Do men and women differ in their response to interdisciplinary chronic pain management?

Women report more pain than men. It also seems that gender may moderate responses to pharmacological agents used to combat pain, suggesting that men and women differ in treatment efficacy. Recent research suggests that gender differences may also exist in response to interdisciplinary pain management interventions. We, therefore, report data from a treatment-outcome program at a UK Pain Management Unit. The sample consisted of 98 chronic pain patients (33 males; 65 females) who completed a series of measures relating to pain and distress at three different time points: immediately prior, on completion, and 3 months following an interdisciplinary pain management intervention. The pain management intervention consisted of a 3- or 4-week residential program that aimed to enhance daily functioning, and which involved physiotherapists, occupational therapists, a nurse, physicians, and clinical psychologists. Analyses revealed that the pain management intervention produced improvements in a range of domains of outcome for both men and women, and that such effects were sustained at 3 months following treatment. However, although both men and women exhibited significant post-treatment reduction in measures of current pain intensity and with one measure of pain-related distress, at 3 months following treatment men showed similar reductions as at post-treatment, whereas for women there were no significant differences from pre-treatment scores. This suggests that gender may play a role in reports of pain and distress following interdisciplinary chronic pain management. However, the current results are different from those previously reported. We discuss potential reasons for such differences.     

Do questionnaires for the assessment of change really assess change?

PROBLEM: Two methods for the assessment of change are evaluated: (1) subjects' ratings of the outcome taken after termination of the treatment, and (2) comparison of test scores taken before the beginning and after termination of the treatment. METHODS: Included in the analysis are 82 subjects with chronic headache and/or back pain who participated in psychological group treatment for pain. They were given an outcome rating scale with 15 items (ORS) after therapy in addition to pain diaries and questionnaires for the assessment of physical symptoms, mood and quality of life. Diaries and questionnaires were filled in twice, before and after therapy. RESULTS: The ORS demonstrates satisfying psychometric properties. Internal consistency is 0.94 (Cronbach's alpha) and retest reliability is 0.74. Correlations of this scale with outcome criteria based on pre-post comparisons, however, are mostly nonsignificant. Significant correlations are found when the ORS scores are related to the questionnaire scores after therapy. CONCLUSION: It is concluded that, contrary to the formulation of the items, the ORS scale does not so much assess change, but rather depicts the state of the subjects at the time the assessment is made.     

Adherence to PECARN criteria in children transferred to a pediatric trauma center: An opportunity for improvement?

BackgroundThe Pediatric Emergency Care Applied Research Network (PECARN) criteria identify children at low risk of clinically important traumatic brain injury (ciTBI) in whom CT head (CTH) is unnecessary. We assessed compliance with PECARN at outside hospitals (OSH) among children transferred to our pediatric trauma center.MethodsPatients <18 years transferred between May 2016 and December 2018 undergoing CTH at an OSH were reviewed. A ciTBI was defined as one requiring hospitalization ≥2 midnights, intubation >24 h, neurosurgical intervention, or causing death.Results202 children were transferred after CTH. 53 were excluded for incomplete records (16), suspected abuse (33), or penetrating injury (4). Of the 149 included children, PECARN recommended CTH in 39 (26.2%), shared decision making in 79 (53.0%), and no imaging in 31 (20.8%). 26 children (17.4%) had a radiographic traumatic brain injury (rTBI) while only 6 (4.0%) had ciTBIs. Of those with ciTBIs, PECARN recommended CTH in 4 and shared decision making in 2. No child in whom CTH was not recommended had a ciTBI. 45 (30.2%) children had isolated extracranial injuries requiring transfer and 83 (55.7%) were transferred despite normal CTHs and no associated injuries. 2 (1.3%) children underwent non-emergent surgery for ciTBI.ConclusionsCompliance with PECARN was low among referring facilities with nearly 75% of CTHs being potentially avoidable with proper adherence and parental counseling. Deferring imaging until after transfer appears safe as no child underwent emergent intervention upon arrival. Early transfer and improved compliance with PECARN may reduce the number of CTHs performed.     

What Do Medical Students Do for Self-Care? A Student-Centered Approach to Well-Being

Phenomenon: Despite the promotion of medical student health and wellness through recent program and curricular changes, research continues to show that medical education is associated with decreased well-being in medical students. Although many institutions have sought to more effectively assess and improve self-care in medical students, no self-care initiatives have been designed using the explicit perspectives of students themselves. Approach: Using concept mapping methodology, the research team created a student-generated taxonomy of self-care behaviors taken from a national sample of medical students in response to a brainstorming prompt. The research team examined how students’ conceptualizations of self-care may be organized into a framework suitable for use in programming and curricular change in medical education. Findings: Ten clusters of self-care activities were identified: nourishment, hygiene, intellectual and creative health, physical activity, spiritual care, balance and relaxation, time for loved ones, big picture goals, pleasure and outside activities, and hobbies. Using results of the two-dimensional scaling analysis, students’ individual self-care behaviors were organized within two orthogonal dimensions of self-care activities. Insights: This concept map of student-identified self-care activities provides a starting point for better understanding and ultimately improving medical student self-care. Students’ brainstormed responses fit within a framework of varying levels of social engagement and physical-psychological health that included a wide range of solitary, social, physical, and mental health behaviors. As students’ preferred self-care practices did not often include programmatic activities, medical educators may benefit from consulting this map as they plan new approaches to student self-care and in counseling individual students searching for more effective ways to ease the burdens of medical school.     

