An Adaptive Pragmatic Randomized Controlled Trial of Emergency Department Acupuncture for Acute Musculoskeletal Pain Management.

STUDY OBJECTIVE: Acute musculoskeletal pain in emergency department (ED) patients is frequently severe and challenging to treat with medications alone. The purpose of this study was to determine the feasibility, acceptability, and effectiveness of adding ED acupuncture to treat acute episodes of musculoskeletal pain in the neck, back, and extremities. METHODS: In this pragmatic 2-stage adaptive open-label randomized clinical trial, Stage 1 identified whether auricular acupuncture (AA; based on the battlefield acupuncture protocol) or peripheral acupuncture (PA; needles in head, neck, and extremities only), when added to usual care was more feasible, acceptable, and efficacious in the ED. Stage 2 assessed effectiveness of the selected acupuncture intervention(s) on pain reduction compared to usual care only (UC). Licensed acupuncturists delivered AA and PA. They saw and evaluated but did not deliver acupuncture to the UC group as an attention control. All participants received UC from blinded ED providers. Primary outcome was 1-hour change in 11-point pain numeric rating scale. RESULTS: Stage 1 interim analysis found both acupuncture styles similar, so Stage 2 continued all 3 treatment arms. Among 236 participants randomized, demographics and baseline pain were comparable across groups. When compared to UC alone, reduction in pain was 1.6 (95% confidence interval [CI]: 0.7 to 2.6) points greater for AA+UC and 1.2 (95% CI: 0.3 to 2.1) points greater for PA+UC patients. Participants in both treatment arms reported high satisfaction with acupuncture. CONCLUSION: ED acupuncture is feasible and acceptable and can reduce acute musculoskeletal pain better than UC alone.

The financial lives of female sex workers in Addis Ababa, Ethiopia: Implications for economic strengthening interventions for HIV prevention.

Understanding the financial context of the lives of female sex workers (FSWs) is essential to address structural drivers of HIV risk. We used a financial diary methodology to record daily financial transactions over six weeks from a stratified purposive sample (n = 34) of FSWs in Addis Ababa, Ethiopia. FSWs also provided information on their experience with gender-based violence and condom use. FSWs generated 90.1% of total cash from sex work, with a median weekly income of USD 60.53. They engaged mostly in protected vaginal sex, earning approximately USD 4.57 per act. Food, housing, and clothing represented the largest areas of expenditure. Around 17% of expenses were recorded as costs of sex work (e.g., alcohol). Median weekly expenditures accounted for 62% of median weekly income. Nearly all participants reported depositing money into savings at least once over six weeks, while 71% reported a loan transaction during the six-week period, most as borrowers. Findings suggest that financial literacy and formalized savings activities, with life skills and empowerment training, have potential to build FSW's economic resilience, mitigating a structural driver of sex work and HIV risk.

The lysophosphatidic acid axis in fibrosis: Implications for glaucoma.

Glaucoma is a common progressive optic neuropathy that results in visual field defects and can lead to irreversible blindness. The pathophysiology of glaucoma involves dysregulated extracellular matrix remodelling in both the trabecular meshwork in the anterior chamber and in the lamina cribrosa of the optic nerve head. Fibrosis in these regions leads to raised intraocular pressure and retinal ganglion cell degeneration, respectively. Lysophosphatidic acid (LPA) is a bioactive lipid mediator which acts via six G-protein coupled receptors on the cell surface to activate intracellular pathways that promote cell proliferation, transcription and survival. LPA signalling has been implicated in both normal wound healing and pathological fibrosis. LPA enhances fibroblast proliferation, migration and contraction, and induces expression of pro-fibrotic mediators such as connective tissue growth factor. The LPA axis plays a major role in diseases such as idiopathic pulmonary fibrosis, where it has been identified as an important pharmacological target. In glaucoma, LPA is present in high levels in the aqueous humour, and its signalling has been found to increase resistance to aqueous humour outflow through altered trabecular meshwork cellular contraction and extracellular matrix deposition. LPA signalling may, therefore, also represent an attractive target for treatment of glaucoma. In this review we wish to describe the role of LPA and its related proteins in tissue fibrosis and glaucoma.

