Gender disparity in analgesic treatment of emergency department patients with acute abdominal pain

Demystifying Acute Pain Management in the Emergency Department: A Case-Based Approach

Introduction

Acute pain is one of the most common complaints that presents to the emergency department. Despite its ubiquity, oligoanalgesia, or the undertreatment of pain, remains a problem in medicine, possibly due to minimal dedicated pain teaching for senior medical students transitioning to residency.

Methods

We designed a 2.5-hour interactive seminar for senior medical students transitioning into residency. The seminar included a chalk talk and case-based discussion, reviewed pain physiology, revisited pain assessment, and introduced pain management strategies using a novel acute pain plan to organize an analgesic approach from presentation through disposition from the emergency department. The didactic chalk talk was interwoven with a case of acute pain. Seminar materials promoted a near-peer teaching opportunity for future facilitators. Learners completed open-ended pre-/postsession knowledge assessments.

Results

Data were obtained from 19 fourth-year medical students enrolled in three iterations of a preinternship course at Harvard Medical School. Prior to the seminar, learners scored an average of 23.0 out of 53.0 points (SD = 9.0) on the knowledge assessment, which improved to 36.6 out of 53.0 points (SD = 6.7) following the seminar (paired t test p < .001). Learner satisfaction data revealed a positive response to the seminar: Learners felt more confident managing pain and highly recommended the seminar's continuation in the future.

Discussion

Initial data from this seminar suggest a need for and benefit of targeted pain education for senior medical students. Seminar materials can easily be adapted for learners in other departments or in early graduate medical education.

Perception of typical migraine images on the internet: Comparison between a metropolis and a smaller rural city in Germany

The medial portrayal of migraine is often stereotypical and inaccurate but reflects how society perceives migraine. The discrepancy between others' views and the reality of affected individuals may negatively affect access to treatment and the disease course of patients with migraine. This study aimed to investigate whether images presented in the media as typical migraine attacks are perceived as realistic and representative by migraine patients in Rostock, a smaller town in rural Germany, and compare the results to those from Berlin, a large metropolis. We performed an online survey in Rostock. Migraine patients were shown ten images of migraine attacks, which were among the most downloaded stock pictures on the internet under the search term "migraine". They rated on a scale of 0-100 to what extent the pictures were realistic for migraine attacks (realism score), representative of their own migraine (representation score), or the society's view of migraine (society score). In addition, we compared our results with a recently published study from the metropolitan region of Berlin. A total of 174 migraine patients completed our survey. Mean (SD) realism, representation, and society scores were 59.9 (17.5), 56.7 (18.3), and 58.4 (17.1) respectively. Images of older patients were perceived as significantly more realistic and representative than those of younger patients (P < .001). Patients in Rostock (rural region) rated the images as significantly more realistic and representative than survey participants in Berlin (metropolis). Migraine patients in a rural region found typical migraine images only moderately realistic and representative but to a higher degree than their counterparts from a metropolis.

Time ratio disparities among ED patients undergoing head CT

PURPOSE

To assess if patients who underwent head computed tomography (CT) experienced disparities in the emergency department (ED) and if the indication for head CT affected disparities.

METHODS

This study employed a retrospective, IRB-approved cohort design encompassing four hospitals. All ED patients between January 2016 and September 2020 who underwent non-contrast head CTs were included. Furthermore, key time intervals including ED length of stay (LOS), ED assessment time, image acquisition time, and image interpretation time were calculated. Time ratio (TR) was used to compare these time intervals between the groups.

RESULTS

A total of 45,177 ED visits comprising 4730 trauma cases, 5475 altered mental status cases, 11,925 cases with head pain, and 23,047 cases with other indications were included. Females had significantly longer ED LOS, ED assessment time, and image acquisition time (TR = 1.012, 1.051, 1.018, respectively, P-value < 0.05). This disparity was more pronounced in female patients with head pain complaints compared to their male counterparts (TR = 1.036, 1.059, and 1.047, respectively, P-value < 0.05). Black patients experienced significantly longer ED LOS, image acquisition time, and image assessment time (TR = 1.226, 1.349, and 1.190, respectively, P-value < 0.05). These disparities persisted regardless of head CT indications. Furthermore, patients with Medicare/Medicaid insurance also faced longer wait times in all the time intervals (TR > 1, P-value < 0.001).

CONCLUSIONS

Wait times for ED head CT completion were longer for Black patients and Medicaid/Medicare insurance holders. Additionally, females experienced extended wait times, particularly when presented with head pain complaints. Our findings underscore the importance of exploring and addressing the contributing factors to ensure equitable and timely access to imaging services in the ED.

Sex differences in patient journeys to diagnosis, referral, and surgical treatment of trigeminal neuralgia: implications for equitable care

OBJECTIVE

Trigeminal neuralgia (TN) is an orofacial pain disorder that is more prevalent in females than males. Although an increasing number of studies point to sex differences in chronic pain, how sex impacts TN patients' journeys to care has not been previously addressed. This study sought to investigate sex differences in patients' journeys to diagnosis, referral, and treatment of TN within a large national context.

METHODS

Patients with classic TN (n = 100; 50 females and 50 males) were randomly selected through chart reviews at the largest surgical treatment center for TN in Canada for a cross-sectional study. Statistical tests, including Welch's t-test, the chi-square test, Pearson's correlations, and analyses of covariance, were conducted with Python.

RESULTS

Key discrepancies between sexes in access to care were identified. Females had a significantly longer referral time interval (average 53.2 months vs 20.4 months, median 27.5 months vs 11.0 months, p = 0.018) and total time interval (average 121.1 months vs 67.8 months, median 78.0 months vs 45.2 months, p = 0.018) than males, despite reporting higher pain intensity at referral. Although medically intolerant patients had a significantly shorter referral time interval than medically tolerant patients (average 13.0 months vs 41.0 months, median 6.0 months vs 17.0 months, p < 0.001), medically tolerant females had a significantly longer referral time interval than medically tolerant males (average 59.9 months vs 21.7 months, median 30.0 months vs 12.0 months, p = 0.017). No statistically significant differences were detected between the sexes for diagnostic time interval (average 63.3 months vs 43.0 months, median 24.0 months vs 24.0 months, p = 0.263) or treatment time interval (average 4.6 months vs 4.7 months, median 4.0 months vs 3.0 months, p = 0.986).

CONCLUSIONS

Critical sex differences in patients' journeys to TN surgical treatment were identified, with females enduring considerably longer referral timelines and expressing significantly greater pain intensity than males at referral. Taken together, our findings suggest the presence of unconscious bias and discrimination against females and highlight the need for expediting TN treatment referral for female TN patients.

Gender and sex bias in prevention and clinical treatment of women's chronic pain: hypotheses of a curriculum development

This discursive paper focuses on undergraduate medical education's role in tackling gender bias in clinical practice, specifically preventing and managing from a non-biomedical perspective chronic pain in women. A preliminary web search of medical schools' curricula was performed to identify programs content related to gender bias in pain management. The web search included 10 universities' websites selected from the top 10 rankings QS Universities Rankings 2022 for medical schools. Additionally, a questionnaire was sent to all deans of the selected academic institutions to explore the curriculum content further. The web search, and the lack of response from the deans, highlighted that relevant curriculum components on gender bias and chronic pain needed to be implemented. Therefore, this paper introduces an innovative curriculum development approach designed by the multi-professional research team to be implemented in medical school programs. This novel educational strategy could also cross-contaminate other healthcare practitioners' university programs and, thus, stimulate an interprofessional debate into fostering inclusiveness and equal opportunities in health.

Acute Ostracism-Related Pain Sensitization in the Context of Accumulated Lifetime Experiences of Ostracism

Ostracism (ie, being ignored/excluded) is a form of social adversity that powerfully impacts health and well-being. While laboratory research indicates that experimentally manipulated experiences of ostracism impact pain, findings have been mixed. Prior investigations have not considered moderating or main effects of individual histories of ostracism, and have been limited in the scope of their pain testing. In this study, participants without current pain reported lifetime experiences of ostracism prior to a laboratory visit where they were randomized to experience either a single episode of ostracism (ie, acute ostracism) or control condition that was immediately followed by quantitative sensory testing. Results indicate that the experimental effect of a single episode of ostracism on pain ratings, after-sensations, and temporal summation of pain is moderated by lifetime ostracism; no main effects were found. For individuals with histories of more lifetime ostracism, encountering a single episode of ostracism led to greater pain sensitization relative to the control condition, whereas no experimental effect was observed for individuals with little lifetime exposure to ostracism. These findings indicate that acute experiences of ostracism may be accompanied by periods of hyperalgesia for people who are chronically ostracized, implicating ostracism as a potential social moderator of pain sensitization. People who are stigmatized may therefore experience enhanced pain burden with repeated and accumulating experiences of ostracism. PERSPECTIVE: Results suggest that in the context of accumulated lifetime experiences of ostracism, single experiences of ostracism evoke central sensitization. In this way, ostracism may function to trigger central sensitization and shape socially- and societally-determined patterns of pain burden and disparity.

