Comparative Effectiveness of Aspirin Dosing in Cardiovascular Disease.

BACKGROUND: The appropriate dose of aspirin to lower the risk of death, myocardial infarction, and stroke and to minimize major bleeding in patients with established atherosclerotic cardiovascular disease is a subject of controversy. METHODS: Using an open-label, pragmatic design, we randomly assigned patients with established atherosclerotic cardiovascular disease to a strategy of 81 mg or 325 mg of aspirin per day. The primary effectiveness outcome was a composite of death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke, assessed in a time-to-event analysis. The primary safety outcome was hospitalization for major bleeding, also assessed in a time-to-event analysis. RESULTS: A total of 15,076 patients were followed for a median of 26.2 months (interquartile range [IQR], 19.0 to 34.9). Before randomization, 13,537 (96.0% of those with available information on previous aspirin use) were already taking aspirin, and 85.3% of these patients were previously taking 81 mg of daily aspirin. Death, hospitalization for myocardial infarction, or hospitalization for stroke occurred in 590 patients (estimated percentage, 7.28%) in the 81-mg group and 569 patients (estimated percentage, 7.51%) in the 325-mg group (hazard ratio, 1.02; 95% confidence interval [CI], 0.91 to 1.14). Hospitalization for major bleeding occurred in 53 patients (estimated percentage, 0.63%) in the 81-mg group and 44 patients (estimated percentage, 0.60%) in the 325-mg group (hazard ratio, 1.18; 95% CI, 0.79 to 1.77). Patients assigned to 325 mg had a higher incidence of dose switching than those assigned to 81 mg (41.6% vs. 7.1%) and fewer median days of exposure to the assigned dose (434 days [IQR, 139 to 737] vs. 650 days [IQR, 415 to 922]). CONCLUSIONS: In this pragmatic trial involving patients with established cardiovascular disease, there was substantial dose switching to 81 mg of daily aspirin and no significant differences in cardiovascular events or major bleeding between patients assigned to 81 mg and those assigned to 325 mg of aspirin daily. (Funded by the Patient-Centered Outcomes Research Institute; ADAPTABLE ClinicalTrials.gov number, NCT02697916.).

Decontamination of metals from firefighter turnout gear.

Firefighters are exposed to many different contaminants during structural fires. Moreover, if their protective gear is not successfully decontaminated, firefighters are at risk of being repeatedly exposed to contaminants from previous fires. Thus, the successful removal of contaminants from firefighter turnout gear is necessary to prevent or reduce repeated exposure risks. Laundering methods can reduce the probability of re-exposure to contaminants, such as heavy metals, thus reducing repeated exposure risks. In this study, the efficiencies of heavy metal removal from the firefighter turnout gear outer textile by Decon7 cleaning solution and a standard reference detergent were compared. Nitric acid digests were used to extract metals from textile samples, which were cut from small sections of firefighter jackets, before and after their laundering with either cleaning solution. Inductively coupled plasma mass spectrometry (ICP-MS) was utilized to determine metal contents, including arsenic (As), antimony (Sb), cadmium (Cd), chromium (Cr), and lead (Pb) concentrations. Results from multiplicate samples indicated that, on average, Decon7 was significantly more efficient than a standard detergent in decreasing the concentrations of the five metals studied herein.

Chemical exposures from upholstered furniture with various flame retardant technologies.

Upholstered furniture is often manufactured with polyurethane foam (PUF) containing flame retardants (FRs) to prevent the risk of a fire and/or to meet flammability regulations, however, exposure to certain FRs and other chemicals have been linked to adverse health effects. This study developed a new methodology for evaluating volatile organic compound (VOC) and FR exposures to users of upholstered furniture by simulating use of a chair in a controlled exposure chamber and assessing the health significance of measured chemical exposure. Chairs with different fire-resistant technologies were evaluated for VOC and FR exposures via inhalation, ingestion, and dermal contact exposure routes. Data show that VOC exposure levels are lower than threshold levels defined by the US and global indoor air criteria. Brominated FRs were not detected from the studied chairs. The organophosphate FRs added to PUF were released into the surrounding air (0.4 ng/m3 ) and as dust (16 ng/m2 ). Exposure modeling showed that adults are exposed to FRs released from upholstered furniture mostly by dermal contact and children are exposed via dermal and ingestion exposure. Children are most susceptible to FR exposure/dose (2 times higher average daily dose than adults) due to their frequent hand to mouth contact.

