Pain Management Care Research Articles

Association between history of childbirth and chronic, functionally significant back pain in later life

BackgroundBack pain is more prevalent among women than men. The association with sex could be related to pregnancy and childbirth, unique female conditions. This association has not been thoroughly evaluated.MethodsUsing a retrospective cohort design, we evaluated the relationship between history of childbirth on the prevalence and severity of functionally consequential back pain in 1069 women from a tertiary care pain management clinic. Interactions among preexisting, acute peripartum, and subsequent back pain were evaluated as secondary outcomes among the parous women using logistic and linear regression as appropriate.ResultsThe women who had given birth had a higher risk for functionally significant back pain compared to women who had not given birth (85% vs 77%, p < 0.001, Risk Ratio 1.11 [1.04-1.17]). The association was preserved after correction for age, weight, and race. Back pain was also more slightly severe (Numerical Rating Score for Pain 7[5-8] vs 6[5-7] out of 10, p = 0.002). Women who recalled severe, acute postpartum back pain had a higher prevalence of current debilitating back pain (89% vs 75%, Risk Ratio 1.19 (1.08-1.31), p = 0.001). Twenty-eight percent of acute postpartum back pain never resolved and 40% reported incomplete resolution.ConclusionsA history of pregnancy and childbirth is a risk factor for chronic functionally significant back pain in women. Severe acute postpartum back pain is a risk factor for future disability suggesting that the peripartum period may provide an important opportunity for intervention. Early recognition and management may mitigate future disability.Trial registrationThe study was registered with clinicaltrials.gov as “Association Between Chronic Headache and Back Pain with Childbirth” (NCT04091321) on 16/09/2019 before it was initiated.

Impact of Telehealth on Palliative Care and Pain Management in Primary Care

Primary health care focuses on the public's needs for a sustainable healthy existence without placing any financial burden on patients in order to ensure the highest degree of health and well-being and their equitable distribution. When pain management and palliative care are incorporated into primary healthcare, patients' quality of life and satisfaction improve. Palliative care includes supportive medical care for patients at any stage of disease with the goals of symptom relief, pain control, stress management, carer respite, and enhancing the quality of life. Globally, a wide range of technologies have been created to establish novel approaches to treating various chronic pain problems. Furthermore, utilising telehealth systems, which have been increasingly included in specialized palliative care over the past ten years and most recently during the COVID-19 pandemic, is one way to address the growing need for palliative care. Through the utilisation of a wide variety of public communication channels, telehealth can be employed for various primary healthcare goals. Telehealth is expected to be effective for conducting routine evaluations. reduced patient burden and missed appointments, as well as improved convenience and treatment of some chronic illnesses such as diabetes and hypertension. However, patients must get instruction and assistance in using this platform, with specific support made accessible for groups known to be at risk. Telehealth’s role in primary care needs further elaborated study. The purpose of this research is to review the available information about the impact of telehealth on palliative care and pain management in primary care.Primary health care focuses on the public's needs for a sustainable healthy existence without placing any financial burden on patients in order to ensure the highest degree of health and well-being and their equitable distribution. When pain management and palliative care are incorporated into primary healthcare, patients' quality of life and satisfaction improve. Palliative care includes supportive medical care for patients at any stage of disease with the goals of symptom relief, pain control, stress management, carer respite, and enhancing the quality of life. Globally, a wide range of technologies have been created to establish novel approaches to treating various chronic pain problems. Furthermore, utilising telehealth systems, which have been increasingly included in specialized palliative care over the past ten years and most recently during the COVID-19 pandemic, is one way to address the growing need for palliative care. Through the utilisation of a wide variety of public communication channels, telehealth can be employed for various primary healthcare goals. Telehealth is expected to be effective for conducting routine evaluations. reduced patient burden and missed appointments, as well as improved convenience and treatment of some chronic illnesses such as diabetes and hypertension. However, patients must get instruction and assistance in using this platform, with specific support made accessible for groups known to be at risk. Telehealth’s role in primary care needs further elaborated study. The purpose of this research is to review the available information about the impact of telehealth on palliative care and pain management in primary care.

