Rejected

: It has been well documented that interdisciplinary, comprehensive pain education can foster positive pain beliefs among medical students, in addition to improving students' abilities to diagnose and treat pain. Though some work has been done to quantify the number of hours of pain education students receive, the content itself has received little attention. : This study seeks to identify what medical students learn about chronic pain throughout an undergraduate medical degree program in Ontario. : Three undergraduate medical schools in Ontario were selected on the basis of variety in curricular structure and instructional methods. Written documents comprising the formal curriculum were analyzed through qualitative and quantitative content analysis. These findings were compared with promising practices from the pain education literature. : The three curricula studied here dedicate the bulk of pain education to three topics: pain mechanisms, pain management, and opioids and addiction. The curricula vary considerably in organization of content and hours of pain training. All three curricula were found to contain negative pain beliefs that characterize pain patients as difficult, overwhelming, and unrewarding to work with. Two of the medical schools studied here do not have a pain curriculum. : The results of this study indicate a need for medical schools to develop comprehensive, interdisciplinary pain curricula. Though increasing the number of hours of pain training is crucial, equally imperative is a consideration of what, and how, students learn about pain.

: Chronic postsurgical pain (CPSP) and associated long-term opioid use are major public health concerns. : The Toronto General Hospital Transitional Pain Service (TPS) is a multidisciplinary, hospital-integrated program developed to prevent and manage CPSP and support opioid tapering. This clinical practice-based study reports on preliminary outcomes of the TPS psychology program, which provides acceptance and commitment therapy (ACT) to patients at risk for CPSP and persistent opioid use. : Ninety-one patients received ACT, whereas 252 patients did not (no ACT group). Patient outcomes were compared for the two groups at first and last TPS visits. Pain, pain interference, sensitivity to pain traumatization, pain catastrophizing, anxiety, depression, and opioid use were analyzed using two-way (Group [ACT, no ACT] × Time [first, last visit]) analyses of variance (ANOVAs). : Patients referred to ACT were more likely to report a mental health condition preoperatively ( < 0.001), had higher opioid use ( < 0.001) at the first postsurgical visit, and reported higher sensitivity to pain traumatization ( < 0.05) and anxiety ( < 0.05) than the no ACT group at both time points. Both groups showed reductions in pain, pain interference, pain catastrophizing, anxiety, and opioid use by the last TPS visit ( < 0.05). The ACT group demonstrated greater reductions in opioid use and pain interference and showed reductions in depressed mood ( = 0.001) by the end of treatment compared to the no ACT group. : Preliminary outcomes suggest that ACT was effective in reducing opioid use while pain interference and mood improved.

: The objective of this study was to identify biopsychosocial factors predicting primary care chronic non-cancer pain (CNCP) patients' risk of being heavy health care users. : Patients reporting moderate to severe CNCP for at least 6 months with an active analgesic prescription from a primary care physician were recruited in community pharmacies. Recruited patients completed questionnaires documenting biopsychosocial characteristics. Using administrative databases, direct costs were estimated for health care services used by each patient in the year preceding and following the recruitment. Heavy health care users were defined as patients in the highest annual direct health care costs quartile. Logistic multivariate regression models using the Akaike information criterion were developed to identify predictors of heavy health care use. : The median annual direct health care cost incurred by heavy health care users ( = 63) was CAD (Canadian dollars) 7627, versus CAD 1554 for standard health care users ( = 188). The final predictive model of the risks of being a heavy health care user included pain located in the lower body (odds ratio [OR] = 3.03; 95% confidence interval [CI], 1.20-7.65), pain-related disability (OR = 1.24; 95% CI, 1.03-1.48), and health care costs incurred in the year prior to recruitment (OR = 17.67; 95% CI, 7.90-39.48). Variables in the model also included sex, comorbidity, patients' depression level, and attitudes toward medical pain cure. : Patients suffering from CNCP in the lower body and showing greater disability were more likely to be heavy health care users, even after adjusting for previous-year direct health care costs. Improving pain management for these patients could have positive impacts on health care use and costs.

Determining when to entrust trainees to perform procedures is fundamental to patient safety and competency development.

: Chronic pain affects one in five Canadians. People with chronic pain frequently experience loss in their lives related to work, relationships, and their independence. They may be referred to a chronic pain program, which aims to strengthen coping through medical intervention and self-management skills. Data suggest that, even when individuals begin their pain program, many feel overwhelmed and do not continue. : The aim of this study was to conduct a needs assessment to explore the acceptability and feasibility of developing a psychosocial intervention, narrative therapy (NT), to address loss for chronic pain patients on the wait list of a chronic pain program. : Two focus groups were conducted with ten patients who had experienced being on a wait list for a provincial chronic pain management program (CPMP). Transcribed interviews were subjected to thematic and interpretive analysis. : Two major themes emerged from the analysis: loss of identity and sharing a story of chronic pain. All patients were enthusiastic toward an NT intervention, although individual preferences differed regarding mode of delivery. : Loss is a significant part of the chronic pain experience. NT seems to be an acceptable intervention to address loss for patients on the wait list for a chronic pain program.

