Peer Victimization, Posttraumatic Stress Symptoms, and Chronic Pain: A Longitudinal Examination.

Chronic pain and posttraumatic stress disorder symptoms (PTSS) co-occur at high rates in youth and are linked to worse pain outcomes and quality of life. While peer victimization has been posited as a mechanism underlying the PTSS-pain relationship in youth, empirical evidence suggests that it may exacerbate both PTSS and pain. The present study aimed to longitudinally examine PTSS as a mediator in the relationship between peer victimization at baseline and pain-related outcomes at 3 months in youth with chronic pain. Participants included 182 youth aged 10 to 18 years recruited from a tertiary-level children's hospital in Western Canada. At baseline, participants completed measures to assess pain (intensity and interference), peer victimization (relational and overt), and PTSS. The pain was reassessed at a 3-month follow-up. Primary hypotheses were tested utilizing a series of mediation analyses with PTSS as a proposed mediator in the associations between peer victimization and pain outcomes. Youth PTSS mediated the relationship between higher baseline relational victimization and higher 3-month pain interference while controlling for baseline pain interference. Three-month pain intensity was not correlated with peer victimization; thus, pain intensity was not included in the analyses. These findings reveal that PTSS may be an underlying factor in the co-occurrence of peer victimization and chronic pain in youth. Further research is needed to better understand the role of peer victimization in the maintenance of chronic pain to ensure appropriate, effective, and timely interventions that address the social and mental health issues impacting the lives of these youth as well as their pain. PERSPECTIVE: PTSS may be an underlying factor in the co-occurrence between peer victimization and chronic pain in youth, highlighting the need to assess for both peer relationship problems and PTSS in youth with chronic pain.

Psychotherapy for Ketamine's Enhanced Durability in Chronic Neuropathic Pain: Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: Chronic pain affects approximately 8 million Canadians (~20%), impacting their physical and mental health while burdening the health care system with costs of upwards of US $60 billion a year. Indeed, patients are often trialed on numerous medications over several years without reductions to their symptoms. Therefore, there is an urgent need to identify new therapies for chronic pain to improve patients' quality of life, increase the availability of treatment options, and reduce the burden on the health care system. OBJECTIVE: The primary objective of this study is to examine the feasibility of a parallel 3-arm pilot randomized controlled trial whereby patients are randomized to either intravenous ketamine alone, cognitive behavioral therapy (CBT) and mindfulness meditation (MM) training (CBT/MM), or the combination of intravenous ketamine and CBT/MM. The secondary outcome is to assess the durability and efficacy of combination intravenous ketamine and CBT/MM for treatment of chronic pain as compared to CBT/MM or intravenous ketamine alone (assessed at week 20 of the study). METHODS: This is a single-center, 16-week, 3-arm pilot study that will take place at the Chronic Pain Clinic at St. Michael's Hospital, Toronto, Ontario, which receives 1000 referrals per year. Patients will be enrolled in the study for a total of 20 weeks. Participants who are allocated CBT/MM therapy will receive remote weekly psychotherapy from week 1 to week 16, inclusive of health coaching administered through the NexJ Health Inc (NexJ Health) platform. Patients who are allocated ketamine-infusion therapy will receive monthly ketamine infusion treatments on weeks 2, 7, and 12. Patients who are allocated ketamine+CBT/MM will receive weekly psychotherapy from weeks 1 to 16, inclusive, as well as ketamine infusion treatments on weeks 2, 7, and 12. We will be assessing recruitment rates, consent rates, withdrawal rates, adherence, missing data, and adverse events as pilot outcome measures. Secondary clinical outcomes include changes relative to baseline in pain intensity and pain interference. RESULTS: As of November 1, 2023, the recruitment process has not been initiated. Given the recruitment, consent, and intervention target of 30 participants for this feasibility study, with each patient undergoing monitoring and treatments for a course of 20 weeks, we expect to complete the study by December 2025. CONCLUSIONS: This study assesses the feasibility of conducting a 3-arm randomized controlled trial to examine the effects of ketamine administration with the concurrent use of CBT/MM in a population with chronic neuropathic pain. The results of this pilot randomized controlled trial will inform the development of a larger-scale randomized controlled trial. Future studies will be aimed at including a sufficiently powered sample that will inform decisions about optimal treatment calibration and treatment effect duration. TRIAL REGISTRATION: ClinicalTrials.gov NCT05639322; https://classic.clinicaltrials.gov/ct2/show/NCT05639322. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/54406.

