Early change in fatigue, insomnia, and cognitive impairment and symptom severity 3 years post-treatment in breast cancer survivors.

PURPOSE: Breast cancer is the most common form of cancer among Canadian women. Survivorship challenges include fatigue, sleep disturbance, and cognitive impairment. This study examined (1) symptom trajectory from diagnosis to 3 years; (2) whether symptom change in the first 4 months was associated with prolonged difficulties after 3 years; and (3) which factors were associated with deterioration in symptoms during the first 4 months. METHODS: This prospective observational cohort study examined 53 women (Mage = 58.6, 96.2% White, 67.9% stage I) with newly diagnosed breast cancer over 3 years. Women completed assessments before starting treatment, 4 months, and 3 years after diagnosis. Three-way repeated-measures ANOVAs evaluated symptom trajectories. A repeated-measures mediation analysis was performed to determine if change from pre-treatment to 4 months accounted for change from pre-treatment to 3 years. A series of between-subjects ANOVAs were used to determine what variables significantly differed by deterioration status. RESULTS: Perceived cognitive impairment and fatigue increased linearly from diagnosis to 3 years. Change in fatigue in the first 4 months fully accounted for its change over 3 years. Insomnia severity and sleep quality deteriorated from diagnosis to 4 months, but returned to pre-treatment levels at 3 years. Those whose fatigue and cognitive ability deteriorated during the first 4 months were younger. CONCLUSION: Efforts to identify those who are at risk of experiencing fatigue, sleep disturbance, and cognitive impairment; monitor patients early after receiving a diagnosis; and provide targeted interventions may prevent long-term deterioration and improve well-being.

Perceived Executive Functioning Deficits After Diagnosis in Women with Non-Metastatic Breast Cancer Prior to Adjuvant Therapies.

BACKGROUND: Perceived deficits in executive functioning are among the many difficulties that women diagnosed with breast cancer experience. This study assessed the presence of perceived deficits in executive functioning among women with breast cancer prior to systemic treatment and radiation and associations between perceived deficits in executive function and comorbid fatigue, sleep, and mood disturbance. METHOD: Participants were recruited following their breast cancer diagnosis and assessed using the Behavior Rating Inventory of Executive Function for Adults (BRIEF-A), subjective and objective measures of sleep duration and efficiency, and self-report measures of insomnia severity, sleep quality, fatigue, and mood disturbance. Hierarchical regression was used to examine associations between symptoms, adjusting for age and education. RESULTS: The final sample included 92 women with a mean age of 60.7 years and 13.5 years of education. Thirteen percent of participants reported global executive dysfunction. After partitioning out variability from other independent variables, fatigue (p = < .001), perceived sleep quality (p = .030), and symptoms of insomnia (p = .008) accounted for 13.3%, 5.7%, and 8.5% of unique variance in perceived executive functioning, respectively. Emotional fatigue was most strongly associated with perceived deficits in executive functioning. Neither subjective or objective sleep duration or efficiency was associated with perceived deficits in executive functioning. CONCLUSION: Fatigue, particularly emotional fatigue, insomnia, and poor sleep quality had the strongest associations with perceived deficits in executive functioning. Sleep interventions and fatigue management strategies may prove useful for women who seek to improve their perceived executive functioning.

Implementing One-at-a-Time Therapy in community addiction and mental health centres: a retrospective exploration of the implementation process and initial outcomes.

BACKGROUND: The Department of Health of the Government of New Brunswick and Regional Health Authorities elected to implement Stepped Care 2.0 (SC2.0) in 2021, and began with One-at-a-Time (OAAT) therapy in Community Addiction and Mental Health Centres (CAMHCs) to facilitate rapid access to addiction and mental healthcare. This study: 1) explicated the process of implementing OAAT therapy as it aligned to evidence-based implementation frameworks and strategies; 2) assessed readiness for change among providers during the implementation; and 3) evaluated initial client and system outcomes. METHODS: The process of implementing OAAT therapy within CAMHCs was documented and retrospectively aligned with the Active Implementation Frameworks-Stages of Implementation, Consolidated Framework for Implementation Research, and incorporated strategies endorsed by the Expert Recommendations for Implementing Change. Providers working in CAMHCs completed online asynchronous courses in OAAT therapy and SC2.0, and were recruited to participate in research on perceptions of organizational readiness. Initial outcomes of the implementation were evaluated through client satisfaction surveys administered in CAMHCs and system performance indicators. RESULTS: Aligning with implementation stages, key strategies included: 1) continuously monitoring readiness and soliciting stakeholder feedback for iterative improvement; 2) building a representative implementation team with engaged leaders; 3) creating a comprehensive implementation plan on staff training, communication, and system changes; and 4) supporting sustainability. Providers who participated in research (N = 170, ~ 50% response rate) agreed that their organization was ready for implementation, and that OAAT therapy delivered within a SC2.0 framework was acceptable, appropriate, and feasible. More than 3,600 OAAT therapy sessions were delivered during the initial implementation stage, and waitlists were reduced by 64.1%. The majority of clients who completed surveys (N = 1240, ~ 35% response rate) reported that their OAAT therapy session was helpful, with a minority reporting that additional intervention was needed. CONCLUSIONS: Thoughtful planning and execution, aligned with evidence-based implementation frameworks and strategies, played an important role in this provincial change initiative. Implementation steps outlined can help inform others looking to enact large-scale change.

