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BACKGROUND: Central neuropathic pain syndromes are a result of central nervous system injury, most commonly related to stroke, traumatic spinal cord injury, or multiple sclerosis. These syndromes are distinctly less common than peripheral neuropathic pain, and less is known regarding the underlying pathophysiology, appropriate pharmacotherapy, and long-term outcomes. The objective of this study was to determine the long-term clinical effectiveness of the management of central neuropathic pain relative to peripheral neuropathic pain at tertiary pain centers. METHODS: Patients diagnosed with central (n=79) and peripheral (n=710) neuropathic pain were identified for analysis from a prospective observational cohort study of patients with chronic neuropathic pain recruited from seven Canadian tertiary pain centers. Data regarding patient characteristics, analgesic use, and patient-reported outcomes were collected at baseline and 12-month follow-up. The primary outcome measure was the composite of a reduction in average pain intensity and pain interference. Secondary outcome measures included assessments of function, mood, quality of life, catastrophizing, and patient satisfaction. RESULTS: At 12-month follow-up, 13.5% (95% confidence interval [CI], 5.6-25.8) of patients with central neuropathic pain and complete data sets (n=52) achieved a ≥30% reduction in pain, whereas 38.5% (95% CI, 25.3-53.0) achieved a reduction of at least 1 point on the Pain Interference Scale. The proportion of patients with central neuropathic pain achieving both these measures, and thus the primary outcome, was 9.6% (95% CI, 3.2-21.0). Patients with peripheral neuropathic pain and complete data sets (n=463) were more likely to achieve this primary outcome at 12 months (25.3% of patients; 95% CI, 21.4-29.5) (p=0.012). CONCLUSION: Patients with central neuropathic pain syndromes managed in tertiary care centers were less likely to achieve a meaningful improvement in pain and function compared with patients with peripheral neuropathic pain at 12-month follow-up.
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Doenças do Sistema Nervoso Central/complicações , Neuralgia/terapia , Manejo da Dor , Dor/etiologia , Resultado do Tratamento , Adulto , Idoso , Estudos de Coortes , Intervalos de Confiança , Bases de Dados Bibliográficas/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da DorRESUMO
BACKGROUND: Painful diabetic neuropathy (PDN) is a frequent complication of diabetes mellitus. Current treatment recommendations are based on short-term trials, generally of ≤3 months' duration. Limited data are available on the long-term outcomes of this chronic disease. The objective of this study was to determine the long-term clinical effectiveness of the management of chronic PDN at tertiary pain centres. METHODS: From a prospective observational cohort study of patients with chronic neuropathic non-cancer pain recruited from seven Canadian tertiary pain centres, 60 patients diagnosed with PDN were identified for analysis. Data were collected according to Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials guidelines including the Brief Pain Inventory. RESULTS: At 12-month follow-up, 37.2% (95% confidence interval [CI], 23.0-53.3) of 43 patients with complete data achieved pain reduction of ≥30%, 51.2% (95% CI, 35.5-66.7) achieved functional improvement with a reduction of ≥1 on the Pain Interference Scale (0-10, Brief Pain Inventory) and 30.2% (95% CI, 17.2-46.1) had achieved both these measures. Symptom management included at least two medication classes in 55.3% and three medication classes in 25.5% (opioids, antidepressants, anticonvulsants). CONCLUSIONS: Almost one-third of patients being managed for PDN in a tertiary care setting achieve meaningful improvements in pain and function in the long term. Polypharmacy including analgesic antidepressants and anticonvulsants were the mainstays of effective symptom management.
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Analgésicos Opioides/uso terapêutico , Anticonvulsivantes/uso terapêutico , Antidepressivos/uso terapêutico , Neuropatias Diabéticas/tratamento farmacológico , Manejo da Dor , Resultado do Tratamento , Idoso , Canadá , Estudos de Coortes , Neuropatias Diabéticas/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Clínicas de Dor , Medição da DorRESUMO
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.