The Sensitivity to Pain Traumatization Scale-Child Version (SPTS-C): Development and preliminary validation.

Background: Sensitivity to pain traumatization is defined as the propensity to develop cognitive, affective, and behavioral responses to pain that resemble a traumatic stress reaction. To date, sensitivity to pain traumatization has been assessed in adults (Sensitivity to Pain Traumatization Scale [SPTS-12]) and parents of youth with chronic pain (Sensitivity to Pain Traumatization Scale-Parent version [SPTS-P]). SPT may be relevant in the context of pediatric chronic pain given the substantial comorbidity between posttraumatic stress symptoms and pain. Aims: This prospective study aimed to adapt the SPTS-12 for use in youth and to evaluate the psychometric properties of the new scale. Methods: Participants included 175 youth with chronic pain (Mage = 14.31 years, 73% girls) referred to outpatient chronic pain programs. At baseline, youth self-reported the levels of their sensitivity to pain traumatization (Sensitivity to Pain Traumatization Scale-Child version [SPTS-C]), as well as their pain symptoms, pain-related anxiety, posttraumatic stress symptoms, and attentional control. Three months later, youth self-reported their pain symptoms and completed the SPTS-C. Results: The SPTS-C had a one-factor structure that explained 48% of variance and demonstrated good reliability and construct validity. SPTS-C baseline scores predicted follow-up levels of pain interference but not pain intensity or pain unpleasantness. Conclusions: The results provide preliminary evidence for the psychometric properties of the SPTS-C and the potential role of SPT in pediatric chronic pain outcomes.

Contexte: La sensibilité à la traumatisation de la douleur est définie comme la propension à développer des réponses cognitives, affectives et comportementales à la douleur qui ressemblent à une réaction de stress traumatique. À ce jour, la sensibilité à la traumatisation de la douleur a été évaluée chez les adultes (Échelle de sensibilité à la traumatisation de la douleur [SPTS-12]) et chez les parents de jeunes souffrant de douleur chronique (Échelle de sensibilité à la traumatisation de la douleur - Version parent [SPTS-P]). La sensibilité à la traumatisation de la douleur peut être pertinente dans le contexte de la douleur chronique pédiatrique étant donné la comorbidité importante entre les symptômes de stress post-traumatique et la douleur.Objectifs: Cette étude prospective visait à adapter le SPTS-12 pour une utilisation chez les jeunes et à évaluer les propriétés psychométriques de la nouvelle échelle.Méthodes: Les participants comprenaient 175 jeunes souffrant de douleur chronique (âge M = 14,31 ans, 73 % de filles) référés aux programmes de traitement ambulatoire de la douleur chronique. Au départ, les jeunes ont autodéclaré les niveaux de leur sensibilité à la traumatisation de la douleur (Échelle de sensibilité à la traumatisation de la douleur - version enfant [SPTS-C]), ainsi que leurs symptômes de douleur, leur anxiété liée à la douleur, leurs symptômes de stress post-traumatique et leur contrôle attentionnel. Trois mois plus tard, les jeunes ont autodéclaré leurs symptômes de douleur et ont répondu au SPTS-C.Résultats: Le SPTS-C avait une structure à un facteur qui expliquait 48 % de la variance et démontrait une bonne fiabilité ainsi qu'une bonne validité de la construction. Les scores obtenus au SPTS-C au départ prédisaient les niveaux d'interférence de la douleur au suivi mais pas l'intensité de la douleur ou le désagrément de la douleur.Conclusions: Les résultats présentent des preuves préliminaires des propriétés psychométriques du SPTSC et le rôle potentiel de la sensibilité à la traumatisation de la douleur dans les résultats liés à la douleur chronique pédiatrique.

