Investigations in Chronic Pain: Improving Assessment and Bolstering Outcomes

Faculty Mentor’s Name: Dr. Rene Przkora
Phone Number: (352) 273-6575
Project Category: Clinical
International Component or Travel: No

Research Project Description:
Chronic pain is a major public health issue with significant functional and financial consequences to individuals, the community, and the healthcare system. Even more concerning, the consequences of chronic pain extend beyond disability and decreased quality of life to include an increased incidence of morbidity and mortality. Research investigation and clinical management of chronic pain is difficult due to significant individual variability and the lack of biological indices with which to evaluate risk and protective factors, progression, and treatment response. Our scientific pursuits are specific to investigating the interactive influences of biological, psychosocial, cognitive, and behavioral factors associated with chronic pain conditions with an emphasis on stress, aging, health disparities, and resilience. The intentions underlying our investigations are to 1) elucidate biological measures reflecting the stress-related biological burden resulting from chronic pain conditions; 2) delineate resilience and vulnerability factors for prevention and treatment; and 3) identify biobehavioral strategies to optimize chronic pain treatment interventions. The overarching goals of our efforts are to contribute to the research and medical community by improving the understanding of the biological interface of chronic pain and associated stressors, to formulate a clinical composite for assessing and evaluating treatment interventions, and to identify strategies and targets to prevent, reduce or ameliorate chronic pain
Medical Student Role: A number of possible research opportunities are available such as assisting with pre-study efforts, data collection, literature reviews, and participating in manuscript development.
Rene Przkora MD, PhD Anesthesiology, Division of Pain Medicine
Kimberly Sibille, PhD, MA Department of Aging & Geriatric Research

Relevant Publications:
Romman AN, Hsu CM, Chou LN, Kuo YF, Przkora R, Gupta RK, Lozada JM: Opioid Prescribing to Medicare Part D Enrollees, 2013–2017: Shifting Responsibility to Pain Management Providers. Pain Medicine. 2020 Jan.
Johnson AJ, Terry E, Bartley EJ, Garvan C, Cruz-Almeida Y, Goodin B, Glover TL, Staud R, Bradley LA, Fillingim RB, Sibille KT (2019). Resilience factors may buffer cellular aging in individuals with and without chronic knee pain. Mol Pain. 15:1744806919842962.
Przkora R, Kinsky M, Fisher S, Babl C, Heyde CE, Vasilopoulos T, Kaye A, Volpi E: Functional Outcomes Utilizing the Short Physical Performance Battery (SPPB) After Epidural Steroid Injection Compared to Medication Therapy in Elderly Patients with Lumbar Spinal Stenosis. Original Research Manuscript. Curr Pain Headache Rep. 2019 Feb 22;23(2):14. PMID: 30796532
Mora JC, Przkora R, Cruz-Almeida Y: Knee osteoarthritis: pathophysiology and current treatment modalities. J Pain Res. 2018 Oct 5;11:2189-2196. PMID: 30323653.
Sibille KT, Chen H, Bartley EJ, Riley J III, Glover TL, King CD, Zhang H, Cruz-Almeida Y,
Goodin BR, Sotolongo A, Petrov ME, Herbert M, Bulls HW, Edberg JC, Staud R, Redden D, Bradley LA, Fillingim RB (2017). Accelerated Aging in Adults with Knee Osteoarthritis Pain: Consideration for Frequency, Intensity, Time, and Total Pain Sites. PAIN Reports. 2(3) e591,May/June. PMID: 29392207.
Sibille KT, Bartsch F, Reddy D, Fillingim RB, Keil A (2016). Increasing neuroplasticity to bolster chronic pain treatment: A role for intermittent fasting and glucose administration? J of Pain. Epub PMID: 26848123
Sibille KT, Steingrímsdóttir OA, Fillingim RB, Stubhaug A, Schirmer H, Chen H, McEwen BS,
Nielsen CS (2016). Investigating the burden of chronic pain: Inflammatory and metabolic composite. Pain Res Manag. 2016:1-11. PMID: 27445627.

