Healthcare professionals' experiences of interdisciplinary collaboration in pain centres - A qualitative study.

OBJECTIVES: The complexity of chronic pain requires interdisciplinary collaboration. Although this is recognisable in the framework for pain centres, few studies have investigated how interdisciplinary collaboration in pain centres is experienced by healthcare professionals, including the facilitators and barriers to interdisciplinary collaboration. The aim of the current study was therefore to investigate experiences of interdisciplinary collaboration in the treatment of patients with chronic pain among healthcare professionals in tertiary care pain centres. METHODS: Eleven healthcare professionals, representing different healthcare disciplines from the four regional pain centres in Norway, participated in semi-structured individual interviews. The data were analysed thematically. RESULTS: The results were categorised into three themes 'The best approach for chronic pain treatment', 'Collegial collaboration', and 'Challenges with interdisciplinary teamwork'. The informants valued the interdisciplinary work at the pain centre. They perceived it as the best approach for their patients and appreciated the support the collegial collaboration gave them as professionals. Although working together was rewarding and provided new insights, the informants also experienced the interdisciplinary teamwork as challenging, e.g., when the different professions disagreed on recommendations for further treatment or did not manage to work together as a team. CONCLUSION: The informants found the interdisciplinary collaboration at the pain centre to provide the best treatment approach for their patients. It should be acknowledged that interdisciplinary teamwork can be challenging, and efforts should be put into establishing a good climate for collaboration and gaining knowledge about each profession's unique character and how they contribute to pain centre treatments.

Robot-assisted laparoscopic nephrectomy: early outcome measures with the implementation of multimodal analgesia and intrathecal morphine via the acute pain service.

PURPOSE: The objective of this study was to perform a retrospective cohort analysis, in which we measured the association of an acute pain service (APS)-driven multimodal analgesia protocol that included preoperative intrathecal morphine (ITM) compared to historic controls (i.e., surgeon-driven analgesia protocol without ITM) with postoperative opioid use. METHODS: This was a retrospective cohort study in which the primary objective was to determine whether there was a decrease in median 24-h opioid consumption (intravenous morphine equivalents [MEQ]) among robotic nephrectomy patients whose pain was managed by the surgical team prior to the APS, versus pain managed by APS. Secondary outcomes included opioid consumption during the 24-48 h and 48-72 h period and hospital length of stay. To create matched cohorts, we performed 1:1 (APS:non-APS) propensity score matching. Due to the cohorts occurring at the different time periods, we performed a segmented regression analysis of an interrupted time series. RESULTS: There were 76 patients in the propensity-matched cohorts, in which 38 (50.0%) were in the APS cohort. The median difference in 24-h opioid consumption in the pre-APS versus APS cohort was 23.0 mg [95% CI 15.0, 31.0] (p < 0.0001), in favor of APS. There were no differences in the secondary outcomes. On segmented regression, there was a statistically significant drop in 24-h opioid consumption in the APS cohort versus pre-APS cohort (p = 0.005). CONCLUSIONS: The implementation of an APS-driven multimodal analgesia protocol with ITM demonstrated a beneficial association with postoperative 24-h opioid consumption following robot-assisted nephrectomy.

A content analysis of the interventions for low back pain promoted on the websites of Australian pain clinics.

BACKGROUND: The Internet is a widely used source of health information, yet the accuracy of online information can be low. This is the case for low back pain (LBP), where much of the information about LBP treatment is poor. METHODS: This research conducted a content analysis to explore what pain treatments for LBP are presented to the public on websites of Australian pain clinics listed in the PainAustralia National Pain Services Directory. Websites providing information relevant to the treatment of LBP were included. Details of the treatments for LBP offered by each pain service were extracted. RESULTS: In total, 173 pain services were included, with these services linking to 100 unique websites. Services were predominantly under private ownership and located in urban areas, with limited services in non-urban locations. Websites provided detail on a median of six (IQR 3-8) treatments, with detail on a higher number of treatments provided by services in the private sector. Physical, psychological and educational treatments were offered by the majority of pain services, whereas surgical and workplace-focused treatments were offered by relatively few services. Most services provided details on multidisciplinary care; however, interdisciplinary, coordinated care characterised by case-conferencing was infrequently mentioned. CONCLUSIONS: Most websites provided details on treatments that were largely in-line with recommended care for LBP, but some were not, especially in private clinics. However, whether the information provided online is a true reflection of the services offered in clinics remains to be investigated.