The Femoral Nerve Block Setting the Agenda for Nursing Care of Older Patients With hip Fractures-A Qualitative Study.

Hip fractures among older people are common worldwide, and it is often associated with preoperative pain. Due to increased comorbidity and high age, traditional pain relief can be a challenge. An alternative to traditional pain relief is a femoral nerve block, which is safe and suitable for anesthesia and analgesia for hip fractures among patients with or without dementia. It is essential to provide adequate pain management, and nurses report negative attitudes toward opioids and seem to prefer alternative pain management. To our knowledge, no study has focused on staff's experiences of nursing care for patients treated with femoral nerve block. To describe staff's experiences providing nursing care in preoperative pain and pain management to older patients with a hip fracture who received a femoral nerve block. A qualitative exploratory design. Semistructured interviews with 19 nurses or assistant nurses in an orthopedic ward or emergency department. They were experienced in caring for patients with hip fractures who received treatment with a femoral nerve block. The interviews were subjected to qualitative content analysis. Staff described the femoral nerve block as setting the agenda when caring for older patients with hip fractures in the preoperative phase. The outcome of the femoral nerve block affected nursing care, depending on if the femoral nerve block was successful or not. Nursing care requires timing, with a need for staff orienting to time and customizing their communication. Further, staff faced ethical challenges regarding doing good and not harm, relieving pain, and avoiding side effects. The femoral nerve block was an important issue for nursing staff in patients with hip fractures in the preoperative phase. Our results point toward the benefits of giving femoral nerve blocks as soon as possible to facilitate nursing care, however, this should be studied in future research.

A review on the pathogenesis of cutaneous non-melanoma skin cancer (NMSC) and selected herbs as chemoprotective agents

The high incidence of NMSC (non-melanoma skin cancer) and the side effects of the available treatments disrupt the quality of life in more than one way. Particularly in the later stages, pain management and palliative care is the sole mean of alleviating the agony, all this warrants the need for alternative strategies with enhanced efficacy, better tolerance, and wide safety margins. Therefore, herbs in NMSC prevention and intervention are engaging due to their accessibility, efficacy, cost-effectiveness, and tolerated nature. Various components in the crude extracts follow 'Pharmacodynamic synergy', augment the beneficial effects of the active constituents, and reduce the likelihood of drug resistance. The extracts/active constituents of Azadirachta indica, Catharanthus roseus, Ocimum sanctum, Phyllanthus emblica, Santalum album, Tinospora cordifolia, and Withania somnifera demonstrated the anti-cancerous effect on distinct cancerous cells and animal models. Nonetheless, there is a lack of in vivo investigations validating its chemopreventive efficacy in experimental models of skin carcinogenesis. Therefore, the current review suggests the scientific community emphasize the extensive research on these herbs to obtain an efficacious drug as well as the people around the globe incorporate these herbs in their daily dietary habits/meals to obtain maximum benefit from these herbs.

Medical School Students’ Knowledge of Pain and Palliative Care: An Observational Study

Background: Pain and palliative care are a reality in daily routines of medical treatment. However, the theoretical-practical curricula of traditional medical school course still unsatisfactorily contemplate pain management, as well as the palliative care approach. Objective: To assess the knowledge of medical students about pain and palliative care, as well as to identify their perception of teaching these topics during hospitalization. Methods: A cross-sectional observational study, with a descriptive and exploratory approach, data collection for which was carried out between August and November 2020. The target population was medical students, who responded to an online survey of a quantitative, anonymous and follow-up nature. The survey study variables concerned knowledge about pain management and palliative care. Results: An expressive majority of academics showed difficulty in understanding the pathophysiology of pain related to prescribing drugs for pain management purposes, and all of them believe that it is necessary to acquire more knowledge about pain treatment. In parallel, only 9.3% report having received sufficient information regarding palliative care during medical school. Conclusion: The results suggest a certain lack of knowledge and insecurity among medical school students with respect to pain management and care for patients receiving palliative care. The didactical approach to this theme is still deficient in the medical curriculum and requires immediate improvement and new proposals that address the training of these professionals in a more specific and effective way.

