratio (HR) 2.01, 95% CI 1.21-3.35) and benzodiazepines (HR 2.99, 95% CI 1.82-4.91) were associated with death by suicide; opioids (HR 3.62, 95% CI 2.46-5.34), benzodiazepines (HR 2.77, 95% CI 1.73-4.42), sedative-hypnotics (HR 1.87, 95% CI 1.06-3.29), antidepressants (HR 1.47, 95% CI 1.03-2.12), antipsychotics (HR 1.81, 95% CI 1.02-3.22), and antiepileptics (HR 2.17, 95% CI 1.48-3.19) were associated with unintended overdose death. Women who were co-prescribed ≥ 3 psychoactive medications had over 2-fold increased risk of suicide (HR 2.83, 95% CI 1.65-4.84) and unintended overdose death (HR 2.60, 95% CI 1.72-3.94). CONCLUSIONS Long-term psychoactive medications and psychoactive medication polypharmacy were important indicators of risk for death by suicide and death by unintended overdose among midlife and older women Veterans, even after accounting for psychiatric and substance use disorders.
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Affiliation(s)
- Carolyn J Gibson
- San Francisco VA Health Care System, 4150 Clement Street, 116P, San Francisco, CA, 94121, USA.
- University of California, San Francisco, San Francisco, USA.
| | - Yixia Li
- NCIRE-The Veterans Health Research Institute, San Francisco, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Medical Center, Bedford, USA
- Boston University School of Medicine, Boston, USA
| | - Salomeh Keyhani
- San Francisco VA Health Care System, 4150 Clement Street, 116P, San Francisco, CA, 94121, USA
- University of California, San Francisco, San Francisco, USA
| | - Amy L Byers
- San Francisco VA Health Care System, 4150 Clement Street, 116P, San Francisco, CA, 94121, USA
- University of California, San Francisco, San Francisco, USA
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Hargrave AS, Maguen S, Inslicht SS, Byers AL, Seal KH, Huang AJ, Gibson CJ. Veterans Health Administration Screening for Military Sexual Trauma May Not Capture Over Half of Cases Among Midlife Women Veterans. Womens Health Issues 2022; 32:509-516. [PMID: 35821182 PMCID: PMC9949350 DOI: 10.1016/j.whi.2022.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 05/26/2022] [Accepted: 06/08/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Approximately 1 in 3 women veterans endorse military sexual trauma (MST) during Veterans Health Administration (VHA) screening. Higher rates have been reported in anonymous surveys. OBJECTIVE We compared MST identified by VHA screening to survey-reported MST within the same sample and identified participant characteristics associated with discordant responses. METHODS Cross-sectional data were drawn from an observational study of women veterans aged 45-64 enrolled in VHA care in Northern California, with data from mail- and web-based surveys linked to VHA electronic health records (EHRs). Between March 2019 and May 2020, participants reported sociodemographic characteristics, current depressive (Patient Health Questionnaire-9) and posttraumatic stress (PTSD checklist for DSM-5) symptoms, and MST (using standard VHA screening questions) in a survey; depression and posttraumatic stress disorder diagnoses (ICD-10 codes) and documented MST were identified from EHRs. Associations between sociodemographic characteristics, mental health symptoms and diagnoses, and discordant MST reports (EHR-documented MST vs. MST reported on survey, not in EHR) were examined with multivariable logistic regression. RESULTS In this sample of midlife women veterans (n = 202; mean age 56, SD = 5), 40% had EHR-documented MST, and 74% reported MST on the survey. Sociodemographic characteristics, mental health symptoms, and diagnosed depression were not associated with discordant MST responses. Women with an EHR-documented PTSD diagnosis had fivefold higher odds of having EHR-documented MST (vs. survey only; odds ratio 5.2; 95% confidence interval 2.3-11.9). CONCLUSIONS VHA screening may not capture more than half of women who reported MST on the survey. VHA screening may underestimate true rates of MST, which could lead to a gap in recognition and care for women veterans.
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Affiliation(s)
- Anita S Hargrave
- University of California San Francisco, San Francisco, California.
| | - Shira Maguen
- University of California San Francisco, San Francisco, California; San Francisco VA Medical Center, VA Health Care System, San Francisco, California
| | - Sabra S Inslicht
- University of California San Francisco, San Francisco, California; San Francisco VA Medical Center, VA Health Care System, San Francisco, California
| | - Amy L Byers
- University of California San Francisco, San Francisco, California; San Francisco VA Medical Center, VA Health Care System, San Francisco, California
| | - Karen H Seal
- University of California San Francisco, San Francisco, California; San Francisco VA Medical Center, VA Health Care System, San Francisco, California
| | - Alison J Huang
- University of California San Francisco, San Francisco, California
| | - Carolyn J Gibson
- University of California San Francisco, San Francisco, California; San Francisco VA Medical Center, VA Health Care System, San Francisco, California
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10
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Blanken A, Gibson CJ, Li Y, Huang AJ, Byers AL, Maguen S, Inslicht S, Seal K. Racial/ethnic disparities in the diagnosis and management of menopause symptoms among midlife women veterans. Menopause 2022; 29:877-882. [PMID: 35796560 PMCID: PMC9884100 DOI: 10.1097/gme.0000000000001978] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Racial/ethnic disparities in menopause symptoms and hormone therapy management remain understudied among women served by the Veteran's Health Administration, despite the unique racial/ethnic diversity of this population. Thus, we determined racial/ethnic disparities in medical record-documented menopause symptoms and prescribed menopausal hormone therapy among women veterans. METHODS We conducted cross-sectional analyses of national Veteran's Health Administration electronic health record data from 2014 to 2015. We used logistic regression models to compare medical-record documented menopause symptoms and treatment (eg, vaginal estrogen or systemic hormone therapy) by self-identified race/ethnicity, adjusting for age, body mass index, and depression. Models examining hormone treatment were adjusted for menopause symptoms. RESULTS Among 200,901 women veterans (mean age 54.3, SD 5.4 y; 58% non-Hispanic/Latinx White, 33% non-Hispanic/Latinx Black, 4% Hispanic/Latinx, and 4% other), 5% had documented menopause symptoms, 5% were prescribed vaginal estrogen, and 5% were prescribed systemic hormone therapy. In fully adjusted multivariable models, non-Hispanic/Latinx Black women veterans had lower odds of documented menopause symptoms relative to non-Hispanic/Latinx White women (OR 0.82, 95% CI: 0.78-0.86). Moreover, non-Hispanic/Latinx Black women (OR 0.74, 95% CI: 0.70-0.77), as well as Hispanic/Latinx women (OR 0.68, 95% CI: 0.61-0.77), had lower likelihood of systemic hormone therapy prescription. Hispanic/Latinx women had higher odds of vaginal estrogen prescription (OR 1.12 95% CI: 1.02-1.24) than non-Hispanic/Latinx White women. Non-Hispanic/Latinx Black women had lower likelihood of estrogen use (OR 0.78 95% CI: 0.74-0.81) than non-Hispanic/Latinx White women. CONCLUSION Despite evidence suggesting higher menopause symptom burden among Black women in community samples, documented menopause symptoms and hormone therapy were less common among Black, compared with White, women veterans. Additionally, Hispanic/Latinx women veterans had lower odds of prescribed systemic menopause therapy and yet higher odds of prescribed vaginal estrogen, despite no difference in documented symptoms. These findings may signal important disparities in symptom reporting, documentation, and/or treatment for minority women veterans.
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Affiliation(s)
- Anna Blanken
- San Francisco VA Health Care System
- University of California, San Francisco
| | - Carolyn J. Gibson
- San Francisco VA Health Care System
- University of California, San Francisco
| | - Yongmei Li
- San Francisco VA Health Care System
- University of California, San Francisco
| | | | - Amy L. Byers
- San Francisco VA Health Care System
- University of California, San Francisco
| | - Shira Maguen
- San Francisco VA Health Care System
- University of California, San Francisco
| | - Sabra Inslicht
- San Francisco VA Health Care System
- University of California, San Francisco
| | - Karen Seal
- San Francisco VA Health Care System
- University of California, San Francisco
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11
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Abstract
Motivational interviewing (MI; Miller & Rollnick, 2012) has expanded from treating substance use disorders to other health concerns across a range of racial-ethnic groups and ages. The spirit of MI lends itself well to working with culturally diverse populations by eliciting the client's values and goals in a collaborative and client-centered approach in pursuit of behavior change. Additionally, MI has been further adapted for use with racial-ethnic minority groups to enhance its effectiveness with specific populations. The aim of this review was to investigate existing cultural adaptations of MI (CAMI), their effectiveness, and to provide directions for future cultural adaptations in both research and clinical settings. This systematic review identified studies of CAMI over the past 20 years using MEDLINE/Pubmed and Embase. The final dataset consisted of 25 peer review studies. In the randomized controlled trial (RCT) studies that utilized a control condition (n = 17), 10 studies showed that the CAMI condition performed significantly better on at least the primary outcome measure than the control condition. All 10 studies adapted Context, Content, and Concepts-three of the dimensions of cultural adaptation defined by the ecological validity framework used in this study (Bernal et al., 1995). (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Kyle J. Self
- San Francisco VA Health Care System
- University of Miami
| | - Brian Borsari
- San Francisco VA Health Care System
- University of California, San Francisco
| | - Ben Ladd
- Washington State University Vancouver
| | | | - Carolyn J. Gibson
- San Francisco VA Health Care System
- University of California, San Francisco
| | | | - Jennifer K. Manuel
- San Francisco VA Health Care System
- University of California, San Francisco
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12
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Nicosia FM, Gibson CJ, Purcell N, Zamora K, Tighe J, Seal KH. Women Veterans' Experiences with Integrated, Biopsychosocial Pain Care: A Qualitative Study. Pain Med 2021; 22:1954-1961. [PMID: 33547797 DOI: 10.1093/pm/pnaa481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Biopsychosocial, integrated pain care models are increasingly implemented in the Veterans Health Administration to improve chronic pain care and reduce opioid-related risks, but little is known about how well these models address women veterans' needs. DESIGN Qualitative, interview-based study. SETTING San Francisco VA Health Care System Integrated Pain Team (IPT), an interdisciplinary team that provides short-term, personalized chronic pain care emphasizing functional goals and active self-management. SUBJECTS Women with chronic pain who completed ≥3 IPT sessions. METHODS Semistructured phone interviews focused on overall experience with IPT, perceived effectiveness of IPT care, pain care preferences, and suggested changes for improving gender-sensitive pain care. We used a rapid approach to qualitative thematic analysis to analyze interviews. RESULTS Fourteen women veterans (mean age 51 years; range 33-67 years) completed interviews. Interviews revealed several factors impacting women veterans' experiences: 1) an overall preference for receiving both primary and IPT care in gender-specific settings, 2) varying levels of confidence that IPT could adequately address gender-specific pain issues, 3) barriers to participating in pain groups, and 4) barriers to IPT self-management recommendations due to caregiving responsibilities. CONCLUSIONS Women veterans reported varied experiences with IPT. Recommendations to improve gender-sensitive pain care include increased provider training; increased knowledge of and sensitivity to women's health concerns; and improved accommodations for prior trauma, family and work obligations, and geographic barriers. To better meet the needs of women veterans with chronic pain, integrated pain care models must be informed by an understanding of gender-specific needs, challenges, and preferences.