Sympatholytic Effect of the High Thoracic Erector Spinae Plane Block.

BACKGROUND: The erector spinae plane block (ESPB), which was introduced for the management of thoracic pain, is a technically easy and relatively noninvasive ultrasound (ULSD)-guided technique. Although the ESPB is used widely in variable clinical situations, its sympatholytic effect has never been studied. OBJECTIVES: The purpose of this study is to demonstrate the sympatholytic effect of the high thoracic ESPB by comparing the blocked and unblocked sides of patients' upper extremities, using the changes in the perfusion index (PI). STUDY DESIGN: Prospective, single-group, and open-label study. SETTING: The study was carried out in the pain clinic of a tertiary university hospital. METHODS: This study included 47 patients with upper extremity pain and various diseases who received T2 or T3 ESPBs using 20 mL of 0.2% ropivacaine. For the evaluation of the sympatholytic effect, measurements were taken on the numeric rating scale (NRS), the neck disability index (NDI), and the PI. RESULTS: The PIs of the blocked sides demonstrated significant increases at 10, 20, and 30 minutes compared to the PIs of the baseline and unblocked sides (P < 0.001). The PI ratio at 10 minutes was 2.74 ± 1.65, which was the highest value during the measurement period. Until 30 minutes after the ESPB, the PI ratio was significantly higher in the blocked side than in the unblocked side. During the study period, significant reductions in NRS and NDI scores were found irrespective of disease entity. LIMITATION: The period of PI measurement was only 30 minutes, so we could not determine the time point when the PI returned to the baseline value. CONCLUSION: The high thoracic ESPB was effective in relieving upper extremity pain in diverse disease entities, and the PIs of patients' blocked sides demonstrated significant increases over the baseline value and contralateral unblocked sides.

Risk Factors for Opioid Misuse, Abuse, and Dependence Among Pain Clinic Patients: A Cross-Sectional Study at King Khalid University Hospital during 2020.

BACKGROUND Physicians are faced with the risk of patients developing opioid use disorders (OUDs) when prescribing patients opioids for long periods of time. Therefore, it is highly recommended to continuously monitor and evaluate long-term non-cancer pain patients who are prescribed opioids. This study aims to estimate the prevalence of OUDs in 103 patients with active opioid prescriptions attending the Pain Clinic at King Khalid University Hospital. MATERIAL AND METHODS A cross-sectional study was conducted at King Khalid University Hospital's pain clinic from 2020 to 2022. A list of all patients attending the Pain Clinic with an opioid prescription was provided by the hospital. Through telephone interviews, consent was secured followed by the collection of demographic variables and prescription-related variables. Additionally, patients were asked to complete the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST 3.1) opioid questionnaire. RESULTS Most of the 103 patients were at moderate risk for abuse (91.3%), while a smaller percentage were at high risk (dependence) (5.8%) and low risk (misuse) (2.9%). Tramadol was the most-prescribed opioid (43.7%). Young age (<50) (Z=2.534; P=0.011), opioid use for more than 90 days (Z=2.788; P=0.005), and the prescription of tramadol (Z=4.124; P<0.001) were associated with higher risk of OCDs. CONCLUSIONS Younger patients, opioid use >90 days, and tramadol are associated with a higher risk of opioid misuse. However, further studies on a larger scale and in various settings are needed to provide evidence accurately reflecting the general population, as this study focused on the population of pain clinic attendees.

National review of acute pain service utilization, models of care, and clinical practices within the Veterans Health Administration.

INTRODUCTION: The Veterans Health Administration (VHA) is the largest healthcare network in the USA and has been a national leader in opioid safety for acute pain management. However, detailed information on the availability and characteristics of acute pain services within its facilities is lacking. We designed this project to assess the current state of acute pain services within the VHA. METHODS: A 50-question electronic survey developed by the VHA national acute pain medicine committee was emailed to anesthesiology service chiefs at 140 VHA surgical facilities within the USA. Data collected were analyzed by facility complexity level and service characteristics. RESULTS: Of the 140 VHA surgical facilities contacted, 84 (60%) completed the survey. Thirty-nine (46%) responding facilities had an acute pain service. The presence of an acute pain service was associated with higher facility complexity level designation. The most common staffing model was 2.0 full-time equivalents, which typically included at least one physician. Services performed most by formal acute pain programs included peripheral nerve catheters, inpatient consult services, and ward ketamine infusions. CONCLUSIONS: Despite widespread efforts to promote opioid safety and improve pain management, the availability of dedicated acute pain services within the VHA is not universal. Higher complexity programs are more likely to have acute pain services, which may reflect differential resource distribution, but the barriers to implementation have not yet been fully explored.