Nurses Experience and Perceived Challenges of Using Nonpharmacological Pain Interventions for Musculoskeletal Pain: A Qualitative Study.

Current musculoskeletal pain management guidelines encourage utilizing nonpharmacological pain measures. Despite their positive effect in alleviating musculoskeletal pain, nurses reported negative attitudes toward utilizing nonpharmacological pain measures. Therefore, assessing nurses' perception of nonpharmacological pain measures is essential to promote patient comfort. The aim of the study was to explore the nurses' experience and perceived challenges in using nonpharmacological pain measures in caring for patients with musculoskeletal pain. A descriptive qualitative design was carried out. Face-to-face semistructured interviews were conducted among 11 nurses. Colaizzi's method was employed in analyzing the data. Four themes emerged, namely, constant monitoring and observation, selection of nonpharmacological pain measures, and various barriers related to patients and nurses. One of the ways to overcome these barriers or challenges, we should promote interprofessional teams in planning patient-centered pain management care. Also, defining the role of the pain management nurse would be pivotal to ensuring effective pain management measures. The nursing workforce needs to initiate and utilize these measures as a common practice in managing musculoskeletal pain and in turn create a culture that strongly supports the utilization of nonpharmacological pain measures.

Liposomal Bupivacaine Versus Continuous Nerve Block: Liposomal Bupivacaine May be Non-inferior and More Cost Effective

BackgroundRegional anesthesia with adductor canal block has become the standard of care for pain management after total knee arthroplasty (TKA). We hypothesized that liposomal bupivacaine (LB) may be noninferior to continuous nerve block with a pain pump in terms of average pain scores, 30- and 90-day readmissions, and emergency department (ED) visits while reducing cost. MethodsA retrospective chart review was performed on primary TKA patients from 2015 to 2020 by 23 orthopaedic surgeons at a single institution. The inclusion criteria was treatment with LB or a pain pump, and exclusion criteria was receipt of both anesthetics and revision surgery. A total of 2,378 patients met the inclusion criteria with 1,640 patients treated with LB and 738 treated with the pain pump. Demographic differences were not statistically significant. Primary outcomes were average pain scores, 30- and 90-day readmissions, and ED visits. Secondary outcomes were average milligram morphine equivalents per admission, hospital lengths of stay , and costs. ResultsThere was no significant difference in pain scores on postoperative days 0, 1, 2, or 3 (P = .77, .86, 0.08, and 0.40, respectively), 30- or 90- day readmissions (P = .527 and P = .374), ED visits (P = .129 and P = .108), milligram morphine equivalents utilizations (P = .194), or average hospital LOS (P = .348). We estimated a potential cost savings of $95 per patient and $155,800 over the course of the study. ConclusionLB was found to be noninferior to a pain pump, and the transition to this medication was associated with cost savings.

Palliative Sedation Therapy Practice Comparison - A Survey of Pediatric Palliative Care and Pain Management Specialists.

Context: Palliative sedation therapy (PST) can relieve suffering at end-of-life (EOL) in children with intolerable and refractory symptoms. However, updated and consistent guidance on PST practices are imperative. Objectives: We investigate current variations in clinical practice and PST implementation among pediatric palliative care (PPC) and pain management (PM) specialists. Methods: We distributed an IRB-exempt electronic anonymous survey via email through the Society of Pediatric Pain Medicine, and the American Academy of Hospice and Palliative Medicine. Survey responses were collated and descriptively reported. Results: Of 83 survey responses, the majority (75%) represented large academic children's hospitals. The distribution between PPC and pediatric pain management specialists' responses was 60% and 40%, respectively. Most respondents reported having designated pain management and/or palliative care teams (70% and 90%, respectively). Approximately half (48%) reported following an institutional PST protocol, most not requiring formal ethics consult (69%). Only 54% of respondents noted that the Do Not Resuscitate (DNR) order was required prior to PST initiation. PST was primarily utilized for children with oncologic diagnoses (76%). The primary and secondary medications of choice for PST implementation were reported to be opioids (39%) and benzodiazepines (36%) by pain management specialists, and benzodiazepines (52%) and barbiturates (28%) by palliative care specialists. Conclusions: Our study highlights the variability in the practice and implementation of PST. Further educational efforts are key for establishing PST practices and efficient protocol development.