The Selah Pilot Study of Spiritual, Mindfulness, and Stress Inoculation Practices on Stress-Related Outcomes Among United Methodist Clergy in the United States.

The job-demand-control-support model indicates that clergy are at high risk for chronic stress and adverse health outcomes. A multi-group pre-test-post-test design was used to evaluate the feasibility, acceptability, and range of outcome effect sizes for four potentially stress-reducing interventions: stress inoculation training, mindfulness-based stress reduction (MBSR), the Daily Examen, and Centering Prayer. All United Methodist clergy in North Carolina were eligible and recruited via email to attend their preferred intervention. Surveys at 0, 3, and 12 weeks assessed symptoms of stress, anxiety, and perceived stress reactivity. Heart rate variability (HRV) was assessed at baseline and 12 weeks using 24 h ambulatory heart rate monitoring data. A subset of participants completed in-depth interviews and reported skill practice using daily text messages. Standardized mean differences with 95% and 75% confidence intervals were calculated for the change observed in each intervention from baseline to 3 and 12 weeks post-baseline to determine the range of effect sizes likely to be observed in a definitive trial. 71 clergy participated in an intervention. The daily percentage of participants engaging in stress management practices ranged from 47% (MBSR) to 69% (Examen). Results suggest that participation in Daily Examen, stress inoculation, or MBSR interventions could plausibly result in improvement in stress and anxiety at 12 weeks with small-to-large effect sizes. Small effect sizes on change in HRV were plausible for MBSR and Centering Prayer from baseline to 12 weeks. All four interventions were feasible and acceptable, although Centering Prayer had lower enrollment and mixed results.

When Shepherds Shed: Trajectories of Weight-Related Behaviors in a Holistic Health Intervention Tailored for US Christian Clergy.

Maintaining healthy behaviors is challenging. Based upon previous reports that in North Carolina (NC), USA, overweight/obese clergy lost weight during a two-year religiously tailored health intervention, we described trajectories of diet, physical activity, and sleep. We investigated whether behavior changes were associated with weight and use of health-promoting theological messages. Improvements were observed in sleep, calorie-dense food intake, and physical activity, with the latter two associated with weight loss. While theological messages were well-retained, their relationship with behaviors depended on the specific message, behavior, and timing. Findings offer insights into weight loss mechanisms, including the role of theological messages in religiously tailored health interventions.

Proof of Concept for a Mindfulness-Informed Intervention for Eating Disorder Symptoms, Self-Efficacy, and Emotion Regulation among Bariatric Surgery Candidates.

Up to 64% of patients seeking bariatric (weight-loss) surgery report eating disorder (ED) symptoms (addictive-like eating, binge eating, emotional eating, grazing) that can interfere with post-surgical weight loss. This prospective proof-of-concept study aimed to evaluate the impact of a pre-surgical mindfulness-informed intervention (MII) on ED symptoms and potential mechanisms-of-action to inform optimization of the intervention. Surgery-seeking adults attended four, 2-hour, MII sessions held weekly. Participants completed validated questionnaires assessing ED symptoms, eating self-efficacy, emotion regulation, and mindful eating pre-MII, post-MII, and at a 12-week follow-up. The MII consisted of mindfulness training, with cognitive, behavioral, and psychoeducational components. Fifty-six patients (M = 47.41 years old, 89.3% female) participated. Improvements in addictive-like eating, binge eating, emotional eating, and grazing were observed from pre- to post-MII. ED symptom treatment gains were either maintained or improved further at 12-week follow-up. Eating self-efficacy and emotion regulation improved from pre-MII to follow-up. Scores on the mindful eating questionnaire deteriorated from pre-MII to follow-up. In mediation analyses, there was a combined indirect effect of emotion regulation, eating self-efficacy, and mindful eating on grazing and binge eating, and an indirect effect of emotion regulation on emotional eating and addictive-like eating. Participation in the MII was associated with improvements in ED symptoms and some mechanisms-of-action, establishing proof-of-concept for the intervention. Future work to establish the MII's efficacy in a randomized controlled trial is warranted.

An experimental study revisiting the link between media attention and breast cancer concern: exploring the role of cognitive fusion.

