BUT FIRST I'D JUST LIKE TO
ACKNOWLEDGE TH TO THANK THOSE FR
HELPING TO ORGANIZE THIS, THEY
DID AN AMAZING JOB, SO THANK
YOU.
THIS IS THE 19TH ANNUAL PAIN
CONSORTIUM.
IT'S HARD TO BELIEVE IT'S BEEN
THAT LONG BUT IT HAS, AND IT'S
THE FIRST ONE ON WOMEN'S HEALTH
AND THAT'S -- FOCUSING ON
WOMEN'S HEALTH.
THAT'S WHY I'M ONE OF THE
CO-CHAIRS OF THIS FROM THE
OFFICE OF RESEARCH OND WOMEN' OS
HEALTH, FOCUSING ON THIS
IMPORTANT ISSUE THAT AFFECTS
WOMEN PREDOMINANTLY OR MORE SO
THAN MEN.
WITH THAT, I'D LIKE TO INTRODUCE
OUR FIRST SPEAKER, WHO IS
DR. COURTNEY AKLIN, ACTING
DIRECTOR OF NINR BUT PREVIOUSLY
WITH THE OD DOING A TREMENDOUS
JOB, BEFORE THAT, THE DEPUTY
DIRECTOR OF NIMHD AND I DON'T
HAVE HER BIO SO I CAN'T GO BACK
ANY FURTHER BUT WE'RE THRILLED
TO HAVE YOU HERE, AND ALSO
CONNECTED TO THE PAIN
CONSORTIUM, BECAUSE HER HUSBAND,
A FRIEND OF MINE, IS NOW THE
NIDA PAIN CONSORTIUM REP.
SO THERE'S THAT CONNECTION TOO.
SO COURTNEY, HOPE YOUR SLIDES
WORK BUT IT'S ALL YOURS.
>> GOOD MORNING, EVERYONE.
THANK YOU SO MUCH FOR YOUR
PATIENCE AS WE ARE DEALING WITH
TECHNICAL DIFFICULTIES.
I BELIEVE THOSE ON ZOOM MAY NOT
BE ABLE TO SEE MY SLIDES BUT I'M
GOING TO RUN THROUGH THIS VERY
QUICKLY BECAUSE THERE'S SO MANY
OTHER PEOPLE COMING AFTER ME.
WE HAVE SOME REALLY GREAT TALKS
TO TALK ABOUT THE RESEARCH THAT
WE'RE REALLY INTERESTED IN.
I WANT TO WELCOME YOU ALL ON
BEHALF OF THE EXECUTIVE
COMMITTEE OF THE NATIONAL
INSTITUTES OF HEALTH PAIN
CONSORTIUM.
THE SYMPOSIUM IS TRULY AN HONOR
TO BE HERE WITH YOU TODAY, SUCH
A DISTINGUISHED AUDIENCE OF
RESEARCHER, THOUGHT LEADERS,
STAKEHOLDERS WHO ARE DEDICATED
TO UNDERSTANDING THE UNDERLYINGS
OF PAIN AND TREAT M OF PAIN.
OVER THE NEXT TWO DAYS WE HAVE
EXCITING SESSIONS FOR ALL OF YOU
IN CONVERSATION CENTERED AROUND
UNDERSTANDING THIS YEAR'S THEME
OF SEX AND GENDER DIFFERENCES IN
NEUROBIOLOGY OF PAIN, ITS
EXPERIENCES AND MANAGEMENT.
SO I'M GOING TO TALK JUST A
LITTLE BIT BECAUSE AGAIN WE HAVE
SPEAKERS FOLLOWING OF ME OF WHAT
IT IS WE'RE TRYING TO FOCUS ON.
THE MISSION AS WE GATHER HERE
TODAY BOTH IN PERSON AND
VIRTUALLY, WE ARE UNITED BY A
COMMON GOAL WHICH IS TO PUSH THE
BOUNDARIES OF PAIN RESEARCH AND
TO IMPROVE THE LIVES OF MILLIONS
WHO SUFFER FROM PAIN.
PAIN AS WE KNOW IS NOT JUST A
MEDICAL CONDITION BUT A PROFOUND
HUMAN EXPERIENCE THAT AFFECTS
CONDITIONS PHYSICALLY, MENTALLY
AND SOCIAL WELL-BEING OF ALL OF
US.
OUR COLLECTIVE EFFORTS IN THIS
FIELD ARE MORE CRITICAL NOW THAN
EVER BEFORE.
25 INSTITUTES ACROSS NIH AND
BOUND TOGETHER FOR THIS
CONSORTIUM TO ADDRESS SOME OF
THE MOST CHALLENGING AND COMPLEX
ISSUES AND QUESTIONS RELATING TO
DETERMINING THE UNDERLYING
CAUSES OF PAIN AND FOR
DEVELOPING TARGETED
INTERVENTIONS TO ALLEVIATE PAIN
SYMPTOMS.
WE MUST CONTINUE THE EFFORTS
THAT HAVE BEEN OUTLINED OVER THE
PAST 19 CONSORTIUMS, SUPPORTING
AND DEVELOPING RESEARCH
RESOURCES AND TOOLS AND HOSTING
EVENTS LIKE THIS ONE WHERE WE
HAVE THE OPPORTUNITY TO PROMOTE
COLLABORATION AND HIGHLIGHT
ADVANCES IN PAIN RESEARCH.
AS THE DEPUTY DIRECTOR OF THE
NATIONAL INSTITUTE OF NURSING
RESEARCH, I'M PARTICULARLY
EXCITED ABOUT WHAT IT IS THAT WE
WILL BE TALKING ABOUT OVER THE
NEXT TWO DAYS.
IN THE CONTEXT OF PEOPLE'S LIVES
AND LIVED EXPERIENCES AS WHERE
NURSING SITS TRADITIONALLY,
CLINICALLY AND RESEARCH ORIENTED
BUT AS MANY IN THE AUDIENCE
PROBABLY ALREADY KNOW THE
NURSES' APPROACH TO PREVENTION,
TREATMENT AND CARE IS HOLISTIC
AND IN CONTEXT.
NURSES FOCUS ON PEOPLE, THEIR
LIVES, AND THEIR LIVING
CONDITIONS.
AND BECAUSE NURSES WORK SO
CLOSELY IN A WIDE RANGE OF
SETTINGS, THE ARE GENERALLY THE
MOST TRUSTED INDIVIDUALS IN THE
ROOM.
AND BECAUSE OF THAT, THAT ALLOWS
THEM ACCESS TO TRULY ASK THE
QUESTIONS AND CHALLENGING
ASPECTS TO FORGE FORWARD AND TO
ADDRESS INEQUITIES.
IN FACT, WE BELIEVE THIS SO
STRONGLY THAT THE INSTITUTE HAS
PIVOTED AND MADE THIS PART OF
OUR MISSION, AS YOU SEE HERE.
THE FOCUS OF THIS YEAR'S
SYMPOSIUM SPECIFICALLY ON SEX
AND GENDER DIFFERENCES AND THE
EXPERIENCE AND MANAGEMENT OF
PAIN PAIN SHOULD AUTOMATICALLY
CHALLENGE US TO CONSIDER PAIN
FROM A HEALTH EQUITY PERSPECTIVE
AND ASK OURSELVES THOSE TOUGH
QUESTIONS ON WHY THESE
DIFFERENCES EXIST.
QUESTIONS SUCH AS WHY ARE WOMEN
VETERANS MORE LIKELY TO BE
PRESCRIBED PSYCHIATRIC MEDICINE
FOR PAIN THAN THEIR MALE
COUNTERPARTS?
WHY ARE BLACK, HISPANIC AND
ASIAN WOMEN OFTEN GIVEN NARCOTIC
MEDICATION FOR CESAREAN BIRTH?
WHY DO SEXUAL MINORITY MINORITN
HAVE A LIFETIME RISK OF
EXPERIENCING CHRONIC PELVIC
PAIN?
THEY DO NOT ORIGINATE IN ANY
EXAM ROOM OR HEALTHCARE SETTING
BUT ACTUALLY ARE RATHER THE
EARLIER ECONOMIC STANDARDS AND
PLACES IN SOCIETY THAT AFFECT
THEM.
JUST TO PIVOT FOR A SECOND WE
MUCH LOOK AT THE BIGGER PICTURE.
IT IS ALSO CLEAR THESE UPSTREAM
FACTORS HAVE AN IMPACT ON HOW
WELL INTERVENTIONS WORK AT THE
INDIVIDUAL LEVEL.
PAIN IS MULTIFACETED.
IT'S INFLUENCED BY THE
PSYCHOLOGICAL, SOCIAL AND
ENVIRONMENTAL FACTORS.
SOCIAL DETERMINANTS SUCH AS
SOCIO AND ECONOMIC STATUS AFFECT
A PERSON'S EXPERIENCE OF PAIN
AND THEIR ABILITY TO SEEK
TREATMENT.
FOR PAIN MANAGEMENT
SPECIFICALLY, IT IS NOT
EFFECTIVE IF WE DO NOT THINK
ABOUT THESE PARTICULAR ASPECTS.
SIMPLY INTERVENING AT THE LEVEL
OF SOCIAL DETERMINANT REPRESENTS
AN UPSTREAM APPROACH TO PAIN
MANAGEMENT, AND BY ADDRESSING
THESE BROADER CONCEPTS SUCH AS
HOUSING AND STABLE EMPLOYMENT,
WE CAN PREVENT CHRONIC PAIN.
WE CAN ALSO MITIGATE THEM
EARLIER ON AND REDUCE THE BURDEN
OF HEALTHCARE AND DISPARITIES
THAT WE SEE.
BUT WE MUST MAKE IT A PRIORITY
AS SCIENTISTS TO INCLUDE THESE
SOCIAL DETERMINANTS OF HEALTH
INTO OUR RESEARCH IN A RIGOROUS
AND MEANINGFUL WAY IF WE'RE
GOING TO ACHIEVE THE EQUITABLE
LANDSCAPE THAT WE'RE SET OUT TO
DO.
IN ESSENCE OF TIME I'M JUST
GOING TO HIGHLIGHT ONE STUDY
THAT NINR HAS RECENTLY SUPPORTED
TO ILLUSTRATE THE POINTS I'VE
JUST SPOKE ABOUT.
IN THIS STUDY, RESEARCHERS ARE
USING TELEHEALTH TO IMPLEMENT
EFFECTIVE, EVIDENCE-BASED AND
NON-OPIOID INTERVENTIONS FOR
CHRONIC PAIN MANAGEMENT.
CHALLENGES THAT ARE FACED BY
VETERANS RESIDING IN RURAL AND
REMOTE AREAS.
THE STUDY PURPOSELY DESIGNED TO
ADDRESS SEVERAL SOCIAL
DETERMINANTS OF HEALTH INCLUDING
ACCESS TO CARE BY UTILIZING
TELEHEALTH TO BRIDGE THIS GAP.
MAKING NON-OPIOID PAIN
MANAGEMENT STRATEGIES MORE
ACCESSIBLE TO RURAL COMMUNITIES.
HEALTHCARE INFRASTRUCTURE.
BY IMPLEMENTING WHAT HAS ALREADY
BEEN IN PLACE AND USING THE VA'S
INFRASTRUCTURE THAT ALREADY HAS
INCLUDED WELL HEALTH COACHES,
YOU HAVE THE ABILITY TO SCALE
AND TO REACH AND HAVE A FURTHER
OPPORTUNITY TO HELP VETERANS ANN
THEIR PARTICULAR PLACES WHERE
THEY LIVE AND WORK.
ALSO COMMUNITY ENGAGEMENT,
INVOLVING VETERANS EARLY IN THE
PROCESS SO IN ORDER TO LOOK AT
ACCEPTABILITY AS WELL AS
SCALABILITY.
IN ESSENCE OF TIME I'M GOING TO
SKIP THROUGH THIS.
AND JUST SAY BEFORE I TURN
THINGS OVER TO MY COLLEAGUE FROM
THE OFFICE OF RESEARCH ON
WOMEN'S HEALTH, I WANT TO CLOSE
BY HIGH HEIGHTING THAT THIS
CONSORTIUM HAS SUCCESSFULLY
EXPANDED THE PORTFOLIO OF PAIN
RESEARCH WITHIN NIH BY
ADDRESSING A DIVERSE RANGE OF
PAIN CONDITIONS AND EXPLORING
THE THERAPEUTIC AVENUES.
PROMOTING INTERDISCIPLINARY
COLLABORATIVE WORK, A LITTLE BIT
OF A HEAD NOD BECAUSE I THINK
THAT IS EXTREMELY IMPORTANT,
ESPECIALLY AS WE CONTINUE TO
DELVE INTO THESE COMPLEX ISSUES,
BUT NINR IS PLEASED TO BE A PART
OF THIS CONSORTIUM EVENT AND I'M
SO EXCITED TO LEARN OVER THE
NEXT TWO DAYS OF SOME OF THE NEW
ASPECTS THAT ARE COMING FORWARD
FROM ALL OF YOU.
AND WITH THAT, I'M GOING TO
CLOSE AND TURN IT OVER TO
DR. VIVIAN OTA WONG, DEPUTY
DIRECTOR OF THE NIH OFFICE OF
RESEARCH ON WOMEN'S HEALTH.
>> GOOD MORNING.
IT'S GOING TO LOOK LIKE WE HAVE
SIMILAR SLIDES BUT HERE WE GO.
SO ANYWAY, I'M THE DEPUTY
DIRECTOR OF THE OFFICE OF
RESEARCH ON WOMEN'S HEALTH AT
NIH AND I JUST WOULD ALSO LIKE
TO WELCOME YOU AND PROVIDE YOU A
FEW OPENING REMARKS TO LEVELSET
SOME OF THE THINGS WE'RE GOING
TO BE TALKING ABOUT TODAY.
I WANT ALL OF YOU TO IMAGINE A
WORLD IN WHICH EVERY WOMAN
RECEIVES EVIDENCE-BASED DISEASE
PREVENTION AND TREATMENT
TAILORED TO HER OWN NEEDS,
CIRCUMSTANCES, AND GOALS, AND
FOR YOUR PARTICULAR AREA, WHAT
IS PAIN AND HOW ARE WE TRULY
GOING TO DO THAT?
A DIFFERENT VERSION OF WHAT YOU
JUST SAW, I THINK WE NEED TO PAY
ATTENTION TO THE FULL DIASPORA
OF THE LIVED EXPERIENCE.
WE HAVE THE BIOLOGICAL PIECE
THAT SOME OF YOU ARE DOING MORE
BENCH SCIENCE, WE HAVE TO
UNDERSTAND THE WORLD WHERE WE
LIVE, AND HOW THE POLICIES THAT
WE ARE ACTUALLY OPERATING UNDER
INFLUENCE HUMAN HEALTH.
BECAUSE WHAT WE KNOW IS THAT MEN
AND WOMEN FOLLOW MANY DIFFERENT
PATHS TO DISEASE AND HEALTH, AND
PART OF OUR GOAL IN THIS ROOM
AND IN SCIENCE IS TO FIGURE OUT
WHAT THOSE PATHS ARE AND WHAT WE
CAN DO TO ACTUALLY IMPROVE TO
IMPROVE HEALTH.
THIS IS A BIT OF A BUSY SLIDE
BUT IT'S REALLY TO DEMONSTRATE
TWO POINTS.
ONE, THAT WOMEN DIFFERENTLY
EXPERIENCE HEALTH AND DISEASE
AND AS YOU SEE ON THE RIGHT,
IT'S JUST A LIST OF DIFFERENT
DISEASES, AND WE DO KNOW THAT
WOMEN EXPERIENCE PAIN MORE AND
MORE FREQUENTLY IN INTENSITY
THAN MEN, BUT WHAT THIS ALSO
SHOWS IS THAT THE FREQUENCY OF
THE TYPES OF SYMPTOMS DIFFER BY
MEN AND WOMEN NOT ONLY IN TERMS
OF AMOUNT BUT ALSO BY MAGNITUDE.
SO THIS IS HOW WE SORT OF THINK
ABOUT HEALTH OF WOMEN ACROSS THE
LIFE COURSE AT THE OFFICE OF
RESEARCH ON WOMEN'S HEALTH.
WE LOOK AT THE BOTTOM OF THE
BIOLOGICAL PERSPECTIVES, THEIR
INTERNAL FACTORS.
IT CAN GO AS MICROSCOPING INTO
THE GENOMICS OR GENOMIC
FUNCTIONING.
WE HAVE TO PUT THIS ON THE
LIFESPAN SCALE TO UNDERSTAND THE
LIVED EXPERIENCE OF GIRLS AND
WOMEN FOR PREPREGNANCY ALL THE
WAY TO ADULTHOOD.
THEN WE HAVE TO PUT THE WOMEN IN
CONTEXT, WHAT ARE THE LIVES THAT
THEY LEAD AND WHERE DO THEY LIVE
THAT MAKE A DIFFERENCE IN TERMS
OF THEIR HEALTH OUTCOMES.
IF YOU LOOK ON THE FAR LEFT,
THERE'S INTERACTION EVENT THAT
INTERACTION EFFECTS WEHAVE TO P.
WE HAVE TO PAY ATTENTION TO
INTERACTION OF SEX, THE MODIFY
IRESMODIFIERS ARE BECAUSE OF THE
SOCIAL DETERMINANTS OF HEALTH
THAT WE ARE TALKING ABOUT.
THEY ARE NOT MOVING.
I AM CLICKING AND IT NOT MOVING.
YOU'VE MISSED ALL MY COOL
SLIDES.
OKAY, HERE WE GO.
I'LL GIVE YOU A FLASH.
IT'S STILL NOT WORKING.
WELL, I AM SO SORRY.
HOLD ON.
OKAY, HERE'S MY FIRST SLIDE.
I'M TRYING TO KEEP YOUR
ATTENTION.
IMAGINE THAT WORLD!
OH, NOW IT'S GOING REALLY FAST.
IT'S SKIPPING OVER EVERYTHING.
THERE'S THE BUSY SLIDE I WAS
TELLING YOU ABOUT.
MAGNITUDE AND FREQUENCY.
THIS IS THE DATA THAT SHOWS THAT
WE NEED TO DO SOMETHING, AND WE
NEED TO DO IT NOW, AND WE NEED
TO REALLY FIGURE OUT WHAT IS
GOING ON AROUND WOMEN'S HEALTH
AND WOMEN'S HEALTH RESEARCH.
OKAY.
I'M CATCHING UP.
SO THIS IS WHAT I WAS TALKING
ABOUT ON THE FAR LEFT, TALKING
ABOUT EPIGENOMIC MODIFIERS.
WHY I BRING THIS UP, WE'VE
TALKED A LOT ABOUT GENE
ENVIRONMENT INTERACTION BUT WHAT
WE'RE LEARNING ABOUT THE GENOME,
IT'S THE SOCIAL DETERMINANTS OF
HEALTH THAT DETERMINE WHEN THE
GENES GET TURNED ON AND OFF AND
IT'S ALSO THOSE SOCIAL
DETERMINANTS OF HEALTH THAT ARE
LIKE THE VOLUME OF HOW MUCH
INFLUENCE THEY HAVE ON THE
OUTCOME.
THAT'S WHY THEY'RE SO IMPORTANT.
SO I JUST WANTED TO GIVE YOU A
PLUG FOR THE OFFICE OF RESEARCH
ON WOMEN'S HEALTH, AND OUR
MISSION IS REALLY TO FOCUS ON
WOMEN'S HEALTH RESEARCH BY
INCLUDING WOMEN AND MINORITY
GROUPS IN CLINICAL RESEARCH, AS
WELL AS PROMOTING THE CAREER
DEVELOPMENT FOR WOMEN IN
BIOMEDICAL CAREERS THROUGHOUT
THEIR CAREERS, NOT ONLY AT THE
BEGINNING.
I JUST WANTED TO REMIND ALL OF
US THAT OUR WORK IS REALLY IN
LINE WITH THE NIH VISION AND
MISSION STATEMENT AND THAT
ACTUALLY HIGHLIGHTS THAT SEX AND
GENDER SHOULD BE INTEGRATED INTO
BIOMEDICAL RESEARCH.
EVERYONE AND EVERY WOMAN SHOULD
RECEIVE EVIDENCE-BASED CARE, AND
THAT WOMEN IN SCIENCE CAREERS
REACH THEIR FULL POTENTIAL, NOT
JUST WHAT THE SYSTEM SAYS THEY
SHOULD BE.
OKAY.
SO WHAT WE'RE TALKING ABOUT IS
INCORPORATING SEX AND GENDER
ACROSS THE RESEARCH CONTINUUM TO
ADVANCE SCIENTIFIC RIGOR,
DISCOVERY, AND EQUITY.
AND IT WAS NICE TO HEAR
DR. AKLIN TALKING ABOUT EQUITY
BECAUSE IT'S ALSO A SHARED
FOUNDATION WE HAVE AT THE OFFICE
OF RESEARCH ON WOMEN'S HEALTH.
BUT LET ME TALK A LITTLE BIT
ABOUT THE SEX AS A BIOLOGICAL
VARIABLE POLICY.
THIS HAS BEEN A POLICY THAT'S
BEEN IN PLACE SINCE 2016, AND
HOW DID WE GET THERE TO BEGIN
WITH?
WHY WAS IT NECESSARY?
AND WHAT WE FOUND OUT, THAT A
LOT OF THE RESEARCH, WHETHER
THEY WERE MALE ANIMALS, CELLS OR
PEOPLE, WEREN'T PAYING ATTENTION
TO SEX EFFECTS.
THEY LACKED TRANSPARENCY IN
TERMS OF THE ANALYSIS AND DATA
THEY WERE PRESENTING, AND THEY
WERE INCONSISTENT IN THE
REPORTING IN THEIR MA MANUSCRIP.
SO WHAT IS THE RESULT OF THAT
FOR WOMEN'S HEALTH?
IT MEANS THERE'S INCOMPLETE
KNOWLEDGE ABOUT US AND WHO WE
ARE AND OUR HEALTH STATUS.
IT MEANS THAT WE ARE AT RISK
FORKER FORERRONEOUS CONCLUSIONS.
IT MEANS THE RESEARCH IS EAR
REPRODUCIBLE AND DOESN'T HAVE
THE RIGOR, AND IMPORTANTLY, IT
REALLY PUTS AT RISK PUBLIC
TRUST.
SO SABV IS -- I LIVE IN A WORLD
OF ACRONYM, SO WE'RE GOING TO
ACCULTURATE THAT TO YOU AS WELL.
SABV IS SEX AS A BIOLOGICAL
VARIABLE.
WHAT WE'RE TALKING ABOUT HERE IS
OUR WAY OF UNDERSTANDING TO
REALLY CLOSE THOSE GAPS.
WE WANT TO IMPROVE THE DESIGN OF
ETHICAL RESEARCH AND TRAITS.
IT'S IMPORTANT THAT WE INFORM --
HAVE SEX-INFORMED AND
GENDER-AWARE DIAGNOSES AND
TREATMENT AND IT TRULY ENABLES
INDIVIDUALIZED APPROACHES FOR
WOMEN AND MEN IN THEIR
HEALTHCARE.
BECAUSE WHAT WE'RE DOING, IT
FOSTERS A TRUE SYSTEM-BASED
UNDERSTANDING THAT DR. AKLIN
ALSO TALKED ABOUT FOR SEX AND
GENDER INFLUENCES IN HEALTH.
SO LET ME GIVE YOU AN EXAMPLE.
THE DIFFERENCE IF WE HAVING A
GATED RESULTS OR NOT.
IT'S REALLY NOT DOING IT AGAIN.
OKAY.
IT'S NOT LIKING ME TODAY.
I REALLY WANT TO SHOW YOU THE
NEXT SLIDE.
OKAY.
SO THIS IS REALLY SHOWING ON THE
LEFT, IF WE WERE JUST REPORTING
AGGREGATED RESULTS BASED ON
CONTROL OR TREATMENT, HOW THE
TREATMENT WORKS.
IF YOU LOOK ON THE RIGHT, YOU'LL
FIND THERE'S A SEX DIFFERENCE,
THAT FOR MALES WHEN IT WORKS, IT
REDUCES OBSTRUCTION OF BLOOD
SUPPLY.
BUT FOR FEMALES, IT ACTUALLY
ACCENTUATES IT AND DECREASES IT.
SO THIS IS WHY SEX MATTERS.
AND WHY DOES IT MATTER FOR YOU?
BECAUSE FOR PAIN, THERE ARE
BIOLOGICAL AND SOCIAL FACTORS
FOR SEX AND GENDER DIFFERENCES,
BECAUSE WHAT WE KNOW IS THAT
FEMALES EXPERIENCE MORE CHRONIC
PAIN, THEY RESPOND DIFFERENTLY
TO PAIN AS YOU HEARD EARLIER.
NOT ONLY IN TERMS OF REACTIONS
TO MEDICATION, BUT ALSO THEIR
SELF-ASSESSMENT OF THE MAGNITUDE
OF PAIN.
PART OF IT'S BIOLOGY.
IN GENERAL, FEMALES HAVE SMALLER
BODY MASS WITH HIGHER
FAT-TO-WATER RATIOS THAT MAKE A
DIFFERENCE.
AND WHAT YOU HEARD EARLIER IS
THAT THEY'RE MORE LIKELY TO BE
PRESCRIBED OPIOIDS AT HIGHER
DOSES THAN OTHER -- AND LONGER
COMPARED TO MEN.
SO I CAN TELL YOU WHAT I AM
SEEING ON MY SCREEN IS NOT WHAT
YOU'RE SEEING ON THE SCREEN.
NEXT SLIDE.
HOOKAY, HERE WE GO.
SO THIS IS REALLY EMPHASIZING
THAT WE REALLY NEED TO PAY
ATTENTION TO THE BIOLOGICAL AND
SOCIAL FACTORS IN YOUR WORK IN
PAIN, AND BECAUSE THERE ARE
FACTORS FOR SEX AND GENDER
DIFFERENCES.
I'M JUST GOING TO SKIP THIS, BUT
IT'S REALLY MAKING THE POINT
THAT WE NEED TO PAY ATTENTION TO
THESE DIFFERENCES BECAUSE THERE
ARE PSYCHOLOGICAL AND EMOTIONAL
CONSEQUENCES PAID BY IGNORES
THESE ISSUES.
NOW IT'S MOVING ON ITS OWN.
I'M ACTUALLY -- IT'S NOT WORKING
WELL SO I'M JUST GOING TO JUST
CONTINUE WITHOUT THE SLIDES.
WHAT I DO WANT TO SORT OF END
WITH IS THERE IS SOME EXCITING
WORK ON FOOT.
AND WHAT THAT EXCITING WORK IS,
THAT THERE IS A WHITE HOUSE
INITIATIVE ON WOMEN'S HEALTH
RESEARCH.
AND THE EXECUTIVE ORDER WAS
SIGNED IN THE MIDDLE OF MARCH.
AND WHAT IT'S DOING IS REALLY
MOBILIZING THE FEDERAL
GOVERNMENT INTO FOUR MAIN
POINTS, INTEGRATING WOMEN'S
HEALTH AND HEALTH RESEARCH
ACROSS THE ENTIRE FEDERAL
GOVERNMENT, NOT ONLY THE
NATIONAL INSTITUTES OF HEALTH.
IT IS REALLY PRIORITIZING
INVESTMENTS IN WOMEN'S HEALTH
RESEARCH, WHICH ACTUALLY IS ALL
OF YOU.
AND IN A REALLY EXCITING WAY,
IT'S GALVANIZING NEW RESEARCH IN
WOMEN'S MID LIFE HEALTH.
SO PEOPLE ASK ME WHY MID LIFE
OUT OF ALL OF THE PARTS OF THE
LIFESPAN?
BECAUSE WHAT WE KNOW ABOUT
WOMEN'S MID LIFE, IT'S AN
INFLECTION POINT WHERE WOMEN --
THAT'S WHERE A LOT OF THE
CHRONIC DISEASES START TO POP UP
IN OUR LIVES.
NOT ONLY DO THEY POP UP, IT'S
USUALLY MORE THAN ONE.
SO OUR HEL CARE A OUR HEALTHCARH
STATUS BECOMES A LOT MORE
COMPLICATED AND WE NEED TO
UNDERSTAND THAT BETTER.
ONE OF THE WAYS WE NEED TO DO
THAT, WE NEED TO FIGURE OUT
WHAT'S GOING ORANGES WE NEED TO
ON, WE NEED TOFIGURE OUT THE GAE
PREPARED FOR THE NEXT STAGE,
THAT NEXT GENERATION RESEARCH OF
WOMEN'S HEALTH RESEARCH BUT WE
ALSO HAVE A RESPONSIBILITY FOR
THE NEXT GENERATION OF
PRACTITIONERS AS WELL.
SO THERE'S AN INVESTMENT OF
CAREER DEVELOPMENT.
I'M SORRY YOU CAN'T SEE MY
SLIDES, THEY LOOKED REALLY QUITE
PRETTY FROM MY END HERE, BUT I
THINK THEY'LL BE ACCESSIBLE FOR
YOU, BUT I JUST WANTED TO AT
LEAST GIVE SOME TIME SPACE SO
YOU CAN ACTUALLY HEAR THIS
KEYNOTE SPEAKER BECAUSE I THINK
SHE PROBABLY HAS REALLY MUCH
MORE INTERESTING THINGS TO SAY
THAN I DO.
SO THANK YOU SO MUCH FOR YOUR
TIME.
[APPLAUSE]
>> THANK YOU, VIVIAN.
YOU DID A GREAT JOB DESPITE THE
TECHNICAL DIFFICULTIES.
AND NOW WE'RE GOING TO TURN TO
OUR KEYNOTE SPEAKER, IT'S MY
PLEASURE TO INTRODUCE MARJORIE
JENKINS, WHO IS THE M.D., THE
DEAN OF THE UNIVERSITY OF THE
SOUTH DAKOTA MEDICAL SCHOOL.
SHE'S GOING TO TALK ON PAIN,
SCIENCE, SEX AND STEREOTYPES.
I'M REALLY LOOKING FORWARD TO
HEARING THIS.
ALL YOURS.
>> WELL, GOOD MORNING.
I'M A LITTLE NERVOUS BECAUSE I
HAVE BAD TECH KARMA ANYWAY.
SO IT MAY JUST BE ME CHATTING
WITH YOU HERE.
WE'RE JUST GOING TO SEE.
OH, YES, YOU DON'T SEE.
I DON'T SEE WHAT YOU SEE.
LET ME SEE WHAT WE CAN DO HERE.
MAYBE A LITTLE TUTORIAL MIGHT
HELP ME.
HERE WE GO.
OKAY.
HERE WE DID.
GO.
YES.
ALL RIGHT.
IT COULD WORK.
OKAY.
SO THANK YOU FOR THE
INTRODUCTION.
AND YOU HAVE MY BIO OR YOU CAN
GOOGLE ME, DON'T BELIEVE
EVERYTHING YOU READ ON GOOGLE,
PLEASE.
I'M AN M.D.
I HAVE A MASTER'S IN EDUCATION
FOR HEALTH PROFESSIONS, AND I'VE
WORKED IN THE SEX AND GENDER
FIELD FOR OVER 20 YEARS.
I HAVE KNOWN JANINE CLAYTON AND
THE OFFICE OF RESEARCH ON
WOMEN'S HEALTH AND ALL OF THEIR
AMAZING WORK, IN ADDITION TO THE
SABV POLICY, WHICH WAS -- FOR
THOSE OF US IN THE SEX AND
GENDER WORLD, LIKE FOR ME, IT
WAS LIKE MY BIRTHDAY.
WHEN I SAW THAT POLICY WAS BEING
LAUNCHED.
I'M AN INTERNAL MEDICINE
PHYSICIAN, SO WHEN I WOULD
INTRODUCE MYSELF AS A WOMEN'S
HEALTH PHYSICIAN IN 2001 TO 2,
PEOPLE WOULD ASK ME TO DELIVER
THEIR BABY, OR TAKE OUT THEIR
UTERUS.
SO INTERNS DON'T DO THAT.
DO WE HAVE CLINICIANS IN HERE,
ANY CLINICIANS?
YOU DON'T WANT AN INTERNIST
DOING THAT, UNLESS IT'S ON THE
SIDE OF THE ROAD AND THAT BABY
IS COMING.
SO I'M SORT OF A TEE-OFF FOR YOU
FOR THE CONFERENCE, AND I JUST
WANT TO THANK THE OFFICE OF
WOMEN'S HEALTH, THE PLANNING
COMMITTEE, IT'S SUCH AN HONOR TO
BE BACK HERE.
MY HUSBAND AND I MOVED BACK TO
SILVER SPRING, IT'S REALLY
AWESOME TO BE BACK IN YOUR
SPACE.
SO I HAVE JUST PUT A WORD CLOUD
TOGETHER OF ALL OF THE AMAZING
THINGS WE'RE GOING TO TALK ABOUT
TODAY.
I THINK THE PLANNERS HAVE PUT
TOGETHER A REALLY UNIQUE AND
DIVERSE AGENDA FOR YOU.
YOU'RE GOING TO HEAR FROM
SPEAKERS WHO ARE TOP IN THEIR
FIELD.
AND I THINK IT'S GOING TO BE
REALLY EXCITING AND INTERESTING,
AND I'M LOOKING FORWARD TO
HEARING ABOUT IT.
SO ONE THING WHEN I DO THE --
WHEN I LISTEN TO SPEAKERS AT
CONFERENCES, YOU READ THEIR
BIOBUT YOU REALLY DON'T KNOW
WHERE THEY'RE FROM.
SO I THOUGHT I WOULD TELL YOU
JUST A LITTLE BIT ABOUT WHERE
I'M FROM, BECAUSE I'M GOING TO
CLOSE THIS LOOP AT THE END OF MY
TALK.
I GREW UP HERE.
THIS IS ME AT MY 5-YEAR
GRADUATION CAP AND GOWN.
VERY PRECOCIOUS CHILD.
I'M THE YOUNGEST OF 8 CHILDREN
IN APPALACHIA.
MY MOM MARRIED AT 15.
SHE HAD 8 CHILDREN BY 28, SHE
WAS WIDOWED AT 34 WITH NO HIGH
SCHOOL DIPLOMA.
THIS IS MY JOURNEY.
I WAS TOLD I COULDN'T BE AN
M.D., SO I BECAME A CHEMICAL
ENGINEER.
I'M A CONTROL SYSTEMS ENGINEER
RECOVERING AND WORKED AT KODAK.
I THEN COULD NOT NOT GO TO
MEDICAL SCHOOL, SO I WENT TO
EAST TENNESSEE STATE.
I TRAINED AT UNIVERSITY OF
CINCINNATI IN INTERNAL MEDICINE,
I WENT INTO PRIVATE PRACTICE BUT
I LONGED TO BE IN ACADEMIC
MEDICINE.
BUT MY HUSBAND TOLD ME I NEEDED
TO PAY OFF MY SCHOOL LOANS SO I
HAD TO GET A JOB QUICKLY.
BUT EVENTUALLY MADE TO TEXAS TO
ACADEMIC MEDICINE IN 2001.
AND IN MY PRACTICE, I REALIZED
THAT IN MY 75% WOMEN, 25% MEN
PATIENTS, WOMEN COMMUNICATED
WITH ME DIFFERENTLY.
WOMEN WERE ALSO PARSED OUT TO
DIFFERENT PHYSICIANS.
THEY HAD THEIR PRIMARY CARE, WHO
MIGHT BE FAMILY MEDICINE OR
INTERNAL MEDICINE, AND THEN THEY
WERE SENT TO OB-GYN FOR THEIR
MENOPAUSE MANAGEMENT, HORMONAL
THERAPIES, ET CETERA.
THAT BOTHERED ME, AND THAT AS A
WOMAN, I WANTED TO HAVE WHOLE
CARE IN ONE PLACE WITH ONE
PHYSICIAN BUILDING TRUST IN THAT
SPACE.
SO I QUICKLY LEARNED, STARTED
TALKING ABOUT SEX AND GENDER,
AND LEARNED THAT MARYANN LEGADO
HAD WRITTEN A NINE-HUNDRED PAGE
TOME CALLED GENDER-SPECIFIC
MEDICINE.
IT CAME OUT IN 2003, 2004.
SOMEONE SEPTEMBER SENT ME A CO.
IT WAS THIS BIG.
I SAT IT BY MY BED AND I READ IT
FOR A YEAR AND I WAS LIKE, THIS
IS IT FOR ME.
LIKE, THIS IS THE BEST KEPT
SECRET OF MEDICINE.
IF PEOPLE KNOW THIS, HOW CAN
THEY NOT ACCEPT IT AND ACTUALLY,
THIS IS NOT GOING TO TAKE THAT
LONG TO GET INTO RESEARCH AND
MEDICINE BECAUSE ONCE THEY HEAR
ABOUT IT, IT'S A GIVEN.
THEN IN 2007, I WAS GIVEN THE
OPPORTUNITY TO FOUND IS THE
LAURA BUSH INSTITUTE FOR WOMEN'S
HEALTH AND BECAUSE OF MY
INTERESTS, IT IS FOUNDED ON SEX
AND GENDER DIFFERENCES.
THIS IS WHEN MRS. BUSH WAS IN
THE WHITE HOUSE, AND I WAS THE
FOUNDING EXECUTIVE DIRECTOR OF
THAT AND MY CAREER TOOK QUITE A
DIFFERENT TURN THEN INTO
BUILDING THAT INSTITUTE.
AND AFTER 15 YEARS AT TEXAS
TECH, I HAD AN ENCOUNTER WITH
THE FDA ON A VISIT AND WAS
INVITED TO COME TO WORK IN THE
OFFICE OF WOMEN'S HEALTH IN THE
OFFICE OF THE COMMISSIONER
BECAUSE ALTHOUGH THEY HAD
WOMEN'S HEALTH EXPERTISE, THEY
DID NOT HAVE SEX AND GENDER
EXPERTISE YET IN THAT SPACE.
SO I WAS INVITED FOR A YEAR AND
THEN EVERY SIX MONTHS OR SO, I
WAS INVITED TO STAY ANOTHER
YEAR.
MY INSTITUTION WAS ASKED COULD
THEY BORROW ME, SO I STAYED FOUR
YEARS, AND IT WAS REMARKABLE.
IT WAS A REALLY AMAZING THING TO
LEARN ABOUT REGULATORY SCIENCE
DRUG AND DEVICE APPROVALS.
SO AFTER THE FDA GOING BACK TO
ACADEMIC MEDICINE, I THEN HAD
NOT ON MY BUCKET LIST TO BECOME
THE DEAN OF A MEDICAL SCHOOL AND
THE CHIEF ACADEMIC OFFICER FOR A
$6 MILLION HEALTHCARE SYSTEM,
BUT THAT'S WHERE MY JOURNEY TOOK
ME, THAT'S WHERE MY FAITH TAKES
ME, SO I PLANTED THERE FOR FIVE
YEARS.
I COULD NOT NOT BE ASSOCIATED
WITH SEX AND GENDER MEDICINE.
IT IS IN MY -- IT IS LITERALLY
IN MY DNA.
I AM A PASSIONATE PHYSICIAN AND
SCIENTIST AND EDUCATOR ABOUT
THIS ISSUE.
AND I WILL SHARE WITH YOU THAT
I'VE BEEN TALKING ABOUT THESE
TWO TERMS FOR OVER 20 YEARS.
SEX AS A BIOLOGICAL VARIABLE,
MAJORITY NON-BINARY BUT NOT
TOTALLY.
AND GENDER AS A SOCIAL
CONSTRUCT.
AND WHEN I TALK TO MY SCIENTIST
COLLEAGUES AND RESEARCH
COLLEAGUES AND EVEN CLINICIAN
COLLEAGUES, WHEN I GOT TO THE
SEX DIFFERENCES PIECE OF THEIR
DISEASE PROCESS, WHETHER THEY
WERE A PULMONOLOGIST, A
CARDIOLOGIST, A RHEUMATOLOGIST,
IT WAS ACTUALLY -- THEY GOT IT.
I COULD SHOW THEM DATA AND
RESEARCH, BUT WHEN I STARTED
TALKING ABOUT THE GENDER SOCIAL
CONSTRUCT, THEY GLAZED OVER.
YOU CANNOT -- THESE ARE
INEXORABLY LINKED.
SO GENDER IS A SPECTRUM AND A
SOCIAL CONSTRUCT AND MUCH MORE
COMPLEX.
AND IN FACT, THEY ARE FREQUENTLY
INTERCHANGED, LESS SO NOW IN
2024, BUT STILL SO, AND I --
YES, IT IS AHEAD OF ME BUT
THAT'S OKAY.
I'M JUST GOING TO LEARN HOW TO
DO THIS BETTER.
SO WE STILL USE THESE
INTERCHANGEABLY WHICH MAKES IT
VERY DIFFICULT TO SEARCH IN THE
LITERATURE.
LIVING MY LIFE ALL OVER AGAIN.
NEXT SLIDE.
SO IN THAT SLIDE WITH THE BARS,
WHAT YOU SAW WAS IN A BASIC
SCIENCE JOURNAL OF PHYSIOLOGY,
WHICH REALLY DOESN'T DO A LOT OF
HUMAN TRIALS THAT SOMEWHERE IN
THE 80s AND 90s, WE DECIDED
THAT THAT SEX AND GENDER WERE
EQUAL.
AND WHEN WE DID THAT, WHY DO YOU
THINK THAT HAPPENED IN THE LATE
80s AND EARLY 90s?
CAN ANYONE TELL ME A SOCIAL
NATIONAL GLOBAL EMERGING ISSUE
THAT CAME UP THAT MIGHT MAKE US,
IN SCIENCE, NOT WANT TO USE THE
TERM "SEX"?
>> [INAUDIBLE]
>> GOOD THOUGHT.
AIDS.
EXACTLY.
SO SCIENTISTS VEERED AWAY FROM
THAT, THAT WORD, AND THEY BEGAN
USING GENDER IN RELATION TO
MOLECULAR LEVEL STUDIES, ANIMAL
STUDIES.
WHICH IS ABSOLUTELY NOT
GENDERED.
THOSE ARE SEX VARIABLES.
PLEASE GO BACK.
YOU'RE ONE AHEAD OF ME.
SO, I'VE LEARNED AFTER 20-PLUS
YEARS THAT SEX AND GENDER TERMS
ARE CONCEPTUALLY IMPRECISE.
AS A SCIENTIST, THAT HURTS MY
HEART.
WE LIKE PRECISION SOMETIMES TO
THE .0001.
WE DON'T LIKE OUR DATA TO BE
SCATTERED, WE LIKE TO BE
CONSISTENT, WE WANT OUR RESEARCH
TO BE REPRODUCIBLE.
SO SEX AS A BIOLOGICAL VARIABLE,
THAT IS PRETTY STRAIGHTFORWARD
AS I SAID, BUT GENDER DOES NOT
HAVE A OW UNIVERSAL DEFINITION,D
LET ME TELL YOU WHY THIS
DEFINITION HERE IS NOT A
DEFINITION, BECAUSE IT JUST SAYS
"GENDER REFERS TO" -- X, Y, Z.
THAT IS A DESCRIPTOR, NOT A
DEFINITION.
THAT MAKES IT EVEN HARDER FOR US
TO APPLY THIS TO OUR CLINICAL
CARE.
SO IN 2013, 2014, I WAS
SEARCHING THE LITERATURE TRYING
TO IMPLEMENT SEX AND GENDER INTO
A CURRICULUM, AND WHAT I FOUND
WAS THERE WAS NO SEARCH TOOL IN
PUBMED, SO WE CREATED AND
VALIDATED ONE, AND YOU CAN HAVE
ACCESS TO THIS.
WHEN I FIRST RAN THE FIRST
VALIDATION, THERE WERE ABOUT
43,000 ARTICLES THAT MENTION SEX
AND GENDER IN DIFFERENT SPACES.
I JUST RAN THIS LAST WEEK AND
THERE ARE 120,000 NOW.
SO FROM 2015 TO CURRENTLY.
BUT WHAT ARE WE NOT FINDING?
WE'RE FINDING THAT PEOPLE ARE
ACTUALLY ALTHOUGH PEOPLE ARE
WRITING ABOUT SEX AND GENDER IN
THE MAINSTREAM PUBLICATIONS,
LIKE THE NEW ENGLAND JOURNAL,
WE'RE NOT SEEING THAT.
WE'RE NOT SEEING RESULTS
REPORTED BY SEX OR GENDER.
WE'RE SEEING DESCRIPTORS OF THE
PARTICIPANTS, AND THEN IT JUST
ENDS FROM THERE.
SO YOU CAN SEE WHO ARE FOLLOWING
THE SAG EVIDENT R GUIDELINES,
JAMA, BMJ, AND THEN ALL OF THESE
HIGH IMPACT JOURNALS THAT ARE
REALLY NOT PAYING ATTENTION IN
THEIR EDITORIAL GUIDELINES TO
WHERE WE NEED TO GO.
SO YOUR RESEARCH GETTING
PUBLISHED IN A JOURNAL THAT
DOESN'T REQUIRE THEIR EDITORIAL
REVIEW BOARD TO ACTUALLY LOOK AT
SEX AND GENDER, AND IF YOU HAVE
NOT DISAGGREGATED YOUR DATA AND
ANALYZED IT, IT WASN'T POWERED,
YOU AT LEAST MENTION WHY.
SO THIS JUST TOTAL VACUUM CAUSES
A VACUUM IN THE LITERATURE,
WHICH IS WHERE WE AS CLINICIANS
GET OUR EVIDENCE TO CRAFT THIS
EVIDENCE-BASED MEDICINE.
SO THEN I STARTED LOOKING AT THE
STUDY OF PAIN.
I AM ONE OF THOSE PHYSICIANS, AS
I MOVED IN TO CONSULTATIVE
MEDICINE, I AM ONE OF THOSE
PHYSICIANS THAT WELCOMED TAKING
PATIENTS WITH CHRONIC PELVIC
PAIN, FIBROMYALGIA, ALL THE
SYNDROMES, BECAUSE WHEN
SOMETHING HAS A SYNDROME, YOU
CAN ALMOST BET THAT 8 OUT OF THE
10 PATIENTS ARE WOMEN.
AND I LOOKED UP THE DEFINITION
OF PAIN AND I THINK I LEFT MY
WATER.
IN 1964, YOU CAN READ THAT
DEFINITION.
THEN I LOOKED AT THE IASP
DEFINITION FROM 1979.
AND THEN I READ THE ENTIRE
DOCUMENT AROUND THE REVISION OF
THE 2020 DEFINITION.
AND THE 2020 DEFINITION ACTUALLY
DID ADD EIGHT BULLETS AFTER IT.
AND SO I JUST WANT TO SHARE WITH
YOU, AND I DON'T MEAN THIS TO BE
PERSECUTORIAL AT ALL, IF YOU
NEED EIGHT BULLETS AFTER IT,
IT'S NOT REALLY A GREAT
DEFINITION FOR US TO READ AND
APPLY.
ALSO THIS REMINDED ME OF THE
CARTOONS OF "FIND THE DIFFERENCE
BETWEEN THE TWO."
BECAUSE I HAD TO REALLY FIND THE
DIFFERENCE IN THE WORDS.
AND CAN YOU FIND THE DIFFERENCE
IN THE WORDS?
THERE'S LIKE THREE.
ALL RIGHT.
SO PAIN IS CHALLENGING TO STUDY.
I THINK WE CAN ALL APPRECIATE
THAT.
AND IT IS A HERCULEAN EFFORT TO
DEFINE IT.
AND MANY, MANY BRILLIANT PEOPLE
CAME UP WITH THIS DOCUMENT THAT
I READ AND PUT A LOT OF WORK
INTO IT, BUT IT JUST -- IT'S
JUST -- IT'S A LITTLE AMBIGUOUS.
LET'S GO TO THE NEXT.
SO I WANT TO POINT OUT TO YOU AS
WE TALK ABOUT HEALTH EQUITY,
FIRST AND FOREMOST, I DON'T
THINK WE WILL EVER GET TO
PRECISION CARE IF WE FORGET TWO
BASIC HUMAN VARIABLES WE HAVE
WITHOUT FAIL.
I TELL MY STUDENTS, MY TRAINEES
AND MY COLLEAGUES, YOU CANNOT DO
PERSONALIZED MEDICINE IF YOU
FORGET GENDER AND SEX.
BECAUSE ALL OF YOUR PATIENTS ARE
GOING TO HAVE THOSE TWO
VARIABLES.
THEY ARE FOUNDATIONAL HUMAN
VARIABLES THAT FOR THOUSANDS OF
YEARS SCIENCE JUST SKIPPED RIGHT
OVER.
SO HERE ARE THE WORDS THAT I
PULLED OUT OF SOME PAIN
LITERATURE.
MOSTLY RELATED TO WOMEN
SUBJECTS.
AND LOOK AT THE WORDS THAT
REALLY HIT HOME FOR ME.
SENSITIVITY.
PAIN AWARENESS.
PERCEPTION.
CONCEPTUALIZING PAIN.
EXPERIENCING PAIN.
CHARACTERIZING PAIN, REPORTING
PAIN.
WOMEN DO REPORT ADVERSE EVENTS,
ET CETERA, AND THEIR PAIN.
WE ENGAGE WITH THE HEALTHCARE
SYSTEM MORE OFTEN.
LET'S GO TO THE NEXT SLIDE.
SO HERE, YOU MAY BE ABLE TO READ
THIS, BUT DO YOU SEE THE WORD
VULNERABLE AND PSYCHOSOCIAL
STRESS IN HERE?
AND IT'S RELATED TO WOMEN WHEN
IT'S DESCRIBING WOMEN IN THIS
ABSTRACT.
WE'RE USING THESE TERMS.
IT REMINDS ME OF WHEN WOMEN WERE
PROTECTED SUBJECTS IN RESEARCH.
WHICH ENDED UP FOR DECADES
PROTECTING WOMEN FROM RESEARCH
INSTEAD OF WITH RESEARCH.
NEXT.
SO I -- YOU KNOW, I EAT THIS
STUFF FOR BREAKFAST.
SO I JUST DID A GOOGLE SEARCH OF
CHEST PAIN, LIKE PICTURES OF
PATIENTS WITH CHEST PAIN.
SO HOW MANY MEN DO YOU SEE IN
HERE?
THIS IS JUST A SCREENSHOT FROM
MY LAPTOP.
LIKE 12 OR SO.
THEN I GOGGLED "PATIENTS WITH
HEAD PAIN."
NEXT.
IT IS INSIDIOUS.
WE SAY IMPLICIT BECAUSE IT'S
KIND.
BUT AT 2024, WE PROBABLY NEED TO
USE EXACTLY WHAT IT IS.
WE ARE BIASING THE ENTIRE
POPULATION AROUND WHAT WOMEN
HAVE AND WHAT MEN HAVE, AND HOW
THEY EXPERIENCE PAIN.
NOT ONLY THAT, THERE ARE RARELY
ANY HEALTHCARE PROVIDERS IN
THESE PICTURES AS OPPOSED TO THE
PREVIOUS ONES, RALLYING AROUND
MEN IN THE E.R.
SO NOW LET'S TALK ABOUT
STEREOTYPE.
YOU KNOW, STEREOTYPE IS A BRIEF
DESCRIPTOR, STRAIGHTFORWARD,
USUALLY NOT APPLICABLE -- DOES
ANYONE HAVE A POSITIVE FEELING
ABOUT THE WORD STEREOTYPE?
NO.
BECAUSE IT HIDES -- EVERYTHING
ELSE HIDES BEHIND IT.
OH, THAT'S JUST STEREOTYPICAL.
BUT ALL OF THESE OTHER WORDS
COME INTO PLAY.
I'M GOING TO MOVE INTO
BIOLOGICAL PLAUSIBILITY.
THE EQUITY, THE HEALTH EQUITY,
THE SEX AND GENDER NEED, THE
IMPLICIT, IF YOU WANT TO CALL
THAT, BIAS THAT WE SEE IN OUR
EVERYDAY WORLD, AND I SEE IN
LEARNING MATERIALS WHEN WE TEACH
FUTURE DOCTORS.
BUT BIOLOGICAL PLAUSIBILITY IS
ACTUALLY A CONCEPT THAT I HOPE,
IF YOU HAVEN'T THOUGHT ABOUT IT,
THAT YOU WILL THINK ABOUT IT AS
I GO THROUGH THIS EXAMPLE, AND
I'M GOING TO GO THROUGH AN
EXAMPLE THAT I UTILIZED WHEN I
WAS SPEAKING TO SOME REVIEW
GROUPS AT THE FDA, AND IT IS NOT
ABOUT PAIN.
NEXT.
I TALKED ABOUT THE RESEARCH
ENVIRONMENTS WHERE WE LIVE.
DISCOVERY RESEARCH AT NIH.
AND MANY OTHER RESEARCH, 50,
$48 BILLION WORLD RENOWNED
ENTITY.
AND THEN WE LOOK INTO INDUSTRY
AND PRODUCT DEVELOPMENT, AND
THEN WE GO INTO THE FDA FOR
PRODUCT APPROVAL AND THEN
POSTMARKET.
AND THE FDA DOES LOOK AT BASIC
SCIENCE STUDIES AND IN FACT,
SOMETIMES THAT'S ALL THEY HAVE
TO LOOK AT, ARE ANIMAL STUDIES
TO INCLUDE IN A LABEL,
ESPECIALLY AROUND PREGNANT
WOMEN.
AND THEN ACADEMICS AND HEALTH
SYSTEMS COME INTO PLAY AS WELL.
WE KNOW THAT THE RESEARCH
PIPELINE IS LINED WITH MALES.
ALTHOUGH WOMEN ARE BECOMING MORE
AND MORE THE MAJORITY IN
CLINICAL TRIALS.
BUT IF YOU DON'T DISAGGREGATE
THE DATA, AND YOU JUST CLUMP IT
ALL TOGETHER, WHAT DOES THAT DO?
IT DILUTES DIFFERENCES.
AND YET WOMEN ARE MORE LIKELY TO
ENGAGE IN THE HEALTHCARE SYSTEM
AND THE WORLD HEALTH
ORGANIZATION SAYS THAT WE ARE
80% OF GLOBAL HEALTHCARE
CONSUMERS.
SO THIS IS SEX BIAS IN
INFECTIOUS DISEASES,
INFLAMMATORY DISEASES AND
CANCERS.
VERY QUICKLY, THE NEXT EXAMPLE
GOING THROUGH THE CHECKPOINT
INHIBITORS.
THIS WAS THE RATIONALE FOR THIS
STUDY, BECAUSE SEX HORMONES
REGULATE THE EXPRESSION AND
FUNCTION OF PD-1 AND PD-.
L1, MEDIATING AUTO IMMUNITY.
WHO IS MORE LIKELY TO HAVE
AUTOIMMUNE DISEASES?
TO THE TUNE OF 7, RIGHT?
7 OUT OF 10 AUTOIMMUNE DISEASES.
NEXT.
HERE WE LOOKED AT INCREASED
ADVERSE EVENTS AND MORTALITY IN
RANDOMIZED CONTROLLED TRIALS IN
CHECKPOINT INHIBITOR, AND IN
FACT SOME OF THEM EVEN CROSS
OVER TO NOT BEING -- THE
INTERVENTION NOT BEING BETTER
FOR WOMEN.
NEXT.
AND THEN HERE'S SOME OTHER
BIOLOGICAL PLAUSIBILITY ABOUT
WHY WE WOULD BE THINKING ABOUT
THIS.
FEMALE TUMORS ARE MORE RESISTANT
TO IMMUNOTHERAPIES.
INCREASED SUSCEPTIBILITY OF
WOMEN TO AUTOIMMUNE DISORDERS
COULD LEAD TO MORE CHECKPOINT
INHIBITOR-ADVERSE EVENTS.
THAT DOES HAPPEN.
GENDER DIFFERENCES.
NOW THIS IS HOW WE DRESS.
THIS IS EXPOSURE TO SUN,
BEHAVIORS LIKE SMOKING.
SMOKING BEHAVIOR, MEN MORE THAN
WOMEN, ULTRAVIOLET EXPOSURE, MEN
LESS THAN WOMEN.
SO THINK ABOUT HOW WE GO FROM
THE BENCH TO POST MARKET
CLINICAL CARE THERAPY FOR CANCER
IN A DRUG THAT INTUITIVELY WE
ARE EXPECTING TO HAVE INCREASED
INCIDENCE OF AUTOIMMUNE DISEASES
AND CANCER PATIENTS AND MAY BE
LESS RESPONSE OF THEIR TUMORS.
SO THERE'S A GREAT SUMMARY IN
THIS.
I'VE JUST HIGHLIGHTED SOME OF
THE WORDS.
PATIENTS' SEX SHOULD BE TAKEN
INTO ACCOUNT.
RESEARCHERS WHO ARE DESIGNING
NEW IMMUNOTHERAPY STUDIES -- YOU
CAN PUT PAIN THERE AS WELL,
SHOULD ENSURE A LARGER INCLUSION
OF WOMEN IN TRIALS TO AVOID
ERRONEOUSLY EXTENDING TO WOMEN'S
RESULTS THAT ARE OBTAINED MAINLY
IN MALES.
AND BECAUSE I AM OBSESSIVE ABOUT
THE WORDS WE USE AS I TOLD YOU
BEFORE, THAT SENTENCE, WOMEN
JUXTAPOSED WITH MALE ARE
DISCORDANT TERMS.
THAT IS A GENDER TERM TO A
BIOLOGICAL TERM, MALE/FEMALE OR
MEN/WOMEN.
THAT'S AN ASIDE.
NEXT.
SO THIS IS A PAIN CHALLENGE.
IT COULD BE A PAINFUL CHALLENGE.
I DON'T KNOW.
I'M GOING TO BE HERE MOST OF THE
DAY.
AND I WOULD LIKE YOU TO THINK
ABOUT A CASE FOR BU BIOLOGICAL
PLAUSIBILITY IN YOUR EXPERT
AREA.
AND IF YOU WOULD, PLEASE EMAIL
TO ME.
BECAUSE I WOULD LOVE TO SEE IT.
AND ONE OF THE PEOPLE WHO SENT
ME THIS CASE, I WILL TELL YOU
WHAT YOU WILL RECEIVE AT THE END
OF MY TALK.
SO NCAA, I'M A GAMER.
GAMIFICATION.
I LIKE IT.
I HOPE YOU WILL SHARE YOUR
EXPERTISE WITH ME BECAUSE I CAN
USE IT IN THE FUTURE AS WELL.
AND YOU'RE THE EXPERTS.
I COULD TALK ABOUT MURRAY MU RES
AND TELESCOPING, I COULD HAVE
TALKED ABOUT THAT KAI BUT I
REALLY WANTED YOU TO SEE THE
CONCEPT AND THEN TELL ME WHY
YOUR RESEARCH AT THE BENCH IS
BIOLOGICALLY PLAUSIBLE FOR WHAT
WE'RE SEEING ON THE OTHER END.
SO NOW FOR THE WRAPPING UP, GAPS
IN THE DIAGNOSIS AND TREATMENT
OF PAIN SYNDROMES IN CLINICAL
CARE.
HERE ARE PAIN SYNDROMES.
FEMALE PREVALENCE ON THE LEFT,
MALE PREVALENCE IN THE MIDDLE,
NO SEX PREVALENCE ON THE END.
SO I'VE ENLARGED THE MEN AND
WOMEN.
AND IN THIS, THERE'S AT LEAST
FIVE TO SIX SYNDROMES I TOLD YOU
ABOUT, WHICH MEANS WE DON'T HAVE
A BIOMARKER, AN ANATOMICAL
DIAGNOSIS AS A CULMINATION OF
SYMPTOMS, PHYSICAL EXAM AND
SYMPTOMATOLOGY.
SO I THOUGHT I'D GO THROUGH WITH
YOU A CONDITION A, CONDITION A
HAS PAIN.
WHICH IS OFTEN EXPERIENCED,
PATIENTS WITH CONDITION A,
INCREASED SENSITIVITY.
MUSCLE STIFFNESS, SLEEP
DISTURBANCES AND HEADACHES.
YOU KNOW YOU'RE GOING TO HAVE TO
GUESS CONDITION A, RIGHT?
I'M JUST GIVING YOU A HEADS UP.
SO 50% OF PRIMARY CARE
PHYSICIANS DO NOT APPLY THE
ACCEPTED DIAGNOSTIC CRITERIA
WITHIN PATIENT CARE FOR
CONDITION A.
STUDENTS ARE TAUGHT ABOUT THIS
CONDITION LESS THAN 40% -- LESS
THAN 40% OF NATIONAL CURRICULA.