Effects of perioperative clinical hypnosis on heart rate variability in patients undergoing oncologic surgery: secondary outcomes of a randomized controlled trial.

Introduction: Clinical hypnosis has been proposed for post-surgical pain management for its potential vagal-mediated anti-inflammatory properties. Evidence is needed to understand its effectiveness for post-surgical recovery. Iin this secondary outcome study, it was hypothesized that surgical oncology patients randomized to receive perioperative clinical hypnosis (CH) would demonstrate greater heart-rate variability (HRV) during rest and relaxation at a 1-month post-surgery assessment compared to a treatment-as-usual group (TAU). Methods: After REB approval, trial registration and informed consent, 92 participants were randomized to receive CH (n = 45) or TAU (n = 47). CH participants received a CH session before surgery and during post-surgical in-hospital stay HRV was assessed during rest (5 min) and relaxation (10 min) before and 1-month after surgery. Pain intensity was obtained using a 0-10 numeric rating scale pre and post 1-week and 1-month post surgery. Results: One month after surgery, HRV was significantly higher in CH group (n = 29) during rest and relaxation (both p < 0.05, d = 0.73) than TAU group (n = 28). By contrast, rest and relaxation HRV decreased from pre- to 1-month post-surgery for the TAU (both p < 0.001, d > 0.48) but not the CH group. Pain intensity increased from pre-surgery to 1-week post-surgery (p < 0.001, d = 0.50), and decreased from 1-week to 1-month post-surgery (p = 0.005, d = 0.21) for all participants. Discussion: The results suggest that hypnosis prevents the deleterious effects of surgery on HRV by preserving pre-operative vagal activity. These findings underscore the potential of clinical hypnosis in mitigating the adverse effects of surgery on autonomic function and may have significant implications for enhancing post-surgical recovery and pain management strategies. Clinical Trial Registration: ClinicalTrials.gov, identifier (NCT03730350).

Facilitating the transition to residency: A resident-as-coach pilot program.

BACKGROUND: The transition from medical school to residency is a critical developmental phase; coaching may help students prepare for this role transition. AIMS: We explored whether near-peer coaching could improve a specific workplace skill prior to residency. METHODS: A resident-as-coach program was piloted for the medicine sub-internship, an advanced acting internship rotation. Between March and June 2021, 26 students were assigned a resident coach (n = 16). Resident coaches completed one training session, and student-coach dyads met for one coaching session on 'pre-rounding'- gathering patient data before rounds. The program was evaluated through surveys and focus groups. RESULTS: 20/26 students and 14/16 residents completed the survey. 19/20 students identified a pre-rounding challenge and reported increased pre-rounding efficiency; all committed to one actionable step for improvement. All 16 residents felt their coaching skills improved. In focus groups, students valued the program's focus on honing a relevant skill in a safe, near-peer setting. Residents expressed their intent to incorporate coaching into their future work. CONCLUSIONS: A resident-as-coach model can be effective in preparing students for residency, while concurrently building residents' coaching skills.

Matching males and females undergoing non mesh primary unilateral inguinal hernia repair: evaluating sex differences in preoperative and acute postoperative pain.

