Frederick M Hecht

University of California, San Francisco, San Francisco, California, United States

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Publications (214)1339.78 Total impact


  • No preview · Article · Feb 2016 · AIDS
  • Aric A. Prather · Frederick M. Hecht · Elissa S. Epel

    No preview · Article · Feb 2016 · Brain Behavior and Immunity
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    ABSTRACT: Background: HIV latent infection can be established in vitro by treating resting CD4+ T-cells with chemokines (CK) that bind to chemokine receptors (CKR), CCR7, CXCR3 and CCR6, highly expressed on T-cells. Objective: To determine if CKR identify CD4+ T-cells enriched for HIV in HIV-infected individuals receiving suppressive antiretroviral therapy (ART). Design: A cross-sectional study of CKR expression and HIV persistence in blood from HIV-infected individuals on suppressive ART for >3 years (n = 48). A subset of 20 individuals underwent leukapheresis and sorting of specific CD4+ T-cell subsets. Methods: We used flow cytometry to quantify CCR5, CCR6, CXCR3 and CXCR5 expression on CD4+ T-cells. HIV persistence was quantified using real time PCR to detect total, integrated HIV DNA, 2-LTR circles and cell-associated HIV RNA in total CD4+ T-cells from blood or sorted T-cell subsets. Associations between CKR and HIV persistence in CD4+ T-cells in blood were determined using regression models and adjusted for current and nadir CD4+ T-cell counts. Results: The frequency of cells harbouring integrated HIV DNA was inversely associated with current CD4+ T-cell count and positively associated with CCR5+ CD4+ T-cells, CXCR3+CCR6+ and CXCR3+CCR6- expression on total memory CD4+ T-cells (p < 0.001, 0.048, 0.015 and 0.016 respectively). CXCR3+CCR6+ CM CD4+ T-cells contained the highest amount of integrated HIV DNA compared to all T-cell subsets examined (p = 0.001). Conclusion: CXCR3 and CCR6 co-expression defines a subset of CD4+ T-cells that are preferentially enriched for HIV DNA in HIV-infected individuals on ART.
    No preview · Article · Jan 2016 · AIDS (London, England)
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    ABSTRACT: HIV infection induces phenotypic and functional changes to CD8+ T cells defined by the coordinated upregulation of a series of negative checkpoint receptors that eventually result in T cell exhaustion and failure to control viral replication. We report that effector CD8+ T cells during HIV infection in blood and SIV infection in lymphoid tissue exhibit higher levels of the negative checkpoint receptor TIGIT. Increased frequencies of TIGIT+ and TIGIT+ PD-1+ CD8+ T cells correlated with parameters of HIV and SIV disease progression. TIGIT remained elevated despite viral suppression in those with either pharmacological antiretroviral control or immunologically in elite controllers. HIV and SIV-specific CD8+ T cells were dysfunctional and expressed high levels of TIGIT and PD-1. Ex-vivo single or combinational antibody blockade of TIGIT and/or PD-L1 restored viral-specific CD8+ T cell effector responses. The frequency of TIGIT+ CD4+ T cells correlated with the CD4+ T cell total HIV DNA. These findings identify TIGIT as a novel marker of dysfunctional HIV-specific T cells and suggest TIGIT along with other checkpoint receptors may be novel curative HIV targets to reverse T cell exhaustion.