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Depressão/psicologia , Atenção Plena/métodos , Neoplasias/complicações , Neuralgia/psicologia , Medição da Dor/métodos , Qualidade de Vida/psicologia , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/mortalidade , Inquéritos e Questionários , SobreviventesRESUMO
OBJECTIVE: To describe the impact of the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service on access to specialist care for patients with chronic pain. DESIGN: A cross-sectional descriptive study SETTING: The Champlain Local Health Integration Network, comprising Ottawa, Canada, and the surrounding region. SUBJECTS: All eConsult cases submitted to chronic pain specialists by primary care providers between April 15, 2011 and June 30, 2015. METHODS: Usage data and provider responses to a mandatory closeout survey were analyzed to determine response times, case outcomes, and provider satisfaction. RESULTS: Ninety-three primary care providers submitted 199 eConsults to four chronic pain specialists during the study period. Submitted cases had median response times of 1.9 days. Thirty-six percent of cases resulted in an unnecessary referral being avoided, and over 90% of cases were rated by primary care providers as being of high or very high value for their patients and themselves. CONCLUSION: The eConsult service improved access to specialist care for patients with chronic diseases. By facilitating prompt communication between primary care providers and specialists, eConsult can help mitigate the negative effects of long wait times experienced by patients with chronic pain.
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OBJECTIVE: To evaluate the association between opioid dosage and ongoing therapy with physical function and disability in patients with neuropathic pain (NeP). DESIGN: Secondary analysis of a prospective cohort. SETTING: Multicenter clinical NeP registry. SUBJECTS: Seven hundred eighty-nine patients treated for various NeP diagnoses. METHODS: The following measures were included: dependent variables. 12-month self-reported physical function (pain disability index [PDI] and medical outcomes study short form-12 physical function [PCSS-12]); independent variables: baseline opioid dose (none, ≤200 mg and >200 mg of morphine equivalent), ongoing opioid use; potential confounding variables: age, sex, baseline pain intensity, and psychological distress (profile of mood states). Analysis of covariance models was created to examine the relationship between opioid therapy and both physical functioning outcomes with adjustment for confounding. RESULTS: Complete data was available for 535 patients (68%). Compared with the lower and high dose opioid groups, NeP patients not taking opioids had statistically lower disability and higher physical functioning scores, after adjusting for disease severity. Compared with patients prescribed opioid therapy on an ongoing basis, NeP patients who were not prescribed had statistically lower disability and higher physical functioning scores, after adjusting for disease severity. Improvements in disability and physical functioning scores from baseline and 12-months in all groups were modest and may not be clinically significant. CONCLUSIONS: Physical functioning and disability did not improve in patients with NeP who were prescribed opioids compared with those who are not prescribed, even after adjusting for disease severity.
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Analgésicos Opioides/uso terapêutico , Pessoas com Deficiência/psicologia , Morfina/uso terapêutico , Neuralgia/tratamento farmacológico , Manejo da Dor/métodos , Adulto , Afeto/efeitos dos fármacos , Analgésicos Opioides/administração & dosagem , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Neuralgia/fisiopatologia , Medição da Dor/métodos , Estudos Prospectivos , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
PURPOSE: This narrative review aims to inform health care practitioners of the current literature surrounding the use of intrathecal (IT) and epidural analgesia in cancer patients with refractory pain at end of life. Topics discussed and reviewed include: patient selection, treatment planning, procedure, equipment, medications, complications, policies and procedures, as well as directions for future research. PRINCIPAL FINDINGS: Cancer pain is inadequately treated in an estimated 10% of patients with malignant pain despite the implementation of the World Health Organization three-step analgesic ladder. This has prompted some to advocate for the addition of a fourth step that would include neuraxial interventions. There is moderate evidence supporting the safety and efficacy of IT drug therapy in cancer patients with refractory pain. A detailed assessment and interdisciplinary team approach is necessary to develop and implement care plans for patients requiring neuraxial analgesia. Neuraxial analgesia can significantly improve pain and reduce side effects, but this must be balanced against the increased complexity of care and the risk of uncommon but serious complications. CONCLUSION: Neuraxial drug delivery gives clinicians more options to manage refractory pain at end of life and should be offered to patients with intractable cancer pain. Teams should be interprofessional with clear delineation of roles and responsibilities. They should discuss advanced discharge planning with the patient prior to implantation as well as provide on-call support.
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Analgesia/métodos , Neoplasias/complicações , Analgesia/efeitos adversos , Analgesia Epidural/efeitos adversos , Analgesia Epidural/métodos , Analgésicos/administração & dosagem , Analgésicos/efeitos adversos , Sistemas de Liberação de Medicamentos , Humanos , Injeções Espinhais , Dor Intratável/tratamento farmacológico , Dor Intratável/etiologia , Equipe de Assistência ao Paciente/organização & administração , Seleção de Pacientes , Assistência Terminal/métodosRESUMO
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.