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Affiliation(s)
- Francesca M Nicosia
- San Francisco VA Health Care System, San Francisco, California.,Institute for Health and Aging, University of California San Francisco, San Francisco, California
| | - Carolyn J Gibson
- San Francisco VA Health Care System, San Francisco, California.,Department of Psychiatry, University of California San Francisco, San Francisco, California
| | - Natalie Purcell
- San Francisco VA Health Care System, San Francisco, California.,Institute for Health and Aging, University of California San Francisco, San Francisco, California.,Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, California
| | - Kara Zamora
- San Francisco VA Health Care System, San Francisco, California.,Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, California
| | - Jennifer Tighe
- San Francisco VA Health Care System, San Francisco, California
| | - Karen H Seal
- San Francisco VA Health Care System, San Francisco, California.,Department of Psychiatry, University of California San Francisco, San Francisco, California.,Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, California.,Department of Medicine, University of California San Francisco, San Francisco, California, USA
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13
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Abstract
BACKGROUND Among midlife and older women, menopause symptoms and menopausal hormone therapy have been linked to mental health disorders and other comorbidities related to suicide. However, the role of hormone therapy as a prognostic factor of suicide risk is largely unknown. OBJECTIVES To examine associations between menopausal hormone therapy, suicide attempts, and suicide among midlife and older women Veterans. RESEARCH DESIGN In this longitudinal analysis of national Veterans Health Administration data from women Veterans aged 50 years and above, we used Fine-Gray proportional hazards models to examine associations between menopausal hormone therapy (prescribed in 2012-2013) and incident suicide attempts and suicide (index date-2016). MEASURES Menopausal hormone therapy and psychoactive medications from pharmacy records; suicide attempts and suicide from national suicide data repositories; demographic variables, medical and psychiatric diagnoses, and substance use disorders from electronic medical record data and International Classification Diagnoses-9-CM codes. RESULTS In this national sample of 291,709 women Veterans (mean age 60.47, SD 9.81), 6% were prescribed menopausal hormone therapy at baseline. Over an average of 4.5 years, 2673 had an incident suicide attempt (93%) or death by suicide (7%). Adjusting for age, race, and medical diagnoses, menopausal hormone therapy was associated with increased risk of suicide attempt (hazard ratio 1.41; 95% confidence interval, 1.22-1.64) and over 2-fold increased risk of death by suicide (hazard ratio 2.47; 95% confidence interval, 1.58-3.87). Associations with death by suicide remained significant after accounting for psychiatric comorbidity and psychoactive medications. CONCLUSIONS Menopausal hormone therapy may be an important indicator of suicide risk among midlife and older women.
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Affiliation(s)
- Carolyn J. Gibson
- San Francisco VA Health Care System
- Department of Psychiatry, University of California
| | - Yixia Li
- San Francisco VA Health Care System
- NCIRE—The Veterans Health Research Institute, San Francisco, CA
| | - Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Medical Center, Bedford
- Boston University School of Public Health, Boston, MA
| | - Kyle J. Self
- San Francisco VA Health Care System
- Department of Psychiatry, University of California
| | - Karen H. Seal
- San Francisco VA Health Care System
- Departments of Medicine and Psychiatry, University of California, San Francisco, CA
| | - Amy L. Byers
- San Francisco VA Health Care System
- Department of Psychiatry, University of California
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14
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Silvestrini M, Nicosia F, Spar MJ, Gibson CJ, Brown RT. "We Have a Long Way to Go:" A Case Study Examination of Older Women Veterans' Experiences in VA Primary Care. Inquiry 2020; 57:46958020931311. [PMID: 32525421 PMCID: PMC7290258 DOI: 10.1177/0046958020931311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Women Veterans are a growing population with complex care needs. While previous research has examined the experiences of women Veterans, little attention has been paid to the specific experiences of older women Veterans. These case studies present the experiences of 2 older women Veterans who have been enrolled in Veterans Affairs (VA) health care for several decades. Results suggest that these older women Veterans have faced gender-specific challenges and barriers throughout their time accessing VA care. The experiences of these participants suggest that they have gender-sensitive needs that are not always addressed by VA primary care and that women’s groups are important mechanisms by which they have gained psychological support in a gender-sensitive environment. These cases suggest that access to gender-sensitive services and women-centered spaces are important for these 2 older women Veterans and should be explored in future research.
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Affiliation(s)
- Molly Silvestrini
- San Francisco VA Health Care System, CA, USA.,University of California, San Francisco, USA
| | - Francesca Nicosia
- San Francisco VA Health Care System, CA, USA.,University of California, San Francisco, USA
| | - Malena J Spar
- San Francisco VA Health Care System, CA, USA.,University of California, San Francisco, USA
| | - Carolyn J Gibson
- San Francisco VA Health Care System, CA, USA.,University of California, San Francisco, USA
| | - Rebecca T Brown
- San Francisco VA Health Care System, CA, USA.,University of California, San Francisco, USA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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15
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Gibson CJ, Grasso J, Li Y, Purcell N, Tighe J, Zamora K, Nicosia F, Seal KH. An Integrated Pain Team Model: Impact on Pain-Related Outcomes and Opioid Misuse in Patients with Chronic Pain. Pain Medicine 2020; 21:1977-1984. [DOI: 10.1093/pm/pnaa003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Abstract
Objective
Biopsychosocial integrated pain team (IPT) care models are being implemented in Veterans Health Administration (VA) and other health care systems to address chronic pain and reduce risks related to long-term opioid therapy, with little evaluation of effectiveness to date. We examined whether IPT improves self-reported pain-related outcomes and opioid misuse.
Design
Single-group quality improvement study.
Setting
Large VA health care system.
Subjects
Veterans with chronic pain (N = 99, 84% male, mean age [SD] = 60 [13] years).
Methods
Using paired t tests and Wilcoxon matched-pairs signed-ranks tests, we examined pain experience (Brief Pain Inventory, Pain Catastrophizing Scale), opioid misuse (Current Opioid Misuse Measure), treatment satisfaction (Pain Treatment Satisfaction Scale), and pain management strategies among patients with chronic pain before and after three or more IPT encounters.
Results
After an average (SD) of 14.3 (9) weeks engaged in IPT, patients reported improvement in pain interference (mean [SD] = 46.0 [15.9] vs 40.5 [16.2], P < 0.001), pain catastrophizing (mean [SD] = 22.9 [13.0] vs 19.3 [14.1], P = 0.01), treatment satisfaction (i.e., “very satisfied” = 13.1% at baseline vs 25.3% at follow-up, P = 0.01), and reduced opioid misuse (mean [SD] = 11.0 [7.5] vs 8.2 [6.1], P = 0.01). Patients reported increased use of integrative (i.e., acupuncture, 11% at baseline vs 26% at follow-up, P < 0.01) and active pain management strategies (i.e., exercise, 8% at baseline vs 16% at follow-up, P < 0.01) and were less likely to use only pharmacological pain management strategies after IPT engagement (19% at baseline vs 5% at follow-up, P < 0.01).
Conclusions
Biopsychosocial, integrated pain care may improve patient-centered outcomes related to opioid misuse and the subjective experience and nonpharmacological self-management of chronic pain.
