Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty.

BACKGROUND: Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA. METHODS: This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use. DISCUSSION: The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making. TRIAL REGISTRATION: Prospectively registered in Clinicaltrials.gov (NCT04968132).

Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): A feasibility randomized controlled trial in knee replacement patients.

Background: Total knee arthroplasties are the second most common surgery in Canada. Most patients recover well, but 20% or more still suffer from persistent pain and opioid use. Though opioids are an important part of perioperative pain management, their potential for long-term adverse effects is well recognized. Limiting opioids may be insufficient to overcome the issue of opioid overuse. Pain and opioid use are highly linked, so an effective alternative needs to address both issues. Objectives: The principal objective of this pilot trial is to assess the feasibility. The clinical objectives are to determine the effects of a multicomponent care pathway on opioid-free pain control, persisting pain and opioid use, functional knee outcomes, quality of life, and return to function. Methods: We will include adult patients scheduled for primary elective total knee arthroplasty. Patients in the intervention group will undergo a multicomponent intervention pathway that will be facilitated by an intervention coordinator linking each patient and their surgical/ perioperative team. The interventional pathway will include (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation using cognitive behavioral skills, (3) personalized postdischarge analgesic prescriptions, and (4) continued support for pain control and recovery up to 8 weeks. Patients in the control group will receive the usual care at their institution. Discussion: The overarching goal is to implement and evaluate a coordinated approach to clinical care to improve pain control and reduce harms, with an emphasis on patient-centered care and shared decision making.Trial Registration Number: NCT04968132 (informed consent/ research ethics board statement).

Contexte: L'arthroplastie totale du genou est la deuxième chirurgie la plus courante au Canada. La plupart des patients se rétablissent bien, mais au moins 20 pour cent d'entre eux souffrent encore de douleur persistante et de consommation d'opioïdes. Bien que les opioïdes soient un élément important de la prise en charge périopératoire de la douleur, leur potentiel d'effets indésirables à long terme est bien reconnu. La limitation des opioïdes peut être insuffisante pour surmonter le problème de la surconsommation d'opioïdes. La douleur et la consommation d'opioïdes sont étroitement liées, de sorte qu'une option de rechange efficace doit s'attaquer à ces deux problèmes.Objectifs: L'objectif principal de cet essai pilote est d'évaluer la faisabilité. Les objectifs cliniques sont de déterminer les effets d'une voie de soins à composantes multiples sur la maitrise de la douleur sans opioïdes, la douleur persistante et la consommation d'opioïdes, les résultats fonctionnels du genou, la qualité de vie et le retour à la fonction.Méthodes: Nous inclurons les patients adultes devant subir une arthroplastie primaire totale élective du genou. Les patients du groupe d'intervention seront soumis à une voie d'intervention à composantes multiples qui sera facilitée par un coordonnateur d'intervention reliant chaque patient et son équipe chirurgicale/périopératoire. La voie d'intervention comprendra (1) une éducation préopératoire sur la douleur et la consommation d'opioïdes, (2) la détermination et l'atténuation des risques préopératoires à l'aide de compétences comportementales cognitives, (3) des prescriptions analgésiques personnalisées après la sortie, et (4) un soutien continu pour la maîtrise de la douleur et la récupération pendant une période allant jusqu'à huit semaines. Les patients du groupe témoin recevront les soins habituels à leur établissement.Discussion: L'objectif global est de mettre en œuvre et d'évaluer une approche coordonnée des soins cliniques afin d'améliorer la maitrise de la douleur et réduire les méfaits, en mettant l'accent sur les soins centrés sur le patient et la prise de décision partagée. Numéro d'enregistrement de l'essai : NCT04968132 (consentement éclairé/déclaration du comité d'éthique de la recherche).

Psychological interventions for reducing anxiety in patients undergoing first-time colonoscopy: a pilot and feasibility study.