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Neoplasias da Mama , Sobreviventes de Câncer , Atenção Plena , Neuralgia , Neoplasias da Mama/complicações , Feminino , Humanos , Pessoa de Meia-Idade , Atenção Plena/métodos , Qualidade de Vida/psicologia , Estresse Psicológico/etiologia , Estresse Psicológico/terapiaRESUMO
OBJECTIVES: To evaluate the effect of a collaborative interdisciplinary pain assessment program on pain and health-related quality of life among individuals with chronic pain who frequently visit the emergency department (ED). METHODS: Individuals with chronic pain who frequented the ED (ie, ≥8 visits within the previous 12 months) were randomly assigned to a collaborative chronic pain management program or treatment as usual. Primary outcomes were change in physical function and visits to the ED from baseline to 12 months using validated measures. Secondary measures included physical and emotional functioning, insomnia, health-related quality of life, risk of aberrant opioid use, and health care use. Mixed model analyses of variances were used to evaluate intervention effectiveness among the whole sample (ie, using intention to treat principles) and individuals who completed more than 50% of follow-up assessments. RESULTS: One hundred participants were assessed for eligibility and 46 patients were enrolled with 24 being randomized to intervention and 22 to treatment as usual (TAU). Eleven of the 24 patients randomized to the intervention were lost to follow-up and 3 withdrew participation. Two of the 22 patients randomized to TAU were lost to follow-up, and 7 withdrew. Although patients assigned to the intervention improved more rapidly on measures of pain and health related quality of life, both groups had similar improvements overall between baseline to 12 months. Average pain intensity reduction (numeric rating scale [SE]) was 4.63 (0.40) in the intervention and 4.82 (0.53) in the treatment as usual at the 12-month follow-up. A significant group × time interaction was present for risk of aberrant opioid use, with individuals in the intervention group reporting greater improvement in risk of aberrant opioid use by 12-month follow-up. CONCLUSION: Participation in an interdisciplinary program may accelerate improvements in pain- and health-related quality of life and reduce risk of aberrant opioid use to manage pain and related distress. Further research is needed to better understand and address barriers to engagement in chronic pain care.
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There is strong evidence that musical engagement influences children's language development but little research has been carried out on the relationship between the home musical environment and language development in infancy. The current study assessed musical exposure at home (including parental singing) and language development in 64 infants (8.5-18 months). Results showed that the home musical environment significantly predicted gesture development. For a subgroup of infants' below 12 months, both parental singing and overall home musical environment score significantly predicted word comprehension. These findings represent the first demonstration that an enriched musical environment in infancy can promote development of communication skills.
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Música , Criança , Compreensão , Gestos , Humanos , Lactente , Desenvolvimento da Linguagem , PaisRESUMO
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.
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Dor Crônica , Canadá , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Transtornos Relacionados ao Uso de SubstânciasRESUMO
Background and aims Chronic pain (CP) management presents a challenge for the healthcare system as many individuals experiencing CP cannot access appropriate services. Consequently, individuals may visit emergency departments (EDs) to address their CP, even though this setting is not the most appropriate. CP was identified as a common factor amongst patients with repeat ED use at a hospital in Ottawa, Canada. Thus, staff of the Pain Clinic developed the Rapid Interdisciplinary Pain Assessment Program to improve the care of patients with CP who had a minimum of 12 ED visits in the previous year, who were considered high frequency users (HFUs) of the ED. This evaluation was conducted to guide program improvements in advance of a clinical trial. The results are reported here in order to describe lessons that could be applied to the development of similar programs. The benefits of the program in reducing ED use, pain intensity, disability, and psychological distress have been described elsewhere (Rash JA et al. Pain Res Manag 2018:1875967). Methods Thirty-five people completed semi-structured interviews or a focus group, including eight patients, six ED staff, four primary care physicians (PCP), five Pain Clinic physicians, and 12 program staff members. Questions focused on the program's implementation, as well as strengths and areas for improvement. Results The program was generally consistent in offering the intended patients the services that were planned. Specifically, patients received an interdisciplinary assessment that informed the development of an assessment and treatment plan. These plans were shared with the PCP and added to the patient's hospital electronic medical record. Patients also received education about CP and had access to medical pain management, substance use, and psychological treatments. Inter-professional communication was facilitated by case conferences. Numerous aspects of the program were perceived as helpful, such as the quick access to services, the comprehensive assessment and treatment plans, the individualized treatment, the use of an interdisciplinary approach to care, and the communication and relationships with other care providers. However, challenges arose with respect to the coordination of services, the addition of supplementary services, the accessibility of the program, patients' perceptions of being misunderstood, communication, and relationship-building with other service providers. Conclusions The program sought to improve the care of HFUs with CP and reduce their ED use for CP management. The program had numerous strengths, but also encountered challenges. Developers of programs for HFUs with CP are encouraged to consider these challenges and suggested solutions. These programs have the potential to deliver effective healthcare to individuals with CP and reduce ED overutilization. Implications Our findings suggest that the following points should be considered in the development of similar programs: the inclusion of a case manager; the use of strategies to ensure inter-professional communication, such as secure electronic consultation, approaches to allow access to assessment and treatment plans, and offering a range of modalities for communication; holding regular case conferences; determining the appropriate types of services to offer; and working to address patients' fears of being labelled.
