Mindfulness-Based Stress Reduction in Breast Cancer Survivors with Chronic Neuropathic Pain: A Randomized Controlled Trial.

Objectives: The purpose of this study was to compare the effects of group-delivered mindfulness-based stress reduction as compared to a waitlist control group among breast cancer survivors living with CNP. Methods: A randomized controlled trial design was applied, and outcomes collected included pain, emotional function, quality of life, and global impression of change. Results: A total of 98 women were randomized and included in analyses. The sample included 49 women in the mindfulness-based stress reduction group, and 49 women in the waitlist control group. The intervention group participants (mean age 51.3 years, standard deviation = 11.4) and waitlist participants (mean age 55.1 years, standard deviation = 9.6) reported an average pain duration of approximately three years. No significant differences were found on the primary outcome of the proportions of women with reduced pain interference scores from the time of randomization to 3 months after the intervention was received. No significant changes were found among secondary outcomes. Conclusion: Our randomized clinical trial did not find significant benefits of group-based mindfulness-based stress reduction for the management of CNP. The current study findings should be replicated and are important to consider given ongoing concerns that nonsignificant results of mindfulness-based stress reduction are often unpublished.

Who, what, when, where, why, and how: A systematic review of the quality of post-stroke cognitive rehabilitation protocols.

BACKGROUND: Rehabilitation research findings are not routinely incorporated into clinical practice. A key barrier is the quality of reporting in the original study, including who provided the intervention, what it entailed, when and where it occurred, how patient outcomes were monitored, and why the intervention was efficacious. OBJECTIVES: To facilitate clinical implementation of post-stroke cognitive rehabilitation research, we undertook a review to examine the quality of intervention reporting in this literature. METHODS: Four databases were systematically searched, identifying 27 randomised controlled trials of post-stroke cognitive rehabilitation. The quality of intervention protocol descriptions in each study was independently rated by 2 of the authors using the 12-item Template for Intervention Description and Replication (TIDieR) checklist. RESULTS: Why, when, and where items were reported in more than 70% of interventions, what materials and procedures used was described in 50% to 70%, how items were described in approximately half of the interventions, and who provided interventions was reported in 22% of studies. No study addressed all 12 TIDieR items. "Active ingredients" that may further characterise an intervention and the potential mechanisms of action included restorative training, massed practice, feedback, and tailoring demands (present in approximately 50% of studies). CONCLUSIONS: Descriptions of intervention protocols are variable and frequently insufficient, thereby restricting the ability to understand, replicate, and implement evidence-based cognitive rehabilitation. Use of reporting checklists to address this barrier to research translation is a readily achievable and effective means to advance post-stroke care.

SPIRALS: An Approach to Non-Linear Thinking for Medical Students in the Emergency Department.

Context We lack guidelines to inform the necessary components of an emergency medicine undergraduate rotation. Traditionally, clinical reasoning has been taught using linear thought processes likely not ideal for diagnostic and management decisions made in the emergency department.  Methods We used the Delphi method to obtain consensus on a set of competencies for undergraduate emergency medicine that illustrate the non-linear concepts we believe are necessary for learners. Competencies were informed by a naturalistic observational study of emergency physicians. A survey outlining these competencies was subsequently circulated to emergency physicians who rated their relative importance. Results Eleven competencies were included in Round 1, all rated within the "for consideration" for inclusion range. This was reduced to 10 competencies in Round 2, which was only marginally more definitive with respondents rating one competency in the "definite inclusion range" and the remaining in the "for consideration" range.  Conclusions This study was conducted to address a gap in the current undergraduate emergency medicine curriculum. Consensus on the relative importance of each competency was not achieved, though we believe that the competencies that arose from this study will help medical students develop the non-linear thinking processes necessary to succeed in emergency medicine.

Characteristics of frequent users of the emergency department with chronic pain.

OBJECTIVES: To identify the proportion of high-frequency users of the emergency department (ED) who have chronic pain. METHODS: We reviewed medical records of adult patients with ≥ 12 visits to a tertiary-care, academic hospital ED in Canada in 2012-2013. We collected the following demographics: 1) patient age and sex; 2) visit details - number of ED visits, inpatient admissions, length of inpatient admissions, diagnosis, and primary location of pain; 3) current and past substance abuse, mental health and medical conditions. Charts were reviewed independently by two reviewers. ED visits were classified as either "chronic pain" or "not chronic pain" related. RESULTS: We analyzed 4,646 visits for 247 patients, mean age was 47.2 years (standard deviation = 17.8), and 50.2% were female. This chart review study found 38% of high-frequency users presented with chronic pain to the ED and that women were overrepresented in this group (64.5%). All high-frequency users presented with co-morbidities and/or mental health concerns. High-frequency users with chronic pain had more ED visits than those without and 52.7% were prescribed an opioid. Chronic abdominal pain was the primary concern for 54.8% of high-frequency users presenting with chronic pain. CONCLUSIONS: Chronic pain, specifically chronic abdominal pain, is a significant driver of ED visits among patients who frequently use the ED. Interventions to support high-frequency users with chronic pain that take into account the complexity of patient's physical and mental health needs will likely achieve better clinical outcomes and reduce ED utilization.

