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Background National strategies from North America call for substantive improvements in entry-level pain management education to help reduce the burden of chronic pain. Past work has generated a valuable set of interprofessional pain management competencies to guide the education of future health professionals. However, there has been very limited work that has explored the development of such competencies for individual professions in different regions. Developing profession-specific competencies tailored to the local context is a necessary first step to integrate them within local regulatory systems. Our group is working toward this goal within the context of entry-level physiotherapy (PT) programs across Canada. Aims This study aimed to create a consensus-based competency profile for pain management, specific to the Canadian PT context. Methods A modified Delphi design was used to achieve consensus across Canadian university-based and clinical pain educators. Results Representatives from 14 entry-level PT programs (93% of Canadian programs) and six clinical educators were recruited. After two rounds, a total of 15 competencies reached the predetermined endorsement threshold (75%). Most participants (85%) reported being “very satisfied” with the process. Conclusions This process achieved consensus on a novel pain management competency profile specific to the Canadian PT context. The resulting profile delineates the necessary abilities required by physiotherapists to manage pain upon entry to practice. Participants were very satisfied with the process. This study also contributes to the emerging literature on integrated research in pain management by profiling research methodology that can be used to inform related work in other health professions and regions.

Background: Research objectives should be focused toward advancing knowledge that has meaningful impact on health. However, research agendas are mostly driven by the health care community, with limited input from patients. Aims: In this study, prioirities of uncertainties for the management of fibromyalgia (FM) that could propel future research were identified by a defined process using the James Lind Alliance Priority Setting Partnership (JLA-PSP) methodology. Methods: As a first step, a survey was distributed across Canada that engaged patients, caregivers, and health care professionals to provide narrative input to eight open-ended questions regarding FM care. Responses were thematically condensed and synthesized into an initial list of 43 uncertainties used to guide a comprehensive literature search. Questions already effectively addressed in the literature were excluded, leaving 25 uncertainties that were ranked during a one-day consensus workshop. Results: Three broad themes emerged: the value of personalized targeted treatment and subgrouping of patients; the efficacy of various self-management strategies and educational initiatives; and identification of the ideal health care setting to provide FM care. Opioids and cannabinoids were the only specific pharmacologic interventions ranked as needing further research. Conclusions: The prioritized questions highlight the importance of recognizing the heterogeneity of FM symptoms, the need for a personalized treatment approach, and a better understanding of the value of self-management strategies. This is the first study that uses an established and transparent methodology to engage all FM stakeholders to help inform researchers and funding bodies of clinically relevant research priorities.

Background: Women with physical disabilities are faced with challenges in many aspects of life-education, work, income, relationships, as well as their general health. These women are at a greater risk of developing heart disease. This study aimed to explore the cardiac pain experiences of women with physical disabilities and heart disease within a Canadian healthcare context. Methods: In this qualitative study, 8 women with physical disabilities and heart disease from across Canada were interviewed. They were asked about their pre-, peri-, and post-diagnostic experiences in the Canadian healthcare system. Transcripts of the interviews were analyzed using a hermeneutic phenomenological approach inspired by Ricoeur. Results: Two main themes were uncovered in the analysis of the transcripts, as follows: (i) the diagnostic journey; and (ii) life with cardiac symptoms and a disability. The women indicated that they had experienced difficulties in utilizing the Canadian healthcare system prior to receiving a cardiac diagnosis, including long waitlists, expensive and unreliable transport, issues with accessibility, and dealing with providers’ attitudinal barriers regarding disability. Receiving a diagnosis was challenging due to poor relationships with healthcare providers; however, having a same-sex provider seemed essential to receiving adequate care. Self-managing a disability and heart disease had significant physical and psychological impact, which was lightened by financial and social supports, modified lifestyle choices, and self-advocacy. Conclusions: Women with physical disabilities are often forgotten in discussions encompassing equity and inclusion. The participants’ experiences offer insight into what changes are needed within the Canadian healthcare system in order to improve outcomes for these women. Contexte: Les femmes qui présentent une incapacité physique doivent composer avec des défis dans de nombreux aspects de leur vie, notamment en ce qui touche l’éducation, le travail, le revenu, les relations et la santé en général. Le risque de cardiopathie est plus important dans leur cas. Cette étude visait à examiner comment la douleur cardiaque est vécue par les femmes présentant une incapacité physique et une cardiopathie dans le contexte des soins de santé au Canada. Méthodologie: Dans le cadre de cette étude qualitative, huit femmes présentant une incapacité physique et une cardiopathie ont participé à des entrevues menées à l’échelle du Canada. Elles ont été interrogées sur leurs expériences au sein du système de santé canadien au cours des périodes précédant, entourant et suivant le diagnostic. Les transcriptions des entrevues ont été analysées en fonction d’une approche phénoménologique herméneutique inspirée par Ricœur. Résultats: Deux grands thèmes ressortent de l’analyse des transcriptions, à savoir : (i) le parcours diagnostique; (ii) la vie avec des symptômes cardiaques et une incapacité physique. Les femmes interrogées ont indiqué qu’elles avaient éprouvé des difficultés dans leur parcours au sein du système de santé canadien avant de recevoir un diagnostic en cardiologie, évoquant à cet égard les longues listes d’attente, les services de transport coûteux et peu fiables, les problèmes d’accessibilité et les obstacles liés à l’attitude des fournisseurs de soins vis-à-vis de l’incapacité physique. Le fait de recevoir un diagnostic a été éprouvant en raison de rapports difficiles avec les fournisseurs de soins de santé; cependant, le fait d’avoir un fournisseur de soins de sexe féminin semblait être une condition essentielle à une prestation de soins adéquate. L’autoprise en charge d’une incapacité physique et d’une cardiopathie a eu des répercussions physiques et psychologiques importantes qui ont pu être allégées par le soutien financier et social, des modifications des habitudes de vie et l’autonomie sociale. Conclusions: Les femmes qui présentent une incapacité physique sont souvent laissées pour compte dans les discussions portant sur l’équité et l’inclusion. Le vécu des participantes donne un aperçu des changements qui doivent être apportés au sein du système de santé canadien afin d’améliorer les résultats chez ces femmes. Funding was received from the Women’s Xchange 15K Challenge, Women’s College Hospital, Toronto, Ontario, Canada.