THESE ARE THE DRUGS THAT CAN BE
USED IN CONDITION A, BUT ONLY
ONE OF THE GROUPS HAS
FDA-APPROVED MEDICATIONS,
APPROVED FOR CONDITION A.
PATIENTS WITH THIS CONDITION MAY
ENDURE MEDICAL AND PERSONAL
GASLIGHTING.
EVERYBODY KNOW WHAT GASLIGHTING
IS?
IT'S AMAZING THAT A DATING TERM
HAD TO BRING IT INTO MEDICINE.
THAT'S ALL I'M SAYING.
SO GAS LIGHTING IS WHEN SOMEONE
TRIES TO GET YOU TO KNOW THAT
WHAT YOU KNOW IS TRUE IS NOT
TRUE AND THEY REALLY TRY TO DO
MIND GAMES WITH YOU.
THIS IS ALL IN YOUR HEAD.
YOU'RE NOT -- NOTHING IS WRONG
WITH YOU.
WE DID ALL YOUR LABS AND X-RAYS.
YOU'RE NOT HAVING ANY PAIN.
OH, OKAY, THANK YOU.
VERY MUCH.
THIS IS WHAT PATIENTS HEAR.
YOU'RE FINE, YOU'RE FINE.
THIS IS WHAT THEY SAY TO
THEMSELVES.
I BASICALLY CANNOT OWN MY OWN
EXPERIENCE AND WE'RE GOING TO
TALK ABOUT LIFE EXPERIENCE
TODAY.
AND I STARTED TO FEEL LIKE THE
COMPLAINER THAT I WAS.
AND ALSO OUR FAMILY AND OUR
FRIENDS, BECAUSE WE DON'T HAVE
OBVIOUS SIGNS OF DISEASE, DON'T
UNDERSTAND AND SUPPORT US
EITHER.
I CAN'T GO OUT WITH YOU TODAY
BECAUSE I AM SO TIRED, I HAVE TO
LAY ON THE COUCH ALL DAY.
I CANNOT WALK BECAUSE MY HIPS
ARE HURTING.
OH, COME ON, TAKE SOME TYLENOL,
ADVIL.
THEN THIS IS A STUDY THAT
BASICALLY CHILDHOOD EXPERIENCES
AND LIFE EXPERIENCES WHICH
YOU'RE GOING TO HEAR ABOUT AS
WELL IMPACT PAIN CONDITIONS.
AND THE POTENTIAL YOU MAY HAVE A
PAIN CONDITION LATER IN LIFE.
WHO'S HEARD OF THE ADVERSE
CHILDHOOD EXPERIENCES, ACE?
ACE, ACE, ACE.
EVERYBODY.
WHO'S CALCULATED THEIR ACE
SCORE?
I'M AN OBSESSIVE COMPULSIVE.
I TAKE THESE TESTS.
SO MY ACE SCORE OUT OF 10 IS 8.
SO SEVERAL RESEARCH STUDIES
SUGGEST THERE MAY BE A
CORRELATION OF CONDITION A WITH
EARLY CHILDHOOD TRAUMA.
ALL RIGHT?
SO NEXT.
AND THEN JUST BECAUSE I AM --
THIS IS REALLY A LITTLE BIT OF A
SOAP BOX ISSUE FOR ME AS WOMEN
IN PREGNANCY AND LACTATION AND
HOW WE ARE NOT TAKING CARE OF
THEM WITH RESEARCH.
SO LET'S SAY SOMEONE WITH
CONDITION A IS PREGNANT.
LET'S GO TO THE NEXT SLIDE.
GO TO THE ONE BEFORE.
SO I REPRESENTED THE
COMMISSIONER ON A CONGRESSIONAL
TASK FORCE FOR A YEE, THE PRGLAC
TASK FORCE.
FOR A YEAR.
I INITIATED AN AUDIT OF 517
DRUGS THAT HAD THEIR LABELS
CHANGED FROM THE ABCD TO THE NEW
LABELING.
WHAT I WANTED TO FIND OUT WAS
HOW MUCH HUMAN DATA THERE WAS IN
THE SECTION 8 1, 2 AND 3 FOR
PREGNANCY AND LACTATION.
72% OF THOSE DRUGS HAD NO HUMAN
DATA.
SO AS A CLINICIAN, IF I'M TAKING
CARE OF A PREGNANT WOMAN OR A
WOMAN WHO'S BREASTFEEDING AND I
GO TO THAT SECTION OF THE LABEL,
WHICH BY THE WAY IS IN 3-POINT
FONT AND I'M LIKE, OKAY, AND I
READ THIS MUCH, IT STILL DOESN'T
GIVE ME WHAT I NEED TO KNOW TO
HELP COUNSEL THIS PERSON.
SO I'M GOING TO GO WITH THE END
OF THIS SECTION ON CLINICAL
CARE, THE POINT OF CARE, TO WHAT
I CALL MJ STACKING MODEL OF
DISPROPORTIONATE IMPACT.
NO, I HAVE NOT PUBLISHED THIS
AND SO DON'T REPEAT IT, AS A
PEER REVIEWED PUBLICATION MODEL.
BUT THINK ABOUT HOW WE STACK
BECAUSE WE TALK ABOUT
INTERSECTIONALITY, RIGHT?
RACE, GENDER, SOCIOECONOMIC
STATUS, DISABILITY.
SEXUAL IDENTITY.
GENDER IDENTITY.
ALL OF THAT INTERSECTS.
BUT THAT, TO ME, IS SIMPLIFIED
BECAUSE THAT MEANS IT INTERSECTS
AT A POINT.
THIS IS WHAT HAPPENS IN THE
CLINICAL SPACE.
SO THE PATIENT HAS INCREASED
ADVERSE CHILDHOOD EXPERIENCES IF
THEY'RE A WOMAN.
RESEARCH SHOWS THAT.
WE HAVE MORE.
INTERACTION WITH THE HEALTHCARE
SYSTEM.
WE INTERACT MORE BECAUSE OF OUR
REPRODUCTIVE NEEDS.
AND WE'RE MORE LIKELY TO ENGAGE
ANYWAY WITH THE SYSTEM.
WE HAVE INCREASED PREVALENCE OF
PAIN SYNDROMES.
WE HAVE DELAYS IN DIAGNOSING AND
GASLIGHTING THAT HAPPENS AROUND
PAIN.
AND WE HAVE LIMITED TREATMENT SO
WE START SELF-MEDICATING,
ALCOHOL, DRUGS.
PAIN LEADS TO DEPRESSION, THE
MAJORITY OF PEOPLE WITH CHRONIC
DAILY PAIN HAVE DEPRESSION, AND
THAT BUILDS UP TO THAT PERSON
NOT BEING ABLE TO WORK, TO
SUPPORT THEIR FAMILY, TO ENGAGE
WITH THEIR CHILDREN, TO ENGAGE
WITH THEIR LIFE.
YOU CAN STACK AN ENTIRELY
'NOTHER PICTURE OF THAT STACK
WITH THE SOCIAL DETERMINANTS OF
HEALTH THAT THAT PERSON COULD
ALSO HAVE.
WOMEN OF COLOR.
LGBTQ POPULATIONS.
TRANSGENDER PEOPLE.
AND YOU ARE GOING TO GET THIS
BROAD STACK THAT IS HEAVILY
WEIGHTED DOWN UNTIL IT WILL
LITERALLY CRUSHES THAT PATIENT.
AND THEY ARE NOT GOING TO GET
WHAT THEY NEED FROM THE HEALTH
SYSTEM OR THEIR PROVIDER.
AND THEIR LIFE IS INEXORABLY
IMPACTED.
NEXT.
SO THE PRACTICE OF MEDICINE IS
BASED ON SCIENTIFIC EVIDENCE AND
ALL OF YOUR WORK MATTERS.
YOU ARE ALL IMPORTANT TO WHAT
THAT CONTINUUM IS.
TO TREATING THAT PATIENT.
HOWEVER, RESEARCH DOES NOT SAVE
LIVES.
PLEASE DON'T THROW ANYTHING AT
ME.
NEXT.
IT CAN AND DOES SAVE LIVES WHEN
IT'S APPLIED TO PATIENT CARE.
THE VITAL STEP IN THIS PROCESS
IS EDUCATING THE PROVIDER.
WE TALK ABOUT THE VALLEY OF
DEATH IN RESEARCH.
THIS IS THE VALLEY OF DEATH IN
GIVING EVIDENCE-BASED MEDICINE
TO THE PATIENT.
MEDICAL STUDENTS WANT TO KNOW
ABOUT SEX AND GENDER
DIFFERENCES, AND YET THE
MAJORITY OF MEDICAL SCHOOLS ARE
NOT TEACHING THIS.
SPECIFICALLY IN PAIN, WE DON'T
HAVE FORMAL CURRICULA.
I STARTED AND BUILT A NATIONAL
INITIATIVE WITH COLLEAGUES
AROUND SEX AND GENDER IN
MEDICINE, NURSING AND PHARMACY
IN ALLIED HEALTH SCHOOLS, AND
BUILT AND STARTED A REPOSITORY
AT THE LAURA BUSH INSTITUTE THAT
IS STILL GROWING TODAY, TO HELP
EDUCATORS INTRODUCE SEX AND
GENDER.
WE NEED THAT FOR PAIN.
WE NEED TO EDUCATE OUR STUDENTS
ABOUT PAIN.
WHAT DO PHYSICIANS AND NURSE
PRACTITIONERS AND OTHER -- PAs
THAT ARE FRONT LINE POINT OF
CARE WANT TO DO FOR THEIR
PATIENTS MORE THAN ANYTHING?
THEY WANT TO HELP THEM.
WHEN PATIENTS COME IN WITH
CHRONIC PAIN OF YEARS, OR
MONTHS, HAVE TRIED FIVE
DIFFERENT TREATMENTS, THEY'RE
FRUSTRATED, THEY MAY HAVE BEEN
GASLIGHTED, PHYSICIANS FEEL
FRUSTRATED, AND THEY FEEL AT A
LOSS.
WE HAVE TO GIVE THEM THE TOOLS.
SO IF YOU EVER ARE IN THE
POSITION TO INSTITUTE CURRICULAR
CHANGE, WHETHER IT'S MASTERS,
HEALTH PROFESSIONS, UNDERGRAD,
YOU HAVE TO HAVE A TEAM, AND
THESE ARE THE TEAM MEMBERS
BECAUSE I'VE DONE THIS SEVERAL
TIMES BEFORE, THIS IS WHAT YOU
NEED TO CREATE THE CHANGE.
NEXT.
AND THEN A SHAMELESS PLUG FOR
ME -- NO, NOT REALLY.
I WAS SO EXCITED IN 2019 WHEN,
AFTER 20 YEARS, I WAS ABLE TO
WORK WITH A GROUP OF REALLY
TALENTED SEX AND GENDER
RESEARCHERS AND CLINICIANS TO
CREATE A PRACTICAL CLINICAL
TEXTBOOK AROUND SEX AND GENDER
IN CLINICAL CARE, AND IT TOOK 20
YEARS FOR ME TO GET THERE.
I ALSO LED ONE IN 2006 THAT
NEVER HIT THE MARKET.
BECAUSE IT WASN'T READY YET.
THE SECOND EDITION WILL COME OUT
NEXT YEAR.
I ALSO WROTE A LABOR OF LOVE
WITH SOME COLLEAGUES ON WHY
WOMEN AREN'T WINNING AT HEALTH
BUT CAN, WHICH INCLUDES SOME OF
THE THINGS WE TALKED ABOUT
TODAY.
IF YOU SEND ME YOUR BIOLOGICAL
PLAUSIBILITY CASE, MJENKINS@ --
I'M SORRY, IT'S NOT SOUTH
DAKOTA.
I DON'T WHAT TO TAKE THAT SCHOOL
AS MY SCHOOL.
I WILL LET YOU KNOW IF YOU
WIN -- YOU CAN SELECT EITHER
BOOK YOU WANT AND I'LL SEND TO
YOU.
NEXT.
SO I WANT TO SAY THANK YOU.
I KNOW WE'RE RUNNING BEHIND.
I'M GOING TO STAY AROUND FOR
QUESTIONS TODAY.
I'LL BE AVAILABLE AROUND LUNCH.
I'M HAPPY TO TAKE YOUR EMAIL AND
EMAIL WITH YOU, TALK TO YOU.
I JUST WANT TO LET YOU KNOW THAT
IN YOUR CAREER, SOMETIMES IT'S
FRUSTRATING, BUT SOMETIMES
THERE'S GREAT JOY.
AND SO THIS IS MY GRANDSON.
SUPER COOPER.
OVER HERE, THIS SEEMS TO ME LIKE
ME WHEN I G I GOT THE 800-PAGE ,
READ IT AND THOUGHT THIS IS A
REAL THING, EVEN THOUGH I WAS
THREAT EBBED TO HAVE MY MEDICAL
LICENSE PULLED IN TEXAS BECAUSE
I WAS PRACTICING THIS SEX AND AD
GENDER MEDICINE.
AND THEN WHEN THE SABV POLICY
CAME OUT, I HAVE TO SEND THIS TO
JANINE, THIS IS WHAT I LOOKED
LIKE.
WE GOT IT!
HERE WE ARE!
AND THEN THIS IS WHERE I AM
TODAY WHEN I SEE THE AMAZING
PROGRESS THAT WE MADE.
YOU'RE GOING TO HEAR THERE'S
AMBIGUITY, YOU'RE GOING TO HEAR
THERE'S GAPS, BUT THAT'S WHAT
WE'RE HERE FOR, TO FILL THE
GAPS.
THAT'S WHAT YOU DO.
AND I KNOW YOU ARE ALL GOING TO
CONTRIBUTE WELL.
SO THANK YOU SO MUCH FOR YOUR
TIME AND THE HONOR OF BEING YOUR
KEYNOTE.
>> GOOD MORNING, EVERYONE.
SO THEY'LL TRY TO FIX IT FOR THE
ZOOM SPEAKER BECAUSE OUR FIRST
SPEAKER OF THIS PANEL SESSION IS
GIVING TALK THROUGH ZOOM.
SO WELCOME AGAIN, AND THIS
CONVERSATION IS SPECIFICALLY ON
PAIN BY SEX, GENDER AND SEXUAL
IDENTITY, WHAT ARE THE
DIFFERENCES AND WHAT ARE THE
EXPERIENCES THERE.
SO AS YOU ALREADY HEARD AND WE
ALL KNOW FROM THE PUBLISHED
LITERATURE AND FROM CLINICAL
PRACTICE, THAT THERE ARE MANY
ASPECTS IN CHRONIC AND ACUTE
PAIN THAT ARE REALLY INFLUENCED
BY SEX, GENDER AND SEXUAL
IDENTITIES, AND IT'S NOT ONLY IN
HUMANS BUT ALSO IN OTHER SPECIES
TOO, AND YO YOU'LL HEAR SOME
STORIES AND SOME SCIENCE FROM
THERE.
WE KNOW IN HUMANS, AS YOU HEARD
ALREADY, THAT MORE WOMEN
EXPERIENCE PAIN AND REPORT MORE
OF CHRONIC PAIN AND HIGH IMPACT
CHRONIC PAIN THAN IN MEN.
AND ALSO THERE ARE SEVERAL
STUDIES WHICH HAVE SAID A LOT OF
LIGHT ON THE MECHANISMS OF
UNDERSTANDING -- NOT ONLY
BIOLOGICAL UNDERSTANDING BUT
ALSO PSYCHOSOCIAL ASPECTS OF
THESE UNDERLYING SEX AND GENDER
DIFFERENCES IN PAIN.
SORE WITH THAT, WE'LL HAVE FOUR
SPEAKERS IN THIS PANEL SESSION,
AND OUR FIRST SPEAKER IS
ACTUALLY JOINING OVER ZOOM SO
LET'S HOPE -- I SEE THEM THERE,
AND PLEASE KEEP ALL YOUR
QUESTIONS DURING THE END OF THE
PANEL DISCUSSION SO THAT WE'LL
HAVE ALL THE SPEAKERS SPEAK
ABOUT THEIR TALKS AND THEN WE
CAN GO TO THE PANEL DISCUSSION.
SO WITH THAT, LET ME INTRODUCE
OUR FIRST SPEAKER.
HE'S DR. JEFF MOGIL.
HE'S CURRENTLY HOLDING A
PROFESSORSHIP IN PAIN STUDIES
AND ALSO HE'S A DISTINGUISHED
MCGILL PROFESSOR IN CANADA.
DR. MOGIL HAS MADE SO MANY
SEMINAL CONTRIBUTIONS TO OUR
UNDERSTANDING IN PAIN, SEX
DIFFERENCES IN PAIN, AS WELL AS
PAIN TESTING METHODS IN
LABORATORY ANIMALS AND MULTIPLE
SPECIES THERE.
HE HAS EXTENSIVELY PUBLISHED IN
THE PAIN FIELD, INCLUDING IN
THESE SPECIFIC AREAS, SEX AND
GENDER DIFFERENCES AND PAIN.
AND HE IS THE RECIPIENT OF
LIFETIME ACHIEVEMENT AWARDS FROM
MULTIPLE SOCIETIES LIKE AMERICAN
PAIN SOCIETY AND CANADIAN PAIN
SOCIETY, CANADIAN PSYCHOLOGICAL
ASSOCIATION.
HE'S ALSO CURRENTLY A FELLOW OF
THE CANADIAN ACADEMY OF HEALTH
RESEARCH AND ROYAL SOCIETY OF
CANADA.
HE HAS SERVED IN MULTIPLE ROLES,
INCLUDING EDITORIAL ROLES IN THE
JOURNAL OF PAIN, AS A
COUNCILMEMBER TO INTERNATIONAL
ASSOCIATION FOR STUDY OF PAIN AS
A MEMBER THROUGH PROGRAM
COMMITTEES AND CHAIRING
COMMITTEES IN -- OF PAIN.
HE'S ALSO THE FOU FOUNDER/DIRECR
OF THE NORTH AMERICAN PAIN
SCHOOL, ONE OF OUR SPEAKERS ONE
OF THE PAIN SCHOOL GRADUATES
FROM THERE.
SO WITH THAT, I'LL ASK DR. MOGIL
TO TAKE OVER AND HIS TALK WILL
GO OVER ALMOST ALL ASPECTS OF
PAIN, SEX, GENDER, SO REALLY
INTERESTED TO LEARN ABOUT THAT.
SO JEFF, PLEASE TAKE OVER.
>> THANKS A LOT, DP.
ARE THINGS WORKING?
CAN PEOPLE SEE?
>> WE CAN SEE THE SLIDES HERE
BUT NOT THERE.
>> I THOUGHT NOT BEING IN
BETHESDA MIGHT ACTUALLY BE AN
ADVANTAGE TODAY BUT MAYBE NOT.
>> JEFF, IF YOU CAN HEAR US, WE
HAVE A LITTLE BIT OF TECHNICAL
TROUBLE GOING ON SO THEY'RE
TRYING TO FIX THE SLIDES.
>> I'LL WAIT FOR IT.
CAN YOU HEAR ME?
>> YES, WE CAN HEAR YOU.
>> OKAY.
>> YOU CAN START WITH THE STORY
BY THE TIME THEY ARE FIGURING
OUT.
>> NO, I'M GOING TO NEED SLIDES.
SORRY, WE'RE GOING TO HAVE TO
WAIT.
>> JEFF, WE CAN SEE THE SLIDES.
YOU'RE GOOD TO GO.
>> OKAY, GREAT.
THANKS, DP, AND IT'S NICE TO BE
HERE, SORRY I COULDN'T BE THERE
IN PERSON.
SO I'M GOING TO GO QUICKLY
THROUGH THIS FIRST PART BECAUSE
IT'S COME UP, BUT I THINK IT'S
IMPORTANT THAT WE ALL TAKE A
LOOK AT THE NUMBERS.
WHENEVER THIS TOPIC COMES UP,
THIS IS THE FIRST QUESTION
PEOPLE ASK, WHO'S MORE SENSITIVE
TO PAIN.
IT'S A VERY INTERESTING
SCIENTIFIC QUESTION IN THAT
EVERYONE HAS AN OPINION, YOU GO
AND ASK PEOPLE ON THE STREET
THIS QUESTION, THEY'LL GIVE YOU
AN ANSWER.
USUALLY THEIR ANSWER USES THE
LOGIC OF THIS OLD JOKE.
BUT THE FIRST PERSON TO ACTUALLY
THINK ABOUT THIS IN A SYSTEMATIC
WAY WAS KAREN BERKELEY, WHO
WROTE THIS LOVELY REVIEW PAPER
IN 1997 FEATURING THIS TABLE,
WHERE SHE TOOK ALL OF THE
CHRONIC PAIN SYNDROMES KNOWN AT
THE TIME AND SHE DIVIDED THEM
INTO THREE CATEGORIES, THOSE
KNOWN TO HAVE FEMALE PREVALENCE,
THOSE THAT WERE KNOWN TO HAVE
MALE PREFER LANCE, THOSE THAT
DIDN'T APPEAR TO HAVE A SEX
PREVALENCE.
YOU CAN SEE OF COURSE THAT THE
FEMALE LIST IS LONGER THAN THE
MALE LIST.
IT IS ALSO THE CASE THAT THE
DISORDERS ON THE FEMALE LIST ARE
MORE PREVALENT OVERALL, AND SO
YOU COULD GUESS, THEN, THAT THE
MAJORITY OF CHRONIC PAIN
PATIENTS ARE GOING TO BE WOMEN
AND INDEED, IF YOU ASK PEOPLE
RUNNING TERTIARY PAIN PRACTICES
HOW MANY OF YOUR PATIENTS ARE
WOMEN, YOU GET ESTIMATES THAT
ABOUT 70% OF THEM ARE.
NOW THAT MIGHT BE BECAUSE WOMEN
ARE MORE SENSITIVE TO PAIN, BUT
THERE ARE A LOT OF OTHER REASONS
THAT COULD BE, INCLUDING THE
WELL-KNOWN GENDER DIFFERENCE
THAT WOMEN ARE MORE LIKELY TO GO
TO THE DOCTOR OR, MORE
ACCURATELY, THAT MEN ARE LESS
LIKELY TO GO TO THE DOCTOR.
IF YOU DON'T GO TO THE DOCTOR,
YOU CAN'T BECOME A PATIENT.
SO MAYBE THE BETTER WAY TO ASK
THE QUESTION IS TO DO A LARGE
EPIDEMIOLOGICAL SURVEY AND ASK
PEOPLE IF THEY ENDORSE HAVING
THE SYMPTOMS OF CHRONIC PAIN.
THIS HAS BEEN DONE A NUMBER OF
TIMES, OF COURSE ALL THE STUDIES
HAD COMPLETELY DIFFERENT
DEFINITIONS OF WHAT PAIN WAS BUT
TO FACILITATE COMPARING APPLES
TO ORANGE, I'VE SIMPLY
SUBTRACTED THE MALE PREVALENCE
FROM THE FEMALE PREVALENCE IN
THAT STUDY.
YOU CAN SEE ACROSS THE BOARD
WITH ONE EXCEPTION, WOMEN ARE
MORE LIKELY TO ENDORSE HAVING
THE SYMPTOMS OF CHRONIC PAIN.
NOW AGAIN, THAT MIGHT BE BECAUSE
THEY'RE MORE SENSITIVE TO
CHRONIC PAIN OR MORE SENSITIVE
TO PAIN IN GENERAL, BUT AGAIN
THERE'S ANOTHER POSSIBILITY,
WHICH IS THAT WOMEN MIGHT JUST
BE MORE SUSCEPTIBLE TO
DEVELOPING DISORDERS THAT HAVE
PAIN AS A SYMPTOM.
SO REALLY THE ONLY WAY TO
ACTUALLY ANSWER THE QUESTION IS
TO TAKE MEN AND WOMEN INTO THE
LABORATORY AND GIVE THEM
CONTROLLED STIMULI AND SEE WHO'S
MORE SENSITIVE TO PAIN.
AND THIS HAS BEEN DONE HUNDREDS
AND HUNDREDS OF TIMES.
I'M GOING TO SHOW YOU THE RESULT
IN A SECOND, ALTHOUGH YOU'VE
SEEN IT ALREADY THIS MORNING,
AND THE RESULT HERE IS SO
OVERWHELMINGLY LOPSIDED THAT
IT'S AMAZING TO ME THAT THERE'S
STILL A QUESTION FLOATING IN THE
WORLD.
THE REASON WHY THIS QUESTION IN
SOME PEOPLE'S MINDS IS
UNANSWERED IS THAT IN SOME OF
THESE STUDIES, THERE'S A
STATISTICALLY SIGNIFICANT
DIFFERENCE BETWEEN WOMEN AND
MEN, AND IN OTHER STUDIES, THERE
ISN'T.
BUT THAT, OF COURSE, IS SIMPLY
BECAUSE SOME STUDIES ARE
UNDERPOWERED.
IF YOU FORGET ABOUT THE ISSUE OF
STATISTICAL SIGNIFICANCE AND YOU
SIMPLY ASKED WHO WAS MORE
SENSITIVE TO PAIN IN THAT STUDY,
YOU CAN SEE THAT IT DOESN'T
MATTER HOW YOU MEASURE PAIN AND
IT DOESN'T MATTER WHAT KIND OF
PAIN YOU MEASURE, WOMEN ARE, IN
FACT, MORE SENSITIVE TO PAIN
THAN MEN.
NOW WE COULD QUIBBLE ABOUT HOW
MUCH AND HOW MUCH IT MATTERS,
BUT THIS QUESTION IN MY MIND IS
CLEARLY ANSWERED.
IT'S NOT, HOWEVER, THE IMPORTANT
QUESTION.
THE BIGGER PICTURE, THE BIGGER
PROBLEM, IS THIS DISCONNECT
BETWEEN THE CLINICAL PROBLEM ON
THE LEFT AND HOW WE MODEL THAT
PROBLEM ON THE RIGHT.
AND THE PROBLEM, OF COURSE,
ISN'T THAT IT'S A RAT.
IT'S THAT IT'S A YOUNG MALE RAT
OVERWHELMINGLY STANDING IN FOR
THAT WOMAN.
AND THAT MAY OR MAY NOT BE AN
APPROPRIATE WAY TO MODEL WOMEN
IN PAIN, AND I'M GOING TO TRY TO
CONVINCE YOU THAT IT NOT, BUT OF
COURSE PEOPLE HAVE FIGURED THIS
OUT BY NOW, RIGHT?
SO FUNDING AGENCIES AROUND THE
WORLD, AND AT NIH, THE POLICY
WAS ANNOUNCED IN 2014, IT WENT
INTO EFFECT IN 2016.
I WILL REMIND YOU THAT CANADA
BEAT YOU ON THIS BY 10 YEARS.
BUT THE QUESTION IS WHETHER THIS
POLICY, WHICH IS ONE OF A SERIES
OF POLICIES KNOWN AS SEX AS A
BIOLOGICAL VARIABLE POLICIES OR
SABV, ARE ACTUALLY WORKING.
SO I WENT INTO THE LITERATURE
AND I LOOKED AT PAPERS PUBLISHED
IN THE FLAGSHIP JOURNAL IN THE
FIELD CALLED PAIN FROM 2015 TO
2019.
OVER ON THE LEFT, YOU CAN SEE
FIRST OF ALL THAT THERE WAS A
BIG SPIKE IN THE NUMBER OF
STUDIES THAT WERE SPECIFICALLY
ABOUT SEX DIFFERENCES.
BY 2019.
BUT MORE IMPORTANTLY, ON THE
RIGHT, YOU CAN SEE THAT STARTING
IN 2015, WHICH WAS NO DIFFERENT
FROM TWO DECADES BEFORE THAT,
THE NUMBER OF STUDIES USING MALE
MICE OR MALE RATS ONLY HAS
DECREASED FROM ABOUT 80% IN 2015
TO ONLY 50% IN 2019.
NOW THERE'S STILL A WAYS TO GO
THERE, BUT THIS IS A DEFINITE
IMPROVEMENT AND IT SUGGESTS THAT
THE POLICIES ARE EFFECTIVE.
NOW THAT'S THE GOOD NEWS.
THE BAD NEWS IS WHEN I SHOW YOU
THE DATA FROM STUDIES WITH HUMAN
SUBJECTS IN THE SAME JOURNAL
OVER THE SAME TIME PERIOD, AND
ALTHOUGH VIRTUALLY ALL STUDIES
IN HUMANS USE BOTH MALES AND
FEMALES, THERE IS NO DIFFERENCE
OVER TIME IN THE PROPORTION OF
STUDIES THAT ARE COLORED IN
GREEN THERE, WHICH MEANS THAT
THEY ACTUALLY MENTION TO THE
READER AT ANY POINT LATER IN THE
STUDY WHETHER THERE WAS OR
WASN'T A DIFFERENCE BETWEEN THE
MALES AND FEMALES.
THAT IS TO SAY IN HUMAN STUDIES,
MALES AND FEMALES ARE BOTH USED,
BUT THE DATA 50% OF THE TIME IS
NOT DISAGGREGATED SO WE HAVE NO
IDEA WHETHER THERE WAS OR WASN'T
A SEX DIFFERENCE.
BECAUSE OF THESE POLICIES,
PANDORA'S BOX HAS BEEN OPENED.
AND FOR REASONS THAT ARE UNCLEAR
TO ME AT THIS POINT, THE BIOLOGY
OF PAIN IS ROBUSTLY SEXUALLY
DIMORPHIC.
THIS IS A REVIEW PAPER THAT WILL
BE COMING OUT IN A FEW MONTHS.
AND I WENT VERY CAREFULLY
THROUGH THE LITERATURE AND FOUND
EVERY GENE OR PROTEIN THAT
ANYONE HAS CLAIMED AND PROVIDED
CAUSAL EVIDENCE IS INVOLVED IN
PAIN BIOLOGY IN EITHER MALES BUT
NOT FEMALES ON THE LEFT OR
FEMALES BUT NOT MALES ON THE
RIGHT, BUT YOU CAN SEE THERE'S A
BUNCH.
THERE'S 50 PROTEINS IN MALES
THAT ARE SEX-SPECIFIC, AND ABOUT
35 IN FEMALES THAT A
SEX-SPECIFIC, AND THIS NUMBER IS
GROWING EVERY COUPLE OF WEEKS.
IT REALLY IS AMAZING HOW FAST
THIS FIELD IS MOVING.
I WANT TO TELL YOU A COUPLE
STORIES THAT HAVE COME OUT OF MY
LAB AND THIS ONE WILL EXPLAIN
THE ODD TITLE OF MY TALK.
SO THIS IS JOHN LIEBESKIND, HE
WAS MY GRADUATE ADVISOR, AND HE
WROTE THIS ARTICLE OR EDITORIAL
REALLY IN THE JOURNAL PAIN IN
1991 CALLED PAIN CAN KILL IN
WHICH HE ARGUES PEOPLE DON'T
TAKE PAIN SERIOUSLY BECAUSE IT
CAN DILL KIL YOU, BULL THAT IT
DOES IT INDIRECTLY.
THIS PAPER HAS ABOUT 20 CYTES,
IT'S BEEN COMPLETELY IGNORED
BECAUSE JOHN WAS WAY AHEAD OF
ITS TIME BUT IT'S CAUGHT UP TO
JOHN, AND THE LATEST META
ESTIMATE OF THE MORTALITY RISK
OF LIVING WITH CHRONIC
WIDESPREAD PAIN AS YOU CAN SEE
HERE IS 1.57.
NOW, LIKE YOU, I HAD NO IDEA
WHAT THAT MEANS, SO I EMAILED
GARY MCFARLAND AND I SAID CAN
YOU REPHRASE THAT IN TERMS THAT
NORMAL PEOPLE CAN UNDERSTAND?
AND HE CAME BACK A DAY LATER AND
SAID, THE MORTALITY RISK RATIO
OF 1.57 IS EQUIVALENT TO SAYING
THAT CHRONIC PAIN PATIENTS HAVE
AN EFFECTIVE AGE OF SIX YEARS
HIGHER THAN THEIR CHRONOLOGICAL
AGE AND THAT MUCH CLOSER TO
DEATH.
NOW TO ME, THAT'S SOMETHING THAT
IS REALLY WORTH EXPLAINING.
AND TO MAKE A LONG STORY SHORT,
WE'VE TRIED VERY HARD TO START
TRYING TO EXPLAIN THAT. I WANT
TO TELL YOU ONE VERY INTERESTING
STUDY THAT WAS PUBLISHED A
COUPLE YEARS AGO WHERE WI WE DID
SOMETHING AMAZINGLY WHICH HAD
NEVER BEEN DONE BEFORE, WHICH IS
LOOK TETRAJEK TRI OF CHRONIC
LOOK AT THE TRAJECTORY -- SHE
WAS A STUDENT OF LAURA STONE'S,
RESEARCH ASSOCIATE, CAME INTO MY
LAB EVERY DAY FOR 3 1/2 MONTHS,
TESTED SOME MICE AND THEN I
DIDN'T SEE HER AGAIN FOR 3 1/2
MONTH.
WE USED SOMETHING CALLED THE
SPARED NERVE INJURY WHICH
PRODUCES MECHANICAL ALLODYNIA.
THAT APPARENTLY LASTS FOREVER,
AND INDEED, IN MALE MICE, IT
REALLY DOES LAST FOREVER.
SO YOU CAN SEE IN THE DARK BLUE
THERE THAT THERE'S A LITTLE DROP
FROM THE 3 TO 6-MONTH TIME POINT
BUT AFTER THAT, WITHIN THE
LIMITS OF THE ERROR BARS, IT'S
MORE OR LESS SOLID UNTIL THE DAY
THE MOUSE DIES.
IN FEMALES, ON THE OTHER HAND,
SOMETHING MUCH DIFFERENT
HAPPENS.
WHICH IS THAT THEY HAVE
MECHANICAL ALLODYNIA BUT BY
6 AND 9 MONTHS IT COMPLETELY
RESOLVED.
WE'VE ACTUALLY SEEN THAT THREE
OR FOUR TIMES BEFORE BUT WHAT WE
DIDN'T SEE BECAUSE WE NEVER
LOOKED LONG ENOUGH IS THAT IT
ACTUALLY COMES BACK, AND THAT BY
12, 15, 18 MONTHS, WE'RE RIGHT
BACK WHERE THE MALES WERE.
THIS IS SOMETHING THAT DOES
REALLY NEED TO BE EXPLAINED.
I HAVE SOME HYPOTHESES HERE THAT
SOMEONE MAY WANT TO ASK ME
LATER.
BUT THE REAL REASON WASN'T TO
LOOK TETRAJEK TRI OF PAIN
BEHAVIOR, BUT RATHER TO SEE IF
PAIN HAD ANY EFFECT, ANY IMPACT
ON HOW LONG THE MICE LIVED.
AND AS YOU CAN IMAGINE, THIS
STUDY COST ME A LOT OF MONEY IN
PER DIEMS AND A LOT OF TIME,
THREE YEARS-PLUS, AND THUS I WAS
UNHAPPY WHEN I MADE THIS GRAPH
ONE DAY, WHICH SHOWS THAT THE
SPARED NERVE INJURY OR SNI HAS
ABSOLUTELY NO EFFECT ON LIFESPAN
IN EITHER MALE OR FEMALE MICE.
BUT AFTER SPENDING THIS MUCH
TIME AND MONEY I WASN'T WILLING
TO LET THINGS LIE SO I STARTED
PLAYING AROUND WITH THE DATA A
LITTLE BIT.
I ENDED UP DOING THE FOLLOWING
THING.
SINCE WE HAD DATA OF HOW MUCH
PAIN OR AT LEAST HOW MUCH
MECHANICAL ALLODYNIA MICE HAD
EVERY THREE MONTHS, I DECIDED
THAT I WOULD SIMPLY AVERAGE THEM
OVER THE LIFESPAN OF THAT MOUSE
TO GET AN AVERAGE LEVEL OF HOW
MUCH PAIN THAT MOUSE WAS IN
OVERALL, OVER ITS LIFESPAN.
AND I CORRELATED THAT AVERAGE
WITH HOW MUCH EACH MOUSE LIVED
AND WHEN YOU DO THAT, YOU SEE
THE FOLLOWING RATHER AMAZING
FINDING, WHICH IS THAT IN MALE
MICE ONLY, THERE IS A
SIGNIFICANT CORRELATION BETWEEN
HOW MUCH PAIN THEY WERE IN ON
AVERAGE AND HOW LONG THEY LIVED,
SUCH THAT THOSE WHO WERE IN MORE
PAIN DIED YOUNGER, THOSE WHO
WERE IN LESS PAIN LIVED LONGER,
FOR FEMALES, IT HAD ABSOLUTELY
NO IMPACT AT ALL.
AND THEN WE ASKED OURSELF, OKAY,
IF THAT'S TRUE FOR MICE, IS IT
ALSO TRUE IN PEOPLE AND IT TURNS
OUT THAT THERE'S A WAY TO ANSWER
THAT QUESTION WITH THE U.K.
BIOBANK, WHICH IS DATA FROM A
HALF A MILLION BRITS, AND WHEN
WE ANALYZE THIS DATA, WE SEE THE
FOLLOWING PATTERN.
IN THE U.K. BIOBANK, THEY DON'T
ACTUALLY HAVE PAIN LEVELS.
WHAT THEY HAVE INSTEAD IS HOW
MANY BODY PARTS YOU ENDORSE THAT
ARE IN PAIN, BUT THIS TURNS OUT
TO CORRELATE VERY HIGHLY WITH
PAIN LEVELS SO IT CAN BE
CONSIDERED A PROXY.
AND YOU CAN SEE THAT IN MEN BUT
NOT WOMEN, THE MORE BODY SITES
THEY HAVE THAT ARE IN PAIN, THE
QUICKER THEY DIE.
AND THAT IS AN EFFECT THAT JUST
ISN'T SEEN IN WOMEN.
NOW, THIS IS SORT OF A STRIKING
FINDING BUT IN SOME SENSE, IT'S
ABSOLUTELY EXPLAINABLE, BECAUSE
WE KNOW AND WE'VE KNOWN FOR A
LONG TIME THAT THERE IS A SEX
DIFFERENCE IN HEALTH AND DISEASE
SUCH THAT WOMEN ARE MORE
AFFECTED BY MORBIDITY, RIGHT,
THEY'RE MORE LIKELY TO HAVE THE
CHRONIC DISORDER, WHEREAS MEN
ARE MORE SUSCEPTIBLE TO
MORTALITY.
THEY'RE MORE LIKELY TO DIE FROM
IT.
SO IT SEEMS FOR CHRONIC PAIN,
THIS IS ALSO TRUE.
NOW, THE FINAL THING I WANT TO
SPEND A FEW MINUTE TELLING YOUSU
ABOUT IS SOMETHING THAT I'M KIND
OF EXCITED ABOUT.
I SHOULD POINT OUT, THESE ARE
ABSOLUTELY PRELIMINARY,
UNPUBLISHED DATA FROM OUR LAB.
BUT I THINK THEY MIGHT BE
MEANINGFUL, SO I WANT TO SPEND A
FEW MINUTES.
THEY INVOLVE THE FORMALIN TEST
WHICH I'LL REMIND EVERYONE THAT
INVOLVES THE INJECTION OF AN
INFLAMMATORY SUBSTANCE INTO THE
HIND PAW AND THEY SHOW LICKING
BEHAVIOR.
THIS EXPERIMENT INVOLVED TWO
DIFFERENT SOCIAL CONDITIONS.
SO ON THE LEFT THERE'S THE
NON-SOCIAL CONDITION, A MOUSE IS
IN A HOME CAGE AND THERE IS ONE
OBJECT IN THAT CAGE, WHICH IS
THIS RED TUBE, WHICH IS A
TRANSPARENT TO US BUT TO MICE,
THAT IS AN OPAQUE TUBE, A GOOD
PLACE TO HIDE IN.
AND IN THE SOCIAL CONDITION,
THERE ARE NOW THREE MICE AND
THREE TUBES SO THERE'S NO
COMPETITION TO GET IN THE TUBE,
BUT ONLY ONE MOUSE IS INJECTED
WITH FORMALIN.
IN THE NON-SOCIAL CONDITION,
HERE'S WHAT WE SEE.
IT TURNS OUT THAT MALES ARE
SIGNIFICANTLY MORE LIKELY TO
SPEND TIME IN THE TUBE WHEN
GIVEN FORMALIN, WHICH IS
INTERESTING.
THERE IS NO DIFFERENCE IN THE
OVERALL AMOUNT OF PAIN BEHAVIOR,
WHICH IS LICKING OF THE AFFECTED
HINDPAW BETWEEN MALES AND
FEMALES AND MOST IMPORTANTLY FOR
THIS STUDY, THERE IS NO
DIFFERENCE IN WHERE THE LICKING
BEHAVIOR OCCURS, WHETHER IN THE
TUBE OR OUTSIDE OF THE TUBE.
HOWEVER, IN THE SOCIAL
CONDITION, AGAIN, MALE MICE ARE
A LITTLE BIT MORE LIKELY TO GO
IN THE TUBE.
AGAIN, THERE'S NO DIFFERENCE IN
OVERALL PAIN BEHAVIOR, BUT NOW A
VERY INTERESTING THING HAPPENS,
WHICH YOU CAN SEE MOST EASILY IN
GRAPH E.
MALE MICE ARE DOING A LOT OF
THEIR LICKING BEHAVIOR INSIDE
THE TUBE, WHEREAS FEMALE MICE
ARE DOING ESSENTIALLY ALL OF
THEIR LICKING BEHAVIOR OUTSIDE
THE TUBE.
SO WHAT'S GOING ON HERE?
AND IT SEEMS TO ME THAT THERE'S
TWO OPTIONS.
IT EITHER THAT MALES WANT TO DO
THEIR PAIN BEHAVIOR PRIVATELY,
PROB BLIL BECAPROBABLY BECAUSE ,
OR FEMALES ACTUALLY WANT TO DO
THEIR PAIN BEHAVIOR PUBLICLY.
IN FACT, IF YOU COMPARE THE
NON-SOCIAL TO THE SOCIAL
CONDITION, IT ACTUALLY LOOKS
LIKE IT'S THE SECOND EXPLANATION
THAT IS THE RIGHT ONE, AND
THAT'S PRETTY INTERESTING,
BECAUSE IN 2010, AND BY THE WAY,
THERE'S A PAPER COMING OUT IN
NEURON, IT'S ALREADY PROBABLY
AVAILABLE, THAT REPLICATE THESE
FINDINGS EXACTLY.
THE PAPER WE PUBLISHED IN 2010,
WHERE WE'RE LOOKING AT WHERE A
MOUSE THAT'S FREE TO ROAM GOES
IF PUT IN PROXIMITY TO A MOUSE
IN PAIN VERSUS A MOUSE THAT'S
NOT IN PAIN, AND WHAT WE FOUND
IS THAT IF ALL THREE MICE ARE
GIRLS, IF THEY KNOW EACH OTHER,
SO IF THEY'RE CAGE-MATES, AND IF
PHYSICAL CONTACT BETWEEN THE
MICE THROUGH THE JAIL BARS
HOLDING THE MICE IN AT THE END
IS ALLOWED, THEN THE MOUSE IN
THE MIDDLE WILL SPEND MORE TIME
IN PROXIMITY TO THE MOUSE IN
PAIN AND THE MORE TIME SHE
SPENDS IN PROXIMITY TO THE MOUSE
IN PAIN, THE LESS PAIN THE HOUSE
IN PAIN IS IN.
SO IT LOOKS LIKE THIS SOCIAL
APPROACH OR SOCIAL CONTACT IS
ANALGESIA, AND THAT MAY BE WHY
FEMALE MICE ARE ADVERTISING
THEIR PAIN BEHAVIOR, TO TRY TO
SOLICIT THIS SORT OF SOCIAL
APPROACH.
NOW WHY I'M EXCITED ABOUT THESE
DATA IS THAT I THINK THIS MIGHT
NOT BE A SEX DIFFERENCE.
I THINK IT MIGHT BE A GENDER
DIFFERENCE.
BECAUSE EVERY DEFINITION THAT I
CAN PULL OF THE WORD "GENDER"
OFF OF THE INTERNET HAS ONE
THING IN COMMON, WHICH IS THAT
IT IS SOMETHING EXPRESSED IN A
SOCIAL CONTEXT.
AND HERE IS A BEHAVIORAL
DIFFERENCE BETWEEN MALE AND
FEMALE MICE THAT CAN ONLY BE
SEEN IN A SOCIAL CONTEXT.
NOW, IS THIS GENDER THE SAME WAY
WE SEE IT IN HUMANS?
ALMOST CERTAINLY NOT.
BUT DOES IT DESERVE THE WORD?
I DON'T KNOW.
MAYBE.
I'D BE INTERESTED IN YOUR
THOUGHTS ON THAT MATTER.
SO I WANT TO THANK THE FOLKS
THAT HAVE DONE THE WORK, AND I
WANT TO THANK YOU ALL FOR YOUR
ATTENTION.
THANK YOU VERY MUCH.
>> THANK YOU, JEFF, FOR A
STIMULATING TALK.
HOPEFULLY YOU'LL BE JOINING US
FOR THE PANEL DISCUSSION AT THE
END.
>> I'LL BE HERE.
>> AND SORRY FOR THE TECHNICAL
GLITCH.
SO OUR NEXT SPEAKER IS
DR. ROBERT SORGE.
SO HE'S AN ASSOCIATE PROFESSOR
IN THE DEPARTMENT OF PSYCHOLOGY
AT THE UNIVERSITY OF ALABAMA AT
BIRMINGHAM.
HE'S ALSO THE DIRECTOR OF A LAB
AND ALSO LEADING THE CORE
DIRECTORSHIP OF UNDERGRADUATE
NEUROSCIENCE PROGRAM THERE, AND
HE HAS BEEN STUDYING SEX
DIFFERENCES IN PAIN STARTING
FROM HIS GRADUATE TIME.
OF COURSE WITH JEFF.
AND IN HIS INDEPENDENT CAREER,
HE HAS REALLY CONTINUED FORWARD
WITH THIS AND NOW CONSIDERS
HIMSELF AS THE TRANSLATIONAL A
AND MORE TOWARDS CLINICAL
SCIENTIST, BECAUSE HIS LAB IS
CURRENTLY NOT ONLY LOOKING INTO
THE BASIC SCIENCE BUT ALSO
TRANSLATIONAL AS WELL AS
CLINICAL RESEARCH STUDIES WITH
CLINICAL TRIAL INTERVENTIONS.
SO HE'LL TALK MORE ON PAIN FROM
MICE TO MEN TO WOMEN, SO
HOPEFULLY THE SLIDE WORKS.
>> ALL RIGHT.
THANK YOU AGAIN TO THE
ORGANIZERS FOR INVITING ME.
I'M HAPPY TO BE HERE.
FOR DR. JENKINS, I GREW UP ON A
FARM, SO I LIVE IN ONTARIO IN A
HAMLET OF 350 PEOPLE ON A GRAVEL
ROAD, SO THERE YOU GO, THAT'S
WHERE I'M COMING FROM.
YES, VERY LEAP TO HAPPY TO BE H.
I'M GOING TO TALK ABOUT OUR
JOURNEY FROM MICE TO MEN TO
WOMEN AND HOPEFULLY THIS ALL
WORKS.
THIS IS A BRIEF OUTLINE.
DP ASKED ME TO ADD A LITTLE BIT
OF MECHANISM SO I'M GOING TO
TOUCH A LITTLE ON THE MECHANISM
STUFF AND GO INTO SOME OF OUR
CLINICAL WORK.
SO IN 2015, WE PUBLISHED THIS
PAPER WHICH WAS THE FIRST TO
IDENTIFY THE SEX DIFFERENCE IN
IMMUNE CELL MODULATION OF PAIN
IN MICE.
SPECIFICALLY WITHIN THE SPINAL
CORD.
SO THE SHORT VERSION OF THIS IS
THAT IF WE GAVE MICROGLIAL
INHIBITORS INTRATHECALLY IN MALE
AND FEMALE MICE, WHAT WE SAW IS
THESE DRUGS REVERSED ALLODYNIA
IN FEMALE MICE, WE FOUND THIS
EFFECT WAS TESTOSTERONE
DEPENDENT.
WE TOOK TESTOSTERONE AWAY, THE
DRUGS DIDN'T WORK, IF WE GAVE IT
BACK, THE DRUGS WOULD WORK, AND
IF WE GAVE TESTOSTERONE TO THE
FEMALES, THEN THE DRUG WOULD
WORK SO IT DID SEEM TO DEPEND ON
TESTOSTERONE.
SO THE HE REQUEST IS IF THE
FEMALES ARE NOT USING MICROGLIA
WHAT ARE THEY USING, THEY SEEMED
TO BE USING T CELLS IN THE
SPINAL CORD.
SO AGAIN, IF YOU TAKE THOSE T
CELLS AWAY, THE MICROGLIAL
INHIBITORS WORK JUST FINE, GIVE
THE T CELLS BACK, THEN THOSE
INHIBITORS NO LONGER WORK.
AND SO THE LAST LITTLE BIT OF
DATA FROM THIS EXPERIMENT THAT I
WANT TO SHOW IS LOOKING AT
T-CELL INFILTRATION INTO THE
SPINAL CORD AFTER A NERVE INJURY
IN THESE MALE AND FEMALE MICE.
SO WHAT YOU'LL NOTICE HERE IS
THAT BOTH MALE AND FEMALE MICE
HAVE T CELLS INFILTRATING INTO
THE SPINAL CORD, SO BOTH SEXES
HAVE BOTH SYSTEMS, BUT FEMALES
JUST HAVE MORE T CELLS
INFILTRATING INTO THE SPINAL
CORD THAN THE MALES.
SO AGAIN, THE IMPORTANT THING IS
THAT BOTH SEXES HAVE BOTH
PATHWAYS BUT THEY PREFERENTIALLY
USE ONE OR THE OTHER BASED ON
HORMONE LEVELS AND THE
AVAILABILITY OF THOSE SYSTEMS.
SO I WANT TO HIGHLIGHT THIS
BECAUSE THIS IS GOING TO SHOW UP
AGAIN, TAKEN FROM MONTE PYTHON,
IN OUR CLINICAL WORK.
AND SO SINCE THAT TIME, THERE
HAVE BEEN A NUMBER OF STUDYS
THAT HAVE REPLICATED THESE SORTS
OF EFFECTS IN ANIMALS.
THIS IS NOT AN EXHAUSTIVE LIST,
OF COURSE, BUT THERE'S BEEN A
DECENT NUMBER OF STUDIES AND FOR
THOSE OF US THAT DIDN'T REALLY
BELIEVE WHAT WE WERE SEEING AT
THE BEGINNING, THIS WAS VERY
VINDICATED.
SO THIS HAS BEEN SHOWN NOW
TWICE, SO I'M NOT GOING TO
BELABOR THIS POINT, BUT I DO
WANT TO HIGHLIGHT THAT WHEN THIS
WAS PUBLISHED, THE IDEA WAS THAT
MALES AND FEMALES ARE
DIFFERENTIAL LISTENSTIVE TO
ACUTE PAIN BUT WHEN WE TALK
ABOUT THIS, WE TALK ABOUT THIS
IN TERMS OF MEN AND WOMEN, AND
AS DR. JENKINS SAID, THOSE ARE
VERY DIFFERENT TERMS.
AND SO NOT TO STEP ON JEFF'S
TOES AT ALL, BUT IN MY LAB,
THESE ARE HOW WE DEFINE THESE
TERMS.
SEX IS A BIOLOGICAL ATTRIBUTE,
SEX ASSIGNED AT BIRTH.
GENDER IS A SOCIAL ROLE MORE IN
TUNE WITH SELF-IDENTITY, SO WE
RESERVE THAT FOR PEOPLE.
BUT THAT'S NOT ALWAYS THE CASE
FOR EVERYONE, I GUESS.
SO THEN SOME OTHER TERMS THAT I
WANT TO GO THROUGH.
I'M GOING TO BE USING THESE
SHORT FORMS A LOT, SO CIS MEN
AND WOMEN, NON-BINARY ADULTS,
HORMONE REPLACEMENT THERAPY.
SO A FEW YEARS AGO AS PART OF
ANOTHER ONGOING STUDY, WE
HAPPENED TO RECRUIT A NUMBER OF
TRANS WOMEN ADGED W AND WE THOUT
IT WOULD BE REALLY INTERESTING
TO SEE WHAT WAS GOING ON WITH
PAIN SENSITIVITY IN THESE WOMEN.
THESE WERE ALL BLACK
INDIVIDUALS, ALL HIV-POSITIVE,
ALL HAD CHRONIC PAIN, ALL WERE
AT OR BELOW THE POVERTY LINE.
WE HAD SEVEN TRANS WOMEN, NOW
FOR THOSE THAT AREN'T FAMILIAR
WITH THE TERMS, THESE ARE MALE
ASSIGNED AT BIRTH AND IDENTIFY
AS WOMEN.
AND THEY RAN THROUGH A BUNCH OF
OUR STUDIES AND WHAT I WANT TO
HIGHLIGHT IS THE TEMPORAL
SUMMATION OF HEAT PAIN.
SO WHEN WE LOOK AT CIS MEN AND
WOMEN, WE SEE THE SAME THING
THAT'S BEEN SEEN AS JEFF SAID
HUNDREDS AND HUNDREDS OF TIMES
IN STUDIES ALL OVER THE WORLD
WHERE WOMEN ARE REPORTING HIGHER
LEVELS OF PAIN THAN THE MEN ARE.
NOT TERRIBLY SURPRISING.
BUT WHAT WAS VERY INTERESTING IS
WHEN WE MAP THE TRANS WOMEN,
THEY ARE REPORTING VERY SIMILAR
PAIN SENSITIVITY TO CIS WOMEN.
SO FOR ALL INTENTS AT PURNSES, ,
THEY ARE BEHAVING EXACTLY LIKE
ALL THE OTHER WOMEN IN THE
STUDY.
SO THAT BRINGS US TO OUR CURRENT
STUDY, ONE I'M REALLY, REALLY
EXCITED TO TALK TO YOU ABOUT.
SO THIS IS OUR SHIEP STUDY.
SHINE STUDY.THESE ARE SOME VERYY
RESULTS.
I WANT TO THANK NINR FOR FUNDING
THIS WORK.
THIS STUDY HAD THREE BASIC AIMS,
TO LOOK AT THE RELATIONSHIP
BETWEEN GENDER IDENTITY AND PAIN
SENSITIVITY, AIM TWO,
PSYCHOLOGICAL FACTORS AND PAIN
SENSITIVITY, AND AIM THREE,
BECAUSE OF MY BACKGROUND LOOKING
AT IMMUNE CELLS AND PATHWAY,
WE'RE GOING TO LOOK AT IMMUNE
CELL DIFFERENCES IN OUR
DIFFERENT GROUPS OF INDIVIDUALS.
OUR GROUPS OF INDIVIDUALS ARE
SHOWN HERE.
SO WHAT WE'VE DONE HERE IS SORT
OF ROUGHLY AGGREGATED THEM INTO
DIFFERENT GROUPS.
THE IDEA HERE IS TO ALLOW US,
BASED ON THE OUTCOME, TO SEE
WHAT VARIABLE MIGHT ALLOW FOR
THAT SEPARATION OF GROUPS.
SO FOR INSTANCE, IF GENDER
IDENTITY WAS THE KEY VARIABLE
THAT SEPARATED GROUPS, THEN WE
MIGHT EXPECT THEN THAT CIS MEN
MEN -- AND CIS MEN AND TRANS
WOMEN BOTH ON OR OFF HRT WOULD
ALSO GROUP TOGETHER.
SO DEPENDING ON THE OUTCOME AND
THE GROUPINGS, WE MIGHT BE ABLE
TO FIGURE OUT WHICH VARIABLE OF
INTEREST WAS THE KEY DETERMINING
FACTOR.
SO AS OF I GUESS TWO WEEKS AGO,
WHEN I PULLED THIS DATA, THIS IS
OUR GROUP SIZES SO THEY'RE
ROUGHLY THE SAME SIZE.
THE AGES ARE SIMILAR, THOUGH
WE'VE HAD MORE YOUNGER TRANS MEN
THAN SOME OF THE OTHER GROUPS.
THE RANGES ARE SIMILAR AND OUR
RACIAL DEMOGRAPHIC BREAK DOWN IS
VERY SIMILAR ACROSS THESE
GROUPS.
SO I WANT TO START BY SHOWING
YOU SOME OF OUR DATA.
THESE ARE THREE DIFFERENT TESTS.
IN THE FAR LEFT, THIS IS THE
COLD PRESSOR TEST.
WE ASK PEOPLE TO STICK THEIR
HAND IN COLD WATER AND THEN
REPORT ON A ZERO TO 100 SCALE
WHAT THE INTENSITY OF THAT PAIN
IS, SO THAT'S WHAT'S SHOWN ON
THE AXIS THERE.
IN THE MIDDLE, THIS IS HEAT PAIN
THRESHOLD, SO THIS IS THERMOD ON
THE FOREARM AND AS THE HEAT
RAMPS UP, THEY'RE ASKED TO CLICK
A BUTTON WHEN IT BECOMES PAINFUL
AND WE RECORD THAT TEMPERATURE.
AND THEN ON THE FAR RIGHT, WE
HAVE THE TRAPEZIUS PRESSURE PAIN
THRESHOLD.
SO WE DO PRESSURE PAIN ON THE
TRAPEZIUS MUSCLE AND ON THE
FOREARM, THAT'S THE AMOUNT OF
PRESSURE UNTIL THEY REPORT THAT
AS BEING PAINFUL.
AND THESE ARE THE FOUR GROUPS
THAT WE HAVE SO FAR.
AND SO WHAT YOU'LL NOTICE HERE,
NOW THESE ARE VERY SORT OF BACK
OF THE ENVELOPE STATISTICAL
COMPARISONS, IS THAT WHAT YOU'LL
SEAL IS THAT MEN AND WOMEN,
WHETHER THEY BE CIS OR TRANS,
ARE DIFFERENT.
WHERE MEN REPORT LESS
SENSITIVITY ACROSS ALL OF THESE
MEASURES THAN THE WOMEN.
AND AGAIN, IT DOESN'T MATTER
WHETHER THEY ARE CIS WOMEN OR
TRANS WOMEN, THEY TEND TO GROUP
TOGETHER.
NOW A SUBSET OF THESE
INDIVIDUALS, WE RAN THROUGH FLOW
CYTOMETRY, RAN THEIR BLOOD
THROUGH FLOW CYTOMETRY TO LOOK
AT IMMUNE CELL POPULATIONS.
SO THIS IS FOR CD4 POSITIVE
CELLS AND ACTIVATED CD4 POSITIVE
CELLS, AND AGAIN, JUST LIKE YOU
WOULD EXPECT, WOMEN HAVE MORE
CD4 POSITIVE CELLS AND MORE
ACTIVATED -- THAN MEN DO
REGARDLESS OF WHETHER THEY ARE
CIS OR TRANS.
OBVIOUSLY HORMONES SHOULD HAVE A
MAJOR IMPACT ON IMMUNE CELL
POPULATIONS.
AS IT TURNED OUT WHEN WE RAN
THIS STUDY, WE HAD ONE TRANS MAN
AND ONE TRANS WOMAN THAT
REPORTED NOT BEING ON HRT.
WE HAVEN'T RUN THE HORMONE ASSAY
YET SO WE CAN'T CONFIRM ALL
THAT, BUT IF WE JUST GO BY
SELF-REPORT, WHAT WE SEE HERE IS
THAT THAT REALLY DOESN'T MAKE
MUCH OF A DIFFERENCE.
SO THE INDIVIDUALS NOT ON THE
HRT ARE ON THE DOTTED BARS BUT
THEY TEND TO BE VERY SIMILAR TO
THE OTHER INDIVIDUALS WITHIN
THAT GROUP.
NOW, AM I SUGGESTING THAT GENDER
IDENTITY AFFECTS CELL
POPULATIONS?
NO.
BUT MAYBE.
MAYBE I WILL BE A LITTLE BIT
LATER ON, ONCE WE HAVE MORE
DATA.
BUT IT DOES BEAR THINKING ABOUT.
NOW THE NEXT THING I WANTED TO
DO TO SORT OF BRING US BACK TO
THAT FIRST MOUSE STUDY IS A LOOK
ALL OF THESE INDIVIDUALS BASED
ON THEIR OWN SELF REPORTS, WHAT
THEIR PREDOMINANT HORMONE SHOULD
BE.
NOW AGAIN THIS IS ALL BASED ON
SELF-REPORT, SO FOR CYST MEN
THAT WOULD BE TESTOSTERONE,
TRANS WOMEN, THAT WOULD BE
ESTROGEN.