PURPOSE: The objective was to compare pain and related psychological factors during the preoperative and acute postoperative period between male and female patients, who underwent non mesh primary unilateral inguinal hernia repair. METHODS: After ethics approval, informed consent was obtained, and data were collected. Male and female participants were compared by manually matching one-to-one on 10 variables. Descriptive statistics (mean ± standard deviation and frequency) as well as numerical rating scales from 0 to 10 were used. Comparison tests were performed using Chi-square or Fisher's Exact test for categorical data and independent samples t-test or non-parametric equivalent tests for numerical scores. p < 0.05 is reported as statistically significant. To control type I error, Bonferroni correction was used. RESULTS: 72 participants with 36 matched pairs were included. Sex differences were found for operation length (p = .006), side of operation (p = .002), and hernia type (p = .013). Significant differences between the sexes were not found at the preoperative or postoperative time for resilience, pain interference or pain severity related measures, postoperative hernia pain incidence, pain catastrophizing, depression and anxiety symptoms, or return to normal activities. CONCLUSION: When controlling for known confounders and using a conservative Type I error rate, pain and related factors between the sexes did not differ significantly.

Customised knowledge-sharing platform to foster resident quality improvement activities, tracking and scholarship.

INTRODUCTION: Meeting accreditation requirements to train resident physicians in quality improvement (QI) may require more than education. Barriers to resident QI engagement underscore the need to demonstrate the impact and value of resident QI work. It is not known whether a platform to track and publicise resident QI projects and scholarship is feasible or acceptable to implement within a residency programme. We aimed to create a searchable online platform and associated programming to promote resident QI work. METHODS: This intervention targeted resident physicians in an internal medicine residency training programme at a tertiary, academic medical centre. We designed an intervention to track resident QI and related scholarship in a searchable online platform, including practical details of implementing each project. Newsletters and events were used to publicise these project profiles. RESULTS: During the 2020-2021 academic year, 104 projects were profiled from 238 sourced projects. Average readership was 31.5% across 11 newsletters sent to residents and key faculty. DISCUSSION: A platform to track and share resident QI work and scholarship can be feasibly and acceptably implemented within a residency programme, serving as a novel way to engage residents around QI.

Navigating Uncertainty in Clinical Practice: A Structured Approach.

The practice of clinical medicine is imbued with uncertainty. The ways in which clinicians and patients think about, communicate about, and act within situations of heightened uncertainty can have significant implications for the therapeutic alliance and for the trajectory and outcomes of clinical care. Despite this, there is limited guidance about the best methods for physicians to recognize, acknowledge, communicate about, and manage uncertainty in clinical settings. In this paper, we propose a structured approach for discussing and managing uncertainty within the context of a clinician-patient relationship. The approach involves four steps: Recognize, Acknowledge, Partner, and Seek Support (i.e., the RAPS framework). The approach is guided by existing literature on uncertainty as well as our own experience as clinicians working at different stages of career. We define each component of the approach and present sample language and actions for how to implement it in practice. Our aim is to empower clinicians to regard situations of high uncertainty as an opportunity to deepen the therapeutic alliance with the patient, and simultaneously to grow and learn as practitioners.

A Randomized Controlled Trial of Clinical Hypnosis as an Opioid-Sparing Adjunct Treatment for Pain Relief in Adults Undergoing Major Oncologic Surgery.

Clinical hypnosis is an effective strategy for managing acute pain in the surgical setting. However, the opioid sparing effects of clinical hypnosis are not as well understood. This pre-registered (NCT03730350) randomized, controlled trial (RCT) examined the impact of clinical hypnosis, pre- and post-surgery, on opioid consumption during hospitalization as well as on measures of pain intensity, pain interference, depressed mood, anxiety, sleep, and pain catastrophizing. Participants (M = 57.6 years; SD = 10.9) awaiting oncologic surgery were randomized to treatment-as-usual (n = 47) or hypnosis (n = 45). Intent-to-treat analyses were conducted using linear mixed effects modeling. A significant Group × Time interaction, F(6, 323.34) = 3.32, p = 0.003, indicated an opioid sparing effect of clinical hypnosis during the acute postoperative period. Hypnosis also protected against increases in pain catastrophizing at one-week after surgery, F (1, 75.26) = 4.04, p = 0.048. A perioperative clinical hypnosis intervention had a sparing effect on opioid consumption in-hospital after major oncologic surgery. These findings extend the efficacy of clinical hypnosis as an adjunct tool for perioperative pain management.