Application of remote electrocardiogram monitoring systems in chest pain centers for patients with high-risk chest pain.

BACKGROUND: Chinese chest pain centers (CPCs) have been expanding and maturing for the past decade, but patient wait times for pre-hospital care remain long. OBJECTIVE: To demonstrate that the remote electrocardiogram (ECG) monitoring system can ensure more efficient treatment for patients with ST-elevation myocardial infarction (STEMI) in CPCs, we compared patients with high-risk chest pain who used remote ECG monitoring systems to those who used conventional ECGs in retrospective cohort study. METHODS: Based on the inclusion and exclusion criteria, 290 patients who visited our CPC between June 2019 and March 2022 with acute chest pain and a diagnosis of STEMI as well as patients who had undergone an emergency primary percutaneous coronary intervention were selected. Among them, 73 patients with STEMI had employed remote real-time dynamic 12-lead ECG monitoring devices, while 217 patients with STEMI (i.e., the controls) had used conventional ECG monitoring. The effectiveness of treatment procedures for the two groups was investigated. As statistical measures, the symptom onset-to-wire times, first medical contact (FMC)-to-wire times, door-to-wire times, major adverse cardiac events in hospital, and the troponin T levels were analyzed. RESULTS: Compared with the control group, the patients with remote real-time dynamic 12-lead ECG monitoring devices showed shorter times for both symptom onset-to-wire (234.8 ± 95.8 min vs. 317.6 ± 129.6 min, P= 0.0321) and from symptom onset-to-FMC (170.5 ± 86.3 min vs. 245.3 ± 115.6 min, P= 0.0287); this group also had a lower 30-day mortality rate (2.73% vs. 4.14%, P= 0.003). The differences between the two groups were statistically significant (P< 0.05). CONCLUSION: With remote real-time dynamic 12-lead ECG monitoring equipment, myocardial ischemia can be treated more quickly, leading to fewer possible cardiac events and a better prognosis.

'Engaging on a slightly more human level': A qualitative study exploring the care of individuals with back pain in a multidisciplinary pain clinic.

Chronic low back pain is characterised by multiple and overlapping biological, psychological, social and broader dimensions, affecting individuals' lives. Multidisciplinary pain services have been considered optimal settings to account for the multidimensionality of chronic low back pain but have largely focused on cognitive and behavioural aspects of individuals' pain. Social dimensions are usually underexplored, considered outside or beyond healthcare professionals' scope of practice. Employing Actor Network Theorist Mol's concept multiplicity, our aim in this paper is to explore how a pain service's practices bring to the fore the social dimensions of individuals living with low back pain. Drawing on 32 ethnographic observations and four group exchanges with the service's clinicians, findings suggest that practices produced multiple enactments of an individual with low back pain. Although individuals' social context was present and manifested during consultations at the pain service (first enactment: 'the person'), it was often disconnected from care and overlooked in 'treatment/management' (second enactment: 'the patient'). In contrast, certain practices at the pain service not only provided acknowledgement of, but actions towards enhancing, individuals' social contexts by adapting rules and habits, providing assistance outside the service and shifting power relations during consultations (third enactment: 'the patient-person'). We therefore argue that different practices enact different versions of an individual with low back pain in pain services, and that engagement with individuals' social contexts can be part of a service's agenda.

Design and implementation of a smart Internet of Things chest pain center based on deep learning.

The data input process for most chest pain centers is not intelligent, requiring a lot of staff to manually input patient information. This leads to problems such as long processing times, high potential for errors, an inability to access patient data in a timely manner and an increasing workload. To address the challenge, an Internet of Things (IoT)-driven chest pain center is designed, which crosses the sensing layer, network layer and application layer. The system enables the construction of intelligent chest pain management through a pre-hospital app, Ultra-Wideband (UWB) positioning, and in-hospital treatment. The pre-hospital app is provided to emergency medical services (EMS) centers, which allows them to record patient information in advance and keep it synchronized with the hospital's database, reducing the time needed for treatment. UWB positioning obtains the patient's hospital information through the zero-dimensional base station and the corresponding calculation engine, and in-hospital treatment involves automatic acquisition of patient information through web and mobile applications. The system also introduces the Bidirectional Long Short-Term Memory (BiLSTM)-Conditional Random Field (CRF)-based algorithm to train electronic medical record information for chest pain patients, extracting the patient's chest pain clinical symptoms. The resulting data are saved in the chest pain patient database and uploaded to the national chest pain center. The system has been used in Liaoning Provincial People's Hospital, and its subsequent assistance to doctors and nurses in collaborative treatment, data feedback and analysis is of great significance.

