Implementation of Project ECHO in a university health network: contrasting and comparing experiences across health conditions through a qualitative approach in a Canadian tertiary care centre.

OBJECTIVES: The objective of this study was to compare and contrast the experiences of interdisciplinary attendees (spokes) and experts (hub members) from three Extension for Community Healthcare Outcomes (ECHO) programmes: hepatitis C, chronic pain and concurrent mental health and substance use disorders. DESIGN: Prospective qualitative study. SETTING: Single-centre in tertiary care. PARTICIPANTS: The team conducted 30 one-on-one interviews with spokes and 4 focus groups with hub members from three ECHO programmes. ANALYSES: Three analysts were involved to perform a reflexive thematic analysis. RESULTS: Our results showed the benefits and limitations of the three ECHOs, varying according to specificities of targeted chronic conditions. Three overarching themes were identified from the data analysis: (1) perceived impacts of an interprofessional educational setting; (2) nature of disease and interprofessional interactions as determinants of clinical practice changes in diagnoses and treatments and (3) impacts on patient engagement and care pathways. CONCLUSIONS: The extent to which a chronic disease relies on a biopsychosocial approach, the degree of interdisciplinary care required and the simplicity/complexity of treatment algorithms influence perceived benefits and barriers to participating in ECHO programmes. These points raised by our study are important in the understanding of the successes and limitations of implementing an ECHO programme. They are essential as they provide key information for tailoring Project ECHO to the chronic disease it addresses.

Turkish cross-cultural adaptation, construct validity, and reliability of the treatment expectations in chronic pain scale.

BACKGROUND: Measuring treatment expectations using the Treatment Expectations in Chronic Pain (TEC) scale has the potential to help clinicians and researchers better understand the role that treatment expectations play within the framework of multimodal pain management settings. OBJECTIVE: The purpose of this study is to determine the cross-cultural adaptation, construct validity and reliability of the TEC Scale in the Turkish language. METHODS: The study included 191 volunteers aged 22-65 with chronic musculoskeletal diseases. This study composed of a six-stage cross-cultural adaptation process, which included translation, translation synthesis, back-translation, expert committee review, pre-testing and documentation submission. The Positivity Scale and Illness Cognition Questionnaire were used to measure convergent validity while the Hospital Anxiety and Depression Scale was used to test divergent validity. The psychometric properties of the Turkish version of the TEC scale was examined by confirmatory factor analysis (CFA). Scale's internal consistency was examined using Cronbach's alpha. Pearson correlation coefficients were utilized to evaluate both convergent and divergent validity. The significance level was set at p < .05. RESULTS: The results of the CFA showed that factor structure of predicted subscale fitted well the data (x2/df = 3,07;CFI = 0,91,IFI = 0,91 TLI = 0,87,RMSEA = 0,10). The results of the CFA indicated that factor structure of ideal subscale fitted well with the data (x2/df = 2,38;CFI = 0,92,IFI = 0,93,TLI = 0,90,RMSEA = 0,08). Both subscales of the TEC were strongly correlated. The predicted subscale had moderate relationships to depression, anxiety, and positivity (r = -0.37 to r = 0.55) but poor correlations with measures of acceptance, perceived benefits and helplessness (r = -0.24 to 0.35). The ideal subscale had moderate correlations with measures of positivity (r = 0.36) and depression (r = -0.38) but poor correlations with measures of acceptance, perceived benefits helplessness and anxiety (r = 0.14). CONCLUSIONS: The Turkish version of the TEC scale is acceptable, valid, and reliable for use in Turkish patients with chronic musculoskeletal pain in physiotherapy outpatient practice.

Psychiatric polygenic risk scores: Experience, hope for utility, and concerns among child and adolescent psychiatrists.

Recent advances in psychiatric genetics have enabled the use of polygenic risk scores (PRS) to estimate genetic risk for psychiatric disorders. However, the potential use of PRS in child and adolescent psychiatry has raised concerns. This study provides an in-depth examination of attitudes among child and adolescent psychiatrists (CAP) regarding the use of PRS in psychiatry. We conducted semi-structured interviews with U.S.-based CAP (n = 29) who possess expertise in genetics. The majority of CAP indicated that PRS have limited clinical utility in their current form and are not ready for clinical implementation. Most clinicians stated that nothing would motivate them to generate PRS at present; however, some exceptions were noted (e.g., parent/family request). Clinicians spoke to challenges related to ordering, interpreting, and explaining PRS to patients and families. CAP raised concerns regarding the potential for this information to be misinterpreted or misused by patients, families, clinicians, and outside entities such as insurance companies. Finally, some CAP noted that PRS may lead to increased stigmatization of psychiatric disorders, and at the extreme, could be used to support eugenics. As PRS testing increases, it will be critical to examine CAP and other stakeholders' views to ensure responsible implementation of this technology.

One-year opioid consumption trajectories among individuals receiving multidisciplinary postsurgical care: a single-center observational study from the Toronto General Hospital Transitional Pain Service.

INTRODUCTION: The Transitional Pain Service (TPS) is an innovative, personalized approach to postsurgical opioid consumption and pain management. The objectives of this study were to identify trajectories of opioid consumption and pain intensity within 12 months after initiating treatment through the TPS, identify biopsychosocial factors associated with trajectory membership, and examine the relationship between trajectory membership and other outcomes of interest over the same 12-month period. METHODS: Consecutive patients referred to the TPS were included in the present study (n=466). After providing informed consent, they completed self-report questionnaires at the initial visit at the TPS (either pre surgery or post surgery) and at every TPS visit until 12 months. Growth mixture modeling was used to derive trajectories and identify associated factors. RESULTS: Results showed three distinct opioid consumption trajectories for both presurgical opioid consumers and opioid-naïve patients. These trajectories all decreased over time and among those who were consuming opioids before surgery that returned to presurgical levels. Being man, having a substance use disorder, or reporting higher levels of pain interference were associated with higher daily opioid consumption for presurgical opioid consumers. For presurgical opioid-naïve individuals, higher opioid consumption trajectories were associated with higher levels of psychological distress. Five pain intensity trajectories were identified, and there were no significant association between opioid consumption and pain intensity trajectories. CONCLUSIONS: Results suggest that opioid consumption and pain intensity trajectories mostly decrease after surgery in a high-risk population enrolled in a TPS. Results also show heterogeneity in postsurgical recovery and highlight the importance of using personalized interventions to optimize individual trajectories.

Trajectories of pain and depressive symptoms among people living with low back pain during the COVID-19 pandemic: a 24-month longitudinal study.

Introduction: We explored trajectories of pain intensity and depressive symptoms over the first 24 months of the pandemic in people with low back pain. Methods: This longitudinal study was conducted alongside the Quebec Low Back Pain Study. Starting in April 2020 and every 3 months until July 2022, 291 participants completed an online survey. Group-based trajectory modeling was used to identify patterns of pain intensity and depressive symptoms. Onset outbreak characteristics were then put in relation with trajectory groups using multivariate logistic regression. Results: The analysis revealed 5 trajectories of pain intensity and depressive symptoms, respectively. The pain trajectories were stable mild (n = 17, 5.8%); stable moderate (n = 103, 35.4%); stable severe (n = 81, 27.8%); U-shape (n = 24, 8.3%), and inverted U-shape (n = 66, 22.7%). The trajectories of depressive symptoms were stable none (n = 58, 19.9%); stable very mild (n = 61, 21.0%); stable mild (n = 85, 29.2%); stable moderate (n = 59, 21.7%); and severe slightly improving (n = 24, 8.3%). Pre-COVID everyday/nearly everyday pain, average pain intensity, and widespread bodily pain were predictive of pain trajectory groups. Higher pre-COVID depression, acute stress disorder, and lockdown measures-related stress were associated with moderate/severe depressive trajectories. Discussion: Our findings indicated relative stability of pain and depressive symptoms among participants during the COVID-19 pandemic but also highlighted subgroups of people who experienced temporary deterioration or improvement over the first months of the pandemic that then reverted back to baseline levels. Modifiable risk factors were identified before the onset of the pandemic, which could give preventive measures in targeted populations.

Longitudinal multisite study of the chronobiological control of chronic pain: the CircaHealth CircaPain study protocol.

INTRODUCTION: One in five Canadians lives with chronic pain. Evidence shows that some individuals experience pain that fluctuates in intensity following a circadian (24-hour) rhythm. Endogenous molecular rhythms regulate the function of physiological processes that govern pain mechanisms. Addressing chronic pain rhythmicity on a molecular and biopsychosocial level can advance understanding of the disease and identify new treatment/management strategies. Our CircaHealth CircaPain study uses an online survey combined with ecological momentary assessments and biosample collection to investigate the circadian control of chronic pain and identify potential biomarkers. Our primary objective is to understand interindividual variability in pain rhythmicity, by collecting biopsychosocial measures. The secondary objective accounts for seasonal variability and the effect of latitude on rhythmicity. METHODS AND ANALYSIS: Following completion of a baseline questionnaire, participants complete a series of electronic symptom-tracking diaries to rate their pain intensity, negative affect, fatigue and stress on a 0-10 scale at 8:00, 14:00 and 20:00 daily over 10 days. These measures are repeated at 6 and 12 months postenrolment to account for potential seasonal changes. We aim to recruit ≥2500 adults with chronic pain within Canada. Infrastructure is being developed to facilitate the collection of blood samples from subgroups of participants (~800) two times per day over 24-48 hours to identify rhythmic expression of circulating genes and/or proteins. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained by the Queen's University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board (File No. 6038114). Participants provide informed consent to participate, and their data will not be identifiable in any publication or report. Findings will be published in a relevant scientific journal and disseminated at scientific meetings and online webinars. We maintain a website to post updated resources and engage with the community. We employ knowledge mobilisation in the form of direct data sharing with participants.

Prioritizing chronic pain self-management amid coexisting chronic illnesses: An exploratory qualitative study.

Background: In Canada, one out of five people lives with chronic pain, a condition frequently co-occurring with other chronic illnesses. As with most chronic illnesses, successful engagement in symptom management is key. In the context of multiple illnesses, self-management involves daily prioritization of symptoms and conditions and decision-making, which can be challenging. Self-management of chronic illnesses can require more complex competence and tasks to address the different implications of each condition. Objective: Our research objective was to explore types and processes of self-management symptom prioritization among adults living with chronic pain and other chronic illnesses. Design: This research was carried out as part of a larger study that adopted an explanatory sequential mixed-methods design. This study focused more specifically on the qualitative part of the study. Settings: Participants recruited for the qualitative component took part in a semi-structured individual interview online or in-person at the center hospitalier de l'Université de Montréal. Participants: In total, 25 participants were interviewed, including 18 women and 7 men. Methods: To participate in the qualitative part of the study, participants were selected from the larger study and were eligible if they were 18 years old or older and experiencing pain for more than 3 months and had at least one other chronic illness for which they were receiving treatment or engaged in symptom management. Semi-structured interviews were conducted in-person or virtually and were transcribed verbatim. Reflexive thematic analysis was used to explore patients' narratives, and an open and iterative approach was adopted to code interviews and generate themes. Findings: The first theme, focus on symptom prioritization, showed different prioritization processes, including prioritizing a dominant illness, prioritizing multiple illnesses to avoid undesirable consequences, and finally absence of or automatic processes of prioritization. In the second theme, we identified several characteristics of an illness, in this case chronic pain that made it a self-management priority: uncontrollable and disabling nature, omnipresence, unpredictability, unpleasantness, and invisibility to others. In the last theme, we highlighted that some psychosocial factors influenced levels of engagement in self-management and prioritization processes, including social support and the patient-physician relationship. Conclusions: Chronic pain was the medical condition most often prioritized by participants in their self-management tasks. Because of its characteristics, it was the medical condition that had the most negative impact on day-to-day functioning.

Pain relief and associated factors: a cross-sectional observational web-based study in a Quebec cohort of persons living with chronic pain.

Objectives: Randomized clinical trials are used to evaluate the efficacy of various pain treatments individually, while a limited number of observational studies have portrayed the overall relief experienced by persons living with chronic pain. This study aimed to describe pain relief in real-world clinical settings and to identify associated factors. Methods: This exploratory web-based cross-sectional study used data from 1,419 persons recruited in the community. Overall pain relief brought by treatments used by participants was assessed using a 0%-100% scale (10-unit increments). Results: A total of 18.2% of participants reported minimal pain relief (0%-20%), 60.0% moderate to substantial pain relief (30%-60%), and 21.8% extensive pain relief (70%-100%). Multivariable multinomial regression analysis revealed factors significantly associated with greater pain relief, including reporting a stressful event as circumstances surrounding the onset of pain, living with pain for ≥10 years, milder pain intensity, less catastrophic thinking, use of prescribed pain medications, use of nonpharmacological pain treatments, access to a trusted healthcare professional, higher general health scores, and polypharmacy. Factors associated with lower pain relief included surgery as circumstances surrounding pain onset, use of over-the-counter pain medications, and severe psychological distress. Discussion: In this community sample of persons living with chronic pain, 8 out of 10 persons reported experiencing at least moderate relief with their treatment. The analysis has enabled us to explore potential modifiable factors as opportunities for improving the well-being of persons living with chronic pain.

Where we live matters: a comparison of chronic pain treatment between remote and non-remote regions of Quebec, Canada.

Objective: Where a person lives is a recognized socioeconomic determinant of health and influences healthcare access. This study aimed to compare the pain treatment profile of persons with chronic pain (CP) living in remote regions to those living in non-remote regions (near or in major urban centers). Methods: A cross-sectional study was performed among persons living with CP across Quebec. In a web-based questionnaire, participants were asked to report in which of the 17 administrative regions they were living (six considered "remote"). Pain treatment profile was drawn up using seven variables: use of prescribed pain medications, over-the-counter pain medications, non-pharmacological pain treatments, multimodal approach, access to a trusted healthcare professional for pain management, excessive polypharmacy (≥10 medications), and use of cannabis for pain. Results: 1,399 participants completed the questionnaire (women: 83.4%, mean age: 50 years, living in remote regions: 23.8%). As compared to persons living in remote regions, those living in non-remote regions were more likely to report using prescribed pain medications (83.8% vs. 67.4%), a multimodal approach (81.5% vs. 75.5%), experience excessive polypharmacy (28.1% vs. 19.1%), and report using cannabis for pain (33.1% vs. 20.7%) (bivariable p < 0.05). Only the use of prescribed medications as well as cannabis remained significantly associated with the region of residence in the multivariable models. Discussion: There are differences in treatment profiles of persons with CP depending on the region they live. Our results highlight the importance of considering remoteness, and not only rurality, when it comes to better understanding the determinants of pain management.

Investigating the Impact of Stress on Pain: A Scoping Review on Sense of Control, Social-Evaluative Threat, Unpredictability, and Novelty (STUN Model).

Background: Stress can have paradoxical effects on pain, namely hyperalgesia and hypoalgesia. Four situational characteristics activate the hypothalamic-pituitary-adrenal axis, leading to a physiological stress response: lacking Sense of control, social-evaluative Threat, Unpredictability and Novelty (STUN). This scoping review reports on the types of evidence published on the effects of STUN characteristics on pain outcomes. Databases/Data Treatment: Searches of primary electronic databases were performed to identify articles published on adults between 1990 and 2021 that contained search terms on pain and stress/STUN characteristics. A total of 329 articles were included in the analysis. Results: Only 3.3% of studies examined simultaneously >1 STUN component. Almost all observational studies (177/180) examined the association between perceived stress and pain without measuring physiological stress responses. Of the 130 experimental studies, 78 (60.0%) manipulated stressful characteristics through nociception, and only 38.5% assessed if/how stress manipulation impacted perceived stress. Conclusion: There is a clear lack of integration of the characteristics that trigger a physiological stress response in the pain field. Only 3.3% of studies examined simultaneously more than one STUN component and there is an unequal attention given to individual components of the STUN framework. Recommendations for future research include selection of stress manipulations/measurements that are more precisely inducing/reflecting neurobiological mechanisms of stress responses to insure valid integration of scientific knowledge.

A Prospective Cohort Study of Acute Pain and In-Hospital Opioid Consumption After Cardiac Surgery: Associations With Psychological and Medical Factors and Chronic Postsurgical Pain.

BACKGROUND: Understanding the association of acute pain intensity and opioid consumption after cardiac surgery with chronic postsurgical pain (CPSP) can facilitate implementation of personalized prevention measures to improve outcomes. The objectives were to (1) examine acute pain intensity and daily mg morphine equivalent dose (MME/day) trajectories after cardiac surgery, (2) identify factors associated with pain intensity and opioid consumption trajectories, and (3) assess whether pain intensity and opioid consumption trajectories are risk factors for CPSP. METHODS: Prospective observational cohort study design conducted between August 2012 and June 2020 with 1-year follow-up. A total of 1115 adults undergoing cardiac surgery were recruited from the preoperative clinic. Of the 959 participants included in the analyses, 573 completed the 1-year follow-up. Main outcomes were pain intensity scores and MME/day consumption over the first 6 postoperative days (PODs) analyzed using latent growth mixture modeling (GMM). Secondary outcome was 12-month CPSP status. RESULTS: Participants were mostly male (76%), with a mean age of 61 ± 13 years. Three distinct linear acute postoperative pain intensity trajectories were identified: "initially moderate pain intensity remaining moderate" (n = 62), "initially mild pain intensity remaining mild" (n = 221), and "initially moderate pain intensity decreasing to mild" (n = 251). Age, sex, emotional distress in response to bodily sensations, and sensitivity to pain traumatization were significantly associated with pain intensity trajectories. Three distinct opioid consumption trajectories were identified on the log MME/day: "initially high level of MME/day gradually decreasing" (n = 89), "initially low level of MME/day remaining low" (n = 108), and "initially moderate level of MME/day decreasing to low" (n = 329). Age and emotional distress in response to bodily sensations were associated with trajectory membership. Individuals in the "initially mild pain intensity remaining mild" trajectory were less likely than those in the "initially moderate pain intensity remaining moderate" trajectory to report CPSP (odds ratio [95% confidence interval, CI], 0.23 [0.06-0.88]). No significant associations were observed between opioid consumption trajectory membership and CPSP status (odds ratio [95% CI], 0.84 [0.28-2.54] and 0.95 [0.22-4.13]). CONCLUSIONS: Those with moderate pain intensity right after surgery are more likely to develop CPSP suggesting that those patients should be flagged early on in their postoperative recovery to attempt to alter their trajectory and prevent CPSP. Emotional distress in response to bodily sensations is the only consistent modifiable factor associated with both pain and opioid trajectories.

Trajectories of opioid consumption as predictors of patient-reported outcomes among individuals attending multidisciplinary pain treatment clinics.

PURPOSE: This study aimed to identify opioid consumption trajectories among persons living with chronic pain (CP) and put them in relation to patient-reported outcomes 6 months after initiating multidisciplinary pain treatment. METHODS: This study used data from the Quebec Pain Registry (2008-2014) linked to longitudinal Quebec health insurance databases. We included adults diagnosed with CP and covered by the Quebec public prescription drug insurance plan. The daily cumulative opioid doses in the first 6 months after initiating multidisciplinary pain treatment were transformed into morphine milligram equivalents. An individual-centered approach involving principal factor and cluster analyses applied to longitudinal statistical indicators of opioid use was conducted to classify trajectories. Multivariate regression models were applied to evaluate the associations between trajectory group membership and outcomes at 6-month follow-up (pain intensity, pain interference, depression, and physical and mental health-related quality of life). RESULTS: We identified three trajectories of opioid consumption: "no or very low and stable" opioid consumption (n = 2067, 96.3%), "increasing" opioid consumption (n = 40, 1.9%), and "decreasing" opioid consumption (n = 39, 1.8%). Patients in the "no or very low and stable" trajectory were less likely to be current smokers, experience polypharmacy, use opioids or benzodiazepine preceding their first visit, or experience pain interference at treatment initiation. Patients in the "increasing" opioid consumption group had significantly greater depression scores at 6-month compared to patients in the "no or very low and stable" trajectory group. CONCLUSION: Opioid consumption trajectories do not seem to be important determinants of most PROs 6 months after initiating multidisciplinary pain treatment.

Virtual group psychotherapy for chronic pain: exploring the impact of the virtual medium on participants' experiences.

BACKGROUND: Virtual psychotherapy for chronic pain (CP) has been shown to be feasible, efficacious, and acceptable; however, little is known about how virtual delivery of group psychotherapy affects participants' experiences. This study aimed to explore the impact of a virtual medium during the coronavirus disease 2019 (COVID-19) pandemic on social interactions and therapeutic processes in the context of group psychotherapy for CP management. METHODS: This qualitative, interview-based study collected data on 18 individuals who participated in virtual group psychotherapy in a tertiary care pain management unit. RESULTS: Results of the thematic analysis showed 4 themes. First, the ability to participate and connect was modified by not meeting in person. Connections also occurred differently as the usual patterns of interactions changed. Participants described important shifts in how emotions are communicated and subsequent experience of empathy. Finally, the commonality of chronic pain experience was identified as a central driver of connection between participants. CONCLUSIONS: Mixed impacts of the virtual medium on group psychotherapy dynamics and processes were found. Future research could explore ways to mitigate the negative impacts.

The Medication Quantification Scale 4.0: An Updated Index Based on Prescribers' Perceptions of the Risk Associated With Chronic Pain Medications.

To quantify risks associated with drug utilization in the real world for the treatment of chronic pain (CP), an index called the Medication Quantification Scale (MQS) was developed in 1992 in the United States and last updated in 2003. This study aimed to update, adapt to the contemporary Canadian context, and validate a revised version of the MQS (the MQS-4.0). Step 1: An expert committee adapted the MQS to the Canadian clinical practice context. Step 2: An update of risk weights given to medication subclasses was achieved using a prescriber survey (weights were derived from median 0-10 scores given to each subclass). Step 3: Construct validity of the MQS-4.0 was assessed after applying risk weights to the medication use profile of persons living with CP covered by public drug insurance plan. Thirty-six medication subclasses were included in the MQS-4.0. A total of 207 prescribers (physicians, pharmacists, and nurse practitioners) participated in the perception survey; 10.63% identified as pain specialists. When risk weights were applied to prescription claims (n = 9,122), the MQS-4.0 score was associated (P < .05) with the MQS-III score and variables associated with polypharmacy (eg, Charlson Comorbidity Index, number of prescribers or health care visits). This study provides an updated index intended for adult populations based on prescribers' perceptions of the risk associated with CP medications that can be useful for clinical practice and research among persons living with CP in Canada. It will, however, be relevant to verify whether similar risk weights are obtained in future pain specialist surveys. PERSPECTIVE: The MQS-4.0 is an update of the MQS used for quantifying the risk associated with the use of analgesics/coanalgesics. Adequate psychometrics properties were found.

Changing society, changing research: integrating gender to better understand physical and psychological treatments use in chronic pain management.

ABSTRACT: Treatment of chronic pain should be multimodal and include pharmacological, physical, and psychological treatments. However, because various barriers to physical and psychological treatments (PPTs) exist, a better understanding of biopsychosocial factors leading to their use is relevant. This study aimed to explore the association between gender identity, gender-stereotyped personality traits, and the use of PPTs in chronic pain management. The ChrOnic Pain trEatment cohort, a self-reported data infrastructure resulting from a web-based recruitment of 1935 people living with chronic pain (Quebec, Canada) was analyzed. Gender identity was operationalized as women, men, and nonbinary. Gender-stereotyped personality traits were measured using the Bem Sex-Role Inventory (feminine, masculine, androgynous, undifferentiated). A checklist of 31 types of PPTs that can be used for chronic pain management was presented to participants (yes/no). From the 1433 participants, 85.5% reported using at least one PPT. Hot-cold therapies (43.4%), exercise (41.9%), and meditation (35.2%) were the most frequently used PPTs, but most popular PPTs were not the same among women and men. Women reported a significantly higher use of PPTs in general (87.2% vs 77.2%; P < 0.001). Multivariable and interaction analyses showed that identifying as a man decreased the odds of reporting the use of PPTs (odds ratio: 0.32, 95% confidence interval: 0.11-0.92) but only among participants who scored high on both masculine and feminine personality traits (those classified as androgynous). The high prevalence of PPTs use found in our study is positive. Our results are relevant for a more personalized promotion of PPTs for chronic pain management.

Peritoneal malignancy in the global COVID-19 pandemic: experience of recovery and restoration in a high-volume centre through NHS and independent sector collaboration.

INTRODUCTION: Treatment of peritoneal malignancy with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) requires substantial critical care, theatre and nursing resources. The COVID-19 pandemic caused challenges in providing a high volume, tertiary referral service. METHODS: We reviewed data on referrals and operations performed in a tertiary referral centre in both NHS and independent sector settings. The impact of COVID-19 on activity was assessed using 2019 as a benchmark. RESULTS: New patient referrals were similar, with 891 in 2019 compared with 833 in 2020. Delivery of CRS and HIPEC operations were initially impacted by COVID-19. NHS and independent sector collaboration facilitated recovery, with 284 patients treated in 2020 compared with 280 in 2019. CONCLUSIONS: Close collaboration and structural organisation between the clinical and management teams in the NHS and independent sectors facilitated recovery and restoration of a complex tertiary referral service for peritoneal malignancy during the COVID pandemic.

Co-designing a Canadian adaptation of a lifestyle-oriented intervention aimed to improve daily functioning of individuals living with chronic pain: a multi-method study protocol of REVEAL(OT) Canada.

Background: Living with chronic pain (CP) often implies major lifestyle changes, including modifications of daily routines and work. Surprisingly, few validated and effective interventions specifically target functional outcomes in this population. Redesign your Everyday Activities and Lifestyle with Occupational Therapy [REVEAL(OT)] is a lifestyle-oriented intervention led by occupational therapists that directly targets the daily functional challenges of living with CP. The intervention was initially developed and studied as an add-on to standard treatment delivered by Danish multidisciplinary specialized pain clinics. Adapting, implementing, and evaluating REVEAL(OT) within the Canadian healthcare system will contribute to broadening the scope of treatments offered in specialized pain clinics that do not yet include occupational therapy. Objective: The proposed study aims to define and refine REVEAL(OT)/CA with partners (authors of original intervention, people with lived experience, clinicians, managers). Methods: This participatory action research will use a multi-method design and follow the ORBIT model for developing behavioral treatments for chronic diseases. A process of co-construction with partners and an advisory committee will take place in two Montreal specialized pain clinics. It consists of two related work packages (WPs). In WP1, a first series of focus groups with partners (n = 86) and workshops with the advisory committee will be conducted to co-develop the hypothetical pathway describing intervention components and their potential mechanisms of action on targeted outcomes, as well as the first version of the adapted intervention manual. WP2 will co-refine REVEAL(OT)/CA by exploring its acceptability, feasibility and mechanisms of action through intervention deliveries (at least twice in each of two specialized pain clinics; n ≥ 60 patients) and focus groups and/or individual interviews with participating patients and partners. At the end of this study, the intervention manual will be generated both in French and English. Discussion: This study will set the stage for subsequent implementation and effectiveness assessment projects and be an important step towards the deployment of interventions aiming to improve engagement in meaningful daily activities among adults living with CP. Registration: OSF Registries, osf.io/8gksa. Registered 3 August 2023, https://osf.io/8gksa.

The Calm after the Storm: A State-of-the-Art Review about Recommendations Put Forward during the COVID-19 Pandemic to Improve Chronic Pain Management.

The COVID-19 pandemic has brought its fair share of consequences. To control the transmission of the virus, several public health restrictions were put in place. While these restrictions had beneficial effects on transmission, they added to the pre-existing physical, psychosocial, and financial burdens associated with chronic pain, and made existing treatment gaps, challenges, and inequities worse. However, it also prompted researchers and clinicians to seek out possible solutions and expedite their implementation. This state-of-the-art review focuses on the concrete recommendations issued during the COVID-19 pandemic to improve the health and maintain the care of people living with chronic pain. The search strategy included a combination of chronic pain and pandemic-related terms. Four databases (Medline, PsycINFO, CINAHL, and PubMed) were searched, and records were assessed for eligibility. Original studies, reviews, editorials, and guidelines published in French or in English in peer-reviewed journals or by recognized pain organizations were considered for inclusion. A total of 119 articles were analyzed, and over 250 recommendations were extracted and classified into 12 subcategories: change in clinical practice, change in policy, continuity of care, research avenues to explore, group virtual care, health communications/education, individual virtual care, infection control, lifestyle, non-pharmacological treatments, pharmacological treatments, and social considerations. Recommendations highlight the importance of involving various healthcare professionals to prevent mental health burden and emergency overload and emphasize the recognition of chronic pain. The pandemic disrupted chronic pain management in an already-fragile ecosystem, presenting a unique opportunity for understanding ongoing challenges and identifying innovative solutions. Numerous recommendations were identified that are relevant well beyond the COVID-19 crisis.