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.

The Role of Daily Steps in the Treatment of Major Depressive Disorder: Secondary Analysis of a Randomized Controlled Trial of a 6-Month Internet-Based, Mindfulness-Based Cognitive Behavioral Therapy Intervention for Youth.

BACKGROUND: Current evidence supports physical activity (PA) as an adjunctive treatment for major depressive disorder (MDD). Few studies, however, have examined the relationship between objectively measured PA and MDD treatment outcomes using prospective data. OBJECTIVE: This study is a secondary analysis of data from a 24-week internet-based, mindfulness-based cognitive behavioral therapy program for MDD. The purpose of this analysis was twofold: (1) to examine average daily step counts in relation to MDD symptom improvement, and whether pain moderated this relationship; and (2) to examine whether changes in step activity (ie, step trajectories) during treatment were associated with baseline symptoms and symptom improvement. METHODS: Patients from the Centre for Addiction and Mental Health were part of a randomized controlled trial evaluating the effects of internet-based, mindfulness-based cognitive behavioral therapy for young adults (aged 18-30 years old) with MDD. Data from 20 participants who had completed the intervention were analyzed. PA, in the form of objectively measured steps, was measured using the Fitbit-HR Charge 2 (Fitbit Inc), and self-reported depression severity was measured with the Beck Depression Inventory-II (BDI-II). Linear regression analysis was used to test PA's relationship with depression improvement and the moderating effect of pain severity and pain interference. Growth curve and multivariable regression models were used to test longitudinal associations. RESULTS: Participants walked an average of 8269 steps per day, and each additional +1000-step difference between participants was significantly associated with a 2.66-point greater improvement (reduction) in BDI-II, controlling for anxiety, pain interference, and adherence to Fitbit monitoring (P=.02). Pain severity appeared to moderate (reduce) the positive effect of average daily steps on BDI-II improvement (P=.03). Higher baseline depression and anxiety symptoms predicted less positive step trajectories throughout treatment (Ps≤.001), and more positive step trajectories early in the trial predicted greater MDD improvement at the end of the trial (Ps<.04). However, step trajectories across the full duration of the trial did not significantly predict MDD improvement (Ps=.40). CONCLUSIONS: This study used objective measurements to demonstrate positive associations between PA and depression improvement in the context of cognitive behavioral treatment. Pain appeared to moderate this relationship, and baseline symptoms of anxiety and depression predicted PA trajectories. The findings inform future interventions for major depression. Future research with larger samples should consider additional moderators of PA-related treatment success and the extent to which outcomes are related to PA change in multimodal interventions. TRIAL REGISTRATION: Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/11591.

Impact of a Transitional Pain Service on postoperative opioid trajectories: a retrospective cohort study.

INTRODUCTION: It has been well described that a small but significant proportion of patients continue to use opioids months after surgical discharge. We sought to evaluate postdischarge opioid use of patients who were seen by a Transitional Pain Service compared with controls. METHODS: We conducted a retrospective cohort study using administrative data of individuals who underwent surgery in Ontario, Canada from 2014 to 2018. Matched cohort pairs were created by matching Transitional Pain Service patients to patients of other academic hospitals in Ontario who were not enrolled in a Transitional Pain Service. Segmented regression was performed to assess changes in monthly mean daily opioid dosage. RESULTS: A total of 209 Transitional Pain Service patients were matched to 209 patients who underwent surgery at other academic centers. Over the 12 months after surgery, the mean daily dose decreased by an estimated 3.53 morphine milligram equivalents (95% CI 2.67 to 4.39, p<0.001) per month for the Transitional Pain Service group, compared with a decline of only 1.05 morphine milligram equivalents (95% CI 0.43 to 1.66, p<0.001) for the controls. The difference-in-difference change in opioid use for the Transitional Pain Service group versus the control group was -2.48 morphine milligram equivalents per month (95% CI -3.54 to -1.43, p=0.003). DISCUSSION: Patients enrolled in the Transitional Pain Service were able to achieve opioid dose reduction faster than in the control cohorts. The difficulty in finding an appropriate control group for this retrospective study highlights the need for future randomized controlled trials to determine efficacy.

