Health economists from Johns Hopkins University writing in The Journal of Pain reported the annual cost of chronic pain is as high as $635 billion a year, which is more than the yearly costs for cancer, heart disease and diabetes.

Previous studies have not shown a comprehensive analysis of the impact on health care and labor markets associated with people with chronic pain. The Johns Hopkins researchers estimated the annual economic costs of chronic pain in the U.S. by assessing incremental costs of health care due to pain and the indirect costs of pain from lower productivity. They compared the costs of health care for persons with chronic pain with those who do not report chronic pain.

Data from the 2008 Medical Expenditure Panel Survey was used to gauge the economic burden of pain in the United States. The sample included 20,214 individuals 18 and older to represent 210.7 million U.S. adults.

The authors defined persons with pain as those who have pain that limits their ability to work, are diagnosed with joint pain or arthritis, or have a disability that limits capacity for work. To measure indirect costs, they used a model to predict health care costs if someone has any type of pain and subtracted predicted health care costs of persons who do not have pain. The impact of incremental costs of selected pain conditions were calculated for various payers of health care services.

Results showed that mean health care expenditures for adults were $4,475. Prevalence estimates for pain conditions were 10 percent for moderate pain, 11 percent for severe pain, 33 percent for joint pain, 25 percent for arthritis, and 12 percent for functional disability. Persons with moderate pain had health care expenditures $4,516 higher than someone with no pain, and individuals with severe pain had costs $3,210 higher than those with moderate pain. Similar differences were found for other pain conditions: $4,048 higher for joint pain, $5,838 for arthritis, and $9,680 for functional disabilities.

Also, adults with pain reported missing more days from work than people without pain. Pain negatively impacted three components of productivity: work days missed, number of annual hours worked and hourly wages.

Based on their analysis of the data, the authors determined that that the total cost for pain in the United States ranged from $560 to $635 billion. Total incremental costs of health care due to pain ranged from $261 to $300 billion, and the value of lost productivity ranged from $299 to $334 billion. Compared with other major disease conditions, the per-person cost of pain is lower but the total cost is higher.

The authors noted their conclusions are conservative because the analysis did not consider the costs of pain for institutionalized and non-civilian populations, for persons under 18 and for caregivers.

— If you hire a caregiver from an agency for an elderly family member, you might assume the person had undergone a thorough criminal background check and drug testing, was experienced and trained for the job.

You'd be wrong in many cases, according to new Northwestern Medicine research.

A troubling new national study finds many agencies recruit random strangers off Craigslist and place them in the homes of vulnerable elderly people with dementia, don't do national criminal background checks or drug testing, lie about testing the qualifications of caregivers and don't require any experience or provide real training.

"People have a false sense of security when they hire a caregiver from an agency," said lead study author Lee Lindquist, M.D., an associate professor of medicine at Northwestern University Feinberg School of Medicine and a physician at Northwestern Memorial Hospital. "There are good agencies out there, but there are plenty of bad ones and consumers need to be aware that they may not be getting the safe, qualified caregiver they expect. It's dangerous for the elderly patient who may be cognitively impaired."

The study will be published in the July 13 issue of the Journal of American Geriatrics Society.

Lindquist, a geriatrician, personally has seen a number of bad caregivers accompanying patients in her clinic. "Some of the paid caregivers are so unqualified it's scary and really puts the senior at risk," she said.

Lindquist had a 103-year-old patient whose illiterate caregiver was mixing up her own medications and the patient's medications. The caregiver was giving her own medicines to the elderly patient by mistake. Another patient had dropped 10 percent of her weight and developed pressure ulcers because her caregiver was not properly feeding her or getting her out of bed.

"It was easier for the caregiver to sit and watch TV and not to try to feed the patient or move her," Lindquist said.

Several agencies surveyed in the study actually made up names of screening tests they claimed to give their job applicants.

"We had agencies say they used a 'National Scantron Test for Inappropriate Behavior' and an 'Assessment of Christian Morality Test'," Lindquist said. "To our knowledge, these tests don't exist. If you're not a smart consumer, you won't recognize which agencies are being deceitful."

Identifying the good agencies from the bad is difficult because many agencies have slick websites and marketing campaigns, she added.