BACKGROUND Living and working with chronic pain requires persons to alter lifestyles and have the knowledge as well as support to manage unforeseen challenges. Knowledge for persons living with pain who want to participate in meaningful paid and unpaid work is not easily accessible. While there is literature on chronic pain management, work transitions and return to work, less emphasis has been placed on the complexity of living and working with chronic pain. The Creating a Way Forward Project was envisioned to address this gap and to identify the informational needs of workers with pain, health/helping professionals (workers' advisors, return to work specialists, legal representatives), and stakeholders. The overarching aim of the project was to use evidence and experiential knowledge to inform the development of a foundation for educational guides and toolkits to support workers with pain to achieve their outcomes for remaining at work. METHODS Phase one of the project involved a scoping review of chronic pain and work. Phase two involved stakeholder consultations, a focus group and knowledge integration of the literature and experiential insights. Knowledge synthesis drew on a Template Analysis of multiple sources of data. RESULTS Knowledge domains and key components were identified for persons with pain and for the health/helping professions. CONCLUSION These domains reflect a foundation for knowledge in practical training and the development of curriculum for education in self-management program and in inter professional health profession education. These knowledge domains provide a basis for future research in integrated approaches and knowledge use toward improving transitions for persons living with chronic pain who want to participate in productive paid and unpaid work. Ongoing research in knowledge domains that health providers and persons with pain need will expand the potential for improving health outcomes in living with and managing pain.

Background: Chronic pain affects more than 6 million Canadians. Patients need to be involved in setting research priorities to ensure a focus on areas important to those who will be most impacted by the results. Aims: The aim of this study was to leverage patient experiences to identify chronic pain research priorities in Canada. Method: The process was informed by the James Lind Alliance. After gathering an exhaustive list of questions using surveys, town hall meetings, interviews, and social media consultations, we used a computerized Delphi with four successive iterations to select the final list of research priorities. The final Delphi round was conducted by a panel of ten patients living with chronic pain and ten clinicians from different disciplines. Results: We received more than 5000 suggestions from 1500 people. The Delphi process led to the identification of 14 questions fitting under the following 4 themes: (1) improving knowledge and competencies in chronic pain; (2) improving patient-centered chronic pain care; (3) preventing chronic pain and reducing associated symptoms; and (4) improving access to and coordination of patient-centered chronic pain care. Challenges included the issue of chronic pain being ubiquitous to many diseases, leading to many initial suggestions focusing on these diseases. We also identified the need for further engagement efforts with marginalized groups in order to validate the priorities identified or identify different sets of priorities specific to these groups. Conclusion: The priorities identified can guide patient-oriented chronic pain research to ultimately improve the care offered to people living with chronic pain.