Prevalence of visual art education in medical school curricula: a national survey of US medical schools.

Background: The Association of American Medical Colleges (AAMC) has recommended integrating medically-relevant arts and humanities curricula into medical student education in order promote physician skills development. An analysis of the state of existing visual arts-based medical school pedagogies was conducted to inform future implementation strategies.Methodology: An electronic survey was distributed to representatives of US medical schools to describe the prevalence and characteristics of visual arts-based medical school curricula. Official courses, informal events, cross-registration opportunities, and established art museum partnerships were assessed.Results: Survey response rates were 65% for US allopathic medical schools and 56% for osteopathic medical schools. A majority (79%) of responding institutions incorporate or support medical student art experiences in some format. Thirty-one percent (n = 36) of schools offer stand-alone humanities courses using visual arts. These were primarily allopathic programs (n = 35; 37% of allopathic programs) and only one responding osteopathic program (n = 1; 5% of osteopathic programs). Schools without dedicated courses are less likely to report other curricular and extracurricular visual arts engagement. Most visual art medical courses are offered at medical schools located in the Northeastern United States.Conclusions: Many but not all medical schools are incorporating the visual arts into their medical education curriculum. Opportunities to promote increased uptake, more effective implementation, and collaboration strategies for the AAMC recommendations are proposed.

Stepped collaborative care for pain and posttraumatic stress disorder after major trauma: a randomized controlled feasibility trial.

PURPOSE: To examine feasibility and acceptability of providing stepped collaborative care case management targeting posttraumatic stress disorder (PTSD) and pain symptoms after major traumatic injury. MATERIALS AND METHODS: Participants were major trauma survivors in Victoria, Australia, at risk of persistent pain or PTSD with high baseline symptoms. Participants were block-randomized, stratified by compensation-status, to the usual care (n = 15) or intervention (n = 17) group (46% of eligible patients). The intervention was adapted from existing stepped collaborative care interventions with input from interdisciplinary experts and people with lived experience in trauma and disability. The proactive case management intervention targeted PTSD and pain management for 6-months using motivational interviewing, cognitive behavioral therapy strategies, and collaborative care. Qualitative interviews explored intervention acceptability. RESULTS: Intervention participants received a median of 7 h case manager contact and reported that they valued the supportive and non-judgmental listening, and timely access to effective strategies, resources, and treatments post-injury from the case manager. Participants reported few disadvantages from participation, and positive impacts on symptoms and recovery outcomes consistent with the reduction in PTSD and pain symptoms measured at 1-, 3- and 6-months. CONCLUSIONS: Stepped collaborative care was low-cost, feasible, and acceptable to people at risk of PTSD or pain after major trauma.IMPLICATIONS FOR REHABILITATIONAfter hospitalization for injury, people can experience difficulty accessing timely support to manage posttraumatic stress, pain and other concerns.Stepped case management-based interventions that provide individualized support and collaborative care have reduced posttraumatic stress symptom severity for patients admitted to American trauma centers.We showed that this model of care could be adapted to target pain and mental health in the trauma system in Victoria, Australia.The intervention was low cost, acceptable and highly valued by most participants who perceived that it helped them use strategies to better manage post-traumatic symptoms, and to access clinicians and treatments relevant to their needs.

Serial Neuroendoscopic Lavage for the Treatment of Elevated Cerebrospinal Fluid Protein Levels in Infants with Gram-Negative Rod Ventriculitis.