Do inquiries into health system failures lead to change in clinical governance systems?

Aim

This paper reports the first part of a case study investigation to examine the changes at King Edward Memorial Hospital (KEMH) following an inquiry established to review the quality of obstetric and gynaecological services.

Background

Common findings from a range of health inquiries in recent times include that there have been inadequate adverse event reporting systems, the absence of transparent systems for staff and patients to report concerns about quality of patient care, and an ineffective medical credentialing and performance review system. The similarity of findings from many health inquiries raises the question of whether an inquiry does lead to changes to improve patient care and safety. There has been very little reported in the literature about this.

Method

Using a case study strategy the areas of medical credentialing, performance review and involvement of consumers in care were chosen as the KEMH clinical governance processes to be examined for changes post inquiry. Documents, archives and interviews were used as data sources for this case study. Documents were examined using a normative analytic approach and the Miles and Huberman framework was used for data analysis of the interviews.

Findings

There were significant changes in the area of credentialing and performance review evident in analysis of all sources of data. There were some improvements in the processes of involving consumers in care, but deficits were identified in regard to the provision of training and upskilling for clinicians to improve their communication skills and interactions with patients and families.     

Do caring behaviors in the quality caring model promote the human emotion of feeling cared for in hospitalized stroke patients and their families?

The aim of this study was to explore the discrete behaviors that comprise the human emotion of feeling cared for as described by hospitalized stroke patients and their families. Joanne Duffy's Quality Caring Model© (QCM) describes 8 caring behaviors supporting the experience of caring relationships exhibited during health care encounters. A secondary analysis of data from a guided interview was analyzed by 3 persons independently using general thematic content analysis and predetermined categories from the QCM, with final validation by the theorist. Percent agreement was 74.3% at first analysis, and 100% after secondary analysis. 82 of 100 phrases fit into at least one caring behavior, 17 phrases overlapped, and 18 phrases did not fit. Overlap between the caring behaviors is consistent with published quantitative reports. Patient experiences generating the emotion of “feeling cared for” may be formed from multiple caring behaviors enacted simultaneously by clinicians. Characteristics of clinicians, such as knowledge, may be as important as caring behaviors.     

Do we need a change in ED diagnostic strategy for adult acute epiglottitis?

Objectives

To retrospectively evaluate the diagnostic performance of qualitative and quantitative radiographic parameters for diagnosing adult acute epiglottitis, and identify the prevalence and risk factors of false-negative neck radiography-based diagnosis of acute epiglottitis.

Do patients consult their GP for sexual concerns? A cross sectional explorative study

Objective: To explore how often general practitioners (GPs) deal with patients’ sexual concerns, what kind of concerns are brought up and how the GPs deal with them.

Design: Cross sectional observational study.

Setting/subjects: 22 GPs in Southern Norway.

Main outcome measures: The percentage of consultations dealing with sexual concerns during three consecutive working days, as registered by the GPs on a questionnaire.

Results: Out of 1 117 consultations, 47 (4.2%) dealt with sexual concerns, varying from 1.6 to 10.9% of consultations. The concerns brought up varied widely, with erectile dysfunction and pain related to sexual activity in females as the largest groups. Concerns regarding sexual orientation, preferences or behavior were also dealt with, as were problems due to sexual assaults or rape. In 36 (76.6%) of the consultations, discussion of the problem and/or advice was the only action. Medication was prescribed in one third of the consultations. Patients' mean age was 46.7 years, with a span from 17 up to 75 years and 60% were female. We found no associations between GP characteristics and how frequently they dealt with sexual concerns.

Conclusions: In around 4% of consultations, the GPs dealt with a wide variety of sexual concerns.     

Did publication of a clinical practice guideline recommendation to screen for type 2 diabetes in women with gestational diabetes change practice?

OBJECTIVE: To determine whether women with previous gestational diabetes mellitus (GDM) were screened postpartum for type 2 diabetes according to the Canadian Diabetes Association (CDA) guidelines. RESEARCH DESIGN AND METHODS: The 1998 CDA guidelines recommend that all women diagnosed with GDM be screened postpartum for type 2 diabetes using a 2-h 75-g oral glucose tolerance test (OGTT). The impact of and compliance with this expert opinion-based recommendation is unknown. All women who delivered at the Ottawa Hospital in 1997 (pre-guideline) and 2000 (post-guideline) with confirmed GDM were identified. Using population-based administrative databases, we determined the proportion of these women who had an OGTT, serum glucose test, or glycated hemoglobin (GHb) test in the first postpartum year. Women who had not undergone any blood work were excluded. RESULTS: There were 131 women in 1997 and 123 women in 2000 with confirmed GDM. Of these, only 69 women in 1997 and 52 women in 2000 had blood work recorded in the database. None of these women had an OGTT performed in either period. We found a significant increase in the measurement of serum glucose (50 women pre-guideline [72.1%], 48 women post-guideline [92.3%], P < 0.05) and GHb (8 women pre-guideline [11.6%], 20 women post-guideline [38.5%], P < 0.01). CONCLUSIONS: In our region, physicians are not following the CDA recommendations to screen women with GDM postpartum with an OGTT. However, we did find a significant increase in the measurement of serum glucose and GHb. Publication of expert opinion-based guidelines did not change the postpartum use of an OGTT in these women but may have increased the use of less reliable screening tests for type 2 diabetes.