Wound Bed Preparation 2024: Delphi Consensus on Foot Ulcer Management in Resource-Limited Settings.

GENERAL PURPOSE: To review a practical and scientifically sound application of the wound bed preparation model for communities without ideal resources. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Summarize issues related to wound assessment.2. Identify a class of drugs for the treatment of type II diabetes mellitus that has been shown to improve glycemia, nephroprotection, and cardiovascular outcomes.3. Synthesize strategies for wound management, including treatment in resource-limited settings.4. Specify the target time for edge advancement in chronic, healable wounds.

Chronic wound management in low-resource settings deserves special attention. Rural or underresourced settings (ie, those with limited basic needs/healthcare supplies and inconsistent availability of interprofessional team members) may not have the capacity to apply or duplicate best practices from urban or abundantly-resourced settings. The authors linked world expertise to develop a practical and scientifically sound application of the wound bed preparation model for communities without ideal resources. A group of 41 wound experts from 15 countries reached a consensus on wound bed preparation in resource-limited settings. Each statement of 10 key concepts (32 substatements) reached more than 88% consensus. The consensus statements and rationales can guide clinical practice and research for practitioners in low-resource settings. These concepts should prompt ongoing innovation to improve patient outcomes and healthcare system efficiency for all persons with foot ulcers, especially persons with diabetes.

Transition to Virtual Care Services during COVID-19 at Canadian Pain Clinics: Survey and Future Recommendations.

Introduction: Due to the COVID-19 pandemic, healthcare centers quickly adapted services into virtual formats. Pain clinics in Canada play a vital role in helping people living with pain, and these clinics remained essential services for patients throughout the pandemic. This study aimed to (1) describe and compare the transition from in-person to virtual pain care services at Canadian pain clinics during the onset of the COVID-19 pandemic and (2) provide postpandemic recommendations for pain care services to optimize the quality of patient care. Materials and Methods: We used a qualitative participatory action study design that included a cross-sectional survey for data collection and descriptive analysis to summarize the findings. Survey responses were collected between January and March of 2021. The survey was administered to the leadership teams of 11 adult pain clinics affiliated with the Chronic Pain Centre of Excellence for Canadian Veterans. Responses were analyzed qualitatively to describe the transition to the virtual pain services at pain clinics. Results: We achieved a 100% response rate from participating clinics. The results focus on describing the transition to the virtual care, current treatment and services, the quality of care, program sustainability, barriers to maintaining virtual services, and future considerations. Conclusions: Participating clinics were capable of transitioning pain care services to the virtual formats and have in-person care when needed with proper safety precautions. The pandemic demonstrated that it is feasible and sustainable for pain clinics to have a hybrid of virtual and in-person care to treat those living with pain. It is recommended that moving forward, there should be a hybrid of both virtual and in-person care for pain clinics. Ministries of Health should continue to develop policies and funding mechanisms that support innovations aimed at holistic healthcare, interdisciplinary teams, and the expansion of clinics' geographical reach for patient access.

Benefits and Concerns regarding Use of Cannabis for Therapeutic Purposes Among People Living with Chronic Pain: A Qualitative Research Study.

OBJECTIVE: Although there is growing interest in medically authorized cannabis for chronic pain, little is known about patients' perspectives. We explored perceptions of people living with chronic pain regarding benefits and concerns surrounding their use of cannabis for therapeutic purposes. SETTING: A hospital-based clinic in Hamilton and two community-based interdisciplinary pain clinics in Burlington, Ontario, Canada. METHODS: In this qualitative descriptive study, we conducted semi-structured interviews with 13 people living with chronic pain who used cannabis therapeutically, living in Ontario, Canada. We used thematic analysis, with data collection, coding, and analysis occurring concurrently. RESULTS: People living with chronic pain reported important benefits associated with use of cannabis for therapeutic purposes, including reduced pain, improved functionality, and less risk of harms compared to prescription opioids. Most patients also acknowledged harms, such as grogginess and coughing, and there was considerable variability in patient experiences. Financial costs and stigma were identified as important barriers to use of cannabis. CONCLUSION: Evidence-based guidance that incorporates patients' values and preferences may be helpful to inform the role of cannabis in the management of chronic pain.

Mandatory pharmacist-led education session for patients seeking medical cannabis.

OBJECTIVE: The primary objectives of this pre-post session study, was to evaluate the impact of a pharmacist-led education session on the perceived benefits and safety of cannabis among patients with chronic pain, as well as determine the influence of pharmacist education on the selection of safer cannabis products and dosage forms for medical use among patients. METHODS: A retrospective analysis of completed pre-post session questionnaires was conducted among chronic pain patients attending a mandatory education session led by a pharmacist, prior to being authorized cannabis in clinic. All questionnaire data was analyzed using SPSS v. 25. Demographic and sample characteristics were reviewed using univariate analyses. Chi-Square tests were employed to determine if the group-based education significantly affected knowledge, perception of efficacy and safety of cannabis. RESULTS: Of the 260 session participants, 203 completed pre-post session questionnaires. After the session, a majority of current cannabis users (33.8%) and cannabis naïve/past users (56.9%) reported they would use a low THC product in the future, and a majority of current users (54.5%) would use a high CBD product in the future. After education, participants were more likely to report cannabis as having the potential for addiction (chi-square =42.6, p <0.0001) and harm (chi-square =34.0, p <0.0001). CONCLUSIONS: Pharmacist counselling and education has the potential to influence patient selection and use of cannabis, from more harmful to safer products, as well as moderate the potential perceived benefits of use.

Evaluation of the preclinical analgesic efficacy of naturally derived, orally administered oil forms of Δ9-tetrahydrocannabinol (THC), cannabidiol (CBD), and their 1:1 combination.

Chronic neuropathic pain (NP) is a growing clinical problem for which effective treatments, aside from non-steroidal anti-inflammatory drugs and opioids, are lacking. Cannabinoids are emerging as potentially promising agents to manage neuroimmune effects associated with nociception. In particular, Δ9-tetrahydrocannabinol (THC), cannabidiol (CBD), and their combination are being considered as therapeutic alternatives for treatment of NP. This study aimed to examine whether sex affects long-term outcomes on persistent mechanical hypersensitivity 7 weeks after ceasing cannabinoid administration. Clinically relevant low doses of THC, CBD, and a 1:1 combination of THC:CBD extracts, in medium chain triglyceride (MCT) oil, were orally gavaged for 14 consecutive days to age-matched groups of male and female sexually mature Sprague Dawley rats. Treatments commenced one day after surgically inducing a pro-nociceptive state using a peripheral sciatic nerve cuff. The analgesic efficacy of each phytocannabinoid was assessed relative to MCT oil using hind paw mechanical behavioural testing once a week for 9 weeks. In vivo intracellular electrophysiology was recorded at endpoint to characterize soma threshold changes in primary afferent sensory neurons within dorsal root ganglia (DRG) innervated by the affected sciatic nerve. The thymus, spleen, and DRG were collected post-sacrifice and analyzed for long-term effects on markers associated with T lymphocytes at the RNA level using qPCR. Administration of cannabinoids, particularly the 1:1 combination of THC, elicited a sustained mechanical anti-hypersensitive effect in males with persistent peripheral NP, which corresponded to beneficial changes in myelinated Aß mechanoreceptive fibers. Specific immune cell markers associated with T cell differentiation and pro-inflammatory cytokines, previously implicated in repair processes, were differentially up-regulated by cannabinoids in males treated with cannabinoids, but not in females, warranting further investigation into sexual dimorphisms that may underlie treatment outcomes.

Out of the shadows: Chronic pain in Canadian Armed Forces veterans - Proceedings of a workshop at the 2019 Forum of the Canadian Institute for Military and Veteran Health Research.

This commentary summarizes proceedings of a workshop on chronic pain in military personnel and veterans (released personnel) at the Annual Forum of the Canadian Institute for Military and Veteran Health Research in Gatineau and Ottawa on October 22, 2019. The extent and impact of chronic pain among Canadian Armed Forces (CAF) veterans and their families is significant and has been underappreciated, largely due to limited disclosure by serving and veteran military personnel, stemming from a fear of stigmatization. Living with pain is seen as a fact of life in military cultures, something to be endured and not discussed. Though progress is being made in reducing the stigma of mental illness, the discourse on chronic pain remains censored. This workshop's goal was to bring the discussion of chronic pain out of the shadows in the search for ways to help veterans and active service personnel living with chronic pain. Many points of view were brought forward at this first national Canadian multidisciplinary gathering of researchers, veterans with lived experience, clinicians, and policymakers. A CAF member described his lived experience with constant chronic pain. Clinicians described aspects of chronic pain in military personnel and veterans whom they treat in their clinics. Dr. Ramesh Zacharias described the new Chronic Pain Center of Excellence for Canadian Veterans that will be established with funding from Veterans Affairs Canada. Dr. Norman Buckley highlighted collaboration with the existing Chronic Pain Network funded by the Canadian Institute for Health Research. Audience members identified a diverse variety of issues.

Ce commentaire résume les actes d'un atelier sur la douleur chronique chez le personnel militaire et les anciens combattants (personnel libéré) tenu dans le cadre du Forum annuel de l'Institut canadien de recherche sur la santé des militaires et des vétérans à Gatineau et Ottawa le 22 octobre 2019. L'étendue et l'effet de la douleur chronique chez les anciens combattants des Forces armées canadiennes (FAC) et leurs familles sont importantes et ont été sous-estimées, en grande partie en raison de la divulgation limitée par le personnel militaire en service et les anciens combattants, découlant de la peur de la stigmatisation. Le fait de vivre avec la douleur est considéré comme faisant partie de la vie dans les cultures militaires, quelque chose qu'il faut endurer et dont il ne faut pas discuter. Bien que des progrès aient été réalisés dans la réduction de la stigmatisation de la maladie mentale, le discours sur la douleur chronique continue d'être censuré. L'objectif de cet atelier était de faire sortir de l'ombre la discussion sur la douleur chronique afin de chercher des moyens d'aider les anciens combattants et le personnel de service actif vivant avec la douleur chronique. De nombreux points de vue ont été exprimés lors de cette première rencontre multidisciplinaire nationale canadienne réunissant des chercheurs, des anciens combattants ayant vécu l'expérience de la douleur chronique, des cliniciens et des décideurs. Un membre des FAC a décrit l'expérience de douleur chronique qu'il a vécue. Les cliniciens ont décrit les aspects de la douleur chronique chez le personnel militaire et les anciens combattants qu'ils traitent dans leurs cliniques. Le Dr Ramesh Zacharias a décrit le nouveau Centre d'excellence sur la douleur chronique pour les vétérans canadiens qui sera établi grâce au financement d'Anciens Combattants Canada. Le Dr Norman Buckley a souligné la collaboration avec le Réseau de douleur chronique existant financé par l'Institut canadien de la recherche en santé. Les membres de l'audience ont relevé divers problèmes.

Evaluation of an interdisciplinary chronic pain program and predictors of readiness for change.

Background: One in five Canadians experience chronic pain, and interdisciplinary pain programs are well established as the gold standard of treatment. However, not all patients are ready to engage in interdisciplinary treatment for chronic pain. Aims: The aims of this study were to (1) first demonstrate changes in patient-related outcomes after attending a publicly funded 8-week interdisciplinary pain program and (2) evaluate pain-related predictors of readiness for change. Methods: The institution's research ethics board approved this study. One hundred twenty-nine patients completed questionnaires on the first and last day of attending the program. Paired sample t-tests were utilized to evaluate the changes in patient-related outcomes after attending the program, and linear regressions were utilized to evaluate pain-related predictors of the stages of change. Results: Postprogram, there were significant decreases in pain-related interference, fear of pain/re-injury, pain catastrophizing, and symptoms of stress, depression, and anxiety and a significant increase in wellness-focused coping and self-efficacy. Postprogram, patients also demonstrated lower scores in precontemplation and contemplation and higher scores in action and maintenance stages of readiness for change. In predicting precontemplation, fear of pain/re-injury was the sole predictor, and self-efficacy was the sole predictor of the contemplation, action, and maintenance stages. Conclusion: These results demonstrate the short-term benefits of an 8-week interdisciplinary pain program. It is suggested that preprogram interventions targeting kinesophobia for individuals who are precontemplative and self-efficacy for others may be important to facilitate patient engagement.

Contexte: Un Canadien sur cinq souffre de douleur chronique. Il est bien établi que les programmes interdisciplinaires de la douleur constituent le traitement de référence. Toutefois, ce ne sont pas tous les patients qui sont prêts à suivre un traitement interdisciplinaire pour la douleur chronique.Buts: Les buts de cette étude étaient : 1) démontrer les changements dans les résultats liés aux patients après que ces derniers aient participé à un programme interdisciplinaire de la douleur de huit semaines, financé par des fonds publics, et 2) évaluer les prédicteurs de la disposition au changement lié à la douleur.Méthodes: La commission d'éthique de la recherche de l'institution a approuvé cette étude. Cent vingt-neuf patients ont répondu à des questionnaires le premier et le dernier jour de leur participation au programme. Des tests T pour échantillons appariés ont été utilisés pour évaluer les changements dans les résultats liés aux patients après avoir participé au programme et des régressions linéaires ont été utilisées pour évaluer les prédicteurs des étapes du changement lié à la douleur.Résultats: Après le programme, des diminutions significatives ont été observées dans l'interférence liée à la douleur, la peur de la douleur ou d'une nouvelle blessure, la catastrophisation de la douleur, ainsi que dans les symptômes de stress, de dépression, et d'anxiété. Une augmentation significative des stratégies d'adaptatation axées sur le bien-être et l'efficacité personnelle a aussi été observée. Après le progamme, les patients ont aussi obtenu des scores plus faibles pour la pré-contemplation et la contemplation et des scores plus élevés pour les étapes d'action et de mantien de la disposition au changement. La peur de la douleur ou d'une nouvelle blessure était l'unique prédicteur pour la pré-contemplation et l'efficacité personnelle était l'unique prédicteur des étapes de la contemplation, de l'action et du maintien.Conclusion: Ces résultats démontrent les bienfaits à court terme d'un programme interdisciplinaire de la douleur de huit semaines. Il est suggéré que les interventions pré-programme ciblant la kinésophobie, pour les individus qui sont à l'étape de la pré-contemplation, et l'efficacité personnelle pour d'autres, peuvent être importants pour faciliter l'engagement des patients.

Advancing the pain management in older adults agenda forward through the development of key research and education priorities: A Canadian perspective.

Background: The undermanagement of pain in older adults has been identified as a problem worldwide. Aims: The purpose of this research is to identify priority areas in education and research for future development with the aim of improving pain management in older persons. In addition, barriers to addressing these priorities are identified. Methods: This mixed methods study, based on a modified Delphi approach, included three distinct components: (1) a qualitative component using focus groups with key informants or experts in the field of pain management in older adults (n = 17), (2) a scoping review of the literature, and (3) a survey of ranked responses completed by the same key informants who attended the focus groups. Thematic analysis was used to identify the initial list of issues and descriptive statistics were used for ranking them. Results: A number of concerns related to both education and research were frequently endorsed by participants. For education, they identified the need for more content in both undergraduate and continuing education programs related to documenting about pain; assessing pain, and learning about the complexities of pain. Research priorities included the need to explore successful practice models; costs of untreated pain; effects of mobility on pain; and patient preferences for pain management. Key barriers to addressing these barriers included lack of staff time and resources and unfamiliarity with pain assessment tools. Conclusion: These findings highlight priority issues related to pain management in older adults from a nationwide perspective.

Contexte : La prise en charge insuffisante de la douleur chez les adultes plus âgés est considérée comme un problème partout dans le monde.But : Le but de cette étude est de définir les priorités en matière d'éducation et de recherche pour l'avenir, dans le but d'améliorer la gestion de la douleur chez les personnes plus âgées. De plus, les barrières existantes pour aborder ces priorités sont répertoriées.Méthodes : Cette étude à méthodologie mixte, fondée sur un processus Delphi modifié, comprenait trois composantes distinctes : (1) une composante qualitative ayant recours à des groupes de discussion réunissant des informateurs clés ou des experts du domaine de la gestion de la douleur chez les adultes plus âgés (n = 17); (2) une revue exploratoire de la littérature, et (3) un sondage comprenant des questions à réponses multiples hiérarchisées à laquelle ont répondu les mêmes informateurs qui avaient participé aux groupes de discussion. Une analyse thématique a ensuite été utilisée pour dresser la liste initiale de problèmes, qui ont ensuite été classés de manière hiérarchique à l'aide de statistiques descriptives.Résultats : Certaines préoccupations liées à la fois à l'éducation et à la recherche ont souvent été mentionnées par les participants. Pour l'éducation, ils ont relevé le besoin d'inclure davantage de contenu portant sur la documentation de la douleur, l'évaluation de la douleur et l'apprentissage des complexités de la douleur, tant dans les programmes de premier cycle que dans les programmes d'éducation permanente. Les priorités de recherche comprenaient la nécessité d'étudier les modèles de pratique qui ont connu du succès; les coûts de la douleur non traitée; les effets de la mobilité sur la douleur ; et les préférences des patients en matière de gestion de la douleur. Les barrières clés pour aborder ces questions comprenaient : le manque de personnel, de temps et de ressources, ainsi que la méconnaissance des outils d'évaluation de la douleur.Conclusion : Ces résultats mettent en relief les questions prioritaires liées à la gestion de la douleur chez les adultes plus âgés, dans une perspective nationale.

Improving pain assessment practices and outcomes in long-term care facilities: a mixed methods investigation.

An ongoing concern in long-term care (LTC) is that pain problems are often not identified correctly. There is also evidence that behavioral disturbance due to pain is misattributed to psychiatric conditions and consequently frequently treated with psychotropic rather than analgesic medication. This can result in unnecessary polypharmacy and ineffective pain management. In a previous study, implementation of a pain assessment protocol resulted in changes in administration of pro re nata (PRN) medications and positive outcomes. However, there were no changes in regularly scheduled medications suggesting that assessment results were either not communicated to the prescribing physicians or not taken into account. The goal of this study was to determine whether a pain assessment protocol, augmented with communication of the assessment results to the residents' physicians, affects prescriptions of analgesic and psychotropic medication. Psychotropic medication reduction would help address the problem of polypharmacy frequently seen in LTC facilities. PRN medications were also examined. This investigation involved a two group design (control vs. assessment). A mixed methods analysis included both quantitative and qualitative procedures. At the end of the study, residents in the pain assessment group were administered fewer psychotropic medications than patients in the control group, helping address the problem of polypharmacy. Pain levels were comparable between the groups. Health care staff indicated that the protocol resulted in more careful evaluation of residents' pain and greater appropriateness of prescriptions including reductions in polypharmacy.

Premedications for infliximab infusions do not impact the risk of acute adverse drug reactions.

OBJECTIVE: The purpose of this study was to identify the association of premedication with the adverse drug reaction (ADR) rate in infliximab infusions. DESIGN: A retrospective chart review of 684 patients who received 4077 infusions in a network of community clinics over 16.5 months. Data collected included age, weight, sex, diagnosis, dose, premedications and ADR information, which was coded for time of onset, severity and outcome. SETTING: Community infusion clinics located in Ontario, Canada. PATIENTS: Patients aged 12-91 years who receive regular infliximab infusions to treat their autoimmune condition, mainly either Crohn's disease or rheumatoid arthritis. MAIN OUTCOME MEASURES: The number of infusions to the occurrence of an acute ADR by presence of premedication. RESULTS: ADRs are not significantly different (χ2(1, n=644, p=0.651)=0.204) between those who always received premedications and those who never did. When controlling for age, sex, weight and diagnosis, patients receiving premedications were just as likely to experience an ADR as patients who never received any (OR 1.1, 95% CI 0.7 to 1.9, p=0.5). When assessing the number of infusions to the occurrence of an ADR using the Kaplan-Meier method, no significant difference was found between the two groups. CONCLUSIONS: The use of premedications is not associated with a decreased risk of ADR in patients receiving infliximab. This held true for patients who had never had an ADR prior to receiving premedications and while controlling for age, sex, weight and diagnosis.

The safety of infliximab infusions in the community setting.

BACKGROUND: Tumour necrosis factor-alpha (TNFalpha) has an important role in the pathogenesis of inflammatory conditions such as rheumatoid arthritis, Crohn's disease, ulcerative colitis and psoriasis. Infliximab, a chimeric anti-TNFalpha monoclonal antibody, has been shown to reduce the severity of symptoms or induces remission of active disease. Infusions have generally been limited to the hospital setting due to cost and concerns for patient safety. Studies defining its efficacy and safety have, therefore, originated almost exclusively from hospital settings. OBJECTIVE: To evaluate the safety of infliximab in a community clinic environment, across all types of patients. METHODS: A retrospective chart review of 3161 patients who received a combined 20,976 infusions at a network of community clinics over 16.5 months was conducted. Adverse drug reaction (ADR) information was retrieved and coded for time of onset, severity and outcome. Only ADRs that occurred during or within the first 24 h of the infusion were included. RESULTS: A total of 524 (2.5% of all infusions) acute ADRs in 353 patients (11.2%) were recorded. Most reactions (ie, ADRs) were mild (n=263 [50.2%, 1.3% of all infusions]) or moderate (n=233 [44.5%, 1.1% of all infusions]). Twenty-eight reactions (5.3%, 0.1% of all infusions) were severe. Emergency medical services were called to transport patients to hospital for seven of the severe reactions, of which none required admission. As per pre-established medical directives, adrenaline was administered three times. CONCLUSIONS: Infliximab infusions are safe in the community setting. Severe ADRs were rare. None required active physician intervention; nurses were able to treat all reactions by following standardized medical directives.