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Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: Pain is a multifaceted experience shaped by various factors including context of pain, previous life events, and ongoing ethnocultural circumstances. Moreover, the definition of pain is inconsistent across cultures. Western medicine views physical pain (e.g., associated with a bone fracture) and nonphysical mental pain (e.g., depression) as two distinct conditions. Indigenous perspectives are often more wholistic, encompassing mental, spiritual, emotional, and physical hurt. The subjective nature of pain invites ample opportunity for discrimination in both its assessment and management. As such, it is important to consider Indigenous perspectives of pain in research and clinical practice. To investigate which aspects of Indigenous pain knowledge are currently considered by Western research, we conducted a scoping review of the literature on pain in Indigenous Peoples of Canada., Source: In June 2021, we searched nine databases and downloaded 8,220 papers after removal of duplicates. Two independent reviewers screened abstracts and full-text articles., Principle Findings: Seventy-seven papers were included in the analysis. Using grounded theory, five themes emerged: pain measures/scales (n = 7), interventions (n = 13), pharmaceuticals (n = 17), pain expression/experiences (n = 45), and pain conditions (n = 70)., Conclusion: This scoping review shows that there is a paucity of research on pain measurement in Indigenous Peoples of Canada. This finding is concerning in light of numerous studies reporting that Indigenous Peoples experience their pain as ignored, minimized, or disbelieved. Furthermore, a clear disconnect emerged between pain expression in Indigenous Peoples and assessment in medical professionals. We hope that this scoping review will serve to translate current knowledge to other non-Indigenous academics and to initiate meaningful collaboration with Indigenous partners. Future research led by Indigenous academics and community partners is critically needed to better address pain needs in Canada., (© 2023. Canadian Anesthesiologists' Society.)

Critical loads (CLs) of atmospheric deposition for nitrogen (N) and sulfur (S) are used to support decision making related to air regulation and land management. Frequently, CLs are calculated using empirical methods, and the certainty of the results depends on accurate representation of underlying ecological processes. Machine learning (ML) models perform well in empirical modeling of processes with non-linear characteristics and significant variable interactions. We used bootstrap ensemble ML methods to develop CL estimates and assess uncertainties of CLs for the growth and survival of 108 tree species in the conterminous United States. We trained ML models to predict tree growth and survival and characterize the relationship between deposition and tree species response. Using four statistical methods, we quantified the uncertainty of CLs in 95 % confidence intervals (CI). At the lower bound of the CL uncertainty estimate, 80 % or more of tree species have been impacted by nitrogen deposition exceeding a CL for tree survival over >50 % of the species range, while at the upper bound the percentage is much lower (<20 % of tree species impacted across >60 % of the species range). Our analysis shows that bootstrap ensemble ML can be effectively used to quantify critical loads and their uncertainties. The range of the uncertainty we calculated is sufficiently large to warrant consideration in management and regulatory decision making with respect to atmospheric deposition., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Exposure to air pollution is associated with acute pediatric asthma exacerbations, including reduced lung function, rescue medication usage, and increased symptoms; however, most studies are limited in investigating longitudinal changes in these acute effects. This study aims to investigate the effects of daily air pollution exposure on acute pediatric asthma exacerbation risk using a repeated-measures design. Methods: We conducted a panel study of 40 children aged 8−16 years with moderate-to-severe asthma. We deployed the Biomedical REAI-Time Health Evaluation (BREATHE) Kit developed in the Los Angeles PRISMS Center to continuously monitor personal exposure to particulate matter of aerodynamic diameter < 2.5 µm (PM2.5), relative humidity and temperature, geolocation (GPS), and asthma outcomes including lung function, medication use, and symptoms for 14 days. Hourly ambient (PM2.5, nitrogen dioxide (NO2), ozone (O3)) and traffic-related (nitrogen oxides (NOx) and PM2.5) air pollution exposures were modeled based on location. We used mixed-effects models to examine the association of same day and lagged (up to 2 days) exposures with daily changes in % predicted forced expiratory volume in 1 s (FEV1) and % predicted peak expiratory flow (PEF), count of rescue inhaler puffs, and symptoms. Results: Participants were on average 12.0 years old (range: 8.4−16.8) with mean (SD) morning %predicted FEV1 of 67.9% (17.3%) and PEF of 69.1% (18.4%) and 1.4 (3.5) puffs per day of rescue inhaler use. Participants reported chest tightness, wheeze, trouble breathing, and cough symptoms on 36.4%, 17.5%, 32.3%, and 42.9%, respectively (n = 217 person-days). One SD increase in previous day O3 exposure was associated with reduced morning (beta [95% CI]: −4.11 [−6.86, −1.36]), evening (−2.65 [−5.19, −0.10]) and daily average %predicted FEV1 (−3.45 [−6.42, −0.47]). Daily (lag 0) exposure to traffic-related PM2.5 exposure was associated with reduced morning %predicted PEF (−3.97 [−7.69, −0.26]) and greater odds of “feeling scared of trouble breathing” symptom (odds ratio [95% CI]: 1.83 [1.03, 3.24]). Exposure to ambient O3, NOx, and NO was significantly associated with increased rescue inhaler use (rate ratio [95% CI]: O3 1.52 [1.02, 2.27], NOx 1.61 [1.23, 2.11], NO 1.80 [1.37, 2.35]). Conclusions: We found significant associations of air pollution exposure with lung function, rescue inhaler use, and “feeling scared of trouble breathing.” Our study demonstrates the potential of informatics and wearable sensor technologies at collecting highly resolved, contextual, and personal exposure data for understanding acute pediatric asthma triggers.