A Systematic Approach to Evidence-Based Design for Measurable Health and Wellness Outcomes: Curating and Translating Evidence to Practice.

OBJECTIVES: Evaluating evidence from peer-review literature for use in evidence-based design is often challenging for the design disciplines, requiring access to the peer-reviewed literature, expertise in evaluating methods and findings, and translating the results into actionable design and operational recommendations. PURPOSE: The purpose of this methods paper is to elucidate the process for systematic evaluation of research to translate evidence into practical application to improve design for occupant health and wellness. BACKGROUND: Researchers have found strong connections in environmental design influence on health and wellness that have proven to be substantiative in the effort to improve health and well-being. Design has the capacity to encourage healthy choices and decisions within the built environment. Translation of evidence into applied design solutions may improve public health. METHODS: A protocol is presented that culminates in the translation of evidence into design recommendations focused on improving occupant health. The protocol includes preparation for the literature search and review, search strategy, study selection, data analysis, and development of the literature review. RESULTS: After evaluation of the evidence is completed, there were several positive findings in the example that stakeholders could utilize to improve the health of building occupants with programs and design to support nutrition, physical activity, and circadian entrainment. CONCLUSIONS: There are a variety of software tools and processes to utilize in the curation of evidence to improve the built environment with relevant design recommendations and operational considerations affecting the personal, social, and economic health of our society.

Indoor Finish Material Influence on Contamination, Transmission, and Eradication of Methicillin-Resistant Staphylococcus aureus (MRSA).

OBJECTIVE: The purpose of this study was to evaluate environmental surface materials used in healthcare environments for material composition, methicillin-resistant Staphylococcus aureus (MRSA) viability, and a comparison of two disinfectants, a bleach germicidal cleaner and Decon7, a novel disinfectant. BACKGROUND: Contaminated environmental surfaces have been associated with outbreaks of healthcare-associated illness (HAIs). One in every 20 patients in U.S. acute care hospitals acquire a healthcare-associated illness, leading to consequences such as elevated morbidity, mortality, and a decrease in quality of life. In the patient environment, MRSA can remain viable from hours to up to 14 days. METHODS: Environmental surface materials were evaluated as new and worn. Material composition and properties were assessed to evaluate surface integrity and the influence on the disinfection of MRSA. Inoculated materials were used to assess MRSA viability over time and the efficacy of a manufacturer's recommended cleaning and disinfection product compared to a novel disinfectant. RESULTS: Environmental surface materials respond differently in appearance and roughness, when mechanically worn. When measuring MRSA survival, at 24 hr, MRSA colony forming unit (CFU) counts were reduced on the copper sheet surface and solid surface with cupric oxide. By 72 hr, all MRSA counts were zero. Bleach and the novel disinfectant were equally effective at disinfecting MRSA from all surface types. CONCLUSIONS: This study highlights a gap in knowledge about the impact of type and wear of environmental surface materials used in healthcare environments on contamination with epidemiologically important organisms. In conclusion, environmental surface material wear, properties, and cleaning and disinfection efficacy are important factors to consider when addressing HAIs.

Bacteria Associated with Healthcare-Associated Infections on Environmental Samples Obtained from Two Fire Departments.

(1) Background: Firefighters spend about 64% of their time responding to medical emergencies and providing medical care without a patient history, which can render them vulnerable to healthcare-associated infections (HAI). Infection prevention, control, and surveillance systems have been instituted at hospitals. However, the prevalence of firefighters' exposure to HAI is unknown. The objective of this study was to document evidence of HAI on surfaces in fire stations and engines to inform disinfection procedures and identify which pathogens might contribute to occupational exposures. (2) Methods: High-touch or high-use surfaces of two fire departments were sampled during five separate occasions. One fire station from one fire department was sampled over a 4-week period, whereas four fire stations were sampled from a different fire department only once. Sampled surfaces included: entryway floor, washing machine, medical bag, back seat of engine, keyboard of reporting computer, engine console, and uniform pants. (3) Results: Multiple statistical models determined that bacterial contamination was similar between the two fire departments and their stations. Keyboards were the most contaminated surface for all fire stations and departments, E. coli was the most common bacteria detected, and C. difficile was the least detected bacteria. Adjustments for rates of contamination found that contamination rates varied between fire stations. (4) Conclusions: Comprehensive environmental sampling and clinical studies are needed to better understand occupational exposures of firefighters to HAI.

