Implementation, enrollment, and engagement in an opt-out telehealth pharmacist-assisted tobacco treatment program for patients seen in oncology outpatient clinics.

OBJECTIVE: To describe the workflow, reach, cost, and self-reported quit rates for an opt-out tobacco treatment program (TTP) for patients seen in 43 oncology outpatient clinics. METHODS: Between May 25, 2021, and December 31, 2022, adult patients (≥18 years) visiting clinics affiliated with the Medical University of South Carolina Hollings Cancer Center were screened for smoking status. Those currently smoking were referred to a telehealth pharmacy-assisted TTP. An attempt was made to contact referred patients by phone. Patients reached were offered free smoking cessation counseling and a 2-week starter kit of nicotine replacement medication. A random sample of 420 patients enrolled in the TTP were selected to participate in a telephone survey to assess smoking status 4 to 12 months after enrollment. RESULTS: During the reference period 35,756 patients were screened and 9.3% were identified as currently smoking. Among the 3319 patients referred to the TTP at least once, 2393 (72.1%) were reached by phone, of whom 426 (12.8%) were ineligible for treatment, 458 (13.8%) opted out of treatment, and 1509 (45.5%) received treatment. More than 90% of TTP enrollees smoked daily, with an average of 13.1 cigarettes per day. Follow-up surveys were completed on 167 of 420 patients, of whom 23.4% to 33.5% reported not smoking; if all nonresponders to the survey are counted as smoking, the range of quit rates is 9.3% to 13.3%. CONCLUSION: The findings demonstrate the feasibility of reaching and delivering smoking cessation treatments to patients from a diverse set of geographically dispersed oncology clinics.

Best practice care for persistent pain in adults with spinal cord injuries: a systematic review and narrative synthesis of clinical practice guideline recommendations.

PURPOSE: To review clinical practice guidelines (CPGs) and recent literature to identify common recommendations guiding "best practice" pain care for adults with spinal cord injury (SCI). METHODS: We searched four scientific databases and four guideline repositories from January 2010 to February 2022 for CPGs relating to the management of pain following SCI. We excluded guidelines that related to a single treatment modality, complementary medicines, specific disease processes, and guidelines that were not freely available. RESULTS: We identified 1373 records from which 11 met all eligibility criteria. Seven were classified as "tier 1" and were used to generate 46 care components related to neuropathic pain management. We organised these into three themes: screening and assessment, principles of evaluation and management, and management recommendations; and seven subthemes: screening, assessment and diagnosis, addressing complex care needs, ongoing evaluation, management - interventional, management - pharmacological, and management - non-pharmacological. Four CPGs were classified as "tier 2" and were used to provide supporting evidence. We identified 12 recommendations related to the management of nociceptive pain. CONCLUSIONS: This synthesis of recommendations can guide consumers, clinicians, researchers, and policy makers to inform understanding and clinical implementation of evidence-based "best practice" management of pain in adults with SCI.Implications for rehabilitationPersistent pain is a frequent problem for individuals following spinal cord injury and its effective management is challenging for clinicians.High-quality clinical practice guidelines that are up-to-date and readily accessible have the potential to enhance care quality and outcomes.This synthesis of 58 key care recommendations can guide consumers, clinicians, researchers, and policy makers towards improving pain care for adults with spinal cord injuries.

Are group identity and sense of belonging relevant for group pain management programmes? An exploratory pilot study.