IntroductionMore women experience cardiac pain related to coronary artery disease and cardiac procedures compared with men. The overall goal of this programme of research is to develop an integrated smartphone and web-based intervention (HEARTPA♀N) to help women recognise and self-manage cardiac pain.Methods and analysisThis protocol outlines the mixed methods strategy used for the development of the HEARTPA♀N content/core feature set (phase 2A), usability testing (phase 2B) and evaluation with a pilot randomised controlled trial (RCT) (phase 3). We are using the individual and family self-management theory, mobile device functionality and pervasive information architecture of mHealth interventions, and following a sequential phased approach recommended by the Medical Research Council to develop HEARTPA♀N. The phase 3 pilot RCT will enable us to refine the prototype, inform the methodology and calculate the sample size for a larger multisite RCT (phase 4, future work). Patient partners have been actively involved in setting the HEARTPA♀N research agenda, including defining patient-reported outcome measures for the pilot RCT: pain and health-related quality of life (HRQoL). As such, the guidelines for Inclusion of Patient-Reported Outcomes in Clinical Trial Protocols (SPIRIT-PRO) are used to report the protocol for the pilot RCT (phase 3). Quantitative data (eg, demographic and clinical information) will be summarised using descriptive statistics (phases 2AB and 3) and a content analysis will be used to identify themes (phase 2AB). A process evaluation will be used to assess the feasibility of the implementation of the intervention and a preliminary efficacy evaluation will be undertaken focusing on the outcomes of pain and HRQoL (phase 3).Ethics and disseminationEthics approval was obtained from the University of Toronto (36415; 26 November 2018). We will disseminate knowledge of HEARTPA♀N through publication, conference presentation and national public forums (Café Scientifique), and through fact sheets, tweets and webinars.Trial registration numberNCT03800082.

Objective This review quantified prescriber adherence to opioid prescribing guidelines for chronic noncancer pain (CNCP). Method We searched CINAHL, Embase, MEDLINE, PsycINFO, the Cochrane Library, and the Joanna Briggs Institute EBP Database from inception until June 3, 2019. Studies that focused on provider adherence to opioids guidelines for CNCP in North America were eligible. Four reviewers screened studies, extracted data, and assessed study quality. Results Thirty-eight studies were eligible, comprising 17 cross-sectional studies (n = 11,835 providers) and 22 chart reviews (n = 22,512 patients). Survey data indicated that adherence was 49% (95% CI [40, 59]) for treatment agreements, 33% (95% CI [19%, 47%]) for urine drug testing, 48% (95% CI [26%, 71%]) for consultation with drug monitoring program, 57% (95% CI [35%, 79%]) for assessing risk of aberrant medication-taking behavior, and 61% (95% CI [35%, 87%]) for mental health screening. Chart review data indicated that the proportion of patients with documentation was 40% (95% CI [29, 51]) for treatment agreements, 41% (95% CI [32%, 50%]) for urine drug testing, 40% (95% CI [2%, 78%]) for consultation with drug monitoring program, 41% (95% CI [20%, 64%]) for assessing risk of aberrant medication-taking behavior, and 22% (95% CI [9%, 33%]) for mental health screening. Year of publication, practice guideline referenced, and risk of bias explained significant heterogeneity. No study evaluated whether nonadherence to recommendations reflected well-justified deviations to care. Conclusions Adherence to guideline recommendations for opioids for CNCP is low. It is unclear whether nonadherence reflects thoughtful deviations in care. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

This study is a systematic review of interventions to improve adherence to guideline recommendations for prescribing opioids for chronic noncancer pain.Investigators searched CINAHL, Embase, MEDLINE, PsycINFO, the Cochrane Library, and Joanna Briggs Institute Evid Based Pract database from inception until June 3, 2019. Interventional studies to improve adherence to recommendations made by opioid guidelines for chronic noncancer pain in North America were eligible if outcomes included adherence to guideline recommendations or change in quantity of opioids prescribed. Data were extracted independently and in duplicate. Quantitative synthesis was performed using random effects meta-analysis. Confidence in evidence was determined using the Grades of Recommendation, Assessment, Development, and Evaluation.A total of 20 studies (8 controlled and 12 prospective cohort) involving 1,491 providers and 72 clinics met inclusion. Interventions included education, audit and feedback, interprofessional support, shared decision making, and multifaceted strategies. Multifaceted interventions improved the use of urine drug testing (n=2, or =2.31, 95% CI=1.53, 3.49, z=3.98, p0.01; high-certainty evidence), treatment agreements (n=2, or =1.96, 95% CI=1.47, 2.61, z=4.56, p0.01; moderate-certainty evidence), and mental health screening (n=2, 2.57-fold, 95% CI=1.56, 4.24, z=2.32, p=0.02; low-certainty evidence) when prescribing opioids for chronic noncancer pain. Very low-certainty evidence suggests that several interventions improved the use of treatment agreements, urine drug testing, and prescription drug monitoring programs.Mostly very low-certainty evidence supports a number of interventions for improving adherence to risk management strategies when prescribing opioids for chronic noncancer pain; however, the effect on patient important outcomes (e.g., overdose, addiction, death) is uncertain.