OBJECTIVES: To assess the feasibility of a randomized controlled trial (RCT), evaluating the efficacy and patients' perceptions of a psychological intervention aimed at reducing anxiety levels in adults undergoing first-time colonoscopy. METHODS: Adults undergoing first-time colonoscopy were randomized to a psychological intervention vs. sham intervention. The primary outcome was feasibility, defined as a recruitment rate of >50%. Patients' state anxiety was assessed before and after the intervention using the state-trait inventory for cognitive and somatic anxiety (STICSA) score. Follow-up interviews were performed within 1 week with a sample of patients and focus groups with clinical staff. RESULTS: A total of 130 patients were recruited from 180 eligible patients (72%). Eighty were randomized and completed the study (n = 39) in the psychological intervention group and (n = 41) in the sham. In the psychological intervention group, pre- and postmedian STICSA scores were 29 and 24 (P < 0.001), respectively. In the sham group, pre- and postmedian scores were 31 and 25 (P < 0.001), respectively. Follow-up interviews with patients (n = 13) suggested that 100% of patients perceived the psychological intervention as beneficial and would recommend it to others. CONCLUSION: The study was feasible. Patients in both groups improved their anxiety scores, but there were no significant differences between arms. Despite this, patients receiving psychological intervention perceived a benefit from the relaxation exercises.

Cognitive behavioral therapy to reduce persistent postsurgical pain following internal fixation of extremity fractures (COPE): Rationale for a randomized controlled trial.

Background: Approximately half of all patients who undergo surgical repair of extremity fractures report persistent postsurgical pain (PPSP) at 1-year post-surgery. Psychological factors such as anxiety, depression, catastrophization, poor coping, high somatic complaints, and pessimism about recovery are risk factors for the development of PPSP. It is possible that interventions such as cognitive behavior therapy (CBT) that target psychological factors may reduce the incidence of PPSP in this population. Aims: The current report reviews the role of psychological factors in the development of PPSP and discusses the rationale and protocol development for a multi-site randomized-controlled trial investigating the effectiveness of CBT in reducing PPSP in patients with surgically treated extremity fractures.

Contexte: Près de la moitié des patients qui sont opérés pour des fractures aux extrémités font état de douleur postopératoire persistante un an après la chirurgie. Des facteurs psychologiques tels que l'anxiété, la dépression, la catastrophisation, une piètre capacité d'adaptation, une somatisation élevée et le pessimisme quant à la récupération sont des facteurs de risque pour le développement de la douleur postopératoire persistante. Il est possible que des interventions ciblant les facteurs psychologiques, telles que la thérapie cognitivo-comportementale (TCC), puissent réduire l'incidence de la douleur postopératoire persistante dans cette population.Objectifs: Le présent rapport examine le rôle des facteurs psychologiques dans le développement de la douleur postopératoire persistante et discute de la justification et du développement d'un protocole pour un essai contrôlé randomisé multisite portant sur l'efficacité de la TCC pour réduire la douleur postopératoire persistante chez les patients ayant été opérés pour des fractures aux extrémités.

Modifying interpretation biases: Effects on symptomatology, behavior, and physiological reactivity in social anxiety.

BACKGROUND AND OBJECTIVES: The present study investigated the effects of computerized interpretation training and cognitive restructuring on symptomatology, behavior, and physiological reactivity in an analogue social anxiety sample. METHODS: Seventy-two participants with elevated social anxiety scores were randomized to one session of computerized interpretation training (n = 24), cognitive restructuring (n = 24), or an active placebo control condition (n = 24). Participants completed self-report questionnaires focused on interpretation biases and social anxiety symptomatology at pre and posttraining and a speech task at posttraining during which subjective, behavioral, and physiological measures of anxiety were assessed. RESULTS: Only participants in the interpretation training condition endorsed significantly more positive than negative interpretations of ambiguous social situations at posttraining. There was no evidence of generalizability of interpretation training effects to self-report measures of interpretation biases and symptomatology or the anxiety response during the posttraining speech task. Participants in the cognitive restructuring condition were rated as having higher quality speeches and showing fewer signs of anxiety during the posttraining speech task compared to participants in the interpretation training condition. LIMITATIONS: The present study did not include baseline measures of speech performance or computer assessed interpretation biases. CONCLUSIONS: The results of the present study bring into question the generalizability of computerized interpretation training as well as the effectiveness of a single session of cognitive restructuring in modifying the full anxiety response. Clinical and theoretical implications are discussed.