"It's a cauldron of potentially serious problems that could really hurt the senior," Lindquist said. "These agencies are a largely unregulated industry that is growing rapidly with high need as our population ages. This is big business with potentially large profit margins and lots of people are jumping into it."

For the study, researchers posed as consumers and surveyed 180 agencies around the country about their hiring methods, screening measures, training practices, skill competencies assessments and supervision. They found:

Only 55 percent of the agencies did a federal background check.

"A number of agencies don't do a federal background check or look at other states besides their own," Lindquist said. "Someone could move from Wisconsin to Illinois and could have been convicted of abusing an elder adult or theft or rape and the agency would never know."

Only one-third of agencies interviewed said they did drug testing.

"Considering that seniors often take pain medications, including narcotics, this is risky," Lindquist said. "Some of the paid caregivers may be illicit drug users and could easily use or steal the seniors' drugs to support their own habits."

Few agencies (only one-third) test for caregiver skill competency. A common method of assessing skill competencies was "client feedback," which was explained as expecting the senior or family member to alert the agency that their caregiver was doing a skill incorrectly.

"How do you expect a senior with dementia to identify what the caregiver is doing wrong?" Lindquist asked.

Many agencies (58.5 percent) use self-reports in which they ask the caregiver to describe their own skills. "In the hunt for a job, some people may report they can do tasks that in reality they have no idea how to do," Lindquist said. "We found agencies sending caregivers out into the seniors' home without checking."

Inconsistent supervision of the caregiver.

Agencies should send a supervisor to do a home visit to check on the caregivers more frequently initially and then at least once a month. But this only occurred with 30 percent of the agencies.

"Amazingly, some agencies considered supervision to be asking the caregiver how things were going over the phone or when the employee stopped in to get their paycheck," Lindquist said.

With seniors wishing to remain in their own homes, paid caregivers fill an important role.

"The public should demand higher standards, but in the short term, seniors need to be aware what explicitly to look for when hiring a paid caregiver through an agency," Lindquist said.

Below are Lindquist's 10 questions to ask an agency prior to hiring a paid caregiver:

10 QUESTIONS TO ASK BEFORE HIRING A CAREGIVER

1. How do you recruit caregivers, and what are your hiring requirements?

2. What types of screenings are performed on caregivers before you hire them? Criminal background check — federal or state? Drug screening? Other?

3. Are they certified in CPR or do they have any health-related training?

4. Are the caregivers insured and bonded through your agency?

5. What competencies are expected of the caregiver you send to the home? (These could include lifting and transfers, homemaking skills, personal care skills such as bathing, dressing, toileting, training in behavioral management and cognitive support.)

6. How do you assess what the caregiver is capable of doing?

7. What is your policy on providing a substitute caregiver if a regular caregiver cannot provide the contracted services?

8. If there is dissatisfaction with a particular caregiver, will a substitute be provided?

9. Does the agency provide a supervisor to evaluate the quality of home care on a regular basis? How frequently?

 Scientists at the University of North Carolina at Chapel Hill have identified a new way to deliver long-lasting pain relief through an ancient medical practice.

In an article published in the April 23 online edition of Molecular Pain, UNC researchers describe how exploiting the molecular mechanism behind acupuncture resulted in six-day pain relief in animal models. They call this new therapeutic approach PAPupuncture.

Principal investigator Mark J. Zylka, PhD, associate professor in the Department of Cell and Molecular Physiology and the UNC Neuroscience Center, said this is a promising study that moves his lab's work with prostatic acid phosphatase, known as PAP, towards translational research.

Several years ago, Zylka and members of his lab documented how injecting PAP into the spine eased chronic pain for up to three days in rodents. The only problem was PAP's delivery.

"Spinal injections are invasive and must be performed in a clinical setting, and hence are typically reserved for patients with excruciating pain," said Zylka. Though he had never received acupuncture or researched traditional Chinese medicine, Zylka said recent research showing how acupuncture relieved pain caught his eye.

"When an acupuncture needle is inserted into an acupuncture point and stimulated, nucleotides are released. These nucleotides are then converted into adenosine," said Zylka. Adenosine has antinociceptive properties, meaning adenosine can decrease the body's sensitivity to pain. The release of adenosine offers pain relief, but for most acupuncture patients that relief typically lasts for a few hours.