Knowledge, Attitude, Practice and Perceived Barriers on Palliative Care Pain Management among the Healthcare Providers: A Single Centre Study

Healthcare providers’ knowledge and attitude on cancer pain control remain a debatable topic. The study aims to determine the knowledge, attitude, practice and perceived barriers among the healthcare providers in delivering effective analgesic in palliative care. A cross-sectional study was conducted among the specialists and post-graduate students from the medical and surgical programme using the convenience sampling method. A set of questionnaires related to the pain management in palliative patients was distributed. The questionnaire covered demographic characteristics, knowledge, attitudes, practice, and perceived barrier regarding cancer pain management. A total of 300 questionnaires were analysed with 75% response rate. About two-third (66.3%) of the respondents have knowledge deficit to prescribe opioids in pain management of palliative care patients. The medical specialty and lacking pain management training were significant factors associated with knowledge deficit. About half (48.3%) of the respondents thought that cancer pain therapy could be satisfactorily achieved as an outcome and 58.7% respondents admitting to practice daily pain assessment in patients with cancer. The main perceived barriers in managing pain for palliative patients were inadequate pain assessment (71.2%) and inadequate staff knowledge (53.6%). The knowledge differences among the different medical specialties and lack of pain management training have significantly impacted the pain management in palliative patients. A targeted educational strategy for pain management in palliative care patients is needed to improve physicians’ knowledge and clinical practice.

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

The Impact of P-Glycoprotein on Opioid Analgesics: What's the Real Meaning in Pain Management and Palliative Care?

Opioids are widely used in cancer and non-cancer pain management. However, many transporters at the blood-brain barrier (BBB), such as P-glycoprotein (P-gp, ABCB1/MDR1), may impair their delivery to the brain, thus leading to opioid tolerance. Nonetheless, opioids may regulate P-gp expression, thus altering the transport of other compounds, namely chemotherapeutic agents, resulting in pharmacoresistance. Other kinds of painkillers (e.g., acetaminophen, dexamethasone) and adjuvant drugs used for neuropathic pain may act as P-gp substrates and modulate its expression, thus making pain management challenging. Inflammatory conditions are also believed to upregulate P-gp. The role of P-gp in drug-drug interactions is currently under investigation, since many P-gp substrates may also act as substrates for the cytochrome P450 enzymes, which metabolize a wide range of xenobiotics and endobiotics. Genetic variability of the ABCB1/MDR1 gene may be accountable for inter-individual variation in opioid-induced analgesia. P-gp also plays a role in the management of opioid-induced adverse effects, such as constipation. Peripherally acting mu-opioid receptors antagonists (PAMORAs), such as naloxegol and naldemedine, are substrates of P-gp, which prevent their penetration in the central nervous system. In our review, we explore the interactions between P-gp and opioidergic drugs, with their implications in clinical practice.

"Here's What I Wish You Knew": A Qualitative Narrative Analysis of the Adolescent Sickle Cell Pain Experience

