An international comparative policy analysis of opioid use disorder treatment in primary care across nine high-income jurisdictions

BACKGROUND

Opioid use disorder (OUD) and opioid-related harms are current health priorities in many high-income countries such as Canada. Opioid agonist therapy (OAT) is an effective evidence-based treatment for OUD, but access is often limited.

AIMS

To describe and compare OUD treatment policies across nine international jurisdictions, and to understand how they are situated within their primary care and health systems.

METHODS

Using policy documents, we collected data on health systems, drug use epidemiology, drug policies, and OUD treatment from Australia, Canada, France, Germany, Ireland, Portugal, Sweden, Switzerland, and Taiwan. We used the health system dynamics framework and adapted definitions of low- and high-threshold treatment to describe and compare OUD treatment policies, and to understand how they may be shaped by their health systems context.

RESULTS

Broad similarities across jurisdictions included the OAT pharmacological agents used and the need for supervised dosing; however, preferred OAT, treatment settings, primary care and specialist physicians' roles, and funding varied. Most jurisdictions had elements of lower-threshold treatment access, such as the availability of treatment through primary care and multiple OAT options, but the higher-threshold criteria of supervised dosing.

CONCLUSIONS

From the Canadian perspective, there are opportunities to improve accessibility of OUD care by drawing on how different jurisdictions incorporate multidisciplinary care, regulate OAT medications, remunerate healthcare professionals, and provide funding for services.

Chronic pain trials often exclude people with comorbid depressive symptoms: A secondary analysis of 346 randomized controlled trials

BACKGROUND

Chronic pain and depression are common comorbid conditions, but there is limited evidence-based guidance for management of the two conditions together. In recent years, there has been an increase in the number of chronic pain randomized controlled trials that collect depression outcomes, but it is unknown how often these trials include people with depression or significant depressive symptoms. If trials do not include participants representative of real-world populations, evidence and guidance generated from these trials risk being inapplicable for large proportions of the target population, or worse, risk harm. Thus, in order to identify pathways to improve the conduct of clinical trials, the aims of this study were to (1) estimate the proportion of randomized controlled trials evaluating chronic pain interventions and reporting depression outcomes that include participants with significant depressive symptoms; and (2) assess the variability of inclusion proportions by pain type, intervention type, gender, country of origin, and publication year.

METHODS

Studies were extracted from an umbrella review of interventions for chronic pain that reported depression outcomes. Screening and data extraction were completed in duplicate and conflicts were resolved by a third author. Randomized controlled trials with at least 50% adult participants and validated depression scales were included, and randomized controlled trials with populations whose mean scores were at or above depression thresholds at baseline were considered to have included participants with depression.

RESULTS

Of the 346 randomized controlled trials analyzed, 142 (41%) included participants with depression. Eight pain-type groups and nine intervention types were identified. Randomized controlled trials investigating fibromyalgia and mixed chronic pain had the highest proportion of participants with depression, whereas studies of arthritis and axial pain had among the lowest. Randomized controlled trials from the United States had a significantly lower inclusion proportion compared with non-US studies, especially for studies on arthritis. The increase in inclusion proportion by publication year was driven by the increase in fibromyalgia studies.

DISCUSSION AND CONCLUSION

This study highlights opportunities to improve the conduct of chronic pain clinical trials. The majority of randomized controlled trials s analyzed evaluated participants without significant depressive symptoms at baseline, thus the findings synthesized in systematic reviews and subsequent guidelines are most applicable to the subset of real-world populations that do not have significant depressive symptoms. As well, systemic biases around psychological conditions and gender may be important contributors to differences in the study of depression in fibromyalgia compared with common conditions such as arthritis and axial pain. In order to better inform clinical practice, future research must intentionally include individuals with comorbid depression in trials of common chronic pain conditions, and consider methods to mitigate biases that may distort study design.

Buprenorphine deregulation as an opioid crisis policy response - A comparative analysis between France and the United States

BACKGROUND

In passing the Maintstreaming Addiction Treatment Act, the United States has abolished its federal X waiver, considered a major barrier to the wider buprenorphine prescribing needed to respond to opioid-related harms. Advocates for this policy have drawn on the French response of deregulating buprenorphine prescribing to address increasing overdose mortality around the turn of the millennium. So far, such policy advocacy has incompletely accounted for contextual and health system differences between the two countries.

METHODS

Using the health system dynamics framework, this analysis compares France from 1995 to 2003 (the relevant period of buprenorphine reform) to the US from 2018 until today (the comparison period to explore potential impacts of reform). We used it to guide examination of a) contextual issues relating to opioid use epidemiology and b) health system factors including prescriber supply, sector organization, and insurance coverage for primary care to draw relevant policy learning for the contemporary US.

RESULTS

We identified that the US had a 22.5-fold higher mortality rate and a 2.3-fold higher opioid use disorder (OUD) rate compared to France, despite having rates of prescribed buprenorphine per-capita higher than, and per-person with OUD comparable to, than that of France. These wide gulfs between the scales and nature of the problems between France and the US suggest that relaxing restrictions on buprenorphine prescribing through abolishing the X waiver will be insufficient for achieving hoped-for reductions in overdose mortality.

CONCLUSION

Health system strengthening with a focus on improvements in primary care prescriber supply, coverage, and coordination are likely higher yield policy complements to relaxing buprenorphine regulation. Such an approach would better prepare the US to adapt to ongoing dynamics and uncertainties in the opioid crisis and to optimize the already relatively high levels of buprenorphine prescribing.

From Two Dimensions to Multidimensions: A Mechanistic Model to Support Deliberate CPD Development, Coordination, and Evaluation

INTRODUCTION

The effectiveness of continuing professional development as an intervention to improve health professional behavior and patient health is variable and contentious. To clarify the causal relationships underlying program outcomes and facilitate a necessary shift from outcomes-only-based approaches to outcome-based and theory-based approaches in program development and evaluation, we developed a model of mechanisms mapped to relevant outcomes.

METHODS

Mechanisms identified in a prior realist synthesis of opioid agonist therapy continuing professional development programs were iteratively tested and refined using purposive and opportunistic sampling and realist approaches against two systematic reviews of programs in analgesic prescribing and palliative care. Further testing involved practical application within programs in sustainable health care and pain management.

RESULTS

Ninety reports on 75 programs and practical application to multiple additional programs informed the final model consisting of five distinct mechanisms: motivation transformation, expert influence, confidence development, self-efficacy facilitation, and community of practice expansion. The mechanisms and related analysis emphasize that continuing professional development is heterogeneous, complex, and context dependent.

DISCUSSION

Shifting toward outcome-based and theory-based approaches facilitates further conceptual shifts at intraprogram and interprogram and interintervention levels toward more deliberate program development and evaluation, increased program complementarity and subsequent collaboration. It clarifies opportunities for intercalation of continuing professional development with other intervention sciences. The model presents a resource for practitioners, researchers, and policymakers to advance continuing professional development planning, coordination, and evaluation.

Sudarshan Kriya Meditation Reduces Substance Abuse Cravings and Improves Physical and Emotional Well-Being of Individuals With Opioid Use Disorder: A Pilot Study

Opioid use disorder (OUD) is widely prevalent in the United States and there are high levels of comorbidity between OUD and mental illnesses, such as depression, anxiety, and posttraumatic stress disorder. Psychotherapy, in addition to medication-assisted therapy, are considered important components of long-term OUD treatment. Sudarshan Kriya Yoga (SKY) is a breathing-based mind-body intervention that has been demonstrated to have multiple physiological and psychological benefits. In the current study, participants (N = 8) recruited from a rural community were offered SKY in addition to treatment-as-usual. Physical and psychological well-being were measured using the Behavior and Symptom Identification Scale-24, Short Form-36, Perceived Stress Scale, and participant logs and journals. Of eight participants, seven (87.5%) successfully completed the SKY intervention. Compared to baseline, there was a significant decrease in substance use cravings (p = 0.04) and depression (p = 0.01). In addition, physical functioning and emotional well-being significantly increased after SKY. SKY demonstrated efficacy in improving physical and social functioning along with enhancing mental and emotional well-being. Larger-scale trials should be performed to validate these findings. [Journal of Psychosocial Nursing and Mental Health Services, 61(8), 51-59.].