Acute and post-acute sequelae of SARS-CoV-2 infection: a review of risk factors and social determinants

SARS-CoV-2 infection leading to Coronavirus Disease 2019 (COVID-19) has caused more than 762 million infections worldwide, with 10-30% of patients suffering from post-acute sequelae of SARS-CoV-2 infections (PASC). Initially thought to primarily affect the respiratory system, it is now known that SARS-CoV-2 infection and PASC can cause dysfunction in multiple organs, both during the acute and chronic stages of infection. There are also multiple risk factors that may predispose patients to worse outcomes from acute SARS-CoV-2 infection and contribute to PASC, including genetics, sex differences, age, reactivation of chronic viruses such as Epstein Barr Virus (EBV), gut microbiome dysbiosis, and behavioral and lifestyle factors, including patients' diet, alcohol use, smoking, exercise, and sleep patterns. In addition, there are important social determinants of health, such as race and ethnicity, barriers to health equity, differential cultural perspectives and biases that influence patients' access to health services and disease outcomes from acute COVID-19 and PASC. Here, we review risk factors in acute SARS-CoV-2 infection and PASC and highlight social determinants of health and their impact on patients affected with acute and chronic sequelae of COVID-19.

Factors that affect pain management in adults diagnosed with acute appendicitis in the emergency department: A retrospective study

BACKGROUND

Analgesic treatment, including with opioids, can safely be given to patients who are suspected of having appendicitis. The study examined factors which may influence the treatment of pain in appendicitis in the adult emergency department (ED). A secondary objective was to determine if analgesia affected clinical outcomes.

METHODS

This single-center retrospective study examined medical records of all adult patients with a discharge diagnosis of appendicitis. Patients were categorized based on the type of analgesia received in the ED. Variables included the day of week and staffing shift of presentation, gender, age, and triage pain scale, as well as time to ED discharge, imaging, operation, and hospital discharge. Univariable and multivariable logistic regression models were performed to determine which factors influenced treatment and affected outcomes.

RESULTS

Records of 1839 patients were categorized into three groups - 883 (48%) did not receive analgesia, 571 (31%) received only non-opioid medications, and 385 (21%) received at least one opioid. Patients with a higher triage pain level were significantly more likely to receive analgesia (4-6: OR = 1.85; 95% CI = 1.2-2.84, 7-9: OR = 3.36; 95% CI = 2.18-5.17, 10: OR = 10.78; 95% CI = 6.38-18.23) and at least one opioid (4-6: OR = 2.88; 95% CI = 1.13-7.34, 7-9: OR = 4.36; 95% CI = 1.73-11.01, 10: OR = 6.23; 95% CI = 2.42-16.09). Male gender was associated with a significantly lower likelihood of receiving analgesia (OR = 0.74; 95% CI = 0.61-0.9), but a significantly greater likelihood of receiving at least one opioid given that they received any pain medication (OR = 1.87; 95% CI = 1.41-2.48). Patients aged 25-64 years old were significantly more likely to receive at least one opioid if they received any pain medication (25-44: OR = 1.47; 95% CI = 1.08-2.02, 45-64: OR = 1.78; 95% CI = 1.15-2.76). Presentation to the ED on Sundays was associated with lower rates of opioid treatment (OR = 0.63; 95% CI = 0.42-0.94). Regarding clinical outcomes, patients who received analgesia waited longer for imaging (+0.58 h; 95% CI = 0.31-0.85), stayed longer in the ED (+2.2 h; 95% CI = 1.60-2.79), and had a slightly longer hospitalization (+0.62d; 95% CI = 0.34-0.90).

CONCLUSIONS

Almost half of patients with appendicitis didn't receive analgesia, with most of those treated receiving only non-opioid analgesia. Older age and Sunday presentations were associated with less opioid treatment. Patients who received analgesia waited longer for imaging, stayed longer in the ED, and had a longer hospitalization.

Dismissal informs the priorities of endometriosis patients in New Zealand

Introduction

Endometriosis is a common condition with average delays to diagnosis in New Zealand of almost 9 years.

Methods

In total, 50 endometriosis patients participated in anonymous, asynchronous, online group discussions about their priorities, and their experiences with the development of symptoms, seeking a diagnosis, and receiving appropriate treatment.

Results

Higher subsidy of care was the top change endometriosis patients wanted, followed by more research funding. When asked to choose whether research should be focused on improving diagnosis or improving treatment methods, the results were evenly split. Within this cohort, patients highlighted that they did not know the difference between normal menstrual discomfort and pathological endometriotic pain. If, upon seeking help, medical practitioners classified their symptoms as "normal," these dismissals could instill doubt in patients, which made it more difficult for them to continue to seek a diagnosis and effective treatments. Patients who did not express dismissal had a significantly shorter delay from symptom onset to diagnosis of 4.6 ± 3.4 years vs. 9.0 ± 5.2 years.

Conclusion

Doubt is a frequent experience for endometriosis patients in New Zealand, which was reinforced by some medical practitioners who were dismissive of their pain and thus prolonged the patient's delay to diagnosis.

Female reproductive health impacts of Long COVID and associated illnesses including ME/CFS, POTS, and connective tissue disorders: a literature review

Long COVID disproportionately affects premenopausal women, but relatively few studies have examined Long COVID's impact on female reproductive health. We conduct a review of the literature documenting the female reproductive health impacts of Long COVID which may include disruptions to the menstrual cycle, gonadal function, ovarian sufficiency, menopause, and fertility, as well as symptom exacerbation around menstruation. Given limited research, we also review the reproductive health impacts of overlapping and associated illnesses including myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), postural orthostatic tachycardia syndrome (POTS), connective tissue disorders like Ehlers-Danlos syndrome (EDS), and endometriosis, as these illnesses may help to elucidate reproductive health conditions in Long COVID. These associated illnesses, whose patients are 70%-80% women, have increased rates of dysmenorrhea, amenorrhea, oligomenorrhea, dyspareunia, endometriosis, infertility, vulvodynia, intermenstrual bleeding, ovarian cysts, uterine fibroids and bleeding, pelvic congestion syndrome, gynecological surgeries, and adverse pregnancy complications such as preeclampsia, maternal mortality, and premature birth. Additionally, in Long COVID and associated illnesses, symptoms can be impacted by the menstrual cycle, pregnancy, and menopause. We propose priorities for future research and reproductive healthcare in Long COVID based on a review of the literature. These include screening Long COVID patients for comorbid and associated conditions; studying the impacts of the menstrual cycle, pregnancy, and menopause on symptoms and illness progression; uncovering the role of sex differences and sex hormones in Long COVID and associated illnesses; and addressing historical research and healthcare inequities that have contributed to detrimental knowledge gaps for this patient population.

“Out of This World”: Norwegian Women’s Experiences of Medical Abortion Pain

Introduction

Medical abortion has rapidly become the dominant abortion method in western countries. Pain is a known adverse effect; however, few studies have explored women's subjective experience of medical abortion pain.

Purpose

To explore Norwegian women's experiences of pain when performing a medical abortion at home.

Material and Methods

We recruited 24 women through an advertisement on Facebook and conducted semi-structured, face-to-face interviews. The interviews were transcribed verbatim and the data were analyzed using a phenomenological hermeneutical method.

Results

Our findings consisted of two main themes: 1) Being in pain or becoming pain, and 2) Being caught off guard and struggling to cope. Participants described undergoing severe pain, comparable to giving birth, during the medical abortion. Unprepared for the type and intensity of the pain, they felt anxious and insecure. Pain is physical, but it also has important psychological, social, and existential dimensions. Our culture (in)forms our thoughts and feelings about our pain, affecting our ability to endure suffering. The participants' experiences of abortion pain prompt timely questions concerning gendered socio-cultural and existential meanings connected to pain, specifically in relation to female reproductive functions.

Conclusion

Women need realistic information about the type and intensity of abortion pain, as well as evidence-based pain medication. Psychological factors may affect the experience of abortion pain and should therefore be taken into account in abortion care.

