An AI healthcare ecosystem framework for Covid-19 detection and forecasting using CronaSona.

The primary purpose of this paper is to establish a healthcare ecosystem framework for COVID-19, CronaSona. Unlike some studies that focus solely on detection or forecasting, CronaSona aims to provide a holistic solution, for managing data and/or knowledge, incorporating detection, forecasting, expert advice, treatment recommendations, real-time tracking, and finally visualizing results. The innovation lies in creating a comprehensive healthcare ecosystem framework and an application that not only aids in COVID-19 diagnosis but also addresses broader health challenges. The main objective is to introduce a novel framework designed to simplify the development and construction of applications by standardizing essential components required for applications focused on addressing diseases. CronaSona includes two parts, which are stakeholders and shared components, and four subsystems: (1) the management information subsystem, (2) the expert subsystem, (3) the COVID-19 detection and forecasting subsystem, and (4) the mobile tracker subsystem. In the proposed framework, a CronaSona app. was built to try to put the virus under control. It is a reactive mobile application for all users, especially COVID-19 patients and doctors. It aims to provide a reliable diagnostic tool for COVID-19 using deep learning techniques, accelerating diagnosis and referral processes, and focuses on forecasting the transmission of COVID-19. It also includes a mobile tracker subsystem for monitoring potential carriers and minimizing the virus spread. It was built to compete with other applications and to help people face the COVID-19 virus. Upon receiving the proposed framework, an application was developed to validate and test the framework's functionalities. The main aim of the developed application, CronaSona app., is to develop and test a reliable diagnostic tool using deep learning techniques to avoid increasing the spread of the disease as much as possible and to accelerate the diagnosis and referral of patients by detecting COVID-19 features from their chest X-ray images. By using CronaSona, human health is saved and stress is reduced by knowing everything about the virus. It performs with the highest accuracy, F1-score, and precision, with consecutive values of 97%, 97.6%, and 96.6%.

Upskilling programmes for unregulated care providers to provide diabetic foot screening for systematically marginalised populations: how, why and in what contexts do they work? A realist review.

OBJECTIVE: We aimed to understand how, why and in what context upskilling programmes for unregulated care providers (UCPs) to provide foot screening for systematically marginalised groups living with diabetes were implemented. DESIGN: We used realist synthesis based on Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidance. DATA SOURCES: We searched the Medline, Embase, PsycINFO, CINAHL, ERIC, Web of Science Core Collection, and Scopus databases and the grey literature (Google Scholar, ProQuest Dissertations and Theses) up to November 2022. ELIGIBILITY CRITERIA: We included experimental and non-experimental articles in English that either described mechanisms or discussed expected outcomes for educational interventions for patients and family caregivers or healthcare providers, both regulated and unregulated. We also included articles that evaluated the impact of foot care programmes if the UCPs' training was described. DATA EXTRACTION AND SYNTHESIS: The lead author extracted, annotated and coded uploaded relevant data to identify contexts, mechanisms and outcome configurations using MAXQDA (a qualitative data analysis software). We used deductive and inductive coding to structure the process. Our team members double-reviewed and appraised a random sample of 20% of articles at all stages to ensure consistency. RESULTS: Our search identified 52 articles. Evidence suggested the necessity of developing upskilling foot screening programmes within the context of preventive care programmes that also provide education in diabetes, and early referrals for appropriate interventions. Multidisciplinary programmes created an ideal context facilitating coordination between UCPs and their regulated counterparts. Engaging patients and community partners, using a competency-based model, and incorporating cultural competencies were determinants of success for these programmes. CONCLUSION: This review provides a realistic programme theory for the mechanisms used, the context in which these programmes were developed, and the expected outcomes to train UCPs to provide preventive foot care for systematically marginalised populations. PROSPERO REGISTRATION NUMBER: CRD42022369208.

Understanding how and why upskilling programmes for unregulated care providers can support health equity in underserved communities: a realist review protocol.