Teaching of manual cataract extraction in ophthalmic surgical training programmes.

BACKGROUND: Manual cataract extraction techniques such as extracapsular cataract extraction (ECCE) or manual small incision cataract (MSICS) surgery have been replaced by phacoemulsification cataract surgery. Surgical training opportunities for manual techniques of cataract extraction are limited in modern surgical training programmes. AIMS: This study evaluated the current trends of ECCE/MSICS training opportunities amongst trainees and trainers in the Irish Ophthalmic Surgical Training Program. METHODS: An electronic survey was distributed to all ophthalmic surgical trainees and consultants in the country. It addressed the experience and exposure to ECCE/MSICS. RESULTS: Nineteen of 33 (57%) trainees and 29 of 55 (55%) of consultants completed the survey. Twelve of 19 (63%) trainees viewed an ECCE procedure performed live. Twenty-seven of 29 (93%) consultants performed an ECCE procedure during their surgical career; 8 of 27 (30%) performed an ECCE within the last 1-3 years. Fourteen of 19 (74%) trainees stated they do not feel confident converting from phacoemulsification to ECCE independently. Sixteen of 19 (89%) trainees believe manual cataract extraction training should be included in their surgical training. Nineteen of 29 (65%) consultants believe training in manual cataract extraction should be part of the surgical training programme. CONCLUSIONS: There is a paucity of manual cataract extraction being performed in Ireland, limiting live surgical training in this technique. This survey highlights the limited experience of trainees in this valuable skill that is occasionally required for a successful surgical outcome. The authors conclude that wet laboratory simulated training of manual cataract extraction will bridge this gap.

Managing Chronic Pain in Cancer Survivorship: Communication Challenges and Opportunities as Described by Cancer Survivors.

OBJECTIVES: Many cancer survivors experience chronic pain after completing curative-intent treatment. Based on available data, chronic pain may be undertreated in this context; however, little is known about cancer survivors' experiences with clinical management of chronic pain. The purpose of this study was to better understand cancer survivors' pain management experiences after curative-intent treatment. METHODS: We conducted 13 semi-structured interviews with a convenience sample of cancer survivors who had completed treatment for stage I-III breast, head/neck, lung or colorectal cancer. We used a thematic approach to qualitative data analysis. RESULTS: Participants described that chronic pain often goes unrecognized by their providers, potentially due to limitations in how pain is assessed clinically and the tendency of both cancer survivors and providers to minimize or invalidate the pain experience. To improve communication, participants suggested that providers ask more open-ended questions about their pain, help them to establish functional goals, and provide patients with options for pain management. SIGNIFICANCE OF RESULTS: This study demonstrates the importance of provider-initiated communication around pain management for cancer survivors to make them feel more supported in their care. Communication and shared decision-making interventions may improve cancer survivor-provider communication around chronic pain management, addressing an important gap in survivorship care.

Clinician Perspectives on Managing Chronic Pain After Curative-Intent Cancer Treatment.

PURPOSE: Among cancer survivors who have completed curative-intent treatment, the high prevalence and adverse consequences of chronic pain are well documented. Yet, research on clinicians' experiences with and perspectives on managing chronic pain among cancer survivors is critically lacking. METHODS: We conducted semistructured interviews with 17 clinicians (six oncology, three palliative care, and eight primary care) affiliated with an academic medical center. Interview questions addressed clinicians' experiences with and perspectives on managing chronic pain (with or without opioid therapy) during the transition from active treatment to survivorship. A multidisciplinary team conducted content analysis of interview transcripts to identify and refine themes related to current practices and challenges in managing chronic pain in this context. RESULTS: Overall, clinicians perceived chronic pain to be relatively uncommon among cancer survivors. Identified challenges included a lack of clarity about which clinician (or clinicians) are best positioned to manage chronic pain among cancer survivors, and (relatedly) complexities introduced by long-term opioid management, with many clinicians describing this practice as outside their skill set. Additionally, although most clinicians recognized chronic pain as a biopsychosocial phenomenon, they described challenges with effectively managing psychosocial stressors, including difficulty accessing mental or behavioral health services for cancer survivors. CONCLUSION: Discovered challenges highlight unmet needs related to cancer survivor-clinician communication about chronic pain and the absence of a chronic pain management home for cancer survivors, including those requiring long-term opioid therapy. Research evaluating routine pain monitoring and accessible, tailored models of multimodal pain care in survivorship may help to address these challenges.