Predictors of immigrant children's mental health in Canada: selection, settlement contingencies, culture, or all of the above?

BACKGROUND AND STUDY AIMS: A previous publication from the New Canadian Children and Youth Study, a national study of immigrant children and youth in Canada, showed a gradient of levels of emotional distress with children from Hong Kong (HK) at the most severe end, Filipino children at the least severe, and children from the People's Republic of China (PRC) in between. Based on the premise that country of origin can be regarded as an index for differing immigration trajectories, the current study examines the extent to which arrival characteristics, resettlement contingencies and cultural factors account for country of origin variations in immigrant children's mental health. Arrival characteristics included child's age at arrival, parental education, parental fluency in English or French, and assistance from family at arrival. Resettlement contingencies included parental mental health, intra-familial conflict, settlement stress, separations from parents and child's age when mother started working outside the home. Cultural factors included one-child family composition and parenting styles. METHODS: A national survey of 2,031 families with at least one child between the ages of 4 and 6 or 11 and 13 from HK, the PRC and the Philippines was conducted with the Person Most Knowledgeable (PMK) in snowball-generated samples in 6 different cities across Canada. Predictors of the dependent variable, emotional problems (EP), were examined in a hierarchical block regression analysis. EP was regressed on ethnic and country of origin group in model 1; arrival characteristics were added in model 2; resettlement contingencies in model 3 and cultural factors in model 4. RESULTS: The final set of predictor variables accounted for 19.3 % of the variance in EP scores among the younger cohort and 23.2 % in the older. Parental human and social capital variables accounted for only a small amount of the overall variance in EP, but there were statistically significant inverse relationships between EP and PMK fluency in English or French. Settlement contingencies accounted for a significant increase in the explanatory power of the regression equation, net of the effects of country of origin and selection characteristics. This block of variables also accounted for the Filipino mental health advantage. Levels of parent's depression and somatization, harsh parenting, intrafamilial conflict, and resettlement stress each varied directly with levels of children's EP. Cultural variables made a significant contribution to explaining the variance in EP scores. Harsh parenting was significantly associated with increased levels of EP in both age groups, and supportive parenting was a mental health protective factor for younger children. CONCLUSIONS: Immigrant family human and social capital, according to which immigrants are selected for admission to Canada, play a relatively small role in determining children's mental health. These effects are overshadowed by resettlement contingencies and cultural influences. Concentrating on trying to find a formula to select the "right" immigrants while neglecting settlement and culture is likely to pay limited dividends for ensuring the mental health of children.

Alexithymia and eating disorders: a critical review of the literature.

Alexithymia is characterized by difficulties identifying feelings and differentiating between feelings and bodily sensations, difficulties communicating feelings, and a concrete cognitive style focused on the external environment. Individuals with eating disorders have elevated levels of alexithymia, particularly difficulties identifying and describing their feelings. A number of theoretical models have suggested that individuals with eating disorders may find emotions unacceptable and/or frightening and may use their eating disorder symptoms (i.e., restricting food intake, bingeing, and/or purging) as a way to avoid or cope with their feelings. The current critical review synthesizes the literature on alexithymia and eating disorders and examines alexithymia levels across eating disorders (i.e., anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified), the role of alexithymia in binge eating disorder, and the influence of alexithymia on the development of eating disorders as well as treatment outcome. The clinical implications of the research conducted to date and directions for future research are discussed.

Joint attention in toddlerhood predicts internalizing problems at early school age.