INTRODUCTION: Gram-negative rod (GNR) bacterial ventriculitis is a rare complication of shunt-dependent hydrocephalus, often requiring an extended and invasive treatment course. Accumulation of purulent material, as well as empyema and septation formation, limits circulation of antibiotics and infection clearance. Supplementation of standard care with neuroendoscopic-guided intraventricular lavage with lactated Ringer solution and fenestration of septations may facilitate infection clearance and simplify the eventual shunt construct required. Here, the utility of serial lavage for ventriculitis is described in a population of shunt-dependent neonates and infants at high risk for morbidity and mortality. METHODS: Five infants with shunt-dependent hydrocephalus and subsequent GNR ventriculitis were treated with standard care measures with the addition of serial neuroendoscopic lavage. A retrospective chart review was performed to collect patient characteristics, shunt dependency, and shunt revisions within a year of ventriculitis resolution. RESULTS: Patients demonstrated a mean 74% decrease in cerebrospinal fluid (CSF) protein following each neuroendoscopic lavage and trended toward a shorter time to infection clearance in comparison to previously published literature. Patients required 0-2 shunt revisions at 1-year follow-up following hospitalization for shunt-related ventriculitis (mean 0.8 +/- 0.8). CONCLUSIONS: Serial neuroendoscopic lavage is an effective technique, used alone or in combination with fenestration of septations, to reduce the CSF protein and bacterial load in the treatment of ventriculitis, decreasing time until eradication of infection. Serial lavage may reduce the risk of future shunt malfunction, simplify the future shunt construct, and decrease duration of infection.

The art of empathy: Teaching empathy through art.

BACKGROUND: The instruction of empathy is challenging. Although several studies have addressed how art-based education can foster empathy, there is a need for more evidence showing its impact and students' perceptions, especially in graduate education. APPROACH: We designed and implemented a virtual art-based curriculum focused on fostering empathy-The Art of Empathy. This novel curriculum used diverse art-based education methodologies to promote meticulous and collaborative observation and reflection, building on constructivism. Thirty-six interns at the Brigham and Women's Hospital were invited to participate in the curriculum, while 34 served as control. EVALUATION: We used mixed methods to explore interns' perceptions of the curriculum and assess its impact on their empathy. We used two quantitative instruments with known psychometric characteristics: the Toronto Empathy Questionnaire (TEQ) and the Jefferson Scale of Physicians Empathy (JSPE), which were distributed in a survey and completed by 31/99 (31.3%). We collected qualitative data from four interns using semi-structured interviews. Thematic analysis showed how The Art of Empathy promoted interns' reflections and actions toward empathy. This was partially supported by the quantitative data that showed significantly higher scores on the 'Compassionate Care' subscale of the JSPE (p = 0.039) when compared with interns in the control group. The thematic analysis showed that interns appreciated the curriculum and valued its benefits while highlighting the limitations of the virtual delivery approach. IMPLICATIONS: Our curriculum was well received by interns and showed the potential of art-based methodology to promote empathic capacities in graduate students.

Incidence of opioid use and early postoperative pain intensity after primary unilateral inguinal hernia repair at a single-center specialty hospital.

PURPOSE: This research examined opioid use, pain intensity, and pain management after primary unilateral inguinal hernia repair (PUIHR) at a single-center specialty hospital. METHODS: After research, ethics board approval, and informed consent, pain scores (0-10 numerical rating scale [NRS]) were obtained from survey-based questionnaires administered at the pre- and 3-day postoperative timepoints. Descriptive results are presented as frequency, mean, standard deviation, range, median, and interquartile ranges, as appropriate. Significance tests were conducted to compare participants who did and did not receive opioids after surgery. p-value <0.05 is considered statistically significant. As the standard of care, participants received nonopioid multimodal analgesia (acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)) and opioids, when necessary. RESULTS: A total of 414 and 331 participants completed the pre- and 3-day postoperative questionnaires, respectively. Out of the 414 participants, 38 (9.2%) received opioids during the postoperative stay. There was no significant difference between pain frequency or mean preoperative NRS pain intensity scores of those who did and did not receive opioids. Mean NRS pain intensity scores on day 3 after surgery were significantly higher for participants who received opioids (3.15±2.08) than those who did not (2.19±1.95), p=0.005. CONCLUSION: Most participants did not receive opioids after PUIHR and had lower mean postoperative NRS pain intensity scores compared to those who did, most likely reflecting the need for opioids among the latter. Opioids were discontinued by day 3 for all participants who received them. Therefore, for most patients undergoing PUIHR, effective pain control can be achieved with nonopioid multimodal analgesia in the early postoperative period.