There is strong evidence that psychosocial variables, including pain catastrophizing, influence parental and child ratings of pain, pain expression, and long-term outcomes among children with chronic pain. The role of these factors among children who have communication deficits due to cerebral palsy (CP) and other intellectual and developmental disabilities is currently unclear. In this study, parental pain catastrophizing was assessed before intrathecal baclofen (ITB) pump implantation for spasticity management in 40 children and adolescents with CP, aged 4 to 24 years. Pain was assessed before and after surgery with two methods: a parent-reported pain interference scale, and behavioral pain signs during a standardized range of motion exam. Linear mixed models with clinical/demographic factors and scores from the Pain Catastrophizing Scale for Parents (PCS-P), and child spoken language ability as predictors and the pain variables as the outcomes were implemented. On average, both pain outcomes improved after surgery. Only child spoken language ability predicted change in behavioral reactivity scores, with children with phrase speech showing an increase in reactivity at follow-up compared to pre-surgery levels, on average. A significant interaction between PCS-P scores and spoken language ability on change in pain interference scores over time showed that dyads with children with phrase speech whose parents reported high PCS-P scores reported the least improvement in pain interference at follow-up. Due to the preliminary nature of the study, future work is needed to investigate the parental behaviors that mediate the relationships between parental catastrophizing and pain outcomes in this population., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Byiers, Roberts, Burkitt, Merbler, Craig and Symons.)

Objective: Pain assessment in children continues to challenge clinicians and researchers, as subjective experiences of pain require inference through observable behaviors, both involuntary and deliberate. The presented approach supplements the subjective self-report-based method by fusing electrodermal activity (EDA) recordings with video facial expressions to develop an objective pain assessment metric. Such an approach is specifically important for assessing pain in children who are not capable of providing accurate self-pain reports, requiring nonverbal pain assessment. We demonstrate the performance of our approach using data recorded from children in post-operative recovery following laparoscopic appendectomy. We examined separately and combined the usefulness of EDA and video facial expression data as predictors of children's self-reports of pain following surgery through recovery. Findings indicate that EDA and facial expression data independently provide above chance sensitivities and specificities, but their fusion for classifying clinically significant pain vs. clinically nonsignificant pain achieved substantial improvement, yielding 90.91% accuracy, with 100% sensitivity and 81.82% specificity. The multimodal measures capitalize upon different features of the complex pain response. Thus, this paper presents both evidence for the utility of a weighted maximum likelihood algorithm as a novel feature selection method for EDA and video facial expression data and an accurate and objective automated classification algorithm capable ofdiscriminating clinically significant pain from clinically nonsignificant pain in children.

Pain is a universal experience, but it has been challenging to adequately define. The revised definition of pain recently published by the International Association for the Study of Pain addressed important shortcomings of the previous version; however, it remains narrow in its focus on sensory and emotional features of pain, failing to capture the substantial roles of cognitive and social core components of the experience and their importance to advances in pain management. This paper reviews evidence and theoretical models for the significant role social and cognitive factors play in pain experience and we argue that without explicit recognition of these core components in the definition, significant nuances are lost at a cost to understanding and clinical management of pain. A focus on sensory and emotional features perpetuates biomedical interventions and research, whereas recognition of cognitive and social features supports a multidimensional model of pain, advances in interdisciplinary care, and the benefits of cognitive behavioral therapy and self-management interventions. We also explore the six Key Notes that accompany the new definition of pain, discuss their application to the understanding of pain in childhood, and, in doing so, further explore social and cognitive implications. Considerations are also described for assessment and treatment of pain in pediatric populations., Competing Interests: The authors confirm that they have no conflicts of interest to declare., (© 2021 The Authors. Paediatric and Neonatal Pain published by John Wiley & Sons Ltd.)

Objective: For people who experience social inequities and structural violence, pain and related care are inexorably linked to experiences of injustice and stigma. The purpose of this study was to examine in greater depth the experiences of pain and discrimination and stigma across diverse marginalized communities in order to recommend equity-oriented healthcare approaches., Methods: This community-based qualitative study reports on four focus groups that included 36 people living with pain. All participants identified with one of three groups known to experience high levels of inequities and structural violence including an Indigenous group, a LGBTQ2S group, and two newcomer and refugee groups., Results: Pain was entangled with and shaped by: social locations and identities, experiences of violence, trauma and related mental health issues, experiences of discrimination, stigma and dismissal, experiences of inadequate and ineffective health care, and the impacts of these intersecting experiences., Conclusions: Equity-oriented responses to chronic pain would recognize pain not only as a biomedical issue but as a social justice issue. The EQUIP Framework is an approach to integrating trauma- and violence-informed care; culturally-safe care; and harm reduction in health care that may hold promise for being tailored to people experiencing pain and social marginalization.