Late onset sclerotomy dehiscence in a patient with Marfan syndrome presenting as recurrent episodes of raised intraocular pressure.

A man in his 50s presented to the eye emergency department on three separate occasions complaining of blurred vision and discomfort in the left eye. He had a history of Marfan syndrome and had undergone bilateral 20-gauge (G) pars plana vitrectomy and lensectomy 20 years prior for ectopia lentis. On examination he had epithelial corneal oedema, raised intraocular pressure >40 mm Hg and conjunctival chemosis, which later appeared as a bleb-like conjunctival elevation. Acute treatment with oral acetazolamide and topical ocular hypotensive agents produced a marked reduction in intraocular pressure to 2-4 mm Hg. A presumed diagnosis of a leaking scleral wound was made. He underwent scleral exploration under general anaesthesia and a leaking sclerotomy was uncovered. The defect was repaired successfully using a scleral patch graft. Late dehiscence of a sclerotomy has been reported rarely in patients with Marfan syndrome. This is the first reported case to present atypically with intermittent episodes of raised intraocular pressure rather than with hypotony.

How does qualitative data collection modality affect disclosure of sensitive information and participant experience? Findings from a quasi-experimental study.

Focus groups (FGs) and individual interviews (IDIs) can be conducted in-person or in several different online contexts. We conducted a quasi-experimental study and assessed sharing of sensitive or dissenting information and participant comfort in FGs and IDIs across four modalities: (1) in-person, (2) online video-based, (3) online chat-based (synchronous), and (4) online email/message board-based (asynchronous). Participants were systematically assigned to one of the four modalities and randomized to one of 24 FGs or 48 IDIs (N = 171). The study topic was medical risk during pregnancy. All participants also completed a survey on their perceptions of the data collection process. We found no significant difference in the frequency of disclosure of sensitive information by modality. Text-based FGs (chat and message board) were more likely to contain dissenting opinions than visually-based FGs (in-person and video). Participants also reported feeling less rapport and personal comfort in sharing information in the FG video modality than other modalities. These findings provide initial data that can guide researchers in choosing among data collection modalities to maximize participant engagement and comfort.

Implementation of a comprehensive hospitalist-led initiative to improve care for patients with opioid use disorder.

BACKGROUND: As opioid-related hospitalizations rise, hospitals must be prepared to evaluate and treat patients with opioid use disorder (OUD). We implemented a hospitalist-led program, Project Caring for patients with Opioid Misuse through Evidence-based Treatment (COMET) to address gaps in care for hospitalized patients with OUD. OBJECTIVE: Implement evidence-based treatment for inpatients with OUD and refer to postdischarge care. DESIGN, SETTING, AND PARTICIPANTS: Project COMET launched in July 2019 at Duke University Hospital (DUH), an academic medical center in Durham, NC. INTERVENTION, MAIN OUTCOMES, AND MEASURES: We engaged key stakeholders, performed a needs assessment, and secured health system funding. We developed protocols to standardize OUD treatment and employed a social worker to facilitate postdischarge care. Electronic health records were utilized for data analysis. RESULTS: COMET evaluated 512 patients for OUD during their index hospitalization from July 1, 2019 through June 30, 2021. Seventy-one percent of patients received medication for OUD (MOUD) during admission. Of those who received buprenorphine during admission, 64% received a discharge prescription. Of those who received methadone during admission, 83% of eligible patients were connected to a methadone clinic. Among all patients at DUH with OUD, MOUD use during hospitalization and at discharge increased in the post-COMET period compared to the pre-COMET period (p < .001 for both). CONCLUSION: Our program is one of the first to demonstrate successful implementation of a hospitalist-led, comprehensive approach to caring for hospitalized patients with OUD and can serve as an example to other institutions seeking to implement life-saving, evidence-based treatment in this population.