    Full-text · Article · Jan 2016 · PLoS Pathogens
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    ABSTRACT: BACKGROUND: People with prehypertension (120-130/80-90 mmHg) are at increased risk of progressing to hypertension. Recommendations for prehypertension include engaging in regular physical activity. We aimed to assess feasibility and acceptability and collect preliminary outcome data on ChiRunning for people with elevated blood pressure. ChiRunning is a commercially available running program based on the mindful movements of Tai Chi, which is aimed at decreasing injury by both increasing body awareness and modifying running form. METHODS: We enrolled adults with elevated systolic (130-150 mmHg) or diastolic (80-100 mmHg) blood pressure in a 12-week pilot trial. Participants were randomized 2:1:1 to 8 weeks of: 1) intervention-a trainer-led ChiRunning group (n = 10); 2) active control-a trainer-led running group (n = 6); or 3) educational control-a self-directed running group (n = 6) and followed for 4 more weeks. The active control and educational control groups were combined for analysis. RESULTS: This study was feasible, meeting recruitment, retention and adherence goals, and acceptable to participants. Systolic and diastolic blood pressure did not change significantly over the study for either the ChiRunning or control groups. Changes in BMI over time were significantly different from zero in the ChiRunning group (p = 0.04) but not in the control group (slope for ChiRunning -0.05 [-0.1 to -0.002] vs. control -0.01 [-0.06 to 0.04], between slope difference, p = 0.22). Self-reported running-related injury (i.e. discomfort leading to a decrease in running) was similar between groups (ChiRunning, 4 [1.2 to 8.4] vs. control, 3 [0.7 to 7.1] injuries per 100 h of running, p = 0.72) although self-reported running-related discomfort (i.e. discomfort that does not lead to changes in running) trended higher in the ChiRunning group (ChiRunning, 10 [5.4 to 16.8] vs. control, 4 [1.5 to 9] reports of discomfort per 100 h of running, p = 0.06). CONCLUSION: ChiRunning appears to be a feasible and acceptable exercise program for people with elevated blood pressure. We did not find that ChiRunning had a significant impact on blood pressure or self reported injury, but did see a positive change in BMI over time. ChiRunning warrants further investigation in a larger trial. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01587183.
    Full-text · Article · Dec 2015 · BMC Complementary and Alternative Medicine
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    ABSTRACT: We used a stress and coping model to examine the association of dispositional mindfulness, defined as the tendency to intentionally bring non-judgmental attention and awareness to one's experience in the present moment, with psychological and physical health in adults with HIV. Data were collected at baseline of a randomized controlled trial of Mindfulness-Based Stress Reduction (MBSR). Four facets of mindfulness (acting with attention/awareness, non-judging of inner experience, observing, and describing) were examined as correlates of appraisal, positive and negative affect, coping, and indicators of psychological well-being and physical health. We found that mindfulness was inversely related to depression, stress appraisal, and negative affect, and positively related to positive affect. Mindfulness was also inversely related to escape/avoidance and self-blame forms of coping. Mediational analyses indicate that perceived stress and negative affect were the most consistent mediators of the association of mindfulness and psychological well-being. The findings from this paper contribute to a growing understanding of the potential adaptive role of mindfulness in people living with the stress of serious illness.
    Full-text · Article · Nov 2015 · Personality and Individual Differences
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    ABSTRACT: We evaluated changes in mindful eating as a potential mechanism underlying the effects of a mindfulness-based intervention for weight loss on eating of sweet foods and fasting glucose levels. We randomized 194 obese individuals (M age = 47.0 ± 12.7 years; BMI = 35.5 ± 3.6; 78 % women) to a 5.5-month diet-exercise program with or without mindfulness training. The mindfulness group, relative to the active control group, evidenced increases in mindful eating and maintenance of fasting glucose from baseline to 12-month assessment. Increases in mindful eating were associated with decreased eating of sweets and fasting glucose levels among mindfulness group participants, but this association was not statistically significant among active control group participants. Twelve-month increases in mindful eating partially mediated the effect of intervention arm on changes in fasting glucose levels from baseline to 12-month assessment. Increases in mindful eating may contribute to the effects of mindfulness-based weight loss interventions on eating of sweets and fasting glucose levels.
    Full-text · Article · Nov 2015 · Journal of Behavioral Medicine
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    ABSTRACT: Objective: To examine the feasibility of identifying HIV negative at risk individuals in HIV serodiscordant couples, during voluntary HIV testing in South Brazil. Methods: We surveyed HIV testers at 4 public testing sites in Rio Grande do Sul. We obtained information on risk behaviors and sexual partnerships. HIV testing and testing for recent infection were performed; HIV prevalence and risk behaviors were assessed among subjects who reported having a steady partner who was HIV positive (serodiscordant group) and compared with the general testing population. Results: Among 3100 patients, 490 (15.8%) reported being in a steady relationship with an HIV positive partner. New HIV infections were diagnosed in 23% of the serodiscordant group (vs. 13% in the general population, p = 0.01); among newly positive subjects, recent HIV infections were more frequent (23/86, 26.7%) among testers with positive partners than among the general testing group (52/334; 15.6%; p = 0.016). Less than half of the serodiscordant testers reported having used a condom during the last sexual intercourse with their HIV-positive partner. Participants with inconsistent condom use with steady partner were four times more likely to test positive for HIV compared to those who reported always using condoms with the steady partner (OR: 4.2; 95% CI: 2.3 to 7.5). Conclusion: It is highly feasible to identify large numbers of HIV susceptible individuals who are in HIV serodiscordant relationships in South Brazil testing sites. Condom use within HIV serodiscordant couples is low in this setting, suggesting urgent need for biomedical prevention strategies to reduce HIV transmission.