You Can Change a Girl's Life Today: The Truth About Periods and Endometriosis

While endometriosis, a condition where tissue growing outside the uterus causes pain and infertility, is generally widespread among teenage girls and women, it is often misdiagnosed leading to a delay in treatment while the symptoms and damage from the disease increase. This article uses a case study to illustrate the signs and symptoms of endometriosis in a teenage girl, while also discussing many factors surrounding the issue such as the incidence, disease burden, medical research and women, reasons for diagnostic delay, and the current recommended treatments. School nurses are in the unique position to identify young girls and adolescents who are presenting with painful periods or other symptoms possibly associated with endometriosis and can become advocates for the next generation of patients.

Intersectionality of Systemic Disadvantage on Mortality and Care Following TBI

BACKGROUND

People of color (POC), especially those who also hold social identities associated with disadvantage (non-English-speaking, female, older, lower socioeconomic level), continue to be underserved in the health system, which can result in poorer care and worsened health outcomes. Most disparity research in traumatic brain injury (TBI) focuses on the impact of single factors, which misses the compounding effect of belonging to multiple historically marginalized groups.

OBJECTIVE

To examine the intersectional impact of multiple social identities vulnerable to systemic disadvantage following TBI on mortality, opioid usage during acute hospitalization, and discharge location.

METHODS

Retrospective observational design utilizing electronic health records merged with local trauma registry data. Patient groups were defined by race and ethnicity (POC or non-Hispanic White), age, sex, type of insurance, and primary language (English-speaking vs non-English-speaking). Latent class analysis (LCA) was performed to identify clusters of systemic disadvantage. Outcome measures were then assessed across latent classes and tested for differences.

RESULTS

Over an 8-year period, 10 809 admissions with TBI occurred (37% POC). LCA identified a 4-class model. Groups with more systemic disadvantage had higher rates of mortality. Classes with older populations had lower rates of opioid administration and were less likely to discharge to inpatient rehabilitation following acute care. Sensitivity analyses examining additional indicators of TBI severity demonstrated that the younger group with more systemic disadvantage had more severe TBI. Controlling for more indicators of TBI severity changed statistical significance in mortality for younger groups.

CONCLUSION

Results demonstrate significant health inequities in the mortality and access to inpatient rehabilitation following TBI along with higher rates of severe injury in younger patients with more social disadvantages. While many inequities may be related to systemic racism, our findings suggested an additive, deleterious effect for patients who belonged to multiple historically disadvantaged groups. Further research is needed to understand the role of systemic disadvantage for individuals with TBI within the healthcare system.

Evidence-Based Guidelines for Prehospital Pain Management: Recommendations

This project sought to develop evidence-based guidelines for the administration of analgesics for moderate to severe pain by Emergency Medical Services (EMS) clinicians based on a separate, previously published, systematic review of the comparative effectiveness of analgesics in the prehospital setting prepared by the University of Connecticut Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel (TEP) was assembled consisting of subject matter experts in prehospital and emergency care, and the development of evidence-based guidelines and patient care guidelines. A series of nine "patient/population-intervention-comparison-outcome" (PICO) questions were developed based on the Key Questions identified in the AHRQ systematic review, and an additional PICO question was developed to specifically address analgesia in pediatric patients. The panel made a strong recommendation for the use of intranasal fentanyl over intravenous (IV) opioids for pediatric patients without intravenous access given the supporting evidence, its effectiveness, ease of administration, and acceptance by patients and providers. The panel made a conditional recommendation for the use of IV non-steroidal anti-inflammatory drugs (NSAIDs) over IV acetaminophen (APAP). The panel made conditional recommendations for the use of either IV ketamine or IV opioids; for either IV NSAIDs or IV opioids; for either IV fentanyl or IV morphine; and for either IV ketamine or IV NSAIDs. A conditional recommendation was made for IV APAP over IV opioids. The panel made a conditional recommendation against the use of weight-based IV ketamine in combination with weight-based IV opioids versus weight-based IV opioids alone. The panel considered the use of oral analgesics and a conditional recommendation was made for either oral APAP or oral NSAIDs when the oral route of administration was preferred. Given the lack of a supporting evidence base, the panel was unable to make recommendations for the use of nitrous oxide versus IV opioids, or for IV ketamine in combination with IV opioids versus IV ketamine alone. Taken together, the recommendations emphasize that EMS medical directors and EMS clinicians have a variety of effective options for the management of moderate to severe pain in addition to opioids when designing patient care guidelines and caring for patients suffering from acute pain.

Development of a keyword library for capturing PRO-CTCAE-focused "symptom talk" in oncology conversations

Objectives

As computational methods for detecting symptoms can help us better attend to patient suffering, the objectives of this study were to develop and evaluate the performance of a natural language processing keyword library for detecting symptom talk, and to describe symptom communication within our dataset to generate insights for future model building.

Materials and Methods

This was a secondary analysis of 121 transcribed outpatient oncology conversations from the Communication in Oncologist-Patient Encounters trial. Through an iterative process of identifying symptom expressions via inductive and deductive techniques, we generated a library of keywords relevant to the Patient-Reported Outcome version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) framework from 90 conversations, and tested the library on 31 additional transcripts. To contextualize symptom expressions and the nature of misclassifications, we qualitatively analyzed 450 mislabeled and properly labeled symptom-positive turns.

Results

The final library, comprising 1320 terms, identified symptom talk among conversation turns with an F1 of 0.82 against a PRO-CTCAE-focused gold standard, and an F1 of 0.61 against a broad gold standard. Qualitative observations suggest that physical symptoms are more easily detected than psychological symptoms (eg, anxiety), and ambiguity persists throughout symptom communication.

Discussion

This rudimentary keyword library captures most PRO-CTCAE-focused symptom talk, but the ambiguity of symptom speech limits the utility of rule-based methods alone, and limits to generalizability must be considered.

Conclusion

Our findings highlight opportunities for more advanced computational models to detect symptom expressions from transcribed clinical conversations. Future improvements in speech-to-text could enable real-time detection at scale.

Capturing the lived experiences of women with lymphoma in pregnancy: a qualitative study

Lymphoma in pregnancy is a rare and challenging diagnosis that complicates ∼1:6000 pregnancies; posing a series of unique therapeutic, social, and ethical challenges to the patient, her family, and the medical professionals involved. These difficulties are compounded by the paucity of real-world data on the management of LIP, and a lack of relevant support systems for women in this setting. We conducted a retrospective multicenter qualitative study, interviewing women aged ≥18 years of age diagnosed with Hodgkin (HL) or non-Hodgkin lymphoma (NHL) during pregnancy or within 12 months postpartum, between 1 January 2009 and 31 December 2020 from 13 Australasian sites. Semi-structured telephone interviews were conducted, recorded, and analyzed using QSR Int NVivo 12 Pro (March 2020, USA) to quantify salient themes. Of the 32 women interviewed, 20 (63%) were diagnosed during pregnancy (16, 34, and 13% in the 1st, 2nd, and 3rd trimesters, respectively), while 12 (37%) were diagnosed post-partum. Women recalled that their chief concerns at diagnosis were the welfare of their child (n = 13, 41%) and a fear of dying (n = 9, 28%). Perceived diagnostic delay attributed to pregnancy was reported by 41% of participants. Other key themes were communication, educational materials, psychosocial supports, and oncofertility issues. To our knowledge this is the first report capturing the lived experiences of survivors of lymphoma during pregnancy, affording a unique opportunity to consider the management, psychosocial supports, and delivery of care to meet the needs of these women.What is the NEW aspect of your work? To our knowledge, this is the first report capturing and analyzing the healthcare experiences of survivors of Lymphoma in Pregnancy (LIP).What is the CENTRAL finding of your work? Women valued clear and empathic communication, provision of tailored educational materials, access to psychosocial supports (particularly childcare and financial supports), and timely oncofertility management in their healthcare journey.What is (or could be) the SPECIFIC clinical relevance of your work? Women's personal accounts of positive and negative experiences of LIP care provide insights into their specific concerns and needs which can shape healthcare policy and development of a specific framework for managing and supporting patients with LIP (and other cancers).

Cannabis use for pain relief in the context of health service barriers: Accounts of street-involved Nigerian women suffering chronic pain

INTRODUCTION

This study explored cannabis use for pain relief among socially marginalised Nigerian women in the context of barriers to pain management.

METHODS

The study was designed as a qualitative exploratory study of pain experience and management. Sixteen in-depth, individual interviews were conducted with street-involved women who use drugs and had chronic pain. Transcripts were coded and analysed thematically.