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Serviço Hospitalar de Emergência/organização & administração , Hospitais , Manejo da Dor , Medição da Dor , Equipe de Assistência ao Paciente/organização & administração , Avaliação de Programas e Projetos de Saúde , Adulto , Canadá , Comunicação , Feminino , Grupos Focais , Acessibilidade aos Serviços de Saúde , Humanos , Entrevistas como Assunto , Masculino , Projetos PilotoRESUMO
INTRODUCTION: Chronic pain (CP) is a common driver of emergency department (ED) visits despite the ED not being the ideal setting for CP because of increased risk of adverse events and high costs. PURPOSE: The purpose of this study is to understand factors contributing to CP-related ED visits, patients' care experiences, and patients' perspectives on alternatives to the ED. METHODS: We used a mixed-methods design combining semi-structured interviews and questionnaires with 12 patients with CP who had 12 or more ED visits over 1 year. We analyzed test scores using descriptive statistics and interviews using applied thematic analysis. RESULTS: Four themes emerged. Factors contributing to ED visits included the following: fear (e.g., pain and its impact); inability to cope with pain; family suggestions to go to the ED; and access to other services and resources. Patients had validating and invalidating experiences in the ED: needs were met or not met; and feeling acknowledged or unacknowledged. Patients' experiences with their family physician included feeling supported or unsupported. Alternatives to the ED included working with an interdisciplinary team, developing personalized care plans, and increased community-based resources. CONCLUSIONS: Patients with CP and frequent ED use present with complex pain and care experiences, requiring careful attention to management strategies and the patient-provider relationship.
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Dor Crônica/psicologia , Dor Crônica/terapia , Educação Continuada em Enfermagem/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Pessoal de Saúde/educação , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Currículo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e QuestionáriosRESUMO
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.
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Wait times for many chronic pain programs in Canada range from 6 months to 2 years. This project sought to determine the interest of primary care providers (PCPs) in using an electronic consult system for patient(s) waiting for a pain consultation. This cross-sectional study was conducted at the pain clinic of a Canadian tertiary academic health sciences center. Participants were PCPs who had submitted a referral to this clinic. Referrals received between April 1, 2012, and March 31, 2014, were reviewed to determine their appropriateness for eConsult, and a letter providing information about eConsult and encouraging its use was sent to the referring PCP. Of the 585 referrals that were reviewed, 227 were appropriate for eConsult. Fifty-one (26%) of the 194 PCP responses received were positive. Technologies like eConsult may help address the growing demand for specialist advice. In addition to facilitating response to specific questions, the bidirectional nature of eConsult permits its use for educating PCPs about chronic pain treatment. Given that almost one third of responding PCPs indicated an interest in eConsult, its potential reach is vast. Additional study is needed to understand barriers to PCP acceptance and use of eConsult and the uptake of advice given.