Research examining the link between media attention and breast cancer concern has been frequently conducted with middle/old-age women, even though young women (<40 years old) have been overrepresented media stories about breast cancer. Accordingly, little is known about young women's emotional reactions to breast cancer media messages and the psychological factors modulating such reactions. This study examined the impact of breast cancer media messages and cognitive fusion on negative affect, fear of breast cancer (FBC), and perceived susceptibility to breast cancer. 207 young women were randomly assigned to watch a low- or high-threat video about breast cancer. A MANCOVA revealed that participants who viewed the high-threat video reported greater negative affect and perceived susceptibility, but not FBC; however, participants in both conditions showed moderate/high FBC. Correlational analyses and a MANOVA showed that participants reporting higher cognitive fusion reported higher negative affect across conditions, as well as higher FBC in the high-threat condition. Taken together, these results suggest that young women may show habituation to alarmist media messages, but may nonetheless construe breast cancer as a significant threat. Moreover, young women showing medium/high cognitive fusion seem more likely to show heightened concern upon exposure to alarmist media messages about breast cancer.

Changing Provider Behavior in the Context of Chronic Disease Management: Focus on Clinical Inertia.

Widespread acceptance of evidence-based medicine has led to the proliferation of clinical practice guidelines as the primary mode of communicating current best practices across a range of chronic diseases. Despite overwhelming evidence supporting the benefits of their use, there is a long history of poor uptake by providers. Nonadherence to clinical practice guidelines is referred to as clinical inertia and represents provider failure to initiate or intensify treatment despite a clear indication to do so. Here we review evidence for the ubiquity of clinical inertia across a variety of chronic health conditions, as well as the organizational and system, patient, and provider factors that serve to maintain it. Limitations are highlighted in the emerging literature examining interventions to reduce clinical inertia. An evidence-based framework to address these limitations is proposed that uses behavior change theory and advocates for shared decision making and enhanced guideline development and dissemination.

A systematic review of interventions to improve adherence to statin medication: What do we know about what works?

Suboptimal adherence to statin medication is common and leads to serious negative health consequences but may respond to intervention. This review evaluated the effectiveness of interventions intended to improve adherence to statin medication. Data sources included peer-reviewed publications from Cochrane Register of Randomized Controlled Trials (RCTs), PubMed, CINAHL, and EMBase indexed between 01 October 2008 and 18 October 2015 and studies from reference lists and technical experts. RCTs that evaluated an intervention targeting adherence to self-administered statin medication for primary or secondary prevention were eligible. Two investigators independently reviewed trials, extracted data, and evaluated risk of bias. Twenty-nine RCTs reporting on 39,769 patients met inclusion. Identified RCTs exhibited methodological weaknesses: all but one failed to set inclusion parameters for medication adherence; nearly half lacked sufficient power to detect meaningful effects; and the majority had a risk of bias. Interventions were categorized into five classes (simplification of regimen, prescription cost coverage, reminders, education and information, and multi-faceted) and effects were pooled within each class. Prescription cost coverage, Hedges' g=0.15, 95%CI [0.11:0.21], simplification of drug regimen, Hedges' g=0.38, 95%CI [0.22:0.55], the provision of education, Hedges' g=0.19, 95%CI [0.01:0.37], and the use of multi-faceted interventions, Hedges' g=0.16, 95%CI [0.05:0.27], had small positive effects on statin adherence relative to usual care and reminders were promising, Hedges' g=0.0.27, 95%CI [-0.05:0.60]. In conclusion, there are some successful interventions to improve adherence to statin medication but the effects are small and additional methodologically rigorous trials are needed.

Developmental origins of infant stress reactivity profiles: A multi-system approach.

BACKGROUND: This study tested the hypothesis that maternal physiological and psychological variables during pregnancy discriminate between theoretically informed infant stress reactivity profiles. METHODS: The sample comprised 254 women and their infants. Maternal mood, salivary cortisol, respiratory sinus arrhythmia (RSA), and salivary α-amylase (sAA) were assessed at 15 and 32 weeks gestational age. Infant salivary cortisol, RSA, and sAA reactivity were assessed in response to a structured laboratory frustration task at 6 months of age. Infant responses were used to classify them into stress reactivity profiles using three different classification schemes: hypothalamic-pituitary-adrenal (HPA)-axis, autonomic, and multi-system. Discriminant function analyses evaluated the prenatal variables that best discriminated infant reactivity profiles within each classification scheme. RESULTS: Maternal stress biomarkers, along with self-reported psychological distress during pregnancy, discriminated between infant stress reactivity profiles. CONCLUSIONS: These results suggest that maternal psychological and physiological states during pregnancy have broad effects on the development of the infant stress response systems. © 2016 Wiley Periodicals, Inc. Dev Psychobiol 58: 578-599, 2016.

The effect of intranasal oxytocin administration on acute cold pressor pain: a placebo-controlled, double-blind, within-participants crossover investigation.