RESULTS

Pain was experienced as a pervasive feature of everyday life that disrupted daily routines, affected economic activities, strained social relationships and had adverse effects on health and wellbeing. Participants sought treatment in health facilities, but faced social and health system barriers to service utilisation including financial cost of services, dismissal of symptoms by providers, stigma due to physical appearance, substance use and lack of social support. These barriers encouraged disengagement from services and reliance on cannabis (along with heroin and diverted prescription opioids) for pain management. Cannabis use relieved pain and improved daily functioning, enabling participants to undertake economic activities. However, using cannabis to enhance the effects of opioids and heavy and long-term use owing to pain chronicity and disability generated concerns about harms.

DISCUSSION AND CONCLUSIONS

Findings show the therapeutic benefits of cannabis in the face of barriers to pain management. This support calls to explore the potentials of cannabis for pain management for socially marginalised populations and to develop medical guidelines to reduce the risk of adverse health consequences. Therapeutic cannabis, provided based on medical guidance, could improve pain management for socially marginalised populations.

Deficits and Disparities in Early Uptake of Glucagon-Like Peptide 1 Receptor Agonists and SGLT2i Among Medicare-Insured Adults Following a New Diagnosis of Cardiovascular Disease or Heart Failure

OBJECTIVE

To examine the association of race/ethnicity and socioeconomic deprivation with initiation of guideline-recommended diabetes medications with cardiovascular benefit (glucagon-like peptide 1 receptor agonists [GLP1-RA] and sodium-glucose cotransporter 2 inhibitors [SGLT2i]) among older adults with type 2 diabetes (T2D) and either incident atherosclerotic cardiovascular disease (ASCVD) or congestive heart failure (CHF).

RESEARCH DESIGN AND METHODS

Using Medicare data (2016-2019), we identified 4,057,725 individuals age >65 years with T2D and either incident ASCVD or CHF. We estimated incidence rates and hazard ratios (HR) of GLP1-RA or SGLT2i initiation within 180 days by race/ethnicity and zip code-level Social Deprivation Index (SDI) using adjusted Cox proportional hazards models.

RESULTS

Incidence rates of GLP1-RA or SGLT2i initiation increased over time but remained low (<0.6 initiations per 100 person-months) in all years studied. Medication initiation was less common among those of Black or other race/ethnicity (HR 0.81 [95% CI 0.79-0.84] and HR 0.84 [95% CI 0.75-0.95], respectively) and decreased with increasing SDI (HR 0.96 [95% CI 0.96-0.97]). Initiation was higher in ASCVD than CHF (0.35 vs. 0.135 initiations per 100 person-months). Moderate (e.g., nephropathy, nonalcoholic fatty liver disease) but not severe (e.g., advanced chronic kidney disease, cirrhosis) comorbidities were associated with higher probability of medication initiation.

CONCLUSIONS

Among older adults with T2D and either ASCVD or CHF, initiation of GLP1-RA or SGLT2i was low, suggesting a substantial deficit in delivery of guideline-recommended care or treatment barriers. Individuals of Black and other race/ethnicity and those with higher area-level socioeconomic deprivation were less likely to initiate these medications.

"I Just Want to Feel Safe Going to a Doctor": Experiences of Female Patients with Chronic Conditions in Australia

Background

The androcentric history of medicine and medical research has led to an ongoing sex and gender gap in health research and education. Sex and gender gaps in research and education may translate into real-life health inequities for women. This study aimed to explore the experiences of female patients with chronic health conditions in the Australian health system, considering existing sex and gender gaps in medicine.

Methods

This qualitative study used semistructured in-depth interviews with a sample of adult women with chronic conditions in Australia. Thematic analysis was undertaken, guided by Braun and Clarke. Software NVivoX64 assisted in the management of the data. Coding was performed before grouping into subthemes and central themes. To allow for potential researcher biases, the principal researcher engaged in the practice of reflexivity, including the writing of detailed notes during analysis.

Results

Twenty adult Australian women with chronic conditions were interviewed. Diagnoses were varied and included Ehlers-Danlos syndrome, chronic fatigue syndrome, functional neurological disorder, and inflammatory bowel disease. Four central themes emerged: diagnostic difficulties; spectrum of health care experiences; understanding medical complexity; and coping with symptoms.

Conclusions

Women with chronic conditions in Australia report pain, fatigue, and suffering that significantly impacts upon their daily lives. There was a shared experience of feeling that the pain and suffering of women was dismissed or not taken seriously. Many women expressed trauma because of their experiences in health care and often this led to a fear of accessing health services. The participants highlighted a need for more knowledge, understanding, and empathy from health care practitioners.

Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review

BACKGROUND

Emergency medical services (EMS) often serve as the first medical contact for ill or injured patients, representing a critical access point to the health care delivery continuum. While a growing body of literature suggests inequities in care within hospitals and emergency departments, limited research has comprehensively explored disparities related to patient demographic characteristics in prehospital care.

OBJECTIVE

We aimed to summarize the existing literature on disparities in prehospital care delivery for patients identifying as members of an underrepresented race, ethnicity, sex, gender, or sexual orientation group.

METHODS

We conducted a scoping review of peer-reviewed and non-peer-reviewed (gray) literature. We searched PubMed, CINAHL, Web of Science, Proquest Dissertations, Scopus, Google, and professional websites for studies set in the U.S. between 1960 and 2021. Each abstract and full-text article was screened by two reviewers. Studies written in English that addressed the underrepresented groups of interest and investigated EMS-related encounters were included. Studies were excluded if a disparity was noted incidentally but was not a stated objective or discussed. Data extraction was conducted using a standardized electronic form. Results were summarized qualitatively using an inductive approach.

RESULTS

One hundred forty-five full-text articles from the peer-reviewed literature and two articles from the gray literature met inclusion criteria: 25 studies investigated sex/gender, 61 studies investigated race/ethnicity, and 58 studies investigated both. One study investigated sexual orientation. The most common health conditions evaluated were out-of-hospital cardiac arrest (n = 50), acute coronary syndrome (n = 36), and stroke (n = 31). The phases of EMS care investigated included access (n = 55), pre-arrival care (n = 46), diagnosis/treatment (n = 42), and response/transport (n = 40), with several studies covering multiple phases. Disparities were identified related to all phases of EMS care for underrepresented groups, including symptom recognition, pain management, and stroke identification. The gray literature identified public perceptions of EMS clinicians' cultural competency and the ability to appropriately care for transgender patients in the prehospital setting.

CONCLUSIONS

Existing research highlights health disparities in EMS care delivery throughout multiple health outcomes and phases of EMS care. Future research is needed to identify structured mechanisms to eliminate disparities, address clinician bias, and provide high-quality equitable care for all patient populations.

Evidence-Based Medicine: Feminist Criticisms and Implications for Women's Health

Evidence-based medicine (EBM) dates back to 19th-century Paris and started out as a new paradigm for practicing medicine, with the aim of replacing anecdote with high-quality evidence from positivist-style research. Despite the clear logic underpinning EBM, there have been numerous criticisms, including maintenance of an archaic view of evidence as "facts," failure to acknowledge that all research is underpinned by the beliefs of the researcher, and the simple fact that medical research has historically been androcentric and results generalized to female patients. In this essay, we discuss the criticisms of EBM, with a focus on feminist critiques based on three central feminist epistemologies: feminist empiricism, standpoint theory, and social constructivism. We argue that EBM potentially perpetuates gaps in women's health and advocate for incorporating feminist epistemologies into future medical research to garner further understanding of social influences on women's health. In addition, we argue that EBM may degrade the clinical acumen and that critical thinking should become a key component of medical school curricula.

How gender affects the decoding of facial expressions of pain

OBJECTIVES

Gender has been suggested to play a critical role in how facial expressions of pain are perceived by others. With the present study we aim to further investigate how gender might impact the decoding of facial expressions of pain, (i) by varying both the gender of the observer as well as the gender of the expressor and (ii) by considering two different aspects of the decoding process, namely intensity decoding and pain recognition.

METHODS

In two online-studies, videos of facial expressions of pain as well as of anger and disgust displayed by male and female avatars were presented to male and female participants. In the first study, valence and arousal ratings were assessed (intensity decoding) and in the second study, participants provided intensity ratings for different affective states, that allowed for assessing intensity decoding as well as pain recognition.

RESULTS

The gender of the avatar significantly affected the intensity decoding of facial expressions of pain, with higher ratings (arousal, valence, pain intensity) for female compared to male avatars. In contrast, the gender of the observer had no significant impact on intensity decoding. With regard to pain recognition (differentiating pain from anger and disgust), neither the gender of the avatar, nor the gender of the observer had any affect.

CONCLUSIONS

Only the gender of the expressor seems to have a substantial impact on the decoding of facial expressions of pain, whereas the gender of the observer seems of less relevance. Reasons for the tendency to see more pain in female faces might be due to psychosocial factors (e.g., gender stereotypes) and require further research.