Background Bias, stigmatizing language, and social isolation are significant barriers to the optimal care of pain for adolescents and young adults (AYA) with sickle cell disease (SCD). Qualitative studies that include first-person narratives of SCD pain are underrepresented in outcomes research but provide valuable information for clinical education and community care models. Here, we present the interim analysis of an ongoing thematic research study that analyzes narrative experiences of AYA patients with SCD and their journeys- both in and out of the healthcare system- with chronic pain. Methods In this IRB-approved study, a single semi-structured interview is administered to patients ages 13-21 with sickle cell disease (Hemoglobin SS, SC, and SBeta0Thal genotypes) living in a mid-sized metropolitan center and receiving care at an academic teaching hospital. Patients are offered the opportunity to participate from inpatient units, ambulatory continuity clinics, and community advocacy groups. Interviews are conducted either in-person or remotely, recorded, transcribed, and independently checked for accuracy. The interview includes questions about coping with pain in medical and non-medical settings, interactions with the healthcare team, impacts of pain on social and community life, and opportunities to describe what patients wish family members, teachers, friends, and healthcare providers understood about living with SCD pain. Transcripts are analyzed for thematic coding by 2 independent coders using a deductive approach with latent textual analysis (Braun & Clarke, 2013). Codes are translated into themes by key-words-in-context and indigenous categorization methods (Ryan, 2011). Thematic coders are not members of the patients' clinical care teams, and patients do not provide interviews during acute pain crises. Results At the time of submission, 8 interviews were completed and analyzed. The median patient age was 17 years. Concordant coding revealed five primary themes: the relationship between acute and chronic pain, coping with rituals and cycles of care, the unpredictable nature of pain, navigating a biased healthcare system, and social isolation. The majority of patients detailed their experiences with intense, coexistent physical and emotional pain (6/8) that creates a pervasive sense of uncertainty and foreboding (4/8) in their lives. They described navigating a healthcare system that is difficult to understand, while experiencing doubts and dismissals of their pain from healthcare providers, particularly when making the transition to adult care (4/8). Lack of education and awareness about SCD in academic settings (5/8) and "missing out" on social milestones and norms (6/8) were cited as sources of isolation and emotional fatigue. Having a family member or community-based care advocate was viewed as a critical source of support within both the health system and community (4/8). Discussion and Future Directions This ongoing qualitative research study in adolescent and young adults with SCD provides narrative data about the lived experience of sickle cell pain from the patient perspective. Interim analysis suggests several locations in the care trajectory where reports of pain may be particularly vulnerable to bias: in healthcare settings for management of acute-onset pain crisis, in schools and other academic support settings where knowledge of SCD may be incomplete, and in the transition of care from pediatric to adult care models. Particularly during acute pain management and transition care experiences, patients describe the use of stigmatizing language- in conversation and in the electronic health record- that contribute to feelings of isolation, frustration, and emotional suffering. Results of this study are being used to inform community, pastoral, and school-based sickle cell education programs as well as medical education curricula aimed at reducing stigmatizing language. Results are also being used to develop standard criteria for sickle cell patient advocates, and to improve infrastructure for the integration of patient advocates into sickle cell care teams. Future research will measure the impact of patient participation in narrative research on clinical outcomes and attitudes toward engaging the healthcare system, both for routine care and potential SCD clinical research. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Beers Criteria Medications: To Give or Not Give

Your Patient's Brain| November 2022 Beers Criteria Medications: To Give or Not Give Michelle L. Humeidan, MD, PhD; Michelle L. Humeidan, MD, PhD Search for other works by this author on: This Site PubMed Google Scholar Daniel J. Cole, MD, FASA Daniel J. Cole, MD, FASA Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor November 2022, Vol. 86, 1–6. https://doi.org/10.1097/01.ASM.0000897296.74547.70 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Michelle L. Humeidan, Daniel J. Cole; Beers Criteria Medications: To Give or Not Give. ASA Monitor 2022; 86:1–6 doi: https://doi.org/10.1097/01.ASM.0000897296.74547.70 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: beers criteria, older adult Life is most delightful when it is on the downward slope, but has not yet reached the abrupt decline. – Seneca We have all encountered geriatric patients amid or on the precipice of an “abrupt decline” in health. Our aim as physicians and as a health care community is to not only extend those late-life years but also the quality of those years. Postoperative delirium may certainly incite an abrupt decline in a geriatric surgical patient and deserves our prioritized focus. This is a very common and potentially devastating, yet possibly preventable, postsurgical complication in older patients. Speed and quality of convalescence in geriatric surgical patients is multifactorial, and we have the ability to positively influence key contributors, including premedication, pain management, anesthetic management, and immediate postoperative care. Recently, evaluation of practice trends and perceptions toward postoperative delirium by anesthesiologists revealed that, despite having more information to guide us... You do not currently have access to this content.

Review of the Senegalese Military Emergency Medical Team (EMT) Deployment Following a Tanker Explosion in Freetown, Sierra Leone

Background/Introduction:In November 2021, a tanker exploded in Freetown, injuring and killing people. The WHO facilitated a seven-week first deployment of the Senegalese military to support the Ministry of Health (MOH) in providing care to the wounded in three referral hospitals.Objectives:Review the deployed team’s processes and outputs of medical care provided to burns patients.Method/Description:This is a cross-sectional After-Action Review (AAR) debrief of the deployment, including the WHO and MOH staff (n =14) in a virtual workshop. Six thematic areas: mobilization, deployment, coordination, case management activities, national capacity, and community acceptance were analyzed.Results/Outcomes:The WHO facilitated the team’s deployment and mobilized medical supplies and equipment whilst the MOH provided accommodation and logistics through collaboration. The team dispensed their functions with professionalism, adapted to the environment and available resources, and augmented the care provided by the available health workers. They offered additional care: reconstructive surgery, pain management, palliative and wound care, rehabilitation, physiotherapy, and psychosocial counselling, which were initially inadequate. 87 out of 155 patients were discharged home at the end, the national clinicians acquired additional skills, and the community appreciated the team. Despite being perceived as a weakness, the language barrier did not hinder the patient-doctor/nurse relationship or the provision of clinical care.Conclusion:This sub-regional response had significant benefits, including speed, political acceptability, and health context experience to support rapid and safe deployment. Mechanisms to facilitate rapid and quality-assured deployment of EMTs at regional and sub-regional levels in collaboration with WHO should be strengthened in region to support future responses.

Free-text analysis of general practice out-of-hours (GPOOH) use by people with advanced cancer: an analysis of coded and uncoded free-text data.

People with advanced cancer frequently use the GP out-of-hours (GPOOH) service. Considerable amounts of routine GPOOH data are uncoded. Therefore, these data are omitted from existing healthcare datasets. To conduct a free-text analysis of a GPOOH dataset, to identify reasons for attendance and care delivered through GPOOH to people with advanced cancer. An analysis of a GPOOH healthcare dataset was undertaken. It contained all coded and free- text information for 5749 attendances from a cohort of 2443 people who died from cancer in Tayside, Scotland, from 2013-2015. Random sampling methods selected 575 consultations for free-text analysis. Each consultation was analysed by two independent reviewers to determine the following: assigned presenting complaints; key and additional palliative care symptoms recorded in free text; evidence of anticipatory care planning; and free-text recording of dispensed medications. Inter-rater reliability concordance was established through Kappa testing. More than half of all coded reasons for attendance (n = 293; 51.0%) were 'other' or 'missing'. Free-text analysis demonstrated that nearly half (n = 284; 49.4%) of GPOOH attendances by people with advanced cancer were for pain or palliative care. More than half of GPOOH attendances (n = 325; 56.5%) recorded at least one key or additional palliative care symptom in free text, with the commonest being breathlessness, vomiting, cough, and nausea. Anticipatory care planning was poorly recorded in both coded and uncoded records. Uncoded medications were dispensed in more than one- quarter of GPOOH consultations. GPOOH delivers a substantial amount of pain management and palliative care, much of which is uncoded. Therefore, it is unrecognised and under-reported in existing large healthcare data analyses.