Albuquerque/Bernalillo County, New Mexico, is currently in attainment of the 2015 National Ambient Air Quality Standard (NAAQS) for ozone (70 ppb), but its ozone design values have increased in recent years. Air quality and source apportionment modeling with the Comprehensive Air Quality Model with Extensions (CAMx) was conducted for Albuquerque/Bernalillo County to develop a refined understanding of ozone source apportionment in the region, estimate ozone concentrations in the year 2025 based on projected changes in anthropogenic emissions, and evaluate the sensitivity of future ozone concentrations to various changes in local and non-local emissions. The study focused on two ozone episodes during June and July 2017 when 8-hr average ozone concentrations were greater than 70 ppb. Based on the modeling results, ozone during the June 2017 episode was found to be driven largely by contributions from non-local and regional emissions, whereas ozone during the July 2017 episode was driven more strongly by local emissions from within Albuquerque/Bernalillo County. On high ozone days, anthropogenic emissions from within Albuquerque/Bernalillo County contributed between 8% and 19% (6-14 ppb) of total ozone. Half of this local ozone contribution was from on-road mobile sources. Fire emissions contributed as much as 2 ppb of ozone on a given day. Contributions from large power plants in New Mexico were as large as 1 ppb on a given day but less than 0.5 ppb on most days. Modeled ozone concentrations in Albuquerque/Bernalillo County were also sensitive to emissions from oil and gas emissions in New Mexico. If projected emission reductions by 2025 materialize, these reductions could reduce future peak 8-hr average ozone concentrations by as much as 3-4% compared to 2017 values. Implications: The results of this study have important implications for air quality management in Albuquerque/Bernalillo County. Ozone in Albuquerque/Bernalillo County is the result of local and non-local emissions, is impacted by wildfires, and is sensitive to statewide oil and gas emissions. The magnitude of modeled contributions from anthropogenic emissions within Albuquerque/Bernalillo County is strongly influenced by meteorological conditions, transport pathways, and the presence of wildfire. This modeling is important for understanding the potential effectiveness of local emission controls in Albuquerque/Bernalillo County, and can serve as a basis for testing future regional and local emission control options.

My research and clinical career followed a trajectory of increasing appreciation for the importance of social factors as determinants of pain experience and expression. The social contexts of children's lives determine whether infants and children are exposed to pain, how socialization in family and ethnocultural contexts lead to pain as a social experience, comprised of thoughts and feelings as well as sensory input, how others shape pain experience and expression, less so for automatic/reflexive features than purposeful representations, and how other's appraisals of children's pain reflect the observer's unique background and capacities for intervening in the child's interests. A greater understanding of the social dimensions of pain, as reflected in the social communication model of pain, would support innovation of psychological and social interventions., (© 2020 The Authors. Paediatric and Neonatal Pain published by John Wiley & Sons Ltd.)

Competing Interests: The authors have no conflicts of interest to declare.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Background : The 2018 Global Year for Excellence in Pain Education, an initiative of the International Association for the Study of Pain, brought worldwide attention to the need for education that crosses narrow disciplinary boundaries, addresses up-to-date research methods and findings, and encourages teamwork among trainees and mentors at different levels of training and with different perspectives. Aims : This commentary describes the development of Pain in Child Health (PICH), an interdisciplinary training program for researchers in pediatric pain at the undergraduate, graduate, and postdoctoral levels of training. Methods : Based on documentation of the structure, training processes, leadership, and membership of PICH, we outline its organization and its challenges and accomplishments over the first 12 years of its growth into a well-known international program. Results and Conclusions : Pain in Child Health began as a Strategic Training Initiative of the Canadian Institutes of Health Research in 2002 and developed into an international research training consortium featuring cross-site and cross-discipline mentorship and collaboration. PICH trainees and alumni have contributed extensively to the current scientific literature on children's pain. PICH could serve as a possible model for training and mentorship in other specialized health research domains within and outside thestudy of pain., Competing Interests: No potential conflict of interest was reported by the authors., (© 2019 The Author(s). Published with license by Taylor & Francis Group, LLC.)

The current study examined youths' and their parents' perceptions concerning participation in an investigation of spontaneous and induced pain during recovery from laparoscopic appendectomy. Youth (age range 5-17 years) and their parents independently completed surveys about their study participation. On a 0 (very negative) -to-10 (very positive) scale, both parents 9.4(1.3) [mean(SD)] and youth 7.9(2.4) rated their experience as positive. Among youth, experience ratings did not differ by pain severity and survey responses did not differ by age. Most youth (83%) reported they would tell another youth to participate. Ethical issues regarding instigation of pain in youth for research purposes are examined., Competing Interests: Potential Conflicts of Interest: The authors have no conflicts of interest relevant to this article to disclose.

Diverse behavioral cues have been proposed to be useful cues in infant pain assessment, but there is a paucity of evidence on the basis of formal psychometric evaluation to establish their validity for this purpose. We aimed to examine 2 widely used coding systems, the Neonatal Facial Coding System (NFCS) and the Modified Behavior Pain Scale (MBPS), by examining their factor structures with confirmatory factor analysis using a large archival data set. The results indicated that an item-reduced NFCS scale with 3 items produced a 1-factor pain model that maintained the good psychometric properties of the 7-item scale. In addition, it was found that MBPS also has challenging internal consistency, with items that are weakly correlated as well as highly redundant. One item of the MBPS may be able to capture the construct of pain equally well or potentially improve its psychometric properties. Redefinition of the MBPS with cry as a sole indicator was suggested. This analysis provides 2 new iterations of the NFCS and MBPS that improve construct validity and internal consistency. These shorter versions also improve the feasibility of both measures and increase their potential for clinical use because less time is required for their administration., Perspective: This article presents new iterations of the NFCS and MBPS scales. These revised measures improve the internal consistency of the measures, feasibility of use of the tools in research settings, and the efficiency of the coding process. The revised tools could also improve the feasibility of coding within clinical settings., (Copyright © 2018 The American Pain Society. Published by Elsevier Inc. All rights reserved.)