A systematic review of clinical outcomes for outpatient vs. inpatient shoulder arthroplasty

BACKGROUND

Outpatient shoulder arthroplasty is growing in popularity as a cost-effective and potentially equally safe alternative to inpatient arthroplasty. The aim of this study was to investigate literature relating to outpatient shoulder arthroplasty, looking at clinical outcomes, complications, readmission, and cost compared to inpatient arthroplasty.

METHODS

We conducted a systematic review of Medline, Embase and Cochrane Library databases from inception to 6 April 2020. Methodological quality was assessed using MINORS and GRADE criteria.

RESULTS

We included 17 studies, with 11 included in meta-analyses and 6 in narrative review. A meta-analysis of hospital readmissions demonstrated no statistically significant difference between outpatient and inpatient cohorts (OR = 0.89, p = 0.49). Pooled post-operative complications identified decreased complications in those undergoing outpatient surgery (OR = 0.70, p = 0.02). Considerable cost saving of between $3614 and $53,202 (19.7-69.9%) per patient were present in the outpatient setting. Overall study quality was low and presented a serious risk of bias.

DISCUSSION

Shoulder arthroplasty in the outpatient setting appears to be as safe as shoulder arthroplasty in the inpatient setting, with a significant reduction in cost. However, this is based on low quality evidence and high risk of bias suggests further research is needed to substantiate these findings.

Self-Reported Time to Diagnosis and Proportions of Rediagnosis in Female Patients with Chronic Conditions in Australia: A Cross-sectional Survey

Background

The diagnosis of chronic conditions in women is complicated by the historical androcentricity in medical research. Sex and gender gaps in health research may translate to unequal healthcare for women. This cross-sectional survey study aimed to ascertain the median time to diagnosis, proportions of rediagnosis and time to rediagnosis for Australian women with chronic conditions.

Methods

An online survey collected anonymous data from voluntary participants. Data were analyzed using Stata14. Cox Proportional Hazards model was used to analyze time to diagnosis and rediagnosis. Logistic regression analysis was used to assess the significance of rediagnosis rates by diagnosis, age at diagnosis, income, employment, state of residence, disability status, and Indigenous status.

Results

The median time from first appointment to initial diagnosis was 6 months (range 1 day-50 years) (interquartile range [IQR] 3.74 years). The median time to rediagnosis was 4 years (IQR 9) with a range of 1 day-43 years. Almost half of the women (n = 161/343, 47%) reported their primary condition being rediagnosed. From the complete responses, 40% were rediagnosed from one organic condition to another organic condition, however, 32% of women originally diagnosed with psychological, medically unexplained syndromes, or chronic pain were later rediagnosed with organic conditions.

Conclusion

Median wait times for a diagnosis for women in Australia, when factoring in high rates of rediagnosis and time to rediagnosis, was 4 years. It is important that clinicians are aware of the high rediagnosis rates in female patients with chronic conditions and understand the potential impact of systemic biases on the diagnostic process for women under their care.

Mind the Gap: Reporting and Analysis of Sex and Gender in Health Research in Australia, a Cross-Sectional Study

Introduction

Historically, medical studies have underrepresented female participants and most research data have been collected from males and generalized to other genders. This article aims to determine if there is a sex and/or gender gap in recent Australian health research.

Methods

This descriptive cross-sectional study of the published literature examines recent Australian-based clinical trials for inclusion of sex and gender. Medians and interquartile ranges (IQRs) were calculated for study sample sizes and female:male representation. Proportion of sex and/or gender was analyzed by the clinical specialty of the trials. t-Tests were used to ascertain significance of any difference in recruitment of female and males.

Results

A total of 88 articles were included in the analysis. Most studies (n = 63) were randomized clinical controlled trials. Overall women constituted 55% (IQR 30% of all participants). Of the 71 mixed-sex studies, only 8.9% (n = 7) analyzed the data by sex. Women were significantly underrepresented in cardiology and nephrology studies and overrepresented in psychiatry, care of the elderly, and orthopedic studies.

Conclusions

When analyzed by specialty, women are overrepresented in specialties considered to be female patient dominated, such as psychiatry and care of the elderly, and underrepresented in specialties such as cardiology and nephrology. The overrepresentation of women in some specialties can reinforce gender stereotypes, potentially harming women. In addition, exclusion of males from these areas of research may be of disservice to men's health.

Gender and ethnicity bias in medicine: a text analysis of 1.8 million critical care records

Gender and ethnicity biases are pervasive across many societal domains including politics, employment, and medicine. Such biases will facilitate inequalities until they are revealed and mitigated at scale. To this end, over 1.8 million caregiver notes (502 million words) from a large US hospital were evaluated with natural language processing techniques in search of gender and ethnicity bias indicators. Consistent with nonlinguistic evidence of bias in medicine, physicians focused more on the emotions of women compared to men and focused more on the scientific and bodily diagnoses of men compared to women. Content patterns were relatively consistent across genders. Physicians also attended to fewer emotions for Black/African and Asian patients compared to White patients, and physicians demonstrated the greatest need to work through diagnoses for Black/African women compared to other patients. Content disparities were clearer across ethnicities, as physicians focused less on the pain of Black/African and Asian patients compared to White patients in their critical care notes. This research provides evidence of gender and ethnicity biases in medicine as communicated by physicians in the field and requires the critical examination of institutions that perpetuate bias in social systems.

The Influence of Gender Bias: Is Pain Management in the Field Affected by Health Care Provider's Gender?

INTRODUCTION

Appropriate pain management indicates the quality of casualty care in trauma. Gender bias in pain management focused so far on the patient. Studies regarding provider gender are scarce and have conflicting results, especially in the military and prehospital settings.

STUDY OBJECTIVE

The purpose of this study is to investigate the effect of health care providers' gender on pain management approaches among prehospital trauma casualties treated by the Israel Defense Forces (IDF) medical teams.

METHODS

This retrospective cohort study included all trauma casualties treated by IDF senior providers from 2015-2020. Casualties with a pain score of zero, age under 18 years, or treated with endotracheal intubation were excluded. Groups were divided according to the senior provider's gender: only females, males, or both female and male. A multivariate analysis was performed to assess the odds ratio of receiving an analgesic, depending on the presence of a female senior provider, adjusting for potential confounders. A subgroup analysis was performed for "delta-pain," defined as the difference in pain score during treatment.

RESULTS

A total of 976 casualties were included, of whom 835 (85.6%) were male. Mean pain scores (SD) for the female only, male only, and both genders providers were 6.4 (SD = 2.9), 6.4 (SD = 3.0), and 6.9 (SD = 2.8), respectively (P = .257). There was no significant difference between females, males, or both female and male groups in analgesic treatment, overall and per specific agent. This remained true also in the multivariate model. Delta-pain difference between groups was also not significant. Less than two-thirds of casualties in this study were treated for pain among all study groups.

CONCLUSION

This study found no association between IDF Medical Corps providers' gender and pain management in prehospital trauma patients. Further studies regarding disparities in acute pain treatment are advised.

Physicians prescribe fewer analgesics during night shifts than day shifts

Adequate pain management is one of the biggest challenges of the modern healthcare system. Physician perception of patient subjective pain, which is crucial to pain management, is susceptible to a host of potential biases. Here we explore the timing of physicians' work as a previously unrecognized source of systematic bias in pain management. We hypothesized that during night shifts, sleep deprivation, fatigue, and stress would reduce physicians' empathy for others' pain, leading to underprescription of analgesics for patient pain relief. In study 1, 67 resident physicians, either following a night shift or not, performed empathy for pain assessment tasks and simulated patient scenarios in laboratory conditions. As predicted, following a night shift, physicians showed reduced empathy for pain. In study 2, we explored this phenomenon in medical decisions in the field. We analyzed three emergency department datasets from Israel and the United States that included discharge notes of patients arriving with pain complaints during 2013 to 2020 (n = 13,482). Across all datasets, physicians were less likely to prescribe an analgesic during night shifts (compared to daytime shifts) and prescribed fewer analgesics than generally recommended by the World Health Organization. This effect remained significant after adjusting for patient, physician, type of complaint, and emergency department characteristics. Underprescription for pain during night shifts was particularly prominent for opioids. We conclude that night shift work is an important and previously unrecognized source of bias in pain management, likely stemming from impaired perception of pain. We consider the implications for hospitals and other organizations employing night shifts.