Prevalencia y características clínicas del dolor en pacientes con enfermedad crónica avanzada / Prevalence and clinical characteristics of pain in patients with advanced chronic disease

Objetivos: Determinar la prevalencia y las características clínicas del dolor en pacientes con enfermedad crónica avanzada, e identificar la frecuencia del dolor irruptivo. Diseño: Estudio observacional, descriptivo y transversal. Emplazamiento: Tres equipos de atención primaria y un hospital de cuidados intermedios. Participantes: Se seleccionaron todos los pacientes con enfermedad crónica avanzada. Mediciones principales: Se realizó una entrevista semiestructurada para recoger variables demográficas, clínicas y específicas de dolor mediante escalas validadas. Se registraron la ubicación (domicilio, residencia u hospital) y la trayectoria de cronicidad avanzada (insuficiencia de órgano, enfermedad oncológica, demencia o multimorbilidad). Se valoró la presencia de dolor según la Brief Pain Inventory (BPI) y, en los casos de demencia invalidante, según la Pain Assessment in Advanced Dementia (PAINAD). Análisis estadístico descriptivo y comparativo entre variables utilizando el programa R. Resultados: Se incluyeron 223 pacientes (60,4% de los seleccionados). Prevalencia del dolor: 83,9% (n=187), sin diferencias según la ubicación ni según la trayectoria. Diferencias significativas en la intensidad del dolor según la ubicación (p=0,0046) (moderado-severo en domicilio, moderado en hospital y leve en residencia) y según la trayectoria (p<0,0001) (dolor moderado-severo en insuficiencia de órgano y multimorbilidad, moderado en cáncer y leve en demencia). Se observó impacto funcional por dolor leve-moderado, impacto emocional severo en el 41,5% de los pacientes (n=51) y dolor irruptivo en el 8,6% (n=13). Conclusiones: El dolor debe ser siempre explorado y evaluado en pacientes con cronicidad avanzada, ya que fue muy prevalente en todas las ubicaciones y trayectorias, especialmente intenso en la insuficiencia de órgano y en la multimorbilidad a domicilio. Apareció dolor irruptivo en trayectorias no oncológicas.(AU)

Objectives: Determine pain prevalence and clinical characteristics in patients with advanced chronic disease and identify breakthrough pain frequency. Design: Observational, descriptive, cross-sectional study. Location: Three primary care teams and one intermediate care hospital. Participants: All patients with advanced chronic disease. Main measurements: A semi-structured interview was performed to collect demographic, clinical, and specific variables of pain using validated scales. Patient location (home, nursing home or hospital) and advanced chronicity trajectory (organ failure, oncological disease, dementia, or multimorbidity) were recorded. Pain was assessed based on the Brief Pain Inventory (BPI) and, in cases of disabling dementia, using the Pain Assessment in Advanced Dementia (PAINAD). A statistical descriptive, comparative analysis between variables was performed using the R software. Results: Of all patients selected, 223 (60.4%) were included. Prevalence of pain: 83.9% (n=187), with no differences based on location or trajectory. Significant differences in pain intensity based on location (P=.0046) (moderate-severe in patients at home, moderate in hospital patients, and mild in nursing home patients) and on trajectory (P<.0001) (moderate-severe in patients with organ failure and multimorbidity, moderate in patients with cancer, and mild in patients with dementia). Global functional impact of pain was mild-moderate, emotional impact was severe in 41.5% of patients (n=51), and breakthrough pain was observed in 8.6% (n=13). Conclusions: Pain must always be explored and assessed in patients with advanced chronicity, since it was highly prevalent in all locations and trajectories, being particularly intense in patients at home with organ failure and multimorbidity. Breakthrough pain was found in non-oncological trajectories.(AU)

Costs of Implementing Electronic Context Factor Assessments and Patient-reported Outcomes in Pain Clinic Settings.