Objective pain assessment is required for appropriate pain management in the clinical setting. However, clinical gold standard pain assessment is based on subjective methods. Automated pain detection from physiological data may provide important objective information to better standardize pain assessment. Specifically, electrodermal activity (EDA) can identify features of stress and anxiety induced by varying pain levels. However, notable variability in EDA measurement exists and research to date has demonstrated sensitivity but lack of specificity in pain assessment. In this paper, we use timescale decomposition (TSD) to extract salient features from EDA signals to identify an accurate and automated EDA pain detection algorithm to sensitively and specifically distinguish pain from no-pain conditions.

Accurately determining pain levels in children is difficult, even for trained professionals and parents. Facial activity provides sensitive and specific information about pain, and computer vision algorithms have been developed to automatically detect Facial Action Units (AUs) defined by the Facial Action Coding System (FACS). Our prior work utilized information from computer vision, i.e., automatically detected facial AUs, to develop classifiers to distinguish between pain and no-pain conditions. However, application of pain/no-pain classifiers based on automated AU codings across different environmental domains results in diminished performance. In contrast, classifiers based on manually coded AUs demonstrate reduced environmentally-based variability in performance. In this paper, we train a machine learning model to recognize pain using AUs coded by a computer vision system embedded in a software package called iMotions. We also study the relationship between iMotions (automatically) and human (manually) coded AUs. We find that AUs coded automatically are different from those coded by a human trained in the FACS system, and that the human coder is less sensitive to environmental changes. To improve classification performance in the current work, we applied transfer learning by training another machine learning model to map automated AU codings to a subspace of manual AU codings to enable more robust pain recognition performance when only automatically coded AUs are available for the test data. With this transfer learning method, we improved the Area Under the ROC Curve (AUC) on independent data from new participants in our target domain from 0.67 to 0.72.

Accurately determining pain levels in children is difficult, even for trained professionals and parents. Facial activity and electro- dermal activity (EDA) provide rich information about pain, and both have been used in automated pain detection. In this paper, we discuss preliminary steps towards fusing models trained on video and EDA features respectively. We compare fusion models using original video features and those using transferred video features which are less sensitive to environmental changes. We demonstrate the benefit of the fusion and the transferred video features with a special test case involving domain adaptation and improved performance relative to using EDA and video features alone.

Some pain behaviors appear to be automatic, reflexive manifestations of pain, whereas others present as voluntarily controlled. This project examined whether this distinction would characterize pain cues used in observational pain measures for children aged 4-12. To develop a comprehensive list of cues, a systematic literature search of studies describing development of children's observational pain assessment tools was conducted using MEDLINE, PsycINFO, and Web of Science. Twenty-one articles satisfied the criteria. A total of 66 nonredundant pain behavior items were identified. To determine whether items would be perceived as automatic or controlled, 277 research participants rated each on multiple scales associated with the distinction. Factor analyses yielded three major factors: the "Automatic" factor included items related to facial expression, paralinguistics, and consolability; the "Controlled" factor included items related to intentional movements, verbalizations, and social actions; and the "Ambiguous" factor included items related to voluntary facial expressions. Pain behaviors in observational pain scales for children can be characterized as automatic, controlled, and ambiguous, supporting a dual-processing, neuroregulatory model of pain expression. These dimensions would be expected to influence judgments of the nature and severity of pain being experienced and the extent to which the child is attempting to control the social environment., Competing Interests: The authors declare that there is no conflict of interests regarding the publication of this paper.

Background: Sensitive and responsive maternal caregiving behavior strengthens infant self-regulatory capacities (HL), but this regulatory role may be diminished in some mothers with second-trimester prenatal exposure to depression and/ or anxiety (MDA). This study examined maternal and infant behavior during infant heel lance (HL) when mothers had or did not have MDA. Ethological methods and micro-analytic approaches capable of distinguishing and comparing time-based patterning in maternal and infant behavior were used to clarify biological mechanisms, such as MDA, that may underlie observed behavior. Aims were to examine group differences in caregiving behavior between mothers with and without MDA 5 min Pre-HL and 5 min Post-H, and relationships between MDA, maternal caregiving behavior and infant pain behavior self-regulation, concurrently., Methods: At second trimester, mothers were assessed for symptoms of mild-severe depression or anxiety. Mothers whose scores exceeded predetermined cut-off scores on one or more of the mental health measures were allocated to the MDA-exposure group, those below to the non-MDA-exposure group. Reliable observers, blinded to MDA status and study phases, coded video records of the caregiving behavior of each study mother for the full duration of the 5 min Pre-HL and 5 min Post-HL study phases. Group differences and associations between mean measures of maternal mental health scores, time-based measures of maternal behavior, and time-based measures of infant pain behavior regulation (previously coded) were concurrently analyzed using comparative and correlational statistics., Results: MDA-exposed mothers spent significantly more time not embracing, engaging or responding to infant cues than maternal controls Pre-HL and Post-HL. MDA was associated with atypical maternal caregiving behavior, which in turn was related to atypical infant pain behavior self-regulation during and after the HL., Conclusion: Our findings have implication for practice. We recommend inclusion of mothers with MDA and their infants in interventions that strengthen the early mother-infant interaction and mother's regulatory caregiving role. MDA and maternal caregiving behavior must be considered in future infant pain studies to examine if they confound effectiveness of mother driven caregiving interventions for neonatal pain. We highlight the importance of examining maternal mental health throughout the perinatal and postnatal trajectory, and particularly the newborn period.