Clinical questionWhat is the role of medical cannabis or cannabinoids for people living with chronic pain due to cancer or non-cancer causes?Current practiceChronic pain is common and distressing and associated with considerable socioeconomic burden globally. Medical cannabis is increasingly used to manage chronic pain, particularly in jurisdictions that have enacted policies to reduce use of opioids; however, existing guideline recommendations are inconsistent, and cannabis remains illegal for therapeutic use in many countries.RecommendationThe guideline expert panel issued a weak recommendation to offer a trial of non-inhaled medical cannabis or cannabinoids, in addition to standard care and management (if not sufficient), for people living with chronic cancer or non-cancer pain.How this guideline was createdAn international guideline development panel including patients, clinicians with content expertise, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel applied an individual patient perspective.The evidenceThis recommendation is informed by a linked series of four systematic reviews summarising the current body of evidence for benefits and harms, as well as patient values and preferences, regarding medical cannabis or cannabinoids for chronic pain.Understanding the recommendationThe recommendation is weak because of the close balance between benefits and harms of medical cannabis for chronic pain. It reflects a high value placed on small to very small improvements in self reported pain intensity, physical functioning, and sleep quality, and willingness to accept a small to modest risk of mostly self limited and transient harms. Shared decision making is required to ensure patients make choices that reflect their values and personal context. Further research is warranted and may alter this recommendation.

This paper summarizes the special session, “Uncertainty in Propagation Prediction,” that took place at the 177th meeting of the Acoustical Society of America in Louisville, KY. The session was co-sponsored by Underwater Acoustics, Physical Acoustics, Structural Acoustics and Vibration, Acoustical Oceanography, Signal Processing in Acoustics Technical Committees and Computational Acoustics Technical Specialty Group and consisted of 11 talks by researchers from U.S. academic and government research labs, and French and Canadian universities. The session described techniques for predicting the uncertainty in propagation model inputs and outputs.

Background Back pain is a leading contributor to disability, healthcare costs, and lost work. Family physicians are the most common first point of contact in the healthcare system for people with back pain, but physiotherapists (PTs) may be able to support the primary care team through evidence-based primary care. A cluster randomized trial is needed to determine the clinical, health system, and societal impact of a primary care model that integrates physiotherapists at the first visit for people with back pain. Prior to conducting a future fully powered cluster randomized trial, we need to demonstrate feasibility of the methods. Therefore, the purpose of this pilot study will be to:Determine feasibility of patient recruitment, assessment procedures, and retention.Determine the feasibility of training and implementation of a new PT-led primary care model for low back pain (LBP)Explore the perspectives of patients and healthcare providers (HCPs) related to their experiences and attitudes towards the new service delivery model, barriers/facilitators to implementation, perceived satisfaction, perceived value, and impact on clinic processes and patient outcomes. Methods This pilot cluster randomized controlled trial will enroll four sites and randomize them to implement a new PT-led primary care model for back pain or a usual physician-led primary care model. All adults booking a primary care visit for back pain will be invited to participate. Feasibility outcomes will include: recruitment and retention rates, completeness of assessment data, PT training participation and confidence after training, and PT treatment fidelity. Secondary outcomes will include the clinical, health system, cost, and process outcomes planned for the future fully powered cluster trial. Results will be analyzed and reported descriptively and qualitatively. To explore perspectives of both HCPs and patients, we will conduct semi-structured qualitative interviews with patients and focus groups with HCPs from participants in the PT-led primary care sites. Discussion If this pilot demonstrates feasibility, a fully powered trial will provide evidence that has the potential to transform primary care for back pain. The full trial will inform future service design, whether these models should be more widely implemented, and training agendas. Trial registration ClinicalTrials.gov, NCT03320148. Submitted for registration on 17 September 2017. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2279-7) contains supplementary material, which is available to authorized users.

Chronic noncancer pain includes any painful condition that persists for at least three months and is not associated with malignant disease.[1][1] According to seven national surveys conducted between 1994 and 2008, 15%–19% of Canadian adults live with chronic noncancer pain.[2][2] Chronic

Most practitioners and researchers recognize that knowledge flows are extremely important, especially in the current age where organizations have to learn and innovate continually in order to remain competitive. Given that knowledge is distributed unevenly through the enterprise, rapid and reliable knowledge flows are essential for organizations' sustainable competitive advantage.Knowledge flows across people, organizations, places and times of creation, sharing and application. Knowledge flows are dynamic. And in order to harness the competitive power of this dynamic phenomenon, it is imperative to understand and manage effectively the associated knowledge-flow processes.This minitrack examines the nature and role of knowledge flows (e.g., knowledge transfer, sharing and exchange) in the organizational context. The Call for Papers welcomed theoretical and empirical pieces addressing technical, managerial, behavioral, organizational, and economic perspectives on knowledge flows.

