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Abstract Background Environmental nontuberculous mycobacteria species that are not members of the M. tuberculosis complex, are ordinary inhabitants of a wide variety of environmental reservoirs and their role in human and animal diseases has been fully recognized. Even if spontaneous mycobacterial infections have been reported in a wide variety of reptiles, this is the first report of systemic fatal mycobacteriosis sustained by Mycobacterium goodii in a pet reptile. Case presentation An adult, wild caught (WC), male Kenyan sand boa (Eryx colubrinus loveridgei) age unknown, was presented for clinical examination due to decreased activity level, decreased appetite and diarrhea. Blood tests showed unreliable results. Coprologic exam showed a moderate to severe presence of flagellates. X rays and ultrasound showed moderate presence of air and faeces in the large intestine. The snake was hospitalized and oral metronidazole was chosen as antiprotozoal agent in association with subcutaneous warm fluids. The snake was discharged after 2 weeks therapy in good clinical condition. Faecal exam resulted negative. One month after, the snake was quickly hospitalized again because of a recrudescence of symptoms. Biochemistry showed severe increase of AST, ALT and biliary acids. Severe leucocytosis and moderate to severe anemia were highlighted. Ultrasound examination revealed a severe diffused alteration of the liver parenchyma and a fine needle aspiration was performed. The cytological diagnosis was mixed inflammation, with a numerous of unstained rod-shaped bacteria both inside macrophages and free in the sample. The snake’s condition rapidly deteriorated and euthanasia was performed. The histology of the coelomic organs confirmed a systemic mycobacteriosis. Real-time PCR identified the mycobacteria as Mycobacterium goodii. Conclusions Species from the genus Mycobacterium are among the most important micro-organism including the causative agents of tuberculosis. Even if the general incidence of disease in reptiles due to mycobacteria is comparatively low, they can serve as reservoirs of many ubiquitous mycobacteria species. Mycobacterium goodii is a rapidly growing non‐tuberculous mycobacterium that has recently been associated with severe infections in animals and humans. Although in this case the pathogenesis was not completely clear, we highlight the zoonotic risk of mycobacteriosis in exotic animals especially in WC specimens.

Sex identification through coelioscopy is a minimally invasive surgical technique used to determine the sex of chelonians by directly visualizing their internal reproductive organs. An adequate anaesthesiologic plan is essential to guarantee patient immobilization and proper analgesia during the entire surgical procedure. In this study, we evaluated the effects of a combination of dexmedetomidine (0.05 mg/kg), midazolam (1 mg/kg), ketamine (8 mg/kg), and morphine (1 mg/kg) (DMKM) randomly delivered intramuscularly (IM) or subcutaneously (SC) in twenty-one Aldabra giant tortoise (Aldabrachelys gigantea) into the right antebrachium for celioscopic sex identification. Heart rate (HR), respiratory rate (RR), and body temperature (BT) were measured, along with the skeletal muscle tone of the thoracic and pelvic limbs, neck retraction reflex, palpebral reflex, and jaw tone every 15 min. The anaesthesiologic plan was considered to be adequate at the loss of the thoracic and pelvic limb retraction reflexes. After a 45 min interval, if the anaesthetic plan was deemed insufficient for the celioscopic procedure, a 5 mg/kg dose of propofol was administered intravenously into the subcarapacial venous plexus. At the end of the procedure, atipamezole (0.5 mg/kg) and flumazenil (0.05 mg/kg) were administered intramuscularly into the left antebrachium as reversal agents. Both HR and RR decreased from baseline to both 15 and 30 min. Due to the persistence of thoracic and pelvic limb retraction reflexes 45 min after DMKM administration, 6/11 (55%) cases in the SC group required the additional administration of propofol, in contrast to only 1/10 (10%) cases in the IM group (p = 0.05). The recovery times were comparable between the successfully induced animals in the IM and SC groups. In this study, the intramuscular administration of a DMKM combination quickly produced chemical restraint, suitable for celioscopic sex determination.

Introduction: Emergency department (ED)-based peer recovery coach (PRC) programs can improve access to substance use disorder treatment (SUD) for ED patients. As literature on early stages of PRC implementation is limited, we conducted a qualitative assessment of ED PRC program implementation from several US-based PRC programs focusing on barriers and facilitators for implementation and providing recommendations based on the findings., Methods: We collected qualitative data from 39 key informants (peer recovery coaches, PRC program managers, ED physicians and staff, representatives of community-based organizations) via 6 focus groups and 21 interviews in February-December 2023. We transcribed audio-recordings and analyzed data using codebook thematic analysis., Results: We identified the following major themes related to specific barriers and recommendations to address them. To facilitate timely linkage to PRCs, programs would regularly inform ED staff about the program and its linkage procedures, establish trust between PRC and ED staff, streamline the linkage procedures, and choose an "opt-out" linkage approach. To address barriers related to external referrals, programs use "warm handoff" and "warm line" strategies, maintain and update a comprehensive catalog of resources, and familiarize peer coaches with local service providers. Telehealth services implementation requires addressing logistical barriers, ensuring patients' privacy, and training peer coaches on building trust and rapport online. Peer coaches' wellness and quality of services can be improved by limiting PRC's workload, prioritizing quality over quantity, facilitating self-, peer- and professional care to mitigate stress and burnout; and, importantly, by providing supportive supervision and training to peer coaches and advocating for PRC team as an equal partner in the ED settings. To facilitate PRC program adoption and sustainment program managers engage local communities and program champions, seek diverse sources of funding, and advocate for structural changes to accommodate recruitment and retention of peer recovery coaches., Conclusions: We compiled a wealth of best practices used by PRC programs to address numerous implementation barriers and challenges. These recommendations are intended for PRC program planners, managers and champions, hospital leadership, and state and local public health agencies leading SUD epidemic response., Competing Interests: Declaration of competing interest All authors report no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Background: A healthy nursing workforce is vital to ensuring that patients are provided quality care. Assessing nurses' well-being and related factors requires routine evaluations from health system leaders that leverage brief psychometrically sound measures. To date, measures used to assess nurses' well-being have primarily been psychometrically tested among other clinicians or nurses working in specific clinical practice settings rather than in large, representative, heterogeneous samples of nurses., Objectives: This study aimed to psychometrically test measures frequently used to evaluate factors linked to nurse well-being in a heterogeneous sample of nurses within a large academic health system., Methods: This cross-sectional, survey-based study used a convenience sample of nurses working across acute care practice settings. A total of 177 nurses completed measures, which included the Professional Quality of Life, the short form of the Professional Quality of Life measure, the two-item Connor-Davidson Resilience Scale, the five-item World Health Organization Well-Being Index, the Secondary Traumatic Stress Scale, and the single-item Mini-Z. Internal reliability and convergent validity were assessed for each measure., Results: All the measures were found to be reliable. Brief measures used to assess domains of well-being demonstrated validity with longer measures, as evident by significant correlation coefficients., Discussion: This study provides support for the reliability and validity of measures commonly used to assess well-being in a diverse sample of nurses working across acute care settings. Data from routine assessments of the nursing workforce hold the potential to guide the implementation and evaluation of interventions capable of promoting workplace well-being. Assessments should include psychometrically sound, low-burden measures, such as those evaluated in this study., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Opioid-induced constipation is an adverse effect often experienced among patients taking prescription opioid medication. Despite frequent opioid prescribing after orthopedic injury, there is a dearth of research examining opioid-induced constipation presentations in this population. This analysis examines the frequency of opioid-induced constipation manifestations and association with patient-reported outcomes among participants prescribed opioid medication following orthopedic injury., Design: Secondary analysis of 86 clinical trial participants following orthopedic trauma., Methods: Participants were assessed 2-weeks postoperatively with the following measures: Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference, PROMIS Physical Function, past 24-hour average pain intensity captured on the numeric pain rating scale, and the Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire. Linear regressions examined the association between PAC-SYM scores and both pain intensity and PROMIS T-scores while accounting for injury severity and opioid medication dosage., Results: Most participants (69%) reported experiencing opioid-induced constipation symptoms and 7% reported moderate to severe symptoms. Compared to those without symptoms, participants reporting opioid-induced constipation symptoms were found to have a 3-point increase in PROMIS Pain Interference (95% Confidence Interval [CI]: 0.28-5.90; p = .032), a 3-point decline in PROMIS Physical Function (95% CI: -6.57 to -0.02; p = .049), and a 1.7-point increase in average pain scores (95% CI: 0.50-3.01; p = .007) at 2-weeks following surgery., Conclusions: Opioid-induced constipation symptoms are common after orthopedic trauma and linked to increased pain interference and pain intensity as well as reduced physical function., Clinical Implications: Nurse-led assessments of opioid-induced constipation can support the timely delivery of interventions to alleviate symptoms and potentially improve patient-reported outcomes after injury., Competing Interests: Declaration of competing interest All authors report no conflicts of interests to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Postsurgical opioid utilization may be directly and indirectly associated with a range of patient-related and surgery-related factors, above and beyond pain intensity. However, most studies examine postsurgical opioid utilization without accounting for the multitude of co-occurring relationships among predictors. Therefore, this study aimed to identify factors associated with opioid utilization in the first 2 weeks after arthroscopic surgery and examine the relationship between discharge opioid prescription doses and acute postsurgical outcomes., Methods: In this prospective longitudinal observational study, 110 participants undergoing shoulder or knee arthroscopies from August 2016 to August 2018 at Walter Reed National Military Medical Center completed self-report measures before and at 14 days postoperatively. The association between opioid utilization and both patient-level and surgery-related factors was modeled using structural equation model path analysis., Results: Participants who were prescribed more opioids took more opioids, which was associated with worse physical function and sleep problems at day 14, as indicated by the significant indirect effects of discharge opioid dose on day 14 outcomes. Additional patient-level and surgery-related factors were also significantly related to opioid utilization dose and day 14 outcomes. Most participants had opioid medications leftover at day 14., Conclusion: Excess opioid prescribing was common, did not result in improved pain alleviation, and was associated with poorer physical function and sleep 14 days after surgery. As such, higher prescribed opioid doses could reduce subacute functioning after surgery, without benefit in reducing pain. Future patient-centered studies to tailor opioid postsurgical prescribing are needed., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Addressing threats to the nursing and public health workforce, while also strengthening the skills of current and future workers, requires programmatic solutions. Training programs should be guided by frameworks, which leverage nursing expertise and leadership, partnerships, and integrate ongoing evaluation., Purpose Statement: This article provides a replicable framework to grow, bolster, and diversify the nursing and public health workforces, known as the Nurse-led Equitable Learning (NEL) Framework for Training Programs. The framework has been applied by several multipronged, federally funded training programs led by investigators embedded in an academic nursing institution., Methods: The NEL framework focuses on: (1) increasing equitable access to the knowledge, skills, and competencies needed to prepare a diverse workforce to deliver effective interventions; (2) fostering academic-practice linkages and community partnerships to facilitate the deployment of newly gained knowledge and skills to address ongoing and emerging challenges in care delivery; and (3) continuously evaluating and disseminating findings to inform expansion and replication of programs., Results: Ten programs using this framework have successfully leveraged $18.3 million in extramural funding to support over 1000 public health professionals and trainees. Longitudinal evaluation efforts indicate that public health workers, including nurses, are benefiting from the programs' workplace trainings, future clinicians are being rigorously trained to identify and address determinants of health to improve patient and community well-being, and educators are engaging in novel pedagogical opportunities to enhance their ability to deliver high quality public health education., Conclusions: Training programs may apply the NEL framework to ensure that the nursing and public health workforces achieve equitable, sustainable growth and deliver high quality evidence-based care., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Patients living with substance use disorder (SUD) have complex pain management needs, which may be mismanaged during hospital admission. Ineffectively managed pain following orthopaedic trauma, influenced by clinician biases related to race or SUD diagnosis, may subject patients to worse pain outcomes and subsequent emergency department (ED) encounters. This study examined ED encounters and opioid prescribing for pain-related complaints following orthopaedic trauma, among patients with SUD who identify as Black or African American relative to White patients., Methods: This retrospective analysis included 1089 patients with a SUD diagnosis discharged from a Level I trauma center, following hospitalization for orthopaedic injuries, between 2016 and 2021. Multivariable regressions assessed the associations among race, opioid prescribing, and ED encounters within 90 days for pain-related care., Results: Among the 1089 patients included in the sample, the proportion of individuals with an ED encounter within 90 days for pain-related care was 12.4 % and 4.5 % for Black and White patients, respectively (odds ratio [OR] = 3.0, p < .001). When adjusting for injury severity and demographics, the difference in ED encounters between Black and White patients remained significant (OR = 2.8, p = .002). Opioid prescription doses did not statistically differ by race., Conclusions: The difference in ED encounters between Black and White patients with SUDs following orthopaedic trauma may indicate a need to optimize pain management prior to initial discharge and improve post-injury care., Competing Interests: Declaration of competing interest Nothing to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

During the Coronavirus disease pandemic, many U.S. veterans with posttraumatic stress disorder (PTSD) experienced increased symptomology and worsened mental health and well-being due in part to social isolation and loneliness. The Mission Alliance project explored these ramifications and prioritized critical issues expressed by U.S. veterans and stakeholders (N = 182) during virtual regional meetings (N = 32). Field notes created specifically for this project were recorded and thematically analyzed. Emerging themes included: (1) social isolation: missed opportunities, collapsed social circles, work-life balance, fostering relationships, and evolving health care delivery; (2) loneliness: deteriorated mental health, suffered with PTSD together but alone, looked out for each other, ambivalence toward technology, and strained and broken systems; (3) mental health: sense of chaos, increased demand and decreased access, aggravation, implementation of tools, innovative solutions, fear and loss, and availability of resources; (4) wellbeing: sense of purpose, holistic perspective on well-being, recognition of balance, persisting stigma, redefined pressures, freedom to direct treatment, and reconnection and disconnection. A PTSD-related patient centered outcomes research (PCOR)/comparative effectiveness research (CER) agenda was developed from these themes. Establishment of a veteran and stakeholder network is suggested to support, facilitate, and promote the PTSD-related PCOR/CER agenda. Furthermore, enhancement of opportunities for veterans with PTSD and stakeholders to partner in PCOR/CER is required to develop and conduct projects that lead to PTSD-related comprehensive care of veterans affected by traumatic events with the potential to translate findings to other populations., (© 2023. The Author(s).)

Background: Pain after orthopaedic trauma is complex, and many patients who have experienced orthopaedic trauma are at increased risk for prolonged opioid utilization after the injury. Patient-centered interventions capable of delivering enhanced education and opioid-sparing pain management approaches must be implemented and evaluated in trauma care settings to improve pain outcomes and minimize opioid-related risks., Questions/purposes: Does personalized pain education and management delivered by coaches (1) improve pain-related outcomes, (2) reduce opioid consumption, and (3) improve patient-reported outcome measures (Patient-Reported Outcomes Measurement Information System [PROMIS] scores) compared to written discharge instructions on pain management and opioid safety?, Methods: This clinical trial aimed to examine the effect of a personalized pain education and management intervention, delivered by paraprofessional coaches, on pain-related outcomes and opioid consumption compared with usual care (written discharge instructions on pain management and opioid safety). Between February 2021 and September 2022, 212 patients were randomized to the intervention (49% [104]) or control group (51% [108]). A total of 31% (32 of 104) and 47% (51 of 108) in those groups, respectively, were lost before the minimum study follow-up of 12 weeks or had incomplete datasets, leaving 69% (72 of 104) and 53% (57 of 108) for analysis in the intervention and control group, respectively. Patients randomized to the intervention worked with the paraprofessional coaches throughout hospitalization after their orthopaedic injury and at their 2-, 6-, and 12-week visits with the surgical team after discharge to implement mindfulness-based practices and nonpharmacological interventions. Most participants in the final sample of 129 identified as Black (73% [94 of 129]) and women (56% [72 of 129]), the mean Injury Severity score was 8 ± 4, and one-third of participants were at medium to high risk for an opioid-use disorder based on the Opioid Risk Tool. Participants completed surveys during hospitalization and at the 2-, 6-, and 12-week follow-up visits. Surveys included average pain intensity scores over the past 24 hours measured on the pain numeric rating scale from 0 to 10 and PROMIS measures (physical functioning, pain interference, sleep disturbance). Opioid utilization, measured as daily morphine milligram equivalents, was collected from the electronic health record, and demographic and clinical characteristics were collected from self-report surveys. Groups were compared in terms of mean pain scores at at the 12-week follow-up, daily morphine milligram equivalents both during inpatient and at discharge, and mean PROMIS scores at 12 weeks of follow-up. Additionally, differences in the proportion of participants in each group achieving minimum clinically important differences (MCID) on pain and PROMIS scores were examined. For pain scores, an MCID of 2 points on the pain numeric rating scale assessing past 24-hour pain intensity was utilized., Results: We found no difference between the intervention and control in terms of mean pain score at 12 weeks nor in the proportions of patients who achieved the MCID of 2 points for 24-hour average pain scores (85% [61 of 72] versus 72% [41 of 57], respectively, OR 2.2 [95% confidence interval (CI) 0.9 to 5.3]; p = 0.08). No differences were noted in daily morphine milligram equivalents utilized between the intervention and control groups during hospitalization, at discharge, or in prescription refills. Similarly, we observed no differences in the proportions of patients in the intervention and control groups who achieved the MCID on PROMIS Physical Function (81% [58 of 72] versus 63% [36 of 57], respectively, OR 2.2 [95% CI 0.9 to 5.2]; p = 0.06). We saw no differences in the proportions of patients who achieved the MCID on PROMIS Sleep Disturbance between the intervention and control groups (58% [42 of 72] versus 47% [27 of 57], respectively, OR 1.4 [95% CI 0.7 to 3.0]; p = 0.31). The proportion of patients who achieved the MCID on PROMIS Pain Interference scores did not differ between the intervention and the control groups (39% [28 of 72] versus 37% [21 of 57], respectively, OR 1.1 [95% CI 0.5 to 2.1]; p = 0.95)., Conclusion: In this trial, we observed no differences between the intervention and control groups in terms of pain outcomes, opioid medication utilization, or patient-reported outcomes after orthopaedic trauma. However, future targeted research with diverse samples of patients at increased risk for poor postoperative outcomes is warranted to ascertain a potentially meaningful patient perceived effect on pain outcomes after working with coaches. Other investigators interested in this interventional approach may consider the coach program as a framework at their institutions to increase access to evidence-based nonpharmacological interventions among patients who are at increased risk for poor postoperative pain outcomes. Smaller, more focused programs connecting patients to coaches to learn about nonpharmacological pain management interventions may deliver a larger impact on patient's recovery and outcomes., Level of Evidence: Level I, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

Warning labels help consumers understand product risks, enabling informed decisions. Since the 1966 introduction of cigarette warning labels in the United States, research has determined the most effective message content (health effects information) and format (brand-free packaging with pictures). However, new challenges have emerged. This article reviews the current state of tobacco warning labels in the United States, where legal battles have stalled pictorial cigarette warnings and new products such as electronic cigarettes and synthetic nicotine products pose unknown health risks. This article describes the emerging research on cannabis warnings; as more places legalize recreational cannabis, they are adopting lessons from tobacco warnings. However, its uncertain legal status and widespread underestimation of harms impede strict warning standards. The article also reviews opioid medication warning labels, suggesting that lessons from tobacco could help in the development of effective and culturally appropriate FDA-compliant opioid warning labels that promote safe medication use and increased co-dispensing of naloxone.

Opioids are vital to pain management and sedation after trauma-related hospitalization. However, there are many confounding clinical, social, and environmental factors that exacerbate pain, post-injury care needs, and receipt of opioid prescriptions following orthopaedic trauma. This retrospective study sought to characterize differences in opioid prescribing and dosing in a national Medicaid eligible sample from 2010-2018. The study population included adults, discharged after orthopaedic trauma hospitalization, and receiving an opioid prescription within 30 days of discharge. Patients were identified using the International Classification of Diseases (ICD-9; ICD-10) codes for inpatient diagnosis and procedure. Filled opioid prescriptions were identified from National Drug Codes and converted to morphine milligram equivalents (MME). Opioid receipt and dosage (e.g., morphine milligram equivalents [MME]) were examined as the main outcomes using regressions and analyzed by year, sex, race/ethnicity, residence rurality-urbanicity, and geographic region. The study population consisted of 86,091 injured Medicaid-enrolled adults; 35.3% received an opioid prescription within 30 days of discharge. Male patients (OR = 1.12, 95% CI: 1.07-1.18) and those between 31-50 years of age (OR = 1.15, 95% CI: 1.08-1.22) were found to have increased odds ratio of receiving an opioid within 30 days of discharge, compared to female and younger patients, respectively. Patients with disabilities (OR = 0.75, 95% CI: 0.71-0.80), prolonged hospitalizations, and both Black (OR = 0.87, 95% CI: 0.83-0.92) and Hispanic patients (OR = 0.72, 95% CI: 0.66-0.77), relative to white patients, had lower odds ratio of receiving an opioid prescription following trauma. Additionally, Black and Hispanic patients received lower prescription doses compared to white patients. Individuals hospitalized in the Southeastern United States and those between the ages of 51-65 age group were found to be prescribed lower average daily MME. There were significant variations in opioid prescribing practices by race, sex, and region. National guidelines for use of opioids and other pain management interventions in adults after trauma hospitalization may help limit practice variation and reduce implicit bias and potential harms in outpatient opioid usage., Competing Interests: CR is the founder and CEO of the Christopher Wolf Crusade. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Giordano, Zhao, Kalicheti, Schenker, Wimberly, Rice and Serban.)

A longstanding challenge in catalysis by noble metals has been to understand the origin of enhancements of rates of hydrogen transfer that result from the bonding of oxygen near metal sites. We investigated structurally well-defined catalysts consisting of supported tetrairidium carbonyl clusters with single-atom (apical iridium) catalytic sites for ethylene hydrogenation. Reaction of the clusters with ethylene and H 2 followed by O 2 led to the onset of catalytic activity as a terminal CO ligand at each apical Ir atom was removed and bridging dioxygen ligands replaced CO ligands at neighboring (basal-plane) sites. The presence of the dioxygen ligands caused a 6-fold increase in the catalytic reaction rate, which is explained by the electron-withdrawing capability induced by the bridging dioxygen ligands, consistent with the inference that reductive elimination is rate-determining. Electronic-structure calculations demonstrate an additional role of the dioxygen ligands, changing the mechanism of hydrogen transfer from one involving equatorial hydride ligands to that involving bridging hydride ligands. This mechanism is made evident by an inverse kinetic isotope effect observed in ethylene hydrogenation reactions with H 2 and, alternatively, with D 2 on the cluster incorporating the dioxygen ligands and is a consequence of quasi-equilibrated hydrogen transfer in this catalyst. The same mechanism accounts for rate enhancements induced by the bridging dioxygen ligands for the catalytic reaction of H 2 with D 2 to give HD. We posit that the mechanism involving bridging hydride ligands facilitated by oxygen ligands remote from the catalytic site may have some generality in catalysis by oxide-supported noble metals.

Living with chronic pain has been identified as a significant risk factor for suicide. Qualitative and cross-sectional studies have reported an association between mental defeat and suicidal thoughts and behavior in patients with chronic pain. In this prospective cohort study, we hypothesized that higher levels of mental defeat would be associated with increased suicide risk at a 6-month follow-up. A total of 524 patients with chronic pain completed online questionnaires measuring variables related to suicide risk, mental defeat, sociodemographic, psychological, pain, activity, and health variables. At 6 months, 70.8% (n = 371) of respondents completed the questionnaires again. Weighted univariate and multivariable regression models were run to predict suicide risk at 6 months. The clinical suicide risk cutoff was met by 38.55% of the participants at baseline and 36.66% at 6 months. Multivariable modeling revealed that mental defeat, depression, perceived stress, head pain, and active smoking status significantly increased the odds of reporting higher suicide risk, while older age reduced the odds. Receiver operating characteristic (ROC) analysis showed that assessment of mental defeat, perceived stress, and depression is effective in discriminating between 'low' and 'high' suicide risk. Awareness of the prospective links from mental defeat, depression, perceived stress, head pain, and active smoking status to increased suicide risk in patients with chronic pain may offer a novel avenue for assessment and preventative intervention. PERSPECTIVE: Results from this prospective cohort study suggest that mental defeat is a significant predictor of increased suicide risk among patients with chronic pain, along with depression, perceived stress, head pain, and active smoking status. These findings offer a novel avenue for assessment and preventative intervention before risk escalates., (Copyright © 2023 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Hyperthermia is a known risk for sudden unexpected infant death. The practice of hat placement at birth to prevent transient hypothermia may not be necessary and sets an early standard for clothing infants that may lead to hyperthermia postnatally., Objective: To examine the elimination of hats on thermoregulation (eg, hypothermia, <97.6°F) in full-term newborns with no abnormalities within 24 hours of birth., Methods: In 2018, an institution guideline discontinued the use of hats at birth. Subsequently, newborn body temperatures were respectively extracted from electronic health records and data were compared from 482 infants (>38 weeks' gestation and newborn birth weight >2500 g) prior to ( n = 257) and following ( n = 225) the practice change. Body temperatures prior to and after the practice change to eliminate hats use were compared., Results: No statistically significant difference was observed: (1) in the proportion of infants experiencing hypothermia with or without hat use, respectively, 23.7% compared with 31.1% ( P = .09) and (2) in the odds of an infant experiencing hypothermia when adjusting for relevant covariates (odds ratio = 1.44; 95% confidence interval 0.89-2.32; P = .14)., Conclusions: Our findings demonstrate that the use of hats on infants at birth had no measurable impact on newborn thermoregulation., Competing Interests: The authors have no potential conflicts of interest to disclose. Only Dr Giordano received an honorarium for his effort., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Immersive learning opportunities across care settings enhance nursing students' understanding of the environmental, social, cultural, and policy factors that influence patients' health (e.g., social determinants of health) and care utilization. Hotspotting happens when care teams visit patients with frequent hospital admissions to coordinate outpatient care. However, geographic limitations may inhibit the delivery of hotspotting learning opportunities available to students. Delivering immersive hotspotting opportunities over virtual reality helps to overcome this barrier. This overview summarizes the design and implementation of a virtual reality hotspotting experience designed to aid students in understanding the impact of social determinants of health on care transitions., Competing Interests: The authors have declared no conflict of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc.)

This pilot study examined the concurrent validity of Patient-Reported Outcomes Measurement Information System (PROMIS), Short Form, measures with the longer Multidimensional Fatigue Inventory among patients living with obstructive sleep apnea (OSA). A total of 26 African American patients living with prediabetes and newly diagnosed with OSA completed the six-item short form versions of PROMIS Fatigue and PROMIS Sleep Disturbance, and the longer 20-item Multidimensional Fatigue Inventory. Both PROMIS Fatigue and Sleep Disturbance scales demonstrated high reliability with Cronbach's α of .91 and .92, respectively. PROMIS Fatigue scores were significantly correlated with Multidimensional Fatigue Inventory scores ( r s  = .53; p  = .006) and demonstrated concurrent validity. However, PROMIS Sleep Disturbance scores and Multidimensional Fatigue Inventory scores were not associated with one another. The brief PROMIS Fatigue scale is a useful, succinct approach to assess fatigue severity among diverse patient populations living with OSA. This study is among the first to evaluate the performance of PROMIS Fatigue in a sample living with OSA.

Background: Individuals with chronic pain and a co-occurring substance use disorder present higher risk of suicide, but the individual and joint impacts of chronic pain and substance use disorders on suicide risk are not well defined. The objective of this study was to exam the factors associated with suicidal thoughts and behaviors in a cohort of patients with chronic non-cancer pain (CNCP), with or without concomitant opioid use disorder (OUD)., Design: Cross sectional cohort design., Setting: Primary care clinics, pain clinics, and substance abuse treatment facilities in Pennsylvania, Washington, and Utah., Subjects: In total, 609 adults with CNCP treated with long-term opioid therapy (>/= 6 months) who either developed an OUD (cases, n = 175) or displayed no evidence of OUD (controls, n = 434)., Methods: The predicted outcome was elevated suicidal behavior in patients with CNCP as indicated by a Suicide Behavior Questionnaire-Revised (SBQ-R) score of 8 or above. The presence of CNCP and OUD were key predictors. Covariates included demographics, pain severity, psychiatric history, pain coping, social support, depression, pain catastrophizing and mental defeat., Results: Participants with CNCP and co-occurring OUD had an increased odds ratio of 3.44 in reporting elevated suicide scores as compared to participants with chronic pain only. Multivariable modeling revealed that mental defeat, pain catastrophizing, depression, and having chronic pain, and co-occurring OUD significantly increased the odds of elevated suicide scores., Conclusions: Patients with CNCP and co-morbid OUD are associated with a 3-fold increase in risk of suicide., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Satisfaction with social roles and activities is an important outcome for postsurgical rehabilitation and quality of life but not commonly assessed., Purpose: To evaluate longitudinal patterns of the Patient-Reported Outcomes Measurement Information System (PROMIS) Satisfaction with Social Roles and Activities measure, including how it relates to other biopsychosocial factors, before and up to 6 months after sports-related orthopaedic surgery., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: Participants (N = 223) who underwent knee and shoulder sports orthopaedic surgeries between August 2016 and October 2020 completed PROMIS computer-adaptive testing item banks and pain-related measures before surgery and at 6-week, 3-month, and 6-month follow-ups. In a generalized additive mixed model, covariates included time point; peripheral nerve block; the PROMIS Anxiety, Sleep Disturbance, and Pain Behavior measures; and previous 24-hour pain intensity. Patient-reported outcomes were modeled as nonlinear (smoothed) effects., Results: The linear (estimate, 2.06; 95% CI, 0.77-3.35; P = .002) and quadratic (estimate, 2.93; 95% CI, 1.78-4.08; P < .001) effects of time, as well the nonlinear effects of PROMIS Anxiety ( P < .001), PROMIS Sleep Disturbance ( P < .001), PROMIS Pain Behavior ( P < .001), and pain intensity ( P = .02), were significantly associated with PROMIS Satisfaction with Social Roles and Activities. The cubic effect of time ( P = .06) and peripheral nerve block ( P = .28) were not. The proportion of patients with a 0.5-SD improvement in the primary outcome increased from 23% at 6 weeks to 52% by 6 months postsurgery, whereas those reporting worsening PROMIS Satisfaction with Social Roles and Activities decreased from 30% at 6 weeks to 13% at 6 months., Conclusion: The PROMIS Satisfaction with Social Roles and Activities measure was found to be related to additional domains of function (eg, mental health, behavioral, pain) associated with postsurgical rehabilitation., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: The institution of multiple authors (K.B.H., A.K.) received funding for this Collaborative Health Initiative Research Program (CHIRP) project by the Uniformed Services University through the Henry M. Jackson Foundation for the Advancement of Military Medicine Inc on agreement (CHIRP-91-8843-01). J.C.P. has received education support from Medinc of Texas. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Background: Ongoing postoperative pain assessments are vital to optimizing pain management and attenuating the development of poor health outcomes after surgery. This study aimed to characterize acute multidimensional trajectories of pain impact on physical function, sleep, mood, and stress and to examine clinical characteristics and demographics associated with trajectory membership. Additionally, this study compared levels of pain intensity and prescription opioid use at 2 weeks and 1 month postoperatively across acute symptom trajectories., Methods: Participants (N = 285) undergoing total knee arthroplasty, total hip arthroplasty, and spinal fusion procedures were recruited for this multisite prospective observational study. Longitudinal, joint k-means clustering was used to identify trajectories based on pain impact on activity, sleep, mood, and stress., Results: Three distinct pain impact trajectories were observed: Low (33.7%), Improving (35.4%), and Persistently High (30.9%). Participants in the Persistently High impact trajectory reported pain interfering moderately to severely with activity, sleep, mood, and stress. Relative to other trajectories, the Persistently High impact trajectory was associated with greater postoperative pain at 1 month postoperatively. Preoperatively, participants in the Persistently High impact trajectory reported worse Pain Catastrophizing Scale scores and PROMIS Pain Interference, PROMIS Anxiety, and PROMIS Social Isolation scores than did participants presenting with other trajectories. No statistical differences in opioid use were observed across trajectories., Conclusions: Variation in acute postoperative pain impact on activity, sleep, mood, and stress exists. Given the complex nature of patients' postoperative pain experiences, understanding how psychosocial presentations acutely change throughout hospitalization could assist in guiding clinicians' treatment choices and risk assessments., (Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Sleep disturbance is a modifiable risk factor that, when reduced, may improve subacute postsurgical outcomes (e.g., pain-related impact). Evidence also indicates that pain and sleep may have a bidirectional longitudinal relationship before to (sub) acutely after surgery. The objective of the present study is to examine the degree to which sleep disturbances and pain behavior have uni- or bidirectional relationships in a sample of patients undergoing sports orthopedic surgery. In this observational, longitudinal cohort study, participants ( = 296) were adult (ages 18+) active duty service members who underwent open or arthroscopic shoulder or knee surgery at Walter Reed National Military Medical Center. Participants were asked to complete PROMIS Sleep Disturbance and Pain Behavior computer adaptive testing item banks before surgery, 6 weeks postsurgery, and 3 months postsurgery. Patient-level covariates were analyzed for interrelationships using nonparametric bivariate statistics. Autoregressive and cross-lagged structural equation modeling examined the bidirectional relationships of patient-level covariates and PROMIS outcomes. When controlling for patient-level covariates, sleep disturbance at presurgical and 2-week postsurgical timepoints were positively associated with both sleep disturbance and pain behavior at the subsequent timepoint. Sleep disturbance may contribute to pain-related functioning and quality of life after sports orthopedic surgery. Future studies utilizing multidimensional patient report outcomes and robust analytics are needed to better understand whether sleep-targeted interventions can improve subacute and long-term orthopedic sports surgery outcomes., (© 2022 Orthopaedic Research Society. Published by Wiley Periodicals LLC.)

Background: The Robert Wood Johnson Foundation (RWJF) Future of Nursing Scholars program (FNS) supported 45 nursing schools to create or adapt their PhD curricula to facilitate students completing a PhD degree in 3-years., Purpose: This analysis characterized the PhD program curricula of 45 schools. Differences in curricula were examined based on school characteristics., Methods: Data were collected from five cohorts of school FNS applications. Summaries of curricula are provided and differences in curricula between schools were examined., Findings: Most of the PhD programs (73.3%) were at very high research intensive universities. A median of 60 credit hours were needed to complete a 3-year PhD. Most programs (84.0%) required year-round enrollment, oftentimes inclusive of summers, and placed an emphasis on scholars pursuing additional coursework to meet the 3-year timeline., Discussion: Findings highlight common elements of 3-year PhD curricula that can be utilized to inform the development and educational needs of future nurse scientists., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: This systematic review evaluates the literature for patient-oriented opioid and pain educational interventions that aim to optimize pain management using opioid-sparing approaches in the orthopaedic trauma population. The study protocol was registered with PROSPERO (CRD42021234006)., Data Sources: A review of English-language publications in CINAHL (EBSCO), MEDLINE through PubMed, Embase.com, PsycInfo (EBSCO), and Web of Science Core Collection literature databases published between 1980 and February 2021 was conducted using PRISMA guidelines., Study Selection: Only studies implementing patient-oriented opioid and/or pain education in adult patients receiving acute orthopaedic care were eligible. Outcomes were required to include postinterventional opioid utilization, postoperative analgesia and amount, or patient-reported pain outcomes., Data Extraction: A total of 480 abstracts were reviewed, and 8 publications were included in the final analysis. Two reviewers independently extracted data from selected studies using a standardized data collection form. Disagreements were addressed by a third reviewer. Quality of studies was assessed using the Cochrane Risk of Bias Tool., Data Synthesis: Descriptive statistics characterized study findings, and content analysis was used to discern themes across studies., Conclusion: Our findings indicate the merit for patient-centered educational interventions including verbal/written/audio-visual trainings paired with multimodal approaches to target opioid-sparing pain management and reduce short-term pain scores in urgent and acute care settings after acute orthopaedic injuries. The scarcity of published literature warrants further rigorously designed studies to substantiate the benefit of patient-centric education in reducing prolonged opioid utilization and associated risks after orthopaedic trauma., Level of Evidence: Therapeutic level III., Competing Interests: All authors declare no personal, financial, or nonfinancial conflicts of interest.The authors declare no conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Objectives: In response to a surge of drug overdoses involving polysubstance use among Atlanta service industry workers that resulted in the deaths of five people in the Atlanta area in the summer of 2021, a local community of harm reductionists and nurses organized opioid education and naloxone distribution (OEND) training sessions specifically customized for service industry workers in Atlanta. After the sessions, the nurses and harm reductionists asked attendants to participate in a study concerning their response to overdoses. The reason nurses and harm reductionists conducted the study was to determine the efficacy of OEND training adapted for those working in the service industries as well as to evaluate and possibly modify the training sessions for future use. This pre-post study examined if and how participants' knowledge and attitudes toward an opioid-involved overdose changed after engaging with the OEND training. If the study determined that the sessions were successful in teaching service industry workers how to mitigate the immediate and devastating effects of overdose, we recommend expanding and implementing both adaptable training sessions like the OEND training referenced, as well as accompanying studies to improve the training sessions' effectiveness., Design: The pre-post study used convenience sampling to recruit participants in emergent OEND training. Participants completed an abbreviated version the Opioid Overdose Attitudes Scale (OOAS) which measured how, and to what degree, they changed their attitudes towards overdoses and their responses to them. Participants also completed an abbreviated version of the Opioid Overdose Knowledge Scale (OOKS) which measured how effectively the OEND increased their knowledge when it came to properly responding to an overdose, which included implementing naloxone as part of immediate rehabilitation treatment. Paired nonparametric tests assessed changes in participants' OOAS/OOKS scores., Results: A total of 161 individuals attended, and 72 consented to be in the study. The sample predominately consisted of white (76.4%) and female (66.7%) adults whose age averaged 34.3 years. Attitude and knowledge score improvements were statistically significant: approximately 11 points (p < .001) and 3 points (p < .001), respectively., Conclusions: This rapidly implemented training was associated with improving attitudes and knowledge about responding to an opioid-involved overdose. We recommend expanding the scope of studies like these in order to develop and examine effective, dynamic, and targeted OEND training tailored towards specific community groups and situations, such as polysubstance overdose among service industry workers. As the opioid epidemic worsens, it is critical to equip community members themselves with the skills and tools to recognize and respond to opioid overdoses as a frontline prevention to overdose deaths., (© 2022 The Authors. Public Health Nursing published by Wiley Periodicals LLC.)

Background: The Future of Nursing Scholars program prepared a cadre of PhD prepared nurses for long-term careers advancing science and discovery, strengthening nursing education, and leading transformational change in health care., Purpose: The purpose of this manuscript was to describe the program's impact on Scholars' outcomes, nursing schools, and perceived impact on nursing science., Methods: An independent program evaluation was conducted, including interviewing representatives from schools and reviewing Scholars' Curriculum Vitae., Findings: Two hundred one scholars were supported across 45 institutions. To date, 181 scholars graduated within 3.1 years, on average. Most graduates reported holding appointments in academic institutions. School representatives believed the program supported rapid entry into the field, longer research trajectories, and will improve the nursing faculty pipeline., Discussion: The program achieved its goal of developing cohorts of PhD prepared nurses poised for long-term careers. It provided "proof of concept" on high-quality accelerated PhD education for students well matched with mentors, and elevated the national conversation on PhD education., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Opioid Use Disorder (OUD) is an escalating public health problem with over 100,000 drug overdose-related deaths last year most of them related to opioid overdose, yet treatment options remain limited. Non-invasive Vagal Nerve Stimulation (nVNS) can be delivered via the ear or the neck and is a non-medication alternative to treatment of opioid withdrawal and OUD with potentially widespread applications., Methods: This paper reviews the neurobiology of opioid withdrawal and OUD and the emerging literature of nVNS for the application of OUD. Literature databases for Pubmed, Psychinfo, and Medline were queried for these topics for 1982-present., Results: Opioid withdrawal in the context of OUD is associated with activation of peripheral sympathetic and inflammatory systems as well as alterations in central brain regions including anterior cingulate, basal ganglia, and amygdala. NVNS has the potential to reduce sympathetic and inflammatory activation and counter the effects of opioid withdrawal in initial pilot studies. Preliminary studies show that it is potentially effective at acting through sympathetic pathways to reduce the effects of opioid withdrawal, in addition to reducing pain and distress., Conclusions: NVNS shows promise as a non-medication approach to OUD, both in terms of its known effect on neurobiology as well as pilot data showing a reduction in withdrawal symptoms as well as physiological manifestations of opioid withdrawal.

Purpose: Continued opioid use after total knee and hip arthroplasty (TKA/THA) is well-documented and associated with both surgical and patient-reported factors. Research examining the combined effects of a multitude of factors on continued, and even chronic, opioid use in a systematic algorithmic manner is lacking. This study prospectively evaluated the combined effect of patient-related and surgical factors associated with continued opioid use after TKA/THA., Methods: From 2016 to 2018, 198 participants undergoing TKA or THA were recruited from two tertiary care facilities. Participants completed surveys before surgery and at 2 weeks, 1, 3, and 6 months following surgery. A LASSO approach, followed by an exhaustive covariate selection procedure, was used to build a multivariable mixed-effects logistic regression model estimating the odds ratio of continued postoperative opioid use based on surgical factors and patient-reported factors., Results: Approximately half of the participants underwent either TKA (49%) or THA (51%). Preoperatively, 15% of participants reported taking opioid medication. Opioid use decreased from 68% at 2-week follow-up to 7% by 6 months. In addition, preoperative opioid use (95% CI 1.07-4.37), increased pain (95% CI 1.21-1.62), elevated preoperative Pain Catastrophizing Scale scores (95% CI 1.01-1.04), lower Physical Function scores (95% CI 0.87-0.95), and participants undergoing TKA, compared to THA, (95% CI 0.25-0.67) were found to be significantly associated with continued postoperative opioid use up to 6 months., Conclusion: Preoperative opioid use, average pain, reduced physical function, and TKA were significantly associated with continued postoperative opioid use. Findings illustrate the need for preoperative and longitudinal assessment of patient-reported outcomes to mitigate poor postoperative pain outcomes., Level of Evidence: II., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aim: This study examined the feasibility of integrating actigraphy devices into orthopaedic surgical settings to assess the concurrent validity between objective actigraphy data and PROMIS measures. Additionally, the association between changes in actigraphy data and longitudinal changes in PROMIS measures was examined., Methods: Data were collected from 17 participants using actigraphy devices the week prior to and after orthopaedic surgery from 02/2019 to 03/2020. Participants completed PROMIS measures (Physical Function, Sleep Disturbance, Pain Interference) preoperatively and up to 6 months postoperatively. Nonparametric correlations (r s ) assessed for concurrent validity. Linear mixed-effects models examined the association between changes in actigraphy data and PROMIS measures., Results: Prolonged wake after sleep onset was associated with increased sleep disturbances (r s  = 0.49; p = 0.045) and pain interference (r s  = 0.51; p = 0.04). Changes in pain interference were correlated with increased awakenings (r s  = 0.54; p = 0.03). Increased wake after sleep onset was associated with worsening sleep disturbance (β = 0.12; p = 0.01) and pain interference scores over the postoperative period (β = 0.12; p = 0.02)., Conclusions: This study is among the first to examine changes in objective actigraphy data and longitudinal PROMIS measures following orthopaedic surgery and illustrates the feasibility of incorporating actigraphy into surgical settings to evaluate postoperative recovery., (© 2022 John Wiley & Sons Australia, Ltd. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background: Pennsylvania sudden unexpected infant death rates rank among the highest nationally. A nursing team developed, implemented, evaluated, and disseminated an evidence-based quality improvement (QI) program at birthing hospitals in Pennsylvania to address this issue. To facilitate implementation, clinical nurses were educated as Subject Matter Experts (SMEs) to empower them to transform and sustain outcomes-driven QI for infant safe sleep nursing practice., Methods: This descriptive study examined outcomes from 268 nurses who received comprehensive education on infant safe sleep and the SME role. Likert-type scale surveys measured knowledge gained and progress made in practice following education. A programmatic dashboard tracked program implementation. Descriptive statistics were used to report findings., Intervention: SME nurses ( N = 268) completed two interactive learning modules addressing safe sleep guidelines and teaching strategies and attended a workshop to acquire skills for program implementation. Key competencies included data collection and dissemination, policy development, and communication techniques., Results: Immediate posteducation surveys completed by SMEs indicated that over 98% of respondents strongly agreed or agreed they were able to effectively demonstrate communication strategies, identify SME role components, provide environment surveillance, and demonstrate best practices in infant safe sleep. To allow time for assimilation of the of SME role, a survey was initiated at 6 months to capture progress made. Seventy-eight SMEs responded to the survey and reported exceptional or substantial progress in 10 areas for SME responsibilities., Conclusion: Use of the SME role for program implementation led to highly favorable SME-reported outcomes in leading a hospital-based QI program., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: AIM: This pilot study assessed the feasibility and impact of integrating a Life Care Specialist (LCS) into orthopaedic trauma care., Design: This was a prospective feasibility single group pilot study at a level 1 trauma center., Method: The LCS is a paraprofessional behavior-based "pain coach" and delivered patient-centered opioid safety education, trained participants on nonpharmacologic pain management approaches, conducted opioid risk assessments, and coordinated care. Numeric Rating Scale pain scores were assessed on admission, at discharge, and at 2-week follow-up. Daily morphine milligram equivalents (MME) during hospitalization, opioid medication use at 2-weeks, and patient satisfaction were recorded. T test compared mean morphine milligram equivalents (MME) to historical orthopaedic trauma patient population's mean dosage at discharge from the study site. Generalized linear models assessed pain scores over time., Results: Twenty-two percent of 121 total participants met criteria for moderate to severe risk of opioid misuse at initial hospitalization. On average, 2.8 LCS pain management interventions were utilized, most frequently progressive muscle relaxation (80%) and sound therapy (48%). Mean inpatient MME/day was 40.5, which was significantly lower than mean historical MME/day of 49.7 (p < .001). Pain scores improved over time from admission to 2-weeks postoperatively (p < .001). Nearly all participants agreed that the LCS was helpful in managing pain (99%)., Conclusions: The findings indicate feasibility to integrate LCS into orthopaedic trauma care, evident by participant engagement and satisfaction, and that LCS serve as valuable resources to assist with pain management and opioid education., Competing Interests: Declaration of Competing Interest The authors report no conflicts of interest. The funders had no role in the design of this study, nor did they have any role during its execution, analysis or interpretation of the data., (Copyright © 2022 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Aim: Characterize use and efficacy/effectiveness of virtual, augmented, or mixed reality (VR/AR/MR) technology as non-pharmacological therapy for chronic pain. Methods: Systematic search of 12 databases to identify empirical studies, of individuals who experience chronic pain or illness involving chronic pain, published between 1990 and 2021. JBI Critical Appraisal Checklists assessed study bias and a narrative synthesis was provided. Results: 46 studies, investigating a total of 1456 participants and including 19 randomized controlled trials (RCT), were reviewed. VR/AR/MR was associated with improved pain-related outcomes in 78% of the RCTs. Conclusion: While most studies showed effects immediately or up to one month post treatment, RCTs are needed to further evaluate VR/AR/MR, establish long-term benefits, and assess accessibility, especially among individuals who experience pain management disparities.

Introduction: Ketamine is a vital component for acute pain management in emergency trauma care for both civilian and military hospitals. This preliminary analysis examined whether combat-injured US service members sustaining traumatic brain injuries (TBI) experienced increased odds of ketamine side effects compared with those without TBI., Methods: This preliminary analysis included combat-injured service members, ages ≥18 years with documented pain scores during the 24 hours before and 48 hours after receiving an intravenous ketamine infusion at Walter Reed National Military Medical Center (WRNMMC) between 2007 and 2014. Logistic regression modeling examined the association between TBI and ketamine side effects (eg, hallucinations, nightmares, dysphoria, nausea, decreased oxygen saturation) during hospitalisation., Results: Of the 77 patients, 62% presented with a documented TBI. Side effects were documented for 18.8% of those without TBI and 24.4% of those with TBI. Analyses were unable to find evidence against the null hypothesis with the current sample size, even when adjusting for injury characteristics and preinfusion opioid doses (adjusted OR=0.90 (95% CI 0.26 to 3.34), p=0.87)., Conclusion: In this small sample of combat-injured service members, we were unable to detect a difference in ketamine-related side effects by documented TBI status. These hypothesis-generating findings support the need for future studies to examine the use of intravenous ketamine infusions for pain management, and subsequent care outcomes in patients who experience polytraumatic trauma inclusive of TBI., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To characterize opioid prescribing over a 5-year period to adolescents upon discharge from one urban pediatric medical center., Design and Methods: A retrospective cross-sectional analysis of 4354 adolescents discharged with a pain medication after an admission of ≤5 days between January 2015 and December 2019 was performed. Two outcome groups, based on the analgesics prescribed at discharge, were compared: those discharged with a prescription for a non-opioid only and those discharged with an opioid prescription. The association between year of discharge and receipt of opioid, while adjusting for relevant demographic and clinical characteristics, was also explored., Results: Approximately 64% of the sample was discharged with an opioid prescription. Of those, the median daily dosage was 45.0 morphine milligram equivalents (MME) [IQR: 32.4, 45.0]. Year of discharge was associated with decreased odds of receiving an opioid when adjusting for age, race, sex, insurance, pain scores, opioid exposure during hospitalization, length of stay, and undergoing surgery. The odds of being discharged with an opioid decreased each year by 29% (Adjusted Odds Ratio [AOR] = 0.71, CI:0.68-0.73). Concurrently, the proportion of patients discharged with nonopioid pain medication increased from 25% of adolescent patients in 2015 to 50% in 2019., Conclusions: Overall, opioid prescribing to adolescents at time of discharge decreased over time in our sample., Practice Implications: While prescribing has decreased opioid analgesics are dispensed to young patients. Risk of opioid use disorder and overdose is rare in this population, but adolescence is good opportunity for nursing to promote safe prescribing and analgesic use., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The impact of the COVID-19 pandemic on nurse residents' perceptions of preparedness while learning in a virtual environment remains unknown. This cohort study compared nurse residents' perceptions of preparedness in traditional in-person versus virtual learning environments. Results found no statistically significant differences between these two groups over 1 year. This demonstrates that a virtual learning format can achieve comparable outcomes to a traditional in-person learning format in successfully transitioning newly licensed nurses into the profession., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Partnering with patients and families to make decisions about care needs is a safety and quality standard in Australian health services that is often not assessed systematically., Objective: The objective of this study was to retrospectively evaluate satisfaction with care and involvement in decision-making among family members of patients admitted to the intensive care unit (ICU)., Methods: A retrospective cohort analysis of a satisfaction survey administered to family members of patients admitted to an ICU in an Australian metropolitan tertiary care hospital from 2014 to 2019 was conducted. The Family Satisfaction in the Intensive Care Unit questionnaire (FSICU) questionnaire was used to assess overall satisfaction, satisfaction with care, and satisfaction with decision-making on a scale from "poor" (0) to "excellent" (100)., Results: In total, 1322 family members fully completed the survey. Respondents were typically direct relatives of ICU patients (94.2%) with an average age of 52.6 years. Most patients had an ICU length of stay <7 d (56.8%), with most patients being discharged to the ward (96.8%). The overall mean satisfaction score was high among respondents (90.26%). Similarly, mean satisfaction with care (93.06%) and decision-making (89.71%) scores were high. Satisfaction with decision-making scores remained lower than satisfaction with care scores. Multivariable modeling indicated that those younger than 50 years reported higher satisfaction scores (p = 0.006) and those with prolonged lengths of stay in the ICU were associated with lower overall satisfaction scores (p = 0.039). Despite some criticism of waiting times and noise levels, responses showed sincere gratitude for patients' treatment in the ICU and appreciation for the care, skill, and professionalism of the staff., Conclusion: Very high satisfaction levels were reported by family members during this study. Routine, prospective evaluations of family member satisfaction with ICU experiences are feasible and can be leveraged to provide insight for clinicians and administrators seeking to improve family satisfaction with decision-making and care in ICU settings and meet national standards., Competing Interests: Conflict of interest None., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Complementary and integrative therapies such as physical therapy (PT) and occupational therapy (OT) have been shown to improve functional outcomes and reduce opioid use. Due to the COVID-19 (or SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2]) pandemic, these therapies are switching to telehealth and telemedicine practices, but access and utilization may be limited due to state policies and social vulnerability. Objective: The objective of this cross-sectional analysis was to evaluate the policy changes to telehealth provisions during the pandemic and the degree to which structural barriers could stymie the intended impact of these policies (e.g., PT/OT accessibility). Materials and Methods: Our analysis examined each states' telehealth policies in relation to PT/OT, ranked their telehealth readiness, identified relationships between existing policies and opioid prescription rates, and discussed how social determinants of health may be associated with telehealth availability and accessibility. Results: Approximately two of five states have both telehealth and telemedicine policies, whereas the majority of states had either a PT- or OT-specific policy in place. In addition, almost all states and the District of Columbia (90%) had general telehealth/medicine policy changes as a result of the pandemic. Discussion: Although such policy changes could reduce COVID-19-related barriers, the degree to which these policies can have a large and long-lasting impact may be contingent on structural barriers. Many states that lack broadband access and have high social vulnerability need more improvements to ensure the utilization of telehealth care, including PT and OT. Conclusion: Despite the policies expanding PT/OT telehealth capabilities, structural barriers may further exacerbate inequities in care accessibility.

Background: Pain trajectories have been described in numerous surgical settings where preoperative characteristics have been used to predict trajectory membership. Suboptimal pain intensity trajectories have been linked to poor longitudinal outcomes. However, numerous biopsychosocial modulators of postoperative pain may also have distinct longitudinal trajectories that may inform additional targets to improve postoperative recovery., Methods: Patients undergoing total joint arthroplasty, thoracic surgery, spine surgery, major abdominal surgery, or mastectomy completed Patient Reported Outcome Measurement Information System (PROMIS) measures and additional scales preoperatively and at 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively. A k-means clustering for longitudinal data was utilized to explore and describe distinct pain impact (PROMIS Pain Interference and Physical Function) trajectories and associated changes in additional biopsychosocial measures. Follow-up analyses examined participant demographics and clinical characteristics associated with trajectory memberships., Results: Three postoperative biopsychosocial symptom clusters were identified across all patients (n = 402): low (35%), average (47%), and high (18%) performance cluster trajectories. Participants undergoing total knee arthroplasty (TKA), spinal surgery, reporting presurgical opioid use, and higher pain catastrophizing scale scores were found to be associated with the low performance trajectory. Patients within the low performance trajectory, while demonstrating small improvements by 6 months, remained mild to moderately impaired in both pain impact and physical health outcomes. Alternatively, participants in the average performance trajectory demonstrated improvement in pain impact to population norms compared to baseline and demonstrated continued improvement across physical and psychological outcomes. Patients within the high performance cluster started within population norms across all measures at baseline and returned to baseline or exceeded baseline values by 6 months postoperatively. Self-reported opioid utilization was significantly higher in the low performance cluster across all time points. While a larger proportion of average performance patients reported opioid utilization during the first postoperative month compared to the high performance cluster, no differences were detected at 6 months postoperatively between these 2 clusters., Conclusions: These pain impact trajectories build upon previous unidimensional pain intensity trajectories and suggest that additional distinct biopsychosocial measures may have unique trajectories related to cluster assignment. Additionally, these findings highlight the importance of continued pain impact surveillance through the perioperative recovery period to detect patients at risk of experiencing a poor trajectory and subsequently poor longitudinal health outcomes., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

Background: During the COVID-19 outbreak, standard methods for treating acute respiratory distress syndrome (ARDS) were used for patients presenting with ARDS. One such treatment method involves placing patients prone to improve oxygenation and reduce mortality risk. Challenges in preventing pressure injuries in patients placed prone have been reported, and no studies have explored the effects of including a certified wound and skin care nurse as part of the care team on the incidence of pressure injuries in SARS-CoV-2-infected patients with ARDS., Objectives: To evaluate the association between including a certified wound and skin care nurse on a multiprofessional pronation team and prevention of pressure injuries in SARS-CoV-2-infected patients with ARDS., Methods: This multicenter observational cohort study used retrospective data from the electronic health record. The intervention group consisted of SARS-CoV-2-infected patients diagnosed with ARDS who were treated by a multidisciplinary prone-positioning team that included a certified wound and skin care nurse specialist. The comparison group of SARS-CoV-2-infected patients with ARDS was treated by a multidisciplinary prone-positioning team that did not include a certified wound and skin care nurse specialist., Results: As shown by multivariable logistic regression mixed-effect modeling, patients in the intervention group had a 97% lower adjusted odds ratio of a pressure injury developing than did patients in the comparison group (0.03 [95% CI, 0.01-0.14]; P < .001)., Conclusion: The inclusion of a certified wound and skin care nurse on a multiprofessional prone-positioning team significantly reduced the odds of pressure injuries developing in patients infected with SARS-CoV-2., (©2022 American Association of Critical-Care Nurses.)

Objective: The objective of this overview is to discuss the development, implementation, data content, and structure of the Uniformed Services University Pain Registry Biobank. Additionally, procedures and policies for accessing samples for pain-related research purposes are detailed., Design: Cross-sectional overview., Setting: Multiple military treatment facilities., Subjects: Adult beneficiaries seeking care within the Military Health System., Methods: Participants complete a baseline battery of biopsychosocial survey measures, including Patient-Reported Outcomes Measurement Information System (PROMIS®) measures, and provide biological samples (e.g., blood and saliva). Relevant health history, including medications and surgical history, is extracted from medical records. During the course of the subsequent year, enrolled participants complete surveys and provide biological samples at 3 months, 6 months, and 12 months. Thereafter, participants are contacted once annually to complete self-reported assessments and provide biological samples., Results: In the first year alone, 86 subjects have participated in the Uniformed Services University Pain Registry Biobank and provided 390 observations (e.g., biological samples and biopsychosocial patient-reported outcomes). The Uniformed Services University Pain Registry Biobank's integration of biological samples, patient-reported outcomes, and health record data over a longitudinal period across a diverse sample recruited from multiple military facilities addresses many of the limitations faced by other pain-related registries or biorepositories., Conclusions: The Uniformed Services University Pain Registry Biobank will serve as a platform for conducting research closely aligned with the Federal Pain Research Strategy. The inclusion of active duty service members, beneficiaries, and civilians living with and without acute or chronic pain provides a unique data repository for all investigators interested in advancing pain science., (Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Background: Orthopedic trauma patients face complex pain management needs and are frequently prescribed opioids, leaving them at-risk for prolonged opioid use. To date, post-trauma pain management research has placed little emphasis on individualized risk assessments for misuse and systematically implementing non-pharmacologic pain management strategies. Therefore, a community-academic partnership was formed to design a novel position in the healthcare field (Life Care Specialist (LCS)), who will educate patients on the risks of opioids, tapering usage, safe disposal practices, and harm reduction strategies. In addition, the LCS teaches patients behavior-based strategies for pain management, utilizing well-described techniques for coping and resilience. This study aims to determine the effects of LCS intervention on opioid utilization, pain control, and patient satisfaction in the aftermath of orthopedic trauma., Methods: In total, 200 orthopedic trauma patients will be randomized to receive an intervention (LCS) or a standard-of-care control at an urban level 1 trauma center. All patients will be assessed with comprehensive social determinants of health and substance use surveys immediately after surgery (baseline). Follow-up assessments will be performed at 2, 6, and 12 weeks postoperatively, and will include pain medication utilization (morphine milligram equivalents), pain scores, and other substance use. In addition, overall patient wellness will be evaluated with objective actigraphy measures and patient-reported outcomes. Finally, a survey of patient understanding of risks of opioid use and misuse will be collected, to assess the influence of LCS opioid education., Discussion: There is limited data on the role of individualized, multimodal, non-pharmacologic, behavioral-based pain management intervention in opioid-related risk-mitigation in high-risk populations, including the orthopedic trauma patients. The findings from this randomized controlled trial will provide scientific and clinical evidence on the efficacy and feasibility of the LCS intervention. Moreover, the final aim will provide early evidence into which patients benefit most from LCS intervention., Trial Registration: ClinicalTrials.gov NCT04154384 . Registered on 11/6/2019 (last updated on 6/10/2021)., (© 2021. The Author(s).)

Objective: This study evaluated the association between pain outcomes and post-traumatic stress disorder (PTSD) symptom trajectories after combat-related injury, while adjusting for receipt of regional anesthesia (RA) soon after injury., Methods: The PTSD symptom trajectories of N = 288 combat-injured service members were examined from within a month of injury up to two-years after. Linear mixed-effects models evaluated the association between PTSD symptom trajectories and average pain and pain interference outcomes while adjusting for receipt of RA during combat casualty care., Results: Four PTSD trajectories were characterized: resilient, recovering, worsening, and chronic. Differential pain presentations were associated with PTSD symptom trajectories, even after adjusting for receipt of RA. Compared to those with a resilient PTSD symptom trajectory, individuals presenting with chronic PTSD trajectories were estimated to experience average pain scores 2.61 points higher (95% CI: 1.71, 3.14). Participants presenting with worsening (β = 1.42; 95% CI: 0.77, 1.78) and recovering PTSD trajectories (β = 0.65; 95% CI: 0.09, 1.08) were estimated to experience higher average pain scores than participants with resilient PTSD trajectories. Significant differences in pain interference scores were observed across PTSD trajectories. Receiving RA was associated with improved pain up to two years after injury (β = -0.31; 95% CI: -0.90, -0.04), however no statistically significant association was detected between RA and PTSD trajectories., Conclusions: Chronic and worsening PTSD trajectories were associated with greater pain intensity and interference following combat injury even when accounting for receipt of early RA for pain management. These findings underscore the need to jointly assess pain and PTSD symptoms across the trauma care continuum., (Published by Oxford University Press on behalf of the American Academy of Pain Medicine. This work is written by US Government employees and is in the public domain in the US.)

Aim: The purpose of this study was to determine the extent of agreement between adherence measures obtained using two technological interventions, electronic monitoring (EM) and a smartphone application (App)., Background: Clinicians, patients, and researchers depend on valid measurements of medication adherence to inform the delivery of preemptive care when needed. Technology is routinely used for monitoring medication adherence in both clinical practice and research, yet there is a dearth of research comparing novel App based approaches to traditional approaches used for assessing medication adherence., Methods: Adherence rates were captured on both the EM and the App for 3697 daily observations from 44 participants with acute coronary syndrome over 90 days immediately following discharge from acute care. For EM, adherence was measured using EM equipped pill bottles. For the App, adherence was measured by having participants upload daily photos to the App prior to taking their daily aspirin. Agreement was assessed using a Bland-Altman analysis., Results: The mean adherence rate was higher on the App, 92%, than the EM, 78% (p < 0.001). The mean difference in adherence rates between these methods was 14% (95% Confidence Interval: -23%, -5%)., Conclusions: These findings illustrate a lack of agreement between technological interventions used for measuring adherence in cardiovascular patient populations, with higher adherence rates observed with the App compared to EM. These findings are salient given the increased reliance on telehealth due to the ongoing COVID-19 pandemic., (Copyright © 2021 Elsevier Inc. All rights reserved.)