Gastric Ultrasound in Patients Receiving Enteral Feeding

Faculty Mentor’s Name: Dr. Meghan Brennan
Phone Number: (352) 872-8017
Project Category: Clinical
International Component or Travel: No

Research Project Description:
Background: The goal of this project is to use gastric ultrasound to determine gastric contents of ICU patients receiving enteral feeds. Critically ill patients experience delayed gastric emptying and dysmotility the degree of which is uncertain. Studies of intensive care unit (ICU) patients have documented overall risk of aspiration in the ICU as high as 30% however perioperative risk is unknown. Complications related to aspiration pneumonia and pneumonitis lead to need for prolonged ICU admission, mechanical ventilation, carry significant morbidity and mortality risks. In otherwise healthy patients the main risk factor for pulmonary aspiration of gastric contents is the volume of gastric contents, risk of pneumonitis is also related to gastric pH, with pH < 2.5 at highest risk. It is understood that healthy, fasted individuals commonly have up to 1.5 mL/kg of gastric contents, and this does not appear to significantly increase the risk of pulmonary aspiration. As such, pre-operative fasting guidelines have been developed by the American Society of Anesthesiologists. These guidelines have not been well studied in critically ill patients. This patient population also frequently undergoes interruption of enteral feeds due to procedures and there is no general consensus on optimal methods to minimize these interruptions. The risk of interruption of enteral feeds in this patient population can result in continued worsened malnutrition. We are interested in studying the critically ill patient population receiving enteral tube feeds using established ultrasound techniques to evaluate their gastric volumes with continuous tube feeds.  
Hypothesis: Patients receiving enteral feeding may have what is considered a “full stomach” even after enteral feeds are turned off at the recommended time interval.
Methods: Intensive care unit patients will be consented according to IRB protocol. They will undergo a gastric ultrasound before enteral feeds are started and 6 hours after enteral feeds have been ongoing at goal rate. Patients will also undergo gastric ultrasound at 0, 2, 4, and 6 hours after enteral feeds have stopped.
Medical student role: identify patients who meet study protocol inclusion criteria, consent patients, learn the technique to perform gastric ultrasounds, perform gastric ultrasounds, collect data, analyze data, present results in the form of abstract submissions to conferences, participate in manuscript preparation, submission, and co-authorship.

Estimating the Cost of a Prostate Biopsy False Negative

Faculty Mentor’s Name: Dr. Samsun Lampotang
Phone Number: (352) 294-8148
Project Category: Literature Review
International Component or Travel: No

Research Project Description:
A prostate biopsy false negative (PBxFN) occurs when the biopsy does not sample prostate cancer that is present and. PBxFN has an incidence in patients ranging from 21-47%, a concerning issue even at the low end of the range. There is currently no data on the estimated average cost of a PBxFN even though prostate cancer is the most, or second most,one of the most common cancers in men. The goal is to estimate the cost of a PBxFN based on literature review and the overall financial impact. Metrics that will be evaluated are the cost of repeat biopsies, the cost of delayed diagnosis and the quantifiable impact on survival and quality of life. The medical student will conduct the literature search and will be assisted by the faculty member, Prof. Lampotang and personnel in the CSSALT (Center for Safety, Simulation & Advanced Learning Technologies) lab, including drafting a manuscript for peer-reviewed publication. Funding was via a Department of Defense grant that expired this year. We have multiple proposals being evaluated by DoD and Pfizer currently. Two relevant publications are in the British Journal of Urology International (Revision 2 stage; not yet accepted) and in the British Medical Journal Simulation & Technology Enhanced Learning, BMJ-STEL (submitted pending review).

Effect of Sociodemographic Disparities on Health Outcomes in Surgical Patients

Faculty Mentor’s Name: Dr. Patrick Tighe
Phone Number:(253) 273-7844
Project Category: Clinical
International Component or Travel: No

Research Project Description:
There is limited previous research that shows that among other factors, patients’ preoperative cognitive/functional status may affect their recovery trajectory after surgery. For example, depression will exacerbate the patients’ outcomes after surgery, leading to higher risk of delirium and mortality [1-2] ; and nutritional deficiencies is a significant factor in predicting overall survival of gastric cancer patients undergoing curative resection [3]. Such findings show the importance of factors that may not be routinely considered and applied in deciding the risks and benefits of a surgery, especially for vulnerable populations such as older patient. However, there is limited work on how the combination of demographic, social, and economic backgrounds of patients affect patients’ baseline, and ultimately their postoperative outcomes for various surgery types, with most previous research being limited to single health outcomes and limited data size and variables (e.g. 4-5). It is important to study how a more comprehensive knowledge of patients’ sociodemographic and economics -in terms of important factors such as age and race, living status, education, employment status and household income, neighborhood characteristics, as well as insurance and access to healthcare facilities- affect their baseline status in terms of factors such as physical and cognitive frailty, as well as and leading to their postoperative outcomes.
i) identifying important (relevant) socioeconomic predictors for cognitive and physical frailty as well as postoperative outcomes from previous research;
ii) investigating how these predictors can be reliably extracted from Electronic Health Records and public datasets such as Census and American Community Survey data;
iii) investigating how AI can be used with clinical notes to better understanding patients’ preoperative status;
iv) developing predictive models for postoperative outcomes while incorporating the determined novel variables, and studying whether/how their inclusion improves the model performance in determining postoperative outcomes.

Project 1: Literature review on how sociodemographic factors affect (surgical) patients’ outcomes– including methodologies and variables studied, as well as the results.
Student Role: The student will help in literature search, and preparing a peer-reviewed manuscript draft on the results.

Project 2: Extracting and preparing data from patients’ EHR and public datasets
Student Role: The student will help in data curation and summarizing, as well as learning to analyze the relationships between the extracted variables and health outcomes. Time permitting, the interested student can also learn to and help in analyzing the spatial distribution of socioeconomic variables. They will also help in reporting the findings in forms of abstract and/or peer-reviewed manuscript.

Project 3: Preparing and analyzing clinical notes for better incorporating relevant information on socioeconomic disparities
Student Role: The student(s) will help with data curation/preparation and analysis to examine how further information from clinical notes in terms of socioeconomic disparities can contribute to better incorporate patients’ background (baseline) factors in predicting postoperative health outcomes, and in preparing abstract and articles’ drafts for disseminating the findings.

Project 4: Investigating how incorporating novel geospatial and clinical information may improve prediction of postoperative health outcomes
Student Role: The student(s) will help in preparing the comprehensive and multi-source data and developing classifier and predictive models based on the extracted variables; as well as preparing report drafts for publishing the findings.

  1. Smith PJ, Attix DK, Weldon BC, Greene NH, Monk TG. Executive function and depression as independent risk factors for postoperative delirium. Anesthesiology. 2009;110(4):781-787. doi:10.1097/aln.0b013e31819b5bc2
  2. Wewalka M, Warszawska J, Strunz V, Kitzberger R, Holzinger U, Fuhrmann V, Zauner C, Miehsler W, Moser G. Depression as an independent risk factor for mortality in critically ill patients. Psychosom Med. 2015 Feb-Mar;77(2):106-13. doi: 10.1097/PSY.0000000000000137. PMID: 25626990.
  3. Liu X, Xu P, Qiu H, et al. Preoperative Nutritional Deficiency Is a Useful Predictor of Postoperative Outcome in Patients Undergoing Curative Resection for Gastric Cancer. Transl Oncol. 2016;9(6):482-488. doi:10.1016/j.tranon.2016.09.008
  4. Shen SA, Jafari A, Qualliotine JR, DeConde AS. Socioeconomic and demographic determinants of postoperative outcome after endoscopic sinus surgery. Laryngoscope. 2020 Feb;130(2):297-302. doi: 10.1002/lary.28036. Epub 2019 May 17. PMID: 31099424.
  5. Quintana, J., Garcia, S., Aguirre, U. et al. Relationship of sociodemographic variables with outcomes after cataract surgery. Eye 27, 698–708 (2013).