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Affiliation(s)
- Carolyn J Gibson
- San Francisco VA Health Care System, San Francisco, California
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
| | - Joseph Grasso
- San Francisco VA Health Care System, San Francisco, California
| | - Yongmei Li
- San Francisco VA Health Care System, San Francisco, California
| | - Natalie Purcell
- San Francisco VA Health Care System, San Francisco, California
- Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer Tighe
- San Francisco VA Health Care System, San Francisco, California
| | - Kara Zamora
- San Francisco VA Health Care System, San Francisco, California
| | - Francesca Nicosia
- San Francisco VA Health Care System, San Francisco, California
- Division of Geriatrics, Institute for Health & Aging, University of California, San Francisco, San Francisco, California, USA
| | - Karen H Seal
- San Francisco VA Health Care System, San Francisco, California
- Departments of Medicine, Psychiatry, University of California, San Francisco, San Francisco, California, USA
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16
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Huang AJ, Gibson CJ. Forced and Coerced Sexual Initiation in Women: New Insights, Even More Questions. JAMA Intern Med 2019; 179:1558-1560. [PMID: 31524924 DOI: 10.1001/jamainternmed.2019.3467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alison J Huang
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Carolyn J Gibson
- Department of Medicine, University of California, San Francisco, San Francisco.,San Francisco Veterans Affairs Health Care System, San Francisco, California
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17
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Gibson CJ, Li Y, Huang AJ, Rife T, Seal KH. Menopausal Symptoms and Higher Risk Opioid Prescribing in a National Sample of Women Veterans with Chronic Pain. J Gen Intern Med 2019; 34:2159-2166. [PMID: 31414358 PMCID: PMC6816610 DOI: 10.1007/s11606-019-05242-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 05/15/2019] [Accepted: 07/09/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The greatest increases in long-term opioid use and opioid-related overdose mortality in recent years have been among women in midlife. Common menopausal symptoms broadly affect health and health care utilization in midlife, but their contribution to chronic pain management during this period is unknown. OBJECTIVE To examine relationships between menopausal symptoms and long-term opioid prescription patterns among midlife women with chronic pain. DESIGN Cross-sectional analysis of national Veterans Health Administration medical and pharmacy records (2014-2015). PARTICIPANTS Women Veterans aged 45-64 with ≥ 1 outpatient visit and chronic pain diagnoses spanning ≥ 90 days. MAIN MEASURES Long-term opioids (prescribed oral opioids for ≥ 90 days), high-dose long-term opioids (> 50 mg average morphine equivalent daily dose), and long-term opioids co-prescribed with central nervous system depressants (benzodiazepine and non-benzodiazepine sedative-hypnotics, gabapentin/pregabalin, muscle relaxants). Multivariable logistic regression models were used to examine associations between outcomes and menopausal symptoms (menopausal symptom-related diagnoses (i.e., "symptomatic menopausal states") on ≥ 2 encounters and/or menopausal hormone therapy, adjusting for race, age, body mass index, and mental health and substance use disorder diagnoses. KEY RESULTS In this national sample of 104,984 midlife women Veterans with chronic pain (mean age 54.5, SD 5.4 years), 17% had evidence of menopausal symptoms, 51% were prescribed long-term opioids, 13% were prescribed high-dose long-term opioids, and 35% were co-prescribed long-term opioids and central nervous system depressants. In multivariable analyses, women with menopausal symptoms had increased odds of long-term opioids (OR 1.21, 95% CI 1.18-1.26), high-dose long-term opioids (OR 1.08, 95% CI 1.02-1.13), and long-term opioids co-prescribed with central nervous system depressants (sedative-hypnotics OR 1.25, 95% CI 1.22-1.30; gabapentin/pregabalin OR 1.23, 95% CI 1.20-1.27; muscle relaxants OR 1.24, 95% CI 1.20-1.28). CONCLUSIONS Among midlife women Veterans with chronic pain, evidence of menopausal symptoms was associated with potentially risky long-term opioid prescription patterns, independent of known risk factors.
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Affiliation(s)
- Carolyn J Gibson
- San Francisco VA Health Care System, San Francisco, USA.
- University of California, San Francisco, San Francisco, USA.
| | - Yongmei Li
- San Francisco VA Health Care System, San Francisco, USA
| | - Alison J Huang
- University of California, San Francisco, San Francisco, USA
| | - Tessa Rife
- San Francisco VA Health Care System, San Francisco, USA
- University of California, San Francisco, San Francisco, USA
| | - Karen H Seal
- San Francisco VA Health Care System, San Francisco, USA
- University of California, San Francisco, San Francisco, USA
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18
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Gibson CJ, Richards A, Villanueva C, Barrientos M, Neylan TC, Inslicht SS. Subjective Sleep Related to Post Traumatic Stress Disorder Symptoms among Trauma-Exposed Men and Women. Behav Sleep Med 2019; 17:492-501. [PMID: 29172723 DOI: 10.1080/15402002.2017.1409223] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Objective/Background: Sleep difficulty is both a common symptom of posttraumatic stress disorder (PTSD) and a risk factor for the development and maintenance of PTSD symptomatology. Gender differences in sleep following trauma exposure have been posited to contribute to the increased risk for the development of PTSD among women, but the persistence and long-term contributions of these potential differences to the maintenance and severity of PTSD symptoms is unclear. Participants: Men and women reporting a history of trauma exposure (n = 112, 63% female) participated in this study. Methods: Subjective sleep complaints and PTSD symptom severity were assessed using well-validated measures (Pittsburgh Sleep Quality Index, PTSD Symptom Checklist). Multivariable regression models (full sample and gender-stratified) were used to predict PTSD symptom severity from global, subscale, and individual item sleep parameters, adjusted for gender, age, race/ethnicity, education, and body mass index. Results: In the full sample, traditional measures of sleep quality and sleep disturbance were associated with PTSD symptom severity. Difficulty falling asleep, poor sleep quality, and sleep disturbance from a variety of sources were related to higher PTSD symptom severity in men, while self-reported sleep disturbance related to nightmares and emotional regulation were associated with PTSD symptom severity among women. Conclusions: These findings add to the limited literature on gender-specific risk factors related to sleep and PTSD, and may inform intervention development and implementation related to PTSD severity among vulnerable adults.
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Affiliation(s)
- Carolyn J Gibson
- a Mental Health Service, San Francisco VA Health Care System , San Francisco , CA , USA.,b Department of Psychiatry, San Francisco School of Medicine , University of California , San Francisco , CA , USA
| | - Anne Richards
- a Mental Health Service, San Francisco VA Health Care System , San Francisco , CA , USA.,b Department of Psychiatry, San Francisco School of Medicine , University of California , San Francisco , CA , USA
| | - Cynthia Villanueva
- a Mental Health Service, San Francisco VA Health Care System , San Francisco , CA , USA
| | - Maureen Barrientos
- a Mental Health Service, San Francisco VA Health Care System , San Francisco , CA , USA
| | - Thomas C Neylan
- a Mental Health Service, San Francisco VA Health Care System , San Francisco , CA , USA.,b Department of Psychiatry, San Francisco School of Medicine , University of California , San Francisco , CA , USA
| | - Sabra S Inslicht
- a Mental Health Service, San Francisco VA Health Care System , San Francisco , CA , USA.,b Department of Psychiatry, San Francisco School of Medicine , University of California , San Francisco , CA , USA
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19
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Gibson CJ, Huang AJ, McCaw B, Subak LL, Thom DH, Van Den Eeden SK. Associations of Intimate Partner Violence, Sexual Assault, and Posttraumatic Stress Disorder With Menopause Symptoms Among Midlife and Older Women. JAMA Intern Med 2019; 179:80-87. [PMID: 30453319 PMCID: PMC6583410 DOI: 10.1001/jamainternmed.2018.5233] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Little is known about the prevalence of traumatic exposures among midlife and older women and the association of these traumatic exposures with health issues. OBJECTIVE To examine the associations of intimate partner violence (IPV), sexual assault, and posttraumatic stress with menopause symptoms among midlife and older women. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis of data from a multiethnic cohort of 2016 women 40 to 80 years of age in the Kaiser Permanente Northern California health care system was conducted from November 15, 2008, to March 30, 2012. Statistical analysis was conducted from June 8, 2016, to September 6, 2017. EXPOSURES Lifetime physical or emotional IPV, sexual assault, and current symptoms of posttraumatic stress disorder, assessed with standardized questionnaires. MAIN OUTCOMES AND MEASURES Difficulty sleeping, vasomotor symptoms, and vaginal symptoms, assessed with standardized questionnaires. RESULTS Among the 2016 women enrolled, the mean (SD) age was 60.5 (9.5) years, and 792 of 2011 with race/ethnicity data (39.4)% were non-Latina white (403 [20.0%] Latina, 429 [21.3%] black, and 387 [19.2%] Asian). Lifetime emotional IPV was reported by 423 women (21.0%), lifetime physical IPV was reported by 316 women (15.7%), sexual assault was reported by 382 women (18.9%), and 450 of 2000 women (22.5%) had current clinically significant symptoms of posttraumatic stress disorder. In multivariable analyses adjusted for age, race/ethnicity, educational level, body mass index, menopause status, hormone therapy, and parity, symptoms of posttraumatic stress disorder were associated with difficulty sleeping (odds ratio [OR], 3.02; 95% CI, 2.22-4.09), vasomotor symptoms (hot flashes: OR, 1.69; 95% CI, 1.34-2.12; night sweats: OR, 1.72; 95% CI, 1.37-2.15), and vaginal symptoms (vaginal dryness: OR, 1.73; 95% CI, 1.37-2.18; vaginal irritation: OR, 2.20; 95% CI, 1.66-2.93; pain with intercourse: OR, 2.16; 95% CI, 1.57-2.98). Emotional IPV was associated with difficulty sleeping (OR, 1.36; 95% CI, 1.09-1.71), night sweats (OR, 1.50; 95% CI, 1.19-1.89), and pain with intercourse (OR, 1.60; 95% CI, 1.14-2.25). Physical IPV was associated with night sweats (OR, 1.33; 95% CI, 1.03-1.72). Sexual assault was associated with vaginal symptoms (vaginal dryness: OR, 1.41; 95% CI, 1.10-1.82; vaginal irritation: OR, 1.42; 95% CI, 1.04-1.95; pain with intercourse: OR, 1.44; 95% CI, 1.00-2.06). CONCLUSIONS AND RELEVANCE Lifetime history of IPV or sexual assault and current clinically significant symptoms of posttraumatic stress disorder are common and are associated with menopause symptoms. These findings highlight the need for greater recognition of these exposures by clinicians caring for midlife and older women.