BACKGROUND: This study examined the effect of synthetic oxytocin delivered intranasally on acute pain sensitivity using a placebo-controlled, double-blind, within-participant crossover design. METHODS: Thirty-seven (18 were male) pain-free young adults underwent two laboratory sessions separated by 1 week. Each session consisted of baseline, administration, second baseline, pain, and recovery phases, completed in a fixed order. Participants were given an intransal administration of 40 IU oxytocin or placebo. Blood pressure and heart rate (HR) were measured at 1-minute intervals throughout each phase. Pain was induced by submersing the nondominant hand in cold (2°C) water. Pain threshold, intensity, unpleasantness, and Short-Form McGill Pain Questionnaire-2 pain descriptors were rated immediately after pain testing. Mood was assessed using visual analog scales after baseline, second baseline, and pain phases. The second laboratory session was identical to the first, with the exception that a different nasal spray was administered. RESULTS: Participants reported lower pain intensity (50.57 [20.94] versus 56.73 [20.12], p = .047), pain unpleasantness (47.00 [27.24] versus 55.78 [22.46], p = .033), and Short-Form McGill Pain Questionnaire-2 pain descriptors (53.38 [31.18] versus 60.92 [31.17], p = .031) and higher pain threshold (45.70 [59.55] versus 38.35 [59.12], p = .040) after oxytocin administration relative to placebo. There was a nasal spray by phase interaction on HR (p = .006). Pain-related increase in HR was attenuated by oxytocin nasal spray. Systolic and diastolic blood pressure increased during pain testing but were unaffected by nasal spray. CONCLUSIONS: These results suggest that oxytocin can lead to decreased acute pain sensitivity.

Moms in motion: Predicting healthcare utilization patterns among mothers in Newfoundland and Labrador.

Mothers have a significant influence on family dynamics, child development, and access to family services. There is a lack of literature on the typical Canadian maternal experience and its influence on access to services for mothers despite recognizing the importance of mothers. A cross-sectional study was conducted to address this research gap that employed Andersen's Behavioral Model of Health Service Use in conjunction with a feminist lens. A total of 1,082 mothers who resided in Newfoundland and Labrador (NL) participated in a province-wide survey in 2017 and reported on their wellbeing, family life, and healthcare utilization. Stepwise binomial logistic regressions and linear regressions were used to predict initiation and continued service utilization within the preceding 12 months, respectively. Mothers who participated in this survey were older, and were more likely to be in a relationship than those in the Canadian census, while no difference was observed in annual income. Approximately half of mothers accessed services for themselves over the previous 12-months, with the overwhelming majority accessing services for their children. Medical services were the most likely to be utilized, and mental health and behavioural services were the most likely services to be needed, but not available. Sociodemographic (e.g., age, education attainment), familial relationships and role satisfaction, health need, and health practices predicted maternal initiation and continued use of services, with a larger number of variables influencing maternal service initiation as compared to continuous use of services. Sociodemographic (e.g., maternal age, community population), maternal social support, health need, and maternal health practices predicted maternal access of at least one child service while family relationships, health need, and maternal health practices predicted maternal use of a range of child services conditional on initial access. These results can support the provincial health system to better support access to care by acknowledging the interdependent nature of maternal and child health care utilization. They also highlight the importance of equitable healthcare access in rural locations. Results are discussed in terms of their clinical relevance to health policy.

The Selah trial: A preference-based partially randomized waitlist control study of three stress management interventions.

Chronic stress undermines psychological and physiological health. We tested three remotely delivered stress management interventions among clergy, accounting for intervention preferences. United Methodist clergy in North Carolina enrolled in a partially randomized, preference-based waitlist control trial. The interventions were: mindfulness-based stress reduction (MBSR), Daily Examen prayer practice, and Stress Proofing (stress inoculation plus breathing skills). Co-primary outcomes were symptoms of stress (Calgary Symptoms of Stress Inventory) and 48-hour ambulatory heart rate variability (HRV) at 12 weeks compared to waitlist control. Survey data were collected at 0, 12, and 24 weeks and 48-hour ambulatory HRV at 0 and 12 weeks. The 255 participants were 91% White and 48% female. Forty-nine participants (22%) without a preference were randomly assigned between the three interventions (n = 40) and waitlist control (n = 9). Two hundred six participants (78%) with a preference were randomly assigned to waitlist control (n = 62) or their preferred intervention (n = 144). Compared to waitlist control, MBSR [mean difference (MD) = -0.30, 95% CI: -0.41, -0.20; P < .001] and Stress Proofing (MD = -0.27, 95% CI: -0.40, -0.14; P < .001) participants had lower stress symptoms at 12 weeks; Daily Examen participants did not until 24 weeks (MD = -0.24, 95% CI: -0.41, -0.08). MBSR participants demonstrated improvement in HRV at 12 weeks (MD = +3.32 ms; 95% CI: 0.21, 6.44; P = .036). MBSR demonstrated robust improvement in self-reported and objective physical correlates of stress; Stress Proofing and Daily Examen resulted in improvements in self-reported correlates of stress. These brief practices were sustainable and beneficial for United Methodist clergy during the heightened stressors of the COVID pandemic. ClinicalTrials.gov identifier: NCT04625777.