BACKGROUND: The Healing Encounters and Attitudes Lists (HEALs) patient-reported measures, consisting of 6 separate context factor questionnaires, predict patients' pain improvements. Our Patient-centered Outcomes Research Initiative-funded implementation project demonstrated success in using HEAL data during clinic consultations to enhance patient engagement, improve patient outcomes, and reduce opioid prescribing. OBJECTIVE: We aimed to determine the resources needed for additional sites to implement HEAL to improve pain care treatment. RESEARCH DESIGN: An observational study from March 1 to November 30, 2021, assessing implementation cost data from invoices, time and salary requirements for clinic personnel training, estimates of non-site-based costs, and one-time resource development costs. SUBJECTS: Unique patients eligible to complete a HEAL survey (N=24,018) and 74 clinic personnel. MEASURES: The Stages of Implementation Completion guided documentation of preimplementation, implementation, and sustainment activities of HEAL pain clinic operations. These informed the calculations of the costs of implementation. RESULTS: The total time for HEAL implementation is 7 months: preimplementation and implementation phases (4 mo) and sustainment (3 mo). One hour of HEAL implementation involving a future clinical site consisting of 2 attending physicians, 1 midlevel provider, 1 nurse manager, 1 nurse, 1 radiology technician, 2 medical assistants, and 1 front desk staff will cost $572. A 10-minute time increment for all clinic staff is $95. Total implementation costs based on hourly rates over 7 months, including non-site-based costs of consultations, materials, and technology development costs, is $28,287. CONCLUSIONS: Documenting our implementation costs clarifies the resources needed for additional new sites to implement HEAL to measure pain care quality and to engage patients and clinic personnel.

Assessing the Impact of a Humanistic Care-Based Nursing Model on the Psychological Well-being of Trigeminal Neuralgia Outpatients in Pain Clinics.

Objective: This study aims to assess the impact of a humanistic care-based nursing model on the psychological well-being of individuals diagnosed with primary trigeminal neuralgia (TN) and attending a pain clinic. Methods: A prospective cohort study was conducted, including 166 patients diagnosed with primary trigeminal neuralgia who sought treatment at our hospital's Pain Clinic between March 2022 and December 2022. Among them, 88 patients receiving care based on a humanistic care-based nursing model constituted the observation group, while 78 patients receiving standard nursing care comprised the control group. The Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS) were employed to evaluate patients' psychological states. Additionally, changes in systolic and diastolic blood pressure, along with nursing satisfaction levels, were recorded. A three-month follow-up was conducted, during which the recovery quality was assessed using the Questions of Reality-155 (QOR-15). Results: Following the nursing intervention, the observation group displayed lower SAS/SDS scores and reduced diastolic and systolic blood pressure compared to the control group (P < .05). Moreover, nursing satisfaction in the observation group was significantly higher than in the control group (P < .05). The follow-up results demonstrated that the recovery quality of the observation group was higher compared to the control group (P < .05). Conclusions: Implementing a humanistic care-based nursing model effectively enhances the psychological well-being and recovery quality of trigeminal neuralgia outpatients attending pain clinics.

Rapid access chest pain clinics in Australia and New Zealand.

Chest pain is the second most common reason for adult emergency department presentations. Most patients have low or intermediate risk chest pain, which historically has led to inpatient admission for further evaluation. Rapid access chest pain clinics represent an innovative outpatient pathway for these low and intermediate risk patients, and have been shown to be safe and reduce hospital costs. Despite variations in rapid access chest pain clinic models, there are limited data to determine the most effective approach. Developing a national framework could be beneficial to provide sites with evidence, possible models, and business cases. Multicentre data analysis could enhance understanding and monitoring of the service.

Identifying pain problems, healthcare professional perceptions, expectations and challenges in multidisciplinary pain center establishment.

Aim: Before establishing a multidisciplinary pain center (MPC), the pain problem, healthcare professionals (HCP) perceptions, expectations and the potential challenges of MPC establishment need to be identified. Methods: A quantitative survey study of 1058 Indonesian HCPs. The study uses a national inquiry sent by the International Association for the Study of Pain (IASP) chapter for pain. Results: 99.0% of respondents had met patients with pain as the primary complaint and acute pain as the most common complaint. Insufficient pain management in Indonesian healthcare, insufficient pain epidemiological data and unaware HCP about MPC become problems of pain management in Indonesia. However, most HCP agreed that health facilities should have MPC. Financial issues (insufficient patient insurance) were considered the most important barrier for referring patients to MPC. Conclusion: The identified core problem, HCP perceptions, expectations and challenges of MPC establishment should become a consideration in the strategic planning of MPC establishment.