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Affiliation(s)
- Carolyn J Gibson
- Research Service, San Francisco Veterans Affairs Health Care System, San Francisco, California.,Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco
| | - Alison J Huang
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco
| | - Brigid McCaw
- Division of Research, Kaiser Permanente, Oakland, California
| | - Leslee L Subak
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - David H Thom
- Department of Family and Community Medicine, University of California, San Francisco
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Gibson CJ. Do current treatment options fall short for persistent vasomotor symptom bother in women over 60? Menopause 2018; 25:1063-1064. [DOI: 10.1097/gme.0000000000001183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bertenthal D, Yaffe K, Barnes DE, Byers AL, Gibson CJ, Seal KH. Do postconcussive symptoms from traumatic brain injury in combat veterans predict risk for receiving opioid therapy for chronic pain? Brain Inj 2018; 32:1188-1196. [PMID: 29985653 DOI: 10.1080/02699052.2018.1493535] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Opioid therapy is contraindicated in patients with traumatic brain injury (TBI) with neuropsychological impairment, yet guidelines do not consistently predict practice. We evaluated independent risk for initiation of opioid therapy among combat veterans with chronic pain diagnoses and persistent postconcussive symptoms. METHODS We assembled a retrospective cohort of 53 124 Iraq and Afghanistan veterans in Veterans Affairs (VA) healthcare between October 2007 and March 2015 who received chronic pain diagnoses, completed a Comprehensive TBI Evaluation (CTBIE) and had not received opioid therapy in the prior year. Primary exposure variables were self-reported severe or very severe Emotional, Vestibular, Cognitive and Somatic/Sensory symptoms measured using the Neurobehavioral Symptom Inventory. Outcome measures were initiation of short-term and long-term opioid therapy within the year following CTBIE. RESULTS Self-reported severe and very severe postconcussive symptoms predicted initiation of long-term and short-term opioid use for chronic pain in both unadjusted and adjusted analyses. In adjusted analyses, all four postconcussive symptom domains significantly predicted initiation of long-term opioid therapy, with Emotional symptoms being the strongest predictor [ARR = 1.68 (1.52, 1.86)]. CONCLUSIONS Increased opioid prescribing in veterans with self-reported severe persistent postconcussive symptoms indicates a need to educate prescribers and make non-opioid pain management options available for veterans with TBI and neuropsychological sequelae.
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Affiliation(s)
- Daniel Bertenthal
- a San Francisco Veterans Affairs Health Care System , San Francisco , CA, USA
| | - Kristine Yaffe
- a San Francisco Veterans Affairs Health Care System , San Francisco , CA, USA.,b Department of Psychiatry, University of California , San Francisco , CA, USA.,c Department of Epidemiology and Biostatistics, University of California , San Francisco , CA, USA.,d Department of Neurology, University of California , San Francisco , CA, USA
| | - Deborah E Barnes
- a San Francisco Veterans Affairs Health Care System , San Francisco , CA, USA.,b Department of Psychiatry, University of California , San Francisco , CA, USA.,c Department of Epidemiology and Biostatistics, University of California , San Francisco , CA, USA
| | - Amy L Byers
- a San Francisco Veterans Affairs Health Care System , San Francisco , CA, USA.,b Department of Psychiatry, University of California , San Francisco , CA, USA.,c Department of Epidemiology and Biostatistics, University of California , San Francisco , CA, USA
| | - Carolyn J Gibson
- a San Francisco Veterans Affairs Health Care System , San Francisco , CA, USA.,e Department of Medicine, University of California , San Francisco , CA, USA
| | - Karen H Seal
- a San Francisco Veterans Affairs Health Care System , San Francisco , CA, USA.,b Department of Psychiatry, University of California , San Francisco , CA, USA.,e Department of Medicine, University of California , San Francisco , CA, USA
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Inslicht SS, Rao MN, Richards A, O'Donovan A, Gibson CJ, Baum T, Metzler TJ, Neylan TC. Sleep and hypothalamic pituitary adrenal axis responses to metyrapone in posttraumatic stress disorder. Psychoneuroendocrinology 2018; 88:136-143. [PMID: 29268182 PMCID: PMC6170159 DOI: 10.1016/j.psyneuen.2017.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 12/05/2017] [Accepted: 12/05/2017] [Indexed: 11/19/2022]
Abstract
Disturbed sleep is a core feature of posttraumatic stress disorder (PTSD), characterized in part by decreased delta power sleep that may result from stress-related alterations in corticotropin releasing factor (CRF), hypothalamic pituitary adrenal axis (HPA) regulation and glucocorticoid signaling. Overnight HPA axis response mediating sleep disturbances in men and women with PTSD was examined using a metyrapone challenge. Metyrapone blocks cortisol synthesis, removing negative feedback, and increases the release of hypothalamic CRF and pituitary adrenocorticotropic hormone (ACTH). Laboratory-based polysomnography was used to monitor the sleep of 66 medically healthy, medication-free men and pre-menopausal follicular phase women including 33 with chronic PTSD (16 women and 17 men) and 33 age- and sex-matched controls (14 women and 19 men) over 3 consecutive nights. Participants completed an overnight metyrapone challenge after an adaptation and baseline night of sleep and ACTH was obtained by repeated blood sampling. Metyrapone resulted in a greater increase in ACTH and greater decreases in cortisol and delta spectral power sleep in PTSD subjects compared to controls, and a greater increase in ACTH in women compared to men. There was no sex difference in metyrapone effects on delta power sleep, and no significant metyrapone by PTSD by sex interactions with either ACTH or delta power sleep. Regression analyses indicated that a greater increase in ACTH response was associated with a greater decrease in delta power sleep response in PTSD subjects, but no such relationship was found in controls. The PTSD group difference was similar in men and women. These results suggest that stress-related alterations of the HPA axis in PTSD may contribute to sleep difficulties. Therapeutics that target the HPA axis may offer promise as a potential future treatment for PTSD and related sleep difficulties.
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Affiliation(s)
- Sabra S Inslicht
- San Francisco VA Healthcare System, 4150 Clement St. (116P), San Francisco, CA 94121, United States; Department of Psychiatry, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA 94143, United States; Northern California Institute for Research and Education (NCIRE), The Veterans Health Research Institute, San Francisco, CA 94121, United States.
| | - Madhu N Rao
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, United States
| | - Anne Richards
- San Francisco VA Healthcare System, 4150 Clement St. (116P), San Francisco, CA 94121, United States; Department of Psychiatry, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA 94143, United States; Northern California Institute for Research and Education (NCIRE), The Veterans Health Research Institute, San Francisco, CA 94121, United States
| | - Aoife O'Donovan
- San Francisco VA Healthcare System, 4150 Clement St. (116P), San Francisco, CA 94121, United States; Department of Psychiatry, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA 94143, United States; Northern California Institute for Research and Education (NCIRE), The Veterans Health Research Institute, San Francisco, CA 94121, United States
| | - Carolyn J Gibson
- San Francisco VA Healthcare System, 4150 Clement St. (116P), San Francisco, CA 94121, United States; Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, United States
| | - Tierney Baum
- Institute of Neurodegenerative Disease, University of California, San Francisco, San Francisco, CA 94158, United States
| | - Thomas J Metzler
- San Francisco VA Healthcare System, 4150 Clement St. (116P), San Francisco, CA 94121, United States; Department of Psychiatry, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA 94143, United States; Northern California Institute for Research and Education (NCIRE), The Veterans Health Research Institute, San Francisco, CA 94121, United States
| | - Thomas C Neylan
- San Francisco VA Healthcare System, 4150 Clement St. (116P), San Francisco, CA 94121, United States; Department of Psychiatry, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA 94143, United States; Northern California Institute for Research and Education (NCIRE), The Veterans Health Research Institute, San Francisco, CA 94121, United States
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Gibson CJ, Thurston RC, Matthews KA. Cortisol dysregulation is associated with daily diary-reported hot flashes among midlife women. Clin Endocrinol (Oxf) 2016; 85:645-51. [PMID: 27059154 DOI: 10.1111/cen.13076] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 02/14/2016] [Accepted: 04/02/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Hot flashes are reported by 70-80% of women during the menopause transition. It has been proposed that cortisol dysregulation is involved in hot flashes, but the relationship between cortisol and hot flashes has received little empirical attention. This study examined the relationship between cortisol and daily self-reported hot flashes. DESIGN For 7 days, participants used electronic diaries to report their hot flash frequency, severity and bothersomeness, along with mood and health behaviours, multiple times each day. Participants also provided hair samples for cortisol assays at baseline and morning and bedtime saliva samples for salivary cortisol collection over 3 days during the observation period. Hierarchical linear regression was used to examine the relationships between cortisol and hot flashes. PARTICIPANTS Forty-four women (41% African American, 39% non-Hispanic White) who reported daily hot flashes were enrolled. MEASUREMENTS Salivary cortisol, hair cortisol and the frequency, severity and bothersomeness of daily diary-reported hot flashes were measured in this study. RESULTS Controlling for health and demographic variables, higher hair cortisol was associated with a higher frequency of hot flashes (β = 0·05, P = 0·01). A flatter diurnal cortisol slope was associated with greater hot flash severity (β = 0·09, P = 0·03) and bother (β = 0·10, P = 0·01). Hair cortisol was no longer significant after adjusting for depression or disturbed sleep; all other associations persisted. CONCLUSION Cortisol dysregulation was related to more frequent, severe and bothersome daily self-reported hot flashes. These findings support a potential role of the HPA axis in the aetiology and phenomenology of these common menopause symptoms.
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Affiliation(s)
- Carolyn J Gibson
- San Francisco VA Medical Center, San Francisco, CA, USA.