Women's Health: Population Patterns and Social Determinants

Women's health, and what we know about it, are influenced by social factors. From the exclusion of women's bodies in medical research, to the silence and stigma of menstruation and menopause, to the racism reflected in maternal mortality, the relevance of social factors is paramount. After a brief history of research on women's health, we review selected patterns, trends, and inequalities in US women's health. These patterns reveal US women's poor and declining longevity relative to those in other high-income countries, gaps in knowledge about painful and debilitating conditions that affect millions of women, and deep inequalities that underscore the need to redress political and structural features of US society that enhance health for some and diminish it for others. We close by describing the challenges and opportunities for future research, and the promise of a social determinants of health approach for advancing a multilevel, intersectional, and biosocial understanding of women's health.

Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department

This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.

Disparities in Insurance Status are Associated With Outcomes But Not Timing of Trauma Care

INTRODUCTION

Patient factors influence outcomes after injury. Delays in care have a crucial impact. We investigated the associations between patient characteristics and timing of transfer from the emergency department to definitive care.

METHODS

This was a review of adult trauma patients treated between January 1, 2016, and December 31, 2018. Bivariate analyses were used to build Cox proportional hazards models. We built separate logistic and negative binomial regression models for secondary outcomes using mixed-step selection to minimize the Akaike information criterion c.

RESULTS

A total of 1219 patients were included; 68.5% were male, 56.8% White, 11.2% Black, and 7.8% Asian/Pacific Islander. The average age was 51 ± 21 y. Overall, 13.7% of patients were uninsured. The average length of stay was 5 d and mortality was 5.9%. Shorter transfer time out of the emergency department was associated with higher tier of activation (relative risk [RR] 1.39, 95% confidence interval [CI] 1.09-1.77; P = 0.0074), Injury Severity Score between 16 and 24 points (RR 1.57, 95% CI 1.04-2.32; P = 0.0307) or ≥25 (RR 3.85, 95% CI 2.45-5.94; P = 0.0001), and penetrating injury. Longer time to event was associated with Glasgow coma scale score ≥14 points (RR 0.47, 95% CI 0.27-0.85; P = 0.0141). Uninsured patients were less likely to be admitted (odds ratio 0.29, 95% CI 0.17-0.48; P = 0.0001) and more likely to experience shorter length of stay (incidence rate ratio 0.34, 95% CI 0.24-0.51; P = 0.0001).

CONCLUSIONS

Injury characteristics and insurance status were associated with patient outcomes in this retrospective, single-center study. We found no disparity in timing of intrafacility transfer, perhaps indicating that initial management protocols preserve equity.

Opioids for chronic pain management in patients with dialysis-dependent kidney failure

Chronic pain is highly prevalent among adults treated with maintenance haemodialysis (HD) and has profound negative effects. Over four decades, research has demonstrated that 50-80% of adult patients treated with HD report having pain. Half of patients with HD-dependent kidney failure (HDKF) have chronic moderate-to-severe pain, which is similar to the burden of pain in patients with cancer. However, pain management in patients with HDKF is often ineffective as most patients report that their pain is inadequately treated. Opioid analgesics are prescribed more frequently for patients receiving HD than for individuals in the general population with chronic pain, and are associated with increased morbidity, mortality and health-care resource use. Furthermore, current opioid prescribing patterns are frequently inconsistent with guideline-recommended care. Evidence for the effectiveness of opioids in pain management in general, and in patients with HDKF specifically, is lacking. Nonetheless, long-term opioid therapy has a role in the treatment of some patients when used selectively, carefully and combined with an ongoing assessment of risks and benefits. Here, we provide a comprehensive overview of the use of opioid therapy in patients with HDKF and chronic pain, including a discussion of buprenorphine, which has potential as an analgesic option for patients receiving HD owing to its unique pharmacological properties.

Sex Inequalities in Medical Research: A Systematic Scoping Review of the Literature

Background: Historically, medical studies have excluded female participants and research data have been collected from males and generalized to females. The gender gap in medical research, alongside overarching misogyny, results in real-life disadvantages for female patients. This systematic scoping review of the literature aims to determine the extent of research into the medical research sex and gender gap and to assess the extent of misogyny, if any, in modern medical research. Methods: Initial literature searches were conducted using PubMed, Science Direct, PsychINFO and Google Scholar. Articles published between January 01, 2009, and December 31, 2019, were included. An article was deemed to display misogyny if it discussed the female aesthetic in terms of health, but did not measure health or could not be utilized to improve clinical practice. Results: Of the 17 included articles, 12 examined the gender gap in medical research and 5 demonstrated misogyny, assessing female attractiveness for alleged medical reasons. Females remain broadly under-represented in the medical literature, sex and gender are poorly reported and inadequately analyzed in research, and misogynistic perceptions continue to permeate the narrative. Conclusion: The gender gap and misogynistic studies remain present in the contemporary medical literature. Reasons and implications for practice are discussed.

Perioperative Pain Management Practices Vary Across Time and Setting for Pediatric ACL Reconstruction: Trends From a National Database in the United States

Background:

Surgical and anesthetic techniques have enabled a shift to the ambulatory setting for the majority of patients with anterior cruciate ligament (ACL) tears. While this change likely reflects improvements in acute pain management, little is known about national trends in pediatric perioperative pain management after ACL reconstruction (ACLR).

Purpose:

To describe recent trends in the United States in perioperative pain management for pediatric ACLR.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Pediatric patients (age, ≤18 years) who underwent ACLR with peripheral nerve blocks between January 2008 and December 2017 were identified in the Pediatric Health Information System database. We modeled the use of oral and intravenous analgesic medications over time using Bayesian logistic mixed models. Models were adjusted for patient age, sex, race, primary payer, and treatment setting (ambulatory, observation, or inpatient).

Results:

The study criteria produced a sample of 18,605 patients. Older children were more likely to receive intravenous acetaminophen, intravenous ketorolac, and oral and intravenous opioids. Younger children were more likely to receive ibuprofen. In our adjusted logistic model, treatment setting was found to be an independent predictor of the utilization of all medications. We found an increase in the overall utilization of oral acetaminophen (adjusted odds ratio [adj OR], 1.14 [95% CI, 1.04-1.23]), intravenous acetaminophen (adj OR, 1.42 [95% CI, 1.22-1.65]), and oral opioids (adj OR, 1.16 [95% CI, 1.06-1.28]) over the study period at a typical hospital. We found significant heterogeneity in medication use across hospitals, with the most heterogeneity in intravenous acetaminophen. Other studied descriptive variables did not appear to predict practices.

Conclusion:

After adjusting for patient characteristics and treatment settings, pain management strategies varied among hospitals and over time. Patient age and treatment setting predicted practices. Regional anesthesia, opioid medications, and intravenous ketorolac remained the mainstays of treatment, while intravenous acetaminophen emerged in use over the course of the study period. The variability in the pain management of pediatric patients undergoing ACLR suggests that further study is necessary to establish the most effective means of perioperative pain management in these patients.

Analysis of patient preferences on patient-provider interactions through the OpenNotes online portal in dermatology

Background: Many medical centers are beginning to use OpenNotes (ON) to empower patients. However, there is a lack of literature reviewing the ON system in dermatology and any differences in attitudes between men and women. If so, it is uncertain what concerns are more important to female patients. Given the complex lexicon of notes in dermatology, the outpatient setting of dermatology practices, and the often-complex nature of treatment regimens, investigation was merited.

Objective: This paper aimed to evaluate a survey of dermatologic patients on their attitudes toward the ON system.

Methods: From July through October 2015, 333 dermatologic patients at the Beth Israel Deaconess Medical Center completed an anonymous, voluntary, 25-question survey of the ON system while in the waiting room. Approximately 60% of respondents were female and 40% were male. Respondents were older, with 27% age >65 years, 21% between 56 and 65 years, 16% between 46 and 55 years, 17% between 36 and 45 years, 14% between 26 and 35 years, and 4% between 18 and 25 years. Eighty-five percent of respondents were white, and 73% had, at minimum, graduated from college.

Results: Patient response to ON was positive, with 93% agreeing ON is a good idea. Of the patients who accessed their own notes (69% of respondents), 99.6% desired continued access. In addition, 85.6% of patients felt ON allowed them to control their own health, and 70% reported increased confidence in their dermatologist. Nineteen percent of respondents thought ON presented a privacy concern.

Conclusion: The results showed that female patients strongly desire access to their medical records, but concerns about privacy and security exist. Preliminary analysis by a statistician did not find any statistically significant variations between men and women within the results of the survey. Due to the wide agreement in responses, it is unlikely that there are significant differences in opinion on ON between men and women.