"We knew that PAP makes adenosine and lasts for days following spinal injection, so we wondered what would happen if we injected PAP into an acupuncture point?" Zylka said. "Can we mimic the pain relief that occurs with acupuncture, but have it last longer?"

To find out, Zylka and his lab injected PAP into the popliteal fossa, the soft tissue area behind the knee. This also happens to be the location of the Weizhong acupuncture point. Remarkably, they saw that pain relief lasted 100 times longer than a traditional acupuncture treatment. What's more, by avoiding the spine the researchers could increase the dose of PAP. A single injection was also effective at reducing symptoms associated with inflammatory pain and neuropathic pain.

"Pinning down the mechanisms behind acupuncture, at least in animal models, was critical," said Zylka. "Once you know what chemicals are involved, you can exploit the mechanism, as we did in our study."

The next step for PAP will be refining the protein for use in human trials. UNC has licensed the use of PAP for pain treatment to Aerial BioPharma, a Morrisville, N.C.-based biopharmaceutical company.

Zylka said PAP could be applicable to any area where regional anesthesia is performed to treat pain. And PAP has the potential to last longer than a single injection of local anesthetic — the class of drugs used in regional anesthesia.

"When it comes to pain management, there is a clear need for new approaches that last for longer periods of time," said Julie Hurt, PhD, a postdoctoral fellow in Zylka's lab.

Zylka co-authored the paper with Hurt. The research was undertaken at UNC and was supported by the National Institute of Neurological Disorders and Stroke, a component of the National Institutes of Health.

 An increase or decrease in your blood pressure during middle age can significantly impact your lifetime risk for cardiovascular disease (CVD), according to research in Circulation: Journal of the American Heart Association.

Researchers found people who maintained or reduced their blood pressure to normal levels by age 55 had the lowest lifetime risk for CVD (between 22 percent to 41 percent risk). In contrast, those who had already developed high blood pressure by age 55 had a higher lifetime risk (between 42 percent to 69 percent risk).

Using data from 61,585 participants in the Cardiovascular Lifetime Risk Pooling Project, researchers examined how changes in blood pressure during middle age affected lifetime CVD risk. Previous studies had considered a single measurement at a given age. In this study, age 55 was considered a mid-point for middle age.

Starting with baseline blood pressure readings from an average of 14 years prior, researchers tracked blood pressure changes until age 55, then continued to follow the patients until the occurrence of a first cardiovascular event (including heart attack or stroke), death or age 95.

"Taking blood pressure changes into account can provide more accurate estimates for lifetime risk of cardiovascular disease, and it can help us predict individualized risk, and thus, individualized prevention strategies," said Norrina Allen, Ph.D., lead author of the study and assistant professor in the Department of Preventive Medicine at the Northwestern University Feinberg School of Medicine in Chicago. "Both avoiding hypertension during middle age or delaying the onset of the development of hypertension appear to have a significant impact on an individual's remaining lifetime risk for CVD."

Researchers also found:

• Almost 70 percent of all men who develop high blood pressure in middle age will experience a CVD event by 85.
• Women who develop high blood pressure by early middle-age (average age 41) have a higher lifetime risk for CVD (49.4 percent) than those who have maintained normal blood pressure up to age 55.
• Women, in general, had higher increases in blood pressure during middle age.
• At an average age 55, 25.7 percent of men and 40.8 percent of women had normal blood pressure levels; 49.4 percent of men and 47.5 of women had prehypertension.
• The overall lifetime CVD risk for people 55 years or older was 52.5 percent for men and 39.9 percent for women, when factoring in all blood pressure levels.
• The lifetime risk for CVD was higher among Blacks compared with Whites of the same sex, and increased with rising blood pressure at middle age.

"Since the data suggests that both early elevations and changes over time in blood pressure measurements impact the future risk of CVD, people can take preventive steps early on to reduce their chances of heart attack or stroke," said Donald M. Lloyd-Jones, M.D., Sc.M., co-author of the study and chair of the Department of Preventive Medicine at the Northwestern University Feinberg School of Medicine.