SARS-CoV-2 Viability on 16 Common Indoor Surface Finish Materials.

AIM: This study investigated the stability of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on 16 common environmental surface materials. BACKGROUND: SARS-CoV-2 is the causative agent of severe coronavirus disease, a significant public health concern that quickly led to a pandemic. Contamination of environmental surface materials is of concern, with previous studies identifying long-term detection of infectious particles on surfaces. These contaminated surfaces create an increased risk for contact transmission. METHODS: Surface materials were inoculated with 10,000 plaque forming units and samples were collected 4, 8, 12, 24, 30, 48, and 168 hours post infection (hpi). Viral titers were determined for each sample and time point using plaque assays. Nonparametric modeling utilized the Turnbull algorithm for interval-censored data. Maximum likelihood estimates for the survival curve were calculated. Parametric proportional hazards regression models for interval censored data were used to explore survival time across the surface materials. RESULTS: There was a sharp decline in recoverable virus after 4 hpi for all tested surfaces. By 12 hpi, infectious SARS-CoV-2 was recoverable from only four surfaces; and by 30 hr, the virus was recoverable from only one surface. There were differences in survival curves based on the materials although some groups of materials are similar, both statistically and practically. CONCLUSIONS: While very low amounts of infectious SARS-CoV-2 are recoverable over time, there remains a risk of viral transmission by surface contamination in indoor environments. Individuals and institutions must follow appropriate procedures to decontaminate indoor environment and increase diligence for hand hygiene and personal protective equipment.

Validation of Cardiovascular End Points Ascertainment Leveraging Multisource Electronic Health Records Harmonized Into a Common Data Model in the ADAPTABLE Randomized Clinical Trial.

BACKGROUND: The ADAPTABLE trial (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) is the first randomized trial conducted within the National Patient-Centered Clinical Research Network to use the electronic health record data formatted into a common data model as the primary source of end point ascertainment, without confirmation by standard adjudication. The objective of this prespecified study is to assess the validity of nonfatal end points captured from the National Patient-Centered Clinical Research Network, using traditional blinded adjudication as the gold standard. METHODS: A total of 15 076 participants with established atherosclerotic cardiovascular disease were randomized to two doses of aspirin (81 mg and 325 mg once daily). Nonfatal end points (hospitalization for nonfatal myocardial infarction, nonfatal stroke, and major bleeding requiring transfusion of blood products) were captured with the use of programming algorithms applied to National Patient-Centered Clinical Research Network data. A random subset of end points was independently reviewed by a disease-specific expert adjudicator. The positive predictive value of the programming algorithms were calculated separately for end points listed as primary and as nonprimary diagnoses. RESULTS: A total of 225 end points were identified (91 myocardial infarction events, 89 stroke events, and 45 bleeding events), including 142 (63%) that were listed as primary diagnoses. Complete source documents were missing for 14% of events. The positive predictive value were 90%, 72%, and 93% for hospitalizations for myocardial infarction, stroke, and major bleeding, respectively, as compared to adjudication. When only primary diagnoses were considered, positive predictive value were 93%, 91%, and 97%, respectively. When only nonprimary diagnoses were considered, positive predictive value were 82%, 36%, and 71%. CONCLUSIONS: As compared with blinded adjudication, clinical end point ascertainment from queries of the National Patient-Centered Clinical Research Network distributed harmonized data was valid to identify hospitalizations for myocardial infarction in ADAPTABLE. The proportion of contradicted events was high for hospitalizations for bleeding and strokes when nonprimary diagnoses were analyzed, but not when only primary diagnoses were considered.

Healthy Behaviors through Behavioral Design-Obesity Prevention.