Multidisciplinary pain centers (MPC) provide benefits to patients, healthcare professionals (HCP) and the community in general but are not yet established in Indonesia and other developing countries. Before establishing a MPC, the problem in pain, HCP's perceptions, expectations and challenges in MPC establishment need to be identified. From the national survey on 1058 HCP, almost all respondents (99.0%) had met patients with pain as the primary complaint and acute pain as the most common complaint (51.2%). Insufficient pain management in Indonesian healthcare, insufficient pain epidemiological data and unaware HCP about MPC have become problems in pain management in Indonesia. However, most HCP agreed that health facilities should have pain centers as well as a center for the study of pain and recommended 'pain that requires intervention' should be referred to a MPC. Financial issues such as insufficient patient insurance was considered the most important barrier for referring patients to MPCs in Indonesia. The high incidence of pain, insufficient pain management in health facilities and insufficient data on pain have become the core problem that underlies the need for MPC establishment in Indonesia. Overall, HCPs have positive perceptions and expectations regarding MPCs. Financial barriers are thought to be a potential burden in the development of MPCs. By understanding the pain problem, HCP perceptions, expectations and potential challenges on the MPC establishment, strategic planning in MPC establishment is expected to be achieved especially in developing countries.

The Acute Perioperative Pain Service: Impact, Organization, and Future Directions.

PURPOSE OF REVIEW: The Acute Perioperative Pain Service has been established as a relatively new but important concept and service in clinical patient care. Many surgical institutions have dedicated inpatient acute pain services with variable compositions. This review aims to investigate the purpose, clinical and economic implications, and future direction of the Acute Perioperative Pain Service (APPS). RECENT FINDINGS: There is growing evidence of the multiple benefits of a dedicated APPS, especially pertaining to patients at higher risk of poorly controlled postoperative pain. Healthcare providers furthermore realize the importance of the perioperative pain management continuity of care, consisting of preoperative pain evaluations and post-discharge follow-up in an outpatient pain management setting, in coordination with the primary teams. The Transitional Pain Service (TPS) has emerged as the next step in this evolution and has been successfully implemented at various medical centers. With the growing number of surgical procedures and the increasing complexity of the patient population, effective management of acute postoperative pain continues to be challenging, despite ongoing advances in clinical care, analgesic modalities, and research. The APPS is becoming the clinical standard of care for managing postoperative pain, and its role continues to expand worldwide.

Impact of a rapid access chest pain clinic in Singapore to improve evaluation of new-onset chest pain.

BACKGROUND: Chest pain (CP) accounts for 5% of emergency department (ED) visits, unplanned hospitalisations and costly admissions. Conversely, outpatient evaluation requires multiple hospital visits and longer time to complete testing. Rapid access chest pain clinics (RACPCS) are established in the UK for timely, cost-effective CP assessment. This study aims to evaluate the feasibility, safety, clinical and economic benefits of a nurse-led RACPC in a multiethnic Asian country. METHODS: Consecutive CP patients referred from a polyclinic to the local general hospital were recruited. Referring physicians were left to their discretion to refer patients to the ED, RACPC (launched in April 2019) or outpatients. Patient demographics, diagnostic journey, clinical outcomes, costs, HEART (History, ECG, Age, Risk Factors, Troponin) scores and 1-year overall mortality were recorded. RESULTS: 577 CP patients (median HEAR score of 2.0) were referred; 237 before the launch of RACPC. Post RACPC, fewer patients were referred to the ED (46.5% vs 73.9%, p < 0.01), decreased adjusted bed days for CP, more non-invasive tests (46.8 vs 39.2 per 100 referrals, p = 0.07) and fewer invasive coronary angiograms (5.6 vs 12.2 per 100 referrals, p < 0.01) were performed. Time from referral to diagnosis was shortened by 90%, while requiring 66% less visits (p < 0.01). System cost to evaluate CP was reduced by 20.7% and all RACPC patients were alive at 12 months. CONCLUSIONS: An Asian nurse-led RACPC expedited specialist evaluation of CP with less visits, reduced ED attendances and invasive testing whilst saving costs. Wider implementation across Asia would significantly improve CP evaluation.