"Maintaining a healthy diet, combined with exercise and weight control, can help reduce blood pressure levels and, consequently, your risk for CVD later in life."

Co-authors are Jarett D. Berry, M.D., M.S.; Hongyan Ning, M.D., M.S.; Linda Van Horn, Ph.D., R.D.; and Alan Dyer, Ph.D.

 Deep brain stimulation (DBS) has become a common treatment for patients with chronic pain or movement disorders. Now a unique set of experiments shows that electrical stimulation in some of the same brain areas can also affect respiratory function, according to a study in the February issue of Neurosurgery, official journal of the Congress of Neurological Surgeons.

The preliminary findings help to clarify the brain's involvement in controlling lung function, and may lend useful insights for developing new treatments for diseases such as asthma and chronic obstructive pulmonary disease (COPD). The lead author was Dr. Jonathan A. Hyam of University of Oxford, United Kingdom.

Brain Stimulation Shows Effects on Lung Function

Dr. Hyam and colleagues performed a series of experiments in patients undergoing DBS for chronic pain or for movement disorders, such as Parkinson's disease. In DBS, a small electrode is surgically placed in a precise location in the brain. A mild electrical current is delivered to stimulate that area of the brain, with the goal of interrupting abnormal brain activity.

The researchers sought to determine whether DBS could also affect respiratory (breathing) function. Recent studies using advanced functional imaging techniques have helped to clarify the parts of the brain governing the many and complex functions of the autonomic nervous system — the part of the nervous system that controls involuntary functions such as the heartbeat and breathing.

The results showed significant changes in some lung function when electrical stimulation was "on" in two brain areas: the periaqueductal gray matter (PAG), which is stimulated in some patients with chronic pain; and the subthalamic nucleus (STN), which is stimulated in some patients with movement disorders. One key measure — the peak expiratory flow rate, an important measure of lung function in patients with asthma — increased by up to 14 percent in response to stimulation.

In other brain areas tested, stimulation had no effect on lung function. The improvements seemed specifically related to changes in the width of the airways, which is affected by "smooth muscle" under the control of the autonomic nervous system.

Some other key measures of lung function — including an important one called forced expiratory volume (FEV1) — seemed unaffected by stimulation. This may have reflected the fact that most of the patients had normal lung function, with little room for improvement.

However, in one of the patients with chronic pain, tests performed for the study identified mild COPD. This patient had a significant increase in FEV1 and other lung function measures when PAG stimulation was "on."

Further studies would be needed to find out whether DBS can produce larger improvements in lung function for patients with established chronic lung disease. The researchers speculate that the improvement in peak expiratory flow rate may help to explain some of the subjective benefits of DBS.

For now, the study provides valuable new information on the brain's involvement in governing lung function via the autonomic nervous system. Continued research might lead to the development of new approaches to treatment for lung diseases — especially asthma and COPD — that involve narrowing of the airways, Dr. Hyam and coauthors believe. They conclude, "These results lend support to the importance of the PAG and STN in respiratory performance and provide another potential direction for the application of deep brain stimulation."

 A team of scientists has found a novel road-block in the pain pathway, which could be used to treat chronic pain. Their results are published March 13 in the online, open-access journal PLoS Biology.

Pain is an important physiological function that protects our bodies from harm. Pain-sensing nerves transduce harmful stimuli into electrical signals and transmit this information to the brain via the spinal cord. However, when these nerves get activated persistently, such as after injury or inflammation, the information flow into the spinal cord is remarkably amplified. This phenomenon, termed 'synaptic long-term potentiation (LTP)', is an important biological property that is evolutionarily conserved from lower organisms to humans.

To gain a better understanding of how LTP works in the context of pain signaling, the team led by Rohini Kuner (Heidelberg University, Germany) and Ceng Luo (Fourth Military Medical University, China) took advantage of biochemical, genetic, physiological, and behavioral tools available in mice. They studied how LTP works at the synaptic connection between peripheral pain sensors and spinal cord neurons. They found that presynaptic events that unfold in the spinal endings of pain-sensing nerves are required for this pain amplification.