Evidence for behavior modification for improved health outcomes was evaluated for nutrition, physical activity (PA), and indoor environmental quality (IEQ). The databases searched included LISTA, PubMed, and Web of Science, with articles rated using an a priori baseline score of 70/100 to establish inclusion. The initial search produced 52,847 articles, 63 of which were included in the qualitative synthesis. Thirteen articles met inclusion for nutrition: cafeteria interventions, single interventions, and vending interventions. Seventeen articles on physical activity were included: stair use, walking, and adjustable desks. For IEQ, 33 articles met inclusion: circadian disruption, view and natural light, and artificial light. A narrative synthesis was used to find meaningful connections across interventions with evidence contributing to health improvements. Commonalities throughout the nutrition studies included choice architecture, increasing the availability of healthy food items, and point-of-purchase food labeling. Interventions that promoted PA included stair use, sit/stand furniture, workplace exercise facilities and walking. Exposure to natural light and views of natural elements were found to increase PA and improve sleep quality. Overexposure to artificial light may cause circadian disruption, suppressing melatonin and increasing risks of cancers. Overall, design that encourages healthy behaviors may lower risks associated with chronic disease.

In-line radiolabeling: a novel continuous-flow system for commercial-scale protein labeling.

UNLABELLED: A key limitation in developing radiotherapeutic proteins is the expense of manufacturing the drug in small batches using traditional reaction vessels. Removing limitations on the quantity of protein labeled at any one time significantly decreases the cost of production, and nowhere is the need for cost-effective radiotherapeutics more acute than in the treatment of cancer. METHODS: We describe a novel method that can rapidly radiolabel, theoretically, unlimited amounts of protein, without causing significant damage to binding potency or structural integrity. Our process controls the reaction rate for the isotope and reactants as they simultaneously flow through a reaction tube. RESULTS: We have demonstrated proof of principle by labeling nearly a gram of antibody with 481 GBq (13 Ci) of (131)I during a single 30-min reaction run. CONCLUSION: Simple to construct, our system is already used to manufacture a radiolabeled antibody, both in the United States and in India, as part of clinical trials to treat glioblastoma multiforme. Modified, this system may be also applicable for nonradioactive labeling.

A phase 1 trial of pharmacologic interactions between transdermal selegiline and a 4-hour cocaine infusion.

BACKGROUND: The selective MAO-B inhibitor selegiline has been evaluated in clinical trials as a potential medication for the treatment of cocaine dependence. This study evaluated the safety of and pharmacologic interactions between 7 days of transdermal selegiline dosed with patches (Selegiline Transdermal System, STS) that deliver 6 mg/24 hours and 2.5 mg/kg of cocaine administered over 4 hours. METHODS: Twelve nondependent cocaine-experienced subjects received deuterium-labeled cocaine-d5 intravenously (IV) 0.5 mg/kg over 10 minutes followed by 2 mg/kg over 4 hours before and after one week of transdermal selegiline 6 mg/24 hours. Plasma and urine were collected for analysis of selegiline, cocaine, catecholamine and metabolite concentrations. Pharmacodynamic measures were obtained. RESULTS: Selegiline did not change cocaine pharmacokinetic parameters. Selegiline administration increased phenylethylamine (PEA) urinary excretion and decreased urinary MHPG-sulfate concentration after cocaine when compared to cocaine alone. No serious adverse effects occurred with the combination of selegiline and cocaine, and cocaine-induced physiological effects were unchanged after selegiline. Only 1 peak subjective cocaine effects rating changed, and only a few subjective ratings decreased across time after selegiline. CONCLUSION: No pharmacological interaction occurred between selegiline and a substantial dose of intravenous cocaine, suggesting the combination will be safe in pharmacotherapy trials. Selegiline produced few changes in subjective response to the cocaine challenge perhaps because of some psychoactive neurotransmitters changing in opposite directions.

The clinical pharmacology of intranasal l-methamphetamine.

BACKGROUND: We studied the pharmacology of l-methamphetamine, the less abused isomer, when used as a nasal decongestant. METHODS: 12 subjects self-administered l-methamphetamine from a nonprescription inhaler at the recommended dose (16 inhalations over 6 hours) then at 2 and 4 (32 and 64 inhalations) times this dose. In a separate session intravenous phenylephrine (200 microg) and l-methamphetamine (5 mg) were given to define alpha agonist pharmacology and bioavailability. Physiological, cardiovascular, pharmacokinetic, and subjective effects were measured. RESULTS: Plasma l-methamphetamine levels were often below the level of quantification so bioavailability was estimated by comparing urinary excretion of the intravenous and inhaled doses, yielding delivered dose estimates of 74.0 +/- 56.1, 124.7 +/- 106.6, and 268.1 +/- 220.5 microg for ascending exposures (mean 4.2 +/- 3.3 microg/inhalation). Physiological changes were minimal and not dose-dependent. Small decreases in stroke volume and cardiac output suggesting mild cardiodepression were seen. CONCLUSION: Inhaled l-methamphetamine delivered from a non-prescription product produced minimal effects but may be a cardiodepressant.