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Acessibilidade aos Serviços de Saúde , Clínicas de Dor , Manejo da Dor/métodos , Atenção Primária à Saúde/métodos , Encaminhamento e Consulta , Consulta Remota/métodos , Listas de Espera , Adulto , Canadá , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Médicos de Família , Centros de Atenção TerciáriaRESUMO
OBJECTIVES: Several tools have been developed to screen for neuropathic pain. This study examined the sensitivity of the Douleur Neuropathique en 4 Questions (DN4) in screening for various neuropathic pain syndromes. MATERIALS AND METHODS: This prospective observational study was conducted in 7 Canadian academic pain centers between April 2008 and December 2011. All newly admitted patients (n=2199) were approached and 789 eligible participants form the sample for this analysis. Baseline data included demographics, disability, health-related quality of life, and pain characteristics. Diagnosis of probable or definite neuropathic pain was on the basis of history, neurological examination, and ancillary diagnostic tests. RESULTS: The mean age of study participants was 53.5 years and 54.7% were female; 83% (n=652/789) screened positive on the DN4 (≥4/10). The sensitivity was highest for central neuropathic pain (92.5%, n=74/80) and generalized polyneuropathies (92.1%, n=139/151), and lowest for trigeminal neuralgia (69.2%, n=36/52). After controlling for confounders, the sensitivity of the DN4 remained significantly higher for individuals with generalized polyneuropathies (odds ratio [OR]=4.35; 95% confidence interval [CI]: 2.15, 8.81), central neuropathic pain (OR=3.76; 95% CI: 1.56, 9.07), and multifocal polyneuropathies (OR=1.72; 95% CI: 1.03, 2.85) compared with focal neuropathies. DISCUSSION: The DN4 performed well; however, sensitivity varied by syndrome and the lowest sensitivity was found for trigeminal neuralgia. A positive DN4 was associated with greater pain catastrophizing, disability and anxiety/depression, which may be because of disease severity, and/or these scales may reflect magnification of sensory symptoms and findings. Future research should examine how the DN4 could be refined to improve its sensitivity for specific neuropathic pain conditions.
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Neuralgia/diagnóstico , Neuralgia/psicologia , Medição da Dor/métodos , Inquéritos e Questionários , Adulto , Idoso , Canadá , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
Objective: To evaluate the feasibility of an individualized interdisciplinary chronic pain care plan as an intervention to reduce emergency department (ED) visits and improve clinical outcomes among patients who frequented the ED with concerns related to chronic pain. Methods: A prospective cohort design was used in an urban tertiary care hospital. As a pilot program, fourteen patients with chronic pain who frequented the ED (i.e., >12 ED visits within the last year, of which ≥50% were for chronic pain) received a rapid interdisciplinary assessment and individualized care plan that was uploaded to an electronic medical record system (EMR) accessible to the ED and patient's primary care provider. Patients were assessed at baseline and every three months over a 12-month period. Primary outcomes were self-reported pain and function assessed using psychometrically valid scales. Results: Nine patients completed 12-month follow-up. Missing data and attrition were handled using multiple imputation. Patients who received the intervention reported clinically significant improvements in pain, function, ED visits, symptoms of depression, pain catastrophizing, sleep, health-related quality of life, and risk of future aberrant opioid use. Discussion: Individualized care plans uploaded to an EMR may be worth implementing in hospital EDs for high frequency visitors with chronic pain.
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Dor Crônica/complicações , Dor Crônica/psicologia , Pessoas com Deficiência/psicologia , Serviço Hospitalar de Emergência , Manejo da Dor , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Idoso , Catastrofização , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos do Humor/etiologia , Transtornos do Sono-Vigília/etiologia , Resultado do TratamentoRESUMO
Rhodium-catalyzed double [2 + 2 + 2] cycloaddition of 1,4-bis(diphenylphosphinoyl)buta-1,3-diyne with tethered diynes provides a straightforward, single-pot procedure for the synthesis of a new class of tropos biaryl diphosphine, NU-BIPHEP. This methodology represents a significant improvement on existing multistep procedures. Enantiopure Lewis acid platinum complexes of these diphosphines are highly efficient catalysts for carbonyl-ene and Diels-Alder reactions, and ruthenium diphosphine-diamine complexes catalyze the asymmetric reduction of ketones to give ee's that rival those obtained with their BINAP counterpart.