Background: Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT—VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom. Objective: Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT). Methods: CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise—death, myocardial infarction, and nonfatal stroke— all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups. Results: Study start-up is underway and usability testing is scheduled to begin in the fall of 2016. Conclusions: Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS. [JMIR Res Protoc 2016;5(3):e149]

Refractory angina (RFA) is a debilitating disease characterized by cardiac pain resistant to conventional treatments for coronary artery disease including nitrates, calcium-channel and β-adrenoceptor blockade, vasculoprotective agents, percutaneous coronary interventions, and coronary artery bypass grafting. The mortality rate of patients living with RFA is not known but is thought to be in the range of approximately 3%. These individuals suffer severely impaired health-related quality of life with recurrent and sustained pain, poor general health status, psychological distress, impaired role functioning, and activity restriction. Effective care for RFA sufferers in Canada is critically underdeveloped. These guidelines are predicated upon a 2009 Canadian Cardiovascular Society (CCS) Position Statement which identified that underlying the problem of RFA management is the lack of a formalized, coordinated, interprofessional strategy between the cardiovascular and pain science/clinical communities. The guidelines are therefore a joint initiative of the CCS and the Canadian Pain Society (CPS) and make practice recommendations about treatment options for RFA that are based on the best available evidence. Concluding summary recommendations are also made, giving direction to future clinical practice and research on RFA management in Canada.

This study reviewed the published literature evaluating multidisciplinary chronic pain treatment facilities to provide an overview of their availability, caseload, wait times, and facility characteristics. A systematic literature review was conducted using PRISMA guidelines following a search of MEDLINE, PsycINFO, and CINAHL databases. Inclusion criteria stipulated that studies be original research, survey more than one pain treatment facility directly, and describe a range of available treatments. Fourteen articles satisfied inclusion criteria. Results showed little consistency in the research design used to describe pain treatment facilities. Availability of pain treatment facilities was scarce and the reported caseloads and wait times were generally high. A wide range of medical, physical, and psychological pain treatments were available. Most studies reported findings on the percentage of practitioners in different health care professions employed. Future studies should consider using more comprehensive search strategies to survey facilities, improving clarity on what is considered to be a pain treatment facility, and reporting on a consistent set of variables to provide a clear summary of the status of pain treatment facilities. This review highlights important information for policymakers on the scope, demand, and accessibility of pain treatment facilities.

Background Characteristics of patients receiving long-term opioid therapy (≥ 6 months) for chronic noncancer pain are poorly understood. We conducted a cross-sectional survey of this patient population to explore demographic variables, pain relief, functional improvement, adverse effects and impressions of an educational pamphlet on long-term opioid therapy. Methods We invited 260 adult patients presenting to the Pain Management Centre at the Hamilton General Hospital, Hamilton, Ontario, with chronic noncancer pain to complete a 20-item survey. Patients who presented for procedures were not eligible for our study. We used adjusted logistic regression models to explore the association between higher morphine equivalent dose and pain relief, functional improvement, adverse events and employment. Results The survey was completed by 170 patients (a response rate of 65.4%). Most respondents (87.6%; 149 out of 170) were receiving long-term opioid therapy, and the median morphine equivalent dose was 180 mg daily (interquartile range 60-501). Most respondents reported at least modest (> 40%) opioid-specific pain relief (74.1%; 106 out of 143) and functional improvement (67.6%; 96 out of 142), and 46.5% (66 out of 142) reported troublesome adverse effects that they attributed to their opioid use. Most patients were receiving disability benefits (68.3%; 99 out of 145) and, among those respondents who were less than 65 years of age (90.3%; 131 out of 145), 10 (7.6%) were working full-time and 14 (10.7%) part-time. In our adjusted analyses, higher morphine equivalent dose was associated with greater self-reported functional improvement (odds ratio [OR] 1.45, 95% confidence interval [CI] 1.07-1.96) but not with pain relief (OR 1.38, 95% CI 1.00-1.89), troublesome adverse effects (OR 0.92, 95% CI 0.70-1.20) or employment (OR 0.80, 95% CI 0.56-1.15). Interpretation Most outpatients receiving long-term opioid therapy for chronic noncancer pain at a tertiary care chronic pain clinic reported at least moderate pain relief and functional improvement; however, adverse effects were common and few patients were engaged in competitive employment.