"Our results indicate that an enzyme termed cGMP-activated Kinase 1 (PKG-I) is a key player in this important process," says Ceng Luo. By removing PKG-1 specifically from the presynaptic neurons in this pathway, their group found that not only was LTP abolished, but that pain-related memory and behavior were also altered. Can these basic biological findings be put to use? Chronic pain is a major cause of poor quality of life worldwide; recent demographic studies indicate that one in every six people in Europe suffers from chronic pain.

"Our observation that genetically silencing PKG-I, or blocking its activation, in pain-sensing nerves markedly reduced chronic inflammatory pain paves the way for potential new therapeutic approaches,'' says Rohini Kuner.

Among obese individuals, having bariatric surgery was associated with a reduced long-term incidence of cardiovascular deaths and events such as heart attack and stroke, according to a study in the January 4 issue of JAMA.

Most epidemiological studies have shown that obesity is associated with increased cardiovascular events and death. "Weight loss might protect against cardiovascular events, but solid evidence is lacking," according to background information in the article.

Lars Sjostrom, M.D., Ph.D., of the University of Gothenburg, Sweden, and colleagues conducted a study to test the hypothesis that bariatric surgery is associated with a reduced incidence of cardiovascular events and examined the relationship between weight change and cardiovascular events. The study (Swedish Obese Subjects [SOS]) is an ongoing, nonrandomized, prospective, controlled study conducted at 25 public surgical departments and 480 primary health care centers in Sweden, and includes 2,010 obese participants who underwent bariatric surgery and 2,037 matched obese controls who received usual care.

Patients were recruited between September 1987 and January 2001. Date of analysis was December 31, 2009, with median (midpoint) follow-up of 14.7 years. Inclusion criteria were age 37 to 60 years and a body mass index of at least 34 in men and at least 38 in women. Surgery patients underwent gastric bypass (13.2 percent), banding (18.7 percent), or vertical banded gastroplasty (68.1 percent), and controls received usual care in the Swedish primary health care system. Physical and biochemical examinations and database cross-checks were undertaken at preplanned intervals. The average changes in body weight after 2, 10,15, and 20 years were -23 percent, -17 percent, -16 percent, and -18 percent in the surgery group and 0 percent, 1 percent, -1 percent, and -1 percent in the control group, respectively.

During follow-up, there were 49 cardiovascular deaths among the patients in the control group and 28 cardiovascular deaths among the patients in the surgery group. In total (fatal and nonfatal), there were 234 cardiovascular events among patients in the control group and 199 cardiovascular events among patients in the surgery group. After adjustment for a number of variables, bariatric surgery was associated with a reduced number of fatal cardiovascular deaths and a lower incidence of total cardiovascular events.

Bariatric surgery was associated with reduced number of fatal heart attack deaths (22 in the surgery group vs. 37 in the control group), with analysis indicating that bariatric surgery was related both to reduced fatal heart attack incidence and total heart attack incidence. Also, bariatric surgery was associated both with reduced number of fatal stroke events and total stroke events.

However, the researchers found no significant relationship between weight change and cardiovascular events in the surgery or control group. The authors suggest that the lack of association between weight loss and reduction of cardiovascular events could be related to inadequate statistical power to detect this relationship. "Alternatively, following relatively modest weight loss induced by bariatric surgery, there is no further risk reduction attributable to greater, subsequent weight loss. Our negative findings also emphasize the need to explore weight loss independent of effects of bariatric surgery."

"In conclusion, this is the first prospective, controlled intervention to our knowledge reporting that bariatric surgery is associated with reduced incidence of cardiovascular deaths and cardiovascular events. These results- together with our previously reported associations between bariatric surgery and favorable outcomes regarding long-term changes of body weight, cardiovascular risk factors, quality of life, diabetes, cancer, and mortality- demonstrate that there are many benefits to bariatric surgery and that some of these benefits are independent of the degree of the surgically induced weight loss."