Background: Current pain assessment methods in youth are suboptimal and vulnerable to bias and underrecognition of clinical pain. Facial expressions are a sensitive, specific biomarker of the presence and severity of pain, and computer vision (CV) and machine-learning (ML) techniques enable reliable, valid measurement of pain-related facial expressions from video. We developed and evaluated a CVML approach to measure pain-related facial expressions for automated pain assessment in youth., Methods: A CVML-based model for assessment of pediatric postoperative pain was developed from videos of 50 neurotypical youth 5 to 18 years old in both endogenous/ongoing and exogenous/transient pain conditions after laparoscopic appendectomy. Model accuracy was assessed for self-reported pain ratings in children and time since surgery, and compared with by-proxy parent and nurse estimates of observed pain in youth., Results: Model detection of pain versus no-pain demonstrated good-to-excellent accuracy (Area under the receiver operating characteristic curve 0.84-0.94) in both ongoing and transient pain conditions. Model detection of pain severity demonstrated moderate-to-strong correlations (r = 0.65-0.86 within; r = 0.47-0.61 across subjects) for both pain conditions. The model performed equivalently to nurses but not as well as parents in detecting pain versus no-pain conditions, but performed equivalently to parents in estimating pain severity. Nurses were more likely than the model to underestimate youth self-reported pain ratings. Demographic factors did not affect model performance., Conclusions: CVML pain assessment models derived from automatic facial expression measurements demonstrated good-to-excellent accuracy in binary pain classifications, strong correlations with patient self-reported pain ratings, and parent-equivalent estimation of children's pain levels over typical pain trajectories in youth after appendectomy., (Copyright © 2015 by the American Academy of Pediatrics.)

Objectives: Assessing pain in young children requires astute judgment by observers. Multidimensional observational scales for pediatric pain contribute by providing behavioral cues believed to characterize pain in children; yet, few measurement items have undergone rigorous psychometric evaluation. This is the case with facial expression, which has been widely recognized as the most sensitive and specific nonverbal indicator of pain. The criteria for identifying facial expressions of pain differ substantially across scales and are frequently inconsistent with empirical descriptions., Materials and Methods: The present study compared observer ratings of children's (aged 1 to 6 y, inclusive) videotaped postoperative pain reactions using the facial activity items from 6 widely used pediatric pain assessment scales and an anatomically based and empirically validated measure, the Child Facial Coding System. We hypothesized that facial expression items that did not correspond to empirical descriptions would lead to less reliable and divergent pain estimates. Intercoder reliability, criterion validity (empirical and convergent), content validity, and face validity were examined., Results: Findings supported hypotheses and indicated that variation in cues proposed for assessing facial expression led to widely ranging scores that could be insensitive to differences in children's pain intensity., Discussion: The facial items varied considerably in coder judgment reliability as well as criterion (empirical and convergent), content, and face validity. Observational scales should provide behavioral cues that correspond to empirical descriptions of the facial expression of pain.

Chronic pain is highly prevalent in the ageing population. Individuals with neurological disorders such as dementia are susceptible patient groups in which pain is frequently under-recognised, underestimated, and undertreated. Results from neurophysiological and neuroimaging studies showing that elderly adults are particularly susceptible to the negative effects of pain are of additional concern. The inability to successfully communicate pain in severe dementia is a major barrier to effective treatment. The systematic study of facial expressions through a computerised system has identified core features that are highly specific to the experience of pain, with potential future effects on assessment practices in people with dementia. Various observational-behavioural pain assessment instruments have been reported to be both reliable and valid in individuals with dementia. These techniques need to be interpreted in the context of observer bias, contextual variables, and the overall state of the individual's health and wellbeing., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Mononuclear invasion of Langerhans islet and the ensuing insulitis triggers signal-transduction for the autoimmune mediated pancreatic beta-cell (β-cell) apoptosis that severely disrupts insulin production resulting in hyperglycemia associated with Type-1 diabetes (T1DM). Today extensive global research is being conducted to eliminate the need for insulin, and even prevent or find a cure for T1DM. The multifactorial combination of autoimmune dysfunction, Langerhans islet hypoxia, and bio-chemical disruption are seen to be contributory factors for β-cell destruction and the consequential disruption to insulin production. Regeneration of β-cells back to physiological levels may restore homeostatic insulin levels, reversing T1DM. Evidence suggests that there are still functioning pancreatic β-cells even in long standing T1DM providing the potential for their regeneration. Although the exact mechanism of extracorporeal shockwaves (ESW) is yet to be fully elucidated, it is seen to influence a complex spectrum of bio-chemical, cellular and neuronal functions (i.e. suppression of pro-inflammatory immune response, improved tissue hemodynamics, anti-microbial properties, and the induction of progenitor cell expression including proangiogenic factors and nitric oxide syntheses). The rationale for the use of ESW as a therapeutic modality in this instance is attributed to its restorative properties and safety profile demonstrated in urology, cardiology, chronic wounds, osteogenesis, complex pain syndromes, and tendinopathies. ESW may restore autoimmune homeostasis creating a suitable environment for pancreatic β-cell proliferation which in-turn may significantly increase or normalize endogenous insulin secretion reducing or totally eliminating dependency of exogenous insulin. The devastating complications, morbidity and mortality associated with T1DM warrants the exploration of homeostatic autoimmune restorative treatment (HART) modalities that may partially or fully reverse this disease condition. We present our hypothesis discussing ESW as a potential homeostatic autoimmune restorative treatment (HART) option for T1DM., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background and Objectives: Pain in Child Health (PICH) is a transdisciplinary, international research training consortium. PICH has been funded since 2002 as a Strategic Training Initiative in Health Research of the Canadian Institutes of Health Research, with contributions from other funding partners and the founding participation of five Canadian universities. The goal of PICH has been to create a community of scholars in pediatric pain to improve child health outcomes., Methods: Quantitative analyses enumerated PICH faculty, trainees, training activities and scientific outputs. Interviews with PICH stakeholders were analyzed using qualitative methods capturing perceptions of the program's strengths, limitations, and opportunities for development and sustainability., Results: PICH has supported 218 trainee members from 2002 through 2013, from 14 countries and more than 16 disciplines. The faculty at the end of 2013 comprised nine co-principal investigators, 14 Canadian coinvestigators, and 28 Canadian and international collaborators. Trainee members published 697 peer-reviewed journal articles on pediatric pain through 2013, among other research dissemination activities including conference presentations and webinars. Networks have been established between new and established researchers across Canada and in 13 other countries. Perceptions from stakeholders commended PICH for its positive impact on the development of pediatric pain researchers. Stakeholders emphasized skills and abilities gained through PICH, the perceived impact of PICH training on this research field, and considerations for future training in developing researchers in pediatric pain., Conclusions: PICH has been successfully developing highly qualified health research personnel within a Canadian and international community of pediatric pain scholarship.