    Full-text · Article · Nov 2015 · PLoS ONE
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    ABSTRACT: Background: Forty-nine million individuals are food insecure in the United States, where food insecurity and HIV/AIDS are prevalent among the urban poor. Food insecurity is associated with risky sexual behaviours among people living with HIV/AIDS (PLHIV). No qualitative studies, however, have investigated the mechanisms underlying this relationship either in a resource-rich setting or among populations that include men who have sex with men (MSM). Methods: Semi-structured in-depth interviews were conducted with 34 low-income PLHIV receiving food assistance in the San Francisco Bay Area. The interviews explored experiences with food insecurity and perceived associations with sexual risk behaviours. Interviews were conducted in English, audio-recorded and transcribed verbatim. Transcripts were coded and analyzed according to content analysis methods using an inductive-deductive approach. Results: Food insecurity was reported to be a strong contributor to risky sexual practices among MSM and female participants. Individuals described engaging in transactional sex for food or money to buy food, often during times of destitution. Participants also explained how food insecurity could lead to condomless sex despite knowledge of and desire to use safe sexual practices, largely because the need to obtain food in the short term was prioritized over the desire to use barrier protection. Conclusions: Our data extend previous research by demonstrating that food insecurity contributes to transactional and unprotected sex among urban poor individuals in a resource-rich setting, including among MSM. These findings underscore the importance of public health and social intervention efforts focused on structural inequalities.
    Full-text · Article · Nov 2015 · Journal of the International AIDS Society
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    ABSTRACT: Gut microbes can profoundly modulate mucosal barrier-promoting Th17 cells in mammals. A salient feature of HIV/simian immunodeficiency virus (SIV) immunopathogenesis is the loss of Th17 cells, which has been linked to increased activity of the immunomodulatory enzyme, indoleamine 2,3-dioxygenase 1 (IDO 1). The role of gut microbes in this system remains unknown, and the SIV-infected rhesus macaque provides a well-described model for HIV-associated Th17 loss and mucosal immune disruption. We observed a specific depletion of gut-resident Lactobacillus during acute and chronic SIV infection of rhesus macaques, which was also seen in early HIV-infected humans. This depletion in rhesus macaques correlated with increased IDO1 activity and Th17 loss. Macaques supplemented with a Lactobacillus-containing probiotic exhibited decreased IDO1 activity during chronic SIV infection. We propose that Lactobacillus species inhibit mammalian IDO1 and thus may help to preserve Th17 cells during pathogenic SIV infection, providing support for Lactobacillus species as modulators of mucosal immune homeostasis.
    Preview · Article · Nov 2015 · Cell Reports
  • Rhianon Liu · Alexandra Chang · Sanjay Reddy · Frederick M Hecht · Maria T Chao
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    ABSTRACT: Objectives: To describe cancer inpatients' prior-year use of complementary and integrative health (CIH) therapies and interest in receiving CIH therapies while in the hospital. Design: Observational, cross-sectional survey of prior-year use of 12 different CIH approaches and interest in receiving any of 7 CIH services in the hospital. Setting: Surgical oncology ward of an academic medical center. Participants: 166 hospitalized oncology patients, with an average age of 54 years. Results: The most commonly used CIH approach was vitamins/nutritional supplements (67%), followed by use of a special diet (42%) and manual therapies (39%). More than 40% of patients expressed interest in each of the therapies if it was offered during their hospital stay, and 95% of patients were interested in at least one. More than 75% expressed interest in nutritional counseling and in massage. CIH use and interest varied somewhat by demographic and clinical characteristics. Conclusion: Rates of CIH use among patients with cancer were high, as were their preferences to have these services available in the inpatient setting. Hospitals have the opportunity to provide patient-centered care by developing capacity to provide inpatient CIH services.
    No preview · Article · Oct 2015 · Journal of alternative and complementary medicine (New York, N.Y.)