INTRODUCTION: Foot ulcers are one of the most devastating complications of diabetes mellitus leading to leg amputations. In Canada, systematically marginalised and racialised populations are more prone to developing foot ulcers and at higher risk of limb amputations. Shortages of regulated healthcare have hindered efforts to provide foot care. Upskilling unregulated care providers (UCPs) to deliver foot screening seems a reasonable solution to reduce limb loss. UCPs can advocate for health equity and deliver appropriate care. There is a need, however, to understand how and why an educational intervention for UCPs providing foot screening for these high-risk groups may or may not work. METHODS AND ANALYSIS: This realist review will follow the Realist And Meta-narrative Evidence Syntheses: Evolving Standards standards. First, we will develop an initial programme theory (PrT) based on exploratory searches and discussions with experts and stakeholders. Then, we will search MEDLINE, Embase, PsycINFO, ERIC, CINAHL and Scopus databases along with relevant sources of grey literature. The retrieved articles will be screened for studies focusing on planned educational interventions for UCPs related to diabetic foot assessment. Data regarding contexts, mechanisms and outcomes will be extracted and analysed using a realist analysis through an iterative process that includes data reviewing and consultation with our team. Finally, we will use these results to modify the initial PrT. ETHICS AND DISSEMINATION: Ethical approval is not required for this review. The main output of this research will be an evidence-based PrT for upskilling programmes for UCPs. We will share our final PrT using text, tables and infographics to summarise our results and draw insights across papers/reports. For academic, clinical, social care and educational audiences, we will produce peer-reviewed journal articles, including those detailing the process and findings of the realist review and establishing our suggestions for effective upskilling programmes. PROSPERO REGISTRATION NUMBER: CRD42022369208.

Identifying chronic low back pain phenotypic domains and characteristics accounting for individual variation: a systematic review.

ABSTRACT: Interpatient variability is frequently observed among individuals with chronic low back pain (cLBP). This review aimed at identifying phenotypic domains and characteristics that account for interpatient variability in cLBP. We searched MEDLINE ALL (through Ovid), Embase Classic and EMBASE (through Ovid), Scopus, and CINAHL Complete (through EBSCOhost) databases. Studies that aimed to identify or predict cLBP different phenotypes were included. We excluded studies that focused on specific treatments. The methodological quality was assessed using an adaptation of the Downs and Black tool. Forty-three studies were included. Although the patient and pain-related characteristics used to identify phenotypes varied considerably across studies, the following were among the most identified phenotypic domains and characteristics that account for interpatient variability in cLBP: pain-related characteristics (including location, severity, qualities, and duration) and pain impact (including disability, sleep, and fatigue), psychological domains (including anxiety and depression), behavioral domains (including coping, somatization, fear avoidance, and catastrophizing), social domains (including employment and social support), and sensory profiling (including pain sensitivity and sensitization). Despite these findings, our review showed that the evidence on pain phenotyping still requires further investigation. The assessment of the methodological quality revealed several limitations. We recommend adopting a standard methodology to enhance the generalizability of the results and the implementation of a comprehensive and feasible assessment framework to facilitate personalized treatments in clinical settings.

Why Questionnaire Scores Are Not Measures: A Question-Raising Article.

ABSTRACT: Any person is provided by characteristics that can be neither located in body parts nor directly observed (so-called latent variables): these may be behaviors, attitudes, perceptions, motor and cognitive skills, knowledge, emotions, and the like. Physical and rehabilitation medicine frequently faces variables of this kind, the target of many interventions. Latent variables can only be observed through representative behaviors (e.g., walking for independence, moaning for pain, social isolation for depression, etc.). To measure them, behaviors are often listed and summated as items in cumulative questionnaires ("scales"). Questionnaires ultimately provide observations ("raw scores") with the aspect of numbers. Unfortunately, they are only a rough and often misleading approximation to true measures for various reasons. Measures should satisfy the same measurement axioms of physical sciences. In the article, the flaws hidden in questionnaires' scores are summarized, and their consequences in outcome assessment are highlighted. The report should inspire a critical attitude in the readers and foster the interest in modern item response theory, with reference to Rasch analysis.

An Assessment of Naturopathic Treatments, Health Concerns, and Common Comorbid Conditions in Fibromyalgia Patients: A Retrospective Medical Record Review.

Background: Fibromyalgia (FM) is characterized by chronic pain, with allodynia and hyperalgesia being the most common signs. Many patients with FM explore, express interest, and use complementary and alternative medicine to help manage symptoms and improve quality of life. However, little is known about the clinical recommendations provided by naturopathic doctors (NDs). Objective: To describe trends in assessment and treatment of patients with FM by NDs. Methods: Retrospectively, medical records of 200 patients with the FM ICD-10 code were reviewed from the Robert Schad Naturopathic Clinic. Of these records, 70 met inclusion criteria and were further analyzed. Comorbid conditions, health concerns, physical and psychological examinations, and treatment were recorded. Patients were excluded if informed consent for research was not signed. The project was approved by the Research Ethics Board of the Canadian College of Naturopathic Medicine. Results: Seventy patients met criