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Over the last decade, the content, delivery and media of pain education have been adjusted in line with scientific discovery in pain and educational sciences, and in line with consumer perspectives. This paper describes a decade-long process of exploring consumer perspectives on pain science education concepts to inform clinician-derived educational updates (undertaken by the authors). Data were collected as part of a quality audit via a series of online surveys in which consent (non-specific) was obtained from consumers for their data to be used in published research. Consumers who presented for care for a persistent pain condition and were treated with a pain science education informed approach were invited to provide anonymous feedback about their current health status and pain journey experience 6, 12 or 18 months after initial assessment. Two-hundred eighteen consumers reported improvement in health status at follow-up. Results of the surveys from three cohorts of consumers that reported improvement were used to generate iterative versions of ‘Key Learning Statements’. Early iteration of these Key Learning Statements was used to inform the development of Target Concepts and associated community-targeted pain education resources for use in public health and health professional workforce capacity building initiatives. Perspective This paper reflects an explicit interest in the insights of people who have been challenged by persistent pain and then recovered, to improve pain care. Identifying pain science concepts that consumers valued learning provided valuable information to inform resources for clinical interactions and community-targeted pain education campaigns. Refereed/Peer-reviewed

The shallow depth of maximum dose and higher dose fall-off gradient of a 2.5 MV beam along the central axis that is available for imaging on linear accelerators is investigated for treatment of shallow tumors and sparing the organs at risk (OARs) beyond it. In addition, the 2.5 MV beam has an energy bridging the gap between kilo-voltage (kV) and mega-voltage (MV) beams for applications of dose enhancement with high atomic number (Z) nanoparticles.We have commissioned and utilized a MATLAB-based, open-source treatment planning software (TPS), matRad, for intensity-modulated radiation therapy (IMRT) dose calculations. Treatment plans for prostate, liver, and head and neck (HN), nasal cavity, two orbit cases, and glioblastoma multiforme (GBM) were performed and compared to a conventional 6 MV beam. Additional Monte Carlo calculations were also used for benchmarking the central axis dose.Both beams had similar planning target volume (PTV) dose coverage for all cases. However, the 2.5 MV beam deposited 6%-19% less integral doses to the nasal cavity, orbit, and GBM cases than 6 MV photons. The mean dose to the heart in the liver plan was 10.5% lower for 2.5 MV beam. The difference between the doses to OARs of HN for two beams was under 3%. Brain mean dose, brainstem, and optic chiasm max doses were, respectively, 7.5%-14.9%, 2.2%-8.1%, and 2.5%-19.0% lower for the 2.5 MV beam in the nasal cavity, orbit, and GBM plans.This study demonstrates that the 2.5 MV beam can produce clinically relevant treatment plans, motivating future efforts for design of single-energy LINACs. Such a machine will be capable of producing beams at this energy beneficial for low- and middle-income countries, and investigations on dose enhancement from high-Z nanoparticles.

Guidelines for chronic noncancer pain prioritize behavioral treatments. In clinical practice transition from opioids to behavioral treatments is often not endorsed by patients or providers. Feasible interventions to support opioid tapering are needed, particularly in primary care. The objectives of this paper is to review the feasibility of behavioral interventions to support opioid tapering. Electronic databases (MEDLINE, Embase, PsycINFO, and CINAHL) were searched from inception to June 2019 to identify original studies reporting feasibility (consent rates; completion rates; patient-reported acceptability; integration into clinical practice; and adverse events) of opioid tapering and transition to behavioral treatments for adults experiencing chronic noncancer pain. Google scholar and contents tables of key journals were also searched. Two authors independently extracted data and assessed methodological quality using The Quality Assessment Tool for Quantitative Studies. Eleven publications met inclusion criteria, of which three were conducted in primary care. Consent rates ranged from 27% to 98% and completion rates from 6.6% to 100%. Four studies rated at least one component of patient acceptability: helpfulness from 50%–81%; satisfaction 71%–94%, and “recommend to others” 74%–91%. Three studies reported provider perspectives and two studies reported adverse events. Quality assessment indicated all 11 studies were moderate or weak, primarily due to selection bias and lack of assessor blinding. There was also considerable heterogeneity in study design. The limited available data suggest that attempts to translate opioid tapering interventions into practice are likely to encounter substantial feasibility challenges. One possible way to ameliorate this challenge may be a clear policy context, which facilitates and support opioid reduction.

Objectives This study examined the effects of sacubitril/valsartan on N-terminal pro–B-type natriuretic peptide (NT-proBNP) levels and determined patient characteristics associated with favorable NT-proBNP reduction response. Background NT-proBNP levels reflect cardiac wall stress and predict event risk in patients with acute decompensated heart failure (ADHF). Methods Post-hoc analysis of the TRANSITION (Comparison of Pre- and Post-discharge Initiation of Sacubitril/Valsartan Therapy in HFrEF Patients After an Acute Decompensation Event) study, including stabilized ADHF patients with reduced ejection fraction, randomized to open-label sacubitril/valsartan initiation in-hospital (pre-discharge) versus post-discharge. NT-proBNP was measured at randomization (baseline), discharge, and 4 and 10 weeks post-randomization. A favorable NT-proBNP response was defined as reduction to ≤1,000 pg/ml or >30% from baseline. Results In patients receiving sacubitril/valsartan in-hospital, NT-proBNP was reduced by 28% at discharge, with 46% of patients obtaining favorable NT-proBNP reduction response compared with a 4% reduction and 18% favorable response rate in patients initiated post-discharge (p Conclusions In-hospital initiation of sacubitril/valsartan produced rapid reductions in NT-proBNP, statistically significant at discharge. A favorable NT-proBNP response over time was associated with a better prognosis and predicted by higher starting dose and predisposing clinical profile. (Comparison of Pre- and Post-discharge Initiation of LCZ696 Therapy in HFrEF Patients After an Acute Decompensation Event [TRANSITION]; NCT02661217)

Nutrition plays an important role in pain management. Healthy eating patterns are associated with reduced systemic inflammation, as well as lower risk and severity of chronic non-cancer pain and associated comorbidities. The role of nutrition in chronic non-cancer pain management is an emerging field with increasing interest from clinicians and patients. Evidence from a number of recent systematic reviews shows that optimising diet quality and incorporating foods containing anti-inflammatory nutrients such as fruits, vegetables, long chain and monounsaturated fats, antioxidants, and fibre leads to reduction in pain severity and interference. This review describes the current state of the art and highlights why nutrition is critical within a person-centred approach to pain management. Recommendations are made to guide clinicians and highlight areas for future research.

Introduction: Integrated team-based primary healthcare is well positioned to support opioid tapering for patients experiencing chronic pain. This paper describes the development, implementation and acceptability of a primary healthcare opioid tapering intervention ‘Assess Inform Manage Monitor’ (AIMM) at two sites. Methods: AIMM involved GP advice; nurse monitoring and potential engagement with: community pharmacist; psychologist; dietitian and exercise physiologist. Individuals receiving 90 days or more of prescription opioids were eligible. Patient and provider surveys and qualitative interviews were completed. Results: Of 140 eligible patients, 37 attended during the study period and were invited to participate. Patient post-intervention surveys (n = 8) and interviews (n = 6) indicated the intervention was acceptable, although the perceived value of some of the integrated team was low. GP and practice nurse support was valued. Providers (n = 4) valued team integration. Low weaning readiness was a barrier to engagement by patients and providers. Key lessons and conclusions: The intervention, whilst conceptually acceptable, was not feasible in its current form. Future efforts to transition patients towards integrated care should retain the practice nurse and place more focus on understanding and reinforcing patients’ readiness to wean. Greater inter-professional collaboration may also be needed. Such refinements may advance the cause of opioid reduction in primary care.

Purpose Active pain self-management (PSM) for patients with chronic pain is assumed to require multidisciplinary care, leaving prescribing analgesics the most accessible option for general practitioners (GPs). We sought to upskill GPs in multimodalPSM with a harm minimisation approach for any opioid prescribing. Design and Methodology Having developed an educational training resource, a multidisciplinary team delivered the program to attendees at a GP conference in 2017. The educational package comprised pre-readings, a 6-hour interactive, skills-based workshop, and post-workshop resources. The single-group intervention was evaluated with an original and unvalidated pre/post-test (three months) survey of four domains: knowledge; attitudes; utilisation of strategies involving PSM and opioid harm minimization. Paired t-tests were conducted on each domain score and overall, with effect sizes assessed with Cohen’s d. A sensitivity analysis was performed on the data lacking a post-test survey response. Post-survey scores were imputed via chained regression equations, then paired t-tests analyses were conducted on imputed datasets using Rubin's method to pool estimates. Findings Of 99 participants, 33 returned both surveys for primary analysis. These were combined in the sensitivity analysis with 60 unpaired surveys. Internal consistency was modest (Cronbach’s alpha 0.736). Primary analysis demonstrated significant self-reported improvements in each educational domain with overall score increasing 10.54 points out of 130 (p

Background General practitioners' (GPs) views about deprescribing prescription opioid analgesics (POAs) may influence the care provided for patients experiencing chronic noncancer pain (CNCP). There are limited data addressing GPs' beliefs about deprescribing, including their decisions to deprescribe different types of POAs. Aim To determine the proportion of GPs who hold attitudes congruent with local pain stewardship, describe their deprescribing decisions, and determine whether type of POA influences deprescribing. Design and setting In 2016, a cross-sectional survey of all GPs (n=1,570) in one mixed urban and regional primary health network (PHN) in Australia was undertaken. Methods A mailed self-report questionnaire assessed agreement with local guidelines for treating CNCP; influences on deprescribing POAs and likelihood of deprescribing in a hypothetical case involving either oral codeine or oxycodone. Results A response rate of 46% was achieved. Approximately half (54%) of GPs agreed POAs should be reserved for people with acute, cancer pain or palliative care and a third (32%) did not agree that a medication focus has limited benefits for peoples' long-term quality of life and function. Most (77%) GPs were less likely to deprescribe when effective alternate treatments were lacking, while various patient factors (eg, fear of weaning) were reported to decrease the likelihood of deprescribing for 25% of GPs. A significantly higher proportion of GPs reported being very likely to deprescribe codeine compared to the equivalent opioid dose of oxycodone for a hypothetical patient. Conclusions Many GPs in the PHN hold attitudes at odds with local guidance that opioids are a nonsuperior treatment for CNCP. Attitudinal barriers to deprescribing include: a lack of consistent approach to deprescribing opioids as a class of drugs, perceived lack of effective treatment alternatives and patient fear of deprescribing. Therefore, the next step in this target population is to appropriately train and support GPs in how to apply the evidence in practice and how to support patients appropriately.

Opioids have important roles in the time-limited treatment of acute and cancer pain, end-of-life pain or dyspnoea, and in opioid dependency. Maintaining focus on biomedical treatments, including drugs, has limited success in chronic pain. Active self-management and healthy lifestyle choices are fundamental to addressing multisystem complexity and harnessing neuroplasticity in chronic pain. Addressing psychosocial maladaptations and physical deconditioning requires a variety of approaches, frequently involving multiple care providers. In practice, most pain care is delivered outside specialist centres by GPs and other non-pain specialists. Although they are well placed to provide multimodal care, they often lack training and confidence in delivering this care.

At 4 a.m. on December 2, 2017, St. Joseph's Healthcare Hamilton - a multi-site, clinically diverse, tertiary academic and research hospital - deployed an electronic health record (EHR) system across the organization using a "big bang" approach. This effectively required all inpatient, emergency and many ambulatory services to put down their pens and document everything electronically at one moment in time without skipping a beat in providing excellent clinical care. The hospital leapt from the bottom to nearly the top of the internationally recognized measurement for EHR adoption - on time, in scope and within budget. This article presents the leadership's view on essential lessons learned with key recommendations for healthcare systems seeking successful implementation with this approach.

Background Chronic non-cancer pain (CNCP) frequently co-occurs with other chronic conditions, resulting in multimorbidity. Objective The aim of this article is to summarise current approaches to CNCP management and explore areas of specificity and overlap with chronic conditions in general. Discussion The biomedical component of the management of chronic conditions may be condition-specific. However, mind-body, connection, activity and nutrition components entail significant overlap and are helpful across conditions. Effective practice avoids overemphasis on medical treatments at the expense of evidence-based, multidimensional lifestyle approaches. CNCP management illustrates the case for reconceptualising chronic condition management using a generic lifestyle-based approach. This capitalises on overlapping treatments, creates system efficiency and allows patients with multimorbidity to be treated more effectively in primary care, with only a small subgroup referred to condition-specific tertiary services.

Background. Local chronic non-cancer pain guidance recommends that general practitioners should consider opioid deprescribing and referral to multidisciplinary healthcare providers for behaviourally based treatments . We designed a training package called AIMM (Assess, Inform, Manage and Monitor) to reinforce this stewardship. Aim. To identify whether participation in AIMM training effectively aligned clinicians’ attitudes with local guidance for treating chronic non-cancer pain . Design and setting. In 2014–15, the AIMM training was tested using a pre–post-test non-randomised design at two sites in NSW, Australia. The primary outcome measure was an 11-item, study-specific, pain attitude questionnaire (PAQ). Method. Step one of AIMM training involved online completion of the PAQ and review of a specialist pain website. Step two involved attendance at two face-to-face, two-hour interactive workshops led by pain experts who addressed opioid deprescribing and switching to broader care. A repeat PAQ survey was completed at the conclusion of the second workshop. Results. Nineteen participants attended the workshops, including general practitioners (n = 7), nurses (n = 5), exercise physiologists (n = 2), a dietitian (n = 1), community pharmacists (n = 2) and psychologists (n = 2). Significant shifts in six attitudes occurred, including prescribing less pain medication, greater emphasis on social reconnection, increasing planned activity and adopting anti-inflammatory nutrition (p

There is a substantial clinical variation in the contemporary treatment of chronic noncancer pain reflecting different explanatory models and treatment emphasis. Hunter Integrated Pain Service and collaborators developed three key messaging videos outlining the foundations of chronic pain treatment, thus challenging unwarranted clinical variation and calling for greater therapeutic consistency. The videos were released on YouTube as a low-cost public health intervention. Each video used an evidenced informed script appropriate for low literacy and a cartoonist to provide matching images. The whole-person approach emphasized the role of the nervous system and active self-management approaches over passively received medical treatments. The first video was launched on YouTube in August 2011 and made freely available through a Creative Commons license. Multisource feedback led to refinement of key messages using a broader advisory group. Two further videos were launched on a dedicated YouTube channel in October 2014 and circulated through varied professional and consumer networks. All videos were widely viewed on YouTube, utilized by diverse health care organizations, and independently translated into multiple languages. They were embedded in multiple health-related websites. The first video “Understanding pain in less than 5 minutes” is known to have been translated into 15 languages by other health care organizations. The subsequent two videos (Brainman stops his opioids, and Brainman chooses) were translated into German and subtitled in French and Japanese. When the organization hosting the first video ceased operation in 2015 due to changes in primary health care funding, the video had received >700,000 views. Each of the three videos continues to receive ~1,500 views per month on YouTube. Release of evidence-informed key messages via YouTube is a simple method of challenging clinical variation and providing education about chronic pain across the health care system and community., Video abstract

In Sandoz Ltd & Hexal AG v G.D. Searle LLC & Janssen Sciences Ireland UC [2017] EWHC 987 (Pat), the UK High Court held that an active ingredient in a pharmaceutical product that was claimed only by reference to a Markush formula and not expressly referred to in the patent was “protected” by a basic patent for the purposes of obtaining a patent term extension under the European Union Supplementary Protection Certificate Regulations. This decision will be welcomed by practitioners in adding some clarity to the interpretation of previous decisions of the Court of Justice of the European Union relating to the definition of what is protected by a basic patent in this extremely commercially important and fast-moving area of jurisprudence. The implication of this decision is discussed further in this report.

The aim of this study was to examine the effect of a six-week 2 &times, 2 design on pain scores, quality of life, and dietary intake in patients attending an Australian tertiary pain clinic. The two intervention components were (1) personalized dietary consultations or waitlist control, and (2) active or placebo dietary supplement (fruit juice). Sixty participants were randomized into one of four groups at baseline (68% female, mean age 49 &plusmn, 15 years) with 42 completing the study (70% retention). All groups had statistically significant improvements in three of five pain outcomes. The personalized dietary consultation groups had clinically important improvements in three of five pain outcomes compared to the waitlist control groups. All groups had a statistically significant improvement in six of eight quality-of-life categories post intervention. All groups increased percentage energy from nutrient-dense foods (+5.2 &plusmn, 1.4%, p &lt, 0.001) with a significant group-by-time effect for percentage energy from total fat (p = 0.024), with the personalized dietary consultations plus placebo fruit juice reporting the largest reduction (&minus, 5.7 &plusmn, 2.3%). This study indicates that dietitian-delivered dietary intervention can improve pain scores, quality of life, and dietary intake of people experiencing chronic pain. Future research should evaluate efficacy in a full-powered randomized control trial.

Background This systematic review aimed to evaluate the impact of nutrition interventions on participant reported pain severity and intensity in populations with chronic pain. Methods Eight databases were systematically searched for studies that included adult populations with a chronic pain condition, a nutrition intervention and a measure of pain. Where possible, data were pooled using meta-analysis. Seventy-one studies were included, with 23 being eligible for meta-analysis. Results Studies were categorised into four groups: (i) altered overall diet with 12 of 16 studies finding a significant reduction in participant reported pain; (ii) altered specific nutrients with two of five studies reporting a significant reduction in participant reported pain; (iii) supplement-based interventions with 11 of 46 studies showing a significant reduction in pain; and (iv) fasting therapy with one of four studies reporting a significant reduction in pain. The meta-analysis found that, overall, nutrition interventions had a significant effect on pain reduction with studies testing an altered overall diet or just one nutrient having the greatest effect. Conclusions This review highlights the importance and effectiveness of nutrition interventions for people who experience chronic pain.

Psychologists are subject to multiple competing emotional demands that increase the risk of burnout. Research has demonstrated that burnout arises from both organizational and personal factors, including psychologists' personal beliefs and coping. Preliminary research indicates that Early Maladaptive Schemas (EMS) are associated with high burnout, yet, to date, the role of EMS and associated coping responses (Maladaptive Coping Modes [MCM]) in predicting high burnout among psychologists has not been investigated. Four hundred and forty‐three psychologists completed a self‐report online questionnaire comprising the Maslach Burnout Inventory—Emotional Exhaustion Scale (EE), Young Schema Questionnaire (YSQ), and Schema Mode Inventory (SMI). The two most common EMS amongst psychologists were Unrelenting Standards and Self Sacrifice. There was substantial indication of burnout, with 18.3% in the high range and 29.6% in the moderate range of EE. The most common MCM were Detached Protector and Detached Self‐Soother. Controlling for demographics and job demands, EMS accounted for an additional 18% variance in EE. MCM accounted for an additional 6% beyond the variance explained by demographics, job demands and EMS. Practical recommendations are suggested to reduce psychologist burnout. Refereed/Peer-reviewed

It is often alleged that households moving into neighborhoods with the aid of housing choice vouchers (HCVs) raise crime rates there. We use 1999–2008 quarterly data from Chicago census tracts to test this allegation with a dynamic panel model designed to overcome the challenges of omitted variable and endogeneity biases. We find no support for the proposition that growth in HCV holders leads to growth in violent crime rates, regardless of neighborhood context. We find that growth in HCV holders is positively associated with growth in property crime rates, however, in higher poverty neighborhoods or if HCVs exceed a threshold concentration.

Introduction Advocacy and commercially funded education successfully reduced barriers to the provision of long-term opioid analgesia. The subsequent escalation of opioid prescribing for chronic noncancer pain has seen increasing harms without improved pain outcomes. Methods This was a one-group pretest-posttest design study. A multidisciplinary team developed a chronic pain educational package for general practitioner trainees emphasizing limitations, risk-mitigation, and deprescribing of opioids with transition to active self-care. This educational intervention incorporated prereadings, a resource kit, and a 90-minute interactional video case-based workshop incorporated into an education day. Evaluation was via pre- and postintervention (two months) questionnaires. Differences in management of two clinical vignettes were tested using McNemar's test. Results Of 58 eligible trainees, 47 (response rate = 81.0%) completed both questionnaires (36 of whom attended the workshop). In a primary analysis including these 47 trainees, therapeutic intentions of tapering opioid maintenance for pain (in a paper-based clinical vignette) increased from 37 (80.4%) pre-intervention to 44 (95.7%) postintervention (P = 0.039). In a sensitivity analysis including only trainees attending the workshop, 80.0% pre-intervention and 97.1% postintervention tapered opioids (P = 0.070). Anticipated initiation of any opioids for a chronic osteoarthritic knee pain clinical vignette reduced from 35 (74.5%) to 24 (51.1%; P = 0.012) in the primary analysis and from 80.0% to 41.7% in the sensitivity analysis (P = 0.001). Conclusions Necessary improvements in pain management and opioid harm avoidance are predicated on primary care education being of demonstrable efficacy. This brief educational intervention improved hypothetical management approaches two months subsequently. Further research measuring objective changes in physician behavior, especially opioid prescribing, is indicated.

We describe the characteristics of patients attending an Australian tertiary multidisciplinary pain service and identify areas for nutrition interventions. This cross-sectional study targets patients experiencing chronic pain who attended the service between June–December 2014. Self-reported data was captured from: (1) an Electronic Persistent Pain Outcomes Collaboration (ePPOC) referral questionnaire, incorporating demographics, pain status, and mental health; (2) a Pain Assessment and Recovery Plan (PARP), which documents patients’ perceived problems associated with pain and personal treatment goals. The ePPOC referral questionnaire was completed by 166 patients and the PARP by 153. The mean (SD) patient age was 53 ± 13 years, with almost 60% experiencing pain for >5 years. Forty-five percent of patients were classified as obese (BMI ≥ 30 kg/m2, mean (SD) BMI was 31 ± 7 kg/m2), with a mean waist circumference of 104 ± 19.4 cm (SD). The most frequent patient nominated treatment goals related to physical activity (39%), followed by nutritional goals (23%). Traditionally, pain management programs have included physical, psychosocial, and medical, but not nutritional, interventions. By contrast, patients identified and reported important nutrition-related treatment goals. There is a need to test nutrition treatment pathways, including an evaluation of dietary intake and nutrition support. This will help to optimize dietary behaviors and establish nutrition as an important component of multidisciplinary chronic pain management.

Purpose Rapid response teams (RRTs) were created to stabilize acutely ill patients on the ward, but recent studies suggest that RRTs may improve end-of-life care (EOLC). To learn more about the role of the RRT in EOLC at our institutions, we conducted a retrospective review. Methods Retrospective review of 300 RRT consultations at 3 academic hospitals in Toronto, Canada. Results The typical consultation was for an elderly patient with chronic illness. More than 90% had a “full resuscitation” order at the time of consultation. One third were admitted to the intensive care unit within 48 hours of the RRT consultation, and 24.7% ultimately died. Twenty-seven (9.3%) had a patient/family conference on the ward within 48h of the RRT consultation, 24 (8.3%) of whom changed their resuscitation order as a result. Among those who changed their resuscitation order, fewer than 20% were referred to the palliative care or spiritual care service, or prescribed comfort medications as needed (pro re nata), within 48h of the RRT consultation; 2 patients died without receiving any common EOLC orders, and 15 (63%) died before discharge. Conclusions RRT consultation is an important milestone for many patients approaching EOL. RRTs frequently participate in EOL discussions and decision-making, but they may miss opportunities to facilitate EOLC.

Introduction Effective teamwork and interprofessional collaboration are vital for healthcare quality and safety; however, challenges persist in creating interprofessional teamwork and resilient professional teams. A study was undertaken to delineate perceptions of individuals involved with the implementation of an interprofessional patient safety competency-based intervention and intervention participants. Methods The study employed a qualitative study design that triangulated data from interviews with six steering committee members and five members of the project team who developed and monitored the intervention and six focus groups with clinical team members who participated in the intervention and implemented local patient safety projects within a large teaching hospital in Canada. Results Our study findings reveal that healthcare professionals and support staff acquired patient safety competencies in an interprofessional context that can result in improved patient and work flow processes. However, key challenges exist including managing projects amidst competing priorities, lacking physician engagement and sustaining projects. Conclusions Our findings point to leaders to provide opportunities for healthcare teams to engage in interprofessional teamwork and patient safety projects to improve quality of patient care. Further research efforts should examine the sustainability of interprofessional safety projects and how leaders can more fully engage the participation of all professions, specifically physicians.

Health care organizations continue to implement organization-wide educational approaches to enhance patient safety with less attention on evaluating the impact of these approaches. In this context, a study was conducted to measure the impact of an organization-wide patient safety network approach on patient safety event reporting. A time-series analysis with reported rates of adverse events (major and moderate), near misses, sentinel events, and incidents from 2 years prior through 13 months following implementation was conducted. Study findings include a significant increase in reporting of patient safety events (an approximately 50% increase in overall reporting of safety events was observed; p < .001), especially near misses (an approximately 100% increase following implementation; p = .002). Study findings suggest that a multifaceted networked approach does contribute to improving patient safety event reporting.

We aimed to evaluate the effect of pain education on opioid prescribing by early-career general practitioners. A brief training workshop was delivered to general practice registrars of a single regional training provider. The workshop significantly reduced "hypothetical" opioid prescribing (in response to paper-based vignettes) in an earlier evaluation. The effect of the training on "actual" prescribing was evaluated using a nonequivalent control group design nested within the Registrar Clinical Encounters in Training (ReCEnT) cohort study: 4 other regional training providers were controls. In ReCEnT, registrars record detailed data (including prescribing) during 60 consecutive consultations, on 3 occasions. Analysis was at the level of individual problem managed, with the primary outcome factor being prescription of an opioid analgesic and the secondary outcome being opioid initiation. Between 2010 and 2015, 168,528 problems were recorded by 849 registrars. Of these, 71% were recorded by registrars in the nontraining group. Eighty-two percentages were before training. Opioid analgesics were prescribed in 4382 (2.5%, 95% confidence interval [CI]: 2.40-2.63) problems, with 1665 of these (0.97%, 95% CI: 0.91-1.04) representing a new prescription. There was no relationship between the training and total prescribing after training (interaction odds ratio: 1.01; 95% CI: 0.75-1.35; P value 0.96). There was some evidence of a reduction in initial opioid prescriptions in the training group (interaction odds ratio: 0.74; 95% CI: 0.48-1.16; P value 0.19). This brief training package failed to increase overall opioid cessation. The inconsistency of these actual prescribing results with "hypothetical" prescribing behavior suggests that reducing opioid prescribing in chronic noncancer pain requires more than changing knowledge and attitudes.

Chronic pain is a growing problem with little obvious explanation for its increasing prevalence. Traditional medical approaches including pain-killing medications have been largely unsuccessful and potentially counterproductive in stemming this growth over the long term. Hence, a more holistic approach incorporating aspects of lifestyle and psychology has begun to be used in pain clinics and primary care, with an expanding role for the lifestyle medicine practitioner.

To evaluate whether a Post-Arrest Consult Team improved care and outcomes for patients with out-of-hospital cardiac arrest.Prospective cohort study of Post-Arrest Consult Team implementation at two hospitals, with concurrent controls from 27 others.Twenty-nine hospitals within the Strategies for Post-Arrest Care Network of Southern Ontario, Canada.We included comatose adult nontraumatic out-of-hospital cardiac arrest patients surviving more than or equal to 6 hours after emergency department arrival who had no contraindications to targeted temperature management.The Post-Arrest Consult Team was an advisory consult service to improve 1) targeted temperature management, 2) assessment for percutaneous coronary intervention, 3) electrophysiology assessment, and 4) appropriately delayed neuroprognostication.We used generalized linear mixed models to explore the association between Post-Arrest Consult Team implementation and performance of targeted processes. We included 1,006 patients. The Post-Arrest Consult Team was associated with a significant reduction over time in rates of withdrawal of life-sustaining therapy within 72 hours of emergency department arrival on the basis of predictions of poor neurologic prognosis (ratio of odds ratios, 0.13; 95% CI, 0.02-0.98). Post-Arrest Consult Team was not associated with improved successful targeted temperature management (ratio of odds ratios, 0.91; 95% CI, 0.31-2.65), undergoing angiography (ratio of odds ratios, 1.91; 95% CI, 0.17-21.04), receiving electrophysiology consultation (ratio of odds ratios, 0.93; 95% CI, 0.11-8.16), or functional survival (ratio of odds ratios, 0.75; 95% CI, 0.19-2.94).Implementation of a Post-Arrest Consult Team reduced premature withdrawal of life-sustaining therapy but did not improve rates of successful targeted temperature management, coronary angiography, formal electrophysiology assessments, or functional survival for comatose patients after out-of-hospital cardiac arrest.