The disease burden of axial spondyloarthritis: through a gendered lens

INTRODUCTION

Axial spondyloarthritis (axSpA) affects patients' health-related quality of life (HRQoL). Prior studies have documented gender differences in axSpA across the disease spectrum. Our study aims to assess gender differences on the effects of axSpA on patients' HRQoL.

METHOD

A secondary qualitative thematic analysis was conducted using data from in-depth interviews (n = 24) of patients with a rheumatologist-confirmed axSpA diagnosis. This analysis focused on gender and HRQoL themes including activity, occupation, sleep, healthcare system, mental health, medication usage, and relationships.

RESULTS

While men on average waited a year longer than women to tell healthcare providers about symptoms (2.5 years men versus 1.6 years women), the interval between first report of symptoms to diagnosis was ~ 2 years longer for women relative to men (7.5 women versus 9.3 years men). Women and men with axSpA shared more similarities than differences regarding the impact of disease on HRQoL including (1) physical health, (2) limited mobility, (3) occupation, (4) sleep, (5) healthcare system obstacles, (6) mental health, (7) medication usage, and (8) relationships. Some women reported being dismissed by doctors due to their gender, and some described the pain experienced during pregnancy and complications during birth.

CONCLUSIONS

axSpA adversely impacts HRQoL regardless of gender, but women seeking care for axSpA may experience greater challenges reaching a diagnosis. It is essential that providers recognize impaired HRQoL among men and women with axSpA. Future studies with larger sample sizes are needed to identify aspects of HRQoL to adequately address people with axSpA. Key Points • While men waited on average a year longer to tell their healthcare provider about their symptoms, the diagnostic delay is 2 years longer for women. • Women and men with axSpA have similar experiences regarding impacts on their health-related quality of life. • Some women describe difficulty during pregnancy and being dismissed by doctors due to their gender.

Patients' and Health Care Workers' Perception of Migraine Images on the Internet: Cross-sectional Survey Study

BACKGROUND

The representation of migraine in the media is stereotypical. Standard images of migraine attacks display stylish young women holding their head in a pain pose. This representation may contribute to the social stigmatization of patients with migraine.

OBJECTIVE

We aimed to analyze how patients with migraine and health care workers perceive online images of migraine.

METHODS

The study consisted of an anonymous web-based survey of patients with migraine at the Headache Center of Charité - Universitätsmedizin Berlin (migraine group) and employees and students at our university (health care group). A total of 10 frequently used Adobe Stock photos of migraine attacks were presented to the participants. Each photo was rated on a scale of 0% to 100% based on how closely it resembled a realistic migraine attack (realism score). Patients with migraine also indicated how much each photo corresponded to their own experience of migraine as a percentage (representation score). We calculated the mean realism and representation scores for all photos and conducted further analyses using the categories male or female models, younger or older models, and unilateral or bilateral pain pose.

RESULTS

A total of 367 patients with migraine and 331 health care employees and students completed the survey. In both groups, the mean realism score was <50% (migraine group: 47.8%, SD 18.3%; health care group: 46.0%, SD 16.2%). Patients with migraine identified their own migraine experience in these photos to a lesser degree (mean representation score 44.4%, SD 19.8%; P<.001 when compared to the realism score). Patients and health care workers considered photos with male models to be more realistic than photos with females (P<.001) and photos with older models to be more realistic than those with younger people (P<.001). In the health care group only, a bilateral pain posture was deemed more realistic than a unilateral pose (P<.001).

CONCLUSIONS

Standard images of migraine attacks are considered only slightly or moderately realistic by patients and health care workers. Some characteristics perceived as more realistic such as male sex or older age are in contrast with migraine epidemiology. A more accurate representation of migraine in the media could help to raise awareness for migraine and reduce the associated stigma.

Patient Recommendations for Shared Decision-Making in Uterine Fibroid Treatment Decisions

Uterine fibroids are noncancerous tumors associated with significant morbidity among symptomatic patients. While medical and surgical treatments have expanded, hysterectomy remains common. We interviewed women diagnosed with uterine fibroids (n = 47) to explore their experiences and recommendations for shared decision-making. A majority were non-Hispanic Black, highly educated (51.1%), and had graduate degrees (40.4%). Participants with both positive and negative provider experiences expressed a desire for a more proactive therapeutic approach, including a presentation by their provider of the spectrum of medical and surgical treatment options, and greater provider recognition of the impact of symptoms on quality of life. Women advocated for expanded shared decision-making that acknowledged their contribution to their own treatment plan and felt early screening and improved patient/provider education of uterine fibroid symptoms would facilitate greater congruence between treatment approaches and patient goals. Perceptions of insufficient input into their treatment plans frequently served as a barrier to care-seeking and treatment acceptance among women with uterine fibroid symptoms. Improved discussion of treatment options in the context of the unique symptom burden and values of the patient may facilitate greater provider trust and acceptance of uterine fibroid treatment.

Delays in emergency department intervention for patients with traumatic brain injury in Uganda

Background

In Sub-Saharan African countries, the incidence of traumatic brain injury (TBI) is estimated to be many folds higher than the global average and outcome is hugely impacted by access to healthcare services and quality of care. We conducted an analysis of the TBI registry data to determine the disparities and delays in treatment for patients presenting at a tertiary care hospital in Uganda and to identify factors predictive of delayed treatment initiation.

Methods

The study was conducted at the Mulago National Referral Hospital, Kampala. The study included all patients presenting to the emergency department (ED) with suspected or documented TBI. Early treatment was defined as first intervention within 4 hours of ED presentation-a cut-off determined using sensitivity analysis to injury severity. Descriptive statistics were generated and Pearson's χ² test was used to assess the sample distribution between treatment time categories. Univariable and multivariable logistic regression models with <0.05 level of significance were used to derive the associations between patient characteristics and early intervention for TBI.

Results

Of 3944 patients, only 4.6% (n=182) received an intervention for TBI management within 1 hour of ED presentation, whereas 17.4% of patients (n=708) received some treatment within 4 hours of presentation. 19% of those with one or more serious injuries and 18% of those with moderate to severe head injury received care within 4 hours of arrival. Factors independently associated with early treatment included young age, severe head injury, and no known pre-existing conditions, whereas older or female patients had significantly less odds of receiving early treatment.

Discussion

With the increasing number of patients with TBI, ensuring early and appropriate management must be a priority for Ugandan hospitals. Delay in initiation of treatment may impact survival and functional outcome. Gender-related and age-related disparities in care should receive attention and targeted interventions.

Level of evidence

Prognostic and epidemiological study; level II evidence.

Positive and differential diagnosis of autism in verbal women of typical intelligence: A Delphi study

Diagnostic criteria for autism are relatively vague, and may lead to over and underdiagnosis when applied without clinical expertise. Indeed, autism is best reliably identified by experienced clinicians who take into account qualitative aspects of the condition. When assessing for autism in women, little guidance exists to support clinicians deciding whether to attribute adaptive difficulties to autism, a psychiatric condition, or both. The purpose of this study was therefore to propose guidelines for clinicians assessing for autism in women. To do this, we aimed to describe the clinical expertise involved in making positive and differential diagnoses of autism in adult women of typical intelligence. We interviewed 20 experienced clinicians from seven countries. We then elaborated Delphi statements summarizing participant views on the topic, which our participants rated. We obtained a final list of 37 suggested clinical guidelines to improve specificity and sensitivity of autism diagnosis in women. Participants had developed individual assessment strategies, although much overlap existed across participants. Participants provided insight to differentiate autism from post-traumatic stress disorder and Borderline Personality Disorder, and underlined the importance of being able to make differential diagnoses particularly in cases where non-autistic people had strongly self-identified with the spectrum.

Gender Biases in Estimation of Others' Pain

Caregiving and other interpersonal interactions often require accurate perception of others' pain from nonverbal cues, but perceivers may be subject to systematic biases based on gender, race, and other contextual factors. Such biases could contribute to systematic under-recognition and undertreatment of pain. In 2 experiments, we studied the impact of perceived patient sex on lay perceivers' pain estimates and treatment recommendations. In Experiment 1 (N = 50), perceivers viewed facial video clips of female and male patients in chronic shoulder pain and estimated patients' pain intensity. Multi-level linear modeling revealed that perceivers under-estimated female patients' pain compared with male patients, after controlling for patients' self-reported pain and pain facial expressiveness. Experiment 2 (N = 200) replicated these findings, and additionally found that 1) perceivers' pain-related gender stereotypes, specifically beliefs about typical women's vs. men's willingness to express pain, predicted pain estimation biases; and 2) perceivers judged female patients as relatively more likely to benefit from psychotherapy, whereas male patients were judged to benefit more from pain medicine. In both experiments, the gender bias effect size was on average 2.45 points on a 0-100 pain scale. Gender biases in pain estimation may be an obstacle to effective pain care, and experimental approaches to characterizing biases, such as the one we tested here, could inform the development of interventions to reduce such biases. Perspective: This study identifies a bias towards underestimation of pain in female patients, which is related to gender stereotypes. The findings suggest caregivers' or even clinicians' pain stereotypes are a potential target for intervention.