A common source of stress, which can harm physical and mental health, is work. Clergy engage in a profession that requires toggling between varied and interpersonally complex tasks, providing emotional labor, and experiencing stressors such as public criticism. Practical, brief practices are needed to manage occupational stress. We invited all United Methodist clergy in North Carolina to enroll in a stress management study. Participants chose their preferred of three interventions: mindfulness-based stress reduction (MBSR), Daily Examen prayer practice, or Stress Proofing (a combination of stress inoculation plus breathing skills). Clergy without a preference were randomly assigned to one of the three interventions and a waiting group. Clergy with a preference were randomly assigned to either begin the intervention or wait at least 6 months and provide data while waiting. Participants practiced each of the three interventions at high levels across 24 weeks. Compared to clergy who waited for an intervention, MBSR participants evidenced robust improvement in self-reported (stress and anxiety symptoms) and physiological (heart rate variability measured across 48 hours) outcomes, whereas Stress Proofing and the Daily Examen only resulted in improvements in self-reported outcomes. The three brief practices were sustainable and beneficial for United Methodist clergy during the heightened stressors of the COVID pandemic.

Randomized Controlled Trial of Virtually Delivered Cognitive Behavioral Therapy for Insomnia to Address Perceived Cancer-Related Cognitive Impairment in Cancer Survivors.

PURPOSE: Comorbid insomnia and cancer-related cognitive impairment (CRCI) are experienced by up to 26% of individuals diagnosed with cancer. This study examined the efficacy and durability of cognitive behavioral therapy for insomnia (CBT-I) on perceived CRCI in cancer survivors. METHODS: Atlantic Canadian cancer survivors with insomnia and CRCI were randomly assigned to receive seven weekly virtual CBT-I sessions (n = 63) or placed in a waitlist control group (n = 69) to receive treatment after the waiting period. Participants completed assessments at baseline, 1 month (mid-treatment), and 2 months (post-treatment). Age- and education-adjusted mixed-effects models using intention-to-treat principles assessed change at post-treatment. Data from both groups were then pooled to assess the durability of effects at 3 and 6 months. A mediation analysis examined whether change in insomnia symptoms mediated the effect of CBT-I on cognitive outcomes. RESULTS: The mean age of the sample was 60 years, 77% were women, and breast cancer was the most common diagnosis (41%). The treatment group reported an 11.35-point reduction in insomnia severity, compared with a 2.67-point reduction in the waitlist control group (P < .001). The treatment group had a greater overall improvement than the waitlist control on perceived cognitive impairment (P < .001; d = 0.75), cognitive abilities (P < .001; d = 0.92), and impact on quality of life (P < .001; d = 1.01). These improvements were maintained at follow-up. Change in insomnia symptoms fully mediated the effect of CBT-I on subjective cognitive outcomes. CONCLUSION: Treating insomnia with CBT-I produces clinically meaningful and durable improvements in CRCI. There is an urgent need increase access to evidence-based treatment for insomnia in cancer centers and the community.

Acceptability of the power over pain portal among patients awaiting tertiary care consultation: A qualitative study of patients' perceptions.

Objective: Chronic pain affects approximately 7.6 million Canadians and access to care remains an issue. The Power Over Pain (POP) Portal offers immediate access to evidence-based resources ranging from low- (e.g. education, self-management), to high- (e.g. individual counseling) intensity. We explored the POP Portal's acceptability, usability, and perceived usefulness among patients newly referred to a tertiary care pain clinic. Methods: We used a descriptive, qualitative approach with a prospective cohort of 60 adult patients recently referred to The Ottawa Hospital Pain Clinic. Patients were offered an orientation session and asked to participate in a seven-week follow-up interview. Data were thematically analyzed in an iterative process, whereby responses were reviewed and coded by two members of the research team. Results: Of the 60 patients referred to the POP Portal by clinic clerks, 45 participated in the orientation session, and 40 completed a four-week follow-up. All 40 patients had used the POP Portal and recommended that we continue to offer the POP Portal to patients awaiting care. We identified overarching themes of acceptability (five subthemes), usability (ten subthemes), accessibility (three subthemes), and patient value of the POP Portal (three subthemes). This includes (1) the POP Portal provides easy access to chronic pain resources; (2) the POP Portal is helpful in developing an understanding of chronic pain; and (3) improvements to the POP Portal are needed to increase usability and foster a user-friendly experience. Conclusions: The POP Portal offers accessible and diverse resources for people living with pain awaiting a tertiary care consultation; however, patients would like to see resources specific to diagnosis. Improvements are suggested to allow greater increase the POP Portal usability.

Androgen deprivation therapy and radiation for prostate cancer-cognitive impairment, sleep, symptom burden: a prospective study.