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Journal Reference:

1. L. Sjostrom, M. Peltonen, P. Jacobson, C. D. Sjostrom, K. Karason, H. Wedel, S. Ahlin, A. Anveden, C. Bengtsson, G. Bergmark, C. Bouchard, B. Carlsson, S. Dahlgren, J. Karlsson, A.-K. Lindroos, H. Lonroth, K. Narbro, I. Naslund, T. Olbers, P.-A. Svensson, L. M. S. Carlsson. Bariatric Surgery and Long-term Cardiovascular Events. JAMA: The Journal of the American Medical Association, 2012; 307 (1): 56 DOI: 10.1001/jama.2011.1914

 Acupuncture significantly reduces levels of a protein in rats linked to chronic stress, researchers at Georgetown University Medical Center (GUMC) have found. They say their animal study may help explain the sense of wellbeing that many people receive from this ancient Chinese therapy.

Published online in December in Experimental Biology and Medicine, the researchers say that if their findings are replicated in human studies, acupuncture would offer a proven therapy for stress, which is often difficult to treat.

"It has long been thought that acupuncture can reduce stress, but this is the first study to show molecular proof of this benefit," says the study's lead author, Ladan Eshkevari, Ph.D., an assistant professor at Georgetown's School of Nursing & Health Studies, a part of GUMC.

Eshkevari, who is also a nurse anesthetist as well as a certified acupuncturist, says she conducted the study because many of the patients she treats with acupuncture in the pain clinic reported a "better overall sense of wellbeing — and they often remarked that they felt less stress."

While traditional Chinese acupuncture has been thought to relieve stress — in fact, the World Health Organization states that acupuncture is useful as adjunct therapy in more than 50 disorders, including chronic stress — Eshkevari says that no one has biological proof that it does so.

So she designed a study to test the effect of acupuncture on blood levels of neuropeptide Y (NPY), a peptide that is secreted by the sympathetic nervous system in rodents and humans. This system is involved in the "flight or fight" response to acute stress, resulting in constriction of blood flow to all parts of the body except to the heart, lungs, and brain (the organs most needed to react to danger). Chronic stress, however, can cause elevated blood pressure and cardiac disease.

Eshkevari used rats in this study because these animals are often used to research the biological determinants of stress. They mount a stress response when exposed to winter-like cold temperatures for an hour a day.

Eshkevari allowed the rats to become familiar with her, and encouraged them to rest by crawling into a small sock that exposed their legs. She very gently conditioned them to become comfortable with the kind of stimulation used in electroacupuncture — an acupuncture needle that delivers a painless small electrical charge. This form of acupuncture is a little more intense than manual acupuncture and is often used for pain management, she says, adding "I used electroacupuncture because I could make sure that every rat was getting the same treatment dose."

She then selected a single acupuncture spot to test: Zuslanli (ST 36 on the stomach meridian), which is said to help relieve a variety of conditions including stress. As with the rats, that acupuncture point for humans is on the leg below the knee.

The study utilized four groups of rats for a 14-day experiment: a control group that was not stressed and received no acupuncture; a group that was stressed for an hour a day and did not receive acupuncture; a group that was stressed and received "sham" acupuncture near the tail; and the experimental group that were stressed and received acupuncture to the Zuslanli spot on the leg.

She found NPY levels in the experimental group came down almost to the level of the control group, while the rats that were stressed and not treated with Zuslanli acupuncture had high levels of the protein.

In a second experiment, Eshkevari stopped acupuncture in the experimental group but continued to stress the rats for an additional four days, and found NPY levels remained low. "We were surprised to find what looks to be a protective effect against stress," she says.

Eshkevari is continuing to study the effect of acupuncture with her rat models by testing another critical stress pathway. Preliminary results look promising, she says.

The study was funded by the American Association of Nurse Anesthetists doctoral fellowship award to Eshkevari, and by a grant from the National Institutes of Health's National Center for Complementary and Alternative Medicine.

Co-authors include Georgetown researchers Susan Mulroney, Ph.D., Rupert Egan, Dylan Phillips, Jason Tilan, Elissa Carney, Nabil Azzam, Ph.D., and Hakima Amri, Ph.D.

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Journal Reference:

1. L. Eshkevari, R. Egan, D. Phillips, J. Tilan, E. Carney, N. Azzam, H. Amri, S. E. Mulroney. Acupuncture at ST36 prevents chronic stress-induced increases in neuropeptide Y in rat. Experimental Biology and Medicine, 2011; DOI: 10.1258/ebm.2011.011224