IF WE BROKE IT DOWN THAT WAY,
WHAT WE SEE FOR ALL THESE
DIFFERENT CELL POPULATIONS IS
THAT INDIVIDUALS WITH HIGHER --
PRESUMABLY HIGHER LEVELS OF
ESTROGEN HAVE HIGHER LEVELS OF
ALL OF THESE DIFFERENT T-CELL
MARKERS.
SO CD3 POSITIVE, 4 POSITIVE,
8 POSITIVE, ACTIVATED CD8 AND
CD4 AND REGULATORY T CELLS.
SO AGAIN, RIGHT BACK TO THAT
ANIMAL STUDY SHOWING THAT
FEMALES JUST HAVE MORE OF THESE
CELLS.
AND THAT IS SOMETHING THAT'S
BEEN SEEN FOR MANY, MANY YEARS,
AND IS SEEN HERE.
SO FROM OUR DATA SO FAR, IT
WOULD SUGGEST THAT GENDER
DIFFERENCES ARE THE KEY PLAYER
WHEN IT COMES TO ACUTE PAIN
SENSITIVITY THAT SEEMS TO BE
INDEPENDENT OF SEX ASSIGNED AT
BIRTH OR GENDER MINORITY STATUS.
WHETHER CIS OR TRANS.
HOWEVER, AND THIS IS WHERE IT
GETS A LITTLE BIT MORE
COMPLICATED, WHEN WE START
LOOKING AT THE PSYCHOSOCIAL
ASPECTS, WE SEE THAT THERE ARE
VERY BIG DIFFERENCES THAT SEEM
TO SEGREGATE BASED ON GENERAL
GENDERMINORITY ASPECTS.
SO ON YOU CAN SEE TRANS
INDIVIDUALS REPORT HIGHER LEVELS
THAN OUR CIS INDIVIDUALS.
SO IT ISN'T AS SIMPLE AS JUST
JEB DGENDER DIFFERENCES.
GENDER AND GENDER MINORITY
STATUS ALSO PLAYS A VERY BIG
ROLE IN THESE DIFFERENT
POPULATIONS.
WHEN WE LOOK AT FINANCIAL
SECURITY, AND AGAIN, THIS IS
JUST SELF-REPORTED FINANCIAL
SECURITY OR INSECURITY, WE SEE
OUR TRANS INDIVIDUALS ARE MORE
LIKELY TO REPORT BEING SOMEWHAT
INSECURE OR TOTALLY FINANCIALLY
INSECURE.
WHICH, AGAIN, SPEAKS TO ALL OF
THESE VARIABLES.
NOW THE LAST THING I WANT TO
MENTION IS, AGAIN, A VERY
INTERINTERESTING THING FOR US.
WE HAD A SIMILAR STUDY RUNNING
THAT ENROLLED THREE NON-BINARY
ADULTS SO I WANT TO SHOW YOU HOW
THOSE DATA STACK UP AGAINST OUR
DATA SO FAR.
IN THE COLD PRESSOR TEST AND
HEAT THRESHOLD, THE NON-BINARY
ARE SHOWN IN BLUE THERE.
WHAT YOU'LL NOTICE IS THEY MAP
VERY CLOSELY TO THE WOMEN.
NOW, AS IT TUSHES TURNS OUT, AE
WERE ASSIGNED FEMALE AT BIRTH.
SO FAR WE DON'T KNOW WHETHER
NON-BINARY INDIVIDUALS ARE MORE
SENSITIVE AND THAT HAPPENS TO BE
MORE SIMILAR TO THE WOMEN, OR,
WHETHER IN THE ABSENCE OF
IDENTIFYING AS A BINARY GENDER,
SEX THEN BECOMES THE DETERMINING
FACTOR WHEN IT COMES TO PAIN
SENSITIVITY.
HOPEFULLY I CAN ANSWER THAT
QUESTION, BECAUSE WE'VE APPLIED
FOR AN ADMINISTRATIVE SUPPLEMENT
TO DO THIS, TO ADD 40
INDIVIDUALS TO THE STUDY TO SEE
WHERE THAT FALLS.
SO WE'RE REALLY EXCITED ABOUT
THAT POTENTIAL.
SO HOPEFULLY IN ANOTHER FEW
YEARS, I'LL BE ABLE TO TELL YOU
THE ANSWER TO THAT QUESTION.
SO FOR RIGHT NOW, FINAL
THOUGHTS, SEX AND HORMONES PLAY
A KEY ROLE IN THOSE NEUROIMMUNE
PAIN MECHANISMS.
WE'VE SHOWN THAT IN ANIMALS, WE
SEE THAT IN PEOPLE AS WELL.
BUT GENDER IDENTITY PROBABLY
PLAYS A MUCH BIGGER ROLE IN PAIN
EXPERIENCE, BUT ALL OF THESE
OTHER ASPECTS OF THIS
BIOPSYCHOSOCIAL MODEL DEFINITELY
INTERACT IN ORDER TO REALLY
CREATE THAT WHOLE PAIN
EXPERIENCE AND SHOULD BE TAKEN
INTO ACCOUNT.
SO I TRIED TO SPEED THROUGH THIS
TO GET US CLOSER TO ON TIME.
SO I WANT TO THANK THE PEOPLE
THAT HELPED ALONG THE WAY, IN
JEFF'S LAB, MY COLLABORATOR,
BUREL GOODIN, MY LAB AT UAB, OUR
FUNDING SOURCES, OF COURSE, AND
THE TWO COMMUNITY GROUPS THAT
HAVE HELPED US WITH THIS SHINE
STUDY, BIRMINGHAM AIDS OUTREACH
AND TAKE BIRMINGHAM.
SO WITH THAT, THANK YOU VERY
MUCH.
>> THANK YOU, ROB.
THAT WAS VERY STIMULATING AND A
LOT OF INTERESTING FINDINGS.
I'M SURE THERE WILL BE MANY
QUESTIONS AND THEORIES ON THAT,
AND REALLY LOOKING FORWARD FOR
MORE LIKE ACTIVE DISCUSSION ON
THAT.
IT'S REALLY EXCITING.
SO OUR NEXT SPEAKER IS DR. HANNA
GROL-PROKOPCZYK.
I AM SORRY IF I'M -- I APOLOGIZE
IF I'M PRONOUNCING YOUR NAME
WRONG.
SHE'S AN ASSOCIATE PROFESSOR OF
SOCIOLOGY AT UNIVERSITY AT
BUFFALO, MEDICAL SOCIOLOGIST AND
DEMOGRAPHER.
REALLY INTERESTING BACKGROUND
AND BRINGS SOME VERY IMPORTANT
PROSPECT TO THIS ASPECT OF PAIN.
SHE HAS BEEN STUDYING PAIN,
CHRONIC PAIN AND MULTIPLE ANGLES
LIKE ITS MEASUREMENTS, THE
SOCIAL DISTRIBUTION,
CONSEQUENCES, INCLUDING OPIOID
USE AND MORTALITY, AND SHE ALSO
CONDUCTED A SEARCH ON HOW
SURVEYS CAN REALLY BEST --
INTERPERSONALLY AS WELL AS
INTERNATIONALLY, HOW IT CAN
REALLY BE MADE COMPARABLE WITH
THOSE FINDINGS, MEASURES AND
SUBJECT TO HEALTH CONDITIONS NOT
ONLY IN THE U.S. BUT ALSO
INTERNATIONALLY AND SHE ALSO
SERVES ON THE U.S. -- POLICY
SIDE, SO SHE'LL TALK ON
CORRELATES OF CHRONIC PAIN BY
SEXUAL IDENTITY.
SO PLEASE TAKE IT AWAY.
>> SO I JUST WANT TO CHECK IF I
WILL BE DRIVING.
I THINK I CAN.
ALL RIGHT.
THANK YOU SO MUCH FOR INVITING
ME.
IT'S AN HONOR TO BE HERE.
SO MUCH OF WHAT I'M GOING TO
TALK ABOUT TODAY IS KEY FINDINGS
FROM A PAPER THAT MY RESEARCH
GROUP PUBLISHED LAST YEAR ON
CHRONIC PAIN PREVALENCE IN
SEXUAL AND MINORITY GROUPS.
BUT I WILL ALSO HEED THE CALL TO
LOOK AT EVERYTHING, YOU KNOW,
INTERSECTED WITH SEX/GENDER, SO
I'LL ALSO SHARE FINDINGS
FOCUSING SPECIFICALLY ON THIS.
SO THIS RESEARCH IS SUPPORTED BY
AN R01 FROM THE NATIONAL
INSTITUTE ON AGING THAT I'M VERY
GRATEFUL FOR, AND THE PAPER I
MENTIONED WAS LEAD AUTHORED BY
MYCO-INVESTIGATOR AND FREQUENT
COLLABORATOR, ANNA ZAJACOVA,
ALONG WITH HUI LIU, RIN AND
RICHARD.
SO SINCE THE HIV/AIDS EPIDEMIC
OF THE 1980s, THERE'S BEEN
GROWING INTEREST IN HEALTH AMONG
SEXUAL MINORITIES.
AND IF YOU HAD TO SORT OF
SUMMARIZE A WHOLE BODY OF
RESEARCH IN ONE SENTENCE, YOU
MIGHT SAY SOMETHING LIKE STUDIES
OFTEN BUT NOT ALWAYS FIND THAT
SEXUAL MINORITIES HAVE HIGHER
MORTALITY AND WORSE MENTAL AND
PHYSICAL HEALTH THAN STRAIGHT
INDIVIDUALS.
HOWEVER, THERE ARE EXCEPTIONS
AND ALSO THESE FINDINGS CONTINUE
OVER TIME.
SO FOR EXAMPLE, THE ACCESS
MORTALITY OF GAY MEN RELATIVE TO
STRAIGHTMEN THAT EMERGED DURING
THE HIV EPIDEMIC, RECENT STUDIES
THAT LOOK AT YOUNGER COHORTS
DON'T SEW THAT.
SEE THAT, THEY SEE NO
MORTALITY DISADVANTAGE FOR GAY
MEN.
YOU MIGHT ALSO THINK, WELL,
THERE HAVE BEEN A LOT OF
IMPORTANT LEGISLATIVE VICTORIES
FOR SEXUAL MINORITIES, THERE'S
GREATER SOCIAL ACCEPTANCE, BUT
WE CAN'T ASSUME THAT CHANGES
OVER TIME WILL ALWAYS BE CHANGES
FOR THE BETTER.
IN FACT, A RECENT STUDY BY LIU
AND RECZEK FOUND THAT MENTAL
HEALTH DISPARITIES BY SEXUAL
IDENTITY ARE ACTUALLY LARGER FOR
YOUNGER COHORT, MILLENNIALS,
THAN THEY ARE FOR GEN X'ERS OR
BABY BOOMERS, SO GREATER HEALTH
PENALTY.
SO WE HAVE TO SORT OF KEEP
MONITORING.
REGARDING CHRONIC PAIN IN
PARTICULAR, SO CHRONIC PAIN IS
VERY COMMON AND VERY COSTLY.
THIS AUDIENCE PROBABLY IS
ALREADY AWARE.
BUT I'M JUST GOING TO ADD TO
THAT, THAT CHRONIC PAIN IS
FAIRLY UNIQUE AMONG COMMON
CHRONIC HEALTH CONDITIONS TO THE
EXTENT THAT IT CORRELATES
STRONGLY WITH PHYSICAL HEALTH
CONDITIONS AND MENTAL HEALTH,
DEPRESSION AND ANXIETY IN
PARTICULAR.
SO BECAUSE OF THAT ABILITY TO
PICK UP ON PHYSICAL AND MENTAL
HEALTH, THAT'S ONE REASON THAT
WE'VE ARGUED THAT PAIN IS A
PARTICULARLY SENSITIVE BAROMETER
OF POPULATION HEALTH.
NONETHELESS, WE FOUND ONLY ONE,
SPECIFICALLY ON HEADACHE, THAT
USED NATIONAL DATA TO
CHARACTERIZE PAIN BY SEXUAL
IDENTITY.
WHEN WE STARTED WORKING ON THIS
PAPER AROUND 2021.
ALSO SOME GROUPS ARE
UNDERSTUDIES, SO HISTORIC AND WA
GROWING NUMBER OF INDIVIDUALS
THAT ARE CLASSIFIED AS
"SOMETHING ELSE," SO NOT
STRAIGHT, GAY, LESS TB LESBIAN R
BISEXUAL AND THAT GROUP REMAINS
UNDERSTUDIED, AND THOSE WITH
DISPARITIES NEED TO BE STUDIED
MORE.
SO OUR GOAL IN THIS STUDY WAS
FIRST TO CHARACTERIZE PAIN
PREVALENCE BY SEXUAL IDENTITY
USING NATIONALLY REPRESENTATIVE
DATA AND INCLUDING LESS COMMONLY
STUDIED GROUPS, AND SECOND, TO
THE EXTENT THAT WE COULD, USING
CROSS-SECTIONAL DATA, TO SEE IF
WE COULD IDENTIFY SOME POTENTIAL
MECHANISMS FOR THE OBSERVED
DISPARITY.
SO WE USED SIX CONSECUTIVE YEARS
OF DATA FROM THE NATIONAL HEALTH
INTERVIEW SURVEY.
POOLED THEM TOGETHER TO MAXIMIZE
OUR SAMPLE SIZE.
WE STARTED WITH 2013, SINCE THAT
WAS THE FIRST YEAR IN WHICH --
ASKED ABOUT SEXUAL IDENTITY, AND
WENT THROUGH 2018, THE LAST YEAR
BEFORE A MAJOR SURVEY REDESIGN
PRECLUDED FROM LATER YEARS.
USUALLY WHEN WE USE NH IS, WE
USE THE FULL ADULT AGE RANGE,
BUT BECAUSE WE WANTED TO INCLUDE
THE BISEXUAL AND SOMETHING ELSE
GROUPS, AND VERY FEW INDIVIDUALS
ABOVE AGE 64 IDENTIFIED IN THAT
WAY, FOR SAMPLE SIZE REASONS, WE
DECIDED TO CAP OUR AGE RANGE AT
AGE 64.
BUT WE DID LOOK AT FINDINGS
THROUGH AGE 84 FOR STRAIGHT, GAY
AND LESBIAN INDIVIDUALS AND THE
BASIC PATTERNS I'M GOING TO SHOW
YOU ARE OBSERVED IN THOSE OLDER
AGE GROUPS AS WELL.
SO WE ACTUALLY LOOKED AT A WHOLE
BUNCH OF PAIN MEASURES.
THERE ARE A LOT OF WAYS YOU CAN
CONSTRUCT PAIN MEASURES FROM
NHIS DATA, BUT IN THE PAPER, WE
HIGHLIGHTED TWO OF THEM, AND SO
I'M GOING TO FOCUS ON THOSE HERE
AS WELL.
CHRONIC PAIN WAS OPERATIONALIZED
HERE AS HAVING PAIN MOST DAYS OR
EVERY DAY IN THE PAST THREE TO
SIX MONTHS.
SAMPLE SIZE FOR THOSE ANALYSES
WAS OVER 95,000.
AND OUR SAMPLE ADJUSTED
PREVALENCE WAS 17.4%.
THAT IS A LITTLE LOWER THAN THE
COMMONLY CITED FIGURE OF 20%
CHRONIC PAIN PREVALENCE IN THE
COUNTRY, BUT REMEMBER WE
EXCLUDED PEOPLE OVER AGE 64, AND
THEY WOULD HAVE RAISED THAT
NUMBER.
THE SECOND MEASURE IS PAIN IN
THREE OR MORE SITES OUT OF THE
FIVE SITES THAT NHIS ASKS ABOUT.
SO IT ASKS ABOUT LOW BACK PAIN,
NECK PAIN, SEVERE HEADACHE OR
MIGRAINE, FACIAL/JAW PAIN AND
JOINT PAIN.
AND FOR THOSE ANALYSES, OUR
SAMPLE SIZE WAS ABOVE 130,000
AND THE PREVALENCE WAS 11.7%.
THE SEXUAL IDENTITY QUESTION IN
NHIS READS, WHICH BEST
REPRESENTS HOW YOU THINK OF
YOURSELF?
LESBIAN OR GAY, STRAIGHT, THAT
IS NOT GAY, BISEXUAL, OR
SOMETHING ELSE?
AND WE ALSO HAD A COUPLE DOZEN
VO CACOVARIATES, DEMOGRAPHIC,
SOCIOECONOMIC, HEALTH
BEHAVIORS/HEALTHCARE, AND
PSYCHOLOGICAL DISTRESS THAT WE
OBSERVED AS POTENTIAL MEDIATORS
OF DISPARITIES.
I WANT THED TO HIGHLIGHT THESE,E
PSYCHOLOGICAL DISTRESS MEASURE
THAT WAS THE KESSLER 6 ITEM
SCALE THAT ASKS PEOPLE HOW
FREQUENTLY IN THE PAST MONTH
THEY FELT SAD, RESTLESS,
HOPELESS, WORTHLESS, NERVOUS, OR
LIKE EVERYTHING WAS AN EFFORT.
SO ESSENTIALLY THIS IS TRYING TO
GET AT SYMPTOMS OF DEPRESSION
AND ANXIETY.
YOU MIGHT BE WONDERING WHO
IDENTIFIES AS SOMETHING ELSE IN
TERMS OF SEXUAL IDENTITY.
SO I'M REALLY GRATEFUL TO
RICHARD WHO POINTED OUT TO US
THAT WHEN NIHS IS DEVELOPING OR
FIELDING NEW QUESTION, THEY DO
IN DEPTH COGNITIVE INTERVIEWS
AND THERE'S A GREAT REPORT THAT
SUMMARIZES WHAT THEY LEARNED
FROM THE 386 PEOPLE WHO THEY
INTERVIEWED ASKING THEM WHAT
THEY MEANT OR HOW THEY
INTERPRETED THE SEXUAL IDENTITY
QUESTION.
FROM THAT, WE LEARNED THAT MANY
TRANSGENDER INDIVIDUALS CHOSE
THE "SOMETHING ELSE" CATEGORY,
SO ALREADY A FIRST HINT THAT YOU
CAN'T REALLY ANALYZE SEXUAL
IDENTITY IN ISOLATION OF GENDER.
PEOPLE IDENTIFIED AS QUEER,
PEOPLE WHO REJECTED OTHER LABELS
OR AT LEAST THE LABELS THAT NHIS
OFFERED, AND PEOPLE WHO
IDENTIFIED AS ASEXUAL.
SO THIS REASSURES US THAT THE
"SOMETHING ELSE" GROUP, THIS
WASN'T JUST SYNONYMOUS WITH, YOU
KNOW, DON'T KNOW/REFUSE, WITH
YOU PEOPLBUTPEOPLE WERE SELECTIS
CATEGORY DELIBERATELY AND IT'S A
MEANINGFUL CATEGORY.
SO OUR MAIN RESULT, I GUESS, CAN
BE SUMMARIZED WITH THIS FIGURE.
YOU CAN SEE HERE WE HAVE AGE
ALONG THE X AXIS AND THE GENERAL
CHRONIC PAIN PREVALENCE ALONG
THE Y, AND YOU CAN SEE THAT
THERE ARE SORT OF TWO PAIRS OF
LINES.
SO THE RED AND ORANGE LINE AT
THE TOP SHOWED PREVALENCE FOR
THE "SOMETHING ELSE" AND
BISEXUAL GROUPS.
AND THEN THE GREY AND BLACK
LINES BELOW ARE A SURE
GAY/LESBIAN AND STRAIGHT.
IN OUR MODEL, THE DIFFERENCE
BETWEEN -- YOU CAN SEE
SUBSTANTIVELY IT'S A RELATIVELY
SMALL DIFFERENCE IN PAIN
PREVALENCE.
BUT AS YOU MOVE FROM THOSE LOWER
TWO LINES TO THE UPPER TWO
LINES, THAT'S A VERY SIZABLE
DIFFERENCE.
THE DIFFERENCE IS ALREADY
APPARENT AT AGE 18, PERSISTS AND
EVEN WIDENS OVER THE COURSE OF
THE LIFE COURSE, AND EVEN
LOOKING AT AGE 18, YOU'RE SEEING
ABOUT TWICE THE PREVALENCE AMONG
THE SOMETHING ELSE AND BISEXUAL
GROUPS THAT YOU SEE AMONG THE
STRAIGHT AND GAY/LESBIAN GROUP.
SO IT'S A VERY SIZABLE
DIFFERENCE AND JUST IN ABSOLUTE
TERMS FOR PEOPLE WHO IDENTIFY AS
BISEXUAL OR SOMETHING ELSE, BY
AGE 60 OR SO, PAIN PREVALENCE IS
IN THE RANGE OF -- CHRONIC PAIN
PREVALENCE IS IN THE RANGE OF
50%, WHICH IS REALLY
STAGGERINGLY HIGH.
FOR THE PAIN IN THREE OR MORE
SITES, THE PATTERN WAS A LITTLE
DIFFERENT.
WE HAVE THIS SORT OF DOWNTURN IN
PREVALENCE BY AGE FOR BISEXUAL
INDIVIDUALS, SO A BIT OF A
CONVERGENCE WITH STRAIGHT AND
GAY/LEZLESS BLESBIAN BUT THE GEL
PATTERN OF HIGHER PAIN AS THOSE
TWO IDENTIFY AS SOMETHING ELSE
OR BISEXUAL THAT WE'RE STILL
SEEING.
SO WE DID A FORMAL DECOMPOSITION
ANALYSIS TO SEE WHICH OF THESE
KINDS OF CHARACTERISTICS MAY BE
DRIVING DIFFERENCES IN
PREVALENCE BETWEEN STRAIGHT AND
SEXUAL MINORITY ADULTS.
SO I'M GOING TO SHOW SORT OF THE
PERCENTAGE EXPLAINED.
SOME OF THESE ARE NEGATIVE
BECAUSE THE FACTORS WERE
SUPPRESSORS RATHER THAN
MEDIATORS, BUT IN THE INTEREST
OF TIME, LET ME JUMP RIGHT TO
THE MAIN FINDING HERE.
IF YOU POSIT THAT PSYCHOLOGICAL
DISTRESS IS A POTENTIAL
MEDIATOR, IT SEEMS TO EXPLAIN
ABOUT 63% OF THE MINORITY PAIN
DISADVANTAGE.
AND WE'VE DONE DECOMPOSITION
ANALYSES TO SEE WHAT FACTORS MAY
BE DRIVING RACIAL/ETHNIC
DIFFERENCES IN PAIN, AND REALLY
USUALLY NOTHING EXPLAINS 63%.
I MEAN, THAT'S A REALLY HIGH
PERCENTAGE THERE.
SO I ACTUALLY AM GOING TO GO
BACK TO DESCRIPTIVE STATISTICS
BRIEFLY SINCE NOW IT'S CLEAR
THAT THAT PSYCHOLOGICAL DISTRESS
IS SO IMPORTANT.
IF WE CLASSIFY THAT INTO LOW,
MODERATE, SEVERE TO
PSYCHOLOGICAL DISTRESS, AMONG
STRAIGHT INDIVIDUALS, 3.5% FALL
INTO THE SEVERE DISTRESS
CATEGORY.
BUT WITH EACH SUCCESSIVE GROUP
MOVING LEFT TO RIGHT, THAT
NUMBER GETS HIGHER AND THE
SOMETHING ELSE GROUP ACTUALLY
HAS A FOUR TIMES HIGHER
PREVALENCE OF SEVERE
PSYCHOLOGICAL DISTRESS.
SO IF ANYONE WANTS TO TALK TO ME
ABOUT THE DISTRESS SIDE OF
THINGS, THIS IS SOMETHING I VERY
MUCH WANT TO LEARN MORE ABOUT.
SO DO THESE PATTERNS DIFFER
BETWEEN MEN AND WOMEN?
I WANT TO EXPLAIN THAT NHIS
STRICTLY ENFORCES CLASSIFYING
ALL ITS PARTICIPANTS AS WHAT IT
CALLS MALE OR FEMALE.
SO I'M NOT ABLE TO DISTINGUISH
SEX FROM GENDER, SO I'LL TALK
ABOUT THESE GROUPS AS MEN AND
WOMEN FOR NOW, BUT IDEALLY WE
WOULD GET SOME MORE INFORMATION
IN THE FUTURE ON WHAT THOSE
CATEGORIES MEAN TO PEOPLE.
SO FOR MEN, BEING A SEXUAL
MINORITY DOES NOT ALWAYS PREDICT
HIGHER RISK OF PAIN.
SO FOR THE GENERAL CHRONIC PAIN
MEASURE, THE PREVALENCE IS
ACTUALLY VERY SIMILAR ACROSS THE
SEXUAL IDENTITY GROUPS, ALTHOUGH
FOR PAIN IN THREE OR MORE SITES,
WE DO SEE SIGNIFICANTLY HIGHER
PREVALENCE AMONG BUY SECTION
EULS.
BISEXUALS.
FOR WOMEN IN CONTRAST, IT'S VERY
CONSISTENT FOR THESE TWO
OUTCOMES AND ALSO FOR VARIOUS
OTHER OUTCOMES WE TESTED, THAT
BEING A SEXUAL MINORITY PREDICTS
HIGHER LEVELS OF PAIN.
SO THERE IS AN IMPORTANT
SEX/GENDER DIFFERENCE HERE.
SO TO BRIEFLY SUMMARIZE, SEXUAL
MINORITIES, ESPECIALLY WOMEN,
HAVE HIGHER PAIN PREVALENCE THAN
THEIR STRAIGHT COUNTERPARTS.
PAIN PREVALENCE IS ESPECIALLY
HIGH FOR INDIVIDUALS IDENTIFYING
AS BISEXUAL OR SOMETHING ELSE
FROM YOUNG ADULTHOOD ONWARDS.
THE STRONGEST CORRELATIVE OF
THESE DISPARITIES IS
PSYCHOLOGICAL DISTRESS.
SO I SEE AT LEAST THREE HIGH
PRIORITY DIRECTIONS FOR FUTURE
RESEARCH.
SO A REALLY BIG QUESTION IS,
WHAT EXACTLY IS THE CAUSAL
RELATIONSHIP BETWEEN THE
PSYCHOLOGICAL DISTRESS, THE
PAIN, AND SEXUAL IDENTITY?
SO THERE DEFINITELY IS A LOT OF
EVIDENCE FROM LITERATURE ON
SEXUAL MINORITY HEALTH IN
GENERAL THAT -- DISCRIMINATION
INCREASE STRESS WHICH, YOU KNOW,
WE CAN POSIT COULD INCREASE RISK
OF PAIN.
BUT WE ALSO HAVE DECADES OF
RESEARCH IN THE PAIN WORLD
SHOWING THAT THERE'S ACTUALLY A
COMPLEX RECIPROCAL RELATIONSHIP
BETWEEN PAIN AND DEPRESSION, AND
THAT THE TWO SOMETIMES SEEM TO
SORT OF EMERGE IN TANDEM, SO TO
KIND OF UNDERSTAND WHAT CAUSES
WHAT AND HOW MUCH, WE NEED TO DO
SOME MORE WORK WITH LONGITUDAL
DATA.
AS I MENTIONED, I DIDN'T HAVE
THE DATA TO LOOK AT HOW THESE
PATTERNS DIFFER ACROSS THIS
TRANS AND NON-BINARY GENDERS BUT
THINK THAT WOULD BE A VERY
IMPORTANT DIRECTION.
AND ANOTHER THING THAT'S REALLY
IMPORTANT GIVEN SORT OF WHAT'S
GOING ON IN THE WORLD THESE
DAYS, YOU KNOW, OUR DATA -- OR
THE DATA WE USE ENDED IN 2018,
WHICH IS ONLY SIX YEARS AGO.
IN OUR DATA, FEWER THAN ONE HALF
OF 1% OF RESPONDENTS IDENTIFIED
AS SOMETHING ELSE.
BUT IF YOU WERE TO LOOK AT DATA
TODAY, I WOULD EXPECT THAT
PERCENTAGE TO BE HIGHER,
ESPECIALLY IF YOU'RE LOOKING AT
YOUNG ADULTS.
AND THERE ARE STUDIES SHOWING
MUCH HIGHER PREVALENCE OF PEOPLE
CHOOSING NON-BINARY -- OR
IDENTIFYING WITH NON-BINARY
GENDER OR SORT OF LESS
TRADITIONAL SEXUAL IDENTITY
CATEGORIES, AND SO I THINK IT'S
SORT OF AN OPEN QUESTION, WILL
PEOPLE WHO TAKE ON THESE LESS
COMMON IDENTIFICATIONS SHOW THE
POOR PSYCHOLOGICAL DISTRESS AND
PAIN OUTCOMES THAT WE SAW HERE,
OR WILL THERE ACTUALLY BE A SORT
OF DESTIGMATIZATION, GREATER
LEVEL OF SUPPORT, SORT OF SAFETY
IN NUMBERS, COULD WE ACTUALLY
SEE THINGS MOVE IN THE OPPOSITE
DIRECTION THAT THESE GROUPS
BECOME LESS STIGMATIZED AND
THERE'S LESS DISTRESS AND PAIN,
SO THAT'S AN IMPORTANT OPEN
QUESTION.
ALL RIGHT.
SO THAT'S IT.
THANK YOU.
[APPLAUSE]
>> THANK YOU, HANNA.
THIS WAS NOT ONLY INTERESTING,
EYE OPENING AT LEAST TO ME, A
LOT OF NEW DATA AND NEW
INFORMATION.
THANK YOU AGAIN.
SO OUR LAST SPEAKER, NOT LEAST
BUT VERY INTERESTING TALK COMING
UP.
SO IT'S BY DR. GU GUNISHA KAUR,
FOUNDING DIRECTOR OF HUMAN
RIGHTS IMPACTS LAB THERE IN THE
COLLEGE, AND SHE HAS A REALLY
EXTENSIVE BACKGROUND IN
NEUROSCIENCE, AS A HEALTH -- AN
LICK LITH CAL FRAMEWORK
RESEARCH, AND HER GOAL IS TO
REALLY ADVANCE STUDIES ON --
HEALTH THROUGH SCIENTIFIC -- AND
SHE HAS MADE REALLY SEMINAL
CONTRIBUTIONS TO THE
UNDERSTANDING OF PAIN AND
DISTRESS MAINLY IN THE FORCIBLY
DISTRESSED POPULATION AND HER
WORK HAS BEEN REALLY PUBLISHED
IN MULTIPLE LEADING SCIENTIFIC
AND MEDICAL JOURNALS, AS WELL AS
IN MAINSTREAM NEWS MEDIA
OUTLETS.
SHE HAS GIVEN REALLY OVER A
HUNDRED NATIONAL/INTERNATIONAL
KEYNOTE PRESENTATIONS TO GLOBAL
LEADERS, TO UNITED NATIONS, AND
UNITED STATES GOVERNMENT ON THIS
ASPECT AND THIS TOPIC
SPECIFICALLY.
SHE'S A FACULTY FELLOW AT THE
CENTER FOR INNATIO INTERNATIONAL
STUDIES, AND KELLER TEAM MEMBER
AT THE COUNCIL OF FOREIGN
RELATIONS.
SO IN 2022, SHE WAS SELECTED BY
THE -- AS AN EMERGING LEADER IN
HEALTH AND MEDICINE, AND THE
VERY NEXT YEAR, 2023, SHE WON
THE NATIONAL ACADEMY OF MEDICINE
PRIZE.
SO SHE WILL TALK TODAY, SHEDDING
MORE LIGHT INTO UNDERSTANDING
AND ASSESSING PAIN IN FORCIBLY
DISPLACED POPULATIONS.
SO GUNISHA, PLEASE TAKE OVER.
>> THANK YOU SO MUCH FOR HAVING
ME.
I'M HONORED TO BE HERE TO SHARE
MY EXPERIENCES AS AN
ANESTHESIOLOGIST AND MEDICAL
ANTHROPOLOGIST AND REFUGEE
HEALTH RESEARCHER.
I'M REALLY GOING TO SHARE THE
EXPERIENCES PART OF PAIN IN A
UNIQUE MINORITY POPULATION.
MEDICAL ANTHROPOLOGISTS ARE BY
TRAINING STORYTELLERS, AND I'LL
START BY SHARING THE STORY OF A
6-YEAR-OLD CHILD IN OUR CLINIC
WHO I'LL CALL NOR.
NOR'S FAMILY LIVED IN
AFGHANISTAN, WHERE FOR YEARS HER
FATHER WORKED IN A HIGH-RANKING
POSITION FOR THE U.S.
GOVERNMENT.
WHEN THE 2021 WITHDRAWAL BECAME
INEVIDENT ABLE, NOR'S FAMILY WAS
ESCORTED TO THE AIRPORT, WHERE
IN THE CHAOS, THEY WERE
SEPARATED.
6-YEAR-OLD NOR MADE IT ON TO THE
FLIGHT WITH NO PARENT AND NO
SIBLINGS.
SHE SPENT WEEKS UNIDENTIFIED IN
A REFUGEE CAMP IN THE MIDDLE
EAST UNTIL, FINALLY, SHE WAS
CONNECTED TO AN UNCLE THAT SHE
HAD NEVER MET BEFORE, AND SENT
TO LIVE WITH HIM IN NEW YORK
CITY.
WITHIN MINUTES OF MEETING NOR AS
PART OF OUR CLINIC VISIT, IT WAS
CLEAR TO ME THAT SHE NEEDED
URGENT MEDICAL CARE.
SHE WAS CRYING NONSTOP ASKING
FOR HER PARENTS, BANGING HER
HEAD AGAINST THE WALL, AND
EXPRESSING PAIN AND DISTRESS,
AND SHE WAS RUNNING OUT INTO THE
STREETS OF QUEENS AT NIGHT,
THINKING THAT SHE WAS IN KABUL
AND TRYING TO GET HOME.
BUT THERE WAS ONE THING THAT WE
NEEDED TO WORK ON MORE
IMMEDIATELY THAN ANYTHING ELSE,
AND THAT WAS GETTING HER
REUNITED WITH HER PARENTS IN THE
NOW 72 HOURS BEFORE U.S.
WITHDRAWAL.
BUT NOR WAS NEVER REUNITED WITH
HER PARENTS, NOT THEN AND NOT
NOW.
THEIR SPECIAL IMMIGRANT VISA
APPLICATION LANGUISHED IN THE
U.S. IMMIGRATION SYSTEM.
6-YEAR-OLD NOR LANGUISHED IN THE
U.S. IMMIGRATION SYSTEM.
AND AS THE SUMMER TURNED TO FALL
AND AS THE FALL TURNED TO
WINTER, AS AMERICA'S WRAPPED
ATTENTION TO THE WITHDRAWAL IN
AFGHANISTAN DRIFTED AWAY, NOR'S
STORY WAS FORGOTTEN.
NOR AND THE TENS OF THOUSANDS OF
CHILDREN LIKE HER WHO LA
LANGUISHED, TOO YOUNG AND TOO
INNOCENT TO HAVE THEIR LIVES
IMPACTED BY SUCH PROFOUND
ADVERSITY WERE SIMPLY ERASED
FROM OUR COLLECTIVE MEMORIES.
AT THE WEILL CORNELL CENTER FOR
HUMAN RIGHTS, WE SEE HUNDREDS OF
STORIES LIKE NOR'S EACH YEAR.
OUR CLINIC PROVIDES FORENSIC
MEDICAL EVALUATIONS AS PEOPLE
SEEK ASYLUM IN THE U.S.,
TRANSLATING PHYSICAL AND
PSYCHOLOGICAL SCARS INTO WORDS
THAT AN IMMIGRATION JUDGE CAN
UNDERSTAND.
FOR EXAMPLE, THAT MEMORY GAPS
MAY BE A SYMPTOM OF PTSD OR
DEPRESSION, NOT NECESSARILY A
SIGN OF LYING.
WHEREAS THE NATIONAL RATE OF
ASYLUM LINGERS AROUND 30% WITH
THE FORENSIC MEDICAL EVALUATION
IN HAND.
AT OUR CLINIC, THAT RATE JUMPS
TO OVER 95%.
OUR PATIENTS COME FROM ALL OVER
THE WORLD.
AND AS WAR AND VIOLENCE AND
CLIMATE CHANGE INCREASINGLY
DISPLACE MEN, WOMEN AND
CHILDREN, CURRENTLY AT A RATE OF
NEAR LEGAL 50,000 PEOPLE EACH
DAY, UNDERSTANDING THE NEEDS OF
THIS UNIQUE, IMPORTANT AND
RAPIDLY GROWING PATIENT
POPULATION IS INCREDIBLY
IMPORTANT AT THIS TIME.
ONLY 2% OF THE WORLD'S MIGRANTS
CROSS AN INTERNATIONAL BOUNDARY
AS ASYLUM SEEKERS, SO THESE
PATIENTS, THAT TINY DARK SLIVER
YOU SEE THERE.
THESE PATIENTS TEND TO BE
EDUCATED, HEALTHY, HAVE VAST
SOCIAL NETWORKS AND RESOURCES,
AND THESE ARE THE PATIENTS THAT
WE SEE IN OUR CLINIC.
WHERE A VAST MAJORITY OF PEOPLE
WERE PROFESSIONALS IN THEIR HOME
COUNTRIES, EITHER TEACHERS OR
ENGINEERS, HEALTHCARE PROVIDERS.
THERE'S A NEAR EQUAL SPLIT
BETWEEN MEN AND WOMEN, AND ABOUT
40% ARE CHILDREN UNDER THE AGE
OF 18, AND THESE GLOBAL
MIGRATION FLOWS REALLY MIMIC
WAR, VIOLENCE AND PERSECUTION
THAT IS HAPPENING ACROSS THE
WORLD.
SO WHEN PEOPLE COME TO US,
THEY'RE TYPICALLY COMING BECAUSE
OF AN ACUTE SITUATION, AND YOU
CAN SEE THAT IN THESE SPIKES IN
THE FIGURES.
THIS IS A POPULATION, AGAIN,
THAT TENDS TO BE OTHERWISE YOUNG
AND HEALTHY.
THE AVERAGE AGE IN OUR CLINIC IS
JUST 38 YEARS.
BUT AS THEY MIGRATE, THEY FACE
EXTREME PRESSURES AND STRESS
FROM OBTAINING LEGAL STATUS IN
THEIR HOST COUNTRIES, EXTREME
POVERTY, HOMELESSNESS, LACK OF
ACCESS TO BASIC MEDICAL CARE FOR
THEMSELVES AND THEIR CHILDREN.
THE PATIENTS THAT WE SEE HAVE
INKRED BLIP COMPLEX LIFE AND
MEDICAL HISTORIES.
THAT ARE INEXTRICABLY
INTERTWINED.
THAT IS PARTICULARLY SO FOR
WOMEN WHO MAY FACE SEXUAL
VIOLENCE IN THEIR HOME
COUNTRIES, TRAFFICKING DURING
MIGRATION JOURNEYS, AND SEXUAL
ABUSE ON ARRIVAL TO A HOST
COUNTRY.
I'M AN ANESTHESIOLOGIST BY
TRAINING.
MY CLINICAL PRACTICE IS ROOTED
IN COMPLEX AIRWAY DISEASE AND
ABDOMINAL DISEASE, AND I CAN SAY
OVER THE PAST 15 YEARS, THESE
ARE BY FAR THE MOST COMPLEX
PATIENTS THAT WE SEE IN A
REFUGEE CRA CAMP IN GREECE, CHIN
AS YOUNG AS 4 WERE BEING
TRASKTED AND SOLD INTO MARRIAGE
BECAUSE THEIR FAMILIES JUST
COULD NOT SUPPORT THEM.
SO GLOBALLY, THERE'S A MAJOR GAP
IN OUR UNDERSTANDING OF THE
HEALTH AND HEALTHCARE NEEDS OF
THIS PATIENT POPULATION.
AT THE HUMAN RIGHTS IMPACT LAB,
WE AIM TO CHANGE THAT.
WE AIM TO ESTABLISH A STANDARD
OF CARE FOR THESE PATIENTS
THROUGH A RIGOROUS SCIENTIFIC
APPROACH TO REFUGEE HEALTH
RESEARCH.
FOUNDED IN 2010, WE ARE THE
OLDEST AND LARGEST MEDICAL-LEGAL
ASYLUM CLINIC IN THE COUNTRY,
AND ONE OF THE ONLY SUCH CLINICS
WITH INVESTIGATORS THAT ARE
SUPPORTED BY NIH FUNDING, AND I
THINK THAT JUST GIVES US A
REALLY WONDERFUL OPPORTUNITY TO
FORGE THIS NEW LINE OF
SCIENTIFIC INQUIRY.
THERE ARE SEVERAL CATEGORIES OF
RESEARCH THAT WE CONDUCT THAT
I'M VERY BRIEFLY GOING TO GO
OVER AS BACKGROUND.
THE FIRST IS CLINICAL RESEARCH,
LIKE INVESTIGATING HOW TO
ACCURATELY DIAGNOSE AND TREAT
SOMATIC PAIN AFTER TORTURE,
WHICH IS THE FOCUS OF MY NINDS
K23, AND THIS IS IN A PATIENT
POPULATION WHERE NEARLY ALL OF
PAIN IS THOUGHT TO BE
PSYCHIATRIC OR PSYCHOSOMATIC IN
NATURE.
PEOPLE OBVIOUSLY HAVE A LOT OF
PSYCHOLOGICAL TRAUMA, AND WHEN
YOU LACK AT THE STUDIES THAT
HAVE BEEN DONE ON PAIN, IT'S
ALMOST ALWAYS THOUGHT TO BE
PURELY SINGULARLY PSYCHIATRIC OR
PSYCHOSOMATIC.
BUT WE HAVE FOUND THAT IN ALMOST
90% OF CASES, THE PAIN IS
DIRECTLY ASSOCIATED WITH THE
MECHANISM OF TRAUMA, MEANING
THAT IT'S NOT SIMPLY PSYCHIATRIC
OR PSYCHOSOMATIC.
THE SECOND TYPE OF RESEARCH THAT
WE DO IS LARGE DATABASE
RESEARCH, WHERE WE ANALYZE
TRENDS LIKE THE STUDY LOOKING AT
PAIN AND CVD AND STRESS-RELATED
SPECIFICALLY TO THE THREAT OF
DEPORTATION.
THE THIRD TYPE OF RESEARCH IS
DIGITAL TECHNOLOGY RESEARCH,
WHERE WE USE CUTTING EDGE
DIGITAL TOOLS TO ADVANCE THE
HEALTH OF THIS REALLY VULNERABLE
POPULATION.
WHILE PEOPLE HAVE ALMOST NOTHING
WHEN THEY CROSS AN INTERNATIONAL
BOUNDARY, ALMOST EVERYBODY HAS A
SMARTPHONE, OUR STUDIES HAVE
SHOWN THAT OVER 90% OF U.S.
ASYLUM SEEKERS CARRY
SMARTPHONES, IF% HAVE IPHONES
AND 100% OF OUR PATIENTS HAVE
THE DIGITAL LITERACY NEEDED FOR
CUTTING EDGE DIGITAL EDGE
INTERVENTIONS.
THIS IS A GROUP SO FEARFUL OF
POLICIES LIKE FAMILY SEPARATION
OR DEPORTATION OR IMMIGRATION
DETENTION THAT THEY AVOID
ACCESSING HEALTHCARE AT ALMOST
ALL COSTS.
SO FOR EXAMPLE, WE'VE HAD HIGH
RISK PREGNANT PATIENTS REFUSE
SICKLE CELL TESTING BECAUSE THEY
WERE AFRAID OF BEING SEPARATED
FROM THEIR CHILDREN.
BUT WE HAVE SHOWN THAT WE CAN
USE TECHNOLOGY WEARABLE DEVICES,
SMARTPHONES, TO DETECT AND TREAT
CERTAIN DISEASES REMOTELY AND
EARLY IN THIS PATIENT
POPULATION, WHICH OBVIOUSLY NOT
ONLY ADVANCES THEIR HEALTH BUT
ALSO PUBLIC HEALTH.
ONE OF OUR STUDY, FOR EXAMPLE,
EVALUATES THE EARLY DIAGNOSIS OF
HYPERTENSIVE DISORDERS AND PAIN
IN PREGNANT REFUGEE WOMEN, AND
OUR ABILITY TO CONNECT THESE
HIGH RISK PATIENTS TO HEALTHCARE
PROVIDERS EITHER VIRTUALLY OR IN
PERSON AND LIKE MY CHILDREN, I
TRY NOT TO PICK FAVORITE STUDIES
BUT THIS IS A REALLY IMPORTANT
STUDY THAT'S NEAR AND DEAR TO MY
HEART BECAUSE I THINK THIS IDEA
THAT WE CAN POTENTIALLY ADVANCE
THE HEALTH OF HUNDREDS OF
THOUSANDS OF PREGNANT REFUGEE
WOMEN AND THEIR NEWBORN BABIES
IS JUST SO EXCITING.
SO THIS IS AN EXAMPLE OF ONE OF
OUR HEALTHCARE RESOURCES THAT
WE'VE DESIGNED, A SYSTEM THAT
ALLOWS US TO USE A.I. AND
MACHINE LEARNING FOR EARLY PAIN
DETECTION IN THIS PATIENT
POPULATION, AGAIN, A POPULATION
THAT DOES NOT ENGAGE WITH
HEALTHCARE PROVIDERS IN PERSON
IN GENERAL.
WE CAN USE THE SYSTEM TO
DIAGNOSE DISEASE EARLY OR TRIAGE
FOR FURTHER ASSESSMENT AND
PROVIDE TARGETED CARE.
I THINK IT'S JUST THIS
OPPORTUNITY IS REALLY
TRANSFORMATIVE FOR THIS PATIENT
POPULATION, AND THERE'S A LOT OF
PROMISE IN IT.
OUR PRIMARY GOAL IS REALLY TO
ADVANCE THE HEALTH OF THIS
OTHERWISE YOUNG AND OTHERWISE
HEALTHY PATIENT POPULATION BY
PROVIDING THEM HIGH QUALITY
EVIDENCE-BASED CARE THAT
CONSIDERS NOT JUST THEIR MEDICAL
HISTORIES, BUT ALSO THEIR LIFE
HISTORIES, SO SPECIFICALLY, WHEN
WE LOOK AT CHRONIC SOMATIC PAIN
IN REFUGEE WOMEN, WE FIND THAT
ALL OF WHAT I'VE JUST TALKED
ABOUT, THEIR HISTORIES FLEEING
PERSECUTION, SEXUAL ASSAULT,
WAR, VIOLENCE, CARING FOR THEIR
CHILDREN, THOSE SORTS OF THINGS,
THAT DEEPLY INFLUENCES THEIR
EXPERIENCES OF PAIN.
WHAT MANY PEOPLE WOULD CALL THE
SOCIAL DETERMINANTS OF HEALTH.
IN OUR PATIENT POPULATION, LIKE
HANNA WAS JUST TALKING ABOUT,
THE PSYCHOLOGICAL AND PHYSICAL
SYMPTOMS REALLY INFORM ONE
ANOTHER.
AND THERE'S THIS COMPLEX
INTERPLAY BETWEEN ONE'S LIFE
EXPERIENCES AND THEIR HEALTH.
FOR EXAMPLE, IN A SYSTEMATIC
REVIEW AND META-ANALYSIS OF
GLOBAL METHODS OF HARM WHERE WE
REVIEWED ALMOST 250, 260 STUDIES
AND INCLUDED OVER 100,000
PATIENTS, WE FOUND THAT TORTURE
AS CLASSIFIED BY THE UNITED
NATIONS CONVENTION AGAINST
TORTURE WAS SYSTEMATICALLY
PRACTICED IN OVER 100 OF THE
WORLD'S COUNTRIES, AND
IMPORTANTLY, THE EXPERIENCE OF
WOMEN AND MEN DIFFERED.
WOMEN WERE SIGNIFICANTLY MORE
LIKELY THAN MEN TO EXPERIENCE
TORTURE SUCH AS RAPE OR BURNING
OR PENETRATING TRAUMA, WHEREAS
MEN WERE MORE LIKELY THAN WOMEN
TO EXPERIENCE SUSPENSION FROM
UPPER EXTREMITIES OR BEATING OF
THE SOLES OF THE FEET OR BINDING
OR RESTRICTED MOVEMENTS.
AND AS YOU CAN IMAGINE, THAT
RESULTS IN DIFFERENT PAIN
SYNDROMES AND EXPERIENCES OF
PAIN.
AND NOT LISTED HERE IN THIS
FIGURE ARE TORTURE METHODS
APPLIED TO JUST ONE GENDER.
FOR EXAMPLE, FEMALE GENITAL
MUTILATION OR CUTTING IN WOMEN
VERSUS ROLLER CRUSHING OF
MUSCLES, WHICH IS EXPERIENCED IN
SOUTHEAST ASIA SPECIFICALLY,
ONLY FOR MEN.
SO THESE EXPERIENCES OF TRAUMA
HAD VERY REAL IMPLICATIONS FOR
THE TYPE AND SEVERITY AND
QUALITIES OF POST-TRAUMATIC PAIN
EXPERIENCED BY OUR PATIENTS.
AND I'LL GIVE YOU AN EXAMPLE
SPECIFICALLY OF FEMALE GENITAL
MUTILATION OR CUTTING.
WHILE THE WORLD HEALTH
ORGANIZATION CALLS FOR A
UNIVERSAL BAN ON FGM/C, OVER
200 MILLION WOMEN AND GIRLS
AROUND THE WORLD ARE AFFECTED BY
THIS OON THIS ONGOING PRACTICE.
IN 2020, OVER HALF OF THE TOP 10
COUNTRIES OF ORIGIN FOR ASYLUM
SEEKERS ADMITTED TO THE UNITED
STATES PRACTICED FGM/C WITH SOME
NATIONS HAVE A PREVALENCE OF
NEARLY 90%.
SO WE ARE SEEING THESE PATIENTS
IN OUR CLINICAL PRACTICES.
WE CONDUCTED A STUDY LACKING AT
THE IMPACT OF FEMALE GENITAL
MUTILATION OR CUTTING ON PAINFUL
GYNECOLOGIC OR OBSTETRIC
OUTCOMES, AND SO THIS IS A
FIGURE OF THE FOUR DIFFERENT
TYPES OF FGM/C AND WHAT YOU CAN
SEE THAT EACH OF THESE TYPES
WOULD RESULT IN SIGNIFICANT
COMPLICATIONS FOR CHILDBIRTH AND
IN EVERYDAY LIFE IN TERMS OF
PAIN.
THROUGH OUR PAPER, WE FOUND
EVIDENCE THAT INDIVIDUALS WITH
FG M/C ARE VERY CLEARLY AT
HIGHER RISK FOR DIS -- PROLONGED
LABOR AND' PIECE AND EE PEAZ EP.
WOMEN UNDERGOING FGM/C
EXPERIENCED DISRESPECT FROM
WESTERN MEDICAL PROFESSIONALS
WHO WERE UNFAMILIAR WITH THE
PRACTICE, POTENTIALLY
THREATENING DOCTOR-PATIENT
RELATIONSHIPS AND OUTCOMES.
A SURVEY OF OVER 400 SOMALI
REFUGEE WOMEN WHO GAVE BIRTH IN
CANADA AFTER FGM/C FOR EXAMPLE
FOUND THAT THE VAST MAJORITY
REPORTED OFFENSIVE COMMENTS FROM
THEIR CAREGIVERS BECAUSE OF
THEIR CUTTING.
PATIENTS REPORTED BEING REGARDED
WITH DISGUST AND WITH SHOCK.
THE MAJORITY ALSO FELT THAT
DOCTORS DID NOT UNDERSTAND THEIR
PAIN AND THAT THEIR PHYSICIANS
DID NOT UNDERSTAND THAT WOMEN
WITH FGM/C EXPERIENCED
PARTICULARLY SEVERE POSTPARTUM
PAIN.
THE LITERATURE ALSO DOCUMENTS
WOMEN WHO HAVE BEEN AFFECTED BY
FGM/C BEING LEFT IN STIR UPS FOR
EXTENDED PERIODS OF TIME AS
MEDICAL STUDENTS AND RESIDENTS
INSPECTED THEIR ANATOMY, AND
THESE PATIENTS REPORTED FEELING
DEHUMANIZED WHEN INTERACTING
WITH HEALTHCARE PROVIDERS IN
HIGH INCOME NATIONS.
2 OUT OF 5 WOMEN STATED THEY
WOULD NOT RETURN TO THE SAME
HOSPITAL FOR FUTURE DELIVERIES
AND MORE THAN 10% OF WOMEN
STATED THAT THEY WOULD PREFER
NOT TO ATTEND ANY HOSPITAL FOR
FEFUTURE BIRTHS WHICH IS A
PARTICULARLY POOR OUT COME GIVEN
POTENTIAL COMPLICATIONS OF
FGM/C.
SO WHY IS THIS ALL IMPORTANT?
AS A MEDICAL ANTHROPOLOGIST, I'M
HERE TO STRESS HOW IMPORTANT IT
IS TO UNDERSTAND THE
BIOPSYCHOSOCIAL CONTEXT FROM
WHICH A PERSON IS COMING TO
EXPLAIN THOSE PAIN EXPERIENCES.
FIRSTLY, WHEN WE KNOW A PERSON'S
LIFE HISTORY, FOR EXAMPLE, THAT
THEY ARE FROM A COUNTRY IN
AFRICA WHERE 90% OF WOMEN
EXPERIENCE FGM/C RESULTING IN
CHRONIC PELVIC PAIN OR MENSTRUAL
PAIN, OR THE MIDDLE EAST, WHERE
SUSPENSION FROM UPPER
EXTREMITIES RESULTS IN BRACHIAL
PLEXUS INJURIES OR FROM
SOUTHEAST ASIA, WHERE LEG
HYPEREXTENSION IS VERY COMMON,
RESULTING IN LUMBOSACRAL PLEXUS
INJURIES, THEN I CAN ASK THE
RIGHT QUESTIONS AS A CLINICIAN
AND PROVIDE THE RIGHT DIAGNOSES
AND TREATMENT.
SO THAT'S ONE REASON WHY IT'S
IMPORTANT.
THE SECOND IS THAT THESE ARE
MODIFIABLE RISK FACTORS.
IN MANY CASES, OUR RESEARCH HAS
DISCOVERED THAT, FOR EXAMPLE,
STRESS RELATED TO THE THREAT OF
DEPORTATION REALLY HAS A
PROFOUND IMPACT ON PAIN
EXPERIENCES, AND THAT IS
SOMETHING THAT IS MODIFIABLE.
HERE WE SHOW HOW WOMEN ARE CARED
FOR ITSELF.
THEIR EXPERIENCES WITHIN THE
HEALTHCARE SYSTEM, THAT THAT CAN
BE A MODIFIABLE RISK FACTOR FOR
HOW WOMEN EXPERIENCE PAIN OR
WHAT THEIR EXPERIENCES ARE IN
SEEKING CARE FOR PAIN.
NOT UNDERSTANDING, FOR EXAMPLE,
THAT A WOMAN WITH FGM/C WILL
HAVE WORSE POSTPARTUM PAIN WILL
LEAD TO UNDER- OR MISSED
DIAGNOSES, LACK OF TREATMENT AND
RESULTING DISENGAGEMENT OF
PATIENTS WITH THE HEALTHCARE
SYSTEM.
AND I THINK THAT'S REALLY WHERE
WE HAVE AN OPPORTUNITY TO MAKE A
DIFFERENCE, TO MAKE CONNECTIONS
AND TO HAVE A REAL IMPACT.
AND THAT BRINGS ME TO THE FOURTH
STREAM OF RESEARCH AT THE HUMAN
RIGHTS IMPACT LAB, WHERE WE'RE
CONDUCTING CROSS-DISCIPLINARY
INVESTIGATIONS LIKE OUR WORK
WITH ATTORNEYS OR ECONOMISTINGS,
ORINTHOLOGY, FOR EXAMPLE, OP WHY
REFUGEES, SPECIFICALLY REFUGEE
WOMEN, DO NOT ACCESS PUBLIC
BENEFITS LIKE PREVENTIVE CARE
FOR THEIR CHRONIC SOMATIC
TORTURE PAIN OR PRENATAL CARE OR
CHILDHOOD VACCINATIONS.
AND AS WE'RE DOING THIS
SCIENTIFIC RESEARCH, WE'RE
REALLY WORKING TO BRING OUR
FINDINGS TO THE PUBLIC, WHERE
WE'RE REACHING BEYOND
TRADITIONAL SCIENTIFIC AUDIENCE
TO CHANGE THE LANGUAGE AROUND
REFUGEES AND DEPICTIONS OF WHAT
PEOPLE EXPERIENCE TO BRING OUR
PATIENTS' STORIES TO THE MEDIA,
TO THE PUBLIC, THROUGH RADIO
INTERVIEWS AND ARTICLES.
THE IDEA THAT WE CAN ACTUALLY
REALLY CHANGE THE LIVES OF
PATIENTS WHEN WE BRING THAT
SCIENCE TO THE PUBLIC.
IF I KNOW THAT 10S OF THOUSANDS
OF WOMEN ARE COMING TO THE U.S.
WITH FGM/C AND WILL DELIVER
BABIES AND WILL INTERACT WITH
OBs AND ANESTHESIOLOGISTS AND
GYNECOLOGISTS AFTERWARDS, WE
FEEL THAT IT'S OUR DUTY TO BRING
THAT TO THE PUBLIC TO AUDIENCES
BEYOND THE MEDICAL JOURNALS
WHERE WE TYPICALLY PUBLISH.
SO WHY DOES THIS RESEARCH
MATTER?
WHY IS ANY OF IT AS IMPORTANT AS
MECHANISMS OF ANESTHESIA
RESEARCH, WHICH IS WHAT A LOT OF
MY COLLEAGUES DO OR ION CHANNEL
RESEARCH OR ADDICTION RESEARCH,
AND THERE'S THREE REASONS THAT I
WILL SHARE WITH YOU.
THE FIRST IS REALLY THE VOICE OF
THE MY GRANT IN ME.
MY FAMILY CAME TO THE U.S. TO
ESCAPE POLITICAL VIOLENCE IN THE
1980s, AND SO I KNOW FIRSTHAND
HOW THE EXPERIENCE OF BEING A
NEW IMMIGRANT AND A MY GRANT CAN
LEAVE A DEEP MARK ON AN
INDIVIDUAL'S FUTURE, AND THAT
PROVIDING REALLY EVIDENCE-BASED
CARE TO THIS PATIENT POPULATION,
HOW THAT CAN COMPLETELY ALTER
LIFE TRAJECTORIES.
THE SECOND IS THE VOICE OF THE
CLINICIAN IN ME THAT SAYS THAT
AS WAR AND VIOLENCE AND CLIMATE
CHANGE INCREASINGLY DISPLACES
PEOPLE ACROSS THE WORLD, THAT WE
WILL SEE PEOPLE WHO HAVE BEEN
DISPLACED FROM THEIR HOMES AS
PATIENTS IN OUR CLINICAL
PRACTICES MORE FREQUENTLY.
PATIENTS LIKE NOR.
AND AS CLINICIANS, WE NEED TO
KNOW HOW TO CARE FOR THEM.
WE NEED TO UNDERSTAND THE
BIOPSYCHOSOCIAL FACTORS THAT
BROUGHT THEM HERE, AND HOW THAT
CHANGES THEIR EXPERIENCES
PHYSICALLY, PSYCHOLOGICALLY AND
IN THE HEALTHCARE SYSTEM.
AND THE FINAL IS THE VOICE OF
THE MEDICAL ANTHROPOLOGIST IN ME
THAT SAYS THAT THESE MIGRANTS
ARE PEOPLE JUST LIKE YOU AND
JUST LIKE ME WHO HAVE FOUND
THEMSELVES IN THIS EXTREMELY
VULNERABLE POSITION, AND THE
ONLY THING THAT REALLY SEPARATES
US IS AN EARTHQUAKE OR A FLOOD
OR A MOMENT OF SOCIAL OR
POLITICAL ERUPTION AT HOME, AND
I THINK IT'S THAT SHARED
HUMANITY THAT MAKES IT OUR
RESPONSIBILITY TO DO THIS WORK.
I BELIEVE VERY CLEARLY THAT
FORCED MIGRATION IS THE MOST
URGENT ISSUE OF OUR LIFETIMES,
AND HOW WE RESPOND TO IT WILL
DEFINE OUR GENERATION, AND I
THANK YOU FOR BEING HERE TODAY
WITH ME TO SHARE THIS BRIEF
JOURNEY ON OUR WORK TO IMPROVE
THE HEALTH AND WELL-BEING OF THE
PEOPLE, SPESM SPECIFICALLY THEN
AND GIRLS AFFECTED BY MIGRATION,
AND I'LL END THERE.
THANK YOU.
>> THANK YOU, GUNISHA.
THAT WAS A BIG EYE OPENER FOR
MANY, I'M SURE, HERE.
SO I WOULD LIKE TO THANK ALL THE
SPEAKERS AT THIS POINT, AND ALSO
INVITE THEM TO THE PODIUM SO WE
CAN START THE PANEL DISCUSSION
AND LET'S HOPE JEFF IS ONLINE.
JEFF, CAN YOU HEAR US?
>> YEP.
>> CAN YOU SAY, JEFF?
>> HELLO, HELLO.
>> NO, I CANNOT HEAR YOU.
>> I CAN HEAR YOU.
>> WHILE WE FIGURE OUT THE
TECHNICAL ISSUES, AUDIENCE,
PLEASE COME UP WITH ANY
QUESTIONS, THOUGHTS YOU HAVE.
I DEFINITELY HAVE MANY.
SO MAYBE I'LL START WITH SOME.
SO JUST FRESH WITH GUNISHA, YOUR
TALK, IT WAS REALLY EYE OPENING.
I'M QUITE SURE IT IS VERY
CHALLENGING, NUMBER ONE, TO NOT
ONLY RECRUIT THESE SUBJECTS AND
ALSO HOW YOU DO RESEARCH AND
COLLECT DATA FROM THAT.
IT'S ALWAYS A BIG CHALLENGE, HOW
YOU DESIGN A STUDY, SO MAYBE YOU
CAN SHED A LITTLE LIGHT ON THAT
AND HOPEFULLY WE'LL HAVE MORE
QUESTIONS.
>> SURE.
THANKS FOR THAT QUESTION.
SO I AGREE WITH YOU, I THINK IT
IS REALLY HARD TO WORK WITH
MINORITY POPULATIONS AND I THINK
SOMETIMES LIKE OUR KEYNOTE
SPEAKER WAS SAYING WITH PREGNANT
WOMEN, MINORITY GROUPS, PEOPLE
ARE SO FEARFUL OF DOING
RESEARCH, OF HARMING PEOPLE,
THAT THE DEFAULT IS TO JUST NOT
DO THE WORK, NOT DO THE
RESEARCH, AND I'LL SAY THAT WHEN
WE STARTED THIS WORK IN 20
THRIRN, I THINK IT TOOK US LIKE
A YEAR OR YEAR AND A HALF TO GET
OUR FIRST MINIMAL RISK IRB STUDY
APPROVED, BECAUSE PEOPLE WERE
JUST SO FEARFUL OF HARMING THIS
PATIENT POPULATION AND THE WORK
WE'RE DOING RIGHT NOW IN
PREGNANT REFUGEE WOMEN SIMILARLY
SAT WITH THE IRB FOR A YEAR AND
A HALF BEFORE WE GOT APPROVAL.
I THINK FOR US IT'S REALLY BEEN
ABOUT PERSISTENCE, ABOUT FINDING
THE RIGHT PEOPLE THAT WILL
SUPPORT THE WORK.
THE NIH HAS BEEN UNBELIEVABLY
WONDERFUL, AND I THINK IS REA
REALLY -- I SEE THE NIH AS,
LIKE, ON THE CUTTING EDGE OF THE
WORK THAT WE SHOULD BE DOING AND
SUPPORTING, AND THE FACT THAT
THE NIH IS SUPPORTING THIS WORK,
I THINK MAKES PEOPLE REALIZE
THAT IT'S NOT JUST THESE
INDIVIDUAL STORIES, THAT THERE'S
SOME TATA, THERE'S SOMETHING TO
BE FOUND THERE, AND WORK TO BE
DONE, AND WHEN YOU CAN COLLECT
IT AND PULL IT TOGETHER, THERE'S
A REALLY PROFOUND IMPACT OF
SEEING THE DATA IN THE WAY THAT
WE DO NOW.
>> THANK YOU.
WE HAVE A QUESTION FROM MICHAEL.
>> AGAIN, EVERYBODY ON THE
PANEL, THANK YOU SO MUCH FOR SO
MANY STIMULATING TALKS.
I POSE THE QUESTION TO YOU BUT
I'M SURE THIS QUESTION CAN BE
ANSWERED BY THE OTHER PANELISTS,
AND I ENCOURAGE YOU TO ANSWER IT
ALSO.
BUT USING A VULNERABLE
POPULATION, OR USING A
POPULATION SUCH AS REFUGEES OR
THOSE WHO EXPERIENCE TORTURE AS
A MODEL TO UNDERSTAND THE
PSYCHOSOCIAL ASPECTS OF PAIN,
COULD YOU GIVE US SOME MORE
DETAILS ON THAT, ON HOW YOU'RE
INCORPORATING IN YOUR RESEARCH
AND HOW WE CAN INSPIRE OTHER
RESEARCHERS TO INCORPORATE IT
INTO EITHER THEIR ANIMAL MODEL
STUDIES OR THEIR HUMAN STUDIES
TO REALLY LOOK AT THAT
PSYCHOSOCIAL ASPECT FROM
MODELING -- USING SPECIAL
POPULATIONS AS A MODEL?
>> THANK YOU FOR THAT QUESTION.
THIS IS MY ABSOLUTELY LOVELY
P.O. WHO HAS SINGLE HANDEDLY
CHANGED MY LIFE, WHO I OWE ALL
OF MY CAREER TO RIGHT THERE.
YOU KNOW, IT'S INTERESTING, WE
ARE STILL -- THE WORK IS SO WHAT
I LIKE TO CALL FRINGY, IT'S LIKE
CUTTING EDGE BUT IT'S SCARY TO
USE THIS POPULATION AS SORT OF
YOUR SAMPLE POPULATION FOR OTHER
SUBGROUPS BUT EVERY TALK THAT I
HEARD TODAY, I WAS LIKE, THAT IS
EXACTLY WHAT WE'RE SEEING IN OUR
PATIENT POPULATION, AND HOW CAN
WE USE WHAT WE'RE DOING, YOU
KNOW, WHAT OUR PATIENTS ARE
EXPERIENCING, THIS
SUBPOPULATION, THIS SUPER
INTERESTING POPULATION WHERE
THEY HAVE EXPERIENCED EXTREME
PSYCHOLOGICAL TRAUMA, EXTREME
PHYSICAL TRAUMA.
HOW CAN YOU USE THAT TO ADVANCE
THE HEALTH OF WAR VETERANS OR OF
SEXUAL ASSAULT SURVIVORS IN THE
U.S.?
I MEAN, THERE'S SO MANY
POPULATIONS WHERE YOU COULD TAKE
THIS WORK IN REFUGEES, THIS
LITTLE MICROCHASM, THIS VERY
SPECIFIC UNIQUE POPULATION AND
THEN TAKE IT BEYOND THAT.
I THINK WE'RE GETTING THERE,
WE'RE NOT FULLY THERE YET,
BECAUSE WHEN YOU LOOK AT THIS
FIELD, THERE'S JUST A TOTAL GAP,
THERE'S LIKE NO STUDIES AND SO
MANY OF THESE DIFFERENT
IMPORTANT AREAS.
SO I THINK FIRST WE'RE SORT OF
SETTING THAT UP AND CREATING
THAT EVIDENCE BASE, AND THEN WE
WILL LAYER ON TOP OF IT.
THAT'S MY 40-YEAR WORK PLAN.
>> I CAN ADD JUST A LITTLE BIT
TO THAT.
SO WITH OUR GENDER MINORITY
POPULATIONS, ONE OF THE ISSUES
IS GETTING RECRUITMENT, BUT WE
FOUND REACHING OUT TO COMMUNITY
GROUPS AND SORT OF GETTING THAT
RELATIONSHIP AND MAKING SURE
THAT THEY UNDERSTAND THAT
THEY'RE NOT BEING USED AS GUINEA
PIGS AND THAT THE IDEA IS TO
ACTUALLY ADVANCE OUR
UNDERSTANDING AND HEALTH AND
EVERYTHING FOR EVERYONE, AND SO
IT ISN'T AS SORT OF A
TRANSACTIONAL THING OR IT IS --
IT'S FOR THE GREATER GOOD AND SO
WE'VE HAD GOOD LUCK WITH
RECRUITMENT BECAUSE WE'VE
BROUGHT THEM IN TO DO
SENSITIVITY TRAINING WITH OUR
LAB AND THEY'VE VETTED ALL OF
THE QUESTIONNAIRES TO MAKE SURE
THAT ALL THE LANGUAGE IS
APPROPRIATE, SO I THINK JUST --
AGAIN, I THINK RESPECTING YOUR
POPULATION IS A BIG KEY, AND I
THINK ALL OF US RESPECT OUR
POPULATIONS.
>> AND HANNA, LIKE IF YOU WANT
TO ADD ANYTHING, BECAUSE YOU ARE
ALSO SERVING A POPULATION WHICH
HAVE A LOT OF SIMILARITIES.
WITH
DISPLACED POPULATIONS IN TERMS
OF THEIR PSYCHOSOCIAL CHALLENGES
AND ALSO DAILY LIFE CHALLENGES
COMING TO THE CLINIC.
>> SINCE I'M DOING SECONDARY
DATA ANALYSIS AND NOT DEALING
WITH PEOPLE FACE-TO-FACE, I
THINK THESE WERE BETTER FOLKS TO
ANSWER, BUT YOU KNOW, WE SEE
THESE PATTERNS BUT FROM OUR BIG
NATIONAL DATASETS, WE CAN'T GET
AT LOW LEVEL MECHANISMS AND
PROCESSES AND THAT'S WHY I LOVE
LEARNING ABOUT THIS WORK BECAUSE
IT CAN REALLY SORT OF INFORM US
IN INTERPRETING WHAT MIGHT BE
DRIVING THOSE BROAD NATIONAL
PATTERNS.
>> QUESTION FROM WALTER.
>> HI.
REALLY GREAT STUFF.
HANNA, I JUST HAD A QUESTION FOR
YOU.
YOU SHOWED THE DATA IN TERMS OF
THE PAIN INCIDENCE AND IT'S
CERTAINLY VERY AGE-DEPENDENT.
WONDERING WITH THE PSYCHOLOGICAL
STRESS, DO YOU HAVE THAT SAME
KIND OF DATA TO KNOW IF THE
PSYCHOLOGICAL STRESS IS COMING
EARLIER AND THE PAIN IS
FOLLOWING, OR IS THE
PSYCHOLOGICAL STRESS COMING
AFTER THE BUMP AND THE PAIN?
>> SO THAT'S A GREAT QUESTION
THAT I WISH WE COULD ANSWER.
SO BECAUSE WE JUST HAD
CROSS-SECTIONAL DATA, WE
COULDN'T WITH NHIS DO ANYTHING,
BUT THERE WAS AN INTERESTING
STUDY PUBLISHED RECENTLY USING
DATA THAT SORT OF TRIED TO
QUANTIFY HOW MUCH IS IT
DEPRESSION INCREASE B INCREASIN,
HOW MUCH INCREASING RISK OF
DEPRESSION.
THERE WAS EVIDENCE IN BOTH.
IN THIS STUDY, THEY ACTUALLY
FOUND THAT CHRONIC PAIN WAS A
STRONGER PREDICT TER OF PREDICTN
CAME VICE VERSA, SO THE PAIN
MATTERED MORE FOR THE
DEPRESSION.
EVEN THAT, LIKE YOU ALWAYS HAVE
TO THINK ABOUT HOW IS THE PAIN
MEASURED, AND THAT SURVEY
SURVEYS EVERYONE EVERY TWO YEARS
SO IT NOT A FINE GRAIM TEMPORAL
MEASUREMENT THERE, SO I DON'T
KNOW THAT WE HAVE A DEFINITIVE
ANSWER.
AND ALSO THE ANSWER COULD DIFFER
ACROSS DIFFERENT GROUPS TOO.
SO IT'S A GREAT QUESTION THAT I
DON'T HAVE THE BEST ANSWER TO,
I'M AFRAID.
>> WHAT DO YOU THINK ALL NEW
DATA TYPES, QUESTIONS YOU MIGHT
ASK OR YOU WOULD LIKE TO HAVE IN
THAT DATABASE?
SO THAT HE CAN GET THOSE DATA?
>> SO SOME MORE FINE GRAIN DATA
WOULD BE GREAT, AND I ALSO WOULD
LOVE TO SEE, AND I'M NOT QUITE
SURE HOW THIS COULD BE DONE, BUT
I WOULD LOVE TO SORT OF COMBINE
SOME LONGITUDINAL TATA
COLLECTION WITH QST, SO WE CAN
KIND OF SEE ON A LIKE LOWER
LEVEL WHAT'S GOING ON WITH
CHANGES OVER TIME.
PEOPLE'S PAIN PERCEPTIONS.
>> WONDERFUL TALKS.
MY QUESTION IS PRIMARILY FOR DR.
SO I WAS THINKING DURING YOUR
TALK JUST ABOUT WHAT COULD
EXPLAIN YOUR RESULTS AND I WAS
THINKING ABOUT THE ROLE OF A MAN
IN SOCIETY, AND IT MADE ME
THINK, DID YOU GATHER ANY DATA
ON HESITANCY TO REPORT PAIN WHEN
YOU IDENTIFY AS A MAN OR IF
THERE'S ANY QUESTIONNAIRES THAT
HAVE TO DO WITH HOW PEOPLE WERE
THINKING ABOUT PAIN AND IN
RESPECT TO THEIR IDENTITY?
>> GREAT QUESTION, THANK YOU.
SO WE'RE USING THE GENDER ROLE
EXPECTATION OF PAIN AS WELL, SO
THAT LOOKS AT DO YOU THINK THAT
MEN OR WOMEN ARE MORE LIKELY TO
REPORT PAIN, WHAT IS YOUR
WILLINGNESS TO REPORT PAIN, YOU
KNOW, RELATIVE TO THE AVERAGE
MAN OR WOMAN.
SO WE DO HAVE THAT DATA SO WE'LL
BE ABLE TO LOOK AT THAT A LITTLE
BIT.
I WILL SAY THAT BASED ON HANNA'S
PAPER, ONE OF THE THINGS THAT
WE'VE ADDED IS ADDING QUESTIONS
ABOUT SEXUAL ORIENTATION.
THE ASSUMPTION, FALSE
ASSUMPTION, IS THAT EVERY CIS
INDIVIDUAL IS STRAIGHT, AND THAT
IS ABSOLUTELY NOT TRUE.
IN FACT, ABOUT A QUARTER TO A
THIRD OF EACH OF OUR GROUPS, YOU
KNOW, HAS A DIFFERENT SEXUAL
ORIENTATION THAN SOME OF THE
REST.
SO JUST GETTING THAT AMOUNT OF
DETAIL IS GOING TO BE VERY, VERY
IMPORTANT.
WHEN IT COMES TO
REALLY LOOKING AT THIS DATA.
>> I HAVE -- LOOKING NOOB CD4 T
CELLS IN MEN AND WOMEN, SO I'M
JUST WONDERING, HAVE YOU
CORRELATED OR LOOKED AT THE
LITERATURE, HOW DO ACTIVATED CDN
AND WOMEN ALSO CORRELATE WITH
PEOPLE WHO HAVE AUTOIMMUNE
DISORDERS OR WHO HAVE
IMMUNE-RELATED DISORDERS, AND
WHAT'S THE INTERSECTION OF THAT
WITH PAIN ASSOCIATED WITH THOSE
IMMUNE SYSTEM DISORDERS?
>> THAT'S A GOOD QUESTION.
SO CERTAINLY PEOPLE WITH
AUTOIMMUNE DISORDERS WILL HAVE
VERY DIFFERENT CELL POPULATIONS.
THESE INDIVIDUALS ARE OTHERWISE
ALL HEALTHY, SO THOSE ACTIVATED
LEVELS ARE LOW RELATIVE TO A
CLINICAL POPULATION.
BUT YES, THERE CERTAINLY IS
GOING TO BE MASSIVE DIFFERENCES.
AND GENERALLY THE FACT THAT
WOMEN HAVE HIGHER ACTIVATED
LEVELS, THAT MAY BE ONE OF THE
UNDERLYING REASONS THAT
THEY'RE -- AUTOIMMUNE DISORDERS.
>> THAT COULD BE ALSO EXTENDED
TO CERTAIN SPECIFIC PAIN
CONDITIONS WHERE PERIPHERAL --
OR THE -- ADAPTIVE IMMUNE SYSTEM
INVOLVEMENT IS SO DEEP, MANY
NEUROPATHIES AND PAIN.
>> YEAH, SO ONE OF THE OTHER
TESTS THAT WE'LL BE DOING WITH
FLOW CYTOMETRY IS TAKING THOSE
CELLS AND STIMULATING THEM TO
SEE WHAT SORT OF A STIMULATED
CYTOKINE RESPONSE WE GET FROM
THOSE CELLS, SO NOT ONLY THERE
WILL BE -- BUT HOW ROW ACTIVE
ARE THOSE CELLS TO STIMULATION.
>> I'M SPECIFICALLY INTERESTED
IN ONE OF THOSE CIP -- THOSE
ALREADY NON-PHENOMENON, FOR
CERTAIN TIEF OF CA TYPE OF CANCD
CERTAIN TYPE OF CHEMOTHERAPY,
CHEMOTHERAPY AGENTS, THEY
DEVELOP MORE CIPN AND MORE
PAINFUL -- LIKE NEUROPATHY
VERSUS NON-PAINFUL, SO THAT'S
WHY I'M INTERESTED.
PLEASE.
>> GREAT TALKS.
ONE QUESTION I HAVE FOR ALL OF
YOU, ANY OF YOU REALLY, OBVIOUS
DIFFERENCE BETWEEN MEN AND WOMEN
OR MALES AND FEMALES IS THE -- I
GUESS IT WOULD BE MALES AND
FEMALES IN THIS CASE, IS
MENSTRUAL CRAMPS, RIGHT?
THE HISTORY OF HAVING RECURRING
PAIN STARTING IN EARLY
ADOLESCENCE, WHAT EFFECT DOES
THAT HAVE ON THE STILL
DEVELOPING NERVOUS SYSTEM IN
GIRLS?
AND HAS THAT BEEN LOOKED AT?
COULD THAT BE PART OF THE REASON
WHY IN THE LONG RUN, YOU KNOW,
WOMEN HAVE -- COULD HAVE MORE
PAIN SENSITIVITY, HAVING BEEN
EXPOSED TO THIS RECURRING PAIN
AS THEY WERE DEVELOPING?
BUT ALSO PERHAPS GREATER PAIN
ENDURANCE AND BEING LESS KILLED
IN THE END BY PAIN.
SO I'M JUST CURIOUS, AS JEFF WAS
MENTIONING, JUST CURIOUS YOUR
THOUGHTS ON THIS.
>> JEFF, YOU WANT TO GO FIRST?
>> CAN YOU HEAR ME?
>> YES.
>> OKAY.
I'LL GO FIRST.
UM, SO THERE IS PROBABLY A
LITERATURE ON OUTCOMES OF WOMEN
WITH MENSTRUAL CRAMPS VERSUS
THOSE WITHOUT.
I'M NOT FAMILIAR WITH IT OFF THE
TOP OF MY HEAD, BUT AS A MORE
GENERAL SENSE, ONE OF THE BEST
PREDICTORS OF FUEL TOUR P T FUTS
PAST PAIN, SO LOGICALLY YOU'D
EXPECT THAT RELATIONSHIP, IF IT
WERE THERE, TO BE A POSITIVE
ONE.
THE ISSUE, THOUGH, ABOUT -- I
FORGET EXACTLY HOW YOU PHRASED
IT, BUT REMEMBER IT'S A
DOUBLE-EDGED SWORD, RIGHT?
SO YEAH, MEN DIE, WHICH IS BAD,
BUT WOMEN SUFFER, WHICH IS BAD.
SO YOU HAVE TO ASK YOURSELF
WHO'S GOT IT WORSE.
IT'S NOT AT ALL CLEAR TO ME.
>> I WAS JUST GOING TO SAY, I
THINK THE ISSUE RVETION OF IS -T
HISTORY I THINK HAS A HUGE ROLE
TO PLAY, BUT EVEN CULTURALLY,
THE BEING COMFORTABLE EXPRESSING
THAT PAIN ALSO REALLY DOES
CONTRIBUTE, AND SO AS WE LEARN
MORE AND MORE, YOU KNOW, GETTING
A BETTER IDEA OF PAST HISTORY IS
ALWAYS GOING TO HELP TRY TO
EXPLAIN SOME OF THESE PHENOMENA.
>> WE HAVE ONE QUESTION.
>> I'M GOING TO ASK ABOUT SORT
OF THE CONVERSE IN TERMS OF WHAT
MAKES THE PAIN BETTER.
AND SO WHAT WE KNOW FROM PEOPLE
WHO LIVE WITH PAIN WHO ATTEND
SUPPORT GROUPS AND HAVE A GOOD
RELATIONSHIP WITH A PROVIDER WHO
BELIEVES THEM AND WILL PARTNER
WITH THEM HELPS THEM A LOT.
AND I'M JUST WONDERING IN THE
VERY EXTREME CASE THAT DR. KAUR
YOU'VE TALKED ABOUT, IF YOU'VE
SEEN THINGS IN A SUBSEQUENT
LIFE, LIKE THIS LITTLE GIRL YOU
GAVE AN EXAMPLE OF, IF SHE GETS
INTO A GOOD FAMILY SITUATION OR
IF SHE DEVELOPS FRIENDSHIPS WITH
OTHER KIDS WITH PAIN, HAS ANYONE
FOLLOWED THEM TO SEE WOULD THEY
REDUCE THEIR PAIN FROM CERTAIN
SOCIAL INTERACTIONS?
>> IT'S SUCH A GREAT QUESTION.
AND THE ANSWER IS YES, AND LET
ME TELL YOU A LITTLE BIT OF OUR
RESEARCH EXPERIENCE.
SO THE LAB THAT WE RUN IS
FOUNDED ON THE IDEA THAT TRAUMA
IS NOT FIXED, THAT ALL OF THIS
IS MODIFIABLE, THAT THE PAIN,
PAIN OUTCOMES ARE MODIFIABLE.
I'LL GIVE YOU A SPECIFIC EXAMPLE
OF A STUDY WE JUST FINISHED,
PART OF MY K23, WHERE WE LOOKED
AT THE THREAT OF DEPORTATION,
JUST THE IDEA THAT SOMEBODY
COULD BE DEPORTED, THAT IDEA,
THAT'S IT.
JUST THE THOUGHT THAT THEY COULD
BE -- BEING IN AN UNSTABLE
WAITING FOR ASYLUM, WHICH IN THE
U.S. TAKES ABOUT FIVE TO SEVEN
YEARS.
AND PEOPLE'S PAIN SEVERITY AND
HOW MANY PAIN SYMPTOMS THEY HAD
WERE WORSE, AND WHEN THAT SOCIAL
FACTOR CHANGED, AS SOON AS THEY
GOT STATUS, IT FLIPPED AND THEIR
PAIN ALMOST DISAPPEARED.
NOW THESE ARE PEOPLE WITH LIKE
REAL NEUROPATHIC -- I MEAN, IT'S
REAL PHYSICAL PAIN.
BUT PART OF WHAT'S HAPPENING IS
THE BIOSOCIAL CONTEXT AROUND
THEM.
WHEN THEY'RE AFRAID OF BEING
DEPORTED THEY DON'T LEAVE THE
HOUSE, THEY DON'T MOVE, THEIR
PAIN GETS WORSE, THEY'RE MORE
DEPRESSED, THERE'S THIS
INTERACTION, AND WHEN THEY
SUDDENLY HAVE THE ABILITY TO
LEAVE THEIR HOME OR ENGAGE WITH
HEALTHCARE PROVIDERS WHO, ARE
TRAUMA-INFORMED, LIKE IT HAS TO
BE THE RIGHT KIND OF HEALTHCARE
PROVIDER, THEN THEIR HEALTH
TRAJECTORIES COMPLETELY CHANGE,
AND I THINK THAT'S THE PROMISE
OF THIS RESEARCH, IS THAT YOU
CAN ACTUALLY CHANGE HEALTH
OUTCOMES.
AND THAT'S WHAT'S SO EXCITING
ABOUT IT.
TO THE QUESTION EARLIER ALSO
ABOUT THE PSYCHOLOGICAL AND THE
PHYSICAL AND THE INTERPLAY, I
MEAN, I THINK THERE'S REALLY
GOOD STUDIES IN VETERANS THAT
SHOW US THAT WHILE THERE IS THIS
SORT OF DUAL OFTEN LIKE -- IN
OUR PATIENT POPULATION, 85% OF
PEOPLE HAVE PAIN AND 85% OF
PEOPLE HAVE SOME KIND OF
PSYCHIATRIC OR PSYCHOLOGICAL
SEQUELLA OF THEIR TRAUMA, BUT IN
VETERANS, THERE'S REALLY GOOD
STUDIES THAT SHOW THAT PAIN, IF
TREATED APPROPRIATELY --
DIAGNOSED AND TREATED
APPROPRIATELY, DESPITE THE
PSYCHOLOGICAL TRAUMA, CAN BE
CHANGED, IT CAN BE ALTERED, IT
CAN IMPROVE IF IT'S TREATED.
AND I THINK THAT'S WHERE THERE'S
SO MUCH MORE WORK TO BE DONE TO
UNDERSTAND THE PAIN AND
UNDERSTAND THE PSYCHOLOGICAL
TRAUMA AND INTERPLAY, BUT
THERE'S ALSO LIKE THIS SEPARATE
THING WHICH IS THAT YOU CAN
TREAT IT WITH SOCIAL
INTERACTIONS, WITH CHANGING OF
STATUS, WITH ENGAGEMENT WITH
HEALTHCARE SYSTEMS.
NOR, FOR EXAMPLE, HER ENGAGEMENT
WITH HEALTHCARE PROVIDERS,
PEDIATRICIANS, PSYCHOLOGISTS,
HAS ALTERED SOME OF THAT PAIN
EXPERIENCE AND SUF IRING.
SUFFERING.
>> SO THE HEAL INITIATIVE LATE
TO THE GAME IS JUST STARTING TO
FOCUS ON KIDS' PAIN, SO
WONDERING IF ANYBODY AS THOUGHTS
ABOUT MALE/FEMALE DIFFERENCES IN
KIDS.
HAVE YOU EVER DONE THOSE
EXPERIMENTS IN PRE-PUBERTAL
ANIMALS THAT WOULD BE IMPORTANT
IN TERMS OF GOING AFTER THE
KIDS?
>> CHRISTINE CHAMBERS HAS DONE A
META-ANALYSIS OF THE LITERATURE
ON ACUTE PAIN SENSITIVITY
SHOWING THAT THE SEX DIFFERENCES
DON'T EMERGE UNTIL PUBERTY, SO
THAT'S NOT ALL THAT SURPRISING.
BUT IN TERMS OF THESE SEXUALLY
DIMORPHIC PAIN MECHANISMS THAT
ARE UNDERLYING WHATEVER THE
OVERALL OUTPUT IS, THAT'S A
LITTLE BIT MORE COMPLICATED.
A LOT OF THEM ARE
TESTOSTERONE-BASED, AND THAT'S
SOMETHING THAT COMES ON SLOW.
JUST SOME OF THEM ARE
ORGANIZATIONAL EFFECTS, SO SOME
OF THOSE ARE THERE FROM BIRTH.
THERE'S ONLY BEEN A SLIGHT BIT
OF WORK DONE ON THE SEX
DIFFERENCES IN PAIN IN NEONATAL
MICE AND RATS, SO I DON'T THINK
THERE'S ENOUGH OF A LITERATURE
THERE TO COME TO ANY CONCLUSION
BUT PEOPLE ARE WORKING ON IT
SLOWLY BUT SURELY.
>> ROB, YOU WANT TO ADD
ANYTHING?
>> NO, I DON'T THINK I CAN ADD
TOO MUCH TO THAT.
>> LAURA.
>> PICKING UP WHERE WALTER --
HANNA, I'M WONDERING ABOUT NHIS
OR ANY OTHER LONGITUDINAL
DATASET THAT INCORPORATE
CHILDREN UNDER THE AGE OF 18.
IT LOOKED LIKE WITH YOUR DATA AT
18, WE WERE ALREADY STARTING TO
SEE THE DIFFERENCES, AND SO THE
QUESTION I HAVE IS, DO WE HAVE
DATA OR DOES NIH HAVE -- GOING
DOWN TO 12 OR OTHER YEARS TO BE
ABLE TO LOOK AT SOME OF THOSE
DIFFERENCES IN CHILDHOOD, WHICH
MIGHT PREDICT SOME OF THOSE
CHANGES INTO ADULTHOOD.
>> YEAH, ACTUALLY THE PREVIOUS
QUESTION JUST MADE ME THINK
ABOUT THAT AS WELL, SO WE HAVE
USUALLY USED THE ADULT DATA FROM
NHIS BECAUSE FOR EXAMPLE, WE DO
RESEARCH ON HOW HIGHEST LEVEL OF
EDUCATIONAL ATTAINMENT SHAPES
PAIN, SO YOU NEED TO WAIT UNTIL
PEOPLE ARE OLD ENOUGH TO HAVE
COMPLETED COLLEGE OR NOT.
BUT THERE IS DATA -- I'M LOOKING
AT RICHARD BECAUSE HE KNOWS NHIS
BETTER THAN ANYONE I KNOW.
THE PAIN QUESTIONS AREN'T IN THE
CHILD QUESTIONNAIRE.
OKAY.
SO THAT'S THE LIMITATION.
SO WE DON'T HAVE THE RIGHT DATA
ABOUT THE CHILDREN FROM THAT.
THAT'S HELPFUL.
THANK YOU.
>> ONE MORE QUESTION.
>> -- WOULD DIFFER, BUT IS
THERE RESEARCH ON HOW MALES AND
FEMALES ARE NOT SEXUALLY
DYSMORPHIC?
THINKING AFTER TREATMENT
STRATEGY, WE ARE THINKING
PRECISE TREATMENTS, AND WE
TALKED ABOUT THE EDUCATION GAP
IN MEDICAL STUDENTS AND HOW WE
HAVE TO ACTUALLY, YOU KNOW, HEAR
THE STORY OF THE PERSON, THAT'S
ALL IMPORTANT, BUT AS FAR AS
THINKING ON A TREATMENT
CONSOLIDATION, DO WE HAVE
RESEARCH ON HOW MALES AND
FEMALES EITHER IN RODENTS OR
HUMANS RESPOND SIMILARLY AS FAR
AS MECHANISMS OR TO TREATMENT
OPTIONS?
>> I CAN ADDRESS THAT.
YEAH, SO THERE'S NO GOOD
EVIDENCE SUGGESTING THAT ANY
EXISTING TREATMENT OF PAIN IS
SEXUALLY DIMORPHIC IN ANY WAY
WORTH TALKING ABOUT.
WOMEN ARE A LITTLE BIT MORE
SENSITIVE TO OPIOIDS ACTUALLY.
THERE'S ONE PAPER THAT'S NEVER
BEEN REPLICATED SUGGESTING THEY
MAY BE LESS SENSITIVE TO
NSAIDs, BUT LIKE IN GENERAL,
EVERYTHING USED NOW, THERE'S NOT
A LOT OF SEXUAL DIMORPHISM.
THE ISSUE IS EVERYTHING THAT IS
CURRENTLY BEING RESEARCHED AND
CLINICAL TRIALS THAT HAVE ALMOST
CERTAINLY FAILED BECAUSE THERE
WERE SEX DIFFERENCES THERE THAT
NO ONE KNEW ABOUT.
SO I THINK THIS IS A BIGGER
STORY IN TERMS OF DRUG
DEVELOPMENT THAN IT IS TO
EXPLAIN ANY TREATMENT EFFICACY
TODAY.
THERE'S JUST -- SEX DIFFERENCES
ARE ONE OF A LARGE NUMBER OF
SOURCES OF VARIABILITY LEADING
TO DIFFERENTIAL TREATMENT
EFFICACY.
>> WE HAVE LAST TWO QUESTIONS IN
THE INTEREST OF TIME.
GO AHEAD.
>> OKAY.
SO THE LAST COUPLE OF QUESTIONS
WERE PERTAINING TO CHILDREN IN
PAIN.
I GUESS MY QUESTION IS, WE KNOW
THAT THERE ARE CERTAIN
SOCIOECONOMIC FACTORS THAT CAN
KIND OF PUSH KIDS TO HAVE TO
TAKE ON MORE ADULT LIKE
RESPONSIBILITIES OR BE TREATED
AS ADULTS, AND I WAS WONDERING
FOR THOSE OF YOU WHO WORK
DIRECTLY WITH PATIENTS, ARE
THOSE FACTORS SOMETHING THAT YOU
LOOK INTO AND I GUESS FOR
DR. MOGIL AS A PRE-CLINICAL
RESEARCHER MYSELF, I'M WONDERING
DO YOU HAVE ANY IDEAS ON HOW WE
COULD LIKE MODEL THAT TYPE OF
STRESS IN ANIMALS?
>> I MEAN --
>> GO AHEAD.
>> I'LL JUST QUICKLY SAY, WE
MODEL STRESS IN ANIMALS ALL THE
TIME.
WE DO IT PRETTY GROSSLY, YOU
KNOW, WE PUT THEM IN RESTRAINING
TUBES OR WE PUT THEM IN COLD
WATER OR SOMETHING AND, YOU
KNOW, YOU CAN EITHER BE A LUMPER
AND SAY STRESS IS STRESS, IT'S
PROBABLY SIMILAR, OR YOU CAN BE
A SPLITTER AND SAY THAT THAT
KIND OF STRESS IS NOTHING LIKE
THE STRESS YOU'RE TALKING ABOUT.
I DON'T KNOW THE ANSWER.
>> ANY OF YOU WANT TO ADD
ANYTHING?
ANY THOUGHTS?
>> I THINK IT'S A GOOD QUESTION.
I THINK MODELING THAT IN ANIMALS
IS GOING TO BE DIFFICULT.
I MEAN, YOU KNOW, IT COULD BE
LIKE THE MATERNAL SEPARATION
MODEL IN ANIMALS, YOU KNOW, THAT
MAY BE AN ASPECT.
BUT I DON'T THINK IT GETS TO
WHAT YOU'RE TALKING ABOUT.
I THINK WHEN WE START LOOKING AT
ADULTS, ONE OF THE THINGS THAT
WE TALK ABOUT IN THE PLENARY,
AND IN MY TALK, THE ADVERSE
CHILDHOOD EXPERIENCES, THAT MAY
BE A WAY TO START GETTING AT
THAT.
I MEAN, BUT WE'RE LOOKING AT
ADULTS, AND SORT OF WHAT THOSE
SORT OF CHILDHOOD EXPERIENCES,
HOW THEY MAY CONTRIBUTE TO THE
CURRENT STATE OF THEIR PAIN OR
THEIR PAIN SENSITIVITY.
>> FOR WHAT IT'S WORTH, A NUMBER
OF BIG NATIONAL SURVEYS HAVE
THESE INVENTORIES OF SORT OF
STRESSFUL LIFE EVENTS.
EVERYTHING FROM HAVE YOU EVER
HAD A PARENT DIE, HAVE YOU EVER
FILED FOR BANKRUPTCY, HAVE YOU
EVER SEEN SOMEONE BE KILLED, ALL
KINDS OF THINGS, AND THIS ISN'T
GOING TO BE OF USE IN A
PRE-CLINICAL SETTING, BUT THERE
IS POTENTIAL TO KIND OF LOOK AT
THOSE ASSOCIATIONS WITH SOME
NATIONAL DATASETS.
NOT EXACTLY WHAT YOU WERE
TALKING ABOUT, BUT MAYBE SOME
KIND OF RELATED TYPES OF STRESS.
>> THE OTHER ASPECT IS THAT IN
SOME SITUATIONS LIKE THAT, WHAT
YOU END UP SEEING AS WELL IS
RESILIENCE MEASURES.
AND SO I THINK ADDING THAT NOT
ONLY LOOKING AT EVERYTHING AS A
NEGATIVE STRESSOR, BUT SOME OF
THOSE DO LEAD TO GREATER LEVELS
OF RESILIENCE, SO MEASURING SORT
OF BOTH ASPECTS, I THINK IS
PORCHLT
>> THANK YOU.
>> THE LAST QUESTION.
>> THANK YOU.
SO I KNOW IT WAS BROUGHT UP THAT
WE'RE TRYING TO GET THIS
RESEARCH OUT TO THE COMMUNITY,
WHICH IS GREAT, AND IN -- THINK
THAT'S AMAZING, I WORK ON HEAL
CONNECTIONS AS A FACILITATOR OF
THE LIVED EXPERIENCE PANEL, AND
OUR GOAL WAS AS TO ALLOW
INDIVIDUALS FROM THE COMMUNITY
TO TELL US HOW THEY WANT TO
RECEIVE RESEARCH.
ANOTHER SIDE OF THAT IS THE
AMAZING WORK BEING DONE BY THE
ADDICTION POLICY FORUM.
JESSICA HA HALSEY IS SPEARHEADIG
THAT AND HAS TONS OF ASSOCIATION
PARTNERS INCLUDING INDIVIDUALS
WHO ARE PAYOR PROVIDERS O.A.R.
FITS. OR
PHYSICIANS.
WHAT WE'VE LEARNED IS SOMETIMES
PHYSICIANS OR OTHER RESEARCHERS
DON'TNESS SAIR LEGAL HAVE TIME
TO READ OUT AN ENTIRE SCIENTIFIC
ARTICLE WHEN THEY HAVE 15-MINUTE
PATIENT APPOINTMENTS BACK TO
BACK.
AND SO I'M JUST CURIOUS ON WHAT
WE'RE DOING TO TRY TO GET THIS
RESEARCH ACROSS DIFFERENT FIELDS
AND TO LIKE PCPs OR PROVIDERS,
OTHER PROVIDERS.
>
>> I OBVIOUSLY AGREE WITH YOU, I
THINK IT'S SO IMPORTANT.
SOME OF WHAT WE'VE DONE, SO FOR
EXAMPLE, ONE OF OUR STUDIES
SHOWED THAT REFUGEES AND ASYLUM
SEEKERS SPECIFICALLY DISENGAGE
FROM PUBLIC BENEFITS BECAUSE
THEY'RE SO FEARFUL OF
IMMIGRATION POLICY, AND WITH
DIFFERENT ADMINISTRATIONS,
THERE'S BEEN LIKE 400 CHANGES TO
IMMIGRATION LAW AND POLICY, AND
SO WE FOUND THAT PEOPLE WERE NOT
SEEKING PRENATAL VISITS, THEY
WEREN'T -- CHILDHOOD
VACCINATIONS, THOSE KINDS OF
THINGS.
SO ONE OF THE THINGS WE DID WAS
WE PARTNERED WITH A DIGITAL TECH
COMMUNICATIONS GROUP, A GROUP OF
ATTORNEYS, AND WE CREATED THAT
RESOURCE SO WE CREATED THIS
WEBSITE CALLED RIGHTS FOR HEALTH
WHERE SOMEONE CAN GO IN AND
ENTER WHO THEY ARE AND THEIR
MEDICAL CONDITION SO THEY'LL SAY
I'M A PREGNANT WOMAN.
WHAT DO I NEED?
SO IT SHOWS UP YOU NEED EIGHT
PRENATAL VISITS, THESE ARE THE
THINGS THAT YOU NEED TO DO, AND
THEN IT PAIRS IT WITH WHAT THEY
ARE LEGALLY ALLOWED TO ACCESS.
SO IT WILL SAY YOU NEED -- THIS
WILL NOT AFFECT YOUR IMMIGRATION
CASE, AND THIS IS WHAT IT MEANS,
AND SO THOSE KINDS OF SERVICES,
AND THEN IT ACTUALLY LINKS
PEOPLE TO PROVIDERS, HEALTHCARE
PROVIDERS AND LEGAL PROVIDERS.
I THINK THAT'S AN EXAMPLE OF HOW
WE CAN CONVERT IT FOR THE
PATIENT POPULATION.
I THINK THAT'S REALLY IMPORTANT.
AND THAT EVERYBODY'S RESEARCH,
I'M SURE IS JUST SO -- LIKE PAIN
RESEARCH IS SO IMPORTANT AND
SHOULD JUST BE OUT THERE IN
WHATEVER WAY WE CAN FOR
PATIENTS.
AND THEN THERE'S THE SECOND
ASPECT OF GETTING TO PROVIDERS,
AND ONE OF THE THINGS THAT WE'VE
HEARD AGAIN AND AGAIN FROM OUR
PATIENT POPULATION IS THAT THEIR
ATTORNEYS TELL THEM INFORMATION
THAT'S INCORRECT, DOCTORS TELL
THEM INFORMATION THAT'S
INCORRECT, WE'VE HAD PATIENTS
SAY MY DOCTOR TOLL ME NO TOLD MT
ANY MORE PRENATAL VISITS BECAUSE
I WOULD BE DEPORTED, WHICH IS SO
FRUSTRATING.
SO I THINK IT IS LIKE YOU'RE
SAYING ABOUT DISSEMINATION.
THE WAY WE'VE FOUND THAT TO BE
EFFECTIVE IS THROUGH MEDIA
ARTICLES, BECAUSE PEOPLE CAN
READ LIKE A THREE-MINUTE, YOU
KNOW, NBC ARTICLE WHEN IT MIGHT
TAKE A LITTLE BIT MORE EFFORT TO
READ A PAPER AND WE CAN
HYPERLINK THE PAPER AND THAT'S
USEFUL.
I THINK MY EXPERIENCE IS THAT
PEOPLE IN MEDIA ARE SO EAGER AND
INTERESTED TO SPREAD AWARENESS
ABOUT SCIENTIFIC FINDINGS AND
REALLY IMPORTANT ARTICLES AND
THAT WE JUST AS SCIENTISTS NEED
TO DO A BETTER JOB OF LIKE
PITCHING, YOU KNOW, TO THOSE
GROUPS TO GET THAT INFORMATION
OUT TO PROVIDERS WHO ARE GOING
TO CARE FOR HUNDREDS OR
THOUSANDS OF PATIENTS DURING
THEIR LIFETIMES.
AND I THINK THERE'S REALLY EASY
WAYS TO DO THAT.
WE HAVE REALLY GOOD SUPPORT
SYSTEMS FOR GRANTS MANAGEMENT
BUT NOT REALLY FOR PR AND MEDIA
ENGAGEMENT AND GETTING THE WORK
OUT ONCE THERE'S A FINDING.
HOW MANY PEOPLE READ A
PARTICULAR PAPER VERSUS HOW MANY
PEOPLE WOULD READ A NEWS ARTICLE
OR LISTEN TO A PODCAST?
SO BOTH ARE -- IT'S NOT LIKE ONE
IS -- JUST THAT IS IMPORTANT,
BUT I THINK WE SHOULD AND COULD
DO A BETTER JOB WITH THAT.
>> TOTALLY AGREE.
HOW DO YOU REALLY SIMPLIFY AND
ALSO LIKE TAYLOR MAKE RESEARCH
FINDINGS TO THE PUBLIC, THEIR
SIMPLIFIED UNDERSTANDING AN.
AGAIN, I WOULD LIKE TO THANK ALL
THE SPEAKERS AND ALSO ALL THE
AUDIENCE HERE FOR ACTIVE
DISCUSSION.
THANK YOU AGAIN.
>> HI, EVERYONE.
THANK YOU ALL FOR COMING AND
THANKS TO EVERYONE WHO'S
WATCHING ONLINE.
I JUST WANT TO GIVE YOU SOME
HOUSEKEEPING STUFF.
OVER THE NEXT COUPLE OF HOURS.
SO WE HAVE A POSTER SESSION
GOING ON IN THE ATRIUM.
IT'S SCHEDULED FROM -- WELL,
NOW, UNTIL 12:30, BUT FEEL FREE
TO TAKE AS MUCH TIME AS YOU WANT
LOOKING AT THE POSTERS.
WE WILL BE BACK HERE AT 1:30.
SO FROM 12:30 UNTIL 1:30, WE
HAVE A ROOM THAT WILL BE
LABELED, THERE ARE SIGNS
POINTING YOU TO IT, I THINK IT'S
ROOM AB, IF YOU'D LIKE TO SET
UP -- IF YOU'D LIKE TO NETWORK
WITH EACH OTHER.
I DON'T ACTUALLY KNOW WHAT THE
WEATHER IS LIKE OUTSIDE.
IF THE WEATHER IS BEAUTIFUL, GO
OUTSIDE, TALK TO PEOPLE OUTSIDE,
BUT IF YOU NEED A PLACE TO
GATHER, IF YOU NEED A QUIET
PLACE, WE HAVE A ROOM.
THERE IS A CAFETERIA UPSTAIRS
WHERE YOU CAN GET LUNCH I.
IF YOU NEED ANY OTHER
INFORMATION, JUST FIND ME OR ONE
OF OUR OTHER NIH COLLEAGUES AND
WE'LL BE HAPPY TO POINT YOU IN
THE RIGHT DIRECTION.
AGAIN, THANK YOU SO MUCH AND WE
WILL SEE YOU AT 1:30.
SO IT'S INTERESTING THAT EVEN
THOUGH WE SEE ABDOMINAL PAIN AS
ONE OF THE HIGHEST REPORTED
SYMPTOMS AMONG THIS PATIENT
POPULATION, IT IS NOT THE CORE
SYMPTOM THAT SEEMS TO BE DRIVING
THOSE RELATIONSHIPS WITH OTHER
SYMPTOMS.
WE ARE EXCITED TO DIVE INTO THIS
MORE AND TO REALLY UNDERSTAND
WHAT IS GOING ON.
>> HELLO, MY NAME IS BRIAN, I'M
GOING TO BE TALKING TO YOU ABOUT
MY DISSERTATION PROJECT.
WHAT IS CIPN?
CIPN IS A PREDOMINANTLY SENSORY
DOSE-LIMIT BELIMITING SIDE EFFEO
HAVE TO REDUCE OR CEASE
TREATMENT.
UNFORTUNATELY THERE ARE
CURRENTLY NO FDA-APPROVED DRUGS
SPECIFICALLY FOR THE PREVENTION
OR TREATMENT OF CIPN, AND SO IN
ORDER TO IDENTIFY NOVEL
THERAPEUTIC TARGETS, WE WANTED
TO LOOK AT WHAT ARE SOME
BIOLOGICAL PROCESSES THAT MAY BE
CONTRIBUTING TO THE DEVELOPMENT
OF CIPN, SUCH AS
NEUROINFLAMMATION.
NEUROINFLAMMATION IS MEDIATED BY
THE ACTIVATION OF INFLAMMATORY
IMMUNE CELLS SUCH AS MACROPHAGES
WHICH WILL THEN INFILTRATE
PERIPHERAL NEUROLOGICAL TISSUES.
ONE PROTEIN THAT REALLY STOOD
OUT TO US THAT MAY POTENTIALLY
HAVE A ROLE IN THIS PROCESS WAS
ASTROCYTE ELEVATED GENE 1 OR
AEG1.
AEG1 IS A SCAFFOLDING PROTEIN
THAT PRIMARILY FUNCTIONS BY
PROTEIN-PROTEIN INTERACTIONS AND
HAS BEEN SHOWN TO MODULATE NF KB
INDEPENDENT INFLAMMATION AS WELL
AS MACROPHAGE ACTIVITY.
IN FACT, LOSS RENDERS THEM
FUNCTIONALLY ANERGIC, SO WE
HYPOTHESIZED THAT THIS
EXPRESSION IN MYELOID CELLS
CONTRIBUTES TO THE DEVELOPMENT
AND MAINTENANCE OF CIPN.
WE UTILIZED A MODEL OF CIPN THAT
IS INDUCED BY PACK PACLITAXEL Y
USING GENETICALLY MODIFIED MICE
THAT DO NOT EXPRESS AEG1.
SO WE CAN SEE THE DELETION OF
AEG1 IN M MYELOID CELLS -- YOU N
SEE OUR WILD TYPE MICE STILL
DEVELOPED HYPERMECHANICAL
SENSITIVITY BUT AEG1 KNOCKOUT
MICE DO NOT.
WE SEE SIMILAR -- AND REDUCTIONS
IN PERIPHERAL NERVE FIBER -- THE
LOSS OF INTRAEPIDERMAL NERVE
FIBER DENSITY AS WELL AS A
REDUCTION IN THE EXPRESSION OF
SEVERAL PRO-INFLAMMATORY
CYTOKINES IN THE LUMBER DRGs
AND A COMPLETE INHIBITION OF
MYELOID CELL INFILTRATION INTO
THE DRGs WHICH ARE MARKED
USING F480, A MARKER FOR
MACROPHAGES.
WE'VE ALSO GOT SOME INTERESTING
DATA WHERE WE HAVE DEVELOPED
NANOPARTICLES THAT DELIVER
AEG16789 S RNA AND THAT HAS
SHOWN A LOT OF PROMISE IN
POTENTIALLY PREVENTING AND EVEN
REVERSING PACLITAXEL-INDUCED
MECHANICAL AND COLD
HYPERSENSITIVITY.
SO IF YOU HAVE ANY QUESTIONS OR
YOU'RE INTERESTED IN DATA,
PLEASE STOP BY AND FEEL FREE TO
ASK ANY QUESTIONS.
THANK YOU.
BYE.
>> I AM FROM THE CHILDREN'S
HOSPITAL OF PHILADELPHIA, AND I
WILL BE DISCUSSING CLUSTER
ANALYSIS OF MIGRAINE-ASSOCIATED
SYMPTOMS IN YOUTH.
EVERYONE IS FAMILIAR WITH WHAT A
HEADACHE IS.
BUT MIGRAINE IS A PARTICULAR
TYPE OF HEADACHE THAT IS NOT
ONLY DEFINED BY SEVERE
POTENTIALLY DISABLING HEAD PAIN,
BUT ALSO NEUROLOGICAL SYMPTOMS
THAT COME ALONG WITH THE PAIN.
SOME OF THESE INCLUDING LIGHT
SENSITIVITY, PAIN AND NAUSEA ARE
USED TO DEFINE MAY GRAIN HOWEVER
BRAIN FOG, LIGHT-HEADEDNESS AND
ROOM SPINNINGAGE OTHERS ARE ALSO
COMMONLY EXPERIENCED IN PEOPLE
WITH MIGRAINE.
THERE'S ALSO A HINT THAT
SYMPTOMS COMING ALONG WITH
MIGRAINE CHANGE AS CHILDREN GET
OLDER.
HOWEVER, WHAT IS NOT KNOWN IS
HOW A BROADER RANGE OF SYMPTOMS
ASSOCIATED WITH HEADACHE RELATE
TO EACH OTHER AND WHAT THEY TELL
US ABOUT THE BURDEN OF MIGRAINE
IN DAILY LIFE AND HOW THESE
SYMPTOMS CHANGE ACROSS CHILD
DEVELOPMENT.
WE SURVEYED OVER 10,000 YOUTH
BETWEEN THE AGES OF 6 AND 18
YEARS OLD WHO ARE BEING SEEN FOR
HEADACHE AND WE ASKED ABOUT 11
MIGRAINE-ASSOCIATED SYMPTOMS
WHICH ARE SHOWN IN THE GREEN
GRAPH.
WE USED MULTIPLE CORRESPONDENCE
ANALYSIS TO LOOK AT HOW THESE
RELATE TO EACH OTHER.
THE MAIN FINDINGS ACROSS THE
THREE DIMENSIONS ARE SUMMARIZED
IN THE SCHEMATIC.
SHOWN HERE.
THE FIRST DIMENSION SHOWED THAT
YOUTH WHO REPORTED ANY SYMPTOMS
WERE LIKELY TO REPORT MULTIPLE.
THIS CONSISTENT WITH THE VERY
DIFFICULT NIGDEFINITION OF MIGR,
SEPARATING THOSE WHO HAVE
NEUROLOGIC SYMPTOMS WITH THEIR
HEADACHE FROM THOSE WHO ARE
DON'T.
FOR YOUTH WHO REPORTED
RELATIVELY FEW SYMPTOMS, THEY
TENDED TO BE FEATURES THAT
DEFINE MIGRAINE WHEREAS SYMPTOMS
LIKE LIGHT-HEADEDNESS,
DIFFICULTY THINKING AND VISION
CHANGES WERE LIKELY TO BE
RECORDED WHEN ONLY MANY OTHER
SYMPTOMS WERE PRESENT.
THE SECOND SEPARATED THE
CLASSICAL FROM NON-CLASSICAL
FEATURES OF MIGRAINE AND THE
THIRD SEPARATED THOSE WERE --
FROM VESTIBULAR SYMPTOMS AND
VOMITING.
WE FOUND THESE REVEALED
INFORMATION ABOUT HOW MIGRAINE
ASSOCIATED SYMPTOMS CHANGE
ACROSS HEADACHE BURDEN AND CHILD
DEVELOPMENT.
YOUTH WHO REPORTED --
HEADACHE-RELATED DISABILITY AND
WERE MORE LIKELY TO BE OLDER.
THERE WAS ALSO A SPLIT AROUND
THE AGE OF PUBERTY WHERE FEMALES
STARTED REPORTING MORE SYMPTOMS
THAN MALES.
YOUNGER CHILDREN TENDED TO ONLY
REPORT SYMPTOMS THAT WERE PART
OF THE CLASSICAL MIGRAINE
DIAGNOSIS WHILE TEENS REPORTED A
ADDITIONAL NON-CLASSICAL
SYMPTOMS.
LOOKING AT A BROADER RANGE OF
SYMPTOMS ASSOCIATED WITH
MIGRAINE AND CLUSTERS AND
PROVIDES ADDITIONAL IMPORTANT
INFORMATION ABOUT HEADACHE
BURDEN AND DEVELOPMENTAL CHANGES
IN MIGRAINE.
FURTHER STUDY IS NEEDED TO
DETERMINE IF THESE CLUSTERS CAN
BE USED TO TO PROVIDE MORE
PERSONALIZED SYMPTOM-BASED
MIGRAINE CARE.
>> HI, MY NAME IS DESIREE, I'LL
BE TALKING TO YOU TODAY ABOUT
THE FEASIBILITY TESTING OF AN
MHEALTH APPLICATION THAT
INTEGRATE COGNITIVE BEHAVIORAL
THERAPY FOR PAIN WITH
PHARMACOLOGIC EDUCATION TO
SUPPORT ADVANCED CANCER
PATIENTS' MANAGING PAIN.
WE DEVELOPED THE APP THAT WAS
DESIGNED SPECIFICALLY FOR
ADVANCED CANCER PATIENTS USING
OPIOIDS TO MANAGE CHRONIC PAIN.
IT UTILIZES DAILY SURVEYS OF
PAIN, MOOD, CATASTROPHIZING,
SLEEP AND OPIOID USE.
IT ALSO DELIVERS TAILORED
MESSAGES IN RESPONSE TO THEIR
SYMPTOMS USING JUST IN TIME
ADAPTIVE ALGORITHMS.
THE APP DELIVERS DAILY
PSYCHOEDUCATION ON PAIN, OPIOIDS
AND PAIN CVT PRINCIPLES USING
ANIMATED VIDEOS AND BEHAVIORAL
ALONG WITH RELAXATION EXERCISES
AND WRITTEN ARTICLES.
WE CONDUCTED A SINGLE ARM PILOT
STUDY TO EVALUATE THE
FEASIBILITY AT THE STEVENSON
CANCER CENTER IN OKLAHOMA CITY,
OKLAHOMA.
ADD DULTS WITH SAID VANED SOLID
TUMOR MALIGNANCIES OR HEMO --
4 OR GREATER OUT OF 10 ON THE
BPI AND ACTIVE OPIOID USE WERE
INCLUDED.
SO 26 PARTICIPANTS ENROLLED IN
THE STUDY AND TESTED OUT FOR 28
DAYS.
62% OF THEM WERE FEMALE, AND 54
YEARS OLD ON AVERAGE RANGING
FROM 21 TO 74 YEARS OLD.
AND WHILE 71% WERE WHITE, 19%
WERE NATIVE AMERICAN AND 7% WERE
BLACK.
76% OF PARTICIPANTS USE THE APP
ON MORE THAN HALF OF STUDY DAYS
INDICATING GOOD FEASIBILITY.
PARTICIPANTS COMPLETED A MEDIAN
OF 71% OF THE DAILY SURVEYS AND
ABOUT 50% OF THE DAILY
EDUCATIONAL CONTENT.
THEY ENGAGE WITH SURVEYS FOR AN
AVERAGE OF JUST UNDER FIVE
MINUTES PER DAY, AND SPENT AN
AVERAGE OF 3 1/2 HOURS USING THE
APP IN TOTAL ACROSS THE 28 DAYS.
SOME PATIENTS USE IT FOR ABOUT
26 ^ MINUTES IN TOTAL AND OTHERS
FOR UP TO 1 13 HOURS IN TOTAL.
OVERALL ACCEPTABILITY OF THE APP
WAS HIGH, WITH PARTICIPANTS
RATING 81% OF ALL ACCEPTABILITY
ITEMS AS 4 OR GREATER ON A
5-POINT SCALE.
17 PISHTS COMPLETED OPTIONAL
POST STUDY INTERVIEWS AND
THEMATIC ANALYSIS SUGGESTED THAT
MOST PATIENTS FELT THE APP
IMPROVED THEIR ABILITY TO
SELF-MANAGE THEIR CANCER
CONTINUE RELATED PAIN, BY
SPECIFICALLY FACILITATING
INSIGHT INTO THEIR PAIN TRIGGER,
BUT ALSO BECAUSE IT HELPED TO
INCREASE INSIGHT ON THE
RELATIONSHIP BETWEEN STRESS AND
PAIN.
A PORTION ALSO STATED THAT THE
APP HELPED TO REDUCE PERCEIVED
STIGMA ABOUT USING OPIOIDS AND,
THEREFORE, PROMOTING
CONVERSATIONS WITH THEIR CARE
TEAMS.
MOST PARTICIPANTS WOULD
RECOMMEND THE APP TO ANOTHER
PATIENT.
SO IN CONCLUSION, INTEGRATING
PAIN CVT WITH OPIOID SUPPORT WAS
BOTH FEASIBLE AND ACCEPTABLE TO
PATIENTS WITH ADVANCED CANCER.
SO WE WILL NEXT BE TESTING THE
APP IN A RANDOMIZED PILOT TRIAL
TO FURTHER EVALUATE FEASIBILITY
AND PRELIMINARY EFFICACY FOR
PATIENTS WITH ADVANCED CANCER
END PAIN USING OPIOIDS.
>> MY NAME IS MEREDITH BARRY.
THANK YOU FOR INVITING ME TO
PRESENT MY POSTER.
TODAY I'M GOING TO TALK ABOUT
THE POTENTIAL OF OXYTOCIN TO
REDUCE EXPERIMENTAL PAIN AND
OPIOID-LIKE ABILITY.
OF COURSE OPIOID MISUSE IS A
MAJOR SOURCE OF MORBIDITY AND
MORTALITY.
AND PAIN OF COURSE IS THE
LEADING CAUSE OF DISABILITY IN
THE U.S.
OXYCODONE SPECIFICALLY IS
SPECIFICALLY DESCRIBED FOR PAIN
BUT CAN ALSO BE INVOLVED IN
OVERDOSE DEATHS AND IS WIDELY
MISUSED.
THE POINT OF THIS STUDY IS TO
EXAMINE A NOVEL ADJUNCT
TREATMENT OPTION FOR PAIN
MANAGEMENT THAT COULD
SIMULTANEOUSLY REDUCE THE MISUSE
OF POTENTIAL OPIOIDS, WHICH IS
OXYTOCIN, SOME PROMISING ANIMAL
STUDIES AND HUMAN STUDIES HAVE
LED TO THIS QUESTION SO THE AIMS
OF THE PRESENT STUDY WERE TO
DETERMINE THE EFFECTS OF
INTRAINNASA
OXYTOCIN ---LIKE ABILITY.
SO WE USE THE DOUBLE BLIND
PLACEBO CONTROL STUDY AND THERE
WERE SIX SESSIONS, WITH VARIOUS
COMBINATIONS OF PLACEBO,
OXYCODONE, AND PLACEBO OXYTOCIN
ON 48 NATIONAL UNITS OF
OXYTOCIN.
OUR TARGET IS 30 PARTICIPANTS,
DATA COLLECTION IS ONGOING, AND
WE ONLY HAVE FOUR RIGHT NOW AND
FIVE AND SIX ARE CURRENTLY
RUNNING IN THE STUDY.
SO WE HOPE TO FLECT CLOACT A GRT
DEAL MORE.
OUR PRIMARY OUT COME MEASURES
I'M GOING TO FOCUS ON TODAY IS
THERMAL PAIN AND SUBJECT RATED
MISUSE VIABILITY ON A VISUAL
ANALOG SCALE.
SO JUST VERY QUICKLY GIVEN TIME
CONSTRAINTS THE PRELIMINARY
RESULTS SHOWED THERE DOESN'T
APPEAR TO BE MUCH OF AN EFFECT
IN PAIN RATINGS FOR HEAT PAIN AS
THE PAIN -- OR THE HEAT
GRADUALLY INCREASES ACROSS DOSE
CONDITIONS TIME ONE IS BEFORE
THEY RECEIVED DRUG AND TIME TWO
IS AFTER THEY RECEIVED DRUG AND
THIS IS THE DOSE CONTINUE, THESE
ARE PAIRED.
SO THERE DOESN'T APPEAR TO BE
MUCH DIFFERENCE THERE WHEN
TESTED ON THE HAND, HOWEVER WHEN
WE TEST ON THE TRAPEZIUS USING
COLD PAIN RATING, SO THE COLD
TEMPERATURE INCREASES, THERE
DOES APPEAR TO BE A LITTLE BIT
MORE VARIABILITY AND IN SOME
CASES IN TIME ONE, WHERE BEFORE
THE DRUG IS RECEIVED, AND AFTER
TIME TWO, AFTER DRUG, PLACEBO IS
RECEIVED, THERE DOES APPEAR TO
BE REDUCTION IN PAIN ACROSS SOME
OF THESE CONDITIONS.
SO IT DEPENDS ON THE BODY SITE
AND TYPE OF PAIN ASSAY AND WE'VE
ONLY INITIALLY LOOKED AT THERMAL
PAIN ASSAYS AND WE STILL HAVE
MECHANICAL TO UNPACK.
AND THEN HERE ARE THE
PRELIMINARY RESULTS OF THE
OPIOID-LIKE ABILITY AND THE
DRUG-LIKABILITY IN GENERAL, AND
SO I AM STILL BLINDED TO THESE
CONDITIONS BUT SOME APPEAR A
LITTLE BIT HIGHER THAN OTHERS,
AND THEN THERE APPEARS TO BE
SOME EXPECTANCY EFFECTS WITH --
BECAUSE ONE OF THESE IS
PLACEBO-PLOPLACEBOPLACEBO CONDI.
SO DATA CHECK SHOULD BE IS
GOING, MORE DATA ARE NEEDED TO
EVALUATE THE PAIN AND MISUSE
LIABILITY AND FOR SOME
PARTICIPANTS BUT NOT ALL, THE
SESSIONS IN WHICH EXPERIMENTAL
PAIN SENSITIVITY IS LOWER, THE
MISUSE -- IS LOWER BUT WE NEED
TO LOOK AT THE DATA ON AN
INDIVIDUAL LEVEL AND CONSIDER
THE EFFECTS MIGHT NOT BE THE
SAME ACROSS INDIVIDUAL SUBJECTS.
THIS STUDY HAS POTENTIAL IN
EXAMINING OXYTOCIN AS A
PROMISING AGENT FOR
SIMULTANEOUSLY PAIN, SO
ULTIMATELY CONFIRMATION OF OUR
HYPOTHESES COULD RESULT IN A
LARGER CLINICAL TRIAL TO COMPARE
THE EFFECTS OF OXYTOCIN VERSUS
PLACEBO, WITH AN OPIOID
PRESCRIPTION FOLLOWING SURGERY
AND LOOK AT POTENTIAL OPIOID
SPARING EFFECTS.
THANK YOU VERY MUCH FOR YOUR
TIME.
AND I APPRECIATE BEING ABLE TO
PRESENT.
>> HELLO.
MY NAME IS DR. STAR BOOKER FROM
THE UNIVERSITY OF FLORIDA.
THE PATTERNS BETWEEN PAIN AND
MOVEMENT ARE SO SEEMINGLY
INTUITIVE THAT WE REALLY HADN'T
STUDIED HOW REALTIME MOVEMENT
AFFECTS HIGH IMPACT CHRONIC PAIN
CONDITIONS SUCH AS
OSTEOARTHRITIS.
USING DATA FROM MY K23 STUDY, WE
ARE EXAMINING INTRARACIAL
VARIABILITY AND MOVEMENT EVOKED
PAIN BY SYSTEMATICALLY
ASSESSING, QUANTIFYING AND
CHARACTERIZING PATTERNS IN
AFRICAN AMERICAN ADULTS.
WE MEASURED ZERO TO 10 USING A
PAIN RATING SCALE AND PAIN
SURFACE AREA WHICH IS THE AMOUNT
OF THE KNEE IN PAIN AFTER
MOVEMENT ZERO TO 100% BEFORE
DURING AND AFTER LOW INTENSITY
ACTIVITY SUCH AS THE SHORT
PHYSICAL PERFORMANCE BATTERY,
AND ONE LEG STAND AND THE WALK.
MODERATE INTENSIVITY ACTIVITY
SUCH AS THE THREE MINUTE WALK,
AND HIGH INTENSITY ACTIVITY,
FLEXION AND EXTENSION AT 90 AND
180 DEGREES.
OUR SAMPLE WAS PRIMARILY WOMEN
WITH A MEAN AGE OF 65 YEARS.
SO FIRST WE IMAIR -- BY HAVING
PARTICIPANTS VIEW PICTURES OF
PHYSICAL ACTIVITY AND RATE THE
AMOUNT OF PAIN, THE AMOUNT OF
KNEE PAIN THEY WOULD FEEL AND WE
ALSO MEASURED REALTIME MOVEMENT
EVOKED PAIN USING A BATTERY OF
STANDARDIZED PERFORMANCE BASED
PHYSICAL ACTIVITY.
AS YOU CAN SEE AT THE TABLE,
THERE IS -- FOR MOST ACTIVITIES
EXCEPT FOR STANDING FROM A
SEATED, LAYING POSITION,
ASCENDING STAIRS, AND KNEE
FLEXION AND EXTENSION ON THE LEG
PRESS.
SO HERE WE ATTEMPT TO QUANTIFY
MOVEMENT OF EVOKED PAIN IN FIVE
DIFFERENT WAYS AND THERE WAS
CURRENTLY NO STANDARD METHOD.
ZOO FISO FIRST WE CALCULATED A E
WHICH SHOWED MILD PAIN FOR LOW
AND MILD INTENSITY ACTIVITIES,
THEN WE AVERAGED EACH FUNCTIONAL
ACTIVITY AND LOW INTENSITY
ACTIVITIES HAD A MEAN RANGE,
REPEATED CHAIR STANDS RESULTED
IN HIGHER PAIN INTENSITY AND
MORE OF THE AREA HURTING.
THE AVERAGE -- 42% OF THE KNEE
HURTING, AND THE RANGE FOR HIGH
INTENSITY ACTIVITY WAS 4.4 TO
5.1.
IN PARTICULAR THE BIODEX
RESULTED IN MILD TO MODERATE
PAIN INTENSITY SCORES DURING AND
AFTER MOVEMENT WITH LOW AND
MODERATE ACTIVITIES.
THIRDLY WE AVERAGED ALL POST
ACTIVITY RATINGS AND LOW
INTENSITY ACTIVITIES 3.7 AND
HIGH INTENSITY ACTIVITY HAD A
MEAN OF 4.2.
THE ANALYSIS FOR CALCULATING A
CHANGE SCORE AND MAXIMUM RATING
ARE STILL IN PROGRESS AS WE'RE
STILL TRYING TO FIGURE OUT THE
BEST FORMULA FOR THESE, HOWEVER
SOME ARE INDICATING POSSIBLE
MOVEMENT EVOKED ANALGESIA VERSUS
MOVEMENT EVOKED PAIN FOR SOME
ACTIVITIES.
SO OUR NEXT STEPS IN
CHARACTERIZING MOVEMENT EVOKED
PAIN IS TO PERFORM A CLUSTER
ANALYSIS AND TO IDENTIFY
SPAISPATIENTS BASED ON
SOCIODEMOGRAPHIC
CHARACTERISTICS.
SO STAY TUNED, THERE'S MORE TO
COME, AND SEE YOU IN D.C. .
>> THANK YOU SO VERY MUCH FOR
JOINING US HERE TODAY FOR THIS
PRESENTATION.
MY NAME IS -- TO SHARE OUR
LATEST RESEARCH FINDINGS WITH
YOU.
TODAY I'M PLEASED TO PRESENT OUR
POSTER TITLED IDENTIFYING
FACTORS THAT INFLUENCE THE
TRANSITION FROM ACUTE TO CHRONIC
LOW BACK PAIN IN BLACK/AFRICAN
AMERICANS.
THIS IS A SIGNIFICANT PROBLEM IN
THE UNITED STATES, MAY NOT HAVE
THE HIGHER OVERALL PREVALENCE OF
CHRONIC LOWER BACK PAIN, THEY DO
BEAR A DISPROPORTIONATE BURDEN.
OUR STUDY REALLY AIMED TO -- BY
IDENTIFYING THE PSYCHOSOCIAL AND
NEUROPHYSIOLOGICAL RISK FACTORS
FOR CHRONIC LOWER BACK PAIN THAT
SPECIFICALLY AMONG BLACK AFRICAN
AMERICANS.
WE TRANSITION FROM ACUTE TO
CHRONIC LOW BACK PAIN, WE
EXAMINE THE DIFFERENCES IN
FACTORS SUCH AS PAIN SEVERITY,
STRESS, COPING MECHANISMS, PAIN
SENSITIVITY AT TWO TIME POINTS,
ACUTE ONSET AND AT SIX MONTHS
FOLLOW-UP.
RESULT REALLY INDICATED BLACK
AFRICAN AMERICANS REPORTED
HIGHER PAIN INTENSITY, DIFFERENT
COPING STRATEGIES, INCREASED
PAIN SENSITIVITY, COMPARED TO
NON-HISPANIC WHITES.
ALL FOUND TO INFLUENCE THE
TRANSITION IN BOTH GROUPS.
ASSOCIATED WITH INFLAMMATION,
IMMUNITY AND STRESS RESPONSE.
VERSUS THE UNIQUE RISK THAT RISK
FACTORS THAT REALLY -- TO THE
CHRONIC LOWER BACK PAIN IN BLACK
AFRICAN AMERICANS.
IMPLI KAYTIVELY OUR STUDY
UNDERSCORES THE NECESSITY FOR
TAYLORED APPROACHES TO PAIN
MANAGEMENT AND INTERVENTIONS
THAT HAVE BOTH PSYCHOSOCIAL AND
NEUROBIOLOGICAL ASPECT TO
MITIGATE THE RISK OF CHRONIC
PAIN AND -- IN BLACK AFRICAN
AMERICAN -- THANK YOU SO VERY
MUCH.
FOR LISTENING.
OF SENSORY ION CHANNELS.
SENSORY ION CHANNELS RESIDE IN
NEURONS, NOCICEPTOR, THAT
INTERFACE WITH OUR EXTERNAL
ENVIRONMENT AND RECOGNIZE BOTH
NON-PAIN CAUSING AND PAINFUL
SIGNALS.
SUCH AS ITCH, TEMPERATURE,
CHEMICAL IRRITANTS AND
MECHANICAL FORCE.
UPON RECOGNIZING THESE STIMULI,
THE ION CHANNELS OPEN AND
ELECTRICAL SIGNALS ARE
TRANSMITTED TO OUR SPINAL CORD
AND ULTIMATELY OUR BRAIN.
IN SOME CASES, THIS CAUSES PAIN.
TODAY I WOULD LIKE TO SPEAK TO
YOU ABOUT THE PRIMARY DETECTOR
OF ENVIRONMENTAL COLD.
IT IS ALSO TARGETED BY MENTHOL,
A NATURAL PRODUCT FROM MINT.
IT'S A NON-SELECTIVE CHANNEL AND
IT IS AN IMPORTANT TARGET FOR
TREATING BOTH PATHOLOGICAL COLD
HYPERSENSITIVITY AND CHRONIC
PAIN.
SINGLE PARTICLE CRYO-EM HAS
REVOLUTIONIZED MEMBER AND
PROTEIN STRUCTURAL BIOLOGY.
THE MAJOR ADVANTAGE OF THIS
TECHNIQUE IS THAT THE PROTEIN OF
INTEREST DOESN'T NEED TO RESIDE
IN A SINGLE STATE TO BE CAPTURED
AT HIGH RESOLUTION.
ACTUALLY MULTIPLE DISTINCT
CONFIRMATIONAL STATES CAN BE
CAPTURED SIMULTANEOUSLY.
THIS APPROACH SUCCESSFULLY
CAPTURED TWO DISTINCT
CONFIRMATIONAL STATES, CLOSED
AND DESENSITIZED.
BOTH ARE NON-CONDUCTING.
THE CLOSED STATE WAS OBSERVED
BOTH IN THE ABSENCE OF LIGANDS
AS WELL AS THE PRESENCE OF
ANTAGONISTS.
THE DESENSITIZED STATE WAS
OBSERVED IN THE PRESENCE OF
COLD, AN AGONIST, AND CALCIUM.
CONSISTENT WITH THE FACT THAT
CALCIUM PLAYS A ROLE IN
DESENSITIZATION.
I SAW STRUCTURE WITH TWO
DIFFERENT ANTAGONISTS AND
OBSERVED THAO THESE DRUGS BIND
TO A SIMILAR REGION WITHIN THE
TRANS -- INTERESTINGLY, IT IS
NOW KNOWN THAT ANTAGONISTS,
AGONISTS AND MODULATORY LIPIDS
BIND TO THE SITE.
I ALSO DISCOVERED THAT CALCIUM
BINDS DIRECTLY TO THE CHANNEL.
THE CALCIUM BINDING SITE IS ALSO
LOCATED IN A SIMILAR REGION OF
THE TRANSMEMBRANE DOMAIN.
HOWEVER, IT'S NOT AS DEEPLY
NESTLED WITHIN.
WHAT I MUTATED THE CALCIUM
COORDINATING -- THIS HAS LED US
TO PROPOSE THE FOLLOWING MODEL.
WHEN IT'S OPENED, CALCIUM FLOWS
IN.
IT THEN BINDS TO AN INTERNAL
SITE ON THE CHANNEL.
AND THIS CAUSES THE CHANNEL TO
ENTER A DESENSITIZED STATE AND
ONCE AGAIN CLOSE.
>> I'M ASSISTANT PROFESSOR AT
TEMPLE UNIVERSITY.
I'LL BE PRESENTING RESEARCH
EXPLORING CHANGES IN PAIN
INTERFERENCE FOLLOWING A TAI CHI
INTERVENTION FOR ADULTS WITH HIV
AND CHRONIC PAIN.
I HAVE NO DISCLOSURES OR
CONFLICTS OF INTEREST TO REPORT.
THIS WORK WAS FUNDED BY NIH,
SPECIFICALLY THE NATIONAL CENTER
FOR COMPLEMENTARY AND
INTEGRATIVE HEALTH.
SO ADULTS WITH HIV EXPERIENCE
CHRONIC PAIN AT HIGHER RATES
COMPARED TO THE GENERAL
POPULATION.
RECENT WORK BY OUR GROUP AND
OTHERS HAS DEMONSTRATED THAT
WHILE HIV IS WELL MANAGED,
CURRENT EFFORTS TOWARDS MANAGING
CHRONIC PAIN ARE INEFFECTIVE FOR
MANY.
WE CONDUCTED A SMALL RANDOMIZED
TRIAL TO EXAMINE THE FEES ANLT
AND ACCEPTABILITY OF TAI CHI
COMPARED TO A HEALTH EDUCATION
CONTROL GROUP.
AS YOU CAN SEE IN THE FLOW
CHART, WE RECRUITED AND
RANDOMIZED 36 PARTICIPANTS,
RETENTION AT EACH FOLLOW-UP WAS
NEARLY 90% AND ALL PARTICIPANTS
COMPLETED AT LEAST ONE FOLLOW-UP
ASSESSMENT.
OVERALL THE SAMPLE WAS PRIMARILY
FEMALE AND BLACK WITH 14%
REPORTING HISPANIC ETHNICITY,
THE MEAN AGE WAS 61 YEARS.
WHILE OUR RETENTION WAS
ADEQUATE, THERE WAS A SUBSET OF
PARTICIPANT WHO FAILED TO ATTEND
ANY INTERVENTION OR CONTROL
SESSIONS.
WE DECIDED TO SEPARATE OUT THESE
PARTICIPANTS TO HAVE A CLEAR
ESSENCE OF ANY CHANGES DETECTED
THAT MIGHT BE ASSOCIATED WITH
TAI CHI OR HEALTH EDUCATION
SESSIONS.
WE THOUGHT THIS SUBSET COULD
SERVE AS A THIRD GROUP, THOSE
RECEIVING ASSESSMENT ONLY.
WE HYPOTHESIZE PARTICIPANTS IN
THE TAI CHI GROUP -- RELATIVE TO
HEALTH EDUCATION AND THE
ASSESSMENT ONLY PARTICIPANTS.
WE USED REPEATED MEASURES TO
EXPLORE THESE DIFFERENCES ACROSS
TIME POINTS.
AS YOU CAN SEE IN THE FIGURE
HERE, THOSE WHO FAILED TO ATTEND
ANY SESSIONS REPORTED THE LOWEST
PAIN INTERFERENCE AT BASELINE,
WHICH WAS SIGNIFICANTLY
DIFFERENT THAN THOSE IN HEALTH
EDUCATION AND MARGINALLY
DIFFERENT THAN THOSE RECEIVING
TAI CHI.
AT POST INTERVENTION WE OBSERVED
SIGNIFICANT DECREASE IN PAIN
INTERFERENCE AMONG PARTICIPANTS
WHO RECEIVED TAI CHI AND THIS
DIFFERENCE WAS SIGNIFICANTLY
DIFFERENT THAN THOSE WHO
RECEIVED HEALTH EDUCATION OR
ATTENDED NO SESSIONS.
AS IS THE CASE WITH MANY
BEHAVIORAL TRIALS, THIS
DIFFERENCE MODERATED AT LATER
FOLLOW-UP.
SO THESE FINDINGS SUGGEST THAT
TAI CHI MAY BE EFFECTIVE AT
REDUCING PAIN INTERFERENCE FOR
ADULTS WITH HIV.
FOR THOSE THAT DID NOT ATTEND,
ONE HYPOTHESIS IS THAT LOWER
PAIN INTERFERENCE AT BASELINE
REDUCED THEIR -- WE ACKNOWLEDGE
THAT THIS STUDY IS LIMITED BY
THE SMALL SAMPLE SIZE AS IT WAS
A PILOT TRIAL AND NOT POWERED TO
DETECT SIGNIFICANCE.
I WANT TO AGAIN THANK NCCIH FOR
THEIR FUNDING AND SUPPORT AND
THANK YOU FOR YOUR INTEREST IN
THIS RESEARCH.
>> HI, EVERYONE.
TODAY I'LL BE DISCUSSING SOME
RECENT WORK ON THE EFFICACY OF
ALCOHOL IN REGULATING HIV
ASSOCIATED NEUROPATHIC PAIN.
APPROXIMATELY 70% OF PEOPLE WITH
HIV ARE AFFECTED BY NEUROPATHY,
AND ALCOHOL USE DISORDER OR AUD
IS ALSO FREQUENTLY CALLED -- IN
PEOPLE WITH HIV AND CAN ACTUALLY
EXACERBATE NEUROPATHY SYMPTOMS.
THE RATIONAL FOR ALCOHOL
CONSUMPTION IN THIS PATIENT
POPULATION MAY EXTEND FROM A
DESIRE FOR SELF-MEDICATION OF
PAIN DUE TO THE ANALGESIC
PROPERTIES OF ALCOHOL.
FURTHERMORE, CHRONIC PAIN AND
AUD ARE ASSOCIATED -- ANXIETY
AND DEPRESSION.
WE ARE UTILIZING BOTH THE
PRE-CLINICAL ANIMAL MODEL
ALONGSIDE A CLINICAL COHORT OF
PEOPLE WITH HIV.
OUR PRE-CLINICAL WORK USING THE
RODENT MODEL OF HIV NEUROPATHY
WHICH INVOLVES WRAPPING A
SURGICAL MESH SOAKED IN SOLUTION
OF GP120, WHICH IS ONE OF THE
ENVELOPE PROTEINS OF THE HIV
VIRUS AROUND THE LEFT SCIATIC
NERVE WHICH INDUCES A NEUROPATHY
PHENOTYPE SIMILAR TO THAT SEEN
IN PEOPLE WITH HIV.
OUR CLINICAL WORK SOURCES
FINDINGS FROM THE ALCOHOL USE IN
HIV STUDY AND IN THIS
CROSS-SECTIONAL ANALYSIS OF THAT
DATA, OUR EXPOSURE WAS RECENT
ALCOHOL USE AND WE EXTENDED
THREE OUTCOMES, PAIN, ANXIETY
AND DEPRESSION.
IN A PRE-CLINICAL MODEL, WE
FOUND THAT PERINEURAL MODEL
RESULTS IN MECHANICAL
HYPERALGESIA, WHICH IS EVIDENT
BY THIS REDUCTION IN THRESHOLD
IN OUR GP120 GROUP.
OUR ALCOHOL DOSE-RESPONSE DATA
REVEALED THAT ALCOHOL --
RETURNING THOSE THRESHOLDS CLOSE
TO BASELINE, AND IN THE MALES,
WE SEE THIS ALMOST COMPLETE
ATTENUATION OF THE HYPERALGESIA
EVEN AFTER A MODERATE DOSE OF
ALCOHOL WHILE IN FEMALES IT
REALLY REQUIRES THAT HIGHER
DOSE, THE 1-GRAM PER KILOGRAM
DOSE, TO FULLY ATTENUATE THAT
PAIN.
IN THE NOAH COHORT, WE FOUND
RECENT ALCOHOL USE AS ASSESSED
BY ETHANOL IS ASSOCIATED WITH
REDUCED PAIN INTENSITY AND PAIN
INTERFERENCE SYMPTOMS OR HIGHER
SF36 SCORES.
ADDITIONALLY THERE WAS A
SIGNIFICANT -- WHERE FEMALES
REPORTED SIGNIFICANTLY MORE PAIN
COMPARED TO MALES.
AGAIN, SIGNIFICANTLY LOWER SF36
SCORES.
WE THEN LOOKED AT THE
RELATIONSHIP AND WE FOUND
SIGNIFICANT NEGATIVE
CORRELATIONS.
AGAIN NOTING BACK TO THE
INVERTED NATURE OF THE SF36
SCALE, NEGATIVE CORRELATIONS
REPRESENT POSITIVE ASSOCIATIONS
SO PEOPLE WITH MORE PAIN ARE
EXPERIENCING MORE ANXIETY AND
DEPRESSION.
SO TO SUMMARIZE, OUR
PRE-CLINICAL AND CLINICAL DATA
SUGGESTS THAT ACUTE ALCOHOL
ALLEVIATES HIV NEUROPATHY
SYMPTOMS AND PAIN IN THE KNOW A
COHORT IS --
>> I'M A PHARMACOLOGY PH.D.
CANDIDATE IN THE LAB OF ANDY
KNACKLY AT DUKE UNIVERSITY.
THANK YOU FOR YOUR INTEREST IN
MY PROJECT, MICRORNA 374 FAMILY
AS A KEY REGULATOR OF CHRONIC
MIPRIMARY PAIN ONSET.
YOU HAVE TO COME TO MY POSTER IF
YOU WANT MORE DETAILS BUT FOR
NOW I'LL GIVE YOU A HIGH LEVEL
OVERVIEW OF WHAT I'VE BEEN
RESEARCHING.
IN THE LAB, WE STUDY CHRONIC
PRIMARY PAIN CONDITIONS.
WHICH INCLUDE CONDITIONS LIKE
FIBROMYALGIA SYNDROME,
TEMPOROMANDIBULAR SYNDROME AND
WIDESPREAD BODY PAIN.
WE LOOK AT MICRORNAs, GUIDED
TO SPECIFIC MRNA TRANSCRIPTS AND
IB HIBT THEIR TRANSLATION, SO
YOU HAVE THIS INVERSE
RELATIONSHIP WITH PRO -- GENES.
THROUGH DEEP SEQUENCING
APPROACHES AND THREE DIFFERENT
HUMAN CLINICAL COHORTS, WE
IDENTIFIED THE DOWN REGULATION
OF ONE MICRORNA FAMILY, MICRORNA
374, ACROSS TEMPOROMANDIBULAR
DISORDER, FIBROMYALGIA SYNDROME
AND INDIVIDUALS EXPERIENCING
PAIN FOLLOWING A MOTOR VEHICLE
COLLISION.
FURTHER, WE WERE ABLE TO
REPLICATE THIS DOWN REGULATION
IN A MOUSE MODEL OF CHRONIC
PRIMARY PAIN CONDITIONS AND
FOUND IT WAS SPECIFICALLY DRIVEN
BY FEMALE MICE MORE THAN MAIL
MICE.
THIS IS INTERESTING BECAUSE
WOMEN ARE ACTUALLY MORE LIKELY
TO BE DIAGNOSED AND SUFFER FROM
THESE TYPES OF PAIN CONDITIONS.
AND WE THINK THAT THIS SIGNAL OF
DOWN REGULATION IS COMING FROM
WHITE ADIPOSE TISSUE, SO OUR LAB
HAS BEEN BUILDING A LOT OF
RESEARCH AND EVIDENCE FOR THE
CROSSTALK BETWEEN FAT CELLS AND
THE NERVOUS SYSTEM AND THE
EXCHANGE OF INFLAMMATORY
CYTOKINES, NEUROTRANSMITTERS AND
NOW MICRORNAs IN THIS PROCESS.
SO WE'RE DEVELOPING THIS WORKING
HYPOTHESIS THAT DOWN REGULATION
STARTS FROM WHITE ADIPOSE TISSUE
WHERE THIS LEADS TO IMPACTS IN
THE NERVOUS SYSTEM SUCH AS
UNINHIBITED PAIN -- IN PLACES
LIKE THE SPINAL CORD WHERE WE
SEE AT DIFFERENT POINTS IN OUR
MODEL DOWN REG LITION OF THIS
MICRORNA SPECIFICALLY IN FEMALE
MICE.
BECAUSE ONE MICRORNA TARGET
CAN -- BINDING PARTNERS, WE'VE
BEEN DOING SOME GENE NETWORK
ANALYSIS AND SPECIFIC TARGETED
APPROACHES WITH QPCR TO TRY TO
IDENTIFY GENE SETS THAT COULD BE
DRIVING THIS PHENOTYPE.
SO ON THE RIGHT HERE WE ARE ABLE
TO IDENTIFY TISSUE AND
SEX-SPECIFIC PATTERNS IN
RESPONSE TO THE DOWN REGULATION
OF THE SAME MICRORNA.
FOR EXAMPLE, THIS CLUSTER HERE
OF HIP 1 ALPHA BETA RECEPTOR
2 ARE GENES INVOLVED IN
NEUROPATHIC PAIN UPREGULATED
HERE IN FEMALE MICE IN OUR
MODEL, SPECIFICALLY WHIED
ADIPOSE TISSUE, WHERE THESE SAME
TARGETS ACTUALLY ARE DOWN
REGULATED IN MALE MICE IN THE
SPINAL CORD.
THIS GIVES US NEW EVIDENCE FOR
POTENTIAL HYPOTHESES TO TEST IN
FUTURE EXPERIMENTS.
FLEUPAIN POSES A COMPLEX PROBLES
UNDERMANAGED PAIN BUT ALSO
INCREASED MEDICATION USE SUCH AS
ANALGESICS ARE BOTH ASSOCIATED
WITH WORSE PHYSICAL AND
PSYCHOLOGICAL HEALTH OUTCOMES.
SPARKING AN INTEREST IN THE
DEVELOPMENT OF NON-PHARMACOLOGIC
APPROACHES THAT COULD BE
IMPLEMENTED INTO CLINICAL CARE.
LISTENING TO MUSIC HAS PROMISING
ANALGESIC EFFECTS, HOWEVER THE
BIOLOGICAL MECHANISMS DRIVING
THESE EFFECTS ARE SO POORLY
UNDERSTOOD, WHICH IS REFLECTED
IN THE INCONSISTENT INTERVENTION
DELIVERY FOR MUSIC LISTENING IN
THE LITERATURE, AND THIS THEN
IMPEDES OUR ABILITY TO
STANDARDIZE AND IMPLEMENT INTO
OUR CLINICAL CARE.
SO THE OBJECTIVES OF THIS STUDY
WILL DETERMINE THE FEASIBILITY
OF SELECTING SALIVA AND
BIOMARKERS TO CHARACTERIZE THE
CHANGE IN THESE BIOMARKERS IN
RESPONSE TO MUSIC LISTENING.
CHILDREN RECEIVING MECHANICAL
VERNT LAITIVENTILATION IN THE PE
MUSIC THE CHILD'S PREFERRED
SONGS FOR 20 MINUTES THREE TIMES
A WEEK FOR UP TO TWO WEEKS.
WE COLLECTED SALIVA BASED
CORTISOL USING COTTON SWABS AND
THE CHILD'S BEDSIDE MONITOR
RECORDING OF THEIR
ECHOCARDIOGRAM LEADS WAS
EXTRACTIONED THE 20 MINUTES PRE
TO THE 20 MINUTES POST MUSIC AND
USED TO CALCULATE IN FIVE MINUTE
SAMPLES RESPIRATION RATE, HEART
RATE AND HEART RATE VARIABILITY
METRICS.
THESE BIOMARKERS WERE EXPLORED
AND SALIVA WAS COMPARED AND WE
ASSESSED THE CHANGES IN OUR
PHYSIOLOGIC BIOMARKERS USING
LINEAR GENERALIZED ESTIMATING
EQUATION MODELS CONTROLLING FOR
THE CHILD'S AGE, SEX AND -- SI
VERITY AT PICU ADMISSION.
ACROSS THESE SECTIONS WE WERE
ABLE TO COLLECT USABLE SALIVA
FOR 39% TO 61% OF THOSE
BIOMARKERS, AND FOR 74% OF OUR
PHYSIOLOGIC BASED BIOMARKERS.
CHANGES CAN BE SEEN TO THE RIGHT
AND THE TABLE DEMONSTRATES THAT
WE SAW A SMALL CHANGE IN OUR
CORTISOL AND INTERLEUKIN 6 AND
THE MOST PROMISING OR VISIBLE
CHANGES IN PHYSIOLOGIC
BIOMARKERS.
SO TO SUM, BIOMARKER COLLECTION
IS FEASIBLE, AND OUR PRELIMINARY
FINDINGS SUGGEST THAT MUSIC MAY
INFLUENCE PAIN BY MODULATING THE
AUTO MONIC NERVOUS SYSTEM
POSSIBLY DRIVEN BY THE REDUCTION
RESPIRATION RATES WE SEE IN THE
FIGURE TO THE RIGHT.
FUTURE WORK WILL EXPLORE
INTERACTIONS BETWEEN THESE
BIOMARKERS IN ASSOCIATION WITH
VALIDATED PAIN MEASURES AND WE
LOOK FORWARD TO DEVELOPING
ADDITIONAL WAYS WE CAN IMPROVE
OUR AINLT TO PROVIDE COMFORT
DURING CRITICAL CARE.
>> MANY OF US HAVE EITHER
WATCHED A VIDEO OR EXPERIENCED
THE EFFECTS FOLLOWING A
PROCEDURE.
MECHANISMS OF NITROUS OXIDE --
UNDERSTUDIED.
NITRIC OXIDE IS COMMONLY USED --
UNLIKE GENERAL ANESTHETICS,
NITROUS OXIDE TO PROVIDE POTENT
AN'GESIC EFFECTS IN A STATE OF
SEDATION WHILE ALSO ALLOWING
PATIENTS TO REMAIN CONSCIOUSLY
RESPONSIVE.
PAIN RELIES ON INDIVIDUAL
SELF-REPORT.
MEASURING -- IN THE BRAIN
THROUGH FUNCTIONAL ACTIVITY
OR -- BETWEEN -- SHARED
FUNCTIONAL RELEVANCE.
RECENTLY WE'VE SHOWN -- OF
NITROUS OXIDE INDUCED CHANGES IN
BRAIN FUNCTIONAL REACTIVITY.
BECAUSE BRAIN NETWORKS THAT
INVOLVE THE SOMATOSENSORY CORTEX
ARE ASSOCIATED WITH CHANGES IN
PAIN PERCEPTION, HERE OUR
INVESTIGATION FOCUSED ON
EXAMINING THE EFFECTS OF PAIN
AND NITROUS OXIDE WITH THE -- 70
DATA FROM 16 HEALTHY INDIVIDUALS
WHO CONSENT TODAY OUR STUDY --
NITROUS OXIDE AT REST --
INDIVIDUALS -- EVOKE MODERATE
PAIN -- AFTER THE STIMULUS,
VOLUNTEERS REPORTED RECEIVING
INTENSITY -- OF THE STIMULUS ON
A ZERO TO 10 SCALE WHERE ZERO
EQUALS NO PAIN TO 10 EQUALS
WORST PAIN IMAGINABLE.
WE FOUND -- DURING EXPOSURE TO
NITROUS OXIDE COMPARED TO BEFORE
NITROUS.
SIGNIFICANTLY HIGHER -- DURING
EXPOSURE TO NITROUS OXIDE AND
THE -- STIMULUS, S1 CONNECTIVITY
TO THE -- AND CINGULATE CORT
CORTEX -- LOWER PRIOR TO NITROUS
OXIDE.
-- PAIN INTENSITY AND
UNPLEASANTNESS.
MOREOVER, FUNCTIONAL
CONNECTIVITY INCREASED WITH
THE -- SIGNIFICANTLY DECREASED
DURING NITROUS OXIDE
ADMINISTRATION.
THESE FINDINGS SUGGEST ONE OF
THE MECHANISMS OF NITROUS OXIDE
INCLUDE DISRUPTION OF --
ACTIVITY BETWEEN -- AND OTHER
NETWORK.
MOREOVER, THROUGH EXAMINING
BRAIN NETWORKS, WE HOPE TO
ENHANCE OUR UNDERSTANDING OF
PAIN MECHANISMS AND ANALGESIC IN
THE TREATMENT OF BOTH ACUTE AND
CHRONIC PAIN.
>> ABOUT 10% OF THE WORLD'S
POPULATION IS AFFECTED BY
CHRONIC PAIN.
WHILE MOST BASIC RESEARCH
FOCUSES ON SOMATIC PAIN, IT
REMAINS UNDERSTUDIED.
OUR LAB IS INTERESTED IN LOOKING
AT THE CENTRAL AMYGDALA AND THE
ROLE IT PLAYS IN BLADDER PAIN
PROCESSING.
THE CENTRAL AMYGDALA HAS BEEN
SHOWN TO PAY A KEY ROLE IN PAIN
PROCESSING AND WHAT'S REALLY
INTERESTING ABOUT THE CENTRAL
AMYGDALA IS THAT HUMAN AND
ANIMAL RESEARCH HAS SHOWN
EVIDENCE OF LATERALIZATION.
SO THE AMYGDALA THAT IS ON THE
RIGHT HEMISPHERE OF THE BRAIN IS
THOUGHT TO INCREASE BOTH SOMATIC
AND VISCERAL PAIN, WHERE THE
LEFT AMYGDALA HAS BEEN SHOWN TO
DECREASE BLADDER PAIN.
SO NATURALLY WE'RE INTERESTED IN
WHAT CELL TYPES WITHIN THE
CENTRAL AMYGDALA ARE INVOLVED IN
THE FUNCTIONAL LATERALIZATION
THAT WE SEE.
SO OUR LAB IS FOCUSING ON ONE OF
THOSE CELL TYPES, BEING
CALCITONIN GENE-RELATED POSITIVE
NEWER ONS IN THE CENTRAL
AMYGDALA.
SO WE ARE USING A MOUSE MODEL IN
WHICH WE ARE INJECTING MICE WITH
CYCLOFOS SPHAMIDE, OR ABDOMINAL
VON FRY0 TO 21 DAYS POST INJURY.
SO WHAT DID I FIND?
WELL, I FOUND THAT
CYCLOPHOSPHAMIDE INDUCES
HYPERSENSITIVITY THAT PERSISTS
ABOUT 14 DAYS POST INJURY, AND
THIS SEEN AT TWO DIFFERENT
PRESSURES.
I ALSO SEE OPPOSING EFFECTS OF
CGRP RECEPTOR ANTAGONIST CGRP
837.
SO WHEN THE AN TAG ANYTHING CGRP
738 IS INJECTED INTO THE RIGHT
CENTRAL AMYGDALA, YOU SEE AN
ATTENUATED EFFECT OF MECHANICAL
ABDOMINAL HYPERSENSITIVITY
COMPARED TO ANIMALS THAT
RECEIVED A CSF.
HOWEVER, THE SAME ANTAGONIST,
WHEN IT'S INJECTED INTO THE LEFT
CENTRAL AMYGDALA, THOSE ANIMALS
ARE STILL EXPERIENCING SEVERE
ABDOMINAL MECHANICAL
HYPERSENSITIVITY.
SIMILAR TO THE CONTROL GROUP.
SUGGESTING THAT CGRP RECEPTORS
ARE, IN FACT, INVOLVED IN
FUNCTIONAL LATERALIZATION OF THE
AMYGDALA IN THE CONTEXT OF
BLADDER PAIN.
SO WHY IS THIS IMPORTANT?
WELL, THIS RESEARCH SUPPORTS THE
NOTION THAT ANTICGRP MEDICATIONS
ALREADY FDA-APPROVED FOR
MIGRAINE COULD, IN FACT, BE
USEFUL FOR BLADDER PAIN.
IT ALSO HIGHLIGHTS THE NECESSITY
FOR MORE LATERALIZED RESEARCH IN
THAT ONE SINGLE DRUG COULD HAVE
TWO DIFFERENT OPPOSING EFFECTS.
SO IF YOU'RE INTERESTED ABOUT MY
RESEARCH OR INTERESTED MORE
ABOUT WHAT WE DO IN THE LAB,
FEEL FREE TO CONTACT ME OR LOOK
AT OUR LAB WEBSITE.
>> HELLO, MY NAME IS EVELYN LEE.
POSTBACCALAUREATE RESEARCH
FELLOW AT THE NIH.
TODAY I WILL BE PRESENTING MY
WORK ON MOLECULAR TR TRANSCRIPTE
OUR RESEARCH AIMS TO UNDERSTAND
MOLECULAR PROCESSES BY WHICH
PAIN BEGINS THROUGH LONGITUDAL
SAMPLING OF TISSUE AS OUTLINED
IN PANEL A FROM PATIENTS UND
UNDERGOING -- MODELS THAT ARE
UPREGULATED AND SECRETED AT THE
PATHOLOGICAL WOUND EDGE THAT
POTENTIALLY INTERACT WITH VIE
BERS OF PAIN SENSING NERVE
TERMINALS.
INDUCED BY SURGICAL INCISION
REMARKED AS HITS IN RNA SEQ AND
WE FURTHER SELECTED FOR GENES
THAT ALSO ENCODED SECRETED
PROTEINS MARKING POTENTIAL
MOLECULAR ANALGESIC TARGETS.
WE SPECIFICALLY PRIORITIZE
TRANSCRIPTS BASED ON MAGNITUDE
OF TRANSCRIPTIONAL CHANGES OF
WHICH WE -- THAT ARE ALSO
STRONGLY INDUCED IN THE HEAT MAP
IN PANEL B.
AS YOU CAN SEE, CYTOKINES AND
ANTIMICROBIAL MOLECULES
PREDOMINATE TRANSCRIPTS GIVING
AN IDEA UNDERLYING THE ACUTE
PAIN STATE.
TO BUILD UP OUR DATA WE FOCUSED
ON SOME OF OUR MOST STRONGLY
INDUCED GENES IN ORDER TO
ANATOMICALLY LOCATE WHERE THESE
TRANSDUCTION EVENTS WERE
OCCURRING.
COMPRISED OF PROTEIN S100A8 AND
9 AMONG OUR TOP INDUCED
TRANSCRIPTS.
AS SHOWN IN FIGURE ONE, WE
OBSERVED MARKING NEUTROPHILS IN
A GRADIENT-LIKE FASHION
THROUGHOUT THE TISSUE BUT
PARTICULARLY AMPLIFIED NEAR THE
WOUND EDGE.
THERE WE WANTED TO FURTHER
LOCALIZE TRANSDUCTION EVENTS TO
A GREATER DEGREE OF SPECIFICITY.
WITH MULTI- -- WE FOUND CYTOKINE
INDUCTION IN ACTIVATED
LEUKOCYTES OF BLOOD VESSELS
SHOWN IN FIGURE TWO.
THIS IS JUST ONE PART OF WHAT WE
ARE SEEING IN THE EARLY PAIN
RESPONSE WITH IMMUNE PATHWAYS
SUCH AS NEUTROPHIL ATTRACTION
AND ENDOTHELIAL MIGRATION TO
SITES OF TISSUE DAMAGE.
WE ALSO FOUND THAT INDUCTION
CYTOKINES -- WHICH WE BELIEVE TO
BE SOME CELL POPULATIONS THAT
ARE ALSO IMPLICATED IN THE NENGS
US OF PAIN SIGNALING AND FURTHER
WORK CAN BE VIEWED AT MY POSTER.
OVERALL, OUR DATASET REVEALINGS
THE INDUCTION OF POTENTIAL PAIN
CONTRIBUTING MOLECULES IN
MEDIATORS IN VASCULAR AND
FOLLICULAR STRUCTURES OF THE
SKIN FOLLOWING TISSUE DAMAGE.
WE PLAN TO FURTHER CLARIFY THE
DOWNSTREAM MECHANISMS AND
INTERACTION OF THESE DRIVERS TO
ASSESS THEIR ABILITIES IN ORDER
TO UNDERSTAND HOW THEY
CONTRIBUTE TO NOCICEPTOR
SENSITIZATION AND PAIN.
>> HI, I'M AN ASSISTANT
PROFESSOR IN THE DEPARTMENT OF
EPIDEMIOLOGY AT THE UNIVERSITY
OF TEXAS MEDICAL BRANCH.
TODAY I WILL BE TALKING ABOUT GR
DIFFERENCES IN THE DIAGNOSIS OF
PAIN AMONG OLDER PLED CARE
BENEFICIARIES.
PAIN IS OFTEN UNDERDIAGNOSED
AMONG WOMEN ESPECIALLY BLACK
WOMEN WITH THE EXTENT OF
UNDERDIAGNOSIS IS UNKNOWN.
COGNITIVE STATUS CAN ALSO
COMPLICATE PAIN REPORTING AND
DIAGNOSIS WITH THOSE WHO ARE
COGNITIVELY IMPAIRED BEING LESS
ABLE TO REPORT THEIR PAIN.
OUR OBJECTIVE WAS TO ASSESS THE
ODDS OF HAVING A PAIN DIAGNOSIS
DOCUMENTED IN THE MEDICAL RECORD
BY GENDER WHILE CONSIDERING RACE
AND ETHNICITY IN COGNITIVE
SETTINGS.
WE USED DATA FROM THE 2018
HEALTH IN RETIREMENT STUDY WHICH
IS A NATIONALLY REPRESENTATIVE
STUDY OF ADULTS OVER 50 IN THE
U.S.
THIS WAS LINKED TO MEDICARE
CLAIMS.
WE COMBINE SELF-REPORTED PAIN
WITH DIAGNOSIS OF CHRONIC PAIN
INDICATIONS INTO A THREE-LEVEL
OUT COME.
THOSE WITH NO PAIN,
SELF-REPORTED PAIN ONLY AND
DIAGNOSED PAIN WHICH INCLUDED
THOSE WHO HAD BOTH DIAGNOSED
PAIN ONLY AND THOSE WHO
SELF-REPORTED PAIN AND DIAGNOSED
PAIN.
WE LOOKED AT RACE AND ETHNICITY
AND COGNITIVE STATUS AS
POTENTIAL EFFECT MODIFIERS.
FIGURE ONE SHOWS THOSE REPORTING
PAIN BY GENDER WITH WOMEN IN RED
AND MEN IN TEAL.
WOMEN MORE OFTEN HAD DIAGNOSED
PAIN WHILE MEN MORE OFTEN HAD NO
PAIN OR UNDIAGNOSED PAIN.
WE USE REGRESSION MODELS TO
ASSESS THE ODDS OF PAIN
DIAGNOSIS BY GENDER CONTROLLING
FOR SOCIODEMOGRAPHIC AND HEALTH
CHARACTERISTICS.
WOMEN HAD HIGHER ODDS OF
DIAGNOSED PAIN COMPARED TO MEN.
THERE IS A SIGNIFICANT
INTERACTION BETWEEN PAIN AND
RACE AND ETHNICITY WHICH PEEL WL
FOCUS ON BUT NOT BETWEEN PAIN
AND COGNITIVE STATUS.
FIGURE TWO SHOWS REGRESSION
RESULTS WITH ASSOCIATION OF PAIN
WITH RACE ANDE AND ETHNICITY
STRATIFIED BY GENDER.
THE SOLID BLACK DOTS ARE FOR
UNDIAGNOSED PAIN WHERE THE WHITE
DOTS REPRESENT THOSE -- COMPARED
TO THEIR NON-HISPANIC WHITE
COUNTERPARTS, NON-HISPANIC BLACK
WOMEN HAD LOWER ODDS OF
DIAGNOSED PAIN WHICH IS
CONSISTENT IN THE LITERATURE
THAT SHOWS BLACK WOMEN HAVE
THEIR PAIN UNDER
ODDS BOTH DIAGNOSED AND
UNDIAGNOSED PAIN.
THIS MIGHT BE DUE TO THE FACT
WE HAVE SMALL NUMBERS OF BLACK
AND HISPANIC MEN BUT OUR FUTURE
WORK WILL PULL DATA FROM
2006-2018 SO WE CAN LOOK AT
THIS ON A LARGER SCALE.
THANK YOU SO MUCH FOR YOUR TIME
AND ATTENTION.
>> CHRONIC SKELETAL MUSCLE PAIN
IS THE MOST COMMON TYPE.
THE CRITICAL DEVELOPMENTAL
PERIOD INCLUDES MANY CHANGES.
NOT TO MENTION SEVERAL
CHALLENGES SUCH AS ESTABLISHING
AUTONOMY AND INDEPENDENCE IN
VARIOUS AREAS INCLUDING HIGHER
EDUCATION, RELATIONSHIPS AND
EVEN TRANSITIONING FROM
PEDIATRIC TO ADULT HEALTHCARE
SETTINGS.
THESE CHALLENGES ARE ALREADY
DEMANDING FOR YOUTH IN GENERAL.
NOW IMAGINE HOW DIFFICULT THIS
BECOMES WHILE ALSO COPING WITH
THE PSYCHO SOCIAL AND
FUNCTIONAL LIMITATIONS THAT
TYPICALLY ACCOMPANY CHRONIC
PAIN.
UNTIL RECENTLY RESEARCH FOCUSED
ON UNDERSTANDING THE RISK AND
VULNERABILITY FACTORS
UNDERLYING PAIN.
HOWEVER, IT'S ESSENTIAL TO
UNCOVER THE POSITIVE PROTECTIVE
FACTORS THAT MAY PROMOTE
RESILIENCE WITH THE ABILITY TO
BOUNCE BACK IN THE FACE OF PAIN.
WE KNOW RESILIENCE PLAYS AN
IMPORTANT ROLE WITH PAIN.
HOWEVER PSYCHOLOGICAL, SOCIAL,
BIOLOGICAL AND HEALTH AND
LIFESTYLE DOMAINS HAVE YET TO
BE EXPLORED IN MANY WAYS.
OUR ON GOING INVESTIGATION AIMS
TO CHARACTERIZE RESILIENCE
PROFILES ACROSS DOMAINS AND
A.Y.A.'S WITH AND WITHOUT
CHRONIC MUSCULAR SKELETAL PAIN.
PAIN MODULATION AND ESTABLISH
PREDICTIVE UTILITY OVERTIME.
AGES 16-21 YEARS ALONG WITH
THEIR PARENT OR CAREGIVER
COMPLETE QUESTIONNAIRES
INCLUDING LIFE AND SOCIAL
FACTORS.
THEY ATTEND TWO LABORATORY
VISITS TO MEASURE PAIN
SENSITIVITY AND CONDITIONED
PAIN MODULATION USING PRESSURE
AND COLD WATER STIMULI AND
PERFORMING FUNCTIONAL TASK.
ASSESSMENT OF DAILY ACTIVITY OF
PAIN IN REAL-TIME.
ALL PARTICIPANTS ATTEND A
6-MONTH FOLLOW-UP VISIT.
THUS FAR WE SUCCESSFULLY
ENROLLED TEN PARTICIPANTS AND
TEN HEALTHY CONTROLS.
PRELIMINARY ANALYSES FOR YOUTH
WITH PAIN REVEAL HIGHER LEVELS
HOPE AND SELF-EFFICACY ARE
ASSOCIATED WITH LESS PAIN
FUNCTIONALITY.
GREATER THAN 7 DAY IS
ASSOCIATED WITH LESS SOCIAL
SUPPORT.
THESE SIGNIFICANT RELATIONSHIPS
ARE PROMISING AS WE CONTINUE TO
EXAMINE PROTECTIVE FACTORS
RELATED TO PAIN AND
DISABILITIES.
INFORMATION GAINED FROM THIS
WORK WILL BE INVALUABLE FOR
DEVELOPING PATIENT CENTERED
STRENGTH-BASED PREVENTION OR
INTERVENTION EFFORTS FOR
MUSCULAR SKELETAL PAIN.
>> I'M WITH THE SCHOOL OF
NURSING, OUR PROJECT FOCUSED ON
EXPLORING RELATIONSHIP BETWEEN
PAIN AND DEPRESSION.
PAIN IS A STRESSOR, ACCORDING
TO THE MODEL THAT COULD BE
EXPERIENCED FOCALLY OR AS A
PRIMARY CONCERN, CONTEXTUALLY
AS A STRESSOR THAT IS SECONDARY
OR TERTIARY OR A RESIDUAL TYPE
OF STRESSOR.
ONE IS NOT EVEN IDENTIFIED YET.
WE ALSO KNOW THERE'S A PAIN
DEPRESSION CYCLE UNMET PAIN
NEEDS WORSEN THE EXPERIENCE OF
DEPRESSION AND DEPRESSION
SYMPTOMS CAN EXACERBATE PAIN
INTERFERENCE.
INTERESTINGLY DESPITE THE HIGH
INCIDENCE OF PAIN AMONG BLACK
OLDER ADULTS, THE INCIDENCE OF
DEPRESSION IS REALLY NOT AS
HIGH AS WE WOULD EXPECT.
WHILE WE KNOW CULTURE
INFLUENCES HEALTH BEHAVIORS
INCLUDING EXPRESSION OF PAIN,
DEPRESSION AND OTHER HEALTH
SYMPTOMS THERE'S BEEN LITTLE
WORK TO INVESTIGATE THE FACTOR
THAT'S CONTRIBUTE TO THE
EXPERIENCES.
WE AIM TO EXPLORE THE
RELATIONSHIP BETWEEN PAIN
INTENSITY AND DEPRESSION
SYMPTOMS BY STUDYING
COMMUNITIES OF A BLACK ADULTS.
TWO RESULTS WERE A PAIN
INTERVENTION GROUP
PARTICIPATING IN A LARGE PAIN
CLINICAL TRIAL IN WHICH WE
GATHER PRELIMINARY OR BASELINE
ASSESSMENT, INCLUDING BOTH
DEPRESSION AND PAIN MEASURES
FROM THIS GROUP.
AS WELL AS A VERY DIFFERENT
GROUP OF FAMILY CAREGIVERS,
BOTH GROUPS WERE OF COURSE
OLDER ADULTS AND BLACK OLDER
ADULTS.
AND IN THE SECOND GROUP, THE
GROUP OF FAMILY CAREGIVERS
THESE INDIVIDUALS WERE
PARTICIPATING IN FOCUS GROUPS
AND THEY ALSO HAD PAIN AND
DEPRESSIVE MEASURES THAT WERE
COMPLETED PRIOR TO THEIR FOCUS
GROUP EXPERIENCE.
WHAT WE FOUND IS THAT 100% OF
COURSE OF THE PAIN STUDY
PARTICIPANTS AND AROUNDLE 88%
OF THE CAREGIVERS REPORTED
DAILY PAIN.
USING PROMISE MEASURES FOR BOTH
GROUPS AND BOTH ACTUALLY FELL
INTO NORMAL POPULATION RANGES,
WHICH AMOUNTS TO AROUND 11% OF
THE GROUP EXPERIENCE AND
DEPRESSION.
WITHIN A FOCUS GROUP
PARTICIPANTS IN PARTICULAR, WE
FOUND THAT THEY HAD MULTIPLE
DESCRIPTIONS OF DEPRESSION WHEN
TALKING ABOUT THE EXPERIENCE OF
CARE GIVING, MORE SO THAN WHAT
WAS REPORTED ON THE ASSESSMENT
MEASURES.
THEY ALSO DID NOT REALLY BRING
UP THEIR PAIN EXPERIENCES AT
ALL.
AND WOULD NOT HAVE BEEN
CAPTURED, HAD NOT THE SPECIFIC
PAIN QUESTIONS BEEN ASKED OF
THE GROUP.
WE IDENTIFIED THAT THE STRONG
BLACK WOMAN SCHEMA WHICH
CHARACTERIZES AN OBLIGATION TO
PRESENT A STRONG SUPPRESS
EMOTIONS, BE INDEPENDENT, BE
DETERMINED TO SUCCEED AND HELP
OTHERS CAN ACTUALLY LEAD TO
LIMITATIONS SEEKING BEHAVIOR AS
WELL AS EXPRESSION OF EMOTIONS
WHICH POSSIBLY MIGHT EXPLAIN
WHY WE ARE SEEING THESE
VARIANCES AND HOW PEOPLE
EXPERIENCE DEPRESSION AND HOW
THEY ARE WILLING TO TALK AND
REPORT THEIR DEPRESSIVE
SYMPTOMS.
THANK YOU.
>> HELLO, WE KNOW THAT
APPROXIMATELY 30% OF THOSE WHO
HAVE END METRIOSIS WILL
CONTINUE TO RECEIVE PAIN EVEN
AFTER LESIONS HAVE BEEN REMOVED
DURING SURGERY.
THEREFORE WE LOOKED AT A NUMBER
OF FACTORS AND HOW THEY ARE
RELATED TO PELVIC PAIN OR PAIN
ASSOCIATED WITH MENSTRUATION.
WE USE THE A.T.A. STUDY,
INCLUDE 426 WITH DIAGNOSED
ENDOMETRIOSIS.
THE MENTAL COMPONENT SCORE 12.
PAIN SEVERITY IN THE PAST THREE
MONTHS REPORTED 0-10.
WE USE MODELING OF THE THREE
OUTCOMES AND PUT THOSE INTO A
LOGISTIC REGRESSION MODEL.
TABLE 1 YOU CAN SEE
PARTICIPANTS ARE YOUNG ON
AVERAGE, WHITE AND CURRENT
HORMONE USERS AND EARLY STAGE
ENDOMETRIOSIS.
YOU COULD SEE SCORES WHICH
RANGE.
59% OF PARTICIPANTS FELL IN
THIS BLUE.
12% IN THE RED.
THOSE IN THAT GROUP WERE MORE
LIKELY TO HAVE OTHER PAIN
CONDITIONS IN ADDITION TO
ENDOMETRIOSIS COMPARED TO THE
AVERAGE GROUP.
MORE LIKELY TO REPORT BEING
LESS THAN THE POPULATION
AVERAGE GROUP.
SCORE RESULTS WERE SIMILAR TO
THOSE IN P.C.S. 12 RESULTS.
FIGURE 2 PILL VICK PAIN SCORES.
THIS RANGES FROM 0 AS NO PAIN,
10 WORST PAIN IMAGINABLE.
ABOUT 40% OF PARTICIPANTS FELL
IN THIS GROUP.
23% IN INCREASING PAIN GROUP.
13% IN THE RED.
WE SAW THOSE IN INCREASING PAIN
AND NON MILD WERE MORE LIKELY
TO REPORT OTHER PAIN CONDITIONS.
MILD PAIN GROUP MORE LIKELY TO
REPORT HIGHER SCORES, BETTER
MENTAL HEALTH QUALITY OF LIFE,
COMPARED TO THE PERSISTENT PAIN
GROUP.
WE SAW ALMOST HALF OUR
PARTICIPANTS HAVE PERSISTENT
PAIN AND PELVIC PAIN THROUGHOUT
THREE YEARS OF FOLLOW-UP.
THERE'S SUGGESTION OF SOME
FACTORS THAT MAY BE PREDICTORS
OF TRAJECTORIES AND HOW
TREATMENTS MAY IMPACT THESE
TRAJECTORIS.
THANK YOU.
>> MY NAME IS EMMA STETTLER,
VISITING FELLOW IN THE
DEPARTMENT OF MEDICINE.
POTENTIAL ENERGY TARGETS
SENSORY NEURONS.
WE KNOW FROM ANIMAL MODELS ONE
ESSENTIAL ELEMENT, MEDIATES BY
INHIBITION OF CHANNELS.
THIS IS THE UNDERLYING
MECHANISM OF ADMINISTERED
OPIOIDS.
PAIN FROM TISSUE DAMAGE IS
COMPLETELY REDUCED, REDUCTION
OF NEUROPATHIC PAIN IS MODERATE
TO POOR.
WE HYPOTHESIZED EXPRESSION OF
GENE, TISSUE DAMAGE AND OTHER
-- POPULATIONS.
TO INVESTIGATE THIS HYPOTHESIS
WE CONDUCTED SERIES OF
EXPERIMENTS.
THESE STUDIES HAD A MATRIX WITH
TRIP U1.
TOGETHER THE OPIUM ONE AND
COMBINATIONS OF ANALGESIC
MOLECULAR MODELS.
WE DIDN'T DETERMINE SEX
DIFFERENCE EXPRESSION OF
MOLECULAR MARKERS.
OUR RESULTS CONFIRMED INITIAL
HYPOTHESIS.
DETECTED A LARGE POPULATION OF
C NODE RECEPTORS --
THIS COMBINATION OF GENES,
TISSUE DAMAGE PAIN --
HIGHEST EXPRESSION DETECTED AND
DISTINCT -- OPIUM 1 POSITIVE
AND -- NEGATIVE.
UNRESPONSIVE TO STIMULATION
UNDER PHYSIOLOGIC CONDITIONS.
WE DETECTED ANOTHER POPULATION.
IT WAS NEGATIVE FOR EXPRESSION
OF OPIUM 1.
THESE WERE CHARACTERIZED BY
EXPRESSION OF THE H RECEPTOR
GMRD AND POPULATION HAS BEEN
SHOWED IN ANIMAL MODELS IN A
SUPERFICIAL EPIDERMIS.
A SIGNIFICANT CONTRIBUTOR TO
NEUROPATHIC PAIN.
IT CANNOT BE ATTENUATED.
OUR INVESTIGATION IS THE FIRST
TO PROVIDE EMPIRICAL EVIDENCE
NOCICEPTIVE.
>> [ INDISCERNIBLE ]
I'M VERY EXCITED TO SHOW YOU
OUR LATEST [ INDISCERNIBLE ]
LAB FOCUSED ON -- INVOLVING
PAIN.
IT PLAYS AN IMPORTANT ROLE.
[ INDISCERNIBLE ] IN THE CENTER
AMYGDALA.
WE ARE AIMING TO UNDERSTAND
FUNCTIONAL -- CDRPR EXPRESS
IN THE CONTEXT OF PAIN.
I USE MODEL WE DEMONSTRATED --
HYPERSENSITIVITY AS COMPARED
TO -- GENES.
HISTOLOGY -- WHAT WE FOUND
THE IMPLANATION WE FOUND IT WAS
CO-LOCALIZED.
SO THESE REGIONS DEMONSTRATED
THE CDR [ INDISCERNIBLE ] AFTER
THIS EXPERIMENT, WHAT WE FOUND
IN THIS EXPERIMENT INDUCED
SPIKE IN THE POSTERIOR AS
OPPOSED TO [ INDISCERNIBLE ].
WE WERE INTERESTED IN THE
BEHAVIOR.
EXPERIMENT INJECTED -- IN THE
CEA-CGRPR MICE.
IN SUMMARY WHAT WE FOUND IN
THIS EXPERIENCE, NEURON
HYPERSENSITIVITY AS YOU CAN SEE
HERE IN THE CUFF MOUSE.
NEURONS IN THE CENTER AMYGDALA
PAIN RELATED HYPE SENSITIVITY.
AS YOU CAN SEE.
WE WERE ALSO INVESTIGATED TO
UNDERSTAND THE ROLE IN MOUSE
MODEL.
WE HAVE YOUTH -- SO WHAT WE
FOUND IN THIS EXPERIMENT WE
FOUND THE MODEL DOESN'T HAVE
DIFFERENCE IN THE SERUM
INJECTED MOUSE.
WE FOUND INHIBITION OF
CEA-CGRPR NEURONS.
SO DEMONSTRATED THAT CDR
NEURONS PLAYS A CRUCIAL ROLE IN
PAIN SENSITIVITY.
SO THANK YOU ALL FOR YOUR KIND
ATTENTION.
>> GOOD MORNING, MY NAME IS
LAURA, I'M ASSISTANT PROFESSOR
AT UNIVERSITY OF PUERTO RICO,
I'M WORKING WITH -- ALSO [
INDISCERNIBLE ] WITH A MEMBER
OF NATIONAL CENTER FOR [
INDISCERNIBLE ] AT N.I.H.
OUR PROJECT IS TITLED EFFECTS
OF CLOSED HEAD INJURY ON PAIN
LIKE BEHAVIORS IN RATS.
LEADS TO CHRONIC PAIN FROM THE
SITE OF INJURY IN ABOUT 60% OF
ADULT PATIENTS.
MEASURE OF THE FUNCTION,
SPECIFICALLY IN THE VENTRI
LATERAL.
A DECREASED -- WAS ALSO
CORRELATED WITH HIGHER PAIN
SCORES IN THESE PATIENTS.
THEREFORE OUR GOAL IS TO TEST
THE HYPOTHESIS THAT MALADAPTIVE
CHANGES IN CONNECTIVITY BETWEEN
RAIN REGIONS CONTRIBUTE TO
CHRONIC PAIN AFTER MILD TO
MODERATE PAIN INJURY.
TO PERFORM OUR GOAL WE FIRST
PERFORMED INJURY USING WEIGHT
DROP MODEL REPRESENTED IN THIS
DIAGRAM.
WE MEASURED MECHANICAL AND
THERMAL SENSITIVITIES AT TIME
POINTS AFTER INJURY.
WE THEN TEST THE DIFFERENT
BRAIN MARKERS IN BRAIN
HISTOLOGY TO UNDERSTAND THE
ROLE OF INFLAMMATION.
IN OUR WEIGHT DROP MODEL WE HAD
A WEIGHT OF 500 GRAMS AND A
GUIDE ONE --
RIGHT AFTER RELEASING THE
WEIGHT WE MEASURED THE TIME TO
WAKE, THE TIME TO WRITE AND
TIME TO AMBULATE.
NO SIGNIFICANT CHANGES WERE
OBSERVED BETWEEN GROUPS.
THIS IS IMPORTANT BECAUSE THIS
REPRESENTS NO LOSS OF
CONSCIOUSNESS WHICH IS A
HALLMARK OF HEAD INJURY.
WE MEASURE BEHAVIORS.
WE USE ELEMENTS TO TEST FOR
MECHANICAL SENSITIVITY.
AS YOU CAN SEE HERE LOWER
THRESHOLD WAS OBSERVED IN THE
INJURY GROUP.
AND HYPERSENSITIVITY WAS
PROLONGED UP UNTIL THE LAST DAY
WE MEASURED THE SENSITIVITY
WHICH WAS AT DAY 35.
HOWEVER, FOR THE OTHER TEST
WHICH MEASURE THERMAL STIMULI
SENSITIVITY WE DIDN'T SEE ANY
SIGNIFICANT CHANGES BETWEEN THE
TWO GROUPS.
IN THE ONGOING EXPERIMENTS WE
ARE MEASURING THE EXPRESSION OF
IVA1, A MARKER OF NODAL
INFLAMMATION, SPECIFICALLY
MICRO GLIA.
CINGULAR CORTEX.
BUT WE WILL INCLUDE THIS OTHER
BRAIN REGION FOR PAIN PROCESS.
IN OUR FUTURE DIRECTIONS WE
WILL USE ANTEROGRADE AND
RETROGRADE IN THE LATERAL --
COMBINED WITH MONITORING TO
IDENTIFY THE SPECIFIC NODAL
CIRCUIT INVOLVED IN INJURY
INDUCED HYPERSENSITIVITY.
THANK YOU FOR YOUR ATTENTION.
>> HELLO, I'M A Ph.D. CANDIDATE
AND NEURO SCIENCE AT THE
UNIVERSITY OF MARYLAND, I WILL
GIVE AN OVERVIEW OF TREATMENT
EXPECTANCIES AND ROLE OF
TESTOSTERONE IN BOTH PHENOMENON.
WHAT WE KNOW FROM RESEARCH OF
SEX DIFFERENCE OF PAIN, WOMEN
EXPERIENCE GREATER PAIN THAN
MEN.
THE MECHANISMS UNDERLYING
DISPARITIES REMAIN LARGELY
UNKNOWN.
PROTECTIVE EFFECTS OF
TESTOSTERONE HAVE BEEN
DEMONSTRATED BUT EFFECTS ON
TREATMENT UNDETERMINED.
DIAGNOSED WITH TMD.
HYPOTHESIZE THE TREATMENT
EXPECTANCY AND WOULD BE GREATER
IN WOMEN COMPARED TO MEN BASED
ON PREVIOUS STUDY ON SEX
DIFFERENCES, WOMEN WITH TMD
EXPERIENCE GREATER PLACEBO
EFFECTS COMPARED TO MEN.
WE THOUGHT HIGHER TESTOSTERONE
WOULD BE ASSOCIATED WITH HIGHER
PAIN TOLERANCE.
WE COLLECTED SPECIMEN OF BLOOD
AND SALIVA FOR HORMONE ANALYSIS
AS WELL AS PSYCHOLOGICAL
ASSESSMENT.
WE CONDUCTED PAIN SENSITIVITY
ASSESSMENTS DETERMINE HIGH AND
LOW THERMAL PAIN LEVELS
TAILORED TO EACH PARTICIPANT.
PARTICIPANTS WERE TOLD
ELECTRODE DELIVERED ON THE
MIDDLE FINGER WOULD BE
EFFECTIVE FOR PAIN REDUCTION.
THEY WERE TOLD SEEING A GREEN
SCREEN WOULD PROVIDE PAIN
RELIEF AND RED WAS OFF.
THE RED SCREEN WAS CORRELATED
WITH HIGH PAIN.
DURING THE TESTING PHASE BOTH
WERE PAIRED WITH A MODERATE
PAIN TO TEST FOR PLACEBO
EFFECTS.
PRESENTATIONS WERE IN A COUNTER
BALANCE MEASURE.
WHAT DID WE FIND?
WE FOUND THAT WOMEN WITH CMB
DEMONSTRATED GREATER REINFORCED
EXPECTATIONS AND POST TEST
EXPECTATIONS COMPARED TO MEN
WITH TMD.
WE OBSERVED THAT WOMEN IN BOTH
TMD AND HEALTHY GROUPS SHOWED
LARGER PLACEBO EFFECTS COMPARED
TO MEN.
TESTOSTERONE WAS CORRELATED
WITH GREATER HEAT PAIN
TOLERANCE.
OVERALL UNDERSTANDING OF SEXUAL
-- PAIN IS CRITICAL FOR
DEMONSTRATING RELEVANCE
INCLUDING SEX AS A FACTOR THAT
COULD INFLUENCE INTERPRETATION
OF TRIALS IN CLINICAL OUTCOMES.
WE WOULD LIKE TO THANK THE
NICDR AND NIH FOR FACILITATING
THIS WORK.
THANK YOU.
>> HELLO, MY NAME IS WEI JAN.
OUT OF UNIVERSITY OF PITTSBURGH.
LIFE TRIGGERED LOCAL AN THEES
SHA.
LOCAL ANESTHETICS ARE A GREAT
ALTERNATIVE FOR TREATING
LOCALIZED PAIN.
HOWEVER SHORT DURATION OF
ACTION NECESSITATES REPEATED
INJECTION.
EVEN WHEN THE DURATION COULD BE
EXTENDED WITH THESE SYSTEMS,
THERE IS A CRITICAL NEED TO
DEVELOP LOCAL AND STATIC
RELEASE SYSTEM WHICH AFTER
FIRST ADMINISTRATION, MULTIPLE
EVENTS OF LOCAL ANESTHESIA CAN
BE TREATED AGAIN.
ONLY WHEN AND WHERE IT IS
NEEDED.
TO ACHIEVE THIS GOAL WE HAVE
THIS RESPONSIVE CONJUGATE.
IN THE DESIGN WE SELECT
TETRACAINE BECAUSE OF
RELATIVELY HIGH POTENCY.
WE SELECTED COUMARIN AS LINKAGE
BECAUSE OF GOOD PHOTO CLEAVAGE
EFFICIENCY.
THE MATERIAL SHOWED STRONG
ADOPTION IN THE BLUE RANGE AND
SHOWED MODULATION NEAR BODY
TEMPERATURE.
THE ABILITY OF THE MATERIAL TO
RELEASE TETRACAINE WAS ALSO
STARTED IN VITRO.
NEXT WE TEST THE MATERIALS IN
VIVO EFFICACY USE A RAT MODEL.
WE CAN SEE THE DRUG WAS
INACTIVATED WHEN CONJUGATED TO
THE POLYMER AND THERE'S NO
ANESTHETIC EFFECT UNLESS THE
INJECTION SITE WAS IRRADIATED
WITH L.E.D.
IT COULD BE MODERATED BY
ADJUSTING IRRADIATION AND COULD
BE TRIGGERED AND REPEATED AGAIN
AND AGAIN.
WE ALSO CHECKED BIO
COMPATIBILITY OF THE MATERIAL.
THE TISSUE REACTION WAS SIMILAR
TO THAT BY THE TETRACAINE,
INDICATING THE MATERIAL WAS
SAFE TO BE USED.
LAST BUT NOT LEAST WE
DEMONSTRATED THAT SUCH DRUG
SYSTEM DESIGN COULD ALSO BE
GENERALLY APPLICABLE TO OTHER
DRUGS.
THANK YOU.
>> HI, EVERYONE, I'M A POST DOC.
I'M HAPPY TO PRESENT MY POSTER,
THE TITLE IS ENHANCING PAIN
ASSESSMENT ACCURACY.
THE IMPACT OF REAL-TIME
FEEDBACK AND TARGET RELIABILITY
ON INTERPRETING EXPRESSIONS OF
THEM.
FACIAL RESPONSE TO PAIN ARE
NEED FOR SOCIAL SUPPORT AND
CLINICAL ATTENTION.
TRAINING WITH FEEDBACK CAN
ENHANCE INDIVIDUALS'
PERFORMANCE TO RECOGNIZE
EMOTIONAL CUES IN OTHERS.
THE ROLE OF QUANTIFIED FEEDBACK
UNDERLYING EMOTION RECOGNITION
PARTICULARLY PAIN RECOGNITION
AND THE INFLUENCE OF TARGETS
REMAINS LARGELY UNEXPLORED.
OUR HYPOTHESES, FEEDBACK
IMPROVED PARTICIPANTS
RECOGNITION ACCURACY OF PAIN
BOTH FOR DISTINGUISHING BETWEEN
EXPRESSIONS OF PAIN AND NO PAIN
AND ASSESSING THE INTENSITY OF
PAIN EXPERIENCED BY OTHERS.
PERSONS IN BOTH GROUPS
CALCULATED PAIN VERSUS NO PAIN
JUDGMENT TASK AND PAIN
INTENSITY JUDGMENT TASK.
FOR BOTH GROUPS SHOWING TARGET
VISUAL RESPONSES WHEN THIS
PERSON WAS RECEIVING
STIMULATION ON LEFT ARM.
AFTER RATED EITHER PAIN OR NO
PAIN FOR THE TARGET OR HOW MUCH
PAIN THEY THOUGHT THE TARGET
WAS GIVEN.
AFTER THE RATING, PERSON IN THE
FEEDBACK GROUP SHOW THE REAL
TARGET OF THE PAIN FEEDBACK.
MULTI-MODAL ANALYSIS SHOW FOR
BOTH TASK FEEDBACK GROUP MORE
ACCURACY COMPARED WITH NO
FEEDBACK GROUP.
PERSON THAT DEMONSTRATED
DISTINGUISHED LEARNING
PERFORMANCE ON DIFFERENT TASKS
ACROSS BOTH FEEDBACK AND NO
FEEDBACK GROUP.
PARTICULARLY WHEN JUDGING PAIN
INTENSITY, FEEDBACK GROUP
SHOWED DIFFERENT LEARNING
PERFORMANCE ON DIFFERENT
TARGETS COMPARED TO NO FEEDBACK
GROUP.
IN CONCLUSION FEEDBACK IMPROVE
LEARNING PERFORMANCE IN BOTH
JUDGING PAIN AND NO PAIN AND
JUDGING PAIN INTENSITY.
THE SECOND LEARNING EFFECT WAS
MODULATED BY TARGET RELIABILITY.
THIS RESEARCH CONTRIBUTE TO OUR
UNDERSTANDING HOW THE
MECHANISMS CAN IMPROVE THE
ACCURACY OF PAIN WITH OTHERS
WITH POTENTIAL IMPLICATIONS FOR
MEDICAL PROFESSIONALS IN
OPTIMIZING PAIN ASSESSMENT AND
MANAGE STRATEGIES.
THANK YOU.
GOOD AFTERNOON.
WELCOME TO THE AFTERNOON
SESSION OF THE PAIN CONSORTIUM
MEETING.
I'M DAVE THOMAS WITH THE
RESEARCH IN WOMEN'S HEALTH.
IT'S A SUPER BIG HONOR FOR ME
TO PRESENT, OR INTRODUCE THE
MITCHELL MAX SESSION TODAY.
I KNEW MITCHELL VERY WELL FOR
MANY YEARS.
HE IS A BRILLIANT PAIN
RESEARCHER AND A BRILLIANT
CLINICIAN WHO WORKED AT NIDR,
FOR THOSE OF YOU WHO WEREN'T
AROUND THERE THAT WAS THE
DENTAL INSTITUTE.
HE WAS A FRIEND, A COLLEAGUE, A
MENTOR TO SO MANY AND ALL THOSE
THINGS TO ME.
IT WAS SUCH AN HONOR TO HAVE A
PILLAR IN THE PAIN FIELD TEACH
ME AND WHEN I WAS JUST A NEWBIE
IN THE PAIN FIELD.
AND THE NIDR PAIN LAB WAS WORLD
RENOWNED.
IT REALLY WAS, FOLKS FROM
AROUND THE WORLD CAME TO BE IN
THAT LAB.
THEY ROTATE IN 2-3 YEARS TO
LEARN AND MITCHELL WAS EYE
ESSENTIAL TO THAT LEARNING THAT
HAPPENED WHEN PEOPLE CAME IN.
I'M SO GLAD THE PAIN CONSORTIUM
HONORS HIS LEGACY WITH A
SESSION AND THAT IT ALSO
HIGHLIGHTS SO MANY PEOPLE THAT
ARE EARLY IN THEIR CAREERS SO
IT'S ALL GOOD THINGS.
CAN I HAVE THE NEXT SLIDE,
PLEASE?
BUT THIS YEAR I WILL SAY A
LITTLE BIT ABOUT MITCHELL AND
THE CONTEXT OF WHERE HE WORKED
AND WHO THEY WERE.
HERE SAY 1994 VERSION OF
NEUROLOGY AND ANESTHESIA LAB
INSTITUTE.
THE LAB STARTED IN THE EARLY
70s AND CONTINUED FOR MANY
YEARS AFTER THIS PHOTO WAS
TAKEN.
I KNEW MANY OF THE PEOPLE IN
THIS PHOTO.
I'M NOT PICTURED BUT IT ALMOST
FEELS LIKE YESTERDAY WE WERE
ALL THIS TEAM WORKING ON THIS
MISSION TOGETHER.
SOME OF THE PEOPLE IN THE
PICTURE ARE STILL AT THE NIH.
THAT INCLUDES MIKE IDEROLA,
DONNA MESSERSMITH.
RIGHT NEXT TO MITCHELL.
AND SUE MANIS WHO WILL CHAIR
ONE OF OUR SESSIONS LATER ON.
AND OTHERS IN THE LAB NOT IN
THE PHOTO INCLUDE WENDY SMITH,
RICHARD NAHAN JUCH OVER THERE
ANSWERING QUESTIONS AND INNA
BELFER.
IT'S ALMOST LIKE COMING HOME
WHEN WE COME TO THESE MEETINGS.
THE LAB WAS TRANSLATIONAL
BEFORE THE CONCEPT OF
TRANSLATION WAS CREATED.
FROM CELLS TO RATS TO NON HUMAN
PRIMATES TO PEOPLE.
AND THE BASIC RESEARCHERS WOULD
GO INTO THE CLINIC AND HELP
WITH THE CLINICAL STUFF AND
LEARN FROM THE CLINICAL STUFF
AND CLINICAL PEOPLE IN THE
GROUP WOULD COME BACK TO THE
BASIC RESEARCHERS AND WE WOULD
ALL INTERMIX.
SOMETIMES ALL BE INVOLVED WITH
THE EXPERIENCE.
FOR EXAMPLE A DOC LIKE ME GOT
INJECTED WITH CAPSAICIN TO SEE
IF IT HURTS AND IT DOES, SO
DON'T DO THAT.
AND JUST, I WOULD LIKE TO PAY
TRIBUTE TO A COUPLE SIGNIFICANT
PEOPLE FROM THIS GROUP THAT ARE
NO LONGER WITH US.
FIRST MRS. RONALD DUBNER.
-- MR. RONALD DUBNER.
VISIONARY AND TRANSLATIONAL
RESEARCHER.
WORLD EXPERT ON PAIN AND EVEN
AFTER HE LEFT NIH IN THE LATE
90s, HE CONTINUED TO COME AND
BE PART OF THE VARIOUS PAIN
ACTIVITIES LIKE PAIN CONSORTIUM
ACTIVITIES AND THINGS LIKE THAT.
SO HE WAS STILL PART OF THE NIH
UNTIL HE WAS GONE.
I REALLY WANTED TO DRAW
ATTENTION TO THE WOMAN AT THE
TOP RIGHT, EMMA RUTA, DEPUTY TO
RON DEBNER IN THAT GROUP.
SHE DISCOVERED OPIOID RECEPTORS
ON PRIMARY AMARINTHS.
I MENTION HER, SHE WAS
PROMOTING THE NEED TO STUDY MEN
AND WOMEN'S PAIN WAY BACK THEN.
SHE PUT OUT A ARTICLE OR
EDITORIAL IN PAIN IN 1993
TALKING ABOUT HOW WE HAVE TO
INCLUDE MALES AND FEMALES.
SHE WAS MAKING THE SAME CASE WE
ARE MAKING TODAY WAY BACK THEN.
DO NOTE SHE CALLED IT GENDER
BACK THEN BECAUSE I GUESS NOW I
LEARNED IT'S BECAUSE OF AIDS
BUT THAT WAS AN ISSUE OF
CALLING IT SEX OR GENDER.
IN FACT IN HER ARTICLE SHE
MENTIONS THAT DILEMMA.
SO SHE WAS A PIONEER.
THE COVER PAIN FOR A WHOLE YEAR
RAN THIS COVER JUST TO RAISE
AWARENESS OF THE ISSUE.
SO I THINK GETTING BACK TO
MITCHELL, MITCHELL WAS PART OF
THE LAB BUT THE LAB WAS PART OF
MITCHELL.
ALL OF US, WE STILL SAY WE ARE
FROM THAT LAB.
SO IN SOME WAYS I FEEL LIKE
THIS AWARD IS A LITTLE BIT AN
AWARD FOR THAT LAB TOO.
I JUST WANT TO PUT MITCHELL IN
CONTEXT AND SHARE SOME OF THE
GREATNESS THAT HAPPENED YEARS
AGO AT THE NIH.
TODAY WE ARE GOING TO GIVE, WE
ARE HAVING THREE PRESENTATIONS
IN THE MITCHELL MAX SESSION.
AND THE PROCESS THAT WE HAVE
USED IS TO PEOPLE YOUNG NEW
INVESTIGATORS WHO SUBMITTED
POSTERS, THE NIH PAIN
CONSORTIUM WOULD REVIEW THEM,
THEY ARE ALL GREAT BUT WE
NARROWED THEM TO THREE AND
ASKED THOSE PEOPLE TO PRESENT.
AND THEN AFTER THE
PRESENTATION, PAIN CONSORTIUM
MEMBERS ARE GOING TO RANK THE
PRESENTATIONS AND THEN WE WILL
COME UP WITH A WINNER THAT WILL
BE ANNOUNCED LATER TODAY.
AND THAT PERSON WILL BECOME
PART OF PAIN CONSORTIUM HISTORY.
OUR THREE PRESENTERS ARE FIRST
DR. KENDRA CAMP, ASSOCIATE
PROFESSOR IN THE DEPARTMENT OF
NEUROBIOLOGICAL BIO BEHAVIORAL
NURSING AND HEALTH INFORMATICS
AT THE UNIVERSITY OF WASHINGTON.
AND THE DIRECTOR OF THE
GASTROINTESTINAL HEALTH AND
WELLNESS LAB.
HER RESEARCH FOCUSES ON
UNDERSTANDING AND IMPROVING,
INCLUDING ABDOMINAL PAIN,
FATIGUE AND SLEEP DISTURBANCES
ASSOCIATED WITH INFLAMMATORY
BOWEL DISEASE.
THE SECOND, I WILL ANNOUNCE
THEM FOR THE KICKOFF HERE SO I
DON'T GET IN THE WAY LATER ON.
THE SECOND SPEAKER WILL BE DR.
BRYAN McIVER, WHO IS A RECENT
Ph.D. LEVEL GRADUATE AT THE LAB
OF DR. IMAN DUMAGE IN THE
DEPARTMENT OF PHARMACOLOGY AND
TOXICOLOGY AT VIRGINIA
COMMONWEALTH UNIVERSITY.
RESEARCH PRIMARILY FOCUSED ON
INVESTIGATING THE ROLE OF ASTRO
CYTES IN GENE 1 IN MAMMALS,
CHRONIC PAIN AND OPIOID INDUCED
NOSE SEPTEMBEROR.
HE HAS ACTED WITH CANCER
SURVIVAL PROGRAM AT MASSEY
CANCER CENTER.
LAST DR. CAROLYN PATTERSON
HEADACHE SPECIALIST AND
SCIENTIST AT CHILDRENS HOSPITAL
OF PHILADELPHIA AND ITS
ASSOCIATE PROFESSOR OF
NEUROLOGY AND PEDIATRICS AT THE
UNIVERSITY OF PENNSYLVANIA,
PEARLMAN SCHOOL OF MEDICINE.
HER RESEARCH FOCUSES ON
IMPROVING MIGRAINE DIAGNOSIS
AND IDENTIFYING EARLY
BIOMARKERS FOR PROLONGED
RECOVERY FROM CONCUSSION AND
HEAD INJURY IN YOUTH.
FIRST, DR. KENDRA.
I FORGOT TO SAY NEXT SLIDE,
SORRY.
>> THANK YOU.
THANK YOU SO MUCH, EVERYONE.
IT'S TRULY AN HONOR TO BE WITH
YOU HERE TODAY.
JUST WAIT A MOMENT FOR THE
SLIDES TO GET PULLED UP AND
THANK YOU TO THE I.T. TEAM FOR
ALL THE WORK YOU ARE DOING
BEHIND AND IN FRONT OF THE
SCENES.
YEP, THAT'S THE ONE.
ALL RIGHT, SO TODAY I WILL BE
TALKING ON GENDER AND SEX
DIFFERENCES AND ABDOMINAL PAIN
AND CORE SYMPTOMS IN FOLKS WITH
INFLAMMATORY BOWEL DISEASE AND
WE TOOK A NETWORK ANALYSIS
APPROACH.
SO I WANT TO THANK NIH AND
SPECIFICALLY THE NATIONAL
INSTITUTES OF NURSING RESEARCH
FOR SUPPORTING MYSELF THROUGH A
K-23, AS WELL AS SUPPORTING
OTHER MEMBERS OF MY TEAM
THROUGH OUR INSTITUTIONAL T-32
FUNDING AS WELL AS A PRE-DOC
AWARD AND 31 TO LINDA YU.
SOME WAS FUNDED THROUGH SIGMA
THETA TAO.
AND COLLEAGUES FUNDED BY
NATIONAL HEALTH INSTITUTES IN
TAIWAN.
BACKGROUND, INFLAMMATORY BOWEL
DISEASE IS KNOWN AS IBD.
IT'S A CHRONIC AUTOIMMUNE
CONDITION.
AND IT'S COMPRISED OF BOTH
ULCERATIVE COLITIS AND CRONE'S
DISEASE.
COMMONLY DIAGNOSED IN YOUNG
ADULTHOOD AROUND THE AGE OF 30.
THERE'S ANOTHER PEAK INCIDENCE
LATER IN LIFE AROUND THE AGE OF
60.
PRIMARY SYMPTOM PATIENTS
EXPERIENCE IS ABDOMINAL PAIN.
IN THE COURSE OF IBD CAN FLICT
WAIT.
-- FLUCTUATE.
PERIODS OF ACTIVE DISEASE AND
PERIODS OF REMISSION.
EVEN WHEN PATIENTS ARE IN
REMISSION ENDOSCOPICKLY THEY
CAN CONTINUE TO EXPERIENCE
SYMPTOMS SUCH AS ABDOMINAL PAIN.
WE SEE SYMPTOMS MAY VARY BASED
ON SEX AND/OR GENDER.
WE SEE FEMALES HAVE INCREASED
DISEASE BURDEN.
THEY HAVE A LONGER TIME TO
DIAGNOSIS, GREATER DISEASE
ACTIVITY, POORER QUALITY OF
LIFE.
AS ALREADY HAS BEEN HIGHLIGHTED
TODAY, THE PREVIOUS LITERATURE
CAN BE A BIT HARD TO EVALUATE
BASED ON DIFFERENT DEFINITIONS
OF SEX AND GENDER OR LACK OF
DEFINITIONS IN GENERAL.
AND FURTHERMORE, THERE'S AN
INADEQUATE REPRESENTATION IN
THE RESEARCH FOR THOSE WHO ARE
OUTSIDE THE GENDER BINARY.
SO THE AIMS OF THIS SPECIFIC
PROJECT WERE TO EXAMINE IF
ABDOMINAL PAIN DIFFERED BY
GENDER AND/OR SEX AND TO
EXPLORE THE RELATIONSHIPS
BETWEEN SYMPTOMS USING A
NETWORK ANALYSIS.
WE RECRUITED PARTICIPANTS
ONLINE THROUGH RESEARCH MATCH.
RESEARCH MATCH IS AN ONLINE
DATABASE OF INDIVIDUALS WHO ARE
INTERESTED IN PARTICIPATING IN
RESEARCH AND IT IS FUNDED BY
THE NIH.
WE RECRUITED ADULTS AGE 18 AND
OLDER WHO HAD IBD.
THEY COMPLETED A VARIETY OF
QUESTIONNAIRES INCLUDING
PROMISE SYMPTOM QUESTIONNAIRES
OF ABDOMINAL PAIN, FATIGUE,
SLEEP DISTURBANCE,
SLEEP-RELATED IMPAIRMENT,
ANXIETY AND DEPRESSION.
THEY ALSO COMPLETED A VARIETY
OF DEMOGRAPHIC AND CLINICAL
QUESTIONNAIRES.
WE DIVIDED INTO THREE
DEMOGRAPHICS.
THEY RESPONDED TO A QUESTION
REGARDING THEIR SEX ASSIGNED AT
BIRTH, AS FEMALE, MALE OR
PREFER NOT TO ANSWER.
THEY ALSO RESPONDED TO
SELF-IDENTIFIED GENDER
VARIABLES, MAN, WOMAN,
NON-BINARY, TRANSGENDER, GENDER
QUEER, NONE OF THESE DESCRIBE
ME OR PREFER NOT TO ANSWER.
INDIVIDUALS WERE IDENTIFIED IF
THEIR SEX ASSIGNED AT BIRTH WAS
DIFFERENT FROM THEIR
SELF-IDENTIFIED GENDER.
WE THEN USE NETWORK ANALYSIS TO
IDENTIFY THOSE CORE SYMPTOMS
WHICH DRIVE THE SYMPTOM
STRUCTURE.
SO OUR PARTICIPANTS.
WE HAD 248 PARTICIPANTS WITH A
MEAN AGE AROUND 38 YEARS OLD.
45% OF THE SAMPLE HAD CRONE'S
DISEASE AND 48% HAD ACTIVE
DISEASE BASED ON SYMPTOM
QUESTIONNAIRES.
WE HAD 167 CISGENDER MEN, 84
SIS GENDER MEN AND SEVEN GENDER
DIVERSE INDIVIDUALS.
WE THEN COMPARED SYMPTOMS
ACROSS THE THREE GROUPS AND
OBSERVED THAT ABDOMINAL PAIN
WAS THE HIGHEST SYMPTOM
SEVERITY OUT OF ALL THE
SYMPTOMS.
AND WHEN LOOKING AT THE TOTAL
SAMPLE, THE MEAN WAS 59.2.
WHICH INDICATES MODERATE TO
HIGH SYMPTOM SEE VIROITY.
-- SEVERITY.
I THINK IT'S ESPECIALLY
IMPORTANT THIS IS A YOUNGER AGE
POPULATION WHO IS STILL
EXPERIENCING THESE HIGH
SYMPTOMS.
WHEN WE LOOKED ACROSS OUR THREE
GROUPS WE SAW ABDOMINAL PAIN
DID DIFFER BASED ON SEX AND
GENDER.
WE SEE THAT CISGENDER MEN HAD
ABDOMINAL PAIN SCORE OF 61.8.
TRANSGENDER OR GENDER DIVERSE,
61.3 AND CISGENDER WOMEN HAD A
SCORE OF 57.8.
WE ALSO SAW DIFFERENCES IN
LEVELS OF DEPRESSION AND WE
ALREADY HEARD THIS THEME TODAY
COMING OUT IN TERMS OF PSYCHO
SOCIAL DISTRESS AND MENTAL
HEALTH.
WE THEN CONDUCTED A NETWORK
ANALYSIS.
THE FIRST NETWORK ANALYSIS
INCLUDES ALL PARTICIPANTS, ALL
248 INDIVIDUALS.
AND THEN WE LOOKED AT CISGENDER
WOMEN SEPARATELY AND CISGENDER
MEN.
DUE TO SAMPLE SIZE WE ARE NOT
ABLE TO DO A NETWORK ANALYSIS
FOR THE GROUP OF TRANSGENDER
AND GENDER DIVERSE INDIVIDUALS.
IN THIS FIGURE EACH CIRCLE
REPRESENTS A SYMPTOM.
AND THE STRENGTH BETWEEN THOSE
SYMPTOMS ARE REPRESENTED BY
THAT THICKNESS OF THE EDGES.
A THICKER EDGE INDICATES A
STRONGER RELATIONSHIP.
SO WE SAW THAT ANXIETY AND
DEPRESSION HAVE A STRONG
RELATIONSHIP.
AND WE SEE THIS HOLD UP ACROSS
ALL PARTICIPANTS AS WELL AS
AMONG CISGENDER WOMEN AND
CISGENDER MEN.
AND FOR INSTANCE, HERE IS THE
RELATIONSHIP BETWEEN FATIGUE
AND SLEEP-RELATED IMPAIRMENT.
SLEEP-RELATED IMPAIRMENT IS
LIKE DAYTIME SLEEPINESS.
WE SEE ALONG CISGENDER WOMEN
THE LINE IS A LOT THICKER, SO
THEY ARE MORE STRONGLY
CONNECTED THAN IT IS FOR
CISGENDERED MEN.
WE THEN LOOKED AT THE STRENGTH
CENTRALITY.
THIS SHOWS STANDARDIZED Z
SCORES FOR SYMPTOMS.
AND HIGHER VALUES INDICATE A
GREATER STRENGTH.
MEANING THAT IS THE CORE
SYMPTOM.
SO WHEN YOU LOOK AT THE TOTAL
SAMPLE, WE SEE THAT BOTH
FATIGUE AND ANXIETY ARE CORE
SYMPTOMS.
THE CORE SYMPTOMS ARE THOSE
THAT ARE MOST HIGHLY CONNECTED.
AND THE THEORY BEHIND IT IS
PERHAPS INTERVENING ON THE CORE
SYMPTOMS YOU CAN THEN IMPACT
THE REST OF THE SYMPTOMS IN THE
NETWORK.
NOW WHEN WE SPLIT IT INTO THE
GROUPS AND WE LOOK AT IT, BASED
ON SEX AND GENDER, WE SEE THAT
FOR CISGENDER WOMEN, THE CORE
SYMPTOM IS FATIGUE, WHEREAS FOR
CISGENDER MEN, THE CORE SYMPTOM
IS ANXIETY.
SO IN CONCLUSION WE SEE
ABDOMINAL PAIN DIFFERS IN SEX
AND GENDER, AND ALTHOUGH
ABDOMINAL PAIN WAS THE HIGH
OEFT REPORTED SYMPTOM, WHEN WE
LOOK AT SYMPTOMS IN NETWORK
ANALYSIS APPROACH WE SEE
FATIGUE AND ANXIETY APPEAR AS
CORE SYMPTOMS AND DEMONSTRATE
POTENTIAL SEX AND GENDER
DIFFERENCE.
WE BELIEVE REPLICATION OF THE
STUDY IS NEEDED WITH AN EVEN
FURTHER CONSIDERATION FOR
TRANSGENDER AND GENDER DIVERSE
PATIENTS.
AND OF COURSE, LIKE ALL GOOD
RESEARCH, THIS HAS LEFT US WITH
MORE QUESTIONS THAN WE BEGAN
WITH.
SO THANK YOU SO MUCH FOR YOUR
TIME.
I WOULD LIKE TO THANK EVERYONE
IN THE RESEARCH LAB WHO HAS
CONTRIBUTED TO THIS WORK, AS
YOU ALL ARE AWARE IT TRULY DOES
TAKE A TEAM TO DO SCIENCE.
SO THANK YOU VERY MUCH.
>> THANK YOU.
I HAVE A FEW QUESTIONS.
WITH THE DIAGRAM I HAVE SEEN
THOSE SORT OF BEFORE AND WE
HAVE TO GET USED TO LOOK AT
DATA IN NEW WAYS.
GET THE THICKNESS IN LINE BUT
WHAT ABOUT THE DISTANCE BETWEEN
THE NODES, IS THAT MEANINGFUL?
>> YES.
IT ALL IS FACTORED INTO HOW
THOSE DIAGRAMS ARE CREATED.
THE DISTANCE IS PART OF THAT
EQUATION.
BUT AS CAN IMAGINE IT'S
ACTUALLY A 3D REPRESENTATION
PUT ON A 2D SCREEN SO SOMETIMES
IT'S HARD TO KNOW WHAT THAT
DISTANCE LOOKS LIKE IN A 3D
SPACE.
>> [OFF MIC]
>> IT'S FACTORED INTO THAT
STRENGTH CALCULATION.
YES?
>> THIS WAS A VERY INTERESTING
PRESENTATION.
IN CHILDREN WITH CROHN'S
DISEASE.
GROWTH PROBLEMS ARE THREE TIMES
MORE COMMON IN MALES WITH
CROHNS DISEASE.
IT APPEARS THAT INFLAMMATION
AFFECTS DIFFERENT PATHWAYS IN
MALES VERSUS FEMALES.
THE GROWTH HORMONE IGF AXIS IS
INVOLVED IN MALES AND
HYPERPITUITARY IN FEMALES.
IT WOULD BE INTERESTED TO LOOK
AT, THEY WOULD BE INTERESTING
FINDINGS.
>> YES, THANK YOU FOR THAT
COMMENT.
THAT'S DEFINITELY AN AREA WE
ARE HOPING TO EXPLORE MORE AT
THOSE INFLAMMATORY MARKERS MORE
IN DEPTH.
MOST OUR WORK SO FAR IS FECAL,
AND ENDOSCOPIC BUT LIKE YOU
SAID THERE'S A WHOLE HOST OF
FACTORS WE SHOULD CONSIDER MORE.
THANK YOU.
>> ALL RIGHT.
THANK YOU.
>> THANKS, KENDRA.
OUR NEXT SPEAKER IS DR. BRIAN
McIVER.
>> IT'S ALWAYS REFRESHING TO
HEAR THAT DOCTOR PART, AS A
RECENT GRADUATE.
TODAY I WILL TALK TO YOU ALL
ABOUT MY DISSERTATION PROJECT
WHERE I INVESTIGATED THE ROLE
OF ASTRO CYTE ELEVATED AEG1,
MULTI-FUNCTIONAL PROTEIN IN
CHEMOTHERAPY INDUCED --
NEUROPATHY.
BRIEFLY I WANT TO GIVE
BACKGROUND ON CHEMOTHERAPY
INDUCED PERIPHERAL NEUROPATHY
OR CIPN.
THE A PREDOMINANTLY SENSORY
DOSE LIMITED SIDE EFFECT OF
CHEMOTHERAPY TREATMENTS.
MANY INCLUDE ALLODYNIA, COLD
BURNING SENSATION.
THERE ARE DIFFERENT CLASSES OF
CHEMO THERAPEUTICS THAT HAVE
VARYING PREVALENCES OF CIPN.
ONE IS TAXANES AND PLATINUM
BASED DRUGS LIKE PACILITAXEL
AND OXALIPLATIN.
MANY HAVE DID I MIN SHISHED
EFFICACY WITH LONG TERM USE AND
CAN PRODUCE SEVERE NEGATIVE
SIDE EFFECTS.
IT'S IMPORTANT WE PRODUCE MORE
EFFICACIOUS TREATMENTS SO WE
CAN DEVELOP PROPHYLACTICS AND
TREATMENTS SPECIFICALLY FOR
CIPN.
IN ORDER TO DO THAT WE WANT TO
LOOK AT MECHANISMS THAT UNDER
LIE THE DEVELOPMENT OF CIPN.
SO ONE IS NEUROINFLAMMATION.
AS MANY OF YOU KNOW, STUDY
PAIN, NEUROINFLAMMATION IS A
COMMON BIOLOGICAL PROCESS
UNDERLYING MANY CHRONIC PAIN
CONDITIONS.
I WANT TO BRIEFLY GO THROUGH
HOW PACLITAXEL INFLUENCES NEURO
INFLAMMATION.
IN THE DRG'S WILL INDUCE NERVE
DAMAGE BY DYING BACK ON THE
AXONS THAT INNERVATE PERIPHERAL
TISSUES SUCH AS THE HANDS AND
FEET.
WITHIN THOSE TISSUES PACILTAXEL
AS WELL AS DAMAGE ASSOCIATED
MOLECULAR PATTERNS THAT COME
OFF THE DAMAGED NEURONS
STIMULATE THE ACTIVATION OF
PERIPHERAL MILE SITES THAT WILL
EXACERBATE NERVE DAMAGE AND
NEUROINFLAMMATION.
LOTS OF PAPERS HAVE GONE ONTO
SHOW PROMINENT THERAPEUTIC
STRATEGY IS TO BLOCK PAC
MEDIATED TO PREVENT CIPN.
WE IDENTIFIED AEG1, AS YOU SAW
ON THE DIAGRAM ONE KEY
PROMINENT PROTEIN ACTIVATED IS
NF KAPPA B.
ASTROCYTE.
YOU CAN SEE FROM THIS DIAGRAM
FROM HUMAN TISSUE ATLAS
PRIMARILY EXPRESSED AT HIGH
LEVELS CELLS RESULTING FROM THE
BONE MARROW AND LYMPHOID
ISSUES, THAT WOULD INCLUDE YOUR
IMMUNE CELLS.
IT'S ALSO A MULTI-FUNCTIONAL
SCAFFOLDING PROTEIN, IT HAS
PROTEIN TO PROTEIN INTERACTIONS
WHICH ALLOWS IT TO BE INVOLVED
IN MANY SIGNAL PATHWAYS SUCH AS
THE NFP KAPPA B PATHWAY.
IT'S ABLE TO MODULATE
INFLAMMATION THROUGH DIRECT
INTERACTION WITH MULTIPLE
PROTEINS INVOLVED IN
INNERVATION.
STUDIES HAVE SHOWN THAT AEG1 IS
INVOLVED IN A REGULATION OF
MACROPHAGE ACTIVITY WHEN AEG IS
LOST, FAK FAITH AND OTHER NERVE
CELLS ARE UNABLE TO
DIFFERENTIATE OR ACTIVATE WHEN
THEY ARE STIMULATED WITH
CHEMAKINS AND CYTOKINES.
BASED ON THIS INFORMATION WE
THOUGHT AEG1 AS MODULATOR OF
INTHE KING AND QUEEN HAVE A OR
-- INFLAMMATION MAY LEAD TO
DEVELOPMENT OF CIPN.
THIS IS A BRIEF LIST OF
MATERIALS, INCLUDING ANIMALS.
THE DRUGS I WILL BE USING.
I WILL GO THROUGH THESE METHODS
AS WELL.
I WANT TO EMPHASIZE, I KNOW WE
ARE HERE TO TALK ABOUT THE
INPLICATIONS OF BIOLOGICAL SEX.
MY STUDIES INCLUDED MALE AND
FEMALE AND WHEN BIOLOGICAL SEX
PRODUCED A SIGNIFICANT EFFECT
THE ANIMALS WERE SEPARATED BY
SEX, IF NOT THEY WERE CONDENSED
INTO SINGLE EXPERIMENT
ALLOGROUPS.
SO JUST A QUICK BACKGROUND ON
MY MODEL CIPN.
BY FOUR INJECTIONS OF
PACILTAXEL.
THERE ARE RELEVANT STUDY
OUTCOMES TO STUDY NEUROPATHY IN
MICE.
BEHAVIORAL STUDIES WHICH ARE
VON FREY TO ASSESS MECHANICAL
SENSITIVITY.
LOOK AT VOLUNTARY MOVEMENTS AND
PHYSIOLOGICAL OUTCOMES WHICH
LOOK AT ELECTROCONDUCTIVITIES
OF PERIPHERAL NERVE FIEBS AND
LOOK AT MORPHOLOGICAL CHANGES
ASSOCIATED WITH PACILTAXEL
ADMINISTRATION.
HERE WE SEE IT REDUCES THE
AMOUNT OF INNERVATING NERVE
FIBERS IN MICE.
I WILL BRIEFLY GO THROUGH
GLOBAL KNOCKOUT MICE DATA FOR
THE SAKE OF TIME.
THE EFFECTS OF GLOBAL AEG
PREVENTED PRETTY MUCH ALL OUR
BEHAVIORAL ELECTROPHYSIOLOGICAL
AND MORPHOLOGICAL OUTCOMES.
FAILED TO PRODUCE COLD
SENSITIVITY.
ELECTROPERIPHERAL NEVER OR IENF
DENSITY.
WE SEE UP REGULATION OF
PROINFLAMMATORY CYTOKINES OR
PROINFLAMMATORY GENES IN WILD
TYPE WITH THE BLACK BARS
COMPLETELY BLOCKED IN OUR AEG1
KNOCKOUT MICE.
WE ALSO SEE THAT GLOBAL
DILUTION OF AEG-1 REDUCES
OXALIPLATIN, MEDIATED BY OTHER
CLASSES OF CHEMOTHERAPIES AND
EFFECTS OF PACILTAXEL IN AEG-1
WE SAW IT INDUCES UP REGULATION
OF AEG-1 IN THE DRG'S OF MICE
BUT NOT IN THE SPINAL CORD.
AND IN PER TONE YAL MACROPHAGES
FROM PACILTAXEL TREATMENT
THERE'S UP REGULATION OF AEG-1
IN PACILTAXEL TREATED ANIMALS
AND FEMALE MICE COMPARED TO
MALE MICE.
UNFORTUNATELY THIS IS THE ONLY
DATASET I SAW A SEX DIFFERENCE.
SO ALL TOGETHER THIS DATA LED
US TO BELIEVE THAT THERE MAY BE
IMPLICATION FOR AEG-1
EXPRESSION IN MYELOID CELL
THAT'S MAY BE CONTRIBUTING TO
CIPN.
WE NEXT USE CONDITIONAL
KNOCKOUT MICE WHICH LACK AEG-1
EXPRESSION IN ONLY MYELOID
TISSUE AND AGAIN WE SEE A
COMPLETE BLOCK OF IN OF
PACILTAXEL, MECHANICAL
SENSITIVITY, COLD AND
DEPRESSION -- WE SEE
PREVENTION, REDUCTION IN
PERIPHERAL NERVE FIBER
AMPLITUDE AND LOSS OF IENF
DENSITY.
WE LOOKED AT OUR DRG
EXPRESSION, WE SEE A SIMILAR
PATTERN WHERE PROINFLAMMATORY
GENES ARE UP REGULATED IN WILD
TYPE BUT COMPLETELY BLOCKED IN
OUR AEG-1 KNOCKOUT MICE.
HISS STO CHEMISTRY STUDIES
LOOKING AT MACROPHAGES, USING
F480 AS A MARKER.
IN WILD TYPE PAXEL TREATED
THERE'S AN INCREASE IN OUR
CONDITIONAL KNOCKOUT MICE.
SIMILARLY THERE'S A BLOCK CADE
OF NF KAPPA B AND THEY ARE
TREATED WITH PACLITAXIN.
--
HERE WE PERFORMED A TIME COURSE
TO LOOK AT WHEN IS THE OPTIMAL
KNOCK DOWN WITH OUR NANO
PARTICLES.
WE SEE IT'S ON DAY 3.
AND SO WE THEN INJECTED MICE
AGAIN AND WE STIMULATED PER
TONE YAL MACROPHAGES USING GLIO
GLYCOLATE, HERE WE SEE OUR NANO
PARTICLES CARRYING AEG1 NOT
ONLY DOWN REGULATED IN OUR
MACROPHAGES BUT ALSO
SUBSEQUENTLY GENES ASSOCIATED
WITH NF KAPPA B ACTIVATION.
THERE WAS NO CHANGE IN OUR
DEPLETED CELLS WHICH ARE NON
MACROPHAGE TYPE CELLS.
SO THEN WE WANTED TO SEE CAN WE
UTILIZE THIS AS A STRATEGY TO
REVERSE PACILTAXEL.
FOUR DAYS AFTER FIRST INJECTION
THEY DEVELOPED MECHANICAL
HYPERSENSITIVITY AND NEXT WE
SAVE SRNRA.
WE SEE A TIME DEPENDENT
REVERSAL OF NOT ONLY MECHANICAL
SENSITIVITY BUT ALSO COLD
HYPERSENSITIVITY.
NOW THAT WE CONFIRMED A SINGLE
INJECTION IS EFFECTIVE TO
REVERSE MECHANICAL AND COLD
HYPER SENSITIVE CAN WE PREVENT
IT?
ANSWER TURNS OUT YES.
WE PRE-TREATED MICE WITH SRNA
NANO PARTICLES AND GAVE THEM
TWO INJECTIONS OF PACILTAXEL.
THAT WAS SUFFICIENT TO
COMPLETELY PREVINT MECHANICAL
AND COLD HYPERSENSITIVITY
INDUCED BY PACILTAXEL IN OUR
MOUSE MODEL.
THIS IS A BRIEF SUMMARY OF THE
DATA.
OVERALL I THINK THE MAJOR TAKE
AWAY IS TARGETED INHIBITION OF
AEG-1 REPRESENTS POTENTIALLY
NOVEL THERAPEUTIC TREATMENT FOR
NOT ONLY THE PREVENTION BUT
REVERSAL OF CIPN.
AND SOME FUTURE DIRECTIONS
INCLUDE LOOKING AT CHANGES IN
AEG-1 EXPRESSION IN DIFFERENT
POPULATIONS OF MYELOID CELLS.
IT'S A TERM USED FOR HOMOGENOUS
GROUP OF CELLS.
SO YOU WANT TO LOOK AT NOT JUST
TARGETING IN MACROPHAGES BUT
ALSO IN DENDRITIC CELLS OR
OTHER TYPES OF MYELOID CELLS
AND WE WANT TO DO MORE STUDIES
LOOKING AT IMPACT OF BIOLOGICAL
SEX ON AEG1 EXPRESSION AND
NEURO INFLAMMATION IN MYELOID
CELLS IN CIPN.
WE WANT TO OPTIMIZE OUR USAGE
OF AEG-1 TARGETED NANO
PARTICLES.
WE ONLY TIED ONE DOSE, THIS IS
TOWARD THE END OF MY
DISSERTATION STUDIES, THAT'S
ALL I HAD TIME FOR.
WE WILL CONTINUE TO LOOK AT
DIFFERENT DOSES AND DIFFERENT
TIME POINTS TO TRULY OPTIMIZE
OUR TARGETING OF AEG-1 AND
DETERMINE HOW MUCH DO WE NEED
TO KNOCK IT DOWN TO PREVENT
CIPN AND OTHER PATHOLOGIES
POTENTIALLY WITH OTHER CLASSES
OF CHEMOTHERAPIES AS WELL.
I WANT TO THANK MY LAB MEMBERS.
FORMER POSTDOCS OF MY LAB, MY
CO-MENTOR.
MANY PEOPLE FROM MY UNIVERSITY,
INCLUDING MY DEPARTMENT AND
COMMITTEE AS WELL AS NIH FOR
THE MULTIPLE FELLOWSHIPS I HAVE
RECEIVED AT MY TIME AT VCU AND
F-31 FUNDING.
AND THAT IS IT.
>> HOPING IT DIDN'T HAVE
EFFECTS OF ANTI-CANCER EFFECTS?
>> THAT IS DEFINITELY SOMETHING
WE ARE INTERESTED IN STUDYING.
AEG-1 IS A PROMINENT ONCOGENE
AND PLAYS A ROLE IN MANY
HALLMARKS OF CANCER, INCLUDING
CHEMO-RESISTANCE, MY GOAL FOR
THIS AS FUTURE STUDIES MY HOPE
IS SOMEONE WILL COME ALONG AND
CONTINUE TO INVESTIGATE, YOU
KNOW, TARGETING AEG-1 IN
MACROPHAGES DOES IT ALTER THE
AMOUNT OF CHEMOTHERAPY THAT IS
NEEDED IN ORDER TO, I GUESS,
KILL CANCER CELLS.
BUT CAN IT ALSO MEDIATE THAT
LEVEL OF PREVENTION OF CIPN WE
SEE WITH MY RESIECH.
-- RESEARCH.
IT WOULD BE POTENTIALLY
DUALISTIC TYPE OF TREATMENT.
THAT'S THE GOAL, WE HAVEN'T
GOTTEN THERE YET BUT DEFINITELY
SOMETHING WE ARE INTERESTED IN.
>> THANK YOU.
>> BRYAN, IT'S OKAY NOT TO FIND
SEX DIFFERENCES.
IT'S IMPORTANT TO LOOK BUT YOU
DON'T HAVE TO FIND THEM.
AND LAST SPEAKER IN THIS
SESSION IS DR. CAROLINE
PATTERSON GENTILE.
>> WONDERFUL.
THANK YOU FOR OPPORTUNITY TO
SHARE THIS WORK.
IT'S A REAL HONOR TO BE HERE
WITH ALL OF YOU.
I'M GOING TO BE DISCUSSING A
MULTI-CENTERED VALIDATION OF
CLUSTER ANALYSIS WITH MIGRAINE
ASSOCIATED SYMPTOMS WHICH WE
CALL
CAMS FOR SHORT IN YOUTH.
THESE ARE JUST MY DISCLOSURES.
SO WHEN WE THINK OF MIGRAINE,
THE FIRST THING THAT COMES TO
MOST PEOPLE'S MIND IS HEAD PAIN.
HOWEVER IT'S REALLY IMPORTANT
TO NOTE MIGRAINE IS IN PART
NEUROLOGICAL SYMPTOMS OF HEAD
PAIN.
THESE SYMPTOMS ARE VERY
IMPORTANT FOR THE INDIVIDUALS
WITH LIVED EXPERIENCE OF
MIGRAINE.
CRITERION D OF THE
INTERNATIONAL CLASSIFICATION OF
HEADACHE DISORDERS LIGHT AND
SOUND SENSITIVITY, THEY ARE
BASED ON EXPERT OPINION AND
MANY SYMPTOMS ARE ASSOCIATED
WITH MIGRAINE.
DIZZINESS LIKE LIGHT HEADEDNESS
OR VERTIGO, AS WELL AS MENTAL
FOGGINESS.
NOW WE HAVE THE ABILITY WITH
LARGE DATA REGISTRIES TO
PROVIDE A MEANS TO MAKE
DATA-DRIVEN DIAGNOSTIC
CATEGORIES.
WHY THIS IS SO IMPORTANT IS HOW
WE DEFINE THESE CONDITIONS
DETERMINES WHO IS INCLUDED IN
CLINICAL TRIALS AND WHO HAS THE
AVAILABLE TREATMENTS.
TO LOOK WE ASSESS THE
UNDERLYING RELATIONSHIPS OF
SYMPTOMS YOUTH BETWEEN 6-17
YEARS OLD WITH CROSS SECTIONAL
MULTI-CENTERED STUDY BASED ON
HEADACHE INTAKE QUESTIONNAIRES.
I'VE HAD THE GREAT FORTUNE OF
WORKING WITH TWO GIANTS IN MY
FIELD.
ONE DR. CHRISTINE SZPERKA
SITTING OVER THERE, YOU WILL
HEAR FROM HER, MY BOSS AT THE
CHILDREN'S HOSPITAL OF
PHILADELPHIA.
SHE HAS WORKED WITH DR.
HERSHEY, BOTH IN COLLABORATION
WITH DR. HERSHEY HAVE BUILT
THESE LARGE HEADACHE REGISTRIES
BASED ON HEADACHE
QUESTIONNAIRES FILLED OUT AT
CLINICAL VISITS.
WHAT'S GREAT ABOUT THESE
REGISTRIES THEY HAVE VERY
SIMILAR WAYS THE QUESTIONS WERE
ASKED BUT THERE WERE KEY
DIFFERENCES.
AT CINCINNATI CHILDREN'S, THESE
ARE CLINICIAN-GUIDED, THERE'S A
HEADACHE PROVIDER SITTING WITH
THEM HELPING FILL IT OUT, BASED
ON PATIENT RESPONSE EVEN BEFORE
THEY SEE A CLINICAL PROVIDER.
AT CHOP ANYONE COMING INTO
GENERAL NEUROLOGY OR HEADACHE
PROGRAM AND RANGE OF DATA
COLLECTION WAS DIFFERENT FOR
THESE.
SO INCLUDED IN THIS STUDY WAS
REALLY ALL YOUTH WITH HEADACHE,
NOT JUST MIGRAINE.
THIS INCLUDED OVER 10,000
RESPONDENTS ACROSS THE TWO
CENTERS THAT WERE 67 AND 68.4%
FEMALE, SEX ASSIGNED AT BIRTH.
MEDIAN AGE 13 YEARS AND THE
DEMOGRAPHICS RACIAL AND ETHNIC
REFLECTED THE CATCHMENT AREAS
OF THE TWO INSTITUTIONS.
DUE IN PART TO REFERRAL
PATTERNS THERE WERE DIFFERENCES
IN OVERALL HEADACHE BURDEN
METRICS, HEADACHE SEVERITY,
AVERAGE SEVERITY, FREQUENCY OF
BAD HEADACHES AND DISABILITY
WERE OVERALL HIGHER AT
CINCINNATI CHILDREN'S THOUGH A
WIDE RANGE ACROSS THE TWO
INSTITUTIONS.
DIAGNOSIS, LOWEST AT CINCINNATI
WHERE AS 65% HAD PRIMARY
DIAGNOSIS AT C.H.O.P. AND ALL
CHILDREN WERE INCLUDED.
WE LOOKED AT 11 ASSOCIATED
SYMPTOMS.
THE ICHD FEATURES.
PHOTO PHOBIA, NAUSEA ARE COMMON
ACROSS ALL YOUTH WITH HEADACHE.
OTHER SYMPTOMS NOT INCLUDED
LIKE LIGHT HEADEDNESS AND
DIFFICULTY THINKING ARE ALSO
VERY PREVALENT.
WE REALLY WANTED TO UNDERSTAND
HOW THESE SYMPTOMS INTERACTED
WITH EACH OTHER.
WE USED MULTIPLE CORRESPONDENCE
INCIDENCE WHICH REDUCES
VARIANTS IN A SMALLER NUMBER OF
DEMENTIA.
TO GIVE INTUITION OF THIS
GRAPH, SO THE PRESENCE OF A
SYMPTOM IS REPRESENTED BY THE
BUBBLES, THE SIZE OF THE BUBBLE
IS OVERALL PROPORTION OF
RESPONDENTS WHO REPORTED THAT
SYMPTOM.
AND TWO SYMPTOMS BEING CLOSE
TOGETHER OVERLAPPING INDICATE
IF YOU REPORTED ONE OF THE
SYMPTOMS YOU WERE REALLY LIKELY
TO REPORT THE OTHER.
FOR INSTANCE YOU CAN SEE PHOTO
PHOBIA AND PHONOPHOBIA CLOSELY
OVERLAP.
THIS SUGGEST IF ONE WAS PRESENT
THE OTHER WAS PRESENT.
IF YOU LOOK AT X AXIS WHICH
CAPTURES THE MOST AMOUNT OF
VARIANCE YOU SEE IT SPLITS
RESPONDENT ANSWERS INTO TWO
MAIN CATEGORIES.
SO IF YOU HAD NO SYMPTOMS, YOU
KNOW, THEN YOU HAVE HAD NO
SYMPTOMS BUT IF YOU HAD ONE
SYMPTOM YOU WERE MORE LIKELY TO
REPORT MULTIPLE.
THERE WAS A RANGE WHERE YOU
COULD SEE VOMITING KIND IS IN
THE MIDDLE OF THE GRAPH.
EVEN THOUGH REPORTED AT SIMILAR
REPORTED CHANGES IT WAS A
SYMPTOM THAT COULD BE REPORTED
AS THE SOLE SYMPTOM AND
REPORTED BY ITSELF, VISION
CHANGES WERE MOST LIKELY TO
OCCUR IF OTHER SYMPTOMS WERE
PRESENT.
THIS MODEL HAD NO PRECONCEIVED
NOTION, AGNOSTIC TO PREEXISTING
ICHD SYMPTOMS.
BUT THEY SPLIT INTO ICHD.
THE BOTTOM PART ARE ALL OF THE
SYMPTOMS NOT INCLUDED.
SO THIS SUGGESTS THAT THE MOST
COMMON SYMPTOMS WE ACTUALLY ASK
ABOUT AS PART OF DIAGNOSIS DO
TEND TO CO-OCCUR.
AND ARE SOMEWHAT SEPARATE FROM
OTHER SYMPTOMS LIKE LIGHT
HEADEDNESS, VISION CHANGES,
SPINNING.
IT WASN'T A PRIMARY, THESE WERE
ALSO SYMPTOMS THAT HAPPENED
WHEN OTHER SYMPTOMS WERE
PRESENT.
THE THIRD DIMENSION IN COLOR,
IT SEPARATED INTO SENSORY HYPE
SENSITIVITIES AND SEPARATELY
WHAT I WOULD CONSIDER MORE VEST
IB LAR SYMPTOMS AND NAUSEA AND
VOMITING.
WE USED LINEAR MIX EFFECTS
MODEL WITH RANDOM MIX VARIABLE
AND COMPARED THESE THREE CAMS
DIMENSION.
WE FOUND THE FIRST THAT A
GREATER NUMBER OF MIGRAINE
ASSOCIATED SYMPTOMS CORRELATED
WITH GREATER HEADACHE.
THE PRESENCE OF ICHD VERSUS NON
SYMPTOMS IF YOU REPORTED MORE
NON ICHD SYMPTOMS YOU TENDED TO
REPORT MORE FREQUENCY BUT LESS
SEVERITY.
THE ICHD HAVE A ROT OF SENSORY
HYPERSENSITIVITY ASPECTS AND
REPORTING GREATER PAIN.
BUT OTHER PATIENTS WHO HAVE
DIZZINESS SYMPTOMS, LIGHT
HEADEDNESS, ROOM SPIN, OTHER
SYMPTOMS LIKE THAT, HIGHER
FREQUENCY BUT MAYBE NOT AS
INTENSE PAIN.
AND WE LOOKED AT THIS ALSO
ACROSS AGE AND SEX.
I THINK THIS IS A GOOD POINT TO
GIVE A PLUG FOR PEDIATRIC
RESEARCH.
YOU ASK SEE REALLY INTERESTING
CHANGES FOCUSING AT THIS
POPULATION LEVEL.
WHAT WE SEE IS WITH SYMPTOM
NUMBER, THE X AXIS IS AGE, AND
THE Y AXIS IN THIS CASE IS THE
CAMS WHETHER ABUNDANCE OF
SYMPTOMS OR NO SYMPTOMS
PRESENT, YOUNG CHILDREN
GENERALLY REPORT VERY FEW OR NO
SYMPTOMS.
AS THEY GET OLDER THE NUMBER OF
SYMPTOMS THEY REPORT INCREASES.
BUT AT THE AGE OF 12 THERE'S A
SPLIT WHERE FOR MALES THE
NUMBER OF SYMPTOMS THEY REPORT
PLATEAUS AND CONTINUES TO
INCREASE FOR FEMALES.
WE NEXT LOOKED AT THE SECOND
DIMENSION.
SO ICHD VERSES NON ICHD
SYMPTOMS AND YOUNGER CHILDREN
TENDED TO ONLY REPORT ICHD
SYMPTOMS.
OVERALL MALES REPORTED MORE
SYMPTOMS WHEREAS FEMALES COULD
REPORT ALSO SOME NON ICHD
SYMPTOMS.
THIS TREND TENDED TO MOVE
TOWARD MORE NON ICHD SYMPTOMS
AS CHILDREN GOT OLDER.
SO THERE WASN'T THE SAME DIE
VERGENCE WE SEE AT THE TIME THE
PUBERTY.
WHAT WE FIND INTERESTING ABOUT
THIS, IT ALMOST MIRRORS LINEAR
GROWTH.
I WOULD BE CURIOUS TO SEE WHAT
OTHER GROUPS ARE SEE IN THEIR
CHRONIC PAIN CONDITIONS.
BUT WE ARE SEEING A LOT OF
JOINT HYPER MOBILITY.
WE ARE WONDERING IF THIS MIGHT
BE MIRRORING JOINT HYPER
MOBILITY IN SOME WAY.
IT'S PURE SPECULATION BUT
SOMETHING WE ARE THINKING ABOUT.
WHEN WE LOOK AT FINAL CAMS,
THERE ACTUALLY ISN'T AN AGE OR
SEX DIFFERENCE OR DEPENDENCE,
SUGGESTING THESE MIGHT BE MORE
FIXED PROPERTIES OF MIGRAINE
THAT DON'T CHANGE ACROSS THESE
DIMENSIONS.
SO IN SUMMARY, WE FOUND THAT
LOOKING AT A BROADER RANGE OF
MIGRAINE ASSOCIATED SYMPTOMS
AND LOOKING AT UNDER LIE
RELATIONSHIPS, INFORMATIVE FOR
HEADACHE BURDEN AND REVEALED
DIFFERENCES ACROSS CHILD
DEVELOPMENT AND SEX.
WE ALSO FOUND, I THINK THIS IS
IMPORTANT TO NOTE, I SHOWED YOU
COMBINED DATA BUT WHEN WE RAN
SEPARATELY ON SITES WE SAW THE
SAME CLUSTERS.
THIS INDICATES THAT EVEN ACROSS
SITES THAT THESE SYMPTOM
CLUSTERS ARE INHERENT TO
MIGRAINE.
AND WE PROPOSE THIS MIGHT
REPRESENT SENT ENDOPHENONO
TYPIC SYMPTOM CLUSTERS THAT
INVOLVE OVERLAPPING NEURAL
NETWORKS, PERHAPS DISRUPTED TRY
GEM NAL CERVICAL COMPLEX,
BROADER DYSFUNCTION OF NEURAL
NETWORKS.
FURTHER RESEARCH IS NEEDED TO
UNDERSTAND ARE THERE ACTUALLY
UNDERLYING PATH THO PHYSIOLOGIC
DIFFERENCES LEADING TO THIS
RANGE OF SYMPTOMS.
WITH THE ULTIMATE GOAL OF
REALLY REFINING MIGRAINE
DIAGNOSIS AND SUPPORTING
TARGETED TREATMENTED.
WITH THAT, THAINKT YOU FOR YOUR
ATTENTION AND ALL THE PEOPLE
THAT MADE THIS WORK POSSIBLE.
AND HAPPY TO TAKE ANY QUESTIONS.
>> I DIDN'T HAVE SO MUCH A
QUESTION AS MAYBE I WASN'T PAY
ATTENTION.
YOU SHOWED THE BIG CIRCLE SMALL
CIRCLE SLIDE AND THE SLIDE
BEFORE THAT YOU WERE SHOWING
FREQUENCY WITH WHICH THE
DIFFERENT SYMPTOMS OCCUR.
AND I THOUGHT, COULD YOU SHOW
THOSE?
SORRY, MY THROAT.
>> NO WORRIES.
I THINK YOU ARE GETTING AT
THESE PERCENTAGES REPRESENT THE
BUBBLE SIZE ON THE NEXT GRAPH.
IF THAT'S --
>> PRECEDING GRAPH.
>> WAS IT THIS ONE?
>> NOT WORKING, SORRY.
GO TO THE ONE BEFORE THAT.
>> GO BACK ONE?
>> YEAH.
SO THIS ONE.
OSMO PHOBIA WHICH IS LIGHT
SENSE TIFT?
>> SMELL SENSITIVITY.
>> IT'S FAIRLY RARE, RIGHT?
>> YEAH.
>> AND GO TO THE NEXT SLIDE.
SO HERE IT TENDS TO BE ONLY
ASSOCIATED WITH MANY SYMPTOMS.
IT'S RARE, TRYING TO UNDERSTAND
HOW THESE CORRELATE.
>> THAT'S RIGHT.
OSMO PHOBIA IS A NICE EXAMPLE,
PRIOR WORK FIND SPECIFIC BUT
NOT SENSITIVE.
THIS GRAPH KIND OF CONSISTENT
WITH THAT FINDING.
BECAUSE OSMOPHOBIA IS LIKELY TO
CORRELATE WITH THE OTHER
SYMPTOMS BUT LESS COMMON.
>> JUST WANTED TO MAKE SURE I
WAS UNDERSTANDING THAT.
>> YEAH, ABSOLUTELY.
THANK YOU.
>> YOUR COMMENT ABOUT JOINT
HYPER MOBILITY IS REALLY
INTERESTING.
I DON'T KNOW ABOUT CHILDREN BUT
CERTAINLY ADULTS THERE SEEMS TO
BE CO-OCCURRENCE BETWEEN
MIGRAINE AND MYOFACIAL PAIN.
I SEE YOU HAVE NECK PAIN IN
THERE.
WOULD THAT BE SOMETHING
INTERESTING TO PURSUE IN TERMS
OF LOOKING AT MUSCULAR TURE,
NOT JUST HEAD, NECK, SHOULDERS,
ET CETERA.
HAVE YOU THOUGHT ABOUT THAT?
DOING THAT?
>> IT'S A GREAT QUESTION.
AND WE ACTUALLY ARE FORTUNATE
TO WORK WITH MULTI-DISCIPLINARY
TEAM AND WE HAVE A HEADACHE
PHYSICAL THERAPIST I THINK FOR
ME EVEN DURING MY TRAINING
REALLY OPENED THE IMPORTANCE OF
THE WHOLE MUSCULAR SKELETAL AND
ITS RELATION TO HEAD PAIN, IT'S
A REALLY IMPORTANT DIRECTION TO
GO.
HEADACHE I HAVE NOTICED
SOMETIMES LIVES IN ITS OWN
SATELLITE FROM OTHER PAIN
CONDITIONS BUT WHEN I COME TO
THESE PAIN CONSORTIUMS I HEAR
HOW MUCH OVERLAP AND SIMILARITY
THERE IS.
SO I THINK IT'S A REALLY
IMPORTANT DIRECTION TO GO.
>> ADULTS A LOT OF PEOPLE WITH
MIGRAINE GET MYOFACIAL PAIN IN
BETWEEN MIGRAINE PAIN.
>> THANK YOU.
CAN YOU SPEAK THAT LIKELY MOST
OF THESE CHILDREN ARE
ADOLESCENTS ANSWERING THESE ARE
COMING TO THESE SPECIALIZED
TERTIARY PAIN CLINICS.
HOW DOES THAT INFORM THE LARGER
CONTEXT OF HEADACHE TREATMENT
IN GENERAL FOR CHILDREN SOLELY
GOING TO A PEDIATRICIAN OR
FAMILY MEDICINE DOCTOR.
>> ABSOLUTELY.
IT'S AN IMPORTANT QUESTION.
NOTABLE IT'S FOCUSED ON A
SPECIFIC POPULATION.
AND I THINK ONE OF THE, SOO WE
DO HAVE THE ADVANTAGE OF, THAT
AT LEAST WITHIN THE C.H.O.P.
DATASET CHILDREN COMING INTO
NEUROLOGY BUT STILL TALKING
ABOUT A SELECTIVE GROUP.
I WOULD LOVE TO EXPAND THIS
QUESTIONNAIRE TO LIKE THE
PEDIATRICIAN LEVEL TO SEE, ARE
WE SEEING THE SAME KIND OF
PATTERNS?
OR SOMETHING WITHIN JUST THE
PARTICULAR POPULATION WE ARE
SEEING THAT WE ARE SEEING THESE
RELATIONSHIPS.
>> RIGHT.
BECAUSE I THINK ABOUT LIKE
EARLY INTERVENTION.
TRYING TO PREVENT CHRONFICATION
OF THAT PAIN LATER ON.
>> THE CINCINNATI DATASET, I'M
STARTING TO LOOK AT THIS, WE
HAVE LONGITUDINAL INFORMATION.
ARE THESE, KNOW, THERE SEEMS TO
BE ON A CROSS SECTIONAL LEVEL
THERE'S A KHAIFRNG ACROSS AGE.
WE DON'T KNOW IN THE INDIVIDUAL
IS THERE A DIFFERENCE, RIGHT?
WE ARE STARTING TO LOOK AT
THOSE DATA.
BUT I THINK IT'S A REALLY
IMPORTANT QUESTION.
>> REALLY EXCITING WORK.
THANK YOU FOR SHARING.
>> MORE QUESTIONS?
DO YOU TRACK ABDOMINAL PAIN IN
THE KIDS?
>> WE DO.
SO WE DO HAVE -- I DON'T
THINK I HAVE LOOK AT IT
SPECIFICALLY WITH THE CAMS
ANALYSIS.
BUT WE TRACK CO-MORBID CHRONIC
ABDOMINAL PAIN AND ADDITIONAL
QUESTIONS IN ADDITION TO ASKING
BY NAUSEA AND VOMITING DO YOU
HAVE BELLY PAIN.
IT WOULD BE GREAT TO LOOK AT
THIS DATA IN THE CONTEXT OF
ABDOMINAL PAIN.
YEAH.
SO
POTENTIALLY WE SEE ABDOMINAL
MIGRAINE IN OUR CLINICS AND
WOULD HAVE THE ABILITY TO LOOK
AT THAT A BIT AS WELL, YEAH.
>> PLEASE JOIN ME IN THANKING
ALL THE SPEAKERS.
I WISH YOU ALL LUCK WITH THE
MITCHELL MAX AWARD.
I BELIEVE WE ARE ON BREAK.
YEAH, WE ARE ON BREAK RIGHT NOW
FOR THE NEXT 15 MINUTES.
SO ENJOY AND DON'T FORGET TO
CHECK OUT THE POSTERS.
THANKS.
NICU ADMISSION WHICH IS
SOMETHING WE TRY TO AVOID.
THIS IS DATA I WILL PRESENT
FROM A RECENT MULTI-CENTER
STUDY PERFORMED IN THE UNITED
STATES WITH THE SUPPORT OF
SOCIETY OF OBSTETRIC AND
NEONATAL.
WE WANTED TO TRY TO IDENTIFY
THE PREVALENCE OF INTRA
OPERATIVE BREAK THROUGH PAIN
AND TRY TO ALSO CHARACTERIZE
WHAT PATIENTS WERE EXPERIENCING.
SO WE KIND OF DID A BIT OF A
SNAPSHOT AUDIT LOOKING AT ALL
DELIVERIES ACROSS A 1-2 MONTH
PERIOD IN EACH INSTITUTION.
IN ANY PATIENT HAVING A
CAESARIAN UNDER NEUROAXIAL
ANESTHESIA.
WE EXCLUDED PATIENTS WHO
WEREN'T ABLE TO REPORT OR
DIDN'T HAVE ANY INTEROPERATIVE
PAIN.
BUT BASICALLY WE HAD ALL THE
PATIENTS WERE APPROACHED ON UP
TO 36 HOURS POSTPARTUM AND
ASKED THESE THREE QUESTIONS
ABOUT WHETHER THEY EXPERIENCED
PAIN, HOW THEY WOULD RATE THEIR
WORST PAIN AND IF THEY WERE
SATISFIED WITH THE ANESTHESIA
CARE.
AND IF THEY DID EXPERIENCE PAIN
THEY WERE INVITED TO TAKE PART
INTO A MORE DETAILED
CHARACTERIZATION STUDY WITH THE
USE OF A CRF AND MCGILL
QUESTIONNAIRE BASED ON WHAT
THEIR INTRO OPERATIVE
EXPERIENCE WAS.
THIS IS INTERIM DATA BECAUSE WE
ARE STILL WAITING FOR SOME
CENSUS TO SEND THEIR DATA.
BUT WE HAVE A PRETTY GOOD
COHORT FROM 11 SITES AND OVER
2,500 PATIENTS.
THE A PRETTY RACIALLY AND
ETHNICALLY DIVERSE POPULATION
KEEPING IN THE U.S. POPULATION
WE SERVE AND PRIMARY HLAING
SPOKEN IS PRETTY MUCH WHAT WE
ENCOUNTER IN THE CLINICAL
SETTING.
AND SIMILARLY, THE URGENCY OF
THE CAESARIAN DELIVERY
PERFORMED IS ALSO QUITE DIVERSE
AND KEEPING WITH WHAT WE SEE
CLINICALLY.
THE TAKE-HOME MESSAGE HERE IS
AROUND 10% OF PATIENTS HAVE
INTRA OPERATIVE PAIN BREAK
THROUGH.
LET'S DO A DEEPER DIVE IN WHAT
IS ASSOCIATED WITH PAIN.
IN OUR ADJUSTED MODEL WE FOUND
THAT ANESTHESIA MODE WAS THE
ONLY THING THAT WHEN ADJUSTED
FOR OTHER CONFOUNDERS WAS
SIGNIFICANTLY ASSOCIATED WITH
INTRA OPERATIVE PAIN.
PATIENTS ARE BEING TREATED IN A
VARIETY WAYS.
THERE ARE NO GUIDELINES HOW TO
BEST MANAGE INTRA-OPERATIVE
PAIN.
BUT 20% OF PATIENTS ARE BEING
TREATED WITH ANXIETITICS.
PAIN AND ANXIETY ARE DIFFERENT
CONSTRUCTS.
THERE'S LOTS OF WORK TO BE DONE
FOR INTRA OPERATIVE PAIN.
AND 16% OF THE PATIENTS THAT
EXPERIENCED PAIN WERE CONVERTED
TO GENERAL ANESTHESIA AND
DOCUMENTATION IN THE ANESTHESIA
RECORD WAS POOR WITH ONLY
AROUND 57% OF PATIENTS HAVING
THE PAIN DOCUMENTED ON THE
ANESTHESIA CHART BUT NOT
ASSOCIATED AS WE ORIGINALLY
HYPOTHESIZED WITH SPOKEN
LANGUAGE, RACE OR ETHNICITY.
FOR THE PATIENTS THAT CONSENTED
TO GIVING US MORE INFORMATION
ABOUT THE INTRA OPERATIVE BREAK
THROUGH PAIN WE HAD A HEAT MAP
OF WHERE THE PAIN WAS
EXPERIENCED AND YOU CAN SEE
HERE THAT ACTUALLY,
INTERESTINGLY THERE'S MORE PAIN
EXPERIENCED ON THE RIGHT SIDE
OF THE ABDOMEN KEEPING WITH THE
LEFT UTERINE DISPLACEMENT.
WE TEND TO PUT A WEDGE ON THE
RIGHT SIDE SO THE PATIENT IS
TILTED TO THE LEFT TO PREVENT
HYPOTENSION AND CABLE RENAL
COMPRESSION.
THAT'S AN INTERESTING FINDING.
AND THE OVERALL INTENSITY OF
PAIN AS PER NUMERICAL RATING
SCORE WAS 6 OUT OF 10 ACROSS
ALL SURGERIES.
BUT FOR URGENT SURGERIES THE
MEDIAN WAS 7 OUT OF 10.
THAT'S A SEVERE PAIN SCORE.
A QUARTER DESCRIBED PAIN
EXPERIENCE AS DISTRESSING BUT
82% WERE SATISFIED WITH THE
ANESTHESIA MANAGEMENT.
THIS IS A WORD CLOUD ANALYSIS
TAKEN FROM THE MCGILL
QUESTIONNAIRE THAT WAS ANSWERED
BY PATIENTS.
YOU CAN SEE THAT MANY OF THESE
ARE QUITE SEVERE-SOUNDING
DESCRIPTORS AND RESULT IN
SIGNIFICANT EVENTS OF PAIN THAT
PATIENTS ARE EXPERIENCING.
SO WHERE DO WE GO FROM HERE?
IT'S A SIGNIFICANT PROBLEM.
IT'S DISTRESSING FOR A
SIGNIFICANT NUMBER OF PATIENTS
AS WELL.
WE REALLY DON'T KNOW WHAT THE
LONG-TERM PSYCHIATRIC ARE FROM
THESE PAIN EXPERIENCES AND WE
DON'T KNOW HOW MANY GO ONTO
EXPERIENCE CHRONIC PAIN.
I WILL TALK A LITTLE BIT ABOUT
CHRONIC PAIN LATER ON IN THIS
TALK.
SO WE REALLY NEED OPTIMUM
TREATMENT STRATEGY AND
REGIMENTS FOR TREATING BREAK
THROUGH PAIN INTRA OPERATIVELY,
WHAT PORTION GO ONTO EXPERIENCE
POIFT TRAUMATIC STRESS DISORDER.
DATA FROM CHILD BIRTH FROM ALL
DELIVERY MODES, VAGINAL
DELIVERY AND C-SECTION AROUND A
THIRD OF PATIENTS DESCRIBE
THEIR EXPERIENCES AS TRAUMATIC.
AND THIS HAS BEEN BRUSHED UNDER
THE CARPET UNTIL RECENTLY AND
I'M GLAD WE ARE GETTING
ATTENTION AND RIGHTLY SO FOR
THIS IMPORTANT FIELD.
PSYCHIATRIC DISEASE IS NOW THE
LEADING CAUSE OF MATERNAL
MORTALITY IN THE UNITED STATES
TO ONE YEAR POSTPARTUM.
ANXIETY AND DEPRESSION ARE
CLOSELY RELATED TO PSYCHIATRIC
MORBIDITY AND MORTALITY.
AND IS INTRA-OPERATIVE PAIN,
DOES IT RESULT IN P.T.S.D.,
ANXIETY, DEPRESSION AND CHRONIC
PAIN?
LOTS OF WORK TO BE DONE IN THIS
FIELD.
NOW UP UNTIL NOW
DISPROPORTIONATE AMOUNT OF
RESEARCHERS FOCUSED ON
INPATIENT SETTING WHERE
MAJORITY OF THE POSTPARTUM
PERIOD HAPPENS IN THE
OUTPATIENT SETTING.
AS I ELUDED TO THE MAJORITY OF
DEATHS ARE HAPPENING AFTER THE
PATIENT LEAVES HOSPITAL.
WE KNOW PATIENT MORTAL ITERATE
IS ON THE RISE AND THAT'S
BUCKING THE TREND COMPARED TO
OTHER DEVELOPED COUNTRIES.
ANYTHING WE CAN DO TO IMPROVE
OUTPATIENT RECOVERY IS LIKELY
TO IMPROVE MORTALITY AS WELL.
LET'S TALK ABOUT MATERNAL PAIN
WHICH IS A KEY PART OF
POSTPARTUM RECOVERY.
I SPENT THE YEAR AT STANFORD
INTERVIEWING DIFFERENT
STAKEHOLDERS INCLUDING PATIENTS
THAT EXPERIENCED DIFFERENT
DELIVERY MODES, OBSTETRICIANS.
FETAL SPECIALISTS, MIDWIFES AND
PATIENT PARTNERS ABOUT WHAT
POSTPARTUM RECOVERY IS.
THIS IS A WORD CLOUD ANALYSIS
OF 24 HOURS OF INTERVIEWS WHICH
WERE ANALYZED AND PAIN FEATURES
IN THE 100 TOP MOST SPOKEN
WORDS REGARDING POSTPARTUM
RECOVERY.
SO FROM THIS WE ACTUALLY WERE
ABLE TO DEVELOP A CONCEPTUAL
FRAMEWORK WHICH WE CAN USE TO
COMPREHENSIVELY DESCRIBE THE
COMPLEX PHENOMENON THAT IS
POSTPARTUM RECOVERY.
PAIN IS JUST ONE IMPORTANT
ASPECT OF THIS COMPLEX JIGSAW
PUZZLE WHICH CONSTITUTES
RECOVERY ALONG WITH OTHER
THINGS LIKE SLEEP AND HOW THE
BABY IS DOING, PSYCHOLOGICAL
OUTCOMES AND THE SUPPORT THE
MOTHER GETS AND ADAPTING TO THE
MATERNAL ROLE AND BREAST
FEEDING.
WE NOW HAVE THIS FRAMEWORK BUT
WE REALLY DON'T KNOW HOW THESE
DIFFERENT DOMAINS ARE
INTERRELATED AND THEN I
EMBARKED UPON TRYING TO
IDENTIFY THE BEST MEASURES FOR
EACH OF THESE DOMAINS.
AND WE DID THIS BY, FIRST OF
ALL, PERFORMING A MASSIVE
SCOPING REVIEW LOOKING AT 8,000
DIFFERENT ARTICLES TO IDENTIFY
WHAT MEASURES HAVE BEEN USED TO
EVALUATE THESE DOMAINS.
AND LOOKING SPECIFICALLY AT
GLOBAL RECOVERY AND PAIN TO
START WITH, WE IDENTIFIED THAT
ACTUALLY THE BEST MEASURE FOR
POSTPARTUM PAIN THAT'S
CURRENTLY AVAILABLE IS THE
SHORT FORM PAIN INVENTORY BUT
IT WAS ORIGINALLY DEVELOPED FOR
CANCER PATIENTS.
SO THIS IS A VERY DIFFERENT
CONSTRUCT TO POSTPARTUM PAIN
WHERE YOU HAVE A SECOND
PATIENT, THE INFANT THE MOTHER
IS TRYING TO LOOK AFTER.
YOU HAVE OTHER SOURCES OF PAIN,
FOR EXAMPLE, FROM BREAST
FEEDING AND FROM BACK PAIN,
PELVIC GIRDLE PAIN WHICH ARE
OFTEN NEGLECTED BY OTHER
EXISTING MEASURES.
WE ACTUALLY URGENTLY NEED A NEW
POSTPARTUM SPECIFIC MEASURE OF
PAIN.
AND IN ADDITION TO THIS, THERE
IS A HUGE AMOUNT OF
HETEROGENEITY.
THIS WILL HELP FACILITATE DATA
POOLING AND IMPROVE RESEARCH
EFFICIENCY IN THIS FIELD.
SO THIS IS THE SERIES OF
SYSTEMATIC REVIEWS THAT WE HAVE
DONE TO TRY TO IDENTIFY WHAT
THE BEST EXISTING MEASURES ARE.
AND ONE OF THE SHOCKING THINGS
IS THAT MOST OF THE
BESTISMISTING MEASURES ARE NOT
POSTPARTUM SPECIFIC BUT THERE
ARE THREE THAT ARE.
WE REALLY NEED TO DEVELOP A
POSTPARTUM SPECIFIC MEASURE FOR
PAIN, PATIENT REPORTED OUTCOME
MEASURE.
WE ARE IN PROCESS OF DEVELOPING
ONE FOR SLEEP AND ANXIETY AND
WE JUST DEVELOPED ONE FOR
GLOBAL POSTPARTUM RECOVERY I'M
VERY EXCITED ABOUT AND I WILL
TELL YOU MORE ABOUT IN THE NEXT
FEW SLIDES.
BUT AS I MENTIONED NOW WE ARE
IN THIS POSITION WHERE WE CAN
START TO TRACK WHAT RECOVERY IS.
AND IN THE SAME WAY THE BABY
HAS THEIR HEIGHT AND WEIGHT AND
HEAD CIRCUMFERENCE PLOTTED WE
CAN START DOING THIS FOR
DIFFERENT DOMAINS OF MATERNAL
RECOVERY.
THIS IS IMPORTANT BECAUSE IF A
MOTHER ISN'T RECOVERING WELL,
THEN YOU CAN NOW MEASURE IT AND
SAY YOU ARE IN THE BOTTOM FIFTH
PERCENTILE.
WE NEED TO REFER YOU TO A PAIN
SPECIALIST OR SLEEP SPECIALIST
OR PSYCHIATRIST DEPENDING WHERE
THE PATIENT IS NOT PERFORMING
WELL IN THEIR RECOVERY.
THIS IS A FOR MA WE CAN DO FOR
ANY OPERATION.
YOU CAN CHOOSE ANY OPERATION
AND IDENTIFY WHAT RECOVERY IS
AFTER A KNEE REPLACEMENT, HIP
REPLACEMENT, IDENTIFY THE BEST
DOMAINS AND MEASURES.
IF ANYONE IS INTERESTED IN DO
THAT, PLEASE DO REACH OUT.
OKAY, LET'S TALK A LITTLE BIT
ABOUT CHRONIC PAIN.
THIS IS DATA WE ARE ABOUT TO
PUBLISH FROM 27 DIFFERENT
PUBLISHED STUDIES.
OVER 9,000 PATIENTS.
WE WANTED TO IDENTIFY WHAT THE
PREVALENCE IS OF CHRONIC PAIN
DEFINED AS PAIN IN THE ABDOMEN
FROM BETWEEN THREE MONTHS TO
SIX MONTHS.
THE PREVALENCE WE FOUND WAS 15%.
WHAT WAS INTERESTING IS MOST OF
THE STUDIES FOCUSED ON
ABDOMINAL PAIN, BUT AS I
MENTIONED EARLIER, BACK PAIN,
PELVIC PAIN, HEADACHE ARE NOT
UNCOMMON FOLLOWING DELIVERY AND
REALLY UNDER STUDIED IN THE
OUTPATIENT POPULATION.
WE HAVE A HUGE AMOUNT OF WORK
TO DO UNDERSTANDING WHAT
CHRONIC PAIN IS IN THE
POSTPARTUM PERIOD.
UP UNTIL NOW THIS IS JUST AN
EXAMPLE HOW THERE ARE HUGE
DISPARITIES IN HEALTHCARE AND
IN RESEARCH AS WELL.
AND I THINK MATERNAL POSTPARTUM
RECOVERY IS AN UNDER FUNDED AND
UNDER STUDIED AREA.
THIS IS DATA FROM 107 CENTERS
IN THE UNITED KINGDOM WE
PUBLISHED LOOKING AT ETHNIC
DIFFERENCES IN PAIN OUTCOMES.
WE FOUND IN U.K., ASIAN
ETHNICITY WAS AN INDEPENDENT
RISK FACTOR FOR MODERATE TO
SEVERE PAGE DAY 30 FOLLOWING
CAESARIAN DELIVERY.
WE NEED TO REPLICATE STUDIES
LIKE THIS IN THE UNITED STATES
WITH DIFFERENT RACIAL AND
ETHNIC PROFILES AND DEMOGRAPHIC
GROUPS TO LOOK AT.
AND WE REALLY DON'T KNOW WHAT'S
HAPPEN IN THE OUTPATIENT
POSTPARTUM PERIOD IN TERMS OF
RISK FACTORS FOR CHRONIC PAIN.
NOW I ELUDED TO HOW WE CAN GO
ABOUT MEASURING GLOBAL RECOVERY.
I'M VERY EXCITED TO SHARE WITH
YOU A MEASURE I SPENT THE LAST
FIVE YEARS DEVELOPING AND
VALIDATING.
THIS IS CALLED THE STANFORD
OBSTETRIC RECOVERY CHECKLIST OR
THE ACRONYM IS STORC.
FOLLOWING THE SYSTEMATIC REVIEW
WE CONVENED A GROUP OF EXPERTS
MULTI-DISCIPLINARY STAKEHOLDERS
INCLUDING PATIENTS AND WE
DEVELOPED A COMPREHENSIVE
MEASURE USING VALIDATED
QUESTIONS FROM EXISTING
PATIENT-REPORTED OUTCOME
MEASURES AND WE FINALLY
WHITTLED THE 481 QUESTIONS TO
47 QUESTIONS IN THE STORK
MEASURE WHICH COVERS DIFFERENT
AS SUSPECTDS OF POSTPARTUM
RECOVERY.
AND THEN WE VALIDATED THIS IN A
LONGITUDINAL STUDY IN THREE
ACADEMIC, UNTIL WE HAD 100
COMPLETED SIX-WEEK RESPONSES
FROM EACH INSTITUTION.
PATIENTS WERE ASKED TO COMPLETE
THIS MEASURE AT FOUR DIFFERENT
TIME POINTS UP TO THREE MONTHS
POSTPARTUM.
AND WE RECRUITED
ENGLISH-SPEAKING PATIENTS IN
THE FIRST INSTANCE WHO
DELIVERED A LIVE FETUS.
PRIMARY OUTCOME POINT FOR
EVALUATING THIS MEASURE WAS AT
SIX WEEKS BECAUSE THIS IS WHEN
THE OBSTETRIC FOLLOW-UP VISIT
HAPPENS AND SIX WEEKS IS WHEN
INSURANCE TENDS TO CUT OUT IN
THE POSTPARTUM PERIOD.
WE EVALUATED OUR NEW MEASURE
ACCORDING TO CRITERIA LOOKING
AT LOTS OF DIFFERENT PSYCHO
METRIC MEASURES, VALIDITY, DOES
IT MEASURE WHAT IT IS SUPPOSED
TO MEASURE, RELIABILITY, IS IT
REPRODUCIBLE AND DOES IT CHANGE
OVER TIME.
I WON'T GO INTO A LOT OF DETAIL
ABOUT THIS BUT THIS IS THE MOST
VALID MEASURE OF POSTPARTUM
RECOVERY WE HAVE.
WE FOUND INTERESTINGLY AND
FIRST-TIME MOTHERS HAD WORSE
RECOVERY SCORES AT SIX WEEKS
COMPARED TO PATIENTS THAT HAD
BABIES THAT NEEDED A NIC-U STAY
HAD WORSE RECOVERY AT SIX WEEKS
AND PATIENTS WITH A PROLONGED
HOSPITAL STAY HAD WORSE SCORES
AT SIX WEEKS AS WELL.
THIS WAS A RELIABLE MEASURE AND
ABLE TO DETECT CHANGE UP TO
THREE MONTHS POSTPARTUM.
IT ONLY TAKES FIVE MINUTES TO
COMPLETE SO I THINK IT COULD BE
USED IN THE CLINICAL SETTING.
WE ARE ABLE TO TRACK RECOVERY
ACCORDING TO DIFFERENT DOMAINS.
YOU COULD SEE HOW A MOTHER
WOULD BE INTERESTED HOW AM I
DOING IN WEEK 2, HOW DO I
COMPARE TO MY PEERS.
I THINK THIS COULD BE USED TO
DEVELOP EARLY TARGETED
INTERVENTIONS NOT JUST FOR PAIN
BUT PHYSICAL THERAPY, SLEEP,
FATIGUE, BREAST FEEDING AND
PSYCHIATRIC INTERVENTIONS.
SO I'M VERY EXCITED ABOUT THIS
TOOL.
I COULD TALK ABOUT THIS AREA
ALL DAY BUT I'M AWARE I'M AT MY
20 MINUTES.
SO HAPPY TO TAKE ANY QUESTIONS
ABOUT THIS AREA.
THANK YOU SO MUCH.
>> WE WILL SEND THEM VIA EMAIL
THOSE WATCH US.
WE WILL HAVE ALL THE QUESTIONS
AFTER OUR THREE TALKS.
OUR NEXT SPEAKER IS DR. SZPERKA.
THINK ABOUT WHAT YOU DO.
PUT YOURSELF IN THAT MOMENT.
HAVE YOU HAD A HEADACHE TODAY.
MAYBE IT WAS BECAUSE YOU WERE
TRAVELING.
MAYBE YOU MISSED YOUR MORNING
CUP OF COFFEE.
IF YOU PUT YOURSELF, I WILL GO
BACKWARDS.
IF YOU PUT YOURSELF IN THAT
MOMENT, THINK ABOUT WHAT YOU
MIGHT DO, RIGHT.
MAYBE YOU WILL REACH FOR A
DRINK OF WATER.
MAYBE YOU WILL GO EAT
SOMETHING, MAYBE TAKE A MINUTE
AND DO A RELAXATION EXERCISE,
MAYBE MEDICATION.
WHICH OF THOSE THINGS
ESSENTIALLY ARE YOU DOING FOR
YOURSELF IN THAT MOMENT TO HELP
YOURSELF FEEL BETTER?
NOW, IF YOU THINK ABOUT MY
PATIENTS, SO NOW YOU HAVE A
13-YEAR-OLD WHO IS DOING THIS.
THEY ARE PRIMARILY IN SCHOOL,
RIGHT?
OR IF AT HOME THEY ASK THEIR
PARENT FOR HELP.
THE A VERY DIFFERENT EXPERIENCE
TO HAVE HEADACHE OR OTHER PAIN
AS A CHILD COMPARED TO AN ADULT.
YOU HAVE INHERENT BARRIERS TO
TAKE CARE OF YOURSELF AND TREAT
YOURSELF.
CERTAINLY BARRIERS TO DIAGNOSIS
AS WELL.
BUT THERE ARE THINGS THAT STAND
IN YOUR WAY THAT MAKE IT MORE
DIFFICULT FOR YOU TO TAKE CARE
OF YOURSELF AND DO THE THINGS
YOU NEED TO DO.
PEDIATRICS ESSENTIALLY CHILDREN
ARE VULNERABLE ACROSS, YOU
KNOW, ALL CHILDREN TO MANAGE
THEIR HEALTH CONDITIONS AND
OBVIOUSLY PAIN MAGNIFIES ALL
THESE PROBLEMS.
THAT'S FINE.
I WILL BRIEFLY TOUCH ON
DISCLOSURES.
SOME OF THE WORK PRESENTED IS
RELATED TO MIK AND SOME DONE BY
STUDENT I CO-MENTORED WITH MY
PRIMARY MENTOR.
TODAY WE WILL TALK ABOUT
ASPECTS OF HEADACHE UNIQUE TO
CHILDREN AND TEENS AND PLACEBO
IN TREATMENT AND HAID ACHE.
-- HEADACHE.
NEXT SLIDE, PLEASE.
IF WE THINK OF THE ENVIRONMENT,
TO THINK OF EXPERIENCE OF OUR
CHILDREN.
CHILDREN LIVE WITHIN SEVERAL
DIFFERENT LEVELS THEIR WORLD.
IN THE FAMILY STRUCTURE, WE
OFTEN HEAR FROM PARENTS THEY
WILL COME IN AND SAY DO KIDS
REALLY HAVE HEADACHE OR WORRY
ABOUT A TUMOR.
OR I HAVE HAD HEADACHES SINCE I
WAS A CHILD TOO.
AT SCHOOL CHILDREN FACE
SIGNIFICANT STIGMA.
THEY WILL ASK WHY ARE THEY
ABSENT OR LEAVING CLASS.
I'M HERE, I HAVE A HEADACHE, IS
IT REALLY THAT BAD?
THEY ARE DOUBTED.
WITHIN THE HEALTHCARE SYSTEM
THERE ARE A LOT OF WELL-MEANING
CLINICIANS WHO WILL SAY, I
DON'T KNOW HOW TO ASK THEM OR
WHAT TO DO, I DON'T WANT TO
HURT THEM OR CAUSE HARM, THEY
ARE AFRAID TO ACT AND FAIL TO
ACT BECAUSE THEY ARE AFRAID OF
CAUSING HARM.
THIS IS A 3-YEAR-OLD GIRL, NO
SIGNIFICANT PAST MEDICAL
HISTORY.
PARENTS REPORT.
HISTORY OF COLIC AS AN INFANT,
SEVERE VOMITING THAT SEEMED TO
COME OUT OF THE BLUE AND LAST
MANY HOURS.
SHOW OF HANDS WHO THINK THIS IS
MIGRAINE?
KEEP GOING.
BY THE TIME THEY ARE TEENAGERS,
THREE OUT OF FOUR WILL REPORT
THEY HAD A SIGNIFICANT HEADACHE
AT SOME POINT.
MIGRAINE IS THE MOST COMMON
DISABLING PRIMARY HEADACHE
DISORDER.
SECONDARY HEADACHE OR FROM
INFECTION OR TUMOR.
BUT PRIMARY HEADACHE DISORDER
THE HEADACHE IS THE PROBLEM
ITSELF, MIGRAINE IS THE MOST
COMMON DISABLING ONE.
IF YOU LOOK AT THE SLOPE, THE
LOWER RATES IN YOUNGER CHILDREN
AND ESSENTIALLY GOES UP
SUBSTANTIALLY AROUND THE TIME
OF ADOLESCENT AND SPLIT BETWEEN
GIRLS AND BOYS.
AND ABOUT TWO OUT OF 100 KIDS
WALKING AROUND HIGH SCHOOL HAVE
HAD HEADACHES MORE OFTEN THAN
NOT SO THE A VERY COMMON AND
DISABLING PROBLEMS.
ONE OF THE CONCERNS WE HEAR ON
THE CLINICAL SIDE, DOES MY
CHILD HAVE A TUMOR, PARENTS ARE
CONCERNED ABOUT SECONDARY
HEADACHE.
FROM PRIMARY CARE CLINICIANS.
THERE WE GO.
FROM PRIMARY CARE CLINICIANS,
AGAIN THEY ARE WORRIED ABOUT
TUMORS.
SO THIS IS SORT OF JUST A BRIEF
REVIEW.
IT'S A MNEMONIC DEVELOPED TO
THINK ABOUT SIGNS AND SYMPTOMS
THAT COULD BE SUBJECTIVE OF
SECONDARY HEADACHE.
THE QUESTION CAME UP EARLIER IN
TERMS OF FIGURING OUT WHETHER
WE COULD LOOK AT ALL THE
SYMPTOMS WE REPORT IN HEADACHE
IN PRIMARY CARE.
WE ARE DOING WORK TO THINK
ABOUT DIAGNOSIS AND TREATMENT.
MIGRAINE MAY LOOK DIFFERENT IN
CHILDREN.
WE SAY THIS COULD BE MIGRAINE.
HOW DO YOU DIAGNOSE MIGRAINE IN
CHILDREN VERSUS ADULT.
THE DIAGNOSTIC CRITERIA ACCOUNT
FOR THIS, INTERNATIONAL
CLASSIFICATION OF HEAD
DISORDERS.
CURRENT ATTACKS.
IN KIDS LAST AT LEAST TWO
HOURS, FOUR FOR ADULTS.
SPECIFIC CHARACTERISTICS.
ONE-SIDED PAIN.
PULSATING QUALITY,
MODERATE-SEVERE, AGGRAVATED BY
MOVEMENT.
IN CHILDREN OFTEN BILATERAL
WHICH IS ALLOWED.
NAUSEA, OR VOMITING, PHOTO OR
PHONOPHOBIA.
KIDS CAN BE OBSERVED.
IF WE THINK ABOUT THIS
SPECIFICALLY, WE LOOKED AT OUR
DATABASE.
WE'VE GOT ABOUT AT THIS POINT
14,000 CHILDREN HAVE COMPLETED
OUR NEW PATIENT QUESTIONNAIRE
ACROSS NEUROLOGY.
SUBSET OF 11,000 BETWEEN 5-17
AT THE TIME OF THE VISIT.
SO IF YOU LOOK, WE CAN LOOK
ESSENTIALLY AT THE PREVALENCE
OF REPORTING THESE SYMPTOMS AT
THE TIME OF THEIR NEW VISIT.
IF YOU LOOK FIRST AT THE
PURPLE, VOMITING, SOMETHING WE
TYPICALLY THINK OF ASSOCIATED
WITH MIGRAINE IN YOUNGER
CHILDREN AND ESSENTIALLY
YOUNGER CHILDREN REPORT
VOMITING WHEN THEY COME IN
YOUNGER AGES.
THAT DECREASES STEADILY OVER
TIME.
IN CONTRAST NAUSEA THE RED IS
MORE COMMON AND GOES UP VERY
SLIGHTLY OVER TIME.
PHOTO AND PHONOPHOBIA ON OTHER
HAND INCREASE MORSTEADLY
ESSENTIALLY HIGHER RATE OF
ADOLESCENCE.
IF YOU LOOK AT THEM
SPECIFICALLY INDIVIDUALLY AND
MALE VERSUS FEMALE.
IN THIS GRAPH THE MALE IS BLUE
AND FEMALE IS GREEN.
THE VOMITING IS SIMILAR ACROSS
MALES AND FEMALES BUT PERHAPS A
LITTLE MORE COMMON IN THE MALES
AT LEAST A OVERLAP OF THE
INTERVALS.
NAUSEA IS INCREASING.
AND YOU SEE A BIT OF A SPLIT
AROUND THE TIME OF PUBERTY,
MALES PLATEAU OUT AND FEMALES
INCREASE.
PHOTO PHOBIA AND PHONOPHOBIA.
SPLIT AND PLATEAU IN THE MALES,
GIRLS CONTINUE TO RISE
ESSENTIALLY THROUGH THE TIMES
OF ADOLESCENCE.
THIS IS AN EARLIER VERSION OF
DR. PATTERSON'S WORK, LOOKING
AT DIFFERENT CLUSTER-ASSOCIATED
ANALYSIS OF MIGRAINE SYMPTOMS
AND SHE SHOWED YOU THESE SLIDES
EARLIER SO I WON'T TAKE MUCH
TIME BUT SHOWS THE DIFFERENCE
BETWEEN AGE AND BOYS VERSUS
GIRLS.
WHAT ABOUT OTHER SYMPTOMS?
MIGRAINE ISN'T JUST THE
ASSOCIATED SYMPTOMS AT THE
MOMENT OF ATTACK.
OR NEUROLOGICAL SYMPTOMS,
VISUAL, SENSORY, NUMBNESS
TINGLING.
IN ABOUT A QUARTER CHILDREN.
INCREASES IN AGE.
IT'S COMMONLY BILATERAL IN
CHILDREN.
CHILDREN MAY REPORT VISUAL
DISTURBANCES THAT SOUNDS LIKE
AN AURA AN ADULT MIGHT REPORT
BUT ACROSS THE ENTIRE FIELD
INSTEAD OF A QUARTER.
MORE COMMON IN TEENS COMPARED
TO YOUNGER CHILDREN.
CRANIAL SYMPTOMS, EYE TEARING,
FLUSHING, PTOSIS ON ONE SIDE OF
THE FACE, WE THINK OF
ASSOCIATED WITH OTHER HEADACHE
DISORDERS BUT MIGRAINE IS
TYPICALLY BILATERAL AND THESE
ARE COMMON IN CHILDREN.
DIFFICULTY THINK, LIGHT
HEADEDNESS, FATIGUE, MORE
COMMON IN OLDER CHILDREN AND
PERSISTS HOURS BEYOND THE PAIN.
ABOUT 80% OF YOUTH REPORT
DEVELOPMENT OF NEW SYMPTOMS
AFTER THE PAIN HAS REVOLVED.
POINTS TO THE FACT THE MIGRAINE
ATTACK ISN'T JUST PAIN.
WHAT ABOUT OTHER SYMPTOMS SORT
OF FLOATED ABOUT THIS QUESTION
THROUGH SOME OF THE
CONVERSATIONS IN Q&A TODAY.
THESE EPISODIC SYMPTOMS
ASSOCIATED WITH MIGRAINE
PREDOMINANTLY G.I. OR OTHER
SYMPTOMSMENT INFANTILE COLIC
ASSOCIATED WITH MIGRAINE.
VERTIGO.
THESE ESSENTIALLY CHANGE ACROSS
AGE SPECTRUM.
WE THINK OF THESE AS PROBABLY
PRECURSORS AND OFTEN TIMES WE
WILL HAVE THE CHILDREN COME TO
THE CLINIC, SAY THEY ARE 13
YEARS OLD AND REPORTING
HEADACHE BUT YOU LOOK BACK AND
THEY HAVE HAD SOME OF THESE
SYMPTOMS.
IT'S IMPORTANT TO THINK OF THE
WHOLE CHILD.
MIGRAINE CAUSES SIGNIFICANT
DISABILITY, RIGHT?
HEADACHE DISORDERS INCLUDING
MIGRAINE, TENSION-TYPE HEADACHE
THE MOST COMMON NEUROLOGIC
DISABILITY WORLDWIDE.
AND YOUTH WITH HEADACHE HAVE
ALMOST THREE TIMES THE ODDS OF
ABSENCE FROM SCHOOL, HAS
ACADEMIC IMPLICATIONS AND
EMPLOYMENT.
QUALITY OF LIFE IS SIMILAR TO
CHILDREN WITH CANCER AND NUMBER
OF SIMILAR CO MORBIDITIES.
I DIDN'T PUT IT ON THE SLIDE
HERE.
THINKING ABOUT OUR
CONVERSATIONS THIS MORN, WE
TALKED ABOUT ADVERSE CHILDHOOD
EXPERIENCES.
THERE HAVE BEEN A COUPLE OF
DIFFERENT STUDIES LOOKING AT
AVERAGE CHILDHOOD EXPERIENCES
IN CLINICS AND OUR CLINIC, DR.
SANTOS HAS DONE THAT AND SHOWN
ESSENTIALLY FAIRLY SUBSTANTIAL
RATES CHILDREN REPORTING AT
LEAST THREE ACES ON THAT
STANDARDIZED ACE SCREENING.
AND WE ALSO DID A STUDY LOOKING
AT NORTH CAROLINA THERE WERE
ESSENTIALLY DATA COLLECTED, THE
ADD HEALTH STUDY,
POPULATION-BASED STUDY.
SHOWED WITH INCREASED REPORT OF
ACES INCREASED REPORTING OF
HEADACHES.
WE HAVE SEEN THIS IN ADULTS AND
EVEN NOW WITH CHILDREN.
SO WE GET BACK TO OUR CASE.
IT'S SPRING OF FIRST GRADE.
SHE HAS HAD SEVERAL HEADACHES
PER MONTH, EACH LAST A FEW
DAYS, NOW SHE IS IRRITABLE AND
TROUBLE FOCUSING.
SHE HAS GONE TO THE NURSE AFTER
NO BENEFIT FROM IBUPROFEN.
THEY DON'T JUMP RIGHT INTO
TREATMENT TO TALK ABOUT
DIAGNOSIS.
I CAN TALK ABOUT WHY THAT IS
IMPORTANT.
BUT THE SECOND THING THEY TALK
ABOUT HERE IS TREAT EARLY IN
THE ATTACK.
GIVE AN NSAID TO ALL CHILDREN
AND TRIPTAN TO ADOLESCENCE.
I REMEMBER READING THIS AND
SCRATCHING MY HEAD THINKING
THAT DOESN'T MAKE SENSE.
IF YOU LOOK AT THE LIST OF
TRIPTAN, FDA APPROVED TO THE
AGE OF 6.
OUR TRIALS HAVE BEEN FRAUGHT
WITH COMPLICATIONS IN MIGRAINE
BUT FDA CLEARANCE THEY HAD TO
HIT A PRETTY SUBSTANTIAL BAR TO
GET TO THAT.
WHY ONLY INCLUDING TRIPTANS FOR
ADOLESCENCE?
ONE OF THE MAJOR ISSUES HAS
BEEN THE HIGH PLACEBO GROUP
RESPONSE RATE -- THANK YOU.
IN TRIALS FOR CHILDREN WITH
MIGRAINE.
SO WHEN YOU PUT THINGS TOGETHER
ESSENTIALLY LOOKING ACROSS
MULTIPLE TRIALS, THE ESTIMATE
IN ADULT MIGRAINE TRIALS, THE
RESPONSE RATE IS 35%.
PEDIATRICS IT'S CLOSE TO 50%.
THERE ARE A NUMBER OF REASONS
WHY THIS MAY BE.
AS WE TALKED EARLIER THE
ATTACKS FOR MIGRAINE THIS
CHILDREN ARE SHORTER.
SO THERE'S A HIGHER CHANCE
PERHAPS THE CHILD WILL COME OUT
OF THE MIGRAINE, WHETHER IN THE
PLACEBO GROUP OR GETTING THE
ACTIVE MEDICATION.
SEASONAL VARIATION, KIDS WHO
ARE TERRIBLE IN THE FALL WHEN
SCHOOL IS STARTING AND
ADJUSTING BACK AND DO BETTER IN
WINTER.
ALSO ASPECT OF HIGHER
EXPECTANCY, IF I'M ENROLLING
FOR CLINICAL TRIALS FOR
MEDICATIONS YOU HAVE SEEN ON
TELEVISION FIVE YEARS.
I EXPLAIN MEDICATIONS THEY HAVE
SEEN SOME FAMOUS STAR TALK
ABOUT ON TELEVISION OR WRITTEN
IN A MAGAZINE.
THEY EXPECT THE MEDICATIONS ARE
GOING TO WORK BECAUSE THEY HAVE
SEEN THEM ADVERTISED AND HEARD
ABOUT THEM.
I THINK THAT INCREASES THE
PLACEBO RESPONSE.
CHILDREN ENTERING THE STUDIES
ARE RELATIVELY TREATMENT NAIVE,
THEY DON'T HAVE THE SORT OF
NEGATIVE RESPONSE RATE.
SO THIS THING DIDN'T WORK
BEFORE SO I DON'T THINK THIS
NEXT THING WILL WORK.
PROBABLY I'M GOING TO RESPOND,
RIGHT?
AND ALSO THERE IS SOME ASPECT
MAYBE SOME ELEMENT THEY ARE
REASSURED, RIGHT?
THEY ARE TYPICALLY USED TO SOME
OTHER AUTHORITY SAYING WE
EXPECT TO HAPPEN AND THEREFORE
IT HAPPENS.
THEY ARE REASSURED.
HERE IS YOUR DIAGNOSIS, WE
THINK YOU ARE LIKELY TO GET
BETTER, WHETHER SUBCONSCIOUS
THAT THEY WANT TO,LIKELY GET
BETTER, WANT TO PLEASE THEIR
PARENTS AND RESEARCHER.
THERE ARE A LOT OF REASONS.
I HAVEN'T TOUCHED ON ALL BUT
SEVERAL REASONS WHY WE HAVE
THIS HIGH PLACEBO RESPONSE.
THE PART OF THE REASON THE RISE
OF TRIPTAN WAS FDA APPROVED,
CROSS-OVER DESIGNS THAT LED TO
ESSENTIALLY A HIGHER SPLIT
BETWEEN THE ACTIVE AND PLACEBO
GROUPS WHICH IS LARGELY HOW WE
LED TO FDA APPROVAL.
PREVENTIVE STUDIES HAVE SHOWN
POSITIVE RESPONSES ACROSS
GROUPS WHICH IS GREAT WHEN ARE
YOU IN CLINICAL CARE BUT VERY
DIFFICULT IN CLINICAL TRIALS.
IN CLINICAL CARE, LACK OF
EFFICACY IN CLINICAL TRIALS
DOESN'T MEAN MEDICATIONS ARE
INEFFECTIVE.
WE BASE DOSING IN LIQUID FORMS
AND THINGS LIKE THAT.
BUT TREATMENTS WILL ONLY WORK
IF THEY ARE USED.
SO GETTING BACK TO OUR CASE, WE
GAVE HER RISE OF TRIPTAN AND
NAPROXEN, SHE DOES WELL.
WE GIVE HER A LETTER FOR SCHOOL.
HEADACHE ACTION PLAN, MEANT TO
LOOK LIKE THE ASTHMA ZONE TO BE
RECOGNIZED BY SCHOOL NURSES.
GREEN ZONE, YELLOW ZONE AND RED
ZONE.
THIS CONTINUES TO WORK FOR SOME
TIME, BUT AROUND TIME OF
MENSES, HEADACHES INCREASE,
LONGER DURATION.
IN HIGH SCHOOL, MISSED FOUR
DAYS.
MIGRAINE PERSISTED FOR AT LEAST
72 HOURS.
BUT OFTEN TIMES CLINICALLY IF
SOMETHING PERSISTS MORE THAN A
DAY WE TREAT IT WITH THE SAME
APPROACH.
IF IT'S NOT RESPONDED TO USUAL
MEDS.
THERE'S VERY LITTLE EVIDENCE
FOR COMMONLY USED ORAL
TREATMENTS.
WHEN COVID SHUT DOWN HAD WE
WERE NO LONGER ABLE TO BRING
CHILDREN TO THE HOSPITAL IF WE
NEEDED TO, NOT JUST CHILDREN,
ADULTS TOO.
WE PUT TOGETHER A PAPER WHERE
WE GAVE INSTRUCTIONS OF
SUGGESTIONS THESE ARE SOME
THINGS YOU CAN TRY.
INTERESTINGLY ONE OF MY MOST
HIGHLY CITED PAPERS BUT ALL
OPINION.
HERE ARE SOME THINGS YOU CAN
TRY BASED ON MY CLINICAL
EXPERIENCE, NOT EVIDENCE.
I THINK THAT WAS REALLY
TELLING, THERE ARE SO LITTLE
STUDIES IN STATUS MIGRAINEOSUS.
THERE HAVE BEEN STUHTIES OF
MEDICATION, PATHWAYS YOU CAN
WRITE.
BUT NERVE BLOCKS ARE SOMETHING
WE HAVE COMMONLY DONE,
LOCALIZED ANESTHETIC, THE
OCCIPITAL NERVE, TRIGEMINAL.
WHEN IT WORKS IT'S
SUBSTANTIALLY HELPFUL.
THIS IS MY K.
LIDOCAINE CREAM, WE ALLOW FOR
PATIENTS TO SIT FOR 30 MINUTES
TO SEE IF THEY HAD IMPROVED.
IN SOME WAYS THIS IS MEANT TO
MIMIC A PLACEBO LEAD-IN.
CAN WE HELP TO DIFFERENTIATE
THE TWO GROUPS BY USING THIS AS
INITIAL TREATMENT.
IF THEY DID BETTER WITH THE
CREAM ALONE GREAT, THEY DIDN'T
NEED INJECTION.
OUR PRIMARY OUTCOME WAS LOOK AT
THE CHANGE IN PAIN SCORE AT 30
MINUTES.
IF THEY DIDN'T HAVE SUFFICIENT
IMPROVEMENT BASED ON THE
CHILD'S DEFINITION THEY COULD
PROCEED TO ADDITION OPEN LABEL
INJECTION.
I WOULD GET LIDOCAINE OUT OF
THE CLOSET AND DO ADDITIONAL
SHOTS IF THEY WANTED IT.
WE PRESCREENED 438, WE
APPROACHED 148 BECAUSE THEY
SEEMED TO BE ELIGIBLE.
58 MET FULL CRITERIA FOR
ELIGIBILITY.
MOSTLY ESSENTIALLY OLDER
ADOLESCENTS AS YOU MIGHT EXPECT
FROM AN INJECTION TRIAL.
44 FEMALE, 11 MALE, 2 NOONE
BINARY AND ONE TRANSMASCULINE.
MOSTLY WHITE.
THE MIGRAINE FREQUENCY BEFORE
STATUS MIGRAINOSUS.
THEY HAVE HEADACHE AT LEAST
THREE MONTHS, EPISODIC, LOWER
FREQUENCY.
AND FLARE FOR MEDIAN OF 28 DAYS.
THESE WEREN'T TREATMENT ACROSS
THE GROUPS.
THE TOPICAL LIDOCAINE LEAD-IN
MUCH TO MY SURPRISE, MEAN
DECREASE IN PAIN WAS 0.2.
VERY LITTLE CHANGE FROM THE
CREAM.
AND ALL PARTICIPANTS PROCEEDED
TO INJECTION.
30 MINUTES SO WE LOOKED ATOLIDE
CANE HAD A DROP OF ABOUT 2.3
POINTS IN THE 0-10 SCALE,
SALINE WAS 0.1.
SO THIS WAS SIGNIFICANT.
WE LOOKED AT DIFFERENT
OUTCOMES, DIFFERENT WAYS OF
SLICING THE DATA.
FOR ALL THE LIDOCAINE WAS
SUPERIOR TO SALINE EXCEPT PAIN
FREEDOM.
VERY FEW CHILDREN WERE
COMPLETELY PAIN FREE AT THE END
OF THE 30 MINUTES.
I ACTUALLY TRAINED AT A CENTER
I WAS TAUGHT TO DO
CIRCUMFERENTIAL INJECTIONS.
YOU HAVE TO START SOMEWHERE
WITH THE TRIAL AND THIS WAS A
REASONABLE PLACE TO START.
SOMETHING THAT I KIND OF
STARTED TO PICK UP ON WHILE WE
WERE DOING THIS STUDY, THE
SALINE INJECTIONS HURT MORE
THAN LIDOCAINE.
AFTER PARTICIPANTS I STARTED
LEAVING THE ROOM IMMEDIATELY
AFTER DOING IS THE SHOTS IT
SEEMED TO ME THEIR REPORT OF
PAIN WAS THEN, SEEMED HIGHER IN
THOSE CHILDREN WHO WHERE I
LATER ESSENTIALLY SAID I THINK
THEY GOT SALINE SO THEY DIDN'T
GET NUMBNESS, SO I WAS AFRAID I
WAS BLINDING MYSELF SO I LEFT
THE ROOM.
IT WOULD BE A REASONABLE OPTION
FOR A PLACEBO.
BUT THEN, SEEING IT WAS
ACTUALLY CAUSING DISCOMFORT WAS
DISHEARTENING.
WE LOOKED AT 24-HOUR OUTCOMES.
AGAIN THE PAIN RELIEF AND
RELIEF FROM ASSOCIATED
SYMPTOMS, NAUSEA AND THAT SORT
OF THING WERE BOTH BETTER IN
THE LIDOCAINE GROUP.
WE HAVE SOME ADVERSE EFFECTS.
ONE THING TYPICALLY DONE IN
TRIALS YOU SAY DID ANYTHING
BOTHER YOU.
WE ASKED THEM, 57 OUT OF 58 SID
SOMETHING WAS NOT GREAT.
ALSO RELATED TO ANXIETY.
IT CLINICAL CARE I GET CONSENT
AND GO THROUGH THE PROCEDURE.
IN THIS CASE WE DID THAT, I PUT
CREAM ON THEIR HEAD AND ASKED
THEM TO FILL OUT QUESTIONNAIRES
BEFORE THE SHOTS SO THEY WERE
REALLY ANXIOUS.
NO DIFFERENCES BETWEEN THE
GROUPS.
ONE CHILD DEVELOPED CONFUSION
HOURS LATER, WE THINK DEVELOPED
MORE TO THE ORAL MEDICATIONS
AND ONE CHILD IN THE SALINE
GROUP DEVELOPED ANAPHYLAXIS
AFTER GIVEN THE LIDOCAINE
INJECTIONS, VERY UNCOMMON.
THE TIMING OF THE OUTCOME, IS
30 MINUTES TOO EARLY TO LOOK.
WE HAD THEM COLLECT DIARY DATA
FOR 28 DAYS.
DID YOU EXPECT TO GET BETTER?
DID YOUR PARENTS EXPECT YOU TO
GET BETTER AND DID THAT AFFECT
THE OUTCOME.
WE WENT INTO THIS PARTIALLY
TRYING TO UNDERSTAND HOW COULD
WE THINK ABOUT OF THE PLACEBO
GROUP AND DESIGN A STUDY.