Survival rate of patients with combined hepatocellular cholangiocarcinoma receiving medical cannabis treatment: A retrospective, cohort comparative study

Background: Cholangiocarcinoma (CCA) incidence in Northeastern Thailand is very high and a major cause of mortality. CCA patients typically have a poor prognosis and short-term survival rate due to late-stage diagnosis. Thailand is the first Southeast Asian country to approve medicinal cannabis treatment, especially for palliative care with advanced cancer patients. Methods: A retrospective cohort comparative study of survival rates among 491 newly diagnosed advanced CCA patients was carried out between September 1, 2019, and June 30, 2021. A total of 404 patients were in the standard palliative care pain management treatment group (ST), and 87 were in the medicinal cannabis treatment group (CT). Patients with CCA were recruited from four tertiary hospitals and two secondary hospitals in five provinces of Northeast Thailand. The cumulative survival rates were calculated by the Kaplan-Meier method, and independent prognostic factors were investigated using Cox regression. Results: For ST patients, there was a total follow-up time of 790 person-months, with a mortality rate of 48.35/100 person-months. For CT patients the total follow-up time was 476 person-months, with mortality rate of 10.9/ 100 person-months. The median survival time after registration at a palliative clinic was 0.83 months (95% CI: 0.71–0.95) for ST and 5.66 months (95% CI: 1.94–9.38) for CT. Multivariate analysis showed that CT treatment protocol was associated with a significantly better survival (P value &lt;0.001; median time of CT, 5.66 months (95% CI: 1.94–9.38); median time of ST, 0.83 months (95% CI: 0.71–0.95). Therefore, CT had a reduced probability of dying from the disease (HRadj., 0.28 (95% CI: 0.20–0.37) Conclusions: The medical cannabis increased overall survival rates among CCA patients.

Use of the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to guide iterative adaptations: Applications, lessons learned, and future directions.

Implementation science frameworks have been used widely for planning and evaluation, but seldom to guide adaptations during program implementation. There is great potential for these frameworks to be used to inform conceptual and data-driven decisions about adaptations. We summarize recent applications using Iterative RE-AIM to capture and guide adaptations. Iterative RE-AIM can be repeated at multiple time points customized to each project and involves the following activities: identification of key implementation partners; rating importance of and progress on each RE-AIM dimension (reach, effectiveness, adoption, implementation, and maintenance); use of summary data on ratings to identify one or two RE-AIM dimensions for adaptations and implementation strategies; and evaluation of progress and impact of adaptations. We summarize recent and ongoing Iterative RE-AIM applications across multiple care coordination and pain management projects within the Veterans Health Administration, a hypertension control trial in Guatemala, a hospital-based lung ultrasound implementation pilot, and a colorectal cancer screening program in underserved communities. Iterative RE-AIM appears feasible, helpful, and broadly applicable across diverse health care issues, interventions, contexts, and populations. In general, the RE-AIM dimension showing the largest gap between importance and progress has been Reach. The dimensions most frequently selected for improvement have been Reach and Implementation. We discuss commonalities, differences and lessons learned across these various applications of Iterative RE-AIM. Challenges include having objective real time data on which to make decisions, having key implementation staff available for all assessments, and rapidly scoring and providing actionable feedback. We discuss print and online resources and materials to support Iterative RE-AIM. The use of Iterative RE-AIM to guide and support understanding of adaptations has proven feasible across diverse projects and in multiple case studies, but there are still questions about its strengths, limitations, essential components, efficiency, comparative effectiveness, and delivery details. Future directions include investigating the optimal frequency and timing for iterative applications; adding contextual assessments; developing more continuous and rapid data on which to make adaptation decisions; identifying opportunities to enhance health equity; and determining the level of facilitation that is most cost-effective.

Death as "benefit" in the context of non-voluntary euthanasia.

