Persistent pain and its predictors after starting anti-tumour necrosis factor therapy in psoriatic arthritis: what is the role of inflammation control?

OBJECTIVE: While considerable focus has been placed on pain due to inflammation in psoriatic arthritis (PsA), less is reported on pain despite inflammation control. Here, we aimed to investigate the occurrence/predictors of persistent pain, including non-inflammatory components, after starting anti-tumour necrosis factor (anti-TNF) therapy. METHOD: Bionaïve PsA patients starting a first anti-TNF therapy 2004-2010 were identified (South Swedish Arthritis Treatment Group register; N = 351). Outcomes included unacceptable pain [visual analogue scale (VAS) pain > 40 mm], and unacceptable pain despite inflammation control (refractory pain; VAS pain > 40 mm + C-reactive protein < 10 mg/L + ≤ 1 swollen joint of 28), assessed at 0, 3, 6, and 12 months. Baseline predictors were estimated by logistic regression. RESULTS: Upon starting anti-TNF therapy, 85% of patients reported unacceptable pain, falling to 43% at 3 months and then remaining stable. After 12 months, refractory pain constituted 63% of all unacceptable pain. Higher baseline VAS pain/global, worse physical function and lower health-related quality-of-life were associated with a higher risk of unacceptable/refractory pain at 12 months. More swollen joints and higher evaluator's global assessment were associated with a lower risk of 12-month refractory pain. CONCLUSIONS: A substantial proportion of PsA patients reported unacceptable pain throughout the first anti-TNF treatment year. At 12 months, refractory pain constituted about two-thirds of this remaining pain load. More objective signs of inflammation at anti-TNF initiation were associated with less future refractory pain. This highlights insufficient effect of biologics in patients with inflammation-independent pain, warranting alternative treatments.

Geographically diverse canid sampling provides novel insights into pre-industrial microbiomes.

Canine microbiome studies are often limited in the geographic and temporal scope of samples studied. This results in a paucity of data on the canine microbiome around the world, especially in contexts where dogs may not be pets or human associated. Here, we present the shotgun sequences of fecal microbiomes of pet dogs from South Africa, shelter and stray dogs from India, and stray village dogs in Laos. We additionally performed a dietary experiment with dogs housed in a veterinary medical school, attempting to replicate the diet of the sampled dogs from Laos. We analyse the taxonomic diversity in these populations and identify the underlying functional redundancy of these microbiomes. Our results show that diet alone is not sufficient to recapitulate the higher diversity seen in the microbiome of dogs from Laos. Comparisons to previous studies and ancient dog fecal microbiomes highlight the need for greater population diversity in studies of canine microbiomes, as modern analogues can provide better comparisons to ancient microbiomes. We identify trends in microbial diversity and industrialization in dogs that mirror results of human studies, suggesting future research can make use of these companion animals as substitutes for humans in studying the effects of industrialization on the microbiome.

Mammal Molar Size Ratios and the Inhibitory Cascade at the Intraspecific Scale.

Mammalian molar crowns form a module in which measurements of size for individual teeth within a tooth row covary with one another. Molar crown size covariation is proposed to fit the inhibitory cascade model (ICM) or its variant the molar module component (MMC) model, but the inability of the former model to fit across biological scales is a concern in the few cases where it has been tested in Primates. The ICM has thus far failed to explain patterns of intraspecific variation, an intermediate biological scale, even though it explains patterns at both smaller organ-level and larger between-species biological scales. Studies of this topic in a much broader range of taxa are needed, but the properties of a sample appropriate for testing the ICM at the intraspecific level are unclear. Here, we assess intraspecific variation in relative molar sizes of the cotton mouse, Peromyscus gossypinus, to further test the ICM and to develop recommendations for appropriate sampling protocols in future intraspecific studies of molar size variation across Mammalia. To develop these recommendations, we model the sensitivity of estimates of molar ratios to sample size and simulate the use of composite molar rows when complete ones are unavailable. Similar to past studies on primates, our results show that intraspecific variance structure of molar ratios within the rodent P. gossypinus does not meet predictions of the ICM or MMC. When we extend these analyses to include the MMC, one model does not fit observed patterns of variation better than the other. Standing variation in molar size ratios is relatively constant across mammalian samples containing all three molars. In future studies, analyzing average ratio values will require relatively small minimum sample sizes of two or more complete molar rows. Even composite-based estimates from four or more specimens per tooth position can accurately estimate mean molar ratios. Analyzing variance structure will require relatively large sample sizes of at least 40-50 complete specimens, and composite molar rows cannot accurately reconstruct variance structure of ratios in a sample. Based on these results, we propose guidelines for intraspecific studies of molar size covariation. In particular, we note that the suitability of composite specimens for averaging mean molar ratios is promising for the inclusion of isolated molars and incomplete molar rows from the fossil record in future studies of the evolution of molar modules, as long as variance structure is not a key component of such studies.