OBJECTIVES: This paper (1) sought to compare sleep, mood and physical symptom profiles of men with prostate cancer (PCa) who experienced subjective and objective cancer-related cognitive impairment (CRCI) during the first year of treatment and (2) examine if fluctuations in mood and physical symptoms are associated with change in subjective or objective CRCI. METHODS: This prospective observational cohort study examined 24 new patients with PCa receiving androgen deprivation therapy (ADT) and radiation therapy (RT) during the first 12 months of treatment. Participants completed subjective and objective assessments of cognition, sleep continuity and self-report measures of insomnia, fatigue, depression and anxiety. Independent sample t-tests, correlations and hierarchical regressions were used to compare groups, explore associations, and assess change over time. Effects are reported as corrected Cohen's d (dc). RESULTS: Men with objective CRCI reported worse subjective time asleep (dc=0.47) and more depression (dc=0.55). Men with subjective CRCI reported worse insomnia (dc=0.99), hot flashes (dc=0.76), sleep quality (dc=0.54), subjective total sleep time (dc=0.41), wake after sleep onset (dc=0.71), sleep efficiency (dc=0.49), fatigue (dc=0.67) and objectively estimated sleep latency (dc=0.72) than men without subjective CRCI. Declines in perceived cognition was associated with higher anxiety (p=0.05), fatigue (p≤0.01) and symptoms of insomnia (p=0.01). Finally, subjective time awake during the night (p=0.03) and fatigue (p=0.02) were associated with subjective cognitive decline, controlling for objective change. CONCLUSIONS: Subjective concerns of CRCI appear more critical to patient experience than objective measurements in men with PCa who have received RT and ADT. Interventions to improve sleep may result in an improved perception of cognition.

Healthcare provider knowledge, beliefs, and attitudes regarding opioids for chronic non-cancer pain in North America prior to the emergence of COVID-19: A systematic review of qualitative research.

Background: Balance between benefits and harms of using opioids for the management of chronic noncancer pain (CNCP) must be carefully considered on a case-by-case basis. There is no one-size-fits-all approach that can be executed by prescribers and clinicians when considering this therapy. Aim: The aim of this study was to identify barriers and facilitators for prescribing opioids for CNCP through a systematic review of qualitative literature. Methods: Six databases were searched from inception to June 2019 for qualitative studies reporting on provider knowledge, attitudes, beliefs, or practices pertaining to prescribing opioids for CNCP in North America. Data were extracted, risk of bias was rated, and confidence in evidence was graded. Results: Twenty-seven studies reporting data from 599 health care providers were included. Ten themes emerged that influenced clinical decision making when prescribing opioids. Providers were more comfortable to prescribe opioids when (1) patients were actively engaged in pain self-management, (2) clear institutional prescribing policies were present and prescription drug monitoring programs were used, (3) long-standing relationships and strong therapeutic alliance were present, and (4) interprofessional supports were available. Factors that reduced likelihood of prescribing opioids included (1) uncertainty toward subjectivity of pain and efficacy of opioids, (2) concern for the patient (e.g., adverse effects) and community (i.e., diversion), (3) previous negative experiences (e.g., receiving threats), (4) difficulty enacting guidelines, and (5) organizational barriers (e.g., insufficient appointment duration and lengthy documentation). Conclusions: Understanding barriers and facilitators that influence opioid-prescribing practices offers insight into modifiable targets for interventions that can support providers in delivering care consistent with practice guidelines.

Contexte: L'équilibre entre les avantages et les inconvénients de l'utilisation d'opioïdes pour la prise en charge de la douleur chronique non cancéreuse (CNCP) doit être soigneusement examiné au cas par cas. Il n'existe pas d'approche uniforme pouvant être adoptée par les prescripteurs et les cliniciens lorsqu'ils envisagent cette thérapie.Objectif: L'objectif de cette étude était de recenser les obstacles et les facilitateurs pour la prescription d'opioïdes pour la douleur chronique non cancéreuse par une revue systématique de la littérature qualitative.Méthodes: Six bases de données ont été consultées pour la période allant de leur création jusqu'en juin 2019 afin d'y repérer les rapports d'études qualitatives sur les connaissances, les attitudes, les croyances ou les pratiques des prestataires en matière de prescription d'opioïdes pour la douleur chronique non cancéreuse en Amérique du Nord. Les données ont été extraites, le risque de biais a été évalué et la confiance envers les données probantes a été notée.Résultats: Vingt-sept études faisant état de données provenant de 599 prestataires de soins de santé ont été incluses. Dix thèmes influençant la prise de décision clinique lors de la prescription d'opioïdes ont émergé. Les prestataires étaient plus à l'aise pour prescrire des opioïdes lorsque (1) les patients étaient activement engagés dans la prise en charge de la douleur, (2) des politiques de prescription institutionnelles claires et des programmes de surveillance des médicaments d'ordonnance étaient en place, (3) des relations de longue date et une alliance thérapeutique forte étaient présentes, et (4) du soutien interprofessionnel était disponible. Les facteurs qui réduisaient la probabilité de la prescription d'opioïdes comprenaient (1) l'incertitude à l'égard de la subjectivité de la douleur et de l'efficacité des opioïdes, (2) une préoccupation pour le patient (p. ex., effets indésirables) et la collectivité (p. ex., détournement), (3) des expériences négatives antérieures (p. ex., recevoir des menaces), (4) des difficultés à adopter des lignes directrices et (5) des obstacles organisationnels (p. ex., durée insuffisante des rendez-vous et longueur de la documentation).Conclusions: La compréhension des obstacles et des facilitateurs qui influencent les pratiques de prescription d'opioïdes permet d'avoir un aperçu des cibles modifiables pour les interventions qui peuvent aider les prestataires à fournir des soins conformes aux directives de pratique.