- University of California San Francisco, School of Medicine, San Francisco, CA, USA.
| | - Rebecca C Thurston
- Departments of Psychology, Psychiatry and Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Karen A Matthews
- Departments of Psychology, Psychiatry and Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
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Gibson CJ, Gray KE, Katon JG, Simpson TL, Lehavot K. Sexual Assault, Sexual Harassment, and Physical Victimization during Military Service across Age Cohorts of Women Veterans. Womens Health Issues 2016; 26:225-31. [DOI: 10.1016/j.whi.2015.09.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 09/22/2015] [Accepted: 09/23/2015] [Indexed: 10/22/2022]
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Usmani SZ, Cavenagh JD, Belch AR, Hulin C, Basu S, White D, Nooka A, Ervin-Haynes A, Yiu W, Nagarwala Y, Berger A, Pelligra CG, Guo S, Binder G, Gibson CJ, Facon T. Cost-effectiveness of lenalidomide plus dexamethasone vs. bortezomib plus melphalan and prednisone in transplant-ineligible U.S. patients with newly-diagnosed multiple myeloma. J Med Econ 2016; 19:243-58. [PMID: 26517601 DOI: 10.3111/13696998.2015.1115407] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To conduct a cost-effectiveness assessment of lenalidomide plus dexamethasone (Rd) vs bortezomib plus melphalan and prednisone (VMP) as initial treatment for transplant-ineligible patients with newly-diagnosed multiple myeloma (MM), from a U.S. payer perspective. METHODS A partitioned survival model was developed to estimate expected life-years (LYs), quality-adjusted LYs (QALYs), direct costs and incremental costs per QALY and LY gained associated with use of Rd vs VMP over a patient's lifetime. Information on the efficacy and safety of Rd and VMP was based on data from multinational phase III clinical trials and a network meta-analysis. Pre-progression direct costs included the costs of Rd and VMP, treatment of adverse events (including prophylaxis) and routine care and monitoring associated with MM. Post-progression direct costs included costs of subsequent treatment(s) and routine care and monitoring for progressive disease, all obtained from published literature and estimated from a U.S. payer perspective. Utilities were obtained from the aforementioned trials. Costs and outcomes were discounted at 3% annually. RESULTS Relative to VMP, use of Rd was expected to result in an additional 2.22 LYs and 1.47 QALYs (discounted). Patients initiated with Rd were expected to incur an additional $78,977 in mean lifetime direct costs (discounted) vs those initiated with VMP. The incremental costs per QALY and per LY gained with Rd vs VMP were $53,826 and $35,552, respectively. In sensitivity analyses, results were found to be most sensitive to differences in survival associated with Rd vs VMP, the cost of lenalidomide and the discount rate applied to effectiveness outcomes. CONCLUSIONS Rd was expected to result in greater LYs and QALYs compared with VMP, with similar overall costs per LY for each regimen. Results of this analysis indicated that Rd may be a cost-effective alternative to VMP as initial treatment for transplant-ineligible patients with MM, with an incremental cost-effectiveness ratio well within the levels for recent advancements in oncology.
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Affiliation(s)
- S Z Usmani
- a a Levine Cancer Institute/Carolinas Healthcare System , Charlotte, NC , USA
| | - J D Cavenagh
- b b St. Bartholomew's Hospital , West Smithfield, London , UK
| | - A R Belch
- c c Cross Cancer Institute , University of Alberta , Edmonton, AB , Canada
| | - C Hulin
- d d Bordeaux Hospital University Center (CHU) , Bordeaux , France
| | - S Basu
- e e Royal Wolverhampton Hospitals NHS Trust , Wolverhampton , UK
| | - D White
- f f Dalhousie University and QEII Health Sciences Center , Halifax, NS , Canada
| | - A Nooka
- g g Winship Cancer Institute , Emory University , Atlanta , GA , USA
| | | | - W Yiu
- h h Celgene Corporation , Summit, NJ , USA
| | | | - A Berger
- i i Evidera , Lexington, MA , USA
| | | | - S Guo
- i i Evidera , Lexington, MA , USA
| | - G Binder
- h h Celgene Corporation , Summit, NJ , USA
| | - C J Gibson
- h h Celgene Corporation , Summit, NJ , USA
| | - T Facon
- j j Service des Maladies du Sang , Hôpital Huriez , CHRU Lille, Lille , France
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Guerrieri GM, Wakim PG, Keenan PA, Schenkel LA, Berlin K, Gibson CJ, Rubinow DR, Schmidt PJ. Sex differences in visuospatial abilities persist during induced hypogonadism. Neuropsychologia 2015; 81:219-229. [PMID: 26719236 DOI: 10.1016/j.neuropsychologia.2015.12.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 12/04/2015] [Accepted: 12/19/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite well-established sex differences in the performance on tests of several cognitive domains (e.g., visuospatial ability), few studies in humans have evaluated if these sex differences are evident both in the presence of circulating sex hormones and during sex steroid hormonal suppression. Sex differences identified in the relative absence of circulating levels of estradiol and testosterone suggest that differences in brain structure or function exist independent of current hormonal environment and are more likely a reflection of differing developmental exposures and/or genetic substrates. OBJECTIVE To evaluate cognitive performance in healthy eugonadal men and women before and again during GnRH agonist-induced hypogonadism. METHODS Men (n=16) and women (n=15) without medical or psychiatric illness were matched for IQ. Cognitive tests were performed at baseline (when eugonadal) and after 6-8 weeks of GnRH agonist-induced gonadal suppression. The test batteries included measures of verbal and spatial memory, spatial ability, verbal fluency, motor speed/dexterity, and attention/concentration. Data were analyzed using repeated-measures models. RESULTS During both eugonadism and hypogonadism, men performed significantly better than women on several measures of visuospatial performance including mental rotation, line orientation, Money Road Map, Porteus maze, and complex figure drawing. Although some test performances showed an effect of hormone treatment, the majority of these differences reflected an improved performance during hypogonadism compared with baseline (and probably reflected practice effects). CONCLUSION The well-documented male advantage in visuospatial performance, which we observed during eugonadal conditions, was maintained in the context of short-term suppression of gonadal function in both men and women. These findings suggest that, in humans, sex differences in visuospatial performance are not merely dependent on differences in the current circulating sex steroid environment. Thus sex differences in visuospatial performance in adulthood could reflect early developmental effects of sex steroid exposure or other environmental exposures differing across the sexes as our data confirm that these differences are independent of circulating estradiol or testosterone levels in men and women.
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Affiliation(s)
- Gioia M Guerrieri
- Section on Behavioral Endocrinology, National Institute of Mental Health, National Institutes of Health, Department of Health & Human Services, Bldg. 10-CRC, Room 25330, 10 Center Drive, MSC 1277, Bethesda, MD 20892-1277, United States
| | - Paul G Wakim
- Biostatistics and Clinical Epidemiology Service, Clinical Center, National Institutes of Health, Bethesda, MD 20892, United States
| | - P A Keenan
- Cronos Clinical Consulting (formerly Wayne State University), 22 Tanglewood Drive, Titusville, NJ 08560, United States
| | - Linda A Schenkel
- Section on Behavioral Endocrinology, National Institute of Mental Health, National Institutes of Health, Department of Health & Human Services, Bldg. 10-CRC, Room 25330, 10 Center Drive, MSC 1277, Bethesda, MD 20892-1277, United States
| | - Kate Berlin
- Section on Behavioral Endocrinology, National Institute of Mental Health, National Institutes of Health, Department of Health & Human Services, Bldg. 10-CRC, Room 25330, 10 Center Drive, MSC 1277, Bethesda, MD 20892-1277, United States
| | - Carolyn J Gibson
- Section on Behavioral Endocrinology, National Institute of Mental Health, National Institutes of Health, Department of Health & Human Services, Bldg. 10-CRC, Room 25330, 10 Center Drive, MSC 1277, Bethesda, MD 20892-1277, United States
| | - David R Rubinow
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, United States
| | - Peter J Schmidt
- Section on Behavioral Endocrinology, National Institute of Mental Health, National Institutes of Health, Department of Health & Human Services, Bldg. 10-CRC, Room 25330, 10 Center Drive, MSC 1277, Bethesda, MD 20892-1277, United States.
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Katon JG, Gray KE, Gerber MR, Harrington LB, Woods NF, Weitlauf JC, Bean-Mayberry B, Goldstein KM, Hunt JR, Katon WJ, Haskell SG, McCutcheon SJ, Gass ML, Gibson CJ, Zephyrin LC. Vasomotor Symptoms and Quality of Life Among Veteran and Non-Veteran Postmenopausal Women. GERONT 2015. [DOI: 10.1093/geront/gnv104] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Gibson CJ, Dixon BE, Abrams K. Convergent evolution of health information management and health informatics: a perspective on the future of information professionals in health care. Appl Clin Inform 2015; 6:163-84. [PMID: 25848421 DOI: 10.4338/aci-2014-09-ra-0077] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 02/02/2015] [Indexed: 11/23/2022] Open
Abstract
Clearly defined boundaries are disappearing among the activities, sources, and uses of health care data and information managed by health information management (HIM) and health informatics (HI) professionals. Definitions of the professional domains and scopes of practice for HIM and HI are converging with the proliferation of information and communication technologies in health care settings. Convergence is changing both the roles that HIM and HI professionals serve in their organizations as well as the competencies necessary for training future professionals. Many of these changes suggest a blurring of roles and responsibilities with increasingly overlapping curricula, job descriptions, and research agendas. Blurred lines in a highly competitive market create confusion for students and employers. In this essay, we provide some perspective on the changing landscape and suggest a course for the future. First we review the evolving definitions of HIM and HI. We next compare the current domains and competencies, review the characteristics as well as the education and credentialing of both disciplines, and examine areas of convergence. Given the current state, we suggest a path forward to strengthen the contributions HIM and HI professionals and educators make to the evolving health care environment.