Background. Chronic or persistent pain and disability following noncatastrophic “musculoskeletal” (MSK) trauma is a pervasive public health problem. Recent intervention trials have provided little evidence of benefit from several specific treatments for preventing chronic problems. Such findings may appear to argue against formal targeted intervention for MSK traumas. However, these negative findings may reflect a lack of understanding of the causal mechanisms underlying the transition from acute to chronic pain, rendering informed and objective treatment decisions difficult. The Canadian Institutes of Health Research (CIHR) Institute of Musculoskeletal Health and Arthritis (IMHA) has recently identified better understanding of causal mechanisms as one of three priority foci of their most recent strategic plan.Objectives. A 2-day invitation-only active participation workshop was held in March 2015 that included 30 academics, clinicians, and consumers with the purpose of identifying consensus research priorities in the field of trauma-related MSK pain and disability, prediction, and prevention.Methods. Conversations were recorded, explored thematically, and member-checked for accuracy.Results. From the discussions, 13 themes were generated that ranged from a focus on identifying causal mechanisms and models to challenges with funding and patient engagement.Discussion. Novel priorities included the inclusion of consumer groups in research from the early conceptualization and design stages and interdisciplinary longitudinal studies that include evaluation of integrated phenotypes and mechanisms.

Results from three studies suggest fluctuation in estrogen level may influence the expression of borderline personality disorder (BPD) symptoms. In the first study, 226 women were administered the Personality Assessment Inventory, borderline scales (PAI-BOR; L.C. Morey, The Personality Assessment Inventory, Professional Manual, 1991) and a questionnaire that assessed time in menstrual cycle and use of oral contraceptives, that is synthetic estrogens. BPD symptoms were most common in women using oral contraceptives and during times in the menstrual cycle when estrogen level is rising. In Study 2, 52 women were measured four times across one menstrual cycle and provided salivary samples at each test session. The samples were assayed and estrogen levels were obtained. The principle finding was that variation in estrogen levels predicted the presence of BPD symptoms (r=0.4, p

ObjectiveTo describe the current evidence related to the self-management of cardiac pain in women using the process and methodology of evidence mapping.Design and settingLiterature search for studies that describe the self-management of cardiac pain in women greater than 18 years of age, managed in community, primary care or outpatient settings, published in English or a Scandinavian language between 1 January 1990 and 24 June 2016 using AMED, CINAHL, ERIC, EMBASE, MEDLINE, Proquest, PsychInfo, the Cochrane Library, Scopus, Swemed+, Web of Science, the Clinical Trials Registry, International Register of Controlled Trials, MetaRegister of Controlled Trials, theses and dissertations, published conference abstracts and relevant websites using GreyNet International, ISI proceedings, BIOSIS and Conference papers index. Two independent reviewers screened using predefined eligibility criteria. Included articles were classified according to study design, pain category, publication year, sample size, per cent women and mean age.InterventionsSelf-management interventions for cardiac pain or non-intervention studies that described views and perspectives of women who self-managed cardiac pain.Primary and secondary outcomes measuresOutcomes included those related to knowledge, self-efficacy, function and health-related quality of life.ResultsThe literature search identified 5940 unique articles, of which 220 were included in the evidence map. Only 22% (n=49) were intervention studies. Sixty-nine per cent (n=151) of the studies described cardiac pain related to obstructive coronary artery disease (CAD), 2% (n=5) non-obstructive CAD and 15% (n=34) postpercutaneous coronary intervention/cardiac surgery. Most were published after 2000, the median sample size was 90 with 25%–100% women and the mean age was 63 years.ConclusionsOur evidence map suggests that while much is known about the differing presentations of obstructive cardiac pain in middle-aged women, little research focused on young and old women, non-obstructive cardiac pain or self-management interventions to assist women to manage cardiac pain.PROSPERO registration numberCRD42016042806.

Objectives The aim of this review was to understand and synthesize the realm of knowledge on intermittent work capacity (IWC) about strategies to support work sustainability. Specifically, this review focused on literature that examined productive work with individuals who have chronic pain due to Fibromyalgia, Breast Cancer, Multiple Sclerosis, and Human Immunodeficiency Virus. Methods A scoping review of research conducted across 10 databases. Nature of the knowledge base on return to work barriers and strategies and future recommended strategies needed to support persons with IWC in maintaining work participation were charted and thematically analyzed and organized into micro, meso and macro categories. Results Majority of the knowledge base reflects factors impeding and facilitating employment or re-employment at the micro level. At the micro level, self advocacy was a strategy that persons with IWC used to maintain employment and navigate stigmatizing work environments to meet their needs. At the meso level education and knowledge sharing with employers to increase awareness was underscored; at the macro level introduction of new policies was recommended. Conclusions These findings suggest the need for future greater examination of the dialectical relationships across micro, meso and macro level strategies to overcome work disparities for persons with IWC.