Views on and experiences with medicinal cannabis among Canadian veterans who live with pain: A qualitative study.

Background: During fiscal year 2021-2022, Veterans Affairs Canada (VAC) reimbursed 18,388 veterans for medicinal cannabis at a cost of $153 million. Yet, it is not known whether the reimbursement program is producing a net benefit for veterans. Aims: This study investigated the views and experiences Canadian that veterans who live with pain have about medicinal cannabis use, including its use for the management of chronic pain, poor sleep, and emotional distress. Methods: Twelve Canadian veterans who live with pain-eight men, four women; split across four focus groups-were recruited to participate in a semistructured discussion around their experiences with medicinal cannabis use. Results: Using inductive thematic analysis, seven broad categories were identified: (1) cannabis use behaviors, (2) reasons for cannabis use, (3) outcomes from cannabis use, (4) facilitators of cannabis use, (5) barriers to cannabis use, (6) stigma around cannabis use, and (7) questions and concerns about cannabis use. Conclusions: Most veterans initiated cannabis use to manage the symptoms of preexisting medical and/or mental health conditions. Despite some negative side effects, most veterans reported improvements in their overall quality of life, sleep, relationships, mood, and pain. Concern remains around the discrepancy between veterans' qualitative reports of beneficial outcomes from medicinal cannabis use and equivocal findings around the benefit-to-harm ratio in the wider literature. Currently, the VAC reimbursement program remains challenged by unclear indication for which veterans, with what condition(s), at what dose, and in what form medical cannabis is most beneficial.

Contexte: Au cours de l'exercice 2021­2022, Anciens Combattants Canada (ACC) a remboursé 18 388 anciens combattants pour le cannabis médicinal, pour un coût de 153 millions de dollars. Pourtant, on ne sait pas si le programme de remboursement donne lieu à un bénéfice net pour les anciens combattants.Objectifs: Cette étude porte sur les points de vue et les expériences des anciens combattants canadiens qui vivent avec la douleur sur la consommation de cannabis médicinal, y compris son utilisation pour la gestion de la douleur chronique, les problèmes de sommeil et la détresse émotionnelle.Méthodes: Douze anciens combattants canadiens qui vivent avec la douleur - huit hommes et quatre femmes répartis en quatre groupes de discussion - ont été recrutés pour participer à une discussion semi-structurée autour de leurs expériences avec la consommation de cannabis médicinal.Résultats: Une analyse thématique inductive a permis d'établir sept grandes catégories : (1) les comportements de consommation de cannabis, (2) les raisons de la consommation de cannabis, (3) résultats de la consommation de cannabis, (4) les facteurs qui facilitent la consommation de cannabis, (5) les obstacles à la consommation de cannabis, (6) la stigmatisation autour de la consommation de cannabis et (7) les questions et préoccupations concernant la consommation de cannabis.Conclusions: La plupart des anciens combattants ont commencé à consommer du cannabis pour gérer les symptômes de maladies préexistantes et/ou des problèmes de santé mentale. Malgré certains effets secondaires négatifs, la plupart des anciens combattants ont signalé une amélioration de leur qualité de vie globale, de leur sommeil, de leurs relations, de leur humeur et de leur douleur. La préoccupation demeure autour de l'écart entre les rapports qualitatifs des anciens combattants décrivant les résultats bénéfiques de la consommation de cannabis médicinal et les résultats équivoques autour du rapport bénéfice/effet néfaste dans la littérature plus large. Actuellement, le programme de remboursement d'ACC reste contesté en raison d'indications peu claires concernant pour quels vétérans, atteints de quelles affections, à quelle dose et sous quelle forme le cannabis médical est le plus bénéfique.

Provider perceptions of the anticipated benefits, barriers, and facilitators associated with implementing a stepped care model for the delivery of addiction and mental health services in New Brunswick: a mixed-methods observational implementation study.