Putting evidence into practice: evidence-based interventions for the management of oral mucositis.

Mucositis, an inflammation of the mucous membranes, is a commonly occurring side effect of chemotherapy and radiation. Oral mucositis can cause significant clinical consequences, such as pain, malnutrition, and local and systemic infections. Nurses have a critical role in all aspects of managing mucositis, including assessing it, teaching oral care, administering pharmacologic interventions, and helping patients cope with symptom distress. Mucositis can have a negative impact on the overall treatment experience, especially when severe pain or infections occur. Many interventions for managing mucositis exist; however, some are based in tradition or expert opinion and have not been studied in large, randomized, controlled trials. In addition, a variety of assessment tools are available, which creates confusion and difficulties when comparing interventions across studies. This article reviews empirical evidence related to interventions for oral mucositis. Oral care and rinses, pharmacologic interventions, and other techniques are evaluated. Gaps in the literature and opportunities for research, education, and practice changes are discussed.

Pain attitudes and knowledge among RNs, pharmacists, and physicians on an inpatient oncology service.

Patients with cancer often experience pain, yet studies continue to document inadequate and inappropriate assessment and management of cancer-related pain. This study aimed to evaluate the attitudes and knowledge of inpatient oncology healthcare providers toward pain management by surveying nurses, pharmacists, and physicians working on the inpatient oncology units at an academic medical center. Healthcare providers generally reported positive attitudes toward pain management but were deficient in their knowledge of pain management. The authors suggest that pharmacists become more integral members of palliative care teams and actively participate in rounds. A need exists for educational programs in pain management for healthcare providers, especially for those who do not routinely care for patients with cancer.

Human pharmacology of the methamphetamine stereoisomers.

OBJECTIVE: To help predict the consequences of precursor regulation, we compared the pharmacokinetics and pharmacodynamics of the methamphetamine (INN, metamfetamine) stereoisomers. METHODS: In this study 12 methamphetamine abusers received intravenous d-methamphetamine (0.25 and 0.5 mg/kg), l-methamphetamine (0.25 and 0.5 mg/kg), racemic methamphetamine (0.5 mg/kg), or placebo with the use of a 6-session, double-blind, placebo-controlled, balanced crossover design. Pharmacokinetic measures (including area under the plasma concentration-time curve [AUC], elimination half-life, systemic clearance, apparent volume of distribution during the elimination phase, and apparent bioavailability) and pharmacodynamic measures (including heart rate, blood pressure, respiratory rate, and visual analog scale ratings for "intoxication," "good drug effect," and "drug liking") were obtained. RESULTS: Pharmacokinetic parameters for the individual enantiomers given separately were similar, with dose-proportional increases in AUC and maximum plasma concentration. After racemate administration, the AUC for d-methamphetamine was 30% smaller than that for l-methamphetamine (P = .0085). The elimination half-lives were longer for l-methamphetamine (13.3-15.0 hours) than for d-methamphetamine (10.2-10.7 hours) (P < .0001). Compared with placebo, d-methamphetamine (0.25 mg/kg, 0.5 mg/kg, and racemic) increased the heart rate (P < .0001), blood pressure (P < .0001), and respiratory rate (P < .05), and this increase lasted for 6 hours. The peak heart rate changes after racemic methamphetamine and 0.5 mg/kg d- and l-methamphetamine were similar (18.7 +/- 23.4 beats/min, 13.5 +/- 18.5 beats/min, and 10.7 +/- 10.2 beats/min, respectively), but racemic methamphetamine and 0.5 mg/kg d-methamphetamine increased systolic blood pressure more than 0.5 mg/kg l-methamphetamine (33.4 +/- 17.8 beats/min and 34.5 +/- 18.9 beats/min, respectively, versus 19.5 +/- 11.3 beats/min; P < .01). l-Methamphetamine, 0.5 mg/kg, was psychoactive, producing peak intoxication (46.0 +/- 35.3 versus 30.3 +/- 24.9) and drug liking (47.7 +/- 35.1 versus 28.6 +/- 24.8) ratings similar to 0.5 mg/kg d-methamphetamine, but the effects of l-methamphetamine dissipated more quickly (approximately 3 hours versus 6 hours). The effects of 0.25 mg/kg l-methamphetamine were similar to those of placebo. Racemic methamphetamine was similar to d-methamphetamine with regard to most pharmacodynamic measures. CONCLUSION: The pharmacokinetics of the methamphetamine enantiomers are similar, but there are substantial pharmacodynamic differences between the isomers. At high doses, l-methamphetamine intoxication is similar to that of d-methamphetamine, but the psychodynamic effects are shorter-lived and less desired by abusers. Racemic and d-methamphetamine have similar effects and would be expected to have comparable abuse liabilities.