Objectives: Capacities for self-regulation that influence infant adaptation to noxious stimulation require investigation of changes in behavior over time. Prenatal exposure to maternal depression and anxiety (MDA) has been linked to altered infant pain reactivity; however, findings are inconclusive about MDA dynamic impacts on recovery. This study quantified the temporal profile of behavioral response and recovery to routine heel lance (HL) of infants with and without prenatal-MDA exposure. Aims were to examine whether MDA were associated with alterations in time-based measures of infant behavior and sequential patterning in pain expression., Materials and Methods: Videotaped facial, body, and cry behaviors of 21 full-term newborns were coded second-by-second for the duration of HL (baseline, HL, Post-HL) using validated behavioral coding systems. Mean heart rate and proportion of time infants spent exhibiting behavioral measures were compared between infant groups and over subphases of HL. Simple regressions, latency, and Yule-Q measures of effect size examined which behaviors were predicted by prenatal-MDA and magnitude of sequential association between first and subsequent behavior., Results: During HL, all infants reacted immediately and substantially on heart rate, facial, body, and cry measures. Facial reactivity was followed within 2 seconds by body and cry behavior. There were no group differences in magnitude of initial behavioral reactions, but during Post-HL, MDA-exposed infants spent more time crying in a weak/exhausted manner and displayed strained and erratic limb movement and immobility., Conclusions: Temporal measures can further help in understanding of infant complex behavioral responses to pain. Delayed recovery in MDA-exposed infants suggested diminished capacities for self-regulation of noxious distress.

Unlabelled: This study examined the impact of evidence concerning the presence of 1) a biomedical basis for pain and 2) psychosocial influences on practitioner appraisals of patient pain experiences. Furthermore, the potential moderating role of patient pain behavior was examined. In an online study, 52 general practitioners and 46 physiotherapists viewed video sequences of 4 patients manifesting pain, with accompanying vignettes describing presence or absence of medical evidence and psychosocial influences. Participants estimated pain intensity, daily interference, sympathy felt, effectiveness of pain medication, self-efficacy, their likability, and suspicions of deception. Primary findings indicated lower perceived pain and daily interference, less sympathy, lower expectations of medication impact, and less self-efficacy when medical evidence was absent. The same results were found when psychosocial influences were present, but only when the patient displayed higher levels of pain behavior. Furthermore, absence of medical evidence was related to less positive evaluations of the patients and to higher beliefs in deception in both professions. The presence of psychosocial influences was related to less positive evaluations and higher beliefs in deception in both professions. In sum, a range of contextual factors influence health care practitioner responses to patient pain. Implications for caregiving behavior are discussed., Perspective: The present study indicates that in the absence of clear medical evidence and in the presence of psychosocial influences, patient pain might be taken less seriously by health care practitioners. These findings are important to further understand the difficulties that relate to the clinical encounter between pain patients and health care practitioners., (Copyright © 2014 American Pain Society. All rights reserved.)

Retrieval of aerosol optical depth (AOD) from the Moderate Resolution Imaging Spectroradiometer (MODIS) using the Collection 5 (C005) algorithm provides large-scale (10 × 10 km) estimates that can be used to predict surface layer concentrations of particulate matter with aerodynamic diameter smaller than 2.5 μm (PM 2.5 ). However, these large-scale estimates are not suitable for identifying intraurban variability of surface PM 2.5 concentrations during wildfire events when individual plumes impact populated areas. We demonstrate a method for providing high-resolution (2.5 km) kernel-smoothed estimates of AOD over California during the 2008 northern California fires. The method uses high-resolution surface reflectance ratios of the 0.66 and 2.12 μm channels, a locally derived aerosol optical model characteristic of fresh wildfire plumes, and a relaxed cloud filter. Results show that the AOD derived for the 2008 northern California fires outperformed the standard product in matching observed aerosol optical thickness at three coastal Aerosol Robotic Network sites and routinely explained more than 50% of the variance in hourly surface PM 2.5 concentrations observed during the wildfires.