I offer a principled objection to arguments in favour of legalizing non-voluntary euthanasia on the basis of the principle of beneficence. The objection is that the status of death as a benefit to people who cannot formulate a desire to die is more problematic than pain management care. I ground this objection on epistemic and political arguments. Namely, I argue that death is relatively more unknowable, and the benefits it confers more subjectively debatable, than pain management. I am not primarily referring to the claim that it is difficult to make comparisons between live and post-mortem states, but rather to the fact that it is epistemically and metaphysically problematic to impute a "life-worse-than-death" or a state of "suffering-calling-for-death" to people who cannot subjectively wish to die, as though this kind of suffering were a medically observable fact rather than a belief- and value-laden notion. On the contrary, people enduring similar causes of pain may have different experiences of suffering and views on how it affects the worthwhileness of their existence or the desirability of death or of continuing their lives. The projection of a "suffering-calling-for-death" onto infants or people with severe intellectual disabilities may not be indefensible, but it is more controversial than judging that pain management will improve their well-being from the perspective of beneficence. My argument also relies on our society's liberal endeavour to avoid endorsing unverifiable beliefs about life and death or controversial conceptions of the good life. My goal is not to suggest we should not attend the suffering of cognitively disabled people. On the contrary, I only cast doubt on too quick an assumption that ending their lives is the best way of caring for them, when robust palliative treatments are available. Moreover, I express the concern that a lack of attention to distinctions between "pain-calling-for-relief" and "suffering-calling-for-death" may be based on ableist projections and assumptions. I conclude that it is imperative to continue research into the nature of pain and suffering experienced by individuals with mental or cognitive impairments preventing them from expressing autonomous wishes about the kind of treatment that would most benefit them.

A qualitative interview study of GPs' experiences of prescribing opioid medication for chronic pain.

Prescribing of opioid medication has increased over the past 20 years. Most occurs in primary care for chronic pain. There is little evidence that these drugs are effective for this indication. There are concerns about the continuing prescribing of opioids, particularly in the long term and at high doses. To explore GPs' experiences of prescribing opioids, problems encountered, and factors militating against good prescribing practice. Qualitative interviews with GPs who prescribe opioids in primary care in North East Wales. Semi-structured interviews with 20 GPs were transcribed and subjected to thematic analysis utilising the framework approach. Participating GPs identified a range of problems associated with prescribed opioids. They were concerned about limited effectiveness of the drugs and what they perceived as addiction resulting from their use. They identified healthcare system factors that were obstacles to good prescribing practice such as lack of continuity of care, poor access to secondary care pain management support, and, most importantly, constant time pressure. They reported adverse effects on relationships with patients. Unrealistic expectations that pain could be eliminated resulted in pressure to prescribe stronger drugs and increased doses. It led to difficulties in establishing and maintaining trust and in persuading patients to agree to, and to carry out, dose reductions. Themes emerging from this study suggest that GPs lack appropriate control of opioid prescribing. There is a need to develop methods to help patients and GPs to work together to manage chronic pain safely.

Child Life-Facilitated Coping Support With Adult Patients Undergoing Cardiac Surgery: A Pilot Program

Purpose With little empirically known about the translation of child life services into adult patient populations, the purpose of this pilot project was to explore the feasibility of offering non-pharmacological child life support to adult cardiac surgery patients. Specifically, the aims were to explore the practical feasibility of extending and integrating child life care into this adult healthcare service, as well as the preliminary perceptions of adult patients who participated in the pilot program. Methods A pilot program was designed to provide child life care to an initial group of 11 adult patients undergoing cardiac surgery at a large academic medical center in the midwestern United States. Patients were randomized into a control condition consisting of standard pre- and post-cardiac surgery care or an intervention condition that involved five coping support interactions with a Certified Child Life Specialist serving as a “comfort coach.” Patient perceptions were gathered via telephone survey at the conclusion of the study, and insights into practical feasibility were gathered from associated study staff, clinical team members, and leadership to understand stakeholder experiences with the program. Results According to the feedback gathered, it appears that Certified Child Life Specialists can be clinically and practically integrated into adult cardiac surgery populations without patient care disruption. Additionally, feedback from program participants suggested that child life services were appreciated and seen as a beneficial component of the cardiac surgery experience. Conclusion This study suggests that it is both possible and practical to extend non-pharmacological coping support from Certified Child Life Specialists into adult cardiac surgery care, and this appears to be a desirable service from patient and staff perspectives. Future research is needed to evaluate the effects of child life services on specific outcomes in this population specific to anxiety, pain management and overall patient experience and care satisfaction.