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Affiliation(s)
- C J Gibson
- Schulich School of Medicine & Dentistry, Western University , London, ON, CANADA
| | - B E Dixon
- Richard M. Fairbanks School of Public Health, Indiana University , Indianapolis, IN, USA ; Center for Biomedical Informatics, Regenstrief Institute, Inc. , Indianapolis, IN, USA ; Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center , Indianapolis, IN, USA
| | - K Abrams
- Canadian College of Health Information Management , London, ON, CANADA
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Matthews KA, Gibson CJ, El Khoudary SR, Thurston RC. Changes in cardiovascular risk factors by hysterectomy status with and without oophorectomy: Study of Women's Health Across the Nation. J Am Coll Cardiol 2013; 62:191-200. [PMID: 23684687 PMCID: PMC3777736 DOI: 10.1016/j.jacc.2013.04.042] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/04/2013] [Accepted: 04/08/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to compare the changes in risk factors for cardiovascular disease (CVD) leading up to and after hysterectomy with or without bilateral oophorectomy with the changes observed up to and after natural menopause. BACKGROUND Evidence suggests that hysterectomy status with or without bilateral oophorectomy might increase risk for CVD, but most studies retrospectively assess menopausal status. METHODS Study of Women's Health across the Nation enrolled 3,302 pre-menopausal women not using hormone therapy between 42 and 52 years of age and followed them annually for over 11 years for sociodemographic characteristics, menopausal status, surgeries, body mass index, medication use, lifestyle factors, lipids, blood pressure, insulin resistance, and hemostatic and inflammatory factors. By 2008, 1,769 women had reached natural menopause, 77 women had a hysterectomy with ovarian conservation, and 106 women had a hysterectomy with bilateral oophorectomy. Piece-wise hierarchical growth models compared these groups on annual changes in CVD risk factors before and after final menstrual period or surgery. RESULTS Multivariable analyses showed that annual changes in CVD risk factors did not vary by group, with few exceptions, and the significant group differences that did emerge were not in the anticipated direction. CONCLUSIONS Hysterectomy with or without ovarian conservation is not a key determinant of CVD risk factor status either before or after elective surgery in midlife. These results should provide reassurance to women and their clinicians that hysterectomy in midlife is unlikely to accelerate the CVD risk of women.
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Affiliation(s)
- Karen A Matthews
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Carolyn J Gibson
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Samar R El Khoudary
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rebecca C Thurston
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Abstract
OBJECTIVE The directional and temporal nature of relationships between overweight and obesity and hysterectomy with or without oophorectomy is not well understood. Overweight and obesity may be both a risk factor for the indications for these surgeries and a possible consequence of the procedure. We used prospective data to examine whether body mass index (BMI) increased more following hysterectomy with and without bilateral oophorectomy compared with natural menopause among middle-aged women. METHODS BMI was assessed annually for up to 10 years in the Study of Women's Health Across the Nation (SWAN (n=1962)). Piecewise linear mixed growth models were used to examine changes in BMI before and after natural menopause, hysterectomy with ovarian conservation and hysterectomy with bilateral oophorectomy. Covariates included education, race/ethnicity, menopausal status, physical activity, self-rated health, hormone therapy use, antidepressant use, age and visit before the final menstrual period (FMP; for natural menopause) or surgery (for hysterectomy/oophorectomy). RESULTS By visit 10, 1780 (90.6%) women reached natural menopause, 106 (5.5%) reported hysterectomy with bilateral oophorectomy and 76 (3.9%) reported hysterectomy with ovarian conservation. In fully adjusted models, BMI increased for all women from baseline to FMP or surgery (annual rate of change=0.19 kg m(-2) per year), with no significant differences in BMI change between groups. BMI also increased for all women following FMP, but increased more rapidly in women following hysterectomy with bilateral oophorectomy (annual rate of change=0.21 kg m(-2) per year) as compared with following natural menopause (annual rate of change=0.08 kg m(-2) per year, P=0.03). CONCLUSION In this prospective examination, hysterectomy with bilateral oophorectomy was associated with greater increases in BMI in the years following surgery than following hysterectomy with ovarian conservation or natural menopause. This suggests that accelerated weight gain follows bilateral oophorectomy among women in midlife, which may increase risk for obesity-related chronic diseases.
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Affiliation(s)
- C J Gibson
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Gibson CJ, Joffe H, Bromberger JT, Thurston RC, Lewis TT, Khalil N, Matthews KA. Mood symptoms after natural menopause and hysterectomy with and without bilateral oophorectomy among women in midlife. Obstet Gynecol 2012; 119:935-41. [PMID: 22525904 PMCID: PMC3339661 DOI: 10.1097/aog.0b013e31824f9c14] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine whether mood symptoms increased more for women in the years after hysterectomy with or without bilateral oophorectomy relative to natural menopause. METHODS Using data from the Study of Women's Health Across the Nation (n=1,970), depression and anxiety symptoms were assessed annually for up to 10 years with the Center for Epidemiological Studies Depression Index and four anxiety questions, respectively. Piece-wise hierarchical growth models were used to relate natural menopause, hysterectomy with ovarian conservation, and hysterectomy with bilateral oophorectomy to trajectories of mood symptoms before and after the final menstrual period or surgery. Covariates included educational attainment, race, menopausal status, age the year before final menstrual period or surgery, and time-varying body mass index, self-rated health, hormone therapy, and antidepressant use. RESULTS By the tenth annual visit, 1,793 (90.9%) women reached natural menopause, 76 (3.9%) reported hysterectomy with ovarian conservation, and 101 (5.2%) reported hysterectomy with bilateral oophorectomy. For all women, depressive and anxiety symptoms decreased in the years after final menstrual period or surgery. These trajectories did not significantly differ by hysterectomy or oophorectomy status. The Center for Epidemiological Studies Depression Index means were 0.72 standard deviations lower and anxiety symptoms were 0.67 standard deviations lower 5 years after final menstrual period or surgery. CONCLUSION In this study, mood symptoms continued to improve after the final menstrual period or hysterectomy for all women. Women who undergo a hysterectomy with or without bilateral oophorectomy in midlife do not experience more negative mood symptoms in the years after surgery. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Carolyn J Gibson
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Gibson CJ, Bromberger JT, Weiss GE, Thurston RC, Sowers M, Matthews KA. Negative attitudes and affect do not predict elective hysterectomy: a prospective analysis from the Study of Women's Health Across the Nation. Menopause 2011; 18:499-507. [PMID: 21228728 PMCID: PMC3123400 DOI: 10.1097/gme.0b013e3181f9fa35] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Cross-sectional studies suggest an association between hysterectomy and negative affect. Using prospective data, we examined the associations of negative affect, attitudes toward aging and menopause, premenstrual symptoms, and vasomotor symptoms with elective hysterectomy in midlife. METHODS Data were from the Study of Women's Health Across the Nation, a multisite, community-based prospective cohort study of the menopausal transition (n = 2,818). Annually reported hysterectomy at visits 2 to 9 was verified with medical records when available (71%). Anxiety, perceived stress, depressive symptoms, attitudes toward aging and menopause, vasomotor symptoms, and premenstrual symptoms were assessed at baseline using standardized questions. Cox proportional hazards models were used to relate these variables to subsequent elective hysterectomy. Covariates included demographic variables, menstrual bleeding problems, body mass index, hormone levels, and self-rated health, also assessed at baseline. RESULTS Elective hysterectomy was reported by 6% (n = 168) of participants over an 8-year period. Women with hysterectomy were not higher in negative affect or negative attitudes toward aging and menopause compared with women without hysterectomy. Vasomotor symptoms (hazard ratio [HR], 1.44; 95% CI, 1.03-2.01; P = 0.03) and positive attitudes toward aging and menopause (HR, 1.74; 95% CI, 1.04-2.93) at baseline predicted hysterectomy over the 8-year period, controlling for menstrual bleeding problems, site, race/ethnicity, follicle-stimulating hormone, age, education, body mass index, and self-rated health. Menstrual bleeding problems at baseline were the strongest predictor of hysterectomy (HR, 4.30; 95% CI, 2.05-9.05). CONCLUSIONS In this prospective examination, negative affect and attitudes were not associated with subsequent hysterectomy. Menstrual bleeding problems were the major determinant of elective hysterectomy.
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Affiliation(s)
- Carolyn J Gibson
- Department of Psychology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Abstract
Multiple endoscopic biopsy specimens of esophageal mucosa were received from a 13-year-old castrated male standard Poodle. The dog was presented for painful swallowing. Endoscopically, the distal aspect of the esophagus was inflamed with a polypoid mass that protruded into the esophageal lumen. Histologically, the stratified squamous epithelium overlying the mass and lining the adjacent esophageal mucosa was replaced by papillary projections covered by columnar epithelium with goblet cells supported by a fibrous stroma. This article reports a case of spontaneous esophageal adenomatous polyp with intestinal metaplasia (Barrett esophagus) and reviews the pathogenesis of esophageal metaplasia and adenocarcinoma.
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Affiliation(s)
- C J Gibson
- Department of Biomedical Sciences, Section of Pathology, Tufts University Cummings School of Veterinary Medicine, 200 Westboro Road, North Grafton, MA 01536, USA.
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Gibson CJ, Weiss J, Goodrich M, Onega T. False-positive mammography and depressed mood in a screening population: findings from the New Hampshire Mammography Network. J Public Health (Oxf) 2009; 31:554-60. [PMID: 19574274 DOI: 10.1093/pubmed/fdp064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND False positives occur in approximately 11% of screening mammographies in the USA and may be associated with psychologic sequelae. METHODS We sought to examine the association of false-positive mammography with depressed mood among women in a screening population. Using data from a state-based mammography registry, women who completed a standardized questionnaire between 7 May 2001 and 2 June 2003, a follow-up questionnaire between 19 June 2003 and 8 October 2004 and who received at least one screening mammogram during this interval were identified. False positives were examined in relation to depressed mood. RESULTS Eligibility criteria were met by 13 491 women with a median age of 63.9 (SD = 9.6). In the study population, 2107 (15.62%) experienced at least one false positive mammogram and 450 (3.34%) met criteria for depressed mood. Depressed mood was not significantly associated with false positives in the overall population [OR = 0.96; 95% confidence interval (CI) = 0.72-1.28], but this association was seen among Non-White women (OR = 3.23; 95% CI = 1.32-7.91). CONCLUSION Depressed mood may differentially affect some populations as a harm associated with screening mammography.
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Affiliation(s)
- C J Gibson
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Brindle GW, Gibson CJ. Entropy as a measure of diversity in an inventory of medical devices. Med Eng Phys 2007; 30:399-401. [PMID: 17573228 DOI: 10.1016/j.medengphy.2007.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Revised: 05/02/2007] [Accepted: 05/03/2007] [Indexed: 11/27/2022]
Abstract
Quantitative techniques for the measurement of species diversity have been developed in ecological studies. One such technique, based on an entropy measurement, has been applied to the assessment of medical device diversity in large inventories of medical equipment. Using this technique it is possible to identify trends which are not apparent from simple considerations of the total number of devices, or the number of device types. Objective measurements of this type can be used to monitor the progress of planned equipment replacement programmes.
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Affiliation(s)
- G W Brindle
- Department of Medical Physics and Clinical Engineering, John Radcliffe Hospital, Oxford, UK
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Abstract
Ca2+ oscillations are one of the most important signals within the cell. The mechanism for generation of Ca2+ oscillations is still not yet fully elucidated. We studied the role of capacitative Ca2+ entry (CCE) on intracellular Ca2+ oscillations induced by testosterone at the single-cell level in primary myotubes. Testosterone (100 nM) rapidly induced an intracellular Ca2+ rise, accompanied by Ca2+ oscillations in a majority of myotubes. Spectral analysis of the Ca2+ oscillations revealed a periodicity of 20.3 +/- 1.8 s (frequency of 49.3 +/- 4.4 mHz). In Ca(2+)-free medium, an increase in intracellular Ca2+ was still observed, but no oscillations. Neither nifedipine nor ryanodine affected the testosterone-induced Ca2+ response. This intracellular Ca2+ release was previously shown in myotubes to be dependent on inositol-1,4,5-trisphosphate (IP3). Intracellular Ca2+ store depletion in Ca(2+)-free medium, using a sarcoplasmic/endoplasmic reticulum calcium ATPase-pump inhibitor, followed by re-addition of extracellular Ca2+, gave a fast rise in intracellular Ca2+, indicating that CCE was present in these myotubes. Application of either testosterone or albumin-bound testosterone induced Ca2+ release and led to CCE after re-addition of Ca2+ to Ca(2+)-free extracellular medium. The CCE blockers 2-aminoethyl diphenylborate and La3+, as well as perturbation of the cytoskeleton by cytochalasin D, inhibited testosterone-induced Ca2+ oscillations and CCE. The steady increase in Ca2+ induced by testosterone was not, however, affected by either La3+ or cytochalasin D. These results demonstrate testosterone-induced Ca2+ oscillations in myotubes, mediated by the interplay of IP3-sensitive Ca2+ stores and Ca2+ influx through CCE.
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Affiliation(s)
- M Estrada
- Centro de Estudios Moleculares de la Célula and Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Casilla 70005, Santiago 6530499, Chile
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Abstract
Quantitative assessment of radioactive contamination is a desirable aim in any department using radionuclides. Guidance is available for calibration of contamination monitors with sealed reference sources but the calibrations obtained in this way are of limited practical use. In this work, we examined methods for calibration using radionuclides used in the hospital workplace. Calibration factors (s-1 per Bq.cm-2) were obtained for 99mTc, 131I, 90Y and 89Sr for three types of monitor for a range of contamination areas, and minimum detectable activities were calculated. Of the three detectors evaluated, the Berthold LB122/LB6357F proved the most sensitive for all radionuclides tested. The effect of contamination area was found to be significant; calibration factors for a particular monitor varied by up to a factor of 4 with contamination area, which has important implications, for example in the estimation of skin doses. User departments need to be aware of this variation and how to correct for it.
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Affiliation(s)
- J MacDonald
- Medical Physics Department, Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK.
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Abstract
The minimal-preparation, resin-retained adhesive bridge may be considered to be an ideal choice of fixed prosthesis to replace a single missing tooth, especially in the anterior maxillary region. The technique is well documented, enjoys a high success rate, and with suitable case selection generally employs a conservative preparation. Other advantages include reduced cost compared with conventional bridges and simplified laboratory and clinical procedures. Its limitations are principally due to occlusal factors, or the presence of unsuitable abutment teeth--for example, those that are extensively restored. Another traditional contraindication is the presence of diastemas, which may limit the potential aesthetic gains. This paper presents a series of case reports which describe an altered technique in order to maintain anterior spacing.
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Abstract
Nefiracetam, a pyrrolidone derivative, is a nootropic agent that has facilitated cognitive function in a wide variety of animal models of cognitive dysfunction. The purpose of this study was to investigate the efficacy of the chronic postinjury administration of nefiracetam (DM-9384) in improving cognitive performance following central fluid percussion brain injury in rats. Twenty-four hours following surgical preparation, a sham injury or a moderate fluid percussive injury (2.1 atm) was delivered. Nefiracetam was administered chronically (0 or 9 mg/kg, po, for sham animals and 0, 3, or 9 mg/kg for injured animals) on postinjury days 1-15. Cognitive performance was assessed using the Morris water maze (MWM) on postinjury days 11-15. Chronic administration of 3 and 9 mg/kg nefiracetam attenuated MWM deficits produced by central fluid percussive brain injury. Importantly, the MWM performance of the injured animals treated with 9 mg/kg did not significantly differ from uninjured, sham animals. The 9-mg/kg dose of nefiracetam did not have a positive or negative effect on MWM performance of uninjured animals. The results of the present experiment suggest that a nootropic such as nefiracetam may be an appropriate treatment for trauma-induced cognitive dysfunction.
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Affiliation(s)
- S M DeFord
- Department of Psychology, Virginia Commonwealth University, P.O. Box 842018, 808 West Franklin Street, Richmond, VA 23284-2018, USA.
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Abstract
UNLABELLED Propofol has an antiemetic effect that may be mediated by gamma-aminobutyric acid (GABA) influences on the serotonin system, the mechanism of which is not known. We used three techniques, immunohistochemistry, High Performance Liquid Chromatography, and electrophysiology, to define propofol's effects on the rat's brainstem. Paired male Wistar rats received propofol, 20 mg/kg/hr, or Intralipid for 6 h. The brains were then subjected to immunohistochemical analysis of serotonin. In a separate experiment after a propofol or Intralipid infusion, cerebrospinal fluid (CSF) was extracted from the fourth ventricle and analyzed for the amount of serotonin and 5-hydroxyindoleacetic acid. Electrophysiological neuronal recordings were made in the area postrema (AP) in response to propofol with and without a GABA or serotonin antagonist. Results showed that immunohistochemical staining for serotonin in the propofol rats was significantly increased (28 +/- 12%) in the dorsal raphe and decreased in the AP (17 +/- 6%) compared with control. There were no significant changes in the isoflurane-anesthetized animals. Both serotonin and 5-hydroxyindoleacetic acid in the CSF of the fourth ventricle at the level of the AP were significantly reduced by 63% and 36%, respectively. Both propofol and pentobarbital injections reduce AP neuronal activity, but only the propofol response was blocked by bicuculline, a GABA antagonist. We conclude that the reduced levels of serotonin in the AP and the CSF may explain the antiemetic property of propofol. Propofol may also directly act on AP neurons via a GABA(A) receptor to reduce their activity. IMPLICATIONS Propofol may produce its antiemetic effect by depleting the area postrema of serotonin as well as by a direct gamma-aminobutyric acid-mediated inhibition.
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Affiliation(s)
- D F Cechetto
- Departments of Anatomy and Cell Biology and Physiology, University of Western Ontario, London, Ontario.
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41
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Abstract
Audiogenic seizure (AGS) activity can be induced in the seizure-resistant Long-Evans rat by postnatal priming. This study examined the effects of unilateral lesions of the inferior colliculus (IC) and implantation of tectal grafts on AGS components. Animals were primed with a 10-kHz tone burst at 120 dB on postnatal day 14 and tested for AGS susceptibility on day 28, and then two groups were unilaterally lesioned including animals receiving embryonic day 16-17 grafts of caudal tectum. Subsequently, animals were repeatedly tested for wild running and clonic-tonic convulsion components of AGS. The results demonstrate that unilaterally grafted animals with partial IC lesions showed significant reduction in the incidence of clonus expression with greater terminal uniphasic wild running behavior. These effects were stronger than in animals with comparable unilateral lesions alone. Many neurons in graft cases were in direct contact with host tissues to provide a substrate for tissue interactions previously demonstrated to promote neuron survival and remediate IC functions.
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Affiliation(s)
- J R Coleman
- Department of Psychology, University of South Carolina, Columbia 29208, USA
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Gibson CJ. Meandering in Medical Physics: A Personal Account of Hospital Physics. Phys Med Biol 2000. [DOI: 10.1088/0031-9155/45/5/501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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O'Dell DM, Gibson CJ, Wilson MS, DeFord SM, Hamm RJ. Positive and negative modulation of the GABA(A) receptor and outcome after traumatic brain injury in rats. Brain Res 2000; 861:325-32. [PMID: 10760494 DOI: 10.1016/s0006-8993(00)02055-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Glutamate-mediated excitotoxicity has been shown to contribute to cellular dysfunction following traumatic brain injury (TBI). Increasing inhibitory function through stimulation of gamma-aminobutyric acid (GABA(A)) receptors may attenuate excitotoxic effects and improve outcome. The present experiment examined the effects of diazepam, a positive modulator at the GABA(A) receptor, on survival and cognitive performance in traumatically brain-injured animals. In experiment 1, 15 min prior to central fluid percussion brain injury, rats (n=8 per group) were injected (i.p.) with saline or diazepam (5 mg/kg or 10 mg/kg). Additional rats (n=8) were surgically prepared but not injured (sham-injury). Rats pre-treated with the 5 mg/kg dose of diazepam had significantly lower mortality (0%) than injured, saline-treated rats (53%). Also, diazepam-treated (5 mg/kg) rats had significantly shorter latencies to reach the goal platform in the Morris water maze test performed 11-15 days post-injury. In experiment 2, at 15 min post-injury, rats were given either saline (n=5) or 5 mg/kg diazepam (n=6). Rats treated with diazepam did not differ in mortality from injured rats treated with vehicle. However, rats treated with diazepam at 15 min post-injury had significantly shorter latencies to reach the goal platform in the Morris water maze than injured, vehicle-treated rats. In experiment 3, the post-injury administration of bicuculline (1.5 mg/kg, n=8), a GABA(A) antagonist, increased Morris water maze goal latencies compared to injured animals treated with saline (n=8). These results suggest that enhancing inhibitory function during the acute post-injury period produces beneficial effects on both survival and outcome following experimental TBI.
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Affiliation(s)
- D M O'Dell
- Department of Psychology, Virginia Commonwealth University, P.O. Box 842018, Richmond, VA 23284-2018, USA.
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Abstract
Throughout the past decade much research has been directed towards identifying the occurrence, epidemiology, and risks associated with waterborne protozoa. While outbreaks are continually documented, sporadic cases of disease associated with exposure to low levels of waterborne protozoa are of increasing concern. Current methodologies may not be sensitive enough to define these low levels of disease. However, risk assessment methods may be utilised to address these low level contamination events. The purpose of this article is to provide an introduction to microbial risk assessment for waterborne protozoa. Risk assessment is a useful tool for evaluating relative risks and can be used for development of policies to decrease risks. Numerous studies have been published on risk assessment methods for pathogenic protozoa including Cryptosporidium and Giardia. One common notion prevails: microbial risk assessment presents interesting complications to the traditional chemical risk assessment paradigm. Single microbial exposures (non-threshold) are capable of causing symptomatic illness unlike traditional chemical exposures, which require a threshold to be reached. Due to the lack of efficient recovery and detection methods for protozoa, we may be underestimating the occurrence, concentration and distribution of these pathogenic micro-organisms. To better utilize the tool of microbial risk assessment for risk management practices, future research should focus in the area of exposure assessment.
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Affiliation(s)
- C J Gibson
- Department of Marine Science, University of South Florida, St. Petersburg 33701, USA.
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45
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Griffin DW, Gibson CJ, Lipp EK, Riley K, Paul JH, Rose JB. Detection of viral pathogens by reverse transcriptase PCR and of microbial indicators by standard methods in the canals of the Florida Keys. Appl Environ Microbiol 1999; 65:4118-25. [PMID: 10473424 PMCID: PMC99749 DOI: 10.1128/aem.65.9.4118-4125.1999] [Citation(s) in RCA: 142] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In order to assess the microbial water quality in canal waters throughout the Florida Keys, a survey was conducted to determine the concentration of microbial fecal indicators and the presence of human pathogenic microorganisms. A total of 19 sites, including 17 canal sites and 2 nearshore water sites, were assayed for total coliforms, fecal coliforms, Escherichia coli, Clostridium perfringens, enterococci, coliphages, F-specific (F(+)) RNA coliphages, Giardia lamblia, Cryptosporidium parvum, and human enteric viruses (polioviruses, coxsackie A and B viruses, echoviruses, hepatitis A viruses, Norwalk viruses, and small round-structured viruses). Numbers of coliforms ranged from <1 to 1, 410, E. coli organisms from <1 to 130, Clostridium spp. from <1 to 520, and enterococci from <1 to 800 CFU/100 ml of sample. Two sites were positive for coliphages, but no F(+) phages were identified. The sites were ranked according to microbial water quality and compared to various water quality standards and guidelines. Seventy-nine percent of the sites were positive for the presence of enteroviruses by reverse transcriptase PCR (polioviruses, coxsackie A and B viruses, and echoviruses). Sixty-three percent of the sites were positive for the presence of hepatitis A viruses. Ten percent of the sites were positive for the presence of Norwalk viruses. Ninety-five percent of the sites were positive for at least one of the virus groups. These results indicate that the canals and nearshore waters throughout the Florida Keys are being impacted by human fecal material carrying human enteric viruses through current wastewater treatment strategies such as septic tanks. Exposure to canal waters through recreation and work may be contributing to human health risks.
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Affiliation(s)
- D W Griffin
- Department of Marine Sciences, University of South Florida, St. Petersburg, Florida 33701, USA
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Gibson CJ, Munoz DG. Chromogranin A inhibits dopamine release from rat striatal slices. J Neural Transm (Vienna) 1999; 105:1083-9. [PMID: 9928879 DOI: 10.1007/s007020050113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Chromogranin A (CGA), a prohormone and a protein component of endocrine and neural secretory granules, neuritic plaques in Alzheimer's disease and Lewy bodies in Parkinson's disease, inhibited the release of dopamine (DA) from perfused rat striatal slices. Dopamine release was stimulated by a pulse of high potassium (40mM) medium introduced at 20 minutes (K1) and 55 minutes (K2) following equilibration. The ratio of K2/K1 was 0.80+/-0.04 in control tissues, but fell significantly to 0.26+/-0.08 when 100nM purified CGA was added prior to the second potassium pulse. This reduction in DA release was equivalent to that seen when calcium was excluded from the buffer (0.19+/-0.05). Pancreastatin, a centrally active peptide product of CGA, had no effect on stimulated DA release (0.77+/-0.06), although it, as well as the other treatments, did reduce basal DA release. It is likely that the parent molecule itself, CGA, or an as yet unidentified product is responsible for inhibition of K-stimulated striatal DA release.
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Affiliation(s)
- C J Gibson
- Department of Pathology, The University of Western Ontario, London, Canada
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MacDonald J, Gibson CJ, Fish PJ, Assinder DJ. The significance of variations in the angular correction factor in in situ gamma spectrometry. J Radiol Prot 1998; 18:37-42. [PMID: 9594115 DOI: 10.1088/0952-4746/18/1/006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
In situ gamma spectrometry is a powerful method of assessing radioactive contamination in soil. The most widely adopted calibration methodology relates the overall sensitivity of the detector system to the product of three calibration factors: (a) the flux at the detector per unit activity in the ground phi/S(A), (b) the detected count-rate per unit flux incident normally at the detector N0/phi and (c) a correction factor to take into account the angular non-uniformity in response of the detector (Nf/N0). The dependence of the latter factor on the activity distribution with soil depth is generally neglected despite the lack of published evidence to support this. By (i) modelling and (ii) use of published experimental profiles, this work examines the range of Nf/N0 values likely to be encountered in the field. It was found that the use of a fixed angular correction factor is justified given that the maximum errors in the derived activity concentration do not exceed 5% and are far outweighed by other uncertainties.
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Affiliation(s)
- J MacDonald
- The North Wales Medical Physics and Clinical Engineering Service, Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK
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48
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Abstract
Rats with medial prefrontal cortex or sham control lesions were tested on an eight-arm radial maze task to examine memory for the temporal order of a variable and a constant sequence of spatial locations as a function of temporal distance. During the study phase of each trial, rats were allowed to visit each of eight arms once in an order that was randomly selected or fixed for that trial. The test phase required the rats to choose which of two arms occurred earlier in the sequence of arms visited during the study phase. The arms selected as test arms varied according to temporal distance (0, 2, 4, or 6) or the number of arms that occurred between the two test arms in the study phase. For the variable sequences based on new information, control rats showed an increasing temporal distance function. Relative to control rats, medial prefrontal cortex-lesioned rats displayed a temporal order memory deficit across all distances. For the constant sequence based on familiar information, control rats performed well across all distances. Relative to controls, the medial prefrontal cortex-lesioned rats displayed a performance deficit. The results support the idea that the medial prefrontal cortex contributes to mnemonic operations associated with temporal order for new and familiar spatial location information.
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Affiliation(s)
- A A Chiba
- Department of Psychology, University of Utah, Salt Lake City 84112, USA
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49
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Abstract
The development of heterotopic ossification (HO) as a complication of toxic epidermal necrolysis (TEN) has not been previously reported. TEN, also known as Lyell's syndrome, is a rare but serious skin disorder that typically occurs after the administration of drugs, especially sulfonamides, barbiturates, phenytoin, and nonsteroidal anti-inflammatory agents. TEN is characterized by the development of large fluid-filled bullae with separation of large sheets of skin. Complications of TEN can include extensive denudation of skin with dehydration and electrolyte abnormalities, gastrointestinal hemorrhage, acute tubular necrosis, secondary infection of denuded skin, pneumonia, bacterial conjunctivitis, keratitis, and septic infarcts of internal organs. We report a case of HO in a patient with TEN after treatment with trimethoprim-sulfamethoxazole. A 49-year-old man developed an erythematous rash, bullae, fever, and extensive skin loss consistent with a diagnosis of TEN. He was intubated for complications of TEN (pneumonia) and maintained on bed rest for several weeks. In addition, he developed HO that resulted in multiple joint contractures. He was treated with aggressive range of motion by physical therapy, surgical resection of the HO followed by radiation to both elbows, right hip, and right knee. Postoperative outpatient rehabilitation enabled improved function in his mobility and activities of daily living. HO is known to occur after spinal cord and brain injuries and burns. It has not been reported to occur after TEN. Our experience with this case suggests that HO may merit inclusion into the list of complications of TEN.
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Affiliation(s)
- C J Gibson
- Department of Physical Medicine and Rehabilitation, School of Medicine and Dentistry, University of Rochester, NY, USA
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50
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Abstract
Stimulation of the ventral subiculum of the hippocampus activates the hippocampal-accumbens pathway and increases locomotor activity. Dopaminergic terminals in the nucleus accumbens have also been implicated in initiation of locomotor activity, and the release of dopamine in the nucleus accumbens is critical for locomotor responses initiated from the subiculum to occur. We have demonstrated release of dopamine in the nucleus accumbens using in vivo microdialysis after stimulation of the ventral subiculum with NMDA. Extracellular dopamine level in the nucleus accumbens was significantly increased by 40% over baseline as a result of NMDA stimulation of the ventral subiculum. This stimulation also caused more than a 40-fold increase in horizontal activity and total distance covered by the rats. Injection of saline into the subiculum caused neither a change in the dopamine level nor an increase in animal's activity. The dynamics of the measured changes in dopamine overflow correlated with the time course of locomotor changes. The results demonstrate that stimulation of the ventral subiculum causes release of dopamine in the nucleus accumbens which parallels the increase in locomotor activity.
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Affiliation(s)
- S M Brudzynski
- Department of Clinical Neurological Sciences, University of Western Ontario, London, Canada
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