Facial expressions provide a primary source of inference about a child's pain. Although facial expressions typically appear spontaneous, children have some capacity to fake or suppress displays of pain, thereby potentially misleading caregiver judgments. The present study was designed to compare accuracy of different groups of caregivers in detecting deception in children's facial expressions of pain when voluntarily controlled. Caregivers (15 pediatricians, 15 pediatric nurses, and 15 parents) viewed 48 video clips of children, 12 in each of 4 conditions (genuine pain, faked pain, suppressed pain, neutral baseline), and judged which condition was apparent to them. A 3 (group: pediatrician vs pediatric nurse vs parent)×4 (condition: genuine vs faked vs suppressed vs neutral) mixed analysis of variance (ANOVA) of judgment accuracies revealed a significant main effect of group, with nurses demonstrating higher overall accuracy scores than parents, and pediatricians not differing from either group. As well, all caregivers, regardless of group, demonstrated the lowest accuracy when viewing the genuine condition, relative to the faked and suppressed conditions, with accuracy for the neutral condition not differing significantly from the other conditions. Overall, caregivers were more successful at identifying faked and suppressed than genuine expressions of pain in children, and pediatric nurses fared better overall in judgment accuracy than parents., (Copyright © 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Analgesic trials pose unique scientific, ethical, and practical challenges in pediatrics. Participants in a scientific workshop sponsored by the US Food and Drug Administration developed consensus on aspects of pediatric analgesic clinical trial design. The standard parallel-placebo analgesic trial design commonly used for adults has ethical and practical difficulties in pediatrics, due to the likelihood of subjects experiencing pain for extended periods of time. Immediate-rescue designs using opioid-sparing, rather than pain scores, as a primary outcome measure have been successfully used in pediatric analgesic efficacy trials. These designs maintain some of the scientific benefits of blinding, with some ethical and practical advantages over traditional designs. Preferred outcome measures were recommended for each age group. Acute pain trials are feasible for children undergoing surgery. Pharmacodynamic responses to opioids, local anesthetics, acetaminophen, and nonsteroidal antiinflammatory drugs appear substantially mature by age 2 years. There is currently no clear evidence for analgesic efficacy of acetaminophen or nonsteroidal antiinflammatory drugs in neonates or infants younger than 3 months of age. Small sample designs, including cross-over trials and N of 1 trials, for particular pediatric chronic pain conditions and for studies of pain and irritability in pediatric palliative care should be considered. Pediatric analgesic trials can be improved by using innovative study designs and outcome measures specific for children. Multicenter consortia will help to facilitate adequately powered pediatric analgesic trials.

We present a detailed framework for understanding the numerous and complicated interactions among psychological and social determinants of pain through examination of the process of pain communication. The focus is on an improved understanding of immediate dyadic transactions during painful events in the context of broader social phenomena. Fine-grain consideration of social transactions during pain leads to an appreciation of sociobehavioral events affecting both suffering persons as well as caregivers. Our examination considers knowledge from a variety of perspectives, including clinical health psychology, social and developmental processes, evolutionary psychology, communication studies, and behavioral neuroscience.

Objectives: Assessing pain in elderly persons, who have diminished capacity to communicate verbally, requires use of observational scales that focus upon nonverbal behavior. Facial expression has been recognized as providing the most specific and sensitive nonverbal cues for pain. This study examined the validity of facial expression components of 6 widely used pain assessment scales developed for elders with dementia. Descriptions of the facial expression of pain vary widely on these scales., Methods: The detailed, anatomically based, objectively coded, and validated Facial Action Coding System was used as a criterion index to provide a definitive description of the facial expression of pain. Thirty elderly inpatients with clinically significant pain in the back or hip, the majority of whom had cognitive impairments, provided videotaped reactions to physical activities. Participants' facial expressions were videotaped during 4 randomly ordered physical activities and coded by a qualified Facial Action Coding System coder. Three 6-second clips indicative of mild, moderate, and severe pain intensities were selected for study for each participant. The 90 clips were coded by 5 raters using the facial expression components of the following observational scales: Doloplus-2, Mahoney, Abbey, pain assessment checklist for seniors with limited ability to communicate, noncommunicative patient's Pain Assessment Instrument, and Pain Assessment in Advanced Dementia., Results: Overall, scales that provided specific descriptions using the empirically displayed facial actions associated with pain yielded greater sensitivity, interjudge reliability, and validity as indices of pain., Discussion: Facial expression items on observational scales for assessing pain in the elderly benefit from adherence to empirically derived descriptions. Those using the scales should receive specific direction concerning cues to be assessed. Observational scales that provide descriptors that correspond to how people actually display facial expressions of pain perform better at differentiating intensities of pain.

Unlabelled: Major efforts to develop objective measurement tools for neonatal pain assessment have been made. However, the challenge of measuring pain in neonates remains suggesting that contextual factors (cFs) might alter their responses to pain. Although the role of cFs is increasingly discussed as crucial for pain assessment, they are not well described in the literature and are rarely considered in the clinical setting despite their importance., Aim: To systematically examine studies investigating the impact of cFs on pain response in preterm infants., Method: A literature search was undertaken for the period from 1990 to 2009. Studies reporting the relation between one or more cFs and pain response in preterm infants during a heelstick procedure were considered for inclusion., Results: Twenty-three studies satisfied inclusion criteria. The studies varied relative to their design, sample, analysis procedures, and variables examined. Six categories of cFs emerged: age, pain exposure, health status, therapeutic interventions, behavioral status, and demographic factors. The examined cFs varied in the strength of their association with pain response, although none were invariably related, as evidenced by contradictory findings. In some cases the inconsistencies appeared attributable to methodological limitations in studies. Behavioral and physiological pain responses were not always in agreement as would be expected., Conclusion: This review supports the influence of some cFs on pain response. However, the results remain inconclusive which may be, in part, related to the heterogeneity of the studies. Contextual factors need further investigation for a better understanding of the magnitude of their effect on pain response., (Copyright © 2011 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved.)