Effects of 5-HT2C, 5-HT1A receptor challenges and modafinil on the initiation and persistence of gambling behaviours.

RATIONALE: Problematic patterns of gambling are characterised by loss of control and persistent gambling often to recover losses. However, little is known about the mechanisms that mediate initial choices to begin gambling and then continue to gamble in the face of losing outcomes. OBJECTIVES: These experiments first assessed gambling and loss-chasing performance under different win/lose probabilities in C57Bl/6 mice, and then investigated the effects of antagonism of 5-HT2CR with SB242084, 5-HT1AR agonism with 8-OH-DPAT and modafinil, a putative cognitive enhancer. RESULTS: As seen in humans and other species, mice demonstrated the expected patterns of behaviour as the odds for winning were altered increasing gambling and loss-chasing when winning was more likely. SB242084 decreased the likelihood to initially gamble, but had no effects on subsequent gambling choices in the face of repeated losses. In contrast, 8-OH-DPAT had no effects on choosing to gamble in the first place, but once started 8-OH-DPAT increased gambling choices in a dose-sensitive manner. Modafinil effects were different to the serotonergic drugs in both decreasing the propensity to initiate gambling and chase losses. CONCLUSIONS: We present evidence for dissociable effects of systemic drug administration on different aspects of gambling behaviour. These data extend and reinforce the importance of serotonergic mechanisms in mediating discrete components of gambling behaviour. They further demonstrate the ability of modafinil to reduce gambling behaviour. Our work using a novel mouse paradigm may be of utility in modelling the complex psychological and neurobiological underpinnings of gambling problems, including the analysis of genetic and environmental factors.

Comparative evaluation of group-based mindfulness-based stress reduction and cognitive behavioural therapy for the treatment and management of chronic pain: A systematic review and network meta-analysis.

QUESTION: This review compares mindfulness-based stress reduction (MBSR) to cognitive-behavioural therapy (CBT) in its ability to improve physical functioning and reduce pain intensity and distress in patients with chronic pain (CP), when evaluated against control conditions. STUDY SELECTION AND ANALYSIS: Ovid MEDLINE, EmbaseClassic+Embase, PsycINFO and the Cochrane Library were searched to identify randomised controlled trials. The primary outcome measure was physical functioning. Secondary outcomes were pain intensity and depression symptoms. We used random and fixed effects (RE and FE) network meta-analyses (NMA) to compare MBSR, CBT and control interventions on the standardised mean difference scale. FINDINGS: Twenty-one studies were included: 13 CBT vs control (n=1095), 7 MBSR vs control (n=545) and 1 MBSR vs CBT vs control (n=341). Of the 21 articles, 12 were determined to be of fair or good quality. Findings from RE NMA for change in physical functioning, pain intensity and depression revealed clinically important advantages relative to control for MBSR and CBT, but no evidence of an important difference between MBSR and CBT was found. CONCLUSIONS: This review suggests that MBSR offers another potentially helpful intervention for CP management. Additional research using consistent measures is required to guide decisions about providing CBT or MBSR.

Advance Care Planning in Community: An Evaluation of a Pilot 2-Session, Nurse-Led Workshop.

BACKGROUND:: Engaging patients in advance care planning (ACP) is challenging but crucial to improving the quality of end-of-life care. Group visits and multiple patient-clinician interactions may promote advance directive (AD) completion. OBJECTIVE:: Facilitate ACP discussions with patients and caregivers and the creation of notarized AD's at a comprehensive cancer center. DESIGN:: Two-session, nurse-led ACP workshops for patients and their family caregivers. SETTING/PARTICIPANTS:: The workshop was offered to patients with cancer at a comprehensive cancer center and their family caregivers. MEASUREMENTS:: Validated 4-question ACP engagement survey, creation of a notarized AD by end of the workshop, and semistructured interviews. RESULTS:: Thirty-five patients participated in 10 workshops held March 2017 to February 2018. Median age was 52. Of 35, 24 (68.5%) patients completed pre- and postworkshop evaluation surveys. Mean preworkshop ACP readiness was 3.64 of 5; postworkshop readiness increased to 4.26 of 5 ( P = .001). Of 26, 17 (65.4%) of the patients who attended both workshop sessions had a new notarized AD scanned into the electronic medical record at the completion of the workshop series. Three family caregivers completed and had their own ADs notarized. Patient and family member response was overwhelmingly positive, with participants citing opportunities for group discussion and inclusion of family caregivers as important. CONCLUSIONS:: The ACP workshop was well received by participants and increased ACP readiness, discussion, and completion. Attendance at the workshop was low and barriers to attending workshops must be explored.