Introduction: Cognitive Behaviour Therapy (CBT)-based programmes for chronic pain are often conducted in groups, most likely for time and cost efficiencies. However, there has been very little investigation of the role that the group itself, and particularly the processes occurring within the group, may play in individual outcomes. The objective of this study was to explore whether social group processes were relevant to key treatment outcomes of group CBT for chronic pain. Method: Data were collected from 15 groups (N = 118) undertaking a pain management programme in a tertiary setting. Intraclass correlations were computed to determine any clustering of outcomes in groups, and linear mixed modelling analysis explored pre-registered hypotheses of associations between treatment outcomes and the social group processes of Group Identification and Sense of Belonging. Results: A weak association between early identification with the group and changes in pain-related disability was shown. In addition, an enhanced global Sense of Belonging was associated with increased pain self-efficacy. Conclusion: These associations, in a programme that had not been designed to address group processes, suggest that their relevance is worth further investigation, particularly in group programmes that do focus on the social consequences of chronic pain. Future studies should investigate whether manipulation of social group processes within a CBT-based pain programme enhances pain-related outcomes and improves the overall well-being of people with chronic pain.

Key Learning Statements for Persistent Pain Education: An Iterative Analysis of Consumer, Clinician and Researcher Perspectives and Development of Public Messaging.

Over the last decade, the content, delivery and media of pain education have been adjusted in line with scientific discovery in pain and educational sciences, and in line with consumer perspectives. This paper describes a decade-long process of exploring consumer perspectives on pain science education concepts to inform clinician-derived educational updates (undertaken by the authors). Data were collected as part of a quality audit via a series of online surveys in which consent (non-specific) was obtained from consumers for their data to be used in published research. Consumers who presented for care for a persistent pain condition and were treated with a pain science education informed approach were invited to provide anonymous feedback about their current health status and pain journey experience 6, 12 or 18 months after initial assessment. Two-hundred eighteen consumers reported improvement in health status at follow-up. Results of the surveys from 3 cohorts of consumers that reported improvement were used to generate iterative versions of 'Key Learning Statements'. Early iteration of these Key Learning Statements was used to inform the development of Target Concepts and associated community-targeted pain education resources for use in public health and health professional workforce capacity building initiatives. PERSPECTIVE: This paper reflects an explicit interest in the insights of people who have been challenged by persistent pain and then recovered, to improve pain care. Identifying pain science concepts that consumers valued learning provided valuable information to inform resources for clinical interactions and community-targeted pain education campaigns.

Does who I am and what I feel determine what I see (or say)? A meta-analytic systematic review exploring the influence of real and perceived bodily state on spatial perception of the external environment.

Background: Bodily state is theorised to play a role in perceptual scaling of the environment, whereby low bodily capacity shifts visuospatial perception, with distances appearing farther and hills steeper, and the opposite seen for high bodily capacity. This may play a protective role, where perceptual scaling discourages engaging with the environment when capacity is low. Methodology: Our protocol was pre-registered via Open Science Framework (https://osf.io/6zya5/) with all amendments to the protocol tracked. We performed a systematic review and meta-analysis examining the role of bodily state/capacity on spatial perception measures of the environment. Databases (Medline, PsychINFO, Scopus, Embase, and Emcare) and grey literature were searched systematically, inclusive to 26/8/21. All studies were assessed using a customised Risk of Bias form. Standard mean differences and 95% CIs were calculated via meta-analysis using a random-effects model. Results: A total of 8,034 studies were identified from the systematic search. Of these, 68 experiments (3,195 participants) met eligibility and were included in the review. These were grouped into the following categories: fatigue; pain; age; embodiment; body size/body paty size; glucose levels; fitness; and interoception, and interoceptive accuracy. We found low level evidence (limited studies, high risk of bias) for the effect of bodily state on spatial perception. There was consistent evidence that both glucose manipulations and age influence spatial perception of distances and hills in a hypothesised direction (lower capacity associated with increased distance and hill steepness). Mixed evidence exists for the influence of external loads, embodiment, body/body-part size manipulations, pain, and interoceptive accuracy. Evidence for fitness and/or fatigue influencing spatial perception was conflicting; notably, methodological flaws with fitness and fatigue paradigms and heterogenous spatial perception measures may underlie null/conflicting results. Conclusion: We found limited evidence for bodily state influencing spatial perception of the environment. That all studies had high risk of bias makes conclusions about reported effects reflecting actual perceptual shifts (vs merely reflecting experimental demands or error due to inadequate study design) pre-emptive. Rigorous evaluation is needed to determine whether reported effects reflect more than bias (e.g., experimental demands, inadequate blinding). Future work using reliable measures of spatial perception, comprehensive evaluation of relevant confounders, and methodologically robust (and experimentally confirmed) bodily state experimental paradigms is warranted.

Is the psychological composition of the therapeutic group associated with individual outcomes in group cognitive behavioural therapy for chronic pain?

This study explored whether the psychological composition of a group, with respect to mood, catastrophising, fear of movement and pain self-efficacy characteristics at baseline, is associated with individuals' treatment outcomes following group cognitive behavioural therapy (CBT)-based programmes for chronic pain. Retrospective analyses of outcomes from two independently run CBT-based pain management programmes (Programme A: N = 317 and Programme B: N = 693) were conducted. Mixed modelling analyses did not consistently support the presence of associations between group median scores of depression, catastrophising or fear avoidance with outcomes for individuals in either programme. These results suggest that the psychological profiles of groups are not robust predictors of individual outcomes in CBT groups for chronic pain. By implication, efforts made to consider group composition with respect to psychological attributes may be unnecessary.

High-grade neuroepithelial tumor with BCOR exon 15 internal tandem duplication-a comprehensive clinical, radiographic, pathologic, and genomic analysis.

High-grade neuroepithelial tumor with BCOR exon 15 internal tandem duplication (HGNET BCOR ex15 ITD) is a recently proposed tumor entity of the central nervous system (CNS) with a distinct methylation profile and characteristic genetic alteration. The complete spectrum of histologic features, accompanying genetic alterations, clinical outcomes, and optimal treatment for this new tumor entity are largely unknown. Here, we performed a comprehensive assessment of 10 new cases of HGNET BCOR ex15 ITD. The tumors mostly occurred in young children and were located in the cerebral or cerebellar hemispheres. On imaging all tumors were large, well-circumscribed, heterogeneous masses with variable enhancement and reduced diffusion. They were histologically characterized by predominantly solid growth, glioma-like fibrillarity, perivascular pseudorosettes, and palisading necrosis, but absence of microvascular proliferation. They demonstrated sparse to absent GFAP expression, no synaptophysin expression, variable OLIG2 and NeuN positivity, and diffuse strong BCOR nuclear positivity. While BCOR exon 15 internal tandem duplication was the solitary pathogenic alteration identified in six cases, four cases contained additional alterations including CDKN2A/B homozygous deletion, TERT amplification or promoter hotspot mutation, and damaging mutations in TP53, BCORL1, EP300, SMARCA2 and STAG2. While the limited clinical follow-up in prior reports had indicated a uniformly dismal prognosis for this tumor entity, this cohort includes multiple long-term survivors. Our study further supports inclusion of HGNET BCOR ex15 ITD as a distinct CNS tumor entity and expands the known clinicopathologic, radiographic, and genetic features.

Excess cost and inpatient stay of treating deep spinal surgical site infections.

AIM: To determine the excess cost and hospitalisation associated with surgical site infections (SSI) following spinal operations in a New Zealand setting. METHODS: We identified inpatients treated for deep SSI following primary or revision spinal surgery at a regional tertiary spinal centre between 2009 and 2016. Excess cost and excess length of stay (LOS) were calculated via a clinical costing system using procedure-matched controls. RESULTS: Twenty-eight patients were identified. Twenty-five had metalware following spinal fusion surgery, while three had non-instrumented decompression and/or discectomy. Five were diagnosed during their index hospitalisation and 23 (82%) were re-admitted. The average excess SSI cost was NZ$51,434 (range $1,398-$262,206.16) and LOS 37.1 days (range 7-275 days). Infections following metalware procedures had a greater excess cost (average $56,258.90 vs. $11,228.61) and LOS (average 40.4 days vs. 9.7 days) than procedures without metalware. CONCLUSION: The costs associated with spinal SSI are significant and comparable to a previous New Zealand study of hip and knee prosthesis SSI. More awareness of the high costs involved should encourage research and implementation of infection prevention strategies.

Are group size and composition associated with treatment outcomes in group cognitive behavioural therapy for chronic pain?

This study explored whether group size and group member characteristics (age, sex, and compensation status) were associated with patient outcomes (changes in pain and disability). Retrospective analyses of outcome data obtained from 2 independently run group cognitive behavioural therapy (CBT) programs for chronic pain (Program A: N = 317 and Program B: N = 693) were conducted. Intracluster correlations were significant in both studies, indicating group-level effects on patient outcomes in both group CBT programs for chronic pain. Mixed modelling revealed that group size and group member characteristics (age, sex, and compensation status) were related to patient outcomes, but not consistently across programs. The results of our analyses confirm the contribution of group composition to individual treatment outcomes in group CBT for chronic pain, and highlight factors that have the potential to contribute to group-level variability in patient outcomes. Further research is needed to identify the mechanisms that account for the impact of group characteristics on the efficacy of CBT for chronic pain.

Feasibility of Implementing a Hospital-Based "Opt-Out" Tobacco-Cessation Service.

OBJECTIVE: To assess the feasibility and outcomes of implementing a hospital-based "opt-out" tobacco-cessation service. METHODS: In 2014, the Medical University of South Carolina adopted a policy that all hospitalized patients who self-report using tobacco be referred to tobacco-cessation service. This is a descriptive study of a real-world effort to implement guidelines for a hospital-based cessation service consistent with Joint Commission's standards. Between February 2014 and May 2015, 42 061 adults were admitted to the Medical University of South Carolina Hospital. Eligible current cigarette smokers were referred to the tobacco-cessation service, which consisted of a bedside consult and phone follow-up 3, 14, and 30 days after hospital discharge using interactive-voice-response. The primary study outcomes evaluated the proportions of smokers reached by the bedside counselor and/or phone follow-up, smokers who opted out, and smokers who self-reported not smoking when last contacted by phone. RESULTS: Records identified 8423 smokers, of whom 69.4% (n = 5843) were referred into the service. One full-time bedside counselor was able to speak with 1918 (32.8%) patients, of whom 96 (5%) denied currently smoking and 287 (14.9%) refused counselling. Reach at follow-up was achieved for 703 (55%) smokers who received bedside counselling and 1613 (49%) who did not, yielding an overall follow-up reach rate of 60%. Of those reached by phone, 36.4% reported not smoking (51% vs. 27% for those who did and did not receive bedside counselling, respectively). Intent-to-treat abstinence rate was 13.5% according to the last known smoking status. CONCLUSIONS: Findings from this study suggest that an inpatient smoking-cessation service with an "opt-out" approach can positively impact short-term cessation outcomes. IMPLICATIONS: (1) The findings demonstrate the feasibility of implementing an automated large-scale opt-out tobacco-cessation service for hospitalized patients that is consistent with the Joint Commission recommended standards for treating tobacco dependence. (2) Receiving a bedside tobacco-cessation consult while hospitalized increased the use of stop smoking medications and abstinence from smoking after discharge from the hospital. (3) Even in those patients who did not receive a bedside consult, 5% accepted a referral to the South Carolina Tobacco Quitline to get help to stop smoking.

Harnessing group composition-related effects in pain management programs: a review and recommendations.

Cognitive-behavioral therapy, an effective management strategy for chronic pain, is frequently conducted in groups. Although clinicians often report 'knowing when a group will go well or badly', investigations of the effect that group composition might have on outcomes is lacking. Conceptual models, explanatory theories and experiments have been developed in fields of psychotherapy, organizational, social and educational psychology, but there has been no attempt to take on this issue in our field. The current hypothesis-generating review synthesizes these substantial bodies of literature to identify common themes across fields and integrate them with current concepts of cognitive-behavioral therapy-based pain management. We present a putative conceptual model with testable hypotheses relating to features of each group as a whole, the individuals in that group and the group's leader.

Are people who do yoga any better at a motor imagery task than those who do not?

BACKGROUND: Yoga is a popular recreational activity in Western society and there is an abundance of literature suggesting that yoga may be beneficial for people with a chronic pain disorder. Despite consistently positive results in the literature, the mechanisms of effect are unclear. On the grounds that chronic pain is associated with disruptions of brain-grounded maps of the body, a possible mechanism of yoga is to refine these brain-grounded maps. A left/right body part judgement task is an established way of interrogating these brain-grounded maps of the body. OBJECTIVE: To determine if people who do regular yoga practice perform better at a left/right judgement task than people who do not. METHODS: Previously collected, cross-sectional data were used. Using a case-control design, participants who reported taking part in regular yoga were selected against age, gender, neck pain and arm pain-matched controls. Participants viewed 40 photographs of a model with their head turned to the left or right, and were asked to judge the direction of neck rotation. They then completed a left/right-hand judgement task. RESULTS: Of the 1737 participants, 86 of them reported regularly taking part in yoga. From the remaining participants, 86 matched controls were randomly selected from all matched controls. There was no difference between Groups (yoga and no yoga) for either response time (p=0.109) or accuracy (p=0.964). There was a difference between Tasks; people were faster (p<0.001) and more accurate (p=0.001) at making left/right neck rotation judgements than they were at making left/right-hand judgements, regardless of group. CONCLUSIONS: People who do regular yoga perform no differently in a left/right judgement task than people who do not.

Proximal sciatic nerve intraneural ganglion cyst.

Intraneural ganglion cysts are nonneoplastic, mucinous cysts within the epineurium of peripheral nerves which usually involve the peroneal nerve at the knee. A 37-year-old female presented with progressive left buttock and posterior thigh pain. Magnetic resonance imaging revealed a sciatic nerve mass at the sacral notch which was subsequently revealed to be an intraneural ganglion cyst. An intraneural ganglion cyst confined to the proximal sciatic nerve has only been reported once prior to 2009.

Language and the pain experience.

BACKGROUND AND PURPOSE: People in persistent pain have been reported to pay increased attention to specific words or descriptors of pain. The amount of attention paid to pain or cues for pain (such as pain descriptors), has been shown to be a major factor in the modulation of persistent pain. This relationship suggests the possibility that language may have a role both in understanding and managing the persistent pain experience. The aim of this paper is to describe current models of neuromatrices for pain and language, consider the role of attention in persistent pain states and highlight discrepancies, in previous studies based on the McGill Pain Questionnaire (MPQ), of the role of attention on pain descriptors. The existence of a pain neuromatrix originally proposed by Melzack (1990) has been supported by emerging technologies. Similar technologies have recently allowed identification of multiple areas of involvement for the processing of auditory input and the construction of language. As with the construction of pain, this neuromatrix for speech and language may intersect with neural systems for broader cognitive functions such as attention, memory and emotion. METHOD: A systematic search was undertaken to identify experimental or review studies, which specifically investigated the role of attention on pain descriptors (as cues for pain) in persistent pain patients. A total of 99 articles were retrieved from six databases, with 66 articles meeting the inclusion criteria. After duplicated articles were eliminated, the remaining 41 articles were reviewed in order to support a link between persistent pain, pain descriptors and attention. RESULTS: This review revealed a diverse range of specific pain descriptors, the majority of which were derived from the MPQ. Increased attention to pain descriptors was consistently reported to be associated with emotional state as well as being a significant factor in maintaining persistent pain. However, attempts to investigate the attentional bias of specific pain descriptors highlighted discrepancies between the studies. As well as the diversity of pain descriptors used in studies, they were inconsistently categorized into domains of pain. A lack of consistent bias towards certain pain descriptors was observed, and may be explained simply by the fact that the words provided are not those which subjects themselves would use. CONCLUSION: These findings suggest that the multidimensional and individual nature of the persistent pain experience may not be adequately explained by pain questionnaires such as the MPQ. Personalized pain descriptors may communicate the pain experience more appropriately, but may also contribute to an increased sensitivity of cortical pain processing areas by capturing increased attention for that individual. The language used as part of communication between therapists and people with persistent pain may provide an, as yet, unexplored adjunct strategy in management.

Degeneracy and repertoire of the human HIV-1 Gag p17(77-85) CTL response.

CD8+ CTL responses are important for the control of HIV-1 infection. The immunodominant HLA-A2-restricted Gag epitope, SLYNTVATL (SL9), is considered to be a poor immunogen because reactivity to it is rare in acute infection despite its paradoxical dominance in patients with chronic infection. We have previously reported SL9 to be a help-independent epitope in that it primes highly activated CTLs ex vivo from CD8+ T cells of seronegative healthy donors. These CTLs produce sufficient cytokines for extended autocrine proliferation but are sensitive to activation-induced cell death, which may cause them to be eliminated by a proinflammatory cytokine storm. Here we identified an agonist variant of the SL9 peptide, p41 (SLYNTVAAL), by screening a large synthetic combinatorial nonapeptide library with ex vivo-primed SL9-specific T cells. p41 invariably immunized SL9-cross-reactive CTLs from other donors ex vivo and H-2Db beta2m double knockout mice expressing a chimeric HLA-A*0201/H2-Db MHC class I molecule. Parallel human T cell cultures showed p41-specific CTLs to be less fastidious than SL9-CTLs in the level of costimulation required from APCs and the need for exogenous IL-2 to proliferate (help dependent). TCR sequencing revealed that the same clonotype can develop into either help-independent or help-dependent CTLs depending on the peptide used to activate the precursor CD8+ T cells. Although Ag-experienced SL9-T cells from two patients were also sensitive to IL-2-mediated cell death upon restimulation in vitro, the loss of SL9 T cells was minimized with p41. This study suggests that agonist sequences can replace aberrantly immunogenic native epitopes for the rational design of vaccines targeting HIV-1.

Intravascular lymphomatosis presenting with sudden hearing loss.

Intravascular lymphoma (IVL) is a rare disorder characterized by the aggregation of malignant large cell lymphoma cells in small vessels. Neurological manifestations are typically the initial and, often the only, clinically obvious consequences of this malignancy. Diagnosis is dependent on biopsy or postmortem demonstration of the intravascular tumor. We report a patient in whom sudden hearing loss heralded IVL and propose that the hearing loss may have been the consequence of labyrinthine infarction consequent to the aggregation of malignant cells in the internal auditory artery.

Structure of an autoimmune T cell receptor complexed with class II peptide-MHC: insights into MHC bias and antigen specificity.

T cell receptor crossreactivity with different peptide ligands and biased recognition of MHC are coupled features of antigen recognition that are necessary for the T cell's diverse functional repertoire. In the crystal structure between an autoreactive, EAE T cell clone 172.10 and myelin basic protein (1-11) presented by class II MHC I-Au, recognition of the MHC is dominated by the Vbeta domain of the TCR, which interacts with the MHC alpha chain in a manner suggestive of a germline-encoded TCR/MHC "anchor point." Strikingly, there are few specific contacts between the TCR CDR3 loops and the MBP peptide. We also find that over 1,000,000 different peptides derived from combinatorial libraries can activate 172.10, yet the TCR strongly prefers the native MBP contact residues. We suggest that while TCR scanning of pMHC may be degenerate due to the TCR germline bias for MHC, recognition of structurally distinct agonist peptides is not indicative of TCR promiscuity, but rather highly specific alternative solutions to TCR engagement.