The Levant versus the Horn of Africa: evidence for bidirectional corridors of human migrations.

Paleoanthropological evidence indicates that both the Levantine corridor and the Horn of Africa served, repeatedly, as migratory corridors between Africa and Eurasia. We have begun investigating the roles of these passageways in bidirectional migrations of anatomically modern humans, by analyzing 45 informative biallelic markers as well as 10 microsatellite loci on the nonrecombining region of the Y chromosome (NRY) in 121 and 147 extant males from Oman and northern Egypt, respectively. The present study uncovers three important points concerning these demic movements: (1) The E3b1-M78 and E3b3-M123 lineages, as well as the R1*-M173 lineages, mark gene flow between Egypt and the Levant during the Upper Paleolithic and Mesolithic. (2) In contrast, the Horn of Africa appears to be of minor importance in the human migratory movements between Africa and Eurasia represented by these chromosomes, an observation based on the frequency distributions of E3b*-M35 (no known downstream mutations) and M173. (3) The areal diffusion patterns of G-M201, J-12f2, the derivative M173 haplogroups, and M2 suggest more recent genetic associations between the Middle East and Africa, involving the Levantine corridor and/or Arab slave routes. Affinities to African groups were also evaluated by determining the NRY haplogroup composition in 434 samples from seven sub-Saharan African populations. Oman and Egypt's NRY frequency distributions appear to be much more similar to those of the Middle East than to any sub-Saharan African population, suggesting a much larger Eurasian genetic component. Finally, the overall phylogeographic profile reveals several clinal patterns and genetic partitions that may indicate source, direction, and relative timing of different waves of dispersals and expansions involving these nine populations.

Independent and linked migrants: determinants of African American interstate migration.

"Through kinship and other links to destinations, many African American interstate migrants in the United States join other people in destination households. These ¿linked' migrants contrast to ¿independent migrants' who move as individuals or intact groups and set up their own households at the destination. Using U.S. Census Public Use Micro Sample data, this paper first shows that, in the 1985-90 period, about 45 percent of all Black interstate migrants were independent, compared to 38 percent who were linked to housing at the destination and 17 percent who moved into group quarters. Second, a multinomial logit model, incorporating individual and state-level variables, is specified that contrasts the determinants of independent and linked migration.... It is concluded that the understanding of Black migration must take into account a variety of factors beyond traditional labor market conditions, including links to the destination and individual housing circumstances."

A seasonal pattern of hospital medication errors in Alaska.

Specific behavioral consequences of seasonal affective disorder have not been closely examined. Length of daylight is evaluated in relation to medication errors in a medical center located in the far north. Factors such as numbers of patient admissions, discharges, and deaths were controlled with data collected in Anchorage, Alaska, over 5 consecutive years, 1985-89. These data revealed that 58% of all medication errors occurred during the first quarter of the year. Medication errors were 1.95 times more likely in December than September. The best statistical prediction was for errors associated with levels of darkness 2 months earlier. There may be not only an impairment of work performance among hospital nursing staff that reaches a peak in late winter but, more importantly, medication errors appear to follow a pattern that is closely associated with the annual cycle of daylight and darkness.

Workload and environmental factors in hospital medication errors.

Nine hospital workload factors and seasonal changes in daylight and darkness were examined over a 5-year period in relation to nurse medication errors at a medical center in Anchorage, Alaska. Three workload factors, along with darkness, were found to be significant predictors of the risk of medication error. Errors increased with the number of patient days per month (OR/250 patient days = 1.61) and the number of shifts worked by temporary nursing staff (OR/10 shifts = 1.15); errors decreased with more overtime worked by permanent nursing staff members (OR/10 shifts = .85). Medication errors were 95% more likely in midwinter than in the fall, but the effect of increasing darkness was strongest; a 2-month delay was found between the level of darkness and the rate of errors. More than half of all medication errors occurred during the first 3 months of the year.

Learning from the Aloha State.

Since 1974, Hawaii has required its employers to provide health insurance to all employees working at least 20 hours a week. More recently, the state created a new program to cover the "gap group" of 50,000 uninsured residents, along with a new program to create a "seamless system of health care" for all Aloha State residents. And Hawaii has managed to insure nearly all of its citizens while keeping the annual price of health insurance at nearly half of that paid in many mainland states ($1,300 per person and $4,000 per family). At the same time, life expectancy is the highest in the nation and infant mortality is among the lowest. In seeking to reform a dysfunctional national insurance system, policymakers should learn from the Hawaiian experience, which shows that small business can live with an employer mandate, universal coverage can cut costs by encouraging early preventive care, and a dominant payer can reduce administrative expenses.