A case of papillary endobronchial squamous cell carcinoma incidentally discovered on routine imaging studies is described. The patient, a 75-year-old woman, underwent imaging studies as part of a standard evaluation for a fracture on the right side of the hip. Chest radiographs were unremarkable other than for a nodular opacity overlying the left hemidiaphragm. Computed tomography of the chest, however, demonstrated an elongated, irregular mass in the right lower lobe that appeared to be associated with an adjacent segmental right lower lobe bronchus. Endoscopy followed by surgical resection was undertaken, revealing a tan, soft mass measuring 1.5 x 1.3 x 0.8 cm that was confined to the bronchus and did not appear to extend into the surrounding lung parenchyma. Microscopically, the mass showed a papillary, superficial squamous cell carcinoma confined to the bronchial mucosa without invasion of adjacent structures. The pathological and imaging features of this unusual variant of bronchogenic carcinoma are reviewed as well as the radiological differential diagnosis of endobronchial lesions. To our knowledge, this is the first report that describes the computed tomographic features of this rare lesion.

Palindromic rheumatism (PR) is an episodic arthropathy that may precede typical rheumatoid arthritis (RA), although pathogenetic relationships between these disorders remain unclear. The predictive value for those immunogenetic risk factors implicated in RA for disease progression in PR remains to be established. A previous retrospective analysis from our group has implicated rheumatoid factor in disease progression. Our objective was to determine the contribution of HLA and cytokine gene polymorphisms implicated in RA to predisposition to PR and to progression of PR to chronic joint inflammation.We studied 147 patients with PR seen in a tertiary referral center; 87 were selected retrospectively from the period 1986-96 using a structured selection process and 60 were selected prospectively in the period 1997-2001. Comparison groups included 149 patients with RA and 149 ethnically matched controls. Typing for HLA-DRB1 alleles and HLA-DRB1-04 subtypes was performed following polymerase chain reaction (PCR) amplification using sequence-specific primers (SSP). Cytokine genotypes were ascertained following PCR-SSP with and without digestion with restriction enzymes. Time-adjusted survival analysis (Kaplan-Meier) and multivariate logistic regression were used to assess the independent contribution of immunogenetic markers in assessing progression of PR to chronic joint inflammation.Thirty-one percent of patients progressed to connective tissue disease after a mean of 10.6 (retrospective group) and 3.9 (prospective group) years. A significantly increased prevalence of the shared epitope (SE) allele was noted in patients with PR (65%) versus controls (39%) (OR 2.9, 95% CI 1.8-4.6, p0.001). This primarily reflected increased prevalence of the DRB1-0401 and 0404 and not DRB1-01 alleles. A weak contribution to disease susceptibility was also noted with carriage of the IL4 promoter -590T (OR 1.8, 95% CI 1.1-3.0, p = 0.02) and IL4 intron 3 RP1 (OR 1.7, 95% CI 1.1-2.9, p = 0.03) alleles. The TNFa +489A allele was associated with RA (OR = 2.7, 95% CI 1.5-5.1, p = 0.001) in both SE+ and SE- patients, but not with PR. Time-adjusted and multivariate Cox regression analysis revealed that only homozygosity for SE alleles was a significant independent risk factor for disease progression to chronicity in PR (hazard ratio 2.9, 95% CI 1.2-6.9, p = 0.02). However, none of 8 patients homozygous for SE- DRB1 XP4n alleles developed chronic disease after 10 years of followup (p = 0.07).The immunogenetic risk profile for PR resembles that for RA, indicating that PR is likely not an independent entity. A significant gene dose effect for SE alleles is operative in determining risk for progression from PR to RA.

To examine the efficacy and toxicity of ISA(TX)247, a novel calcineurin inhibitor, in comparison to cyclosporine (cyclosporin A, CSA) and placebo in established collagen induced arthritis. ISA(TX)247 has up to 3-fold greater potency than CSA in an in vitro whole blood calcineurin inhibition assay and in in vivo solid organ and cell transplantation models. Phase I clinical trials show no discernible nephrotoxicity.Type II collagen immunized DBA/Lac J mice with established arthritis were randomized to treatment with ISA(TX)247 (125/250/500 microg/mouse), CSA (250/500 microg/mouse), or drug vehicle, by daily intraperitoneal injection for 10 days from the onset of clinical arthritis.A significant dose dependent reduction in clinical severity was observed in ISA(TX)247 treated but not in CSA treated animals 10 days after the onset of established arthritis, and when examined by area under the curve analysis during the treatment period. Significant improvement in paw swelling (p0.001), synovial histology (p0.001), and articular cartilage damage scores (p = 0.002) was also noted in ISA(TX)247 treated animals, even in the 125 pg dose group (p = 0.03 for paw swelling and synovial histology). By comparison, CSA had no significant effect on either synovial inflammation or articular cartilage damage. ISA(TX)247 (500 microg dose group) was the only treatment to significantly decrease the development of proximal interphalangeal joint erosions (p0.05). A significant reduction in Type II collagen antibody titer was noted in ISA(TX)247 animals in both 250 microg (p = 0.02) and 500 microg (p = 0.004) dosage groups, but only in the 500 microg group for CSA (p = 0.004). Treatment was well tolerated, with no significant toxicity in ISA(TX)247 groups.ISA(TX)247 demonstrates efficacy and safety in the treatment of established collagen induced arthritis. Together with its improved potency and nephrotoxicity profile in comparison to CSA, this agent warrants further clinical investigation in autoimmune disease. Phase II studies in rheumatoid arthritis have been initiated.