MY LESSONS HAVE BEEN I DON'T
THINK THE LIDOCAINE CREAM HELPS
PARTICULARLY, THOUGH IT STILL
REMAINS TO BE SEEN IN TERMS OF
BLINDING AND ADDRESSED ISSUES
OF BLINDING.
BUT I DON'T THINK I WOULD USE
SALINE AS A PLACEBO.
WHAT ABOUT THE CONTEXT OF THE
CARE?
WHAT IF THIS CHILD DIDN'T GET
TO MY OFFICE?
WHAT IF THEY WENT TO THE
EMERGENCY DEPARTMENT.
CHILDREN OF COLOR
DISPROPORTIONATELY TREATED FOR
HEADACHE IN THE EMERGENCY
DEPARTMENT, RATHER THAN GOING
TO PRIMARY CARE FOR ANY NUMBER
OF REASONS.
THEY ARE TREATED FOR A NUMBER
OF DIFFERENT CONDITIONS.
THE EMERGENCY DEPARTMENT IS
GEARED TO ACUTE AND NOT FOR
GETTING TO ROOT CAUSES.
WE DID A NUMBER OF STUDIES TO
LOOK AT THE TREATMENT, THE
DIAGNOSIS OF MIGRAINE IN
EMERGENCY DEPARTMENT, THE
TREATMENT OF MIGRAINE PAIN IN
THE EMERGENCY DEPARTMENT.
WE KNOW NON HISPANIC WHITE
RECEIVE HIGHER RATE OF MIGRAINE
DIAGNOSIS, MORE IV MEDICATION,
AND MORE HEAD/BRAIN IMAGING.
BLACK CHILDREN AND MALES LESS
LIKELY TO HAVE NEUROLOGY VISIT
AFTER THE EMERGENCY DEPARTMENT.
SO WE ARE THINKING BROADLY
ABOUT HOW DO WE MANAGE KIDS IN
PRIMARY CARE AND GET THEM THE
APPROPRIATE DIAGNOSIS AND
APPROPRIATE FIRST LINE
TREATMENTS.
WHO NEEDS TO GET TO NEUROLOGY.
WHO NEEDS EMERGENCY DEPARTMENT
TREATMENT?
IF THEY ARE ENTERING THE SYSTEM
IN THE EMERGENCY DEPARTMENT HOW
DO THEY GET TO THE CLINICIAN.
HOW DO WE GET THESE KIDS TO THE
RIGHT DIFFERENT PLACES.
AND WHY DOES IT MATTER, WHY ARE
MALES LESS LIKELY TO GET
DIAGNOSIS OF MIGRAINE IN THE
E.D.
WHY ARE THEY LESS LIKELY TO GET
THAT FOLLOW-UP.
THROUGH THE SLIDES, THANK YOU
TO THE A.V. FOLKS.
THOUGHT ABOUT DIFFERENT ASPECTS
OF HEADACHE IN CHILDREN AND
TEENS AND PLACEBO.
THIS IS MY EMAIL.
HUGE THANKS TO MY TEAM.
>> THANK YOU.
THANK YOU SO MUCH FOR VERY
INTERESTING DATA.
NOW I AM PLEASED TO INTRODUCE
OUR THIRD SPEAKER FOR THE PANEL.
DR. ROGER FILLINGIM.
UNIVERSITY OF FLORIDA.
INVESTIGATE BIOLOGICAL AND
PSYCHOSOCIAL CONTRIBUTIONS TO
INDIVIDUAL DIFFERENCES IN PAIN,
INCLUDING THE INFLUENCES OF
SEX, GENDER, RACE, ETHNICITY
AND AGING ON THE EXPERIENCE OF
PAIN.
DR. FILLINGIM?
HIS RESEARCH HAS BEEN
CONTINUOUSLY FUNDED FOR 30
YEARS BY NIH, SINCE 1994,
INCLUDING CURRENT META AWARD
FOR UNIVERSITY OF AGING.
THE NEXT GENERATION OF PAIN
SCIENTISTS AND HE CURRENTLY
SERVES AS SECRETARY TREASURER
FOR THE INTERNATIONAL -- THE
TOPIC OF HIS TALK IS HOW AGE,
RACE AND ETHNICITY INTERSECT
WITH SEX AND GENDER TO
INFLUENCE PAIN.
>> THANK YOU SO MUCH, INNA AND
THE ORGANIZERS FOR THE
OPPORTUNITY TO BE HERE.
SUCCESS.
SO, AS YOU HAVE HEARD
THROUGHOUT THE DAY AND MANY OF
YOU KNOW THERE ARE INDEED SEX
DIFFERENCES IN THE EXPERIENCE
OF PAIN.
YOU JUST WANT TO LEVEL SET HERE
BEFORE WE START INTRODUCING
SOME OF THE OTHER FACTORS THAT
WE HAVE BEEN INTERESTED IN.
THIS IS SYSTEMATIC REVIEW OF 46
DIFFERENT GLOBAL
EPIDEMIOLOGICAL STUDIES SHOWING
THE FEMALE TO MALE PREVALENCE
OF CHRONIC PAIN, GENERALLY
DEFINED.
AND YOU CAN SEE THAT THERE ARE
MORE FEMALES THAN MALES WHO
HAVE CHRONIC PAIN.
WHICH IS NOT NEWS TO ANY OF US
HERE.
I WOULD SAY THOSE WERE STUDIES
OF ADULTS.
THE SEX DIFFERENCES DO TEND TO
EXTEND TO CHILDREN AS TALKED
ABOUT IN DIFFERENT TALKS TODAY.
MAYBE PREFERENTIALLY FOR SOME
PAIN CONDITIONS LIKE HEADACHE
AND MUSCULAR SKELETAL PAIN AND
THERE ALSO IS LIKELY AN AGE
EFFECT HERE WITH MANY OF THE
DIFFERENCES GETTING LARGER
AFTER PUBERTY.
LOOKING AT THE PREVALENCE OF
CHRONIC PAIN IN GENERAL, AS
WELL AS HIGH IMPACT PAIN, THAT
IS PAIN THAT INTERFERES WITH
LIFE-RELEVANT ACTIVITIES.
YOU CAN SEE THERE'S FAIRLY
MONCTONIC INCREASE IN DIFFERENT
TYPES OF PAIN ACROSS THE AGE
SPAN HERE.
AND YOU HEARD A LITTLE BIT
EARLIER, HER WORK WITH COVA
LOOKED AT DIFFERENCES IN THE
NATIONAL HEALTH INTERVIEW
SURVEYS AND WHAT WE SEE HERE IS
A BIT MORE NUANCED DEPICTURE.
PAIN PREVALENCE, HIGH FOR
NATIVE AMERICAN INDIVIDUALS AND
THOSE WHO IDENTIFY AS
MULTI-RACIAL, THERE ARE, IF
ANY, VERY SMALL DIFFERENCES
BETWEEN NON HISPANIC WHITE, NON
HISPANIC BLACK AND HISPANIC
ADULTS TENDING TOWARD SLIGHTLY
LOWER PREVALENCE OF PAIN.
IF YOU LOOK AT THE UPPER BARS
IN THE RED THERE WITH NON
HISPANIC BLACK INDIVIDUALS
STARTING TO INCH A LITTLE BIT
AHEAD WHEN IT COMES TO SEVERE
PAIN AND HIGH IMPACT PAIN WHICH
GIVES US A SIGNAL THAT CHRONIC
PAIN IN GENERAL MAY NOT BE MORE
COMMON IN SOME OF THESE
MINORITIZED POPULATIONS BUT
SEVERITY MAY BE MORE IN THIS
POPULATION.
YOU SEE THIS PICTURE.
SO FROM THE SAME
EPIDEMIOLOGICAL STUDY, THE
PREVALENCE OF CHRONIC PAIN
THERE ON THE LEFT IS SLIGHTLY
HIGHER IN NON HISPANIC WHITES,
THE PREVALENCE OF HIGH IMPACT
CHRONIC PAIN IS HIGHER IN
NON-HISPANIC BLACK AND HISPANIC
INDIVIDUALS.
SO THERE ARE SOME RACIAL AND
ETHNIC DIFFERENCES IN PAIN BUT
THEY TEND TOWARD THE SEVERITY
OF PAIN RATHER THAN PAIN
PREVALENCE.
IF WE START TRY TO PUT TOGETHER
SOME OF THESE OTHER DEMOGRAPHIC
FACTORS WITH SEX, WE CAN LOOK
AT, FOR EXAMPLE, SEX
DIFFERENCES ACROSS THE EARLY
ADULT TO LATE ADULT LIFE SPAN
HERE.
AND YOU CAN SEE THAT FEMALES
TEND TO HAVE HIGHER PAIN
PREVALENCE ACROSS THE LIFE SPAN.
INTERESTINGLY PAIN PREVALENCE
IN THIS STUDY PEAKED IN MIDDLE
AGES AMONG MEN, AND THEN CAME
DOWN A BIT.
WHEREAS IT SIMPLY PLATEAUED IN
WOMEN AND WOMEN PERSIST WITH
RELATIVELY HIGH PREVALENCE INTO
LATE LIFE.
YOU HAVE ALREADY SEEN THESE
DATA ON HEADACHE, RIGHT?
SO FAR I HAVE BEEN TALKING
ABOUT CHRONIC PAIN IN GENERAL,
AGNOSTIC TO WHAT KIND OF PAIN
YOU HAVE.
THE PATTERN OF SEX DIFFERENCES
ACROSS THE LIFE SPAN LOOKS
DIFFERENT WITH HEADACHE HERE.
AND YOU SAW THESE DATA FROM DR.
SZPERKA, I THINK.
SO THE SEX DIFFERENCES TEND TO
PEAK DURING THE REPRODUCTIVE
YEARS.
YOU GET A SIMILAR PATTERN WITH
ORAFACIAL PAIN.
WE DO SEE IMPORTANT
INTERSECTIONS BETWEEN AGE AND
SEX AND PAIN PREVALENCE.
HOWEVER, IF WE LOOK AT
OSTEOARTHRITIS, THE SEX
DIFFERENCE CONTINUES THROUGHOUT
THE LIFE SPAN AND THE
PREVALENCE CONTINUES TO GO UP
UNTIL DEATH, PRESUMABLY.
AND SO THAT'S LED MANY OF US TO
WONDER WHETHER THERE MIGHT BE
SEX DIFFERENCES IN PAIN
PROCESSING.
SO WE BRING PEOPLE IN THE LAB
AND PERPETRATE DIFFERENT TYPES
OF PAIN UPON THEM.
THIS IS A DATA SET FROM OUR
LABORATORY, I THINK SORT OF
RECAPITULATES THE LITERATURE.
I HAVE STANDARDIZED ALL OF
THESE DATA TO A Z SCORE SO THE
MEAN IS ZERO, BARS THAT GO UP
MEAN HIGHER THRESHOLD AND
HIGHER TOLERANCE, WHICH EQUATES
TO LOWER PAIN SENSITIVITY, IF
YOU WILL.
THE BARS THAT GO DOWN REFLECT
THE OPPOSITE.
CAN SEE ALL THE MALE BARS GO UP
AND ALL THE FEMALE BARS GO DOWN
SUGGESTING AS JEFF MOGUL SAID
EARLIER, NO MATTER HOW WE HURT
THESE INDIVIDUALS IN OUR
LABORATORY, WOMEN ARE
DISPLAYING GREATER SENSITIVITY
TO THESE SENSORY STIMULI.
YOU SEE THE BARS ARE OF
DIFFERENT HEIGHTS.
THAT MEANS SOME OF THE SEX
DIFFERENCES ARE SMALL AND
ARGUABLY NEGLIGIBLE AND SOME
ARE LARGER.
THAT'S A FAIR TOPIC FOR
RESEARCH BUT THE PATTERN IS
FAIRLY CONSISTENT.
THAT'S A SAMPLE OF HEALTHY
YOUNG ADULTS.
WHAT IF WE MOVE INTO
INDIVIDUALS WITH DIFFERENT AGE
RANGES AS THIS WORKED WITH MY
COLLEAGUE DR. RILEY OF
UNIVERSITY OF FLORIDA.
THIS IS CONDITIONED PAIN
MODULATION.
WE ARE TESTING WHETHER PAIN AT
ONE SITE OF THE BODY WILL
INHIBIT THE PAIN PERCEIVED AT
THE OTHER SITE OF THE BODY.
LABORATORY BASED MEASURE HOW
WELL YOUR PAIN INHIBITORY
CENTER IS FUNCTIONING.
MORE PAIN MODULATION WOULD MEAN
A LONGER DOWNWARD BAR HERE.
ONE PAIN REDUCED THE OTHER PAIN
TO A GREATER EXTENT.
YOU COULD SEE THE BARS FOR
YOUNGER ADULTS IN THEIR MID
20'S HERE ARE LARGER THAN THE
BARS FOR OLDER ADULTS.
BUT THE SEX DIFFERENCE IS
RELATIVELY SIMILAR BETWEEN
YOUNGER AND OLDER ADULTS.
THE MAGNITUDE OF PAIN
MODULATION IS DIFFERENCE BUT
THE PATTERN OF SEX DIFFERENCES
IN THIS PAIN INHIBITORY MEASURE
LOOKS SIMILAR IN YOUNGER AND
OLDER ADULTS.
WE HAVE FAR LESS INFORMATION
ABOUT INTERSECTIONS BETWEEN
RACE, ETHNICITY AND SEX.
THIS STUDY IS ONE OF OUR
STUDIES LOOKING AT MIDDLE AGED
AND OLDER ADULTS WITH
OSTEOARTHRITIS PAIN.
KNEE OSTEOARTHRITIS PAIN.
BARLEY LOOKED AT THIS DATA AND
LOOKING AT QUANTITATIVE TESTING
RESULTS.
INTERESTINGLY IN THIS STUDY
THERE WERE NO SEX DIFFERENCES
IN THE SEVERITY OF THEIR
ARTHRITIS PAIN.
WOMEN AND MEN REPORTED SIMILAR
LEVELS OF PAIN AND SIMILAR
LEVELS OF DISABILITY.
HOWEVER, WOMEN HAD
SIGNIFICANTLY MORE SITES OF
PAIN.
WE SEE SIMILAR PATTERN TO
HEALTHY YOUNG ADULTS, WOMEN ARE
REPORTING LOWER PAIN THRESHOLDS
NO MATTER WHERE WE ARE HURTING
THEM.
WOMEN ARE REPORTING GREATER
TEMPORAL WHEN THEIR AFFECTED
KNEE, NOT SO WHEN FOCUSED ON A
NON PAIN SITE.
GREATER TEMPORAL SUMMATION
WHICH SAY TRANSIENT FORM OF
SENSITIZATION IS RESTRICTED TO
THE PAINFUL SITE HERE IN TERMS
OF THE SEX DIFFERENCE.
TEMPORAL SUMMATION OF HEAT WAS
SIMILAR FOR WOMEN NO MATTER
WHERE WE WERE STIMULATING
THERE, AN AFFECTED KNEE OR
UNAFFECTED ARM.
THESE DATA WOULD SUGGEST THAT
MIDDLE AGE AND OLDER WOMEN WITH
NEOARTHRITIS PAIN ARE SHOWING
GREATER PAIN AMPLIFICATION THAN
THEIR MALE COUNTERPARTS.
THIS STUDY WAS DESIGNED HOWEVER
TO FOCUS ON RACIAL AND ETHNIC
DIFFERENCES IN PAIN AND TO TRY
TO UNDERSTAND THOSE DIFFERENCES.
AND SO WE HAVE RELATIVELY EQUAL
NUMBERS.
SLIGHTLY MORE NON-HISPANIC
BLACKS BUT LARGER NUMBERS OF
NON-HISPANIC BLACK AND
NON-HISPANIC WHITE ADULTS WITH
KNEE OSTEOARTHRITIS.
HERE ARE PAIN SCORE TESTS BEING
DONE, THE HIGHER THE SCORE THE
LOWER THE PAIN SENSITIVITY IN
OUR NON-HISPANIC WHITE ADULTS
ARE LESS SENSITIVE TO ALL OF
THESE SENSORY TESTS THAN OUR
NON-HISPANIC BLACK ADULTS.
IT DOESN'T MATTER IF WE ARE
APPLYING THE STIMULI TO AN
AFFECTED KNEE OR NON-AFFECTED
SITE.
WITH THE HEAT PAIN, AFRICAN
AMERICAN NON-HISPANIC BLACK
INDIVIDUALS ARE REPORTING NOT
ONLY MORE PAIN BUT INCREASE IN
SLOPE WITH REPEATED STIMULATION.
THAT'S THE MEASURE OF TEMPORAL
SUMMATION.
THEY ARE SHOWING GREATER PAIN
AMPLIFICATION HERE.
WE SEE A SIMILAR EFFECT WITH
TEMPORAL SUMMATION OF
MECHANICAL PAIN, WHEN WE POKE
THEM ONCE VERSUS WHEN WE POKE
THEM TEN TIMES WITH A NYLON
MONOFILAMENT.
AFRICAN AMERICAN PARTICIPANTS
ARE REPORTING MORE PAIN AND
GREATER TEMPORAL SUMMATION OF
MECHANICAL PAIN BOTH SITES
TESTED.
SO IF WE ARE WONDERING WHERE
SEX, GENDER AND AGE, AND
RACE/ETHNICITY INTERSECT, PART
OF THE ANSWER IS WE DON'T KNOW
FOR SURE.
I HAVE MADE THE MISTAKE OF
SAYING I'M STUDYING RACIAL AND
ETHNIC DIFFERENCES IN THIS
STUDY AND TEMPORARILY IGNORE
THE FACT PEOPLE BRING THEIR SEX
AND GENDER AND AGE WHEN THEY
SHOW UP AT THE LAB.
SO WE ARE INTERESTED IN
LEARNING MORE ABOUT THESE
INTERSECTIONS.
I DID FIND THIS RECENT PAPER
FROM BRAZIL.
IT'S EPIDEMIOLOGIC STUDY
LOOKING AT SOCIOECONOMIC AND
SEX-RELATED INEQUALITIES IN
CHRONIC PAIN.
AND WHAT THEY SHOWED WAS THAT
AMONG FEMALES BOTH UNFAVORABLE
LIVING CONDITIONS AND WHAT THEY
DESCRIBE AS BLACK BROWN RACE,
WERE ASSOCIATED WITH INCREASED
RISK OF CHRONIC PAIN.
WHEREAS IN MALES, LOWER
EDUCATIONAL ATTAINMENT AND LACK
OF FINANCIAL INDEPENDENCE WERE
ASSOCIATED WITH INCREASED RISK
OF CHRONIC PAIN.
SO SOME OF THESE SOCIOECONOMIC,
SOCIO DEMOGRAPHIC FACTORS SEEM
TO IMPACT CHRONIC PAIN RISK
DIFFERENTLY IN MALES AND
FEMALES IN THIS STUDY.
FROM OUR UPLOAD STUDY, DR.
ELLEN TERRY AT UNIVERSITY OF
FLORIDA LOOKED AT HOW
DISCRIMINATION MIGHT INFLUENCE
THE EXPERIENCE OF PAIN IN OUR
PARTICIPANTS WITH KNEE
OSTEOARTHRITIS.
SO WE HAVE A MEASURE,
SELF-REPORT MEASURE OF EVERY
DAY DISCRIMINATION.
YOU SEE THAT THERE IN THE TOP
ROW, OUR NON HISPANIC BLACK
INDIVIDUALS REPORTED HIGHER
DISCRIMINATION THAN OUR
NON-HISPANIC WHITE INDIVIDUALS.
BUT ALSO THE DIFFERENCE BETWEEN
MALES AND FEMALES WAS GREATEST
IN OUR NON-HISPANIC BLACK
INDIVIDUALS.
THE BOLDED MEASURES THERE IN
BLACK TYPE SHOWED A RACE
DIFFERENCE BUT NOT A SEX
DIFFERENCE.
SO OUR AFRICAN AMERICAN
INDIVIDUALS REPORTED HIGHER
LEVELS OF PAIN CATASTROPHIZING,
PAIN INTERFERENCE AND THEY
PERFORMED MORE POORLY ON OUR
SHORT PHYSICAL PERFORMANCE
BATTERY.
BUT DR. TERRY WANTED TO LOOK AT
HOW DISCRIMINATION MIGHT BE
RELATED TO SOME OF THESE
ENDPOINTS.
AND THESE ARE CORRELATIONS, NOT
LEVELS OF DISCRIMINATION, JUST
TO POINT THAT OUT.
BUT YOU CAN SEE THAT THE ONLY
SIGNIFICANT CORRELATIONS
EMERGED FOR FEMALES IN THIS
SAMPLE.
NOT MALES.
AND THAT WAS TO A LARGE DEGREE
REGARDLESS OF RACIAL GROUP.
AND SO DR. TERRY DID SOME
SERIAL MEDIATION MODELS.
AND THIS WAS THE ONE THAT FIT
THE DATA THE BEST.
DISCRIMINATION, WHICH IS
RELATED TO HIGHER LEVELS OF
PAIN.
AND THESE SERIAL MODELS ARE
ONLY IN WOMEN BECAUSE THEY WERE
THE ONLY PART OF THE GROUP THAT
SHOWED A LINK BETWEEN
DISCRIMINATION AND PAIN.
SO DISCRIMINATION IS RELATED TO
WOMAC PAIN.
AND IT DOES SO VIA THIS SERIAL
MEDIATION WHERE DISCRIMINATION
IS ASSOCIATED WITH INCREASED
STRESS, INCREASED STRESS IS
ASSOCIATED WITH INCREASED PAIN
CATASTROPHIZING WHICH THEN IS
ASSOCIATED WITH HIGHER LEVELS
OF PAIN.
AND WE SAW A SIMILAR PATTERN
WITH PAIN INTERFERENCE HERE.
SO DISCRIMINATION, ASSOCIATED
WITH HIGHER STRESS, HIGHER
STRESS WITH HIGHER
CATASTROPHIZING AND THEN HIGHER
LEVELS OF PAIN INTERFERENCE,
AGAIN, BUT ONLY IN WOMEN IN OUR
SAMPLE.
NOTHING IN MEN.
AND SO, IF WE ARE GOING TO
START THINKING MORE ABOUT HOW
THESE DIFFERENT DEMOGRAPHIC
FACTORS MIGHT INTERSECT, IT'S
FAIR TO WONDER WHAT DO THEY
HAVE IN COMMON?
AND WE HAVE HEARD A LOT ABOUT
THE BIO PSYCHO SOCIAL MODEL
ALREADY TODAY.
I WOULD ARGUE THAT SEX/GENDER,
AGE AND RACE/ETHNICITY ARE ALL
PROXIES FOR A VARIETY OF BIO
PSYCHO SOCIAL MECHANISMS, MANY
OF WHICH WE FRANKLY DON'T
UNDERSTAND YET, RIGHT?
SO WE NEED TO CERTAINLY AVOID
THE TEMPTATION TO THINK THAT
SEX OR GENDER OR AGE OR RACE
ARE THE CAUSAL DRIVER OF ANY
DIFFERENCES IN PAIN.
THEY ARE REFLECTING SOMETHING
ELSE THAT WE NEED TO LEARN MORE
ABOUT.
THESE GROUPS ALSO HAVE
HISTORICALLY BEEN EXCLUDED FROM
BIOMEDICAL RESEARCH.
RIGHT?
SO MUCH OF WHAT WE KNOW MAY NOT
APPLY TO WOMEN, TO INDIVIDUALS
FROM MINORITIZED BACKGROUNDS OR
CHILDREN.
THAT'S CHANGING NOW WITH NEW
POLICIES.
IT'S ALSO THE CASE THAT
INDIVIDUALS FROM THESE GROUPS
HAVE OFTEN BEEN TARGETS OF
DISCRIMINATION AND MISTREATMENT.
I SHOWED YOU SOME OF OUR DATA
HERE.
THEY ARE ALSO THE TARGETS OF
PROVIDER BIASES.
AND NOT JUST PROVIDERS.
ALL OF US, BY THE WAY.
BUT THOSE OF US WHO AREN'T
PROVIDERS AREN'T PROVIDING
MEDICAL CARE FOR THESE
INDIVIDUALS.
SO THESE PROVIDER BIASES CAN
CERTAINLY INFLUENCE THEIR
PAIN-RELATED OUTCOMES.
INCLUDING UNDER TREATMENT OF
PAIN.
AND IT'S CERTAINLY WELL
DOCUMENTED THAT INDIVIDUALS
FROM MINORITIZED RACIAL
BACKGROUNDS ARE AT GREAT RISK
FOR UNDER TREATMENT OF THEIR
PAIN.
I WOULD RECOMMEND TO MYSELF
AND TO THE REST OF US WE
ABANDON THE TEMPTATION TO FALL
PREY TO THE SINGLE CAUSE
FALLACY, SCIENCE IS
REDUCTIONISTIC AND HORRIBLY
REDUCTIONISTIC AT TIMES AND WE
NEED TO TRANSITION FROM
THINKING OF CAUSE AND EFFECT TO
CAUSES AND EFFECT.
AS THESE AUTHORS SAID WE NEED
TO REEVALUATE OUR RESEARCH
MODELS AND ALLOW EXPLORATION OF
THE CLINICALLY OBVIOUS CAUSES
AND EFFECT ON HEALTH AND
DISEASE.
SO TAKING THAT TO HEART, IN THE
FUTURE, WE SHOULD EMBARK UPON
STUDIES THAT ARE DESIGNED TO
EXPLORE THIS INTERSECTIONALITY,
NOT JUST DOING IT SORT OF
POSTHOC OR AD HOC.
PAIN IMPACT IS MORE IMPORTANT
THAN PAIN PREVALENCE.
WE WANT TO INVESTIGATE THE
BIOPSYCHOSOCIAL MECHANISMS
CONTRIBUTING TO THE INDEPENDENT
AND COMBINED EFFECTS OF THESE
FACTORS WE ARE INTERESTED IN
AND BANDON THE APPROACH OF
MAKING WHITE MEN THE GOLD
STANDARD AND INSTEAD LOOK AT
FACTORS THAT MIGHT BE DRIVING
PAIN IN A PARTICULAR GROUP,
IRRESPECTIVE OF WHAT MIGHT BE
HAPPENING IN OTHER GROUPS.
AND I CERTAINLY WANT TO
ACKNOWLEDGE MY COLLEAGUES AT
OUR PAIN RESEARCH AND
INTERVENTION CENTER OF
EXCELLENCE.
ACKNOWLEDGE THE N.I.H. AND
THANK YOU FOR THE SUPPORT OF
OUR WORK.
AND IT GOES TO OUR PANEL
DISCUSSION, I BELIEVE.
>> THANK YOU VERY MUCH FOR THIS
GREAT TALK.
AND THANKS TO ALL THREE
SPEAKERS.
AND HOPEFULLY WE WILL SEE DR.
SULTAN ON ZOOM PARTICIPATING IN
THIS PANEL DISCUSSION.
AND I WOULD LIKE TO ENCOURAGE
ALL OF YOU TO ASK QUESTIONS.
WE HAVE ABOUT 18 MINUTES FOR
THE QUESTIONS.
YES?
THE FIRST QUESTION?
>> TREATMENT DIFFERENCES
BETWEEN RACIAL AND ETHNIC
GROUPS, THERE'S BEEN A LITTLE
BIT OF WORK DONE IN OPIOIDS.
I BELIEVE THERE IS CERTAINLY
DATA SHOWING SOME ASIAN
POPULATIONS ARE AT GREATER RISK
FOR ADVERSE EFFECTS OF OPIOIDS.
THERE ARE SOME DATA SUGGESTING
THAT NON-HISPANIC BLACK
INDIVIDUALS MAY SHOW GREATER
ANALGESIC RESPONSE TO OPIOIDS,
ALTHOUGH THAT'S VERY LIMITED
DATA.
PROBABLY WHAT'S MORE STRIKING
IS THE FACT THAT AT LEAST IN
THIS COUNTRY, NON HISPANIC
BLACK INDIVIDUALS ARE MUCH MORE
LIKELY TO BE DENIED OPIOIDS
UNDER CONDITIONS WHEN THEY
WOULD BE APPROPRIATELY PROVIDED.
WE KNOW RELATIVELY LITTLE, AT
LEAST MY READING OF LITERATURE
ABOUT HOW DIFFERENT TREATMENTS
MAY OR MAY NOT BE MORE OR LESS
EFFECTIVE ACROSS GROUPS.
>> THANK YOU.
>> I WILL JUST ADD IN THE
MIGRAINE SPACE, IT'S A
RELATIVELY NEWER ANALYSIS TO BE
LOOKING AT SUBGROUPS.
AND QUITE FRANKLY NEW THAT WE
HAVE ENROLLED ENOUGH SUBJECTS
THAT ARE NOT JUST WHITE
ESSENTIALLY TO BE ABLE TO LOOK
AT THIS, IN THE CGRP STUDIES
THERE'S NOT AN ANALYSIS THAT'S
BEEN DONE, BUT TO WHOM WE OFFER
THERAPIES IS OFTEN VERY
DIFFERENT.
>> THANK YOU.
>> HANNAH?
>> HI, SO MY QUESTION IS
DIRECTED TOWARDS ROGER.
QUANTITATIVE SENSORY TESTING
HAS THE NAME QUANTITATIVE RIGHT
IN THE NAME AND HAS Z SCORES
AND COULD LOOK VERY OBJECTIVE.
BUT I WONDER SINCE GENDER IS
ONE OF THE THEMES OF THE
SYMPOSIUM WHETHER GENDER NORMS
COULD BIAS THE RESULTS OF QST
PEOPLE WHO HAVE SOCIAL
INCENTIVE TO LOOK TOUGH MIGHT
REALLY HOLD THAT AS LONG AS
POSSIBLE BEFORE THEY SAY
SOMETHING IS PAINFUL AND PEOPLE
LESS SEEMING TOUGH MAY REPORT
EARLIER.
WHAT DO WE KNOW ABOUT THAT
POTENTIAL SOURCE OF BIAS?
>> YEAH, THANKS, HANNAH.
AND YOU MAKE A GOOD POINT.
QUANTITATIVE SENSORY TESTING,
IT IS QUANTITATIVE AND PAIN
REPORTS ARE INDEED QUANTITATIVE.
QUANTITATIVE SENSORY TESTING IS
NOT OBJECTIVE, RIGHT?
THE SENSORY STIMULI ARE
OBJECTIVE BUT THE OUTPUT, THE
MEASURES ARE STILL SELF-REPORT
DATA.
AND SO THAT'S IMPORTANT TO
RECOGNIZE.
THERE ARE CERTAINLY GENDER
RELATED NORMS AND STEREOTYPES
HAVE CONSISTENTLY BEEN SHOWN TO
INFLUENCE QUANTITATIVE SENSORY
TESTING AND RESPONSES.
IF YOU GIVE A STANDARD GENDER
STEREOTYPE QUESTIONNAIRE,
INDIVIDUALS WHO IDENTIFY AS
MORE MASCULINE TEND TO HAVE
HIGHER PAIN THRESHOLD AND
TOLERANCE.
IF YOU MANIPULATE THE SEX
AND/OR GENDER OF THE
EXPERIMENTER, THAT AFFECTS THE
RESULTS WITH INDIVIDUALS
TENDING TO REPORT LESS PAIN TO
AN OPPOSITE SEX EXPERIMENTER
THAN THAT EFFECT TENDS TO BE
PARTICULARLY STRONG FOR MEN.
I DON'T THINK WE WANT TO FOOL
OURSELVES THINKING WE ARE
GETTING OBJECTIVE MEASURES OF
PAIN EVEN THOUGH WE ARE DOING
IT IN THE LABORATORY.
WE ARE REMOVING A SOURCE OF
VARIANCE, RIGHT?
IF TWO PEOPLE WITH A BROKEN ARM
REPORT TWO DIFFERENT AMOUNTS OF
PAIN, DON'T KNOW IF IT'S
BECAUSE ONE ARM IS BROKEN WORSE
THAN THE OTHER.
WITH THE STIMULI IN THE LAB I
HAVE REMOVED THAT VARIABLE.
IT'S STILL QUITE SUBJECTIVE AND
SUBJECT TO THE KINDS OF
GENDER-RELATED INFLUENCES THAT
YOU RAISE.
>> THANK YOU.
I HAVE TWO QUESTIONS IN THE
ROOM.
AND REMEMBER YOU CAN ASK DR.
SULTAN.
NOW WE HAVE THE FULL PICTURE.
>> YEAH, THANK YOU.
I JUST HAD A QUESTION, DO YOU,
WHEN WE ARE TALKING ABOUT
GENDER IN TERMS OF MALE/FEMALE
AND MORE PAIN THRESHOLDS HAS
THERE BEEN ANY INDICATION OF
WHAT TYPE OF INSURANCE THEY
HAVE?
LIKE IN TERMS OF, ARE MALES
MORE INSURED THAN WOMEN OR VICE
VERSA?
ANY OF THE STUDIES?
>> YEAH, ACTUALLY WE HAVE THOSE
DATA THOUGH I CAN'T SAY WE HAVE
EVER LOOKED AT THAT.
I DON'T KNOW OF ANY STUDIES
THAT HAVE LOOKED AT THAT
QUESTION IN RELATION TO
QUANTITATIVE SENSORY RESULTS.
YEAH.
>> OKAY, THANK YOU.
>> YES, SO I WAS WONDERING FOR
DIFFERENT VARIABLES THAT ARE
RELATED TO DISCRIMINATION IN
YOUR STUDIES, YOU KNOW WHETHER
IT BE RACE OR GENDER OR MAYBE
EVEN PREVIOUS LIVED EXPERIENCE,
YOU PREVIOUSLY TALKED ABOUT
LIKE, KNOW, RESEARCHER BIAS AND
YOU KNOW, PEOPLE ANSWERING
QUESTIONS AND FILLING OUT
QUESTIONNAIRES.
AND IT MADE ME THINK, YOU KNOW,
THERE MAY NOT BE ENOUGH
INDIVIDUALS FROM THESE SIMILAR
BACKGROUNDS LIKE ENOUGH BLACK
MALE RESEARCHERS OR MAYBE
RESEARCHERS WHO ARE TRANS OR
NON-BINARY OR HAVE HAD CERTAIN
LIVED EXPERIENCES LIKE
OBTAINING A C-SECTION.
SO I WONDER WHAT ARE YOUR
THOUGHTS ON HOW THOSE TYPES OF
DISPARITIES MAY BE IMPACTING
THE PAIN THAT IS BEING REPORTED
IN THESE SPECIFIC TYPES OF
GROUPS?
>> YES.
SO IF I'M GETTING YOUR QUESTION
RIGHT, IT'S SORT OF IF THE
EXPERIMENTERS DON'T SHARE THE
LIVED EXPERIENCE OF THE
PARTICIPANTS THAT COULD CREATE
AN INFLUENCE ON HOW OUR
PARTICIPANTS ARE REPORTING
THEIR PAIN EXPERIENCE.
YES.
>> EXACTLY.
>> THAT'S A GREAT POINT.
IT'S SOMETHING THAT I'VE HAD
DIFFICULTY FIGURING OUT HOW TO
MANAGE, RIGHT?
SO I AGREE WITH YOU.
BUT MY WORKFORCE IS NOT SUCH
THAT I CAN ADDRESS THAT, RIGHT?
NOW I WILL SAY IN OUR FIRST
STUDY IN THIS SPACE, WE ARE
STUDYING HEALTHY YOUNG
INDIVIDUALS FROM DIFFERENT
RACIAL AND ETHNIC GROUPS.
MOST THEM ARE COLLEGE-EDUCATED
OR ON THEIR WAY TO BEING SO.
AND WE WERE ABLE TO ENSURE THAT
IN EVERY TEST, WE HAD ONE
PERSON OF THEIR SAME RACE,
ETHNICITY AND ANOTHER PERSON OF
ANOTHER RACE, ETHNICITY.
BUT WE DIDN'T ADDRESS ANY OTHER
ASPECTS OF THEIR LIVED
EXPERIENCE, RIGHT?
SO THAT CAN CERTAINLY INFLUENCE
OUR RECRUITMENT INTO STUDIES
BUT CAN ALSO INFLUENCE THE
EXPERIENCE OF THE PARTICIPANT
IN THE STUDY.
I WISH I COULD TELL YOU HOW ITS
INFLUENCING THEIR EXPERIENCE
AND THEIR RESPONSE, BUT I JUST
DON'T KNOW.
>> I WOULD ADD IN OUR EMERGENCY
DEPARTMENT STUDIES WE WANTED TO
LOOK AT THIS, IF THERE'S
CONCORDANT VERSUS DISCONCORDANT
PAIRING OF THE PROVIDERS AND
PATIENTS.
IF YOU THINK OF E.D. CARE THERE
ARE SO MANY PROVIDERS THE CHILD
WOULD SEE ALONG THE WAY, EVEN
IF WE COULD IDENTIFY WHO HAS
TOUCHED THE CHART AND WHAT
THEIR RACIAL ETHNIC BACKGROUND
WOULD BE, GENDER, ET CETERA,
THERE WOULD BE TOO MANY PEOPLE
WE COULDN'T SORT IT OUT.
WE THOUGHT ABOUT IT BUT THOUGHT
IT WASN'T POSSIBLE TO BE ABLE
TO EXAMINE.
>> DR. SULTAN, WOULD YOU LIKE
TO ADD SOMETHING?
>> YEAH, OBVIOUSLY, THE GENDER
DIFFERENCE IN OUR POPULATION
ARE NOT REALLY APPLICABLE
BECAUSE MOST OF THE PEOPLE
DELIVER IDENTIFY AS FEMALE AND
IT'S A VERY UNDER EXPLORED AREA
OF PEOPLE THAT DELIVER THAT
DON'T IDENTIFY AS FEMALE IN
TERMS OF THEIR PAIN OUTCOMES.
IT'S JUST NOT BEEN EXPLORED.
SO HUGELY IMPORTANT AREA OF
RESEARCH THAT NEEDS SOME
ATTENTION.
BUT I THINK JUST PROFILING WHAT
A NORMAL PAIN RESPONSE AND
EXPERIENCE IS IN THE PERI AND
POSTPARTUM PERIOD.
WHAT WE NEED IS LARGE CLINICAL
EPIDEMIOLOGICAL STUDY TO
PROFILE PAIN EXPERIENCES AT
DIFFERENT TIME POINTS IN THE
POSTPARTUM PERIOD.
TRADITIONALLY, MOST PEOPLE ARE
TOLD YOUR RECOVERY AFTER CHILD
BIRTH WILL TAKE ABOUT SIX WEEKS
BUT THAT REALLY ISN'T
EVIDENCE-BASED AND CERTAINLY
DOESN'T ADEQUATELY DESCRIBE
RECOVERY FROM A PAIN
PERSPECTIVE.
THERE WAS A STUDY DONE FROM
STANFORD WHERE PATIENTS WERE
CALLED UP EVERY SINGLE DAY
AFTER THEIR CHILD BIRTH AND
ASKED THREE QUESTIONSMENT ONE,
ARE YOU STILL IN PAIN, TWO ARE
YOU STILL NEEDING PAIN KILLERS
AND THREE, DO YOU CONSIDER YOU
HAVE RECOVERED FOLLOWING YOUR
DELIVERY.
ABOUT 10% OF PATIENTS THAT HAD
A C-SECTION AND 5% THAT HAD A
VAGINAL DELIVERY ANSWERED NO TO
THOSE QUESTIONS OR NEGATIVELY.
WE ARE ACTUALLY DEALING WITH A
PUBLIC HEALTH CRISIS.
WE URGENTLY NEED TO KNOW WHAT
IS NORMAL IN THE POSTPARTUM
PERIOD.
HOW LONG IT CARRIES ON FOR.
SURVEY DATA FROM AUSTRALIA AND
UNITED KINGDOM, EVEN WHEN YOU
SURVEY PEOPLE UP TO 18 MONTHS
POSTPARTUM, 75% OF PATIENTS SAY
THEY ARE STILL SUFFERING FROM A
MORBIDITY RELATED TO THEIR
DELIVERY ONE AND A HALF YEARS
AGO.
SO YEAH, WE REALLY NEED TO
URGENTLY IMPROVE POSTPARTUM
RECOVERY.
>> DO I HAVE TIME FOR ONE MORE
QUESTION FOR DR. SULTAN?
I WANTED TO ASK, DID YOU FIND
ANY CORRELATION, OR DO YOU
THINK IT'S SOMETHING TO LOOK AT
IN TERMS OF, BECAUSE I KNOW YOU
ARE LOOKING AT CHRONIC PAIN
DURING POSTPARTUM TOO.
DOES HAVING, IS THERE A
CORRELATION BETWEEN HAVING
CHRONIC PAIN PRIOR TO GIVING
BIRTH AND THE DEVELOPMENT OF
POSTPARTUM DEPRESSION IN THESE
MOTHERS?
>> YEAH, THAT'S A VERY GOOD
QUESTION.
AND WAS ROGER WAS ELUDING TO, I
THINK PAIN IS SUCH A COMPLEX
CONSTRUCT IN ANY SETTING.
BUT PARTICULARLY IN THE
POSTPARTUM SETTING.
BECAUSE YOU'VE GOT THE BABY
WHICH INFLUENCES A LOT OF
THINGS GOING ON.
AND YOU HAVE NEW EXPERIENCES
LIKE BREAST FEEDING AND NORMAL
HORMONAL CHANGES WHICH CHANGE
MOOD AS WELL.
BUT FROM CLINICAL EXPERIENCE AS
AN ANESTHESIOLOGIST PATIENTS
WHO HAVE OPIOID MISUSE DISORDER
AND PATIENTS THAT HAVE CHRONIC
PAIN BEFORE THEIR CAESARIAN
BIRTH DELIVERY WILL HAVE
POSTPARTUM PAIN, AND
BREAK-THROUGH INTRA-OPERATIVE
PAIN AS WELL.
AS I ELUDED TO, THIS ANXIETY
AND PAIN, DIFFERENT CONSTRUCTS
BUT ANXIETY AND MOOD ARE OFTEN
RELATED.
THE PREVALENCE OF CHRONIC PAIN
IS PROBABLY MORE COMMON IN
PATIENTS THAT HAVE THESE
DISORDERS PRE-OPERATIVELY BUT
REALLY IT'S UNDER EXPLORED AND
HOW WE BEST DEFINE WHAT CHRONIC
PAIN IS AT THREE MONTHS.
IS IT JUST IF YOU HAVE A PAIN
SCORE OF ONE?
OR MODERATE TO SEVERE PAIN
SCORE?
OR ITS IMPACTING YOUR QUALITY
OF LIFE AND ABILITY TO GO BACK
TO WORK?
HOW CAN WE ACTUALLY BEST DEFINE
CHRONIC PAIN AFTER HAVING A
BABY?
>> THANK YOU.
>> THANK YOU VERY MUCH.
AND WE HAVE A COUPLE OF
QUESTIONS FROM OUR VIDEOCAST
AUDIENCE.
>> YES, WE DO.
THANK YOU, INNA.
THIS IS A QUESTION FROM ONLINE.
THIS QUESTION CONCERNS NEURAL
SUBSTRATES FOR SEX DIFFERENCES
AND NEURAL SENSIVITY.
CAN YOU COMMENT BEFORE DRG
SPINAL CORD CONTRIBUTE TO SEX
DIFFERENCES OR CONTRIBUTIONS
FROM HIGHER NERVOUS SYSTEM
REGIONS DOMINATE THE SEX
DIFFERENCE?
>> WOULD YOU LIKE TO START?
>> I CAN'T SAY WHERE THE SEX
DIFFERENCES RESIDE.
I CAN CERTAINLY SAY THAT
CONTRIBUTIONS FROM HIGHER
REGIONS, IF THAT INCLUDES
SOCIETY, HAVE AN INFLUENCE,
RIGHT?
SO WE KNOW A VARIETY OF
PSYCHOSOCIAL FACTORS CONTRIBUTE
TO SEX DIFFERENCES AND PAIN.
NOW ARGUABLY, THOSE COULD WORK
THEIR WAY INTO THE SPINAL CORD,
AND INTO THE PERIPHERY,
FRANKLY, BY INFLUENCING
SYSTEMIC INFLAMMATION.
SO WHERE THOSE SORT OF HOW
THOSE PSYCHO SOCIAL FACTORS GET
UNDER THE SKIN, WE DON'T
COMPLETELY KNOW.
THERE HAVE BEEN BRAIN IMAGING
STUDIES SHOWING SOME SEX
DIFFERENCES IN CEREBRAL
ACTIVATION AND RESPONSE TO
SENSORY STIMULI.
WHETHER THOSE DIFFERENCES IN
THE BRAIN STARTED IN THE
PERIPHERY.
I DON'T KNOW.
THAT MAY BE KNOWN BY SOMEONE.
BUT I'M NOT SURE.
I WOULD SAY ITS SAFE TO SAY
THAT SEX DIFFERENCES COULD
OCCUR AT ANY LEVEL OF THE PAIN
PROCESSING SYSTEM.
>> THERE'S NO MORE QUESTIONS,
RIGHT?
OKAY.
SO I HAVE ONE MORE QUESTION TO
ALL THE PANELISTS.
SO WE HAVE THE INTERESTING
INTERSECTION OF INFLUENCES OF
THESE FACTORS ON PAIN.
DR. FILLINGIM ALREADY STARTED
IDENTIFYING SOME OF THE COMMON
FACTORS THAT ALL THE AGE, RACE,
ETHNICITY AND SEX AND GENDER
MAY HAVE INFLUENCING PAIN.
SO COULD YOU POSSIBLY INDICATE
WHICH COMMON FACTORS ARE MORE
FOR PAIN PROCESSING AND WHICH
ARE FOR PAIN RECEPTION.
AND DO WE NEED TO DISTINGUISH
BETWEEN THOSE AND WHAT WOULD BE
THE BEST WAY TO IDENTIFY COMMON
FACTORS FOR PAIN ACROSS LIFE
SPAN AND AMONG THE DIFFERENT
GROUPS?
>> MAYBE I WILL START WITH A
COUPLE OF COMMENTS.
ONE IS, IF YOU ARE LOOKING AT
PAIN PREVALENCE OR PAIN IMPACT
AT KIND OF A CLINICAL OR
EPIDEMIOLOGICAL LEVEL, THAT
BRINGS TREATMENT INTO THE
PROCESS, RIGHT?
AND SO THERE, STRUCTURE OF
HEALTHCARE SYSTEMS.
OTHER SOCIAL INFLUENCES,
PSYCHOLOGICAL AND GENDER ROLE
RELATED INFLUENCES, FOR EXAMPLE.
OR OTHER SORT OF COGNITIVE
BIASES THAT ENTER IN, FOR
EXAMPLE, AS I GET OLDER I'M
TOLD I'M SUPPOSED TO HAVE PAIN,
SO WHY WOULD I GO GET TREATMENT
FOR THAT, RIGHT?
THESE SOCIAL AND PSYCHOLOGICAL
PROCESSES CAN INFLUENCE WHETHER
OR NOT WE SEEK TREATMENT, HOW
THAT TREATMENT IS PROVIDED TO
US, AND POTENTIALLY HOW WOULD
HE RESPOND TO THAT TREATMENT.
AND THAT'S ALL AFTER WE HAVE
DEVELOPED THE PAIN.
AND YOU KNOW, I CERTAINLY THINK
MANY OF THOSE PROCESSES CAN
ALSO INFLUENCE HOW WE
EXPERIENCE PAIN.
EITHER BECAUSE OF HOW WE
PROCESS IT CENTRALLY, OR
POTENTIALLY THROUGH SOME OF THE
PERIPHERAL INFLUENCES, THINGS
LIKE SYSTEMIC INFLAMMATION OR
MAYBE EVEN EPIGENETIC CHANGES
COULD PRODUCE.
SO THAT'S MAYBE SOME GENERAL
COMMENTS.
>> I WOULD LIKE TO ECHO WHAT
ROGER HAS BEEN TALKING ABOUT AS
WELL WITH THE PERCEPTIONS OF
SOCIETY AND THE IMPACT THAT HAS
ON PAIN.
A PERFECT EXAMPLE IS THAT
CHRONIC PAIN HAS ACTUALLY BEEN
DESCRIBED FOLLOWING CHILD BIRTH
FOR DECADES.
THERE WAS A LOT OF RESEARCH
PUBLISHED PROBABLY ABOUT 15
YEARS AGO IN THIS FIELD.
AT THAT TIME THE FINDING ISS
WERE THAT CHRONIC PAIN HAPPENS
IN 10-15% OF PATIENTS AND WE
NEED TO STUDY THIS.
IT WASN'T CONSIDERED A FUNDABLE
AREA.
AND REASON, I THINK, IS BECAUSE
M.D.'S AND PATIENTS ARE OFTEN
SAYING, WELL OF COURSE YOU HAVE
HAD A BABY, OF COURSE YOU ARE
GOING TO BE IN PAIN.
AND OF COURSE YOU HAVE HAD A
BABY, IT'S NOT A SURPRISE
YOU'RE NOT SLEEPING WELL.
OF COURSE YOU HAD A BABY, IT'S
NOT A SURPRISE THAT YOUR MOOD
IS LOW AFTER THE CHILD BIRTH.
BUT I THINK WE REALLY NEED A
PARADIGM SHIFT IN WHAT WE
PERCEIVE AS NORMAL AND
ACCEPTABLE LEVELS OF PAIN AND
SLEEP DISTURBANCE AND THINGS
LIKE THAT.
AND TAKING INTO ACCOUNT THE
FACT THAT THERE'S AN ENTIRE
GENERATION OF M.D.'S THAT ARE
PROBABLY SEEING PATIENTS IN
THEIR CLINICS IN TERMS OF
FAMILY PRACTICE CLINICS.
WHEN PATIENTS COME AND SAY,
I'VE STILL GOT PAIN AFTER MY
C-SECTION.
I'M NOT SLEEPING WELL, RATHER
THAN BRUSHING IT UNDER THE
CARPET, I THINK WE NEED TO
START MEASURING THIS AND
QUANTIFYING HOW PEOPLE ARE
COMPARING TO THEIR PEERS AND
OFFERING INTERVENTIONS AND
REFERRALS TO CHRONIC PAIN
CLINICS IF THERE IS PAIN, WHICH
IS IMPACTING LIFE AND FAMILY
INTERACTIONS, AND PREVENTING
PATIENTS GOING BACK TO WORK FOR
EXAMPLE.
THE INTERESTING THING IS, ONCE
AGAIN, WE DID THESE QUALITATIVE
INTERVIEWS WITH PATIENTS
REPORTING PAIN.
BUT THEY WERE REPORTING LOW
PAIN SCORES OF 1-2 OUT OF 10
BUT IN THE INTERVIEWS THEY WERE
SAYING ITS DEBILITATING BECAUSE
I CAN'T GET MY JEANS ON AND I'M
NOT GOING OUT OF THE HOUSE AS
MUCH.
THAT DOESN'T CORRELATE WHAT WE
WOULD CONSIDER A 1-2 PAIN.
I THINK WE NEED A PARADIGM
SHIFT HOW WE APPROACH THIS
PUBLIC HEALTH CRISIS.
>> THANK YOU VERY MUCH.
FINAL THOUGHT.
>> I AGREE WITH WHAT'S BEEN
SAID CERTAINLY.
AS I THINK ABOUT, LOOKING AT
THE GRAPHS THINKING OF SYMPTOMS
EMERGING AROUND THE TIME OF
PUBERTY, I THINK THAT IN MANY
WAYS POINTS TO BIOLOGICAL
UNDERPINNING, GROWTH, HORMONE
CHANGES ALL THOSE THINGS.
BUT AS SOMEONE BROUGHT UP THIS
MORNING, EXPRESSION OF PAIN,
MENSES AND GIRLS ARE
EXPERIENCING MONTHLY PAIN AND
CRAMPS AND HOW DOES THAT UP
REGULATE.
THERE'S THE LIVED EXPERIENCE
AND THE SHARED EXPERIENCE.
IN SOME OUR ANALYSES OF
EMERGENCY DEPARTMENT WE LOOKED
AT DISMISSIVENESS OF PAIN
SYMPTOMS.
SOME ESSENTIALLY BOYS ARE MORE
LIKELY TO HAVE MISSING
INFORMATION.
HOW MUCH IS FROM THE PROVIDER'S
PERSPECTIVE VERSUS BOY'S
PERSPECTIVE, ARE GIRLS ABLE TO
EXPRESS BETTER BECAUSE THEY
TALK TO THEIR FRIENDS ABOUT
GETTING THEIR PERIODS BUT BOYS
DON'T HAVE THAT SHARED
CONVERSATION YET.
IT'S COMPLEX.
>> THANK YOU VERY, VERY MUCH.
GREAT SESSION.
THANK YOU FOR YOUR INPUT, FOR
SHARING IDEAS.
IS IT A BRIEF QUESTION, WE WILL
ALLOW ONE MORE.
>> IT'S BRIEF.
DR. SULTAN, QUESTION.
DOES THE NUMBER OF DELIVERIES
IMPACT THE PAIN CHRONICITY AND
INTENSITY IN POSTPARTUM PAIN?
DO WE KNOW THAT?
>> THAT'S A FANTASTIC QUESTION.
SO THERE'S EVIDENCE THAT
HAVING, IF YOU ARE A FIRST-TIME
MOTHER YOUR OVERALL PAIN AND
RECOVERY EXPERIENCE TENDS TO BE
WORSE.
WHICH I THINK BRINGS INTO THIS
MULTI-DIMENSIONAL CONSTRUCT OF
PAIN AND OVERALL RECOVERY.
IF YOU ARE FAMILIAR YOU MAY BE
A LITTLE LESS ANXIOUS
SURROUNDING THE EXPERIENCE.
THAT'S PROBABLY AGAINST WHAT
YOU WOULD EXPECT.
IF YOU HAVE HAD A REPEAT
CAESARIAN DELIVERY, YOU ARE
LIKELY TO HAVE ADHESIONS AND
SCARRING, IT SHOULD BE MORE
PAINFUL BUT PATIENTS REPORT A
BETTER RECOVERY EXPERIENCE AND
PAIN EXPERIENCE A SECOND TIME
AROUND.
YEAH, FASCINATING QUESTION.
>> THANK YOU.
THANK YOU VERY MUCH.
AND NOW WE HAVE OUR FINAL
ACTION FOR TODAY.
THANK YOU.
>> SO THIS IS THE LAST ACTIVITY
OF THE DAY, AS INNA SAID AND IN
MY MIND IT'S BEST.
I'M LINDA PORTER, BEEN
ASSOCIATED WITH THE SYMPOSIUM
OVER THE YEARS, DECADES ALMOST.
ALWAYS SO HAPPY TO ACKNOWLEDGE
SOME EARLY STAGE CAREER
SCIENTISTS WHO HAVE REALLY
BRILLIANT FUTURES TO LOOK
FORWARD TO.
IT'S A DIFFICULT SITUATION FOR
US TO CHOOSE THREE PEOPLE FROM
AMONGST THE MANY POSTER
PRESENTERS IN THE ATRIUM AND
LIMIT THAT DOWN TO THREE WHO
WILL PRESENT.
IT'S A PROCESS THAT TAKES US
THROUGH LIKE A VOTING PROCESS
OF STAFF ACROSS THE N.I.H. PAIN
CONSORTIUM MEMBERSHIP.
AND THEN THEY COME AND THEY
LISTEN TO THE PRESENTATIONS AND
WE HAVE CRITERIA ON WHICH WE
SELECT THE TOP ONE OF THE THREE
FOR THE PRESENTATION MATERIALS.
IT'S ALWAYS HARD BECAUSE THEY
ARE ALWAYS GREAT, WE ARE ALWAYS
REALLY CLOSE TO TIES BUT WE DO
HAVE TO COME TO A DECISION ON
ONE.
SO BEFORE I MAKE THAT
ANNOUNCEMENT WHAT I WOULD LIKE
TO DO IS ADD A LITTLE BIT TO
WHAT DAVE THOMAS TOLD US ABOUT
MITCHELL MAX THIS MORNING.
SOME OF US, SOME OF YOU IN THE
AUDIENCE ARE PROBABLY TOO YOUNG
TO HAVE CROSSED PATHS WITH
MITCHELL MAX.
HE WAS A PRETTY AMAZING
SCIENTIST.
A VERY COMPASSIONATE CLINICIAN.
HE WAS A MENTOR TO MANY, MANY
PEOPLE.
AND THIS IS WHY HE WAS CHOSEN
TO ACTUALLY BE GIVEN THE TITLE
FOR THE MITCHELL MAX AWARD.
THERE WERE TWO OF HIS REALLY
CLOSE FRIENDS AFTER HE DIED
TRAGICALLY WROTE AN ARTICLE IN
THE JOURNAL OF PAIN.
I WILL READ YOU A TINY LITTLE
BIT TO GIVE YOU A SENSE OF
MITCHELL.
THIS IS CHUCK AND CATHY
SPEAKING.
BRILLIANT SCIENTIST,
COMPASSIONATE PHYSICIAN, TRUE
HEALER, GIFTED MUSICIAN,
PHILOSOPHER, LOYAL MENTOR,
LOVING HUSBAND AND FATHER AND A
DEAR FRIEND.
SO THEY GO ONTO MENTION THAT
TWO DAYS BEFORE HE PASSED AWAY,
THAT HE HAD GIVEN, I WAS LUCKY
ENOUGH TO BE AT HIS
PRESENTATION AT THE HARVARD
RESEARCH FORUM TALK ON HIS WORK
IN THE GENETICS OF PAIN.
JUST ONE LITTLE AREA OF ALL THE
AREAS OF PAIN RESEARCH, PAIN
CARE AND PAIN MANAGEMENT THAT
MITCHELL REALLY DOVE INTO, AND
MADE AN AMAZING CONTRIBUTION.
NOW TO THE BUSINESS OF THE
PRESENTATION.
WE HAVE A GIFT FOR THE WINNER.
I TOOK A LITTLE QUICK LOOK
THROUGH IT.
IT'S A REALLY BEAUTIFUL BOOK
CALLED "SEEING THE MIND".
LITTLE CHAPTERS ABOUT
NEUROSCIENCE OF THE BRAIN AND
IMAGES THAT GO ALONG WITH THE
PARTICULAR AREAS OF THE BOOK.
IT'S BEAUTIFULLY WRITTEN AND
BEAUTIFULLY ILLUSTRATED.
I'M ACTUALLY PUTTING IT ON MY
CHRISTMAS LIST.
WHAT I WOULD LIKE TO DO NOW IS
JUST TELL YOU, HOW WONDERFUL IT
WAS TO SEE THESE DIFFERENT
PRESENTATIONS AND GIVEN THE
BREADTH OF THE TYPE OF RESEARCH
THAT THEY TALKED ABOUT, I THINK
KIND OF HIGHLIGHTS THE
COMPLEXITY OF PAIN AND THE
COMPLEXITY OF PAIN RESEARCH.
AS A REMINDER WE HAD KENDRA
KAMP WHO TALKED ABOUT SEX AND
GENDER DIFFERENCE IN ABDOMINAL
PAIN, A GREAT PRESENTATION.
BRYAN McKIVER WHO TALKED ABOUT
THE MECHANISMS FOR THE
UNDERSTANDING AND PREVENTION OF
CHEMOTHERAPY INDUCED PAIN.
WE WOULD LIKE TO EXTEND OUR
CONGRATULATIONS TO BRYAN, WE
THINK WE FINISHED HIS Ph.D. IN
MAY, I CAN'T SEE IN THE
AUDIENCE, IS THAT CORRECT?
LIKE A WEEK OR TWO AGO?
CONGRATULATIONS, BRYAN.
AND THEN WE HAD CARLYN
PATTERSON GENTILE A HEADACHE
SPECIALIST AND TALKED ABOUT
CLUSTER ANALYSIS FOR MIGRAINE
ASSOCIATED SYMPTOMS.
MITCHELL MAX AWARD GOES TO
CARLYN PATTERSON GENTILE OF
CLUSTER ANALYSIS OF MIGRAINE
ASSOCIATED SYMPTOMS IN YOUTH.
CARLYN, COULD YOU COME UP?
HERE IS YOUR BOOK.
>> THANK YOU.
>> HERE IS YOUR PLAQUE, CAN PUT
THAT ON THE WALL.
THANK YOU SO MUCH FOR YOUR
PRESENTATION, ALL YOUR HARD
WORK AND BEST OF ALL IN THE
FUTURE FOR YOUR RESEARCH, IT'S
VERY MUCH APPRECIATED.
WE WILL MAKE YOU STAND UP HERE
AND TAKE A PICTURE.
SO THAT CONCLUDES THE DAY.
THANK YOU VERY MUCH.
WE WILL SEE YOU ALL TOMORROW
MORNING.