The mismanagement of empty containers of pesticides, posing a risk to the environment and the health of people, has motivated the promotion of international policies and guidelines to mitigate such problems. Despite these guidelines, attention to this problem is inadequate in Bolivia. The objective was to study the knowledge and practical management of the containers and to implement a responsible management plan for empty pesticide containers.

: Interscalene brachial plexus (ISB) block is routinely used to provide anesthesia and analgesia for shoulder surgery. Traditional local anesthetic volumes for ISB result in near universal ipsilateral phrenic nerve paresis potentially including oxygenation and ventilation. : The purpose of this study was to determine the lowest minimal effective anesthetic volume in 95% of patients (MEAV 95) of ropivacaine 0.75% for ISB that provides surgical anesthesia for arthroscopic shoulder surgery. : Prospective observational cohort study in patients undergoing arthroscopic shoulder surgery under ISB (C6 level) with sedation. The dose finding protocol used the Narayana rule for up/down sequential allocation to estimate the MEAV 95 of ropivacaine 0.75%. Successful ISB was defined as complete absence of pinprick sensation in the C5 and C6 dermatomes 30 min postblock. Secondary outcomes assessed included ability to complete surgery with propofol sedation, change in slow vital capacity, room air oxygen saturation postblock, block duration, ISB complications, and numeric rating scale for pain immediately after surgery. : The study was stopped early due to futility. Among 225 participants approached, 54 consented to participate. The MEAV 95 for ultrasound-guided ISB of ropivacaine 0.75% for shoulder surgery was unable to be accurately estimated. Local anesthetic volumes between 5 and 20 ml did not influence any of the predefined secondary outcomes. : The MEAV 95 (at 30 min) of ropivacaine 0.75% for ultrasound-guided ISB exceeds the local anesthetic volumes that consistently produces hemidiaphragmatic impairment. ISB cannot be guaranteed to provide surgical anesthesia at 30 min without the potential for concomitant phrenic nerve block.

: Chronic pain is highly prevalent in the general population and may be even higher among public safety personnel (PSP; e.g., correctional officers, dispatchers, firefighters, paramedics, police). Comprehensive data on chronic pain among diverse Canadian PSP are relatively sparse. : The current study was designed to provide initial estimates of chronic pain frequency and severity among Canadian PSP. : Estimates of chronic pain frequency and severity (i.e., intensity and duration) at different bodily locations were derived from self-reported data collected through an online survey. Participants included 5093 PSP (32.5% women) grouped into six categories (i.e., call center operators/dispatchers, correctional officers, firefighters, municipal/provincial police, paramedics, Royal Canadian Mounted Police [RCMP]). : Substantial proportions of participants reported chronic pain, with estimates ranging from 35.3% to 45.4% across the diverse PSP categories. Across PSP categories, chronic lower back pain was the most prevalent. For some pain locations, firefighters and municipal/provincial police reported lower prevalence, but paramedics reported lower intensity, and duration, than some other PSP groups. Over 50% of RCMP and paramedics reporting chronic pain indicated that the pain was associated with an injury related to active duty. : Discrepancies emerged across PSP members with respect to prevalence, location, and severity. The current data suggest that additional resources and research are necessary to mitigate the development and maintenance of distressing or disabling chronic pain for Canadian PSP.

: The aim of this study was to explore the factors influencing orthopedic surgery nurses' decisions to administer pro re nata (PRN) opioid analgesia for postoperative pain. : Fast-track surgery programs reduce length of stay by identifying and addressing factors causing patients to remain in hospital, including pain (H. Kehlet, Lancet. 2013;381:9878(9878)). The management of acute pain is an important component of quality care for patients after total knee arthroplasty. : The study used a qualitative design of focused ethnography. Ten nurses working on an orthopedic surgery unit at a large urban hospital in western Canada participated in semistructured interviews that used a patient vignette to examine factors that influenced participants' pain management in the context of fast-track surgery. Interviews were transcribed and analyzed using thematic analysis and constant comparison. : Nurses described a complex clinical environment where the interplay of several factors informed decisions to administer PRN opioid analgesia. The unit's culture and physical space influenced nurses' assessments of pain and their decisions whether to treat pain with PRN opioids. Each nurse's self-concept affected pain management decisions because of perceived importance of pain control and perceived duty to provide analgesics. The subjectivity of pain added another layer of complexity as nurses responded to the patient's expression of pain from within the milieu of the unit culture and their unique self-concept. : Understanding the complexity of factors that influence nurses' postoperative pain management provides clinical nurses and nursing leaders with directions for future education and research, guided by the goal of continued improvement in pain management in the challenging setting of fast-track surgeries.