Treatment use and satisfaction in Australian women with endometriosis: A mixed-methods study

AIMS

This study aimed to document the frequency of conventional and complementary treatments used by Australian women with endometriosis and the perceived efficacy of these treatments; and to qualitatively explore women's treatment satisfaction.

METHODS

Using a mixed-methods design, 532 women with self-reported endometriosis were recruited from the community.

METHOD

Participants were asked about their medication, complementary and self-care treatment use, as well as perceived efficacy on a 0 (not effective) - 10 (extremely effective) numeric rating scale (NRS), and open-ended qualitative survey items about treatment satisfaction.

RESULTS

97% of women used medication for pain relief (mean perceived efficacy = 5.05) and 89% used complementary/ self-care strategies (mean perceived efficacy = 3.70), with medication rated as significantly more effective (p <.001). Content analysis of the qualitative data identified that 36% of women were dissatisfied with treatment, 34% were somewhat satisfied, and 24% were satisfied. We identified qualitative themes relating to: 1) Barriers to treatment, which included lack of access, stigma, and disappointment with medical professionals who were perceived as uncaring, unhelpful and in some cases, psychologically damaging; 2) The need for holistic, interdisciplinary care; and 3) Patient knowledge, advocacy and resilience in endometriosis management.

CONCLUSIONS

Our findings reveal important limitations in the current Australian healthcare model, including the need for patient-centred interdisciplinary care that treats the biopsychosocial needs of people with endometriosis; and widespread pain education, spanning medical training to community awareness. This article is protected by copyright. All rights reserved.

Sex- and Gender-Dependent Differences in Clinical and Preclinical Sepsis

ABSTRACT

In this mini-review we provide an overview of sex- and gender-dependent issues in both clinical and preclinical sepsis. The increasing recognition for the need to account for sex and gender in biomedical research brings a unique set of challenges and requires researchers to adopt best practices when conducting and communicating sex- and gender-based research. This may be of particular importance in sepsis, given the potential contribution of sex bias in the failures of translational sepsis research in adults and neonates. Clinical evidence of sex-dependent differences in sepsis is equivocal. Since clinical studies are limited to observational data and confounded by a multitude of factors, preclinical studies provide a unique opportunity to investigate sex differences in a controlled, experimental environment. Numerous preclinical studies have suggested that females may experience favorable outcomes in comparison with males. The underlying mechanistic evidence for sex-dependent differences in sepsis and other models of shock (e.g., trauma-hemorrhage) largely centers around the beneficial effects of estrogen. Other mechanisms such as the immunosuppressive role of testosterone and X-linked mosaicism are also thought to contribute to observed sex- and gender-dependent differences in sepsis. Significant knowledge gaps still exist in this field. Future investigations can address these gaps through careful consideration of sex and gender in clinical studies, and the use of clinically accurate preclinical models that reflect sex differences. A better understanding of sex-and gender-dependent differences may serve to increase translational research success.

Gender differences in female and male Australian Football injuries - A prospective observational study of emergency department presentations

OBJECTIVES

To compare injury-profiles of females and males presenting to Emergency Departments (EDs) with an Australian Football injury.

DESIGN

Prospective observational study.

METHODS

All patients presenting to one of 10 EDs in Victoria, Australia, with an Australian Football injury were included in the study. Data were prospectively collected over a 10 month period, coinciding with a complete Australian Football season, including pre-season training and practice matches. Relevant information was extracted from patient medical records regarding injury-type, body part injured, investigations and treatments required. Female and male data were compared with chi-squared and Fisher's exact tests.

RESULTS

1635 patients were included, of whom 242 (14.8%) were female. Females had a higher proportion of hand/finger injuries (34.3% v 23.4%), neck injuries (6.6% v 2.5%) and patella dislocations (2.9% v 0.6%). Males had a higher proportion of shoulder injuries (11.5% v 5.8%), skin lacerations (8.0% v 1.7%), and thorax/abdominal/pelvic injuries (5.7% v 2.1%). Concussion rates were similar between the genders, occurring in 14.1% of all patients. Anterior cruciate ligament injuries were infrequent (1.0%) and not significantly different between genders. Females received more imaging investigations (83.1% v 74.7%) and analgesia (62.4% v 48.5%). A higher proportion of males required admission to hospital (5.0% v 2.1%), usually for surgery.

CONCLUSION

Australian Football injury profiles differed between females and males. Gender-specific injury prevention and management programs would be indicated based on the study findings.

Perceived Injustice Helps Explain the Association Between Chronic Pain Stigma and Movement-Evoked Pain in Adults with Nonspecific Chronic Low Back Pain

OBJECTIVE

For most patients with chronic low back pain (cLBP), the cause is "nonspecific," meaning there is no clear association between pain and identifiable pathology of the spine or associated tissues. Laypersons and providers alike are less inclined to help, feel less sympathy, dislike patients more, suspect deception, and attribute lower pain severity to patients whose pain does not have an objective basis in tissue pathology. Because of these stigmatizing responses from others, patients with cLBP may feel that their pain is particularly unjust and unfair. These pain-related injustice perceptions may subsequently contribute to greater cLBP severity. The purpose of this study was to examine whether perceived injustice helps explain the relationship between chronic pain stigma and movement-evoked pain severity among individuals with cLBP.

METHODS

Participants included 105 patients with cLBP who completed questionnaires assessing chronic pain stigma and pain-related injustice perception, as well as a short physical performance battery for the assessment of movement-evoked pain and physical function.

RESULTS

Findings revealed that perceived injustice significantly mediated the association between chronic pain stigma and cLBP severity (indirect effect = 6.64, 95% confidence interval [CI] = 2.041 to 14.913) and physical function (indirect effect = -0.401, 95% CI = -1.029 to -0.052). Greater chronic pain stigma was associated with greater perceived injustice (P = 0.001), which in turn was associated with greater movement-evoked pain severity (P = 0.003).

CONCLUSIONS

These results suggest that perceived injustice may be a means through which chronic pain stigma impacts nonspecific cLBP severity and physical function.

Medication risk management and health equity in New Zealand general practice: a retrospective cross-sectional study

BACKGROUND

Despite an overt commitment to equity, health inequities are evident throughout Aotearoa New Zealand. A general practice electronic alert system was developed to notify clinicians about their patient's risk of harm due to their pre-existing medical conditions or current medication. We aimed to determine whether there were any disparities in clinician action taken on the alert based on patient ethnicity or other demographic factors.

METHODS

Sixty-six New Zealand general practices from throughout New Zealand participated. Data were available for 1611 alerts detected for 1582 patients between 1 and 2018 and 1 July 2019. The primary outcome was whether action was taken following an alert or not. Logistic regression was used to assess if patients of one ethnicity group were more or less likely to have action taken. Potential confounders considered in the analyses include patient age, gender, ethnicity, socio-economic deprivation, number of long term diagnoses and number of long term medications.

RESULTS

No evidence of a difference was found in the odds of having action taken amongst ethnicity groups, however the estimated odds for Māori and Pasifika patients were lower compared to the European group (Māori OR 0.88, 95 %CI 0.63-1.22; Pasifika OR 0.88, 95 %CI 0.52-1.49). Females had significantly lower odds of having action taken compared to males (OR 0.76, 95 %CI 0.59-0.96).

CONCLUSIONS

This analysis of data arising from a general practice electronic alert system in New Zealand found clinicians typically took action on those alerts. However, clinicians appear to take less action for women and Māori and Pasifika patients. Use of a targeted alert system has the potential to mitigate risk from medication-related harm. Recognising clinician biases may improve the equitability of health care provision.

Disparities in Health Care and Medical Evaluations by Gender: A Review of Evidence and Mechanisms: GENDER DISPARITIES: EVIDENCE ON CAUSES AND IMPLICATIONS

Male and female patients often receive different medical evaluations and treatment even when they have the same symptoms, and relative to men, women are less likely to receive benefits within social insurance programs that rely on medical evaluations. This article reviews evidence from prior research that documents the existence of these gender gaps in health care and disability benefit receipt. The article then describes potential mechanisms underlying these gender gaps. The article concludes by discussing new work on the role of health-care providers in contributing to gender gaps.