Pharmaceutical company responses to Canadian opioid advertising restrictions: A framing analysis

The pharmaceutical industry's promotion of opioids in North America has been well-documented. Yet despite the clear consequences of improperly classifying pharmaceutical company messaging and frequently permissive approaches that allow the pharmaceutical industry to self-regulate its own advertising, there has been scarce investigation to date of how pharmaceutical industry stakeholders interpret definitions of "advertising." This study explores how variations of "marketing" and "advertising" are strategically framed by the different actors involved in the manufacturing and distribution of pharmaceutical opioids. We employed a framing analysis of industry responses to Health Canada's letter to Canadian manufacturers and distributors of opioids requesting their commitment to voluntarily cease all marketing and advertising of opioids to health care professionals. Our findings highlight companies' continuing efforts to frame their messaging as "information" and "education" rather than "advertising" in ways that serve their interests. This study also calls attention to the industry's continual efforts to promote self-regulation and internal codes of conduct within a highly permissive federal regulatory framework with little concern for violations or serious consequences. While this framing often occurring out of public sight, this study highlights the subtle means through which the industry attempts to frame their promotion strategies away from "marketing". These framing strategies have significant consequences for the pharmaceutical industry's capacity to influence healthcare professionals, patients, and the general public.

The Impact of Suboxone's Market Exclusivity on Cost of Opioid Use Disorder Treatment

BACKGROUND

Buprenorphine-naloxone is an essential part of the response to opioid poisoning rates in North America. Manipulating market exclusivity is a strategy manufacturers use to increase profitability, as evidenced by Suboxone in the USA.

OBJECTIVE

To investigate excess costs of buprenorphine-naloxone due to unmerited market exclusivity (no legal patent or data protection) in Canada.

METHODS

Using controlled interrupted time-series, this study examined changes in the cost of buprenorphine-naloxone before and after the first generics were listed on public formularies. Methadone cost was the control. Public data from the Canadian Institute of Health Information in British Columbia, Manitoba, and Saskatchewan were used. All buprenorphine-naloxone and methadone claims (2010-2019) accepted for payment by the provincial drug plan/programme were collected. Primary outcome was mean cost per mg of buprenorphine-naloxone after the first listing of generics.

RESULTS

Mean cost per mg of buprenorphine-naloxone before the first listing of generics was $1.21 CAD in British Columbia, $1.27 CAD in Manitoba, and $0.85 CAD in Saskatchewan. Following the introduction of generics, the cost per mg decreased by $0.22 CAD (95% CI - 0.33 to - 0.10; p = 0.0014) in British Columbia, $0.36 CAD (95% CI - 0.58 to - 0.13; p = 0.004) in Manitoba, and $0.27 CAD (95% CI - 0.50 to - 0.05; p = 0.03) in Saskatchewan. Mean cost per mg decreased by $0.26 CAD (95% CI - 0.38 to - 0.13; p = 0.0004) after a third generic was introduced in British Columbia. Excess costs to public formularies during the 4- to 5-year period prior to the listing of generics were $1,992,558 CAD in British Columbia, $80,876 CAD in Manitoba, and $4130 CAD in Saskatchewan. If buprenorphine-naloxone cost $0.61 CAD (mean cost after the third generic entered) instead of $1.21 CAD per mg during the pre-generics period, public payers in British Columbia could have saved $5,016,220 CAD between 2011 and 2015.

CONCLUSIONS

Unmerited 6 years of market exclusivity for brand-name buprenorphine-naloxone in Canada resulted in substantial excess costs. There is an urgent need to implement policies that can help reduce costs for high-priority drugs in Canada.

How policy problems and solutions travel in the scientific literature: An international scientometric analysis of the French Model of opioid use disorder care

RATIONALE

The 2007 article 'Why buprenorphine is so successful in treating opiate addiction in France' has been widely cited to promote various solutions to growing opioid-related harms across multiple jurisdictions globally. However, selective promotion of aspects of the French experience or promotion of the French experience without considering relevant contextual factors may inform policies that will not bring the same outcomes as in France, including the introduction of possible unintended negative consequences. The scientific literature is one important arena in which policy solutions are identified, evaluated, promoted and disseminated. Scientific communication of the French opioid use disorder care model offers a timely and relevant example through which to examine how problem representations travel and to consider the effects of these representations.

AIMS AND OBJECTIVES

We aimed to explore where, when, and how the content of this 2007 index article has travelled through the scientific literature.

METHOD

Informed by Bacchi's understanding of problem representation, we conducted a scientometric analysis of the index article. This included categorical analyses using a combination of citation metadata and content data to identify patterns across locations and time.

RESULTS

Researchers in the United States and Anglophone countries affirmatively cited specific index study content, namely less stringent regulations and positive outcomes, such as reductions in overdose deaths and increases in buprenorphine utilization. These citations were more common after 2015 and were more likely to be in discussion sections of nonempirical publications. Researchers from France cited similar content but did so nonaffirmatively, and throughout the study period. Likewise, the French citations were mostly agenda-setting citations in the introductory sections of empirical studies. US studies received the highest attention based on number of citations and Altmetric scores.

CONCLUSION

US studies, by focusing on less stringent buprenorphine regulation as the primary solution of concern, have constructed opioid-related harms as a problem of restrictive regulations for buprenorphine. This selective focus on regulation, as opposed to other aspects of the French Model elucidated in the index article such as changes pertaining to the values and financing that structure health service delivery, represents an important missed opportunity for evidence-informed policy learning across jurisdictions.

Chronic Struggle: An Institutional Ethnography of Chronic Pain and Marginalization

There have been several recent calls to re-think chronic pain in response to the growing awareness of social inequities that impact the prevalence of chronic pain and its management. This in turn has resulted in new explorations of suffering as it relates to pain. While laudable, many of these clinically oriented accounts are abstract and often fail to offer a critical theoretical understanding of social and structural inequities. To truly rethink pain, we must also reconsider suffering, beginning in the everyday expert knowledge of people with chronic pain who can offer insights in relation to their bodies and also the organization of the social circumstances in which they live. Our team undertook a sociological approach known as institutional ethnography (IE) to explicate the work of people in managing lives beset by chronic pain and the inequities that stem from marginalization. In keeping with our critical paradigm, we describe participant accounts as situated, rather than lived, to de-emphasize the individual in favour of the social and relational. Through our analysis, we offer a new concept of chronic struggle to capture how pain, illness, economic deprivation, and suffering constitute a knot of experience that people living with chronic pain are obliged to simplify in order to fit existing logics of medicine. Our goal is to identify the social organization of chronic pain care which underpins experience in order to situate the social as political rather than medical or individual. PERSPECTIVE: This article explicates the health work of people living with chronic pain and marginalization, drawing on their situated experience. We offer the concept of chronic struggle as a conceptualization that allows us to bring into clear view the social organization of chronic pain in which the social is visible as political and structural rather than medical or individual.

Principles-Focused Evaluation: A Promising Practice in the Evaluation of Continuing Professional Development

ABSTRACT

Outcome-based evaluations still dominate in continuing professional development (CPD) despite the availability of evaluation approaches that address program processes and contexts. Our continued reliance on outcomes-based evaluation fails to respect the importance of complexity and the human element of program planning and implementation. Therefore, it is time that the field of CPD embrace complementary approaches to program evaluation that consider the complexity and maturity of programs and their contexts, while providing credible and relevant information to inform strategic decisions regarding the future of a program. Principles-focused evaluation provides a complement to traditional evaluation approaches through the articulation of a program's values that can be actioned. These "actionable values," known as principles, become the focus of the evaluation for the purposes of program decision-making. This paper describes how one CPD program, designed as a response to growing opioid-related harms, adopted a principles-focused evaluation to inform ongoing iteration of the program. The process used to design the principles, how the principles are informing the transportability of the program, and implications for CPD evaluation are discussed.

A Scoping Review of Gaps Identified by Primary Care Providers in Caring for Patients with Chronic Noncancer Pain

Introduction/Aim

Primary care providers (PCPs), who provide the bulk of care for patients with chronic noncancer pain (CNCP), often report knowledge gaps, limited resources, and difficult patient encounters while managing chronic pain. This scoping review seeks to evaluate gaps identified by PCPs in providing care to patients with chronic pain.

Methods

The Arksey and O'Malley framework was used for this scoping review. A broad literature search was conducted for relevant articles on gaps in knowledge and skills of PCPs and in their health care environment for managing chronic pain, with multiple search term derivatives for concepts of interest. Articles from the initial search were screened for relevance, yielding 31 studies. Inductive and deductive thematic analysis was adopted.

Results

The studies included in this review reflected a variety of study designs, settings, and methods. However, consistent themes emerged with respect to gaps in knowledge and skills for assessment, diagnosis, treatment, and interprofessional roles in chronic pain, as well as broader systemic issues including attitudes toward CNCP. A general lack of confidence in tapering high dose or ineffective opioid regimes, professional isolation, challenges in managing patients with CNCP with complex needs, and limited access to pain specialists were reported by PCPs.

Discussion/Conclusions

This scoping review revealed common elements across the selected studies that will be useful in guiding creation of targeted supports for PCPs to manage CNCP. This review also yielded insights for pain clinicians at tertiary centers for supporting their PCP colleagues as well as systemic reforms required to support patients with CNCP.

Virtually-delivered Sudarshan Kriya Yoga (SKY) for Canadian veterans with PTSD: A study protocol for a nation-wide effectiveness and implementation evaluation

BACKGROUND

Post-traumatic stress disorder (PTSD) remains a significant treatment challenge among Canadian veterans. Currently accessible pharmacological and non-pharmacological interventions for PTSD often do not lead to resolution of PTSD as a categorical diagnosis and have significant non-response rates. Sudarshan Kriya Yoga (SKY), a complementary and integrative health (CIH) intervention, can improve symptoms of PTSD. In response to the COVID-19 pandemic, this intervention has pivoted to virtual delivery and may be reaching new sets of participants who face multiple barriers to care.

OBJECTIVE

To evaluate the implementation and effectiveness of virtually delivered Sudarshan Kriya Yoga (SKY) on decreasing PTSD symptom severity, symptoms of depression, anxiety, and pain, and improving quality of life in Canadian veterans affected by PTSD.

METHODS AND ANALYSIS

Using a mixed-methods approach guided by the RE-AIM framework, we will conduct a hybrid type II effectiveness and implementation study of virtually delivered Sudarshan Kriya Yoga (SKY) for Canadian veterans. Effectiveness will be evaluated by comparing virtually delivered SKY to a waitlist control in a single-blinded (investigator and data analyst) randomized controlled trial (RCT). Change in PTSD symptoms (PCL-5) is the primary outcome and quality of life (SF-36), symptoms of depression (PHQ-9), anxiety (GAD-7), and pain (BPI) are secondary outcomes. The SKY intervention will be conducted over a 6-week period with assessments at baseline, 6-weeks, 12-weeks, and 30 weeks. The reach, effectiveness, adoption, implementation, and maintenance of the intervention will be evaluated through one-on-one semi-structured interviews with RCT participants, SKY instructors, health professionals, and administrators that work with veterans.

DISCUSSION

This is the first investigation of the virtual delivery of SKY for PTSD in veterans and aims to determine if the intervention is effective and implementable at scale.

A Conceptual Framework for Continuing Medical Education and Population Health

ISSUE

Health systems have been increasingly called upon to address population health concerns and continuing medical education (CME) is an important means through which clinical practices can be improved. This manuscript elaborates on existing conceptual frameworks in order to support CME practitioners, funders, and policy makers to develop, implement, and evaluate CME vis-a-vis population health concerns.

EVIDENCE

Existing CME conceptual models and conceptions of CME effectiveness require elaboration in order to meet goals of population health improvement. Frameworks for the design, implementation and evaluation of CME consistently reference population health, but do not adequately conceptualize it beyond the aggregation of individual patient health. As a pertinent example, opioid prescribing CME programs use the opioid epidemic to justify their programs, but evaluation approaches are inadequate for demonstrating population health impacts. CME programs that are built to have population health outcomes using frameworks intended primarily for physician performance and patient health outcomes are thus not able to recognize either non-linear associations or negative unintended consequences.

IMPLICATIONS

This proposed conceptual framework draws on the fields of clinical population medicine, the social determinants of health, health equity, and philosophies of population health to build conceptual bridges between the CME outcome levels of physician performance and patient health to population health. The authors use their experience developing, delivering, and evaluating opioid prescribing- and poverty-focused CME programs to argue that population health-focused CME must be re-oriented in at least five ways. These include: 1) scaling effective CME programs while evaluating at population health levels; 2) (re)interpreting evidence for program content from a population perspective; 3) incorporating social determinants of health into clinically-oriented CME activities; 4) explicitly building fluency in population health concepts and practices among health care providers and CME planners; and 5) attending to social inequity in every aspect of CME programs.

Education as drug policy: A realist synthesis of continuing professional development for opioid agonist therapy

BACKGROUND

Continuing professional development (CPD) for opioid agonist therapy (OAT) has been identified as a key health policy strategy to improve care for people living with opioid use disorder (OUD) and to address rising opioid-related harms. To design and deliver effective CPD programs, there is a need to clarify how they work within complex health system and policy contexts. This review synthesizes the literature on OAT CPD programs and educational theory to clarify which interventions work, for whom, and in what contexts.

METHODS

A systematic review and realist synthesis of evaluations of CPD programs focused on OAT was conducted. This included record identification and screening, theory familiarization, data collection, analysis, expert consultation, and iterative context-intervention-mechanism-outcome (CIMO) configuration development.

RESULTS

Twenty-four reports comprising 21 evaluation studies from 5 countries for 3373 providers were reviewed. Through iterative testing of included studies with relevant theory, five CIMO configurations were developed. The programs were categorized by who drove the learning outcomes (i.e., system/policy, instructor, learner) and their spheres of influence (i.e., micro, meso, macro). There was a predominance of instructor-driven programs driving change at the micro level, with few policy-driven macro-influential programs, inconsistent with the promotion of CPD as a clear opioid crisis policy-level intervention.

CONCLUSION

OAT CPD is challenged by mismatches in program justifications, objectives, activities, and outcomes. Depending on how these program factors interact, OAT CPD can operate as a barrier or facilitator to OUD care. With more deliberate planning and consideration of program theory, programs more directly addressing diverse learner and system needs may be developed and delivered. OAT CPD as drug policy does not operate in isolation; programs may feed into each other and intercalate with other policy initiatives to have micro, meso, and macro impacts on educational and population health outcomes.

Shifting interpretations in evidence and guidance in pain and opioids research: A bibliometric analysis of a highly cited case series from 1986

RATIONALE, AIMS AND OBJECTIVES: Portenoy and Foley's 1986 landmark case series 'Chronic use of opioid analgesics in non-malignant pain: report of 38 cases' has been reproached for opening the floodgates of opioid prescribing for chronic non-cancer pain and the attendant harms. This influential article has been cited over 500 times in the scientific literature over the last four decades. This study seeks to understand the impact of Portenoy and Foley's article on subsequent discussions and research about opioids.

METHODS

We conducted a multi-method bibliometric analysis of all citations of this article from 1986 through 2019 using quantitative relational and qualitative content analysis to determine how uses and interpretations of this case series and associated prescribing guidance have changed over time, in relationship to the evolution of the North American opioid crises.

RESULTS

Using time series analysis, we identified three periods with distinct interpretations and uses of the index article. In the first 'exploration' period (1986-1996), the index article was well-received by the scientific community and motivated further study of the effects of opioids. In the second 'implementation' period (1997-2003, coinciding with the release of OxyContin®), this case series was used as evidence to support widespread prescribing of opioid analgesics, even while it was recognized that long-term effects had not yet been evaluated. The third 'reassessment' period (2004-2019) focused on how opioid-related harms had been overlooked, and in many cases, these harms were directly attributed to this article.

CONCLUSION

These changes in interpretation demonstrate shifting currents of the use and mobilization of evidence regarding pain and opioids, and how these currents both impact and are impacted by clinical practices and major sociohistorical phenomena such as the opioid crisis. Researchers and clinicians must account for these shifting dynamics when developing and interpreting scientific knowledge, including in the form of clinical practice guidelines.

How the Suboxone Education Programme presented as a solution to risks in the Canadian opioid crisis: a critical discourse analysis

OBJECTIVES

Pharmaceutical industry involvement in medical education, research and clinical practice can lead to conflicts of interest. Within this context, this study examined how the 'Suboxone Education Programme', developed and delivered by a pharmaceutical company as part of a federally regulated risk management program, was presented as a solution to various kinds of risks relating to opioid use in public documents from medical institutions across Canada.

SETTING

These documents were issued during the Canadian opioid crisis, a time when the involvement of industry in health policy was being widely questioned given industry's role in driving the overprescribing of opioid analgesics and contributing to population-level harms.

DESIGN

A critical discourse analysis of 69 documents collected between July 2020 and May 2021 referencing the Suboxone Education Program spanning 13 years (2007-2021) from medical, nursing and pharmacy institutions sourced from every Canadian province and territory. Discursive themes were identified through iterative and duplicate analyses using a semistructured data extraction instrument.

RESULTS

Documents characterised the Programme as addressing iatrogenic risks from overprescribing opioid analgesics, environmental risks from a toxic street drug supply and pharmacological risks relating to the dominant therapeutic alternative of methadone. The programme was identified as being able to address these risks by providing mechanisms to surveil healthcare professionals and to facilitate the prescribing of Suboxone. Medical institutions legitimised the Suboxone Education Programme by lending their regulatory, epidemiological and professional authority.

CONCLUSIONS

Addressing risk is considered as a central, moral responsibility of contemporary healthcare services. In this case, moral imperatives to address opioid crisis-related risks overrode other ethical concerns regarding conflicts of interest between industry and public welfare. Failing to address these conflicts potentially imperils efforts of mitigating population health harms by propagating an important driving force of the opioid crisis.

Major complications of airway management: a prospective multicentre observational study

We conducted an observational study of serious airway complications, using similar methods to the fourth UK National Audit Project (NAP4) over a period of 1 year across four hospitals in one region in the UK. We also conducted an activity survey over a week, using NAP4 methods to yield an estimate for relevant denominators to help interpret the primary data. There were 17 serious airway complications, defined as: failed airway management leading to cancellation of surgery (eight); airway management in recovery (five); unplanned intensive care admission (three); and unplanned emergency front of neck access (one). There were no reports of death or brain damage. This was an estimate of 0.028% (1 in 3600) complications using the denominator of 61,000 general anaesthetics per year in the region. Complications in patients with 'predicted easy' airways were rare (approximately 1 in 14,200), but 45 times more common in those with 'predicted difficult' airways (approximately 1 in 315). Airway management in both groups was similar (induction of anaesthesia followed by supraglottic airway or tracheal tube). Use of awake/sedation intubation, videolaryngoscopy and high-flow nasal oxygenation were uncommon even in the predicted difficult airway patients (in 2.7%, 32.4% and 9.5% of patients, respectively). We conclude that the incidence of serious airway complications is at least as high as it was during NAP4. Despite airway prediction being used, this is not informing subsequent management.

Chronic Pain and Opioid Prescribing: Three Ways for Navigating Complexity at the Clinical‒Population Health Interface

Clinically focused interventions for people living with pain, such as health professional education, clinical decision support systems, prescription drug monitoring programs, and multidisciplinary care to support opioid tapering, have all been promoted as important solutions to the North American opioid crisis. Yet none have so far delivered substantive beneficial opioid-related population health outcomes. In fact, while total opioid prescribing has leveled off or reduced in many jurisdictions, population-level harms from opioids have continued to increase dramatically. We attribute this failure partly to a poor recognition of the epistemic and ethical complexities at the interface of clinical and population health. We draw on a framework of knowledge networks in wicked problems to identify 3 strategies to help navigate these complexities: (1) designing and evaluating clinically focused interventions as complex interventions, (2) reformulating evidence to make population health dynamics apparent, and (3) appealing to the inseparability of facts and values to support decision-making in uncertainty. We advocate that applying these strategies will better equip clinically focused interventions as complements to structural and public health interventions to achieve the desired beneficial population health effects. (Am J Public Health. 2022;112(S1):S56-S65. https://doi.org/10.2105/AJPH.2021.306500).

Evaluations of Continuing Health Provider Education Focused on Opioid Prescribing: A Scoping Review

PURPOSE

Continuing health provider education (HPE) is an important intervention supported by health policy to counter the opioid epidemic; knowledge regarding appropriate program design and evaluation is lacking. The authors aim to provide a comprehensive understanding of evaluations of opioid-related continuing HPE programs and their appropriateness as interventions to improve population health.

METHOD

In January 2020, the authors conducted a systematic search of 7 databases, seeking studies of HPE programs on opioid analgesic prescribing and overdose prevention. Reviewers independently screened the titles and abstracts of all studies and then assessed the full texts of all studies potentially eligible for inclusion. The authors extracted a range of data using categories for evaluating complex programs: the use of theory, program purpose, inputs, activities, outputs, outcomes, and industry involvement. Results were reported in a narrative synthesis.

RESULTS

Thirty-nine reports on 32 distinct HPE programs met inclusion criteria. Of these 32, 31 (97%) were U.S./Canadian programs and 28 (88%) were reported after 2010. Measurements of changes in knowledge and confidence were common. Performance outcomes were less common and typically self-reported. Most studies (n = 27 [84%]) used concerns of opioid-related harms at the population health level to justify the educational intervention, but only 5 (16%) measured patient- or population-level outcomes directly related to the educational programs. Six programs (19%) had direct or indirect opioid manufacturer involvement.

CONCLUSIONS

Continuing HPE has been promoted as an important means of addressing population-level opioid-related harms by policymakers and educators, yet published evaluations of HPE programs focusing on opioid analgesics inadequately evaluate patient- or population-level outcomes. Instead, they primarily focus on self-reported performance outcomes. Conceptual models are needed to guide the development and evaluation of continuing HPE programs intended to have population health benefits.

Mal/adaptations: A qualitative evidence synthesis of opioid agonist therapy during major disruptions

BACKGROUND

Opioid agonist therapy (OAT) has been severely disrupted by the COVID-19 pandemic. The risks of opioid withdrawal, overdose, and diversion have increased, so there is an urgent need to adapt OAT to best support people who use drugs (PWUD). This review examines the views and experiences of PWUD, health care providers, and health system administrators on OAT during major disruptions to medical care to inform appropriate health system responses during the current pandemic and beyond.

METHODS

We conducted a systematic review and qualitative evidence synthesis. We searched three comprehensive datasets for qualitative and mixed-methods studies that examined OAT in the context of major disruptions such as natural disasters, and analyzed included studies using thematic analysis and the constant comparative method. We used conceptual frameworks of health systems resilience and adaptive systems to interpret our findings.

RESULTS

We included 10 studies published between 2002 and 2020 that examined OAT in the context of hurricanes, earthquakes, and terrorist attacks. We organized our results into three themes: uncertainty, inconsistency, and vulnerability; regulatory inflexibility; and lack of coordination. The highly regulated but poorly coordinated systems of OAT provision lacked flexibility to adapt to major disruptions, thereby manufacturing vulnerability for both PWUD and health workers.

CONCLUSIONS

OAT programs must be resilient and adaptable to face major disruptions while maintaining quality care. Our findings provide guidance to develop and implement innovative strategies that increase the adaptive potential of OAT programs while focusing on the needs of PWUD.

Tailoring interfacial effect in multilayers with Dzyaloshinskii-Moriya interaction by helium ion irradiation

We show a method to control magnetic interfacial effects in multilayers with Dzyaloshinskii-Moriya interaction (DMI) using helium (He[Formula: see text]) ion irradiation. We report results from SQUID magnetometry, ferromagnetic resonance as well as Brillouin light scattering results on multilayers with DMI as a function of irradiation fluence to study the effect of irradiation on the magnetic properties of the multilayers. Our results show clear evidence of the He[Formula: see text] irradiation effects on the magnetic properties which is consistent with interface modification due to the effects of the He[Formula: see text] irradiation. This external degree of freedom offers promising perspectives to further improve the control of magnetic skyrmions in multilayers, that could push them towards integration in future technologies.

Beyond harm-producing versus harm-reducing: A qualitative meta-synthesis of people who use drugs' perspectives of and experiences with the extramedical use and diversion of buprenorphine

INTRODUCTION

This review synthesizes the literature on the perspectives and experiences of people who use drugs to better understand motivations and behaviors related to the extramedical use and diversion of buprenorphine. Given the particular social construction of buprenorphine against methadone, and the centrality of concerns around extramedical use in delivering opioid agonist therapies, a focus on extramedical buprenorphine use can provide an important lens through which to analyze treatment for opioid use disorder. This review is framed within persistent tensions between potential harm-producing versus harm-reducing effects of extramedical use that have long been described for opioid agonist therapies.

METHODS

The research team conducted a qualitative meta-synthesis based on a systematic search of eight databases as well as hand searching. The review includes all primary qualitative and mixed-methods studies related to the perspectives and experiences of people who use drugs on extramedical buprenorphine use. The study team carried out three rounds of qualitative coding using NVivo 12, and constructivist grounded theory and the constant comparative method informed the synthesis.

RESULTS

The review includes twenty-one studies. Findings are organized into the following three themes: 1) the experiences of people who use drugs (PWUD) with extramedical use of buprenorphine and their motivations to engage in it (including the desire to self-medicate and achieve "stability", to manage ongoing use of other opioids, and to "get high"); 2) the relationship between extramedical use and formal medical opioid agonist therapy programs; and 3) the established drug economy of extramedical buprenorphine.

CONCLUSIONS

The review identified varied and often divergent perspectives and experiences with extramedical buprenorphine use. An examination of the reported "normalizing" effects of extramedical buprenorphine suggests this practice as extending medicalized discipline beyond the clinical environment. Taken together, these findings identify a need to move beyond the tension of harm-reducing versus harm-producing effects toward forms of health care and promotion that focus on the needs, perspectives, and priorities of people who use drugs.

Time series-based bibliometric analysis of a systematic review of multidisciplinary care for opioid dose reduction: exploring the origins of the North American opioid crisis

Bibliometric analyses of systematic reviews offer unique opportunities to explore the character of specific scientific fields. In this time series-based analysis, dynamics of multidisciplinary care for chronic pain and opioid prescribing are analyzed over a forty-four year time span. Three distinct periods are identified, each defined by distinct research areas, as well as priorities regarding the use of opioids and the appropriate management of chronic pain. These scientometrically defined periods align with timelines identified previously by narrative historical accounts. Through cross-correlation with a mortality time series, a significant two-year lag between opioid overdose mortality and citation dynamics is identified between 2004 and 2019. This analysis demonstrates a bidirectional relationship between the scientific literature and the North American opioid overdose crisis, suggesting that the scientific literature is both reflective and generative of an important health and social phenomenon. A scientometric phenomenon of memory lapse, namely an overt and prolonged failure to cite older relevant literature, is identified using a metric of mean time to citation. It is proposed that this metric can be used to analyze changes in emerging literature and thus predict the nature of clinical and policy responses to the opioid crisis, and thus potentially to other health and social phenomena.

1665 Characterising the Escalation in Hospital Trauma Admission During the Easing of the COVID-19 Level 4 Lockdown Restrictions

Introduction

Major trauma reduced by over a third during the institution of UK level-4 national lockdown (Rajput K. et al; 2020). Easing of lockdown on a societal level posed unprecedented uncertainties. With the easing of restrictions, it is expected that the quantity of trauma would increase. In the absence of ‘normality’ it remains uncertain about the extent of the quantity, severity and aetiology of the trauma. The effect of lockdown easing on patterns of traumatic admissions has not been studied and it has important implications upon service provision.

Method

A retrospective cohort study using the data from 2017-2019 were used as a 3-year control to compare each month of 2020. Regional trauma data (TARN data) from Aintree level-1 Major Trauma Centre, the regional tertiary Specialist Units. Easing of restrictions to the regional tier system began in May-July. This index 3months was compared to the control data.

Results

Following easing of restrictions there was a significant increase in the Incident Severity Scores from trauma admissions. The %mortality during the level-4 lockdown decreases but as restrictions are eased there is an increase in the % mortality. The number of stabbings and road traffic collisions are also seen to increase following the ease of restrictions.

Conclusions

There is a decrease in the number of trauma calls seen following the easing of restrictions, yet the severity of the incident and the mortality rate has increased. Therefore, is the trauma more severe of does COVID-19 influence this?

Interventions for Depressive Symptoms in People Living with Chronic Pain: A Systematic Review of Meta-Analyses

OBJECTIVE

This review investigated the effectiveness of clinical interventions on depressive symptoms in people with all types of chronic pain.

METHODS

We searched seven electronic databases and reference lists on September 15, 2020, and included English-language, systematic reviews and meta-analyses of trials that examined the effects of clinical interventions on depressive outcomes in chronic pain. Two independent reviewers screened, extracted, and assessed the risk of bias. PROSPERO registration: CRD42019131871.

RESULTS

Eighty-three reviews were selected and included 182 meta-analyses. Data were summarized visually and narratively using standardized mean differences with 95% confidence intervals as the primary outcome of interest. A large proportion of meta-analyses investigated fibromyalgia or mixed chronic pain, and psychological interventions were most commonly evaluated. Acceptance and commitment therapy for general chronic pain, and fluoxetine and web-based psychotherapy for fibromyalgia showed the most robust effects and can be prioritized for implementation in clinical practice. Exercise for arthritis, pharmacotherapy for neuropathic pain, self-regulatory psychotherapy for axial pain, and music therapy for general chronic pain showed large, significant effects, but estimates were derived from low- or critically low-quality reviews.

CONCLUSIONS

No single intervention type demonstrated substantial superiority across multiple pain populations. Other dimensions beyond efficacy, such as accessibility, safety, cost, patient preference, and efficacy for non-depressive outcomes should also be weighed when considering treatment options. Further effectiveness research is required for common pain types such as arthritis and axial pain, and common interventions such as opioids, anti-inflammatories and acupuncture.

Assessment tools for problematic opioid use in palliative care: A scoping review

BACKGROUND

Screening for problematic opioid use is increasingly recommended in patients receiving palliative care.

AIM

To identify tools used to assess for the presence or risk of problematic opioid use in palliative care.

DESIGN

Scoping review.

DATA SOURCES

Bibliographic databases (inception to January 31, 2020), reference lists, and grey literature were searched to find primary studies reporting on adults receiving palliative care and prescription opioids to manage symptoms from advanced cancer, neurodegenerative diseases, or end-stage organ diseases; and included tools to assess for problematic opioid use. There were no restrictions based on study design, location, or language.

RESULTS

We identified 42 observational studies (total 14,431 participants) published between 2009 and 2020 that used questionnaires (n = 32) and urine drug tests (n = 21) to assess for problematic opioid use in palliative care, primarily in US (n = 38) and outpatient palliative care settings (n = 36). The questionnaires were Cut down, Annoyed, Guilty, and Eye-opener (CAGE, n = 8), CAGE-Adapted to Include Drugs (CAGE-AID, n = 6), Opioid Risk Tool (n = 9), Screener and Opioid Assessment for Patients with Pain (SOAPP; n = 3), SOAPP-Revised (n = 2), and SOAPP-Short Form (n = 5). Only two studies' primary objectives were to evaluate a questionnaire's psychometric properties in patients receiving palliative care. There was wide variation in how urine drug tests were incorporated into palliative care; frequency of abnormal urine drug test results ranged from 8.6% to 70%.

CONCLUSION

Given the dearth of studies using tools developed or validated specifically for patients receiving palliative care, further research is needed to inform clinical practice and policy regarding problematic opioid use in palliative care.

A comparison of gastric gas volumes measured by computed tomography after high-flow nasal oxygen therapy or conventional facemask ventilation. Anaesthesia 2021;76:1184-1189. [PMID: 33651914 DOI: 10.1111/anae.15433]

High-flow nasal oxygen therapy is increasingly used to improve peri-intubation oxygenation. However, it is unknown whether it may cause or exacerbate insufflation of gas into the stomach. High-flow nasal oxygen therapy is now standard practice in our hospital for adult patients undergoing percutaneous thermal ablation of liver cancer under general anaesthesia with tracheal intubation. We compared gastric gas volumes measured from computed tomography images that had been acquired immediately after intubation in two series of patients: 50 received peri-intubation high-flow nasal oxygen therapy and another 50 received conventional facemask pre-oxygenation and ventilation before intubation and before high-flow nasal oxygen therapy became standard practice in our unit. Median (IQR [range]) gastric gas volume was 24.0 (14.2-59.9 [3-167]) cm³ in the high-flow nasal oxygen therapy group and 23.8 (12.6-38.8 [0-185]) cm³ in the facemask group. There was no difference between the two groups in the volume of gastric gas measured by computed tomography imaging (Mann-Whitney U-test, U = 1136, p = 0.432, n₁  = n₂  = 50). Our results demonstrate that a small volume of gastric gas is commonly present after induction of anaesthesia, but that the use of peri-intubation high-flow nasal oxygen therapy for pre-oxygenation and during apnoea does not increase this volume compared with conventional facemask pre-oxygenation and ventilation. This is clinically relevant, as high-flow nasal oxygen therapy is increasingly being used in a peri-intubation context and in patients at higher risk of aspiration.

A retrospective quantitative implementation evaluation of Safer Opioid Prescribing, a Canadian continuing education program

BACKGROUND

Continuing health professions education (CHPE) is an important policy intervention for the opioid epidemic. Besides effectiveness or impact, health policy implementation should be studied to understand how an intervention was delivered within complex environments. Implementation outcomes can be used to help interpret CHPE effects and impacts, help answer questions of "how" and "why" programs work, and inform transferability. We evaluated Safer Opioid Prescribing (SOP), a national CHPE program, using implementation outcomes of reach, dose, fidelity, and participant responsiveness.

METHODS

We conducted a retrospective quantitative implementation evaluation of the 2014-2017 cohorts of SOP. To measure reach and dose, we examined participation and completion data. We used Ontario physician demographic data, including regulatory status with respect to controlled substances, to examine relevant trends. To measure fidelity and participant responsiveness, we analyzed participant-provided evaluations of bias, active learning, and relevance to practice. We used descriptive statistics and measures of association for both continuous and categorical variables. We used logistic regression to determine predictors of workshop participation and analysis of covariance to examine variation in satisfaction across different-sized sessions.

RESULTS

Reach: In total, there were 472 unique participants, 84.0% of whom were family physicians. Among Ontario physician participants, 90.0% were family physicians with characteristics representative of province-wide demographics. Dose: Webinar completion rate was 86.2% with no differences in completion based on rurality, gender, or controlled substance prescribing status with medical regulatory authorities. Fidelity and participant responsiveness: Nearly all participants rated the three webinars and workshop as balanced, and each element of SOP was also rated as highly relevant to clinical practice.

CONCLUSIONS

This evaluation demonstrates that Safer Opioid Prescribing was implemented as intended. Over a short period and without any external funding, the program reached more than 1% of the Ontario physician workforce. This suggests that the program may be a good model for using virtual CHPE to reach a critical mass of prescribers. This study represents a methodological advance of adapting evaluation methods from health policy and complex interventions for continuing health professions education. Future studies will assess effectiveness and impact on opioid prescribing and utilization within evaluation models of complex interventions.

Mind-Body Interventions for Depressive Symptoms in Chronic Pain: A Systematic Review of Meta-Analyses

BACKGROUND

Psychological comorbidities in chronic pain (CP) are common and contribute to adverse health outcomes and poor quality of life. Evidence-based guidance for the management of depressive symptoms in CP is limited, particularly for mind-body interventions.

OBJECTIVES

To investigate the effectiveness of mind-body interventions for the management of depressive symptoms in people with CP.

STUDY DESIGN

Systematic review (SR) of SRs.

SETTING

SRs with meta-analyses of clinical interventions for the management of depressive symptoms in people with CP.

METHODS

This SR was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic searches were performed for MEDLINE, EMBASE, PsycINFO, CINAHL, AMED, the Cochrane Database of Systematic Reviews, and the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports from inception to March 14, 2019. Reference lists and overviews were also hand-searched. SRs of mind-body interventions for CP were included if they conducted a meta-analysis of depression outcomes in people with any CP type not including headache. Two independent reviewers screened, extracted, and evaluated the quality of articles found. Quality was assessed using the AMSTAR 2 criteria and data were summarized narratively with standardized mean differences and 95% confidence intervals of the depression outcome.

RESULTS

Eleven SRs with 20 distinct meta-analyses demonstrated a small to moderate beneficial effect for mind-body interventions (effect sizes: -0.05 to -0.63).

LIMITATIONS

Depressive symptomatology was a subordinate concern compared with other outcomes. The primary literature base was reasonably broad with 33 primary studies, but small when compared with the number of meta-analyses.

CONCLUSIONS

Mind-body interventions show consistent small to moderate effects in reducing depressive symptoms in CP. The literature in this area demonstrates understudy and oversynthesis. There is a need for more clinical trials focusing on people with axial pain, people with comorbid major depressive disorder, and with depression as the primary outcome of interest. Full SR registered on PROSPERO: CRD42019131871.

Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic

BACKGROUND

Cancer diagnostics and surgery have been disrupted by the response of health care services to the coronavirus disease 2019 (COVID-19) pandemic. Progression of cancers during delay will impact on patients' long-term survival.

PATIENTS AND METHODS

We generated per-day hazard ratios of cancer progression from observational studies and applied these to age-specific, stage-specific cancer survival for England 2013-2017. We modelled per-patient delay of 3 and 6 months and periods of disruption of 1 and 2 years. Using health care resource costing, we contextualise attributable lives saved and life-years gained (LYGs) from cancer surgery to equivalent volumes of COVID-19 hospitalisations.

RESULTS

Per year, 94 912 resections for major cancers result in 80 406 long-term survivors and 1 717 051 LYGs. Per-patient delay of 3/6 months would cause attributable death of 4755/10 760 of these individuals with loss of 92 214/208 275 life-years, respectively. For cancer surgery, average LYGs per patient are 18.1 under standard conditions and 17.1/15.9 with a delay of 3/6 months (an average loss of 0.97/2.19 LYGs per patient), respectively. Taking into account health care resource units (HCRUs), surgery results on average per patient in 2.25 resource-adjusted life-years gained (RALYGs) under standard conditions and 2.12/1.97 RALYGs following delay of 3/6 months. For 94 912 hospital COVID-19 admissions, there are 482 022 LYGs requiring 1 052 949 HCRUs. Hospitalisation of community-acquired COVID-19 patients yields on average per patient 5.08 LYG and 0.46 RALYGs.

CONCLUSIONS

Modest delays in surgery for cancer incur significant impact on survival. Delay of 3/6 months in surgery for incident cancers would mitigate 19%/43% of LYGs, respectively, by hospitalisation of an equivalent volume of admissions for community-acquired COVID-19. This rises to 26%/59%, respectively, when considering RALYGs. To avoid a downstream public health crisis of avoidable cancer deaths, cancer diagnostic and surgical pathways must be maintained at normal throughput, with rapid attention to any backlog already accrued.

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review

CONTEXT

Opioid related deaths are at epidemic levels in many developed nations globally. Concerns about the contribution of prescribed opioids, and particularly high-dose opioids, continue to mount as do initiatives to reduce prescribing. Evidence around opioid tapering, which can be challenging and potentially hazardous, is not well developed. A recent national guideline has recognized this and recommended referral to multidisciplinary care for challenging cases of opioid tapering. However, multidisciplinary care for opioid tapering is not well understood or defined.

OBJECTIVE

Identify the existing literature on any multidisciplinary care programs that evaluate impact on opioid use, synthesize how these programs work and clarify whom they benefit.

STUDY DESIGN

Systematic rapid realist review.

DATASET

Bibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library), grey literature, reference hand search and formal expert consultation.

RESULTS

95 studies were identified. 75% of the programs were from the United States and the majority (n = 62) were published after 2000. A minority (n = 23) of programs reported on >12 month opioid use outcomes. There were three necessary but insufficient mechanisms common to all programs: pain relief, behavior change and active medication management. Programs that did not include a combination of all three mechanisms did not result in opioid dose reductions. A concerning 20-40% of subjects resumed opioid use within one year of program completion.

CONCLUSIONS

Providing alternative analgesia is insufficient for reducing opioid doses. Even high quality primary care multidisciplinary care programs do not reduce prescribed opioid use unless there is active medication management accomplished by changing the primary opioid prescriber. Rates of return to use of opioids from these programs are very concerning in the current context of a highly potent and lethal street drug supply. This contextual factor may be powerful enough to undermine the modest benefits of opioid dose reduction via multidisciplinary care.

Sahaj Samadhi Meditation versus a Health Enhancement Program for depression in chronic pain: protocol for a randomized controlled trial and implementation evaluation

Background

Despite the high prevalence of comorbid chronic pain and depression, this comorbidity remains understudied. Meditation has demonstrated efficacy for both chronic pain and depression independently, yet there have been few studies examining its effectiveness when both conditions are present concurrently. Furthermore, while meditation is generally accepted as a safe and effective health intervention, little is known about how to implement meditation programs within or alongside the health care system.

Methods

We will conduct a hybrid type 1 effectiveness–implementation evaluation. To measure effectiveness, we will conduct a randomized controlled trial comparing Sahaj Samadhi Meditation and the Health Enhancement Program in 160 people living with chronic pain, clinically significant depressive symptoms, and on long-term opioid therapy. Changes in depressive symptoms will be our primary outcome; pain severity, pain-related function, opioid use, and quality of life will be the secondary outcomes. The primary end point will be at 12 weeks with a secondary end point at 24 weeks to measure the sustainability of acute effects. Patients will be recruited from a community-based chronic pain clinic in a large urban center in Mississauga, Canada. The meditation program will be delivered in the clinical environment where patients normally receive their chronic pain care by certified meditation teachers who are not regulated health care providers. We will use a mixed-methods design using the multi-level framework to understand the implementation of this particular co-location model.

Discussion

Results of this hybrid evaluation will add important knowledge about the effectiveness of meditation for managing depressive symptoms in people with chronic pain. The implementation evaluation will inform both effectiveness outcomes and future program development, scalability, and sustainability.

Trial registration

ClinicalTrials.gov: NCT04039568. Registered on 31 July 2019.

Runs of homozygosity and testicular cancer risk

BACKGROUND

Testicular germ cell tumour (TGCT) is highly heritable but > 50% of the genetic risk remains unexplained. Epidemiological observation of greater relative risk to brothers of men with TGCT compared to sons has long alluded to recessively acting TGCT genetic susceptibility factors, but to date none have been reported. Runs of homozygosity (RoH) are a signature indicating underlying recessively acting alleles and have been associated with increased risk of other cancer types.

OBJECTIVE

To examine whether RoH are associated with TGCT risk.

METHODS

We performed a genome-wide RoH analysis using GWAS data from 3206 TGCT cases and 7422 controls uniformly genotyped using the OncoArray platform.

RESULTS

Global measures of homozygosity were not significantly different between cases and controls, and the frequency of individual consensus RoH was not significantly different between cases and controls, after correction for multiple testing. RoH at three regions, 11p13-11p14.3, 5q14.1-5q22.3 and 13q14.11-13q.14.13, were, however, nominally statistically significant at p < 0.01. Intriguingly, RoH200 at 11p13-11p14.3 encompasses Wilms tumour 1 (WT1), a recognized cancer susceptibility gene with roles in sex determination and developmental transcriptional regulation, processes repeatedly implicated in TGCT aetiology.

DISCUSSION AND CONCLUSION

Overall, our data do not support a major role in the risk of TGCT for recessively acting alleles acting through homozygosity, as measured by RoH in outbred populations of cases and controls.

Relapse following use of Ponseti method in idiopathic clubfoot

PURPOSE

We assessed the pattern of relapse as well as the correlation between the number of casts required for correction and Pirani and Dimeglio scores at presentation, and age at presentation. We hypothesized that the Ponseti method would be effective in treatment of relapsed clubfoot as well.

METHODS

We evaluated 115 idiopathic clubfeet in 79 children presenting with relapse following treatment by the Ponseti method. The mean age was 33.8 months with mean follow-up of 24 months. All patients were assessed for various patterns of relapsed deformities. Quantification of deformities was done using the Pirani and Dimeglio scores. All relapsed feet were treated by a repeat Ponseti protocol.

RESULTS

Non-compliance to a foot abduction brace was observed to be the main contributing factor in relapse, in 99 clubfeet (86%). Combination of three static deformities (equinus, varus and adduction) together was observed most commonly (38.3% feet). Overall, relapse of equinus deformity was noted most commonly followed by adduction. A painless plantigrade foot was obtained in all 115 feet with a mean of five casts. In all, 71 feet (61.7%) underwent percutaneous tenotomy. A total of 15 feet (13%) required tibialis anterior tendon transfer. Re-relapse rate in group 1 was 21% compared with 12.6% in group 2 and overall 16.5%.

CONCLUSION

We conclude that the Ponseti method is effective and the preferred initial treatment modality for relapsed clubfeet. Surgical intervention should be reserved for residual deformity only after a fair trial of Ponseti cast treatment. Regular follow-up and strict adherence to brace protocol may reduce future relapse rates. Further research is required to identify high-risk feet and develop individualized bracing protocol.

LEVEL OF EVIDENCE

IV.

Follicular porokeratosis: four new cases

Porokeratosis, a disorder of keratinisation, is clinically characterized by the presence of annular plaques with a surrounding keratotic ridge. Clinical variants include linear, disseminated superficial actinic, verrucous/hypertrophic, disseminated eruptive, palmoplantar and porokeratosis of Mibelli (one or two typical plaques with atrophic centre and guttered keratotic rim). All of these subtypes share the histological feature of a cornoid lamella, characterized by a column of 'stacked' parakeratosis with focal absence of the granular layer, and dysmaturation (prematurely keratinised cells in the upper spinous layer). In recent years, a proposed new subtype, follicular porokeratosis (FP_, has been described, in which the cornoid lamella are exclusively located in the follicular ostia. We present four new cases that showed typical histological features of FP.

Visceral Leishmaniasis in a Non-Endemic Area of India

The study included 57 patients with visceral leishmaniasis. The average duration of symptoms was 3.8 ± 3.55 months and pancytopenia was the commonest haematological abnormality. The parasite load directly correlated with the degree of anaemia at presentation (P=0.03). Splenic regression took 9.58 ±4.5 days and haematological parameters recovered in 14.5±9.07 days. There were five deaths over the five-year study duration. Leishmaniasis was not the first diagnosis in 14 patients, of whom eight were residents of non-endemic regions. Diagnosis was achieved in 13.5 days in these patients, compared to 4.5 days in patients where leishmaniasis was suspected at the outset.

Antibody response to Toxoplasma gondii in saliva samples from human immunodeficiency virus-infected patients

Toxoplasma gondii is an important opportunistic infection among human immunodeficiency virus (HIV)-infected patients as it causes fatal encephalitis. In the present study, antibody response to T. gondii is assessed in saliva samples from 100 HIV-seropositive patients and 25 HIV-negative healthy controls by indirect enzyme-linked immunosorbent assay (ELISA). Sensitivity and specificity for detection of IgG and IgM in saliva is calculated using a positive antibody response in serum samples (from an earlier study) as the gold standard. IgG and IgM antibodies were found in 20% and 25% patients, respectively. One control subject showed the presence of IgM antibody. Sensitivity for IgG and IgM antibodies was 64% and 81.25%, respectively, while specificity was 94.67% and 85.71%, respectively. This study indicates that saliva samples can be used as an alternative to serum samples to detect anti-toxoplasma antibodies, particularly IgM, for the diagnosis of toxoplasma encephalitis in HIV/acquired immune deficiency syndrome patients.