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BACKGROUND AND AIMS: Chronic pain is a debilitating condition that requires prompt access to care for effective treatment. Wait times for care often exceed benchmark recommendations, with potential consequences to patient health outcomes. The goal of this paper is to gain the perspectives of patients attending a chronic pain clinic regarding the acceptability of current wait times and the impact of their experiences of waiting for chronic pain care. METHODS: The study took place in a chronic pain clinic at an academic-affiliated teaching hospital in Ottawa, Canada, which housed seven clinicians at the time of the study. New patients attending the chronic pain clinic between July 14, 2014 and August 5, 2015 were eligible to participate based on the availability of the research and clerical staff who administered the survey on a variety of days over the course of the study. Patients completed a self-administered 29-item survey. The survey took approximately five to ten minutes to complete. Questions pertained to patients' socioeconomic factors, chronicity and burden of pain symptoms, and satisfaction with current wait times. Actual wait times were self-reported. Survey results were entered into an Excel spreadsheet, exported to SPSS, and coded numerically to facilitate descriptive analyses using comparative graphs and tables. Open-text responses were reviewed by the authors. RESULTS: Sixty-six patients completed the survey. While 83% of patients stated that their ideal wait time was less than three months, 32% reported receiving an appointment within this period, and 31% reported waiting a year or more. Only 37% of patients felt the wait time for their appointment was appropriate. During their wait, 41% of patients reported receiving written information about chronic pain and 47% were referred to a local chronic pain management group. 94% reported interference with social/recreational activities and normal activities of daily living, 31% had to miss work or school due to the frequency of ongoing symptoms, and 22% reported being unable to attend work or school altogether. Furthermore, 37% of patients reported visiting the emergency room within the previous year and 65% worried about having a serious undiagnosed disease. CONCLUSIONS: Our study found that wait times for chronic pain care, even those triaged as urgent cases, far exceeded what patients considered ideal. Only a third of patients received care within three months of making their appointment, while nearly another third waited over a year. During the waiting period, nearly all patients experienced some impact on their day-to-day activities and work or school attendance, half were unemployed, and nearly a quarter reported a complete inability to attend work or school because of pain. IMPLICATIONS: Wait times for chronic pain care exceed timelines deemed acceptable by patients, causing anxiety and reducing function. The patient perspective must be considered in initiatives attempting to improve access to care for this population with specific needs and goals. Innovative solutions, such as electronic consultation and shared care models, hold promise.
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Agendamento de Consultas , Acessibilidade aos Serviços de Saúde , Clínicas de Dor , Preferência do Paciente/psicologia , Listas de Espera , Canadá , Dor Crônica/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor , Satisfação do Paciente , Encaminhamento e Consulta , Inquéritos e Questionários , Fatores de TempoRESUMO
INTRODUCTION: Excessive wait times for chronic pain are associated with significant reductions in quality of life and worse health outcomes. The Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service can improve access to specialist care for patients with chronic pain by facilitating electronic communication between primary care providers (PCPs) and specialists. We explored the content of eConsult cases sent to chronic pain specialists to identify the major themes emerging from exchanges between PCPs and specialists regarding patients with chronic pain. METHODS: We conducted a thematic analysis of eConsult cases submitted to chronic pain specialists between April 1, 2011 and October 31, 2014, using a constant comparison approach. RESULTS: PCPs submitted 128 cases to chronic pain specialists during the study period. The study team coded 48 cases before data saturation was reached. PCPs sought advice for treating patients with chronic pain arising from a range of medical problems, and who frequently struggled with issues of mental health, substance dependence, and social complexity. Specialists responded with advice on pain management and treatment, directed PCPs to published guidelines and community resources, and validated the PCPs' frustration or concerns. Specialists provided instruction on safe opioid prescribing and how to identify and manage potential cases of substance dependence. CONCLUSION: Providing care to patients with chronic pain is a challenge for PCPs, who often experience frustration at their inability to provide a definitive solution for patients. Specialists offered invaluable feedback not only through guidance and advice, but also with sympathy and encouragement.
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Dor Crônica/terapia , Acessibilidade aos Serviços de Saúde/organização & administração , Atenção Primária à Saúde/métodos , Consulta Remota/métodos , Especialização , Adulto , Feminino , Troca de Informação em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Profissionais de Enfermagem/organização & administração , Médicos de Atenção Primária/organização & administração , Atenção Primária à Saúde/organização & administração , Qualidade de Vida , Consulta Remota/organização & administraçãoRESUMO
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.