Children and young people9s palliative care is an increasingly recognised specialty for life limiting and life threatening conditions. These children often have a difficult life filled with hospital appointments and strange professionals invading their homes. The siblings of these children may often be forgotten about or neglected, as the focus is on the sick child. The siblings have their own grief and bereavement and very often need support in getting through this. Our children9s hospice at home service offers pre and post bereavement support to the whole family, but recognised that more could be done to meet the specific needs of siblings. There was a review of the caseload to identify possible siblings ranging in age from 5 to 19 years. Family9s views were sought, and discussion was had at the multidisciplinary team meetings to identify appropriate participants. Following a successful bid to the Department of Health children9s palliative care funding, two separate age-appropriate support events for siblings were organised. The older children (11 – 19) did not take up the opportunity for a place, so only one event was held for the younger age group. The day was structured and therapeutic group work formed the basis for the sessions, led by specialist children9s palliative care nurses, the play therapist and support staff. It was recognised that the older children regularly attend a youth group which offers them ongoing support. The day was very well evaluated by the children attending, and subsequently their parents. More sibling events will be organised for the future, as the day proved to be an effective way of meeting their needs. Due to the success of the day, there is also a plan to open up future days to the children of our adult palliative care service, who have some similar needs.

Examination of urinary sediment has been recommended as a useful diagnostic aid for renal amyloidosis. This procedure was evaluated in the cases of 57 patients, including 11 with proven renal amyloidosis and 13 considered very likely to have the disease. At least three types of urinary fibrillar material were observed: 10-12-nm-diameter fibrils similar to amyloid; 7-10-nm-diameter fibrils with characteristics of intracellular tonofibrils; and 15-30-nm-diameter fibrils suggestive of fibrin tendrils. Only four of 24 patients who had renal amyloidosis proven or suspected had amyloid-like fibrils in the urinary sediment, while four control patients, including three with diabetic nephropathy, had similar fibrils. Sixty-eight per cent of all urines contained material consistent with tonofibrils. Ultrastructural examination of urinary sediment as a diagnostic aid for renal amyloidosis lacks sensitivity and specificity and has very limited clinical value.

Several crops are being touted as a renewable energy source. Sweet sorghum is adapted to many areas, grows relatively rapidly, has moderate water and nutrient requirements, and develops high levels of fermentables. A long term supply of fermentables is needed to make ethanol production economically feasible. Short term availability of fermentables results in unfavorable returns from investments in equipment and crop production. Two planting dates (15 May and 1 June) and eight harvest dates (30 Sep. to 15 Mar.) were used in efforts to to extend the availability of sweet sorghum fermentables. Respiration of sweet sorghum tissue was measured with an infrared gas analyzer before and after freezing to quantify loss of fermentables associated with delayed harvests. Vital stains were used before and after freezing to estimate cell mortality. No significant difference was found in the level of fermentables in sorghum from the two planting dates. Delay-ing harvest caused fermentables to decline significantly (30%) by mid-November and to continue to drop through March. Respiration dropped 90% after exposure to -8 C, but resumed the same rate after 1 week. Vital stai!1ing showed cells die upon freezing. Relatively high respiration rates in the dead tissue suggests saprophytic microbes are responsible for the large decline in fermentables after freezing. Eleven cultivars and lines were tested for yield of fermentables. Wray was superior in yield of fermentables, while Sumac and Sugardrip were inferior. Master of Science

To the Editor.— Exertional rhabdomyolysis and myoglobinuria have been associated with various types of physical activity. Myoglobinuria has been reported in wrestlers, jack-hammer users, football players, marathon runners, and military recruits. 1-5 It most often occurs in poorly conditioned persons, and when associated with dehydration, acidosis, or hypotension, may lead to acute renal failure. We recently saw a patient who had severe rhabdomyolysis and myoglobinuria after riding a mechanical bucking bull. Riding such a contraption has become an increasingly popular activity in country-western nightclubs as depicted in a recent motion picture. We therefore labeled our patient's condition "urban cowboy" myoglobinuria. Report of a Case.— A 30-year-old man in excellent health spent an evening at a country-western nightclub drinking beer, listening to music, and riding a mechanical bull. Because of some previous rodeo experience, he rode the bull on the "professional" setting. The bull was ridden three times for a total