Understanding the Impact of Chronic Pain in the Emergency Department: Prevalence and Characteristics of Patients Visiting the Emergency Department for Chronic Pain at an Urban Academic Health Sciences Centre.

Background: Canadians make approximately 16 million visits to the emergency department (ED) each year. ED visits for non-urgent reasons contribute to suboptimal patient care and ineffective resource use. Aims: To estimate the proportion of ED visits related to chronic pain at our institution. Methods. We conducted a retrospective review of 1000 randomly selected ED visits at TOH during the 2012-2013 fiscal year (April 1, 2012 to March 31, 2013). Visits for chronic pain were identified using pre-defined criteria. Demographic and medical data were extracted from medical charts. Results: 104 visits during this time period were related to chronic pain (10.4%; 95% CI: 8.2-12.6). All visits were from unique patients (i.e., no patients contributed more than 1 visit). Patients were predominantly women (71%), with a mean age of 45.9 years. Seventy-eight percent of patients had a primary care provider. The most common location of pain included the abdomen (24%), the head or face (21%), and the low back (21%). Only 5% of patients had consultation with a pain medicine specialist while 78% were awaiting a consultation. More than 2/3 of patients (71%) reported using opioids for their pain. Conclusion: Presenting to the ED for chronic pain was found to occur among a sample of ED visits reviewed. This can result in ineffective care for patients with chronic pain. Cost-effective solutions to improve clinical outcomes and reduce ED use for chronic pain may yield significant improvements in health outcomes of patients and benefits for the health care system.

Contexte: Les Canadiens font approximativement 16 millions de visites aux urgences chaque année. Les visites aux urgences pour des raisons non urgentes contribuent à ce que les soins aux patients soient sous-optimaux et que les ressources soient utilisées de manière inefficace.Objectifs: Estimer la proportion de visites aux urgences liées à la douleur chronique à notre institution.Méthodes: Nous avons fait un examen rétrospectif de 1 000 visites aux urgences de l'Hôpital d'Ottawa sélectionnées de manière aléatoire qui avaient eu lieu au cours de l'exercice financier 2012-2013 (1er avril 2012 au 31 mars 2013). Les visites en raison d'une douleur chronique ont été repérées à l'aide de critères prédéfinis. Les données démographiques et médicales ont été extraites des dossiers médicaux.Résultats: Au cours de la période à l'étude, 104 visites étaient liées à la douleur chronique (10,4 %; IC 95% : 8,2 ­ 12,6). Toutes les visites étaient le fait de patients uniques (i.e. aucun patient n'a contribué pour plus d'une visite). Les patients étaient en majeure partie des femmes (71 %), dont l'âge moyen était de 45,9 ans. Soixante-dix huit pour cent des patients avaient un prestataire de soins primaires. L'endroit où la douleur se manifestait le plus fréquemment était l'abdomen (24 %), la tête ou le visage (21 %) et le bas du dos (21 %). Seulement 5 % des patients avaient consulté un médecin spécialiste de la douleur tandis que 78 % étaient en attente d'une consultation. Plus de 2/3 des patients (71 %) ont déclaré avoir utilisé des opioïdes pour leur douleur.Conclusion: Il a été constaté que parmi l'échantillon de visites à l'étude, des patients s'étaient présentés aux urgences en raison d'une douleur chronique. Cette situation peut avoir pour conséquence que les soins prodigués aux patients souffrant de douleur chronique soient inefficaces. La mise en place de solutions efficientes pour améliorer les résultats cliniques et diminuer le recours aux urgences pour de la douleur chronique pourrait grandement améliorer les résultats de santé des patients tout en étant avantageux pour le système de santé.

Chronic Pain in the Emergency Department: A Pilot Mixed-Methods Cross-Sectional Study Examining Patient Characteristics and Reasons for Presentations.