Antigenaemia and antibody response to Toxoplasma gondii in human immunodeficiency virus-infected patients

Toxoplasma encephalitis in immunocompromised patients results from reactivation of previously acquired (latent) infection. The aim of the study is to assess the antigenaemia and antibody response to Toxoplasma gondii in human immunodeficiency virus (HIV)-infected patients to determine the best marker for early diagnosis of toxoplasmosis in such patients. Indirect enzyme-linked immunosorbent assay (ELISA) for detection of IgG, IgM and IgA anti-toxoplasma antibodies and double-sandwich ELISA for toxoplasma antigen is carried out in serum samples collected from 100 HIV seropositive patients and 75 controls. Toxoplasma-specific IgG, IgM and IgA antibody response and antigenaemia were detected in 12%, 6%, 7% and 14% of HIV-infected patients, respectively. On retrospective analysis of 14 patients with antigenaemia only one had central nervous system (CNS) symptoms attributable to toxoplasma infection. In this patient, the CD4+ cell count was below 50/microL and none of the specific immunoglobulin isotype responses could be detected. The patient showed clinical improvement following specific chemotherapy for toxoplasmosis. In 25 HIV-negative and anti-toxoplasma IgG antibody-positive controls, IgM was detected in two (8%), IgA in five (20%) and antigenaemia in 10 (40%), while 50 HIV seronegative healthy controls were negative for both antigen and antibody responses. The study indicates that detection of toxoplasma antigen in addition to IgG antibody response may prove to be a useful indicator in the early diagnosis of reactivated toxoplasmosis in HIV/AIDS patients.

Radiographic and functional outcome of posterolateral lumbosacral fusion for low grade isthmic spondylolisthesis in children and adolescents

Aims

We reviewed 34 consecutive patients (18 female-16 male) with isthmic spondylolysis and grade I to II lumbosacral spondylolisthesis who underwent in situ posterolateral arthodesis between the L5 transverse processes and the sacral ala with the use of iliac crest autograft. Ten patients had an associated scoliosis which required surgical correction at a later stage only in two patients with idiopathic curves unrelated to the spondylolisthesis.

Methods

No patient underwent spinal decompression or instrumentation placement. Mean surgical time was 1.5 hours (1 to 1.8) and intra-operative blood loss 200 ml (150 to 340). There was one wound infection treated with antibiotics but no other complication. Radiological assessment included standing posteroanterior and lateral, Ferguson and lateral flexion/extension views, as well as CT scans.

Results

A solid posterolateral fusion was confirmed in all patients at mean latest follow-up of 4.7 years (3.4 to 9.8) beyond skeletal maturity into early adult life. Fusion of the isthmic lesion was documented in nine patients bilaterally and eight patients unilaterally. The poor fusion rate across the spondylolysis has not affected the excellent functional results of the procedure, which in our series depended on achieving a stable lumbosacral junction.

Conclusion

Quality of life assessment demonstrated significant improvement in all functional scores and high patient satisfaction with 28 patients returning to previous sports activities at an elite competitive level. Take home message: Posterolateral arthrodesis in situ with autologous iliac crest bone without instrumentation has achieved a solid fusion between the L5 transverse processes and the sacral ala in patients with grade I to II isthmic lumbosacral spondylolisthesis and this has produced excellent clinical outcomes and high patient satisfaction. Cite this article: Bone Joint J 2016;98-B:88–96.

Mutations in CUL7, OBSL1 and CCDC8 in 3-M syndrome lead to disordered growth factor signalling

3-M syndrome is a primordial growth disorder caused by mutations in CUL7, OBSL1 or CCDC8. 3-M patients typically have a modest response to GH treatment, but the mechanism is unknown. Our aim was to screen 13 clinically identified 3-M families for mutations, define the status of the GH-IGF axis in 3-M children and using fibroblast cell lines assess signalling responses to GH or IGF1. Eleven CUL7, three OBSL1 and one CCDC8 mutations in nine, three and one families respectively were identified, those with CUL7 mutations being significantly shorter than those with OBSL1 or CCDC8 mutations. The majority of 3-M patients tested had normal peak serum GH and normal/low IGF1. While the generation of IGF binding proteins by 3-M cells was dysregulated, activation of STAT5b and MAPK in response to GH was normal in CUL7(-/-) cells but reduced in OBSL1(-/-) and CCDC8(-/-) cells compared with controls. Activation of AKT to IGF1 was reduced in CUL7(-/-) and OBSL1(-/-) cells at 5 min post-stimulation but normal in CCDC8(-/-) cells. The prevalence of 3-M mutations was 69% CUL7, 23% OBSL1 and 8% CCDC8. The GH-IGF axis evaluation could reflect a degree of GH resistance and/or IGF1 resistance. This is consistent with the signalling data in which the CUL7(-/-) cells showed impaired IGF1 signalling, CCDC8(-/-) cells showed impaired GH signalling and the OBSL1(-/-) cells showed impairment in both pathways. Dysregulation of the GH-IGF-IGF binding protein axis is a feature of 3-M syndrome.

Patient involvement in blood transfusion safety: patients' and healthcare professionals' perspective

BACKGROUND

Blood transfusion is one of the major areas where serious clinical consequences, even death, related to patient misidentification can occur. In the UK, healthcare professional compliance with pre-transfusion checking procedures which help to prevent misidentification errors is poor. Involving patients at a number of stages in the transfusion pathway could help prevent the occurrence of these incidents.

OBJECTIVES

To investigate patients' willingness to be involved and healthcare professionals' willingness to support patient involvement in pre-transfusion checking behaviours.

MEASURES

A cross-sectional design was employed assessing willingness to participate in pre-transfusion checking behaviours (patient survey) and willingness to support patient involvement (healthcare professional survey) on a scale of 1-7.

PARTICIPANTS

One hundred and ten patients who had received a transfusion aged between 18 and 93 (60 male) and 123 healthcare professionals (doctors, nurses and midwives) involved in giving blood transfusions to patients.

RESULTS

Mean scores for patients' willingness to participate in safety-relevant transfusion behaviours and healthcare professionals' willingness to support patient involvement ranged from 4.96-6.27 to 4.53-6.66, respectively. Both groups perceived it most acceptable for patients to help prevent errors or omissions relating to their hospital identification wristband. Neither prior experience of receiving a blood transfusion nor professional role of healthcare staff had an effect on attitudes towards patient participation.

CONCLUSION

Overall, both patients and healthcare professionals view patient involvement in transfusion-related behaviours quite favourably and appear in agreement regarding the behaviours patients should adopt an active role in. Further work is needed to determine the effectiveness of this approach to improve transfusion safety.

Funding source and conflict of interest disclosures by authors and editors in gastroenterology specialty journals revisited

BACKGROUND

A survey of journals published in the field of Gastroenterology conducted 5 years ago showed marked variability in reporting of conflicts of interest or funding sources in these journals.

AIM

To re-examine reporting of conflicts of interest and funding sources for original articles and editorials in Gastroenterology and Hepatology journals.

METHODS

We evaluated all original articles and editorials in 15 leading journals (determined by impact factor-Thomson Reuter Science Citation Index) devoted to Gastroenterology and Hepatology for disclosures of conflicts and for editor's self disclosures. We examined each journal's editorial policy by contacting the journal directly if the information was not revealed on the Web site or print versions of the journal.

RESULTS

Of the 1574 articles evaluated, a total of 1207 (77%) reported the presence or absence of a potential conflict of interest and 1047 (67%) reported the presence or absence of funding sources. A total of 3 of the 15 (20%) journals (American Journal of Gastroenterology, Gastroenterology, and Alimentary Pharmacology and Therapeutics reported the presence or absence of funding sources in all their published original articles. Only 5 of 15 (33%) journals (Gut, Gastrointestinal Endoscopy, American Journal of Gastroenterology, Neurogastroenterology & Motility and Alimentary Pharmacology and Therapeutics) publicly disclosed the conflicts of interest of the editors.

CONCLUSIONS

(i) Funding sources and conflicts of interest are still reported variably in the GI literature. (ii) Editorials and review articles are influential, but have poor reporting of conflicts of interest. (iii) Editors of many journals still do not report their conflicts of interest.