Opioids Induce Bidirectional Synaptic Plasticity in a Brainstem Pain Center in the Rat.

Opioids are powerful analgesics commonly used in pain management. However, opioids can induce complex neuroadaptations, including synaptic plasticity, that ultimately drive severe side effects, such as pain hypersensitivity and strong aversion during prolonged administration or upon drug withdrawal, even following a single, brief administration. The lateral parabrachial nucleus (LPBN) in the brainstem plays a key role in pain and emotional processing; yet, the effects of opioids on synaptic plasticity in this area remain unexplored. Using patch-clamp recordings in acute brainstem slices from male and female Sprague Dawley rats, we demonstrate a concentration-dependent, bimodal effect of opioids on excitatory synaptic transmission in the LPBN. While a lower concentration of DAMGO (0.5 µM) induced a long-term depression of synaptic strength (low-DAMGO LTD), abrupt termination of a higher concentration (10 µM) induced a long-term potentiation (high-DAMGO LTP) in a subpopulation of cells. LTD involved a metabotropic glutamate receptor (mGluR)-dependent mechanism; in contrast, LTP required astrocytes and N-methyl-D-aspartate receptor (NMDAR) activation. Selective optogenetic activation of spinal and periaqueductal gray matter (PAG) inputs to the LPBN revealed that, while LTD was expressed at all parabrachial synapses tested, LTP was restricted to spino-parabrachial synapses. Thus, we uncovered previously unknown forms of opioid-induced long-term plasticity in the parabrachial nucleus that potentially modulate some adverse effects of opioids. PERSPECTIVE: We found a previously unrecognized site of opioid-induced plasticity in the lateral parabrachial nucleus, a key region for pain and emotional processing. Unraveling opioid-induced adaptations in parabrachial function might facilitate the identification of new therapeutic measures for addressing adverse effects of opioid discontinuation such as hyperalgesia and aversion.

Shared Decision-Making in Acute Pain Services.

PURPOSE OF REVIEW: The implementation of shared decision-making (SDM) in acute pain services (APS) is still in its infancies especially when compared to other medical fields. RECENT FINDINGS: Emerging evidence fosters the value of SDM in various acute care settings. We provide an overview of general SDM practices and possible advantages of incorporating such concepts in APS, point out barriers to SDM in this setting, present common patient decisions aids developed for APS and discuss opportunities for further development. Especially in the APS setting, patient-centred care is a key component for optimal patient outcome. SDM could be included into everyday clinical practice by using structured approaches such as the "seek, help, assess, reach, evaluate" (SHARE) approach, the 3 "MAking Good decisions In Collaboration"(MAGIC) questions, the "Benefits, Risks, Alternatives and doing Nothing"(BRAN) tool or the "the multifocal approach to sharing in shared decision-making"(MAPPIN'SDM) as guidance for participatory decision-making. Such tools aid in the development of a patient-clinician relationship beyond discharge after immediate relief of acute pain has been accomplished. Research addressing patient decision aids and their impact on patient-reported outcomes regarding shared decision-making, organizational barriers and new developments such as remote shared decision-making is needed to advance participatory decision-making in acute pain services.

Pain experience of cancer patients receiving care in a multidisciplinary pain management clinic.

BACKGROUND: Few longitudinal studies have focused on patients' cancer pain experience when receiving care in a multidisciplinary pain management clinic (MPMC). This study aimed to evaluate the experiences of a cohort of cancer patients newly engaged in a MPMC. METHODS: This study was based on a longitudinal approach in which data were collected over a 6 months period at the King Hussein Cancer Centre in Jordan. The study adopted the Arabic version of the Brief Pain Inventory to identify the level and prevalence of cancer pain, and to identify the impact of receiving care at the MPMC on patients' pain experience. Data were collected over four time points, and the period between these points ranged from 2 to 3 weeks. RESULTS: The majority of patients demonstrated improvement in their pain after receiving treatment at the MPMC, while a third still experienced severe pain. Significant improvement was reported at T1, and no further decline in pain was noted after this point. This indicates that exposure to the intervention provided by the MPMC generated, on average, an improvement in patients' pain experience. CONCLUSION: The MPMC may be an effective pain management strategy in the treatment of cancer pain.