The Significance of Harm Reduction as a Social and Health Care Intervention for Injecting Drug Users: An Exploratory Study of a Needle Exchange Program in Fresno, California.

Infectious disease remains a significant social and health concern in the United States. Preventing more people from contracting HIV/AIDS or Hepatitis C (HCV), requires a complex understanding of the interconnection between the biomedical and social dimensions of infectious disease. Opiate addiction in the US has skyrocketed in recent years. Preventing more cases of HIV/AIDS and HCV will require dealing with the social determinants of health. Needle exchange programs (NEPs) are based on a harm reduction approach that seeks to minimize the risk of infection and damage to the user and community. This article presents an exploratory small-scale quantitative study of the injection drug using habits of a group of injection drug users (IDUs) at a needle exchange program in Fresno, California. Respondents reported significant decreases in high risk IDU behaviors, including sharing of needles and to a lesser extent re-using of needles. They also reported frequent use of clean paraphernalia. Greater collaboration between social and health outreach professionals at NEPs could provide important frontline assistance to people excluded from mainstream office-based services and enhance efforts to reduce HIV/AIDS or HCV infection.

Repeated psychological stress testing in stimulant-dependent patients.

Decreasing response to stress has been one goal of interventions aimed at reducing relapse to substances of abuse. A laboratory stress test that can be repeated would be helpful in testing the efficacy of interventions in decreasing the response to stress before more extensive trials are begun. The effects of two types of psychological stress tests, the Trier Social Stress Test (TSST) and a stress imagery test, on psychological, physiological, and hormonal responses (salivary cortisol and DHEA) were examined when each test was given twice to cocaine- or methamphetamine-dependent human subjects, 24 of whom completed at least one session. The stress imagery test produced significant changes in several of the subjective response measures in both first and second sessions, including several measures of negative affect and a craving measure. The TSST produced significant changes only in the second session. The stress imagery protocol showed better replicability across two sessions. Cocaine users and methamphetamine users did not respond similarly in their craving responses. Reported craving for methamphetamine after stress testing showed decreases or much smaller increases compared to that for cocaine. Neither stress test significantly increased salivary cortisol or DHEA, and changes in hormone concentrations were not related to subjective responses. These results suggest that stress imagery testing procedures may be useful as provocative tests of stress-induced affect and stimulant drug craving. Although less convincing because of the heterogeneity of the subjects, they also suggest that HPA axis responsivity is not clearly linked to acute stress-induced stimulant craving or affective response.

Unlicensed staff members' experiences with patients' pain on an inpatient oncology unit: implications for redesigning the care delivery system.

Although unlicensed staff have routine contact with patients in pain, little research relates to their role with these patients. The purpose of this study was to describe the experiences of unlicensed inpatient hospital staff caring for cancer patients in pain. We sought to understand pain identification and communication practices, describe common practice situations, and identify training needs. We conducted 4 focus groups with unit secretaries, nurses' aides, and housekeepers (N = 24) on 2 inpatient oncology units at an urban, northeastern teaching hospital. Group processes were tape-recorded, transcribed, and analyzed using Atlas/ti software and content analysis. Analysis generated 5 issues related to pain in the daily practice of unlicensed staff: perceived function with pain, building relationships with patients, interpreting patients' pain, system issues, and job challenges and coping strategies. Unlicensed staff reported performing important functions related to pain, including alerting nursing staff to patients' pain, and providing psychosocial support. Participants shared difficulties of working with patients in pain and expressed interest in education on pain identification and course of illness. Findings provide insight into the role of unlicensed staff, and have implications for the educational preparation of this group as well as the nature of their participation in the care delivery system.