Background. Chronic pain (CP) accounts for 10-16% of emergency department (ED) visits, contributing to ED overcrowding and leading to adverse events. Objectives. To describe patients with CP attending the ED and identify factors contributing to their visit. Methods. We used a mixed-method design combining interviews and questionnaires addressing pain, psychological distress, signs of opioid misuse, and disability. Participants were adults who attended the EDs of a large academic tertiary care center for their CP problem. Results. Fifty-eight patients (66% women; mean age 46.5, SD = 16.9) completed the study. The most frequently cited reason (60%) for ED visits was inability to cope with pain. Mental health problems were common, including depression (61%) and anxiety (45%). Participants had questions about the etiology of their pain, concerns about severe pain-related impairment, and problems with medication renewals or efficacy and sometimes felt invalidated in the ED. Although most participants had a primary care physician, the ED was seen as the only or best option when pain became unmanageable. Conclusions. Patients with CP visiting the ED often present with complex difficulties that cannot be addressed in the ED. Better access to interdisciplinary pain treatment is needed to reduce the burden of CP on the ED.

The relationship between mindfulness, pain intensity, pain catastrophizing, depression, and quality of life among cancer survivors living with chronic neuropathic pain.

PURPOSE: This study aims to examine if mindfulness is associated with pain catastrophizing, depression, disability, and health-related quality of life (HRQOL) in cancer survivors with chronic neuropathic pain (CNP). METHOD: We conducted a cross-sectional survey with cancer survivors experiencing CNP. Participants (n = 76) were men (24 %) and women (76 %) with an average age of 56.5 years (SD = 9.4). Participants were at least 1 year post-treatment, with no evidence of cancer, and with symptoms of neuropathic pain for more than three months. Participants completed the Five Facets Mindfulness Questionnaire (FFMQ), along with measures of pain intensity, pain catastrophizing, pain interference, depression, and HRQOL. RESULTS: Mindfulness was negatively correlated with pain intensity, pain catastrophizing, pain interference, and depression, and it was positively correlated with mental health-related HRQOL. Regression analyses demonstrated that mindfulness was a negative predictor of pain intensity and depression and a positive predictor of mental HRQOL after controlling for pain catastrophizing, age, and gender. The two mindfulness facets that were most consistently associated with better outcomes were non-judging and acting with awareness. Mindfulness significantly moderated the relationships between pain intensity and pain catastrophizing and between pain intensity and pain interference. CONCLUSION: It appears that mindfulness mitigates the impact of pain experiences in cancer survivors experiencing CNP post-treatment. IMPLICATIONS FOR CANCER SURVIVORS: This study suggests that mindfulness is associated with better adjustment to CNP. This provides the foundation to explore whether mindfulness-based interventions improve quality of life among cancer survivors living with CNP.

Botulinum toxin injection for facial wrinkles.

Botulinum toxin injection for treatment of facial wrinkles is the most frequently performed cosmetic procedure in the United States, and it is one of the most common entry procedures for clinicians seeking to incorporate aesthetic treatments into their practice. Treatment of frown lines and crow's feet, which are the cosmetic indications approved by the U.S. Food and Drug Administration, and horizontal forehead lines, offers predictable results, has few adverse effects, and is associated with high patient satisfaction. Wrinkles are formed by dermal atrophy and repetitive contraction of underlying facial musculature. Botulinum toxin is a potent neurotoxin that inhibits release of acetylcholine at the neuromuscular junction. Injection of small quantities of botulinum toxin into specific overactive muscles causes localized muscle relaxation that smooths the overlying skin and reduces wrinkles. Botulinum toxin effects take about two weeks to fully develop and last three to four months. Dynamic wrinkles, seen during muscle contraction, yield more dramatic results than static wrinkles, which are visible at rest. Botulinum toxin injection is contraindicated in persons with keloidal scarring, neuromuscular disorders (e.g., myasthenia gravis), allergies to constituents of botulinum toxin products, and body dysmorphic disorder. Minor bruising can occur with botulinum toxin injection. Temporary blepharoptosis and eyebrow ptosis are rare complications that are technique-dependent; incidence declines as injector skill improves.

Aesthetic procedures in office practice.

Since the approval of botulinum toxin, dermal fillers, and lasers for cosmetic use, minimally invasive aesthetic procedures have rapidly become the treatments of choice for age-related facial changes. In the past 10 years, aesthetic procedures have increased nearly five-fold. Of the 10.2 million aesthetic treatments performed in 2008, 83 percent were minimally invasive procedures. Botulinum toxin and dermal filler injections, laser hair reduction, chemical peels, laser skin resurfacing, microdermabrasion, and intense pulsed light photorejuvenation were the most commonly performed procedures in 2008. These procedures are effective and associated with minimal discomfort, and they have a low incidence of adverse effects and short recovery times. High patient and physician satisfaction have contributed to their growing popularity and availability in the primary care setting. As patient demand for aesthetic treatments increases, family physicians should be familiar with common minimally invasive aesthetic procedures when advising patients or incorporating aesthetic care into office practice.