The main objective of this study was to investigate the capabilities of the receptor-oriented inverse mode Lagrangian Stochastic Particle Dispersion Model (LSPDM) with the 12-km resolution Mesoscale Model 5 (MM5) wind field input for the assessment of source identification from seven regions impacting two receptors located in the eastern United States. The LSPDM analysis was compared with a standard version of the Hybrid Single-Particle Lagrangian Integrated Trajectory (HYSPLIT) single-particle backward-trajectory analysis using inputs from MM5 and the Eta Data Assimilation System (EDAS) with horizontal grid resolutions of 12 and 80 km, respectively. The analysis included four 7-day summertime events in 2002; residence times in the modeling domain were computed from the inverse LSPDM runs and HYPSLIT-simulated backward trajectories started from receptor-source heights of 100, 500, 1000, 1500, and 3000 m. Statistics were derived using normalized values of LSPDM- and HYSPLIT-predicted residence times versus Community Multiscale Air Quality model-predicted sulfate concentrations used as baseline information. From 40 cases considered, the LSPDM identified first- and second-ranked emission region influences in 37 cases, whereas HYSPLIT-MM5 (HYSPLIT-EDAS) identified the sources in 21 (16) cases. The LSPDM produced a higher overall correlation coefficient (0.89) compared with HYSPLIT (0.55-0.62). The improvement of using the LSPDM is also seen in the overall normalized root mean square error values of 0.17 for LSPDM compared with 0.30-0.32 for HYSPLIT. The HYSPLIT backward trajectories generally tend to underestimate near-receptor sources because of a lack of stochastic dispersion of the backward trajectories and to overestimate distant sources because of a lack of treatment of dispersion. Additionally, the HYSPLIT backward trajectories showed a lack of consistency in the results obtained from different single vertical levels for starting the backward trajectories. To alleviate problems due to selection of a backward-trajectory starting level within a large complex set of 3-dimensional winds, turbulence, and dispersion, results were averaged from all heights, which yielded uniform improvement against all individual cases.

Accurate perception of another person's painful distress would appear to be accomplished through sensitivity to both automatic (unintentional, reflexive) and controlled (intentional, purposive) behavioural expression. We examined whether observers would construe diverse behavioural cues as falling within these domains, consistent with cognitive neuroscience findings describing activation of both automatic and controlled neuroregulatory processes. Using online survey methodology, 308 research participants rated behavioural cues as "goal directed vs. non-goal directed," "conscious vs. unconscious," "uncontrolled vs. controlled," "fast vs. slow," "intentional (deliberate) vs. unintentional," "stimulus driven (obligatory) vs. self driven," and "requiring contemplation vs. not requiring contemplation." The behavioural cues were the 39 items provided by the PROMIS pain behaviour bank, constructed to be representative of the diverse possibilities for pain expression. Inter-item correlations among rating scales provided evidence of sufficient internal consistency justifying a single score on an automatic/controlled dimension (excluding the inconsistent fast vs. slow scale). An initial exploratory factor analysis on 151 participant data sets yielded factors consistent with "controlled" and "automatic" actions, as well as behaviours characterized as "ambiguous." A confirmatory factor analysis using the remaining 151 data sets replicated EFA findings, supporting theoretical predictions that observers would distinguish immediate, reflexive, and spontaneous reactions (primarily facial expression and paralinguistic features of speech) from purposeful and controlled expression (verbal behaviour, instrumental behaviour requiring ongoing, integrated responses). There are implicit dispositions to organize cues signaling pain in others into the well-defined categories predicted by dual process theory., (Copyright © 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Unlabelled: Although direct experience and verbal instruction are important sources in the development of pain-related beliefs and behaviors, accumulating evidence indicates that observation of others in pain may be equally as important. Taking a contemporary view on learning as a starting point, we discuss available evidence on observational learning in the context of pain, highlight its importance for both development and management of chronic pain problems, and discuss potential moderators of observational learning effects. We argue that the capacity to understand and appreciate the experience of another person is fundamental to observational learning, including use of this information to establish the association between pain and antecedent or consequent stimuli. A main objective of this paper is to stimulate research on the role of learning about pain from others. Several lines for further research, including clinical applications, are delineated., Perspective: Based upon a contemporary view on learning, this focus article delineates how pain-related beliefs and behaviors may be learnt by observing others. It is discussed how further research on the acquisition of pain-related beliefs/behaviors might further our understanding of pain and disability., (Copyright © 2011 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Pain assessment conventionally has been viewed hierarchically with self-report as its "gold-standard." Recent attempts to improve pain management have focused on the importance of assessment, for example, the initiative to include pain as the "fifth vital sign." We question the focus in the conceptualization of pain assessment upon a "vital sign," not in terms of the importance of assessment, but in terms of the application of self-report as a mechanistic index akin to a biologic measure such as heart rate and blood pressure. We synthesize current inclusive models of pain and pain assessment and propose a more comprehensive conceptualization of pain assessment as a transaction based on an organismic interplay between the patient and clinician.

Facial expression is widely used as a measure of pain in infants; whether nonhuman animals display such pain expressions has never been systematically assessed. We developed the mouse grimace scale (MGS), a standardized behavioral coding system with high accuracy and reliability; assays involving noxious stimuli of moderate duration are accompanied by facial expressions of pain. This measure of spontaneously emitted pain may provide insight into the subjective pain experience of mice.