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    Full-text · Dataset · Sep 2015
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    ABSTRACT: T-cell expression levels of CC chemokine receptor 5 (CCR5) are a critical determinant of HIV/AIDS susceptibility, and manifest wide variations (i) between T-cell subsets and among individuals and (ii) in T-cell activation-induced increases in expression levels. We demonstrate that a unifying mechanism for this variation is differences in constitutive and T-cell activation-induced DNA methylation status of CCR5 cis-regulatory regions (cis-regions). Commencing at an evolutionarily conserved CpG (CpG -41), CCR5 cis-regions manifest lower vs. higher methylation in T cells with higher vs. lower CCR5 levels (memory vs. naïve T cells) and in memory T cells with higher vs. lower CCR5 levels. HIV-related and in vitro induced T-cell activation is associated with demethylation of these cis-regions. CCR5 haplotypes associated with increased vs. decreased gene/surface expression levels and HIV/AIDS susceptibility magnify vs. dampen T-cell activation-associated demethylation. Methylation status of CCR5 intron 2 explains a larger proportion of the variation in CCR5 levels than genotype or T-cell activation. The ancestral, protective CCR5-HHA haplotype bears a polymorphism at CpG -41 that is (i) specific to southern Africa, (ii) abrogates binding of the transcription factor CREB1 to this cis-region, and (iii) exhibits a trend for overrepresentation in persons with reduced susceptibility to HIV and disease progression. Genotypes lacking the CCR5-Δ32 mutation but with hypermethylated cis-regions have CCR5 levels similar to genotypes heterozygous for CCR5-Δ32. In HIV-infected individuals, CCR5 cis-regions remain demethylated, despite restoration of CD4+ counts (≥800 cells per mm(3)) with antiretroviral therapy. Thus, methylation content of CCR5 cis-regions is a central epigenetic determinant of T-cell CCR5 levels, and possibly HIV-related outcomes.
    Full-text · Article · Aug 2015 · Proceedings of the National Academy of Sciences
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    ABSTRACT: Obese individuals vary in their experience of food cravings and tendency to engage in reward-driven eating, both of which can be modulated by the neural reward system rather than physiological hunger. We examined two predictions in a sample of obese women: (1) whether opioidergic blockade reduced food-craving intensity, and (2) whether opioidergic blockade reduced an association between food-craving intensity and reward-driven eating, which is a trait-like index of three factors (lack of control over eating, lack of satiation, preoccupation with food). Forty-four obese, pre-menopausal women completed the Reward-Based Eating Drive (RED) scale at study start and daily food-craving intensity on 5days on which they ingested either a pill-placebo (2days), a 25mg naltrexone dose (1day), or a standard 50mg naltrexone dose (2days). Craving intensity was similar under naltrexone and placebo doses. The association between food-craving intensity and reward-driven eating significantly differed between placebo and 50mg naltrexone doses. Reward-driven eating and craving intensity were significantly positively associated under both placebo doses. As predicted, opioidergic blockade (for both doses 25mg and 50mg naltrexone) reduced the positive association between reward-driven eating and craving intensity to non-significance. Opioidergic blockade did not reduce craving intensity; however, blockade reduced an association between trait-like reward-driven eating and daily food-craving intensity, and may help identify an important endophenotype within obesity. Published by Elsevier Ltd.
    Full-text · Article · Jul 2015 · Eating behaviors

  • No preview · Article · Jul 2015 · Journal of the International AIDS Society
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    ABSTRACT: Quantifying latently infected cells is critical to evaluate the efficacy of therapeutic strategies aimed at reducing the size of the long-lived viral reservoir, but the low frequency of these cells makes this very challenging.
    Full-text · Article · Jun 2015 · EBioMedicine
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    ABSTRACT: Introdução: As estratégias de prevenção da transmissão da infecção pelo vírus da imunodeficiência humana (HIV) em casais sorodiscordantes geralmente são voltadas para as pessoas HIV positivas, não havendo consenso sobre a abordagem das parcerias soronegativas. Objetivo: Identificar e quantificar a ocorrência de comportamentos de risco em pessoas HIV negativas com parceria HIV positiva fixa. Métodos: Examinamos a frequência com que os participantes de um estudo transversal relataram ter parceria HIV positiva no formulário padrão do serviço e/ou no questionário do estudo. Avaliamos comportamentos de risco e novos diagnósticos de infecção pelo HIV em pacientes “potencialmente sorodiscordantes” em comparação com os outros pacientes na população em geral. O diagnóstico de HIV foi realizado seguindo o algoritmo de testagem padrão. O teste BED EIA HIV-1 (Calypte Biomedical, Portland, OR; ODn cutoff=0,8) foi utilizado para classificar pessoas recentemente infectadas pelo HIV. Resultados: Entre os 3.100 pacientes com nenhum teste reagente para HIV anterior, 490 (15,8%) relataram estar em um relacionamento fixo com uma pessoa HIV positiva. Esta proporção foi semelhante tanto para homens que fazem sexo com homens (HSH) como em heterossexuais. Menos da metade dos participantes reportou ter usado o preservativo durante o último ato sexual com o parceiro HIV positivo. Apenas um quarto dos homens heterossexuais e um terço dos HSH e mulheres reportaram o uso consistente de preservativos com seu parceiro no último ano. Os principais motivos para não usar preservativo com o parceiro fixo foram: “confia no parceiro” (31,7%), seguido de “não gosta” (15,1%) e “parceiro não aceita” (8,9%). Foram diagnosticadas novas infecções pelo HIV em 23% do grupo de pacientes potencialmente discordantes (versus 13% na população geral; p=0,01). Participantes com uso inconsistente de preservativos com parceiro fixo apresentaram uma chance 4 vezes maior de ter resultado positivo para HIV, quando comparados com aqueles que reportaram sempre usar preservativos com o parceiro fixo (OR=4,2; IC95% 2,3–7,5). Houve uma maior adesão à utilização de preservativos com parcerias casuais no último ato sexual, variando de 58,5% (homens heterossexuais) a 75% (HSH e mulheres). Conclusão: Parcerias sorodiscordantes fixas, com elevado risco de transmissão do HIV, podem ser identificadas no momento da testagem e do aconselhamento. O acesso a essa população é fundamental para a implantação de estratégias de prevenção em localidades com alta incidência de HIV.
    Full-text · Conference Paper · May 2015
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    ABSTRACT: CD8+ T cells are important for HIV-1 virus control, but are also a major contributing factor that drives HIV-1 virus sequence evolution. Although HIV-1 cytotoxic T cell (CTL) escape mutations are a common aspect during HIV-1 infection, less is known about the importance of T cell pressure in reversing HIV-1 virus back to a consensus sequences. In this study we aimed to assess the frequency with which reversion of transmitted mutations in T cell epitopes were associated with T cell responses to the mutation. This study included 14 HIV-1 transmission pairs consisting of a 'source' (virus-donor) and a 'recipient' (newly infected individual). Non-consensus B sequence amino acids (mutations) in T cell epitopes in HIV-1 gag regions p17, p24, p2 and p7 were identified in each pair and transmission of mutations to the recipient was verified with population viral sequencing. Longitudinal analyses of the recipient's viral sequence were used to identify whether reversion of mutations back to the consensus B sequence occurred. Autologous 12-mer peptides overlapping by 11 were synthesized, representing the sequence region surrounding each reversion and longitudinal analysis of T cell responses to source-derived mutated and reverted epitopes were assessed. We demonstrated that mutations in the source were frequently transmitted to the new host and on an average 17 percent of mutated epitopes reverted to consensus sequence in the recipient. T cell responses to these mutated epitopes were detected in 7 of the 14 recipients in whom reversion occurred. Overall, these findings indicate that transmitted non-consensus B epitopes are frequently immunogenic in HLA-mismatched recipients and new T cell pressures to T cell escape mutations following transmission play a significant role in maintaining consensus HIV-1 sequences.
    Full-text · Article · Apr 2015 · PLoS ONE
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    ABSTRACT: There are currently no commonly used or easily accessible 'biomarkers' of hedonic eating. Physiologic responses to acute opioidergic blockade, indexed by cortisol changes and nausea, may represent indirect functional measures of opioid-mediated hedonic eating drive and predict weight loss following a mindfulness-based intervention for stress eating. In the current study, we tested whether cortisol and nausea responses induced by oral ingestion of an opioidergic antagonist (naltrexone) correlated with weight and self-report measures of hedonic eating and predicted changes in these measures following a mindfulness-based weight loss intervention. Obese women (N=88; age=46.7±13.2 years; BMI=35.8±3.8) elected to complete an optional sub-study prior to a 5.5-month weight loss intervention with or without mindfulness training. On two separate days, participants ingested naltrexone and placebo pills, collected saliva samples, and reported nausea levels. Supporting previous findings, naltrexone-induced cortisol increases were associated with greater hedonic eating (greater food addiction symptoms and reward-driven eating) and less mindful eating. Among participants with larger cortisol increases (+1 SD above mean), mindfulness participants (relative to control participants) reported greater reductions in food addiction symptoms, b=-0.95, SE(b)=0.40, 95% CI [-1.74, -0.15], p=.021. Naltrexone-induced nausea was marginally associated with reward-based eating. Among participants who endorsed naltrexone-induced nausea (n=38), mindfulness participants (relative to control participants) reported greater reductions in food addiction symptoms, b=-1.00, 95% CI [-1.85, -0.77], p=.024, and trended toward reduced reward-based eating, binge eating, and weight, post-intervention. Single assessments of naltrexone-induced cortisol increases and nausea responses may be useful time- and cost-effective biological markers to identify obese individuals with greater opioid-mediated hedonic eating drive who may benefit from weight loss interventions with adjuvant mindfulness training that targets hedonic eating. Copyright © 2015. Published by Elsevier Ltd.
    Full-text · Article · Apr 2015 · Appetite
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    Wolf E Mehling · Mark H Ebell · Andrew L Avins · Frederick M Hecht
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    ABSTRACT: Background context: Primary care clinicians need to identify candidates for early interventions to prevent patients with acute pain from developing chronic pain. Purpose: We conducted a 2-year prospective cohort study of risk factors for the progression to chronic pain and developed and internally validated a clinical decision rule (CDR) that stratifies patients into low-, medium-, and high-risk groups for chronic pain. Study design/setting: This is a prospective cohort study in primary care. Patient sample: Patients with acute low back pain (LBP, ≤30 days duration) were included. Outcome measures: Outcome measures were self-reported perceived nonrecovery and chronic pain. Methods: Patients were surveyed at baseline, 6 months, and 2 years. We conducted bivariate and multivariate regression analyses of demographic, clinical, and psychosocial variables for chronic pain outcomes, developed a CDR, and assessed its performance by calculating the bootstrapped areas under the receiver-operating characteristic curve (AUC) and likelihood ratios. Results: Six hundred five patients enrolled: 13% had chronic pain at 6 months and 19% at 2 years. An eight-item CDR was most parsimonious for classifying patients into three risk levels. Bootstrapped AUC was 0.76 (0.70-0.82) for the 6-month CDR. Each 10-point score increase (60-point range) was associated with an odds ratio of 11.1 (10.8-11.4) for developing chronic pain. Using a less than 5% probability of chronic pain as the cutoff for low risk and a greater than 40% probability for high risk, likelihood ratios were 0.26 (0.14-0.48) and 4.4 (3.0-6.3) for these groups, respectively. Conclusions: A CDR was developed that may help primary care clinicians classify patients with strictly defined acute LBP into low-, moderate-, and high-risk groups for developing chronic pain and performed acceptably in 1,000 bootstrapped replications. Validation in a separate sample is needed.
    Full-text · Article · Mar 2015 · The spine journal: official journal of the North American Spine Society

Publication Stats

12k Citations
1,339.78 Total Impact Points

Institutions

  • 1998-2015
    • University of California, San Francisco
      • • Department of Medicine
      • • Division of HIV/AIDS
      • • Department of Laboratory Medicine
      • • Department of Epidemiology and Biostatistics
      San Francisco, California, United States
  • 2001-2011
    • San Francisco VA Medical Center
      San Francisco, California, United States
  • 2006-2010
    • University of California, San Diego
      • Department of Medicine
      San Diego, California, United States
  • 2008
    • CSU Mentor
      • Department of Medicine
      Long Beach, California, United States
  • 2002-2008
    • Harvard University
      • Center for AIDS Research
      Cambridge, Massachusetts, United States
  • 2007
    • National Institute for Biological Standards and Control
      • Division of Virology
      Potters Bar, England, United Kingdom
  • 2000
    • Stanford University
      Palo Alto, California, United States
  • 1999-2000
    • University of California, Berkeley
      Berkeley, California, United States
    • California State University
      • Department of Medicine
      Long Beach, California, United States