Acupuncture for acute musculoskeletal pain management in the emergency department and continuity clinic: a protocol for an adaptive pragmatic randomised controlled trial.

INTRODUCTION: Chronic musculoskeletal pain causes a significant burden on health and quality of life and may result from inadequate treatment of acute musculoskeletal pain. The emergency department (ED) represents a novel setting in which to test non-pharmacological interventions early in the pain trajectory to prevent the transition from acute to chronic pain. Acupuncture is increasingly recognised as a safe, affordable and effective treatment for pain and anxiety in the clinic setting, but it has yet to be established as a primary treatment option in the ED. METHODS AND ANALYSIS: This pragmatic clinical trial uses a two-stage adaptive randomised design to determine the feasibility, acceptability and effectiveness of acupuncture initiated in the ED and continued in outpatient clinic for treating acute musculoskeletal pain. The objective of the first (treatment selection) stage is to determine the more effective style of ED-based acupuncture, auricular acupuncture or peripheral acupuncture, as compared with no acupuncture. All arms will receive usual care at the discretion of the ED provider blinded to treatment arm. The objective of the second (effectiveness confirmation) stage is to confirm the impact of the selected acupuncture arm on pain reduction. An interim analysis is planned at the end of stage 1 based on probability of being the best treatment, after which adaptations will be considered including dropping the less effective arm, sample size re-estimation and unequal treatment allocation ratio (eg, 1:2) for stage 2. Acupuncture treatments will be delivered by licensed acupuncturists in the ED and twice weekly for 1 month afterward in an outpatient clinic. ETHICS AND DISSEMINATION: This study has been reviewed and approved by the Duke University Health System Institutional Review Board. Informed consent will be obtained from all participants. Results will be disseminated through peer-review publications and public and conference presentations. TRIAL REGISTRATION NUMBER: NCT04290741.

Diagnosing and Treating Chronic Pain: Are We Doing This Right?

The diagnosis, treatment, and management of chronic pain is complex, nuanced, and challenging in primary care settings. These challenges often give rise to internal provider conflicts around appropriate management strategies, perhaps avoiding diagnosis all together. Factors that contribute to internal provider conflict include knowledge, responsibility, and uncertainties surrounding chronic pain management. This piece acknowledges the complexity and competing priorities of chronic pain management from a provider perspective. We advocate for coordinated and committed care of patients with chronic pain and a sense of shared responsibility among providers to adequately address patient needs.

Community optometrist-led post-operative cataract care: how many patients re-present to the hospital ophthalmic department?

BACKGROUND: Cataract surgery represents a significant workload for ophthalmologists in Ireland. Post-operative shared care with community optometrists can reduce the need for hospital follow-up appointments. AIMS: Eight years after the introduction of a shared-care pathway, we wished to quantify the proportion of patients discharged to the community for post-operative follow-up, and the number that re-present to the hospital due to cataract-related issues. METHODS: We collected data on all patients who underwent cataract surgery in our centre over a three month period. Electronic patient records were used to establish whether the patient was discharged on the day of surgery, and whether they re-attended the department post-operatively. Post-operative complications were recorded. RESULTS: 394 cataract procedures were carried out over the three months. 369 patients were discharged to an optometrist for their post-operative care. Of those, 38 were re-referred or re-presented to the hospital ophthalmic service. 21 of these had a post-operative complication. Complications included seven cases of post-operative uveitis, 5 patients with cystoid macular oedema, one retinal detachment and one retained lens fragment. CONCLUSIONS: Community optometrist-led post-operative care for uncomplicated patients is an effective way of reducing the workload associated with cataract surgery. Re-referral pathways must be in place to facilitate timely management of post-operative complications.