The authors examined the longitudinal relation between joint attention and socioemotional functioning in a low-risk, typically developing sample of children when the children were toddlers and again during the early school-age years. Fifty-eight mothers and their children were observed in the home or laboratory engaging in 1 unstructured and 4 semistructured tasks designed to assess joint attention episodes when the children were toddlers. Approximately 4 years later, the mother-child dyads were contacted again and mothers completed the Child Behavior Checklist as a measure of their children's socioemotional outcome at the early school years. The authors found that lower frequencies of joint attention episodes at toddlerhood predicted higher internalizing behaviors at early school age. Preliminary findings are discussed in terms of their theoretical implications for work on early mother-child interactions and children's typical and atypical sociemotional development.

Stresses of passage, balms of resettlement, and posttraumatic stress disorder among Sri Lankan Tamils in Canada.

OBJECTIVES: To explore the salience of pre- and postmigration stresses as risk factors for posttraumatic stress disorder (PTSD) and to identify resilience factors and explore their mental health salience. METHODS: We conducted a mental health survey of 1603 Sri Lankan Tamils in Toronto, incorporating the World Health Organization Composite International Diagnostic Interview for PTSD. RESULTS: According to the International Classification of Diseases, 10th Revision, criteria, lifetime prevalence for PTSD was 12%; according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria it was 5.8%. Female sex and the number of stresses of passage increased the probability of PTSD, whereas satisfaction with life and the availability of nonfamily social relations reduced it. CONCLUSIONS: Consideration of pre- and postmigration stresses of passage and of the nature of resilience contributes to an improved understanding of PTSD among refugees.

An investigation of control among parents of selectively mute, anxious, and non-anxious children.

The authors examined parent­child interactions among three groups: selectively mute, anxious, and non-anxious children in different contexts. The relation between parental control (granting autonomy and high power remarks), child factors (i.e., age, anxiety, verbal participation), and parent anxiety was investigated. Parental control varied by context but parents of children with SM were more controlling than parents in the comparison groups in all contexts. Regression analyses indicated that child and parent anxiety predicted parental control, with increased anxiety associated with increased control. Older child age predicted less parent control. Group categorization moderated the relation between age and high power remarks, such that age was not a significant predictor for children with SM. Finally child-initiated speaking predicted high power remarks over and above other variables. These results support previous theories that parents take over for their children when they fail to meet performance demands, especially when the child or parent is anxious.

Joint attention in parent-child dyads involving children with selective mutism: a comparison between anxious and typically developing children.

Although joint attention processes are known to play an important role in adaptive social behavior in typical development, we know little about these processes in clinical child populations. We compared early school age children with selective mutism (SM; n = 19) versus mixed anxiety (MA; n = 18) and community controls (CC; n = 26) on joint attention measures coded from direct observations with their parent during an unstructured free play task and two structured tasks. As predicted, the SM dyads established significantly fewer episodes of joint attention through parental initiation acts than the MA and CC dyads during the structured tasks. Findings suggest that children with SM may withdraw from their parents during stressful situations, thus missing out on opportunities for learning other coping skills. We discuss the implications of the present findings for understanding the maintenance and treatment of SM.

Establishment of joint attention in dyads involving hearing mothers of deaf and hearing children, and its relation to adaptive social behavior.

Mounting evidence points to joint attention as a mediating variable in children's adaptive behavior development. Joint attention in interactions between hearing mothers and congenitally deaf (n = 27) and hearing (n = 29) children, ages 18-36 months, was examined. All deaf children had severe to profound hearing loss. Mother-child interactions were coded for maternally initiated and child-initiated success rates in establishing joint attention; mothers completed ratings of their children's adaptive behavior. Hearing mother-deaf child dyads had significantly lower maternally initiated success rates. No significant between-group differences on child-initiated success rates were shown. Maternal ratings of adaptive behavior were significantly lower for deaf children, and related positively and significantly to both child-initiated and maternally initiated success rates. The findings suggest that mother-child interactions that are low in successful establishment of joint attention might mediate the development of socioemotional problems evident in deaf children with hearing families.