Sex and gender differences in healthcare utilisation trajectories: a cohort study among Quebec workers living with chronic pain.

OBJECTIVES: Chronic pain (CP) is a poorly recognised and frequently inadequately treated condition affecting one in five adults. Reflecting on sociodemographic disparities as barriers to CP care in Canada was recently established as a federal priority. The objective of this study was to assess sex and gender differences in healthcare utilisation trajectories among workers living with CP. DESIGN: Retrospective cohort study. PARTICIPANTS: This study was conducted using the TorSaDE Cohort which links the 2007-2016 Canadian Community Health Surveys and Quebec administrative databases (longitudinal claims). Among 2955 workers living with CP, the annual number of healthcare contacts was computed during the 3 years after survey completion. OUTCOME: Group-based trajectory modelling was used to identify subgroups of individuals with similar patterns of healthcare utilisation over time (healthcare utilisation trajectories). RESULTS: Across the study population, three distinct 3-year healthcare utilisation trajectories were found: (1) low healthcare users (59.9%), (2) moderate healthcare users (33.6%) and (3) heavy healthcare users (6.4%). Sex and gender differences were found in the number of distinct trajectories and the stability of the number of healthcare contacts over time. Multivariable analysis revealed that independent of other sociodemographic characteristics and severity of health condition, sex-but not gender-was associated with the heavy healthcare utilisation longitudinal trajectory (with females showing a greater likelihood; OR 2.6, 95% CI 1.6 to 4.1). CONCLUSIONS: Our results underline the importance of assessing sex-based disparities in help-seeking behaviours, access to healthcare and resource utilisation among persons living with CP.

Prevalence and Risk Factors for Chronic Postsurgical Pain after Cardiac Surgery: A Single-center Prospective Cohort Study.

BACKGROUND: Chronic postsurgical pain is a common complication of surgery. The role of psychologic risk factors like depression and anxiety is substantially understudied in cardiac surgery. This study sought to identify perioperative factors associated with chronic pain at 3, 6, and 12 months after cardiac surgery. The authors hypothesize that baseline psychologic vulnerabilities have a negative influence on chronic postsurgical pain. METHODS: The authors prospectively collected demographic, psychologic, and perioperative factors in a cohort of 1,059 patients undergoing cardiac surgery at the Toronto General Hospital between 2012 and 2020. Patients were followed and completed chronic pain questionnaires at 3, 6, and 12 months after surgery. RESULTS: The study included 767 patients who completed at least one follow-up questionnaire. The incidence of postsurgical pain (more than 0 out of 10) at 3, 6, and 12 months after surgery was 191 of 663 (29%), 118 of 625 (19%), and 89 of 605 (15%), respectively. Notably, among patients reporting any pain, the incidence of pain compatible with a neuropathic phenotype increased from 56 of 166 (34%) at 3 months to 38 of 97 (39%) at 6 months and 43 of 67 (64%) at 12 months. Factors associated with postsurgical pain scores at 3 months include female sex, pre-existing chronic pain, previous cardiac surgery, preoperative depression, baseline pain catastrophizing scores, and moderate-to-severe acute pain (4 or more out of 10) within 5 postoperative days. CONCLUSIONS: Nearly one in three patients undergoing cardiac surgery reported pain at 3 months of follow-up, with approximately 15% reporting persistent pain at 1 yr. Female sex, pre-existing chronic pain, and baseline depression were associated with postsurgical pain scores across all three time periods.