Using financial diaries to understand the economic lives of HIV-positive pregnant women and new mothers in PMTCT in Zomba, Malawi.

BACKGROUND: Economic strengthening (ES) interventions can address economic barriers to retention and adherence (R&A) to antiretroviral therapy in prevention of mother-to-child transmission (PMTCT) services. To inform tailoring of ES activities for PMTCT, we used financial diaries to understand the economic lives of women in PMTCT and examine associations between participants' finances and their R&A. METHODS: We collected financial data from a stratified sample (n = 241) of HIV-positive pregnant women and new mothers enrolled in PMTCT from three clinics in Zomba, Malawi. For 30 weeks, participants met with staff to record cash and in-kind inflows and outflows. We used clinical records to calculate a measure of R&A for each participant. We summarized diary data using R and used cox proportional hazard models to examine the relationship between R&A and participant characteristics and behavior. RESULTS: There were 68,097 cash transactions over 30 weeks, with 10% characterized as inflows. The median value of cash inflows was US$3.54 compared with US$0.42 for cash outflows. Fewer than 7% of total transactions were considered related to PMTCT, with the majority classified as food or drink. Participants in the rural site had the lowest hazard of non-adherence. Decreased hazard of non-adherence was also linked to having dependents and years on ART. There were significant differences in cash inflows and outflows between those who were always adherent and those who were not. CONCLUSIONS: Financial inflows were large and erratic, whereas outflows were small but consistent. PMTCT expenses comprised a small proportion of overall expenses and focused on proper nutrition. The influence of inflows and outflows on adherence was significant but small; however, always adherent participants demonstrated smoother inflows and outflows, indicating an association between greater adherence and economic stability. Participants would benefit from interventions that bolster and stabilize their economic lives, including income generating activities in the agricultural industry and inclusion in village banks.

Indicators of young women's modern contraceptive use in Burkina Faso and Mali from Demographic and Health Survey data.

BACKGROUND: High total fertility rates in Burkina Faso and Mali are leading to population growth beyond the agricultural and fiscal means of its citizens. Providing access to affordable family planning methods is a key step in driving the demographic transition where fertility and mortality rates decline. Furthermore, both nations face significant challenges as climate change is projected to disproportionately impact the western Sahel region undermining environmental, social and economic stability within the region. This analysis was included in formative research to inform family planning programming. The aim of this study was to examine possible indicators of long acting and permanent contraceptive method (LAPM) and short-term method (STM) use for young women in Burkina Faso and Mali. METHODS: Secondary data analysis was conducted using the three most recent Demographic and Health Survey (DHS) datasets for Burkina Faso (1998, 2003, 2010) and Mali (2001, 2006, 2012). Women ages 15-24, at risk for unwanted pregnancy were included in these analyses. Summary descriptive statistics across all time points are reported and multinomial logistic regression was used with the most recent data to determine potential indicators of different types of modern contraceptive methods. RESULTS: In Burkina Faso in 2010, 24% of women ages 15-24 were using modern contraceptives. Only 2.9% reported using LAPMs in 2010, an increase from 0.3% in 1998. In Mali, modern contraceptive use increased more recently, rising from 9.4% in 2001 to 10.2% in 2006 to 15.3% in 2012. LAPM use also increased from 0.3% in 2001 to 4.1% in 2012. Significant indicators of LAPM contraceptive use in both countries included educational attainment, ideal family size, home ownership and husband's desire for more children. CONCLUSIONS: Young women in Burkina Faso and Mali are increasingly using modern contraceptives for family planning; however, the LAPM contraceptive prevalence rate remains low. Our analysis indicates that social norms around ideal family size for both men and women continue to drive young women's choices around family planning and impede use of LAPMs. To increase modern contraceptive use and curb fertility rates, local governments and development organizations should focus on women's empowerment and include male partners.