BACKGROUND: Providers who work within addiction and mental health (A&MH) services in New Brunswick (NB), Canada completed training in Stepped Care 2.0 and One-at-a-Time (OAAT) therapy as part of a provincial practice change initiative to implement a provincial stepped care model. The present study aimed to identify: (1) the perceived acceptability and feasibility of the SC2.0 model; (2) the perceived benefits, barriers, and facilitators to implement SC2.0 in practice; and (3) perceived impacts on clinical practice. METHODS: This is a mixed-methods observational implementation study. Quantitative surveys were completed after training courses. Open-ended responses were collected after completion of SC2.0 training. A subset of providers who completed surveys were asked to participate in semi-structured interviews. Descriptive statistics were used to describe results from surveys. Open-ended responses and semi-structured interviews were compiled and thematically synthesized in an iterative process using a grounded theory framework. Quantitative and qualitative data were triangulated to build an in-depth understanding of provider perceptions. RESULTS: 316 providers completed surveys and responded to open-ended prompts. Interviews were completed with 28 of those providers. SC2.0 was deemed to be acceptable, a suitable fit, and feasible to implement. Perceived benefits included: (1) timely access to services; (2) increased practice efficiency; and (3) increased availability of services. Perceived barriers included: (1) insufficient availability of resources to populate a SC2.0 continuum of care; (2) provider complacency with their current practice; and (3) difficulty for clients to accept and adjust to change. CONCLUSIONS: Identifying the perceived benefits, facilitators, and barriers to adopting stepped care in practice can lead to targeted implementation strategies and the collection of data that can inform continuous improvement cycles.

Evaluating the efficacy of oxytocin for pain management: An updated systematic review and meta-analysis of randomized clinical trials and observational studies.

Background: There is a need for novel analgesics with favorable risk to benefit profiles. Oxytocin has recently gained attention for its potential analgesic properties. Aim: The aim of this study was to perform an updated systematic review and meta-analysis evaluating the effect of oxytocin for pain management. Method: Ovid MEDLINE, Embase, PsycINFO, CINAHL, and Clinicaltrials.gov were searched for articles reporting on associations between oxytocin and chronic pain management from January 2012 to February 2022. Studies published before 2012 that were identified in our previous systematic review were also eligible. Risk of bias of included studies was assessed. Synthesis of results was performed using meta-analysis and narrative synthesis. Results: Searches returned 2087 unique citations. In total, 14 articles were included that reported on 1504 people living with pain. Results from meta-analysis and narrative review were mixed. Meta-analysis of three studies indicated that exogenous oxytocin administration did not result in a significant reduction in pain intensity relative to placebo (N = 3; n = 95; g = 0.31; 95% confidence interval [CI] -0.10, 0.73). Narrative review provided encouraging evidence that exogenous oxytocin administration reduced pain sensitivity among individuals with back pain, abdominal pain, and migraines. Results suggested that individual difference factors (e.g., sex and chronic pain condition) may influence oxytocin-induced nociception, but the heterogeneity and limited number of studies identified precluded further investigation. Discussion: There is equipoise for the benefit of oxytocin for pain management. Future studies are imperative and should undertake more precise exploration of potential confounds and mechanisms of analgesic action to clarify inconsistency in the literature.

Contexte: Il existe un besoin de nouveaux analgésiques présentant un profil de risque/bénéfice favorable. L'ocytocine a récemment attiré l'attention pour ses propriétés analgésiques potentielles.Objectif: L'objectif de cette étude était d'effectuer une mise à jour d'une revue systématique et une méta-analyse pour évaluer l'effet de l'ocytocine pour la gestion de la douleur.Méthode: Des recherches ont été effectuées dans Ovid MEDLINE, Embase, PsycINFO, CINAHL et Clinicaltrials.gov pour y repérer des articles sur les associations entre l'ocytocine et la prise en charge de la douleur chronique de janvier 2012 à février 2022. Les études publiées avant 2012 qui ont été recensées dans notre revue systématique précédente était également admissibles. Le risque de biais des études incluses a été évalué. Une synthèse des résultats a été réalisée à l'aide d'une méta-analyse et d'une synthèse narrative.Résultats: Les recherches ont permis de recenser 2 087 citations uniques. Au total, 14 articles portant sur 1 504 personnes vivant avec la douleur ont été incluses. Les résultats de la méta-analyse et de l'examen narratif ont été mitigés. Une méta-analyse de trois études a révélé que l'administration d'ocytocine exogène n'avait pas entraîné de réduction significative de l'intensité de la douleur comparativement au placebo (N = 3; n = 95; g = 0,31; Intervalle de confiance à 95 % [IC] −0,10 ; 0,73). L'examen narratif a fourni des preuves encourageantes que l'administration d'ocytocine exogène avait réduit la sensibilité à la douleur chez les personnes souffrant de maux de dos, de douleurs abdominales et de migraines. Les résultats indiquent que les facteurs de différence individuels (par exemple, le sexe et la douleur chronique) peuvent influencer la nociception induite par l'ocytocine, mais le nombre limité d'études recensées et leur hétérogénéité a empêché d'approfondir l'enquête.Discussion: Il existe un équilibre au profit de l'ocytocine pour la prise en charge de la douleur. Il est primordial que d'autres études soient menées afin d'explorer de manière plus précise les facteurs de confusion et les mécanismes de l'action analgésique potentiels et ainsi clarifier l'incohérence dans la littérature.