Health care technology in Australia and New Zealand: contrasts and cooperation.

Australia and New Zealand are neighbouring countries with similarities due to their settlement by Europeans, but with major differences in their economies, populations, geography and political systems. These differences have led to contrasting approaches to the introduction and control of health care technologies. New Zealand has historically had greater success in limiting the use of health technologies which have often been adopted more widely and rapidly in Australia. Recent initiatives in health technology assessment have involved participation by both countries, giving the potential for a joint approach to policy formulation on use of some medical devices and procedures.

Joint venture acquisition of expensive medical technology by Oahu hospitals. Planning, operations and impact of lithotripsy and magnetic resonance imaging.

Expensive diagnostic and treatment services and equipment are naturally suited to large, populous medical market areas, with sufficient forecasted service demand to justify the large investment in capital, construction and staffing. Only major tertiary or secondary medical centers with shared resources can justify the first-generation investment in the multimillion-dollar purchases of magnetic resonance imaging (MRI), megavoltage linear accelerators, or lithotripters. The regional referral system in most nations accommodates the outlying population in the less developed rural sectors.

The development of migration expectations: changes throughout the lifecourse.

This research examines how the relative influence of factors that determine an individual's expectations of moving varies throughout the lifecourse. Factors representing personal characteristics, ties to origin, and ties to potential destinations were used to discriminate between expected migrants and nonmigrants in three population subgroups representing different stages of life. These subgroups included a general adult population, a preretirement population, and an elderly population. The results indicate that personal characteristics are most influential among preretirement persons, ties to origin are most influential among the general and elderly populations, and ties to potential destinations are influential among all population subgroups.

Probable future funding priorities in maternal and child health: a modified Delphi National Survey.

Recent enactment of program consolidation block grants proposed by the Reagan administration has left many observers of public health services wondering about the impact of such a change on categorical programs in maternal and child health (MCH). This study first presents predictions about the future of 23 specific MCH services, derived from a modified Delphi Survey of MCH experts, and then examines the implications of these predictions for future public health.

PIP: Recent enactment of program consolidation block grants proposed by the Reagan administration has left many observers of public health services wondering about the impact. This study 1st presents predictions about the future of 23 specific Maternal-Child Health (MCH) services, and then examines the implications of these predictions for future public health. The predictions were gathered in 1981-2 by means of a Delphi National Survey, a method of seeking consensus among homogeneous groups of experts by aggregating the judgments of individuals and then feeding back the results to a participating panel of experts. 5-year forecasts for 23 categorical MCH services were established through 3 Rounds of questions administered to a panel of 83 nationally recognized experts in MCH from across the US. Information was obtained regarding the survival potential of the 23 services, including expected and projected financial support from government and private sources. Given current economic and sociopolitical indications, several potential future gaps in services for parents and children were indicated. Main areas of concern include declining health care for youth, specifically school programs and adolescent health services, and the lack of commitment to preventive health in the MCH field. If born out by future events, severe gaps in preventive services to mothers and children will occur. A need for state level consideration of private funding sources in their fiscal planning of preventive programs is strongly suggested. Such planning would include close examination of the question of cost-effective primary prevention programs versus less cost-effective secondary and tertiary treatment programs in the long run.

The planner as public health resource allocator: post-Proposition 13 county health services in California and the role of the HSAs in budget review and public hearings.

Immediately following adoption of Proposition 13 in California in June of 1978, the state legislature adopted a Bail-Out program which included procedures for monitoring the detrimental effects of disproportionate reductions in public health, inpatient and outpatient county budgets. For a variety of reasons, the methodology and procedures employed failed to reveal the adverse effects of Proposition 13 on health services. This paper deals with the actual and potential role of health systems agencies (HSAs) in monitoring such effects, commenting in public hearings on budget review and, in general, playing a policy analysis role that links local government with the citizenry on the one hand and the state government on the other. In addition to identifying the weakness of the State's monitoring effort in identifying negative effects in program analysis and staffing reductions, the findings point out the limited role of HSAs. Specific recommendations are offered for improvement of HSA involvement in future resource allocation planning in California and the United States as a whole.

An AID analysis of factors associated with contemporary net migration in the United States.

The authors use Automatic Interaction Detector (AID) analysis to examine variables associated with net U.S. migration by county for the period 1970-1975. "The AID analyses also reveal various ways in which several factors combine to characterize places of substantial growth or decline through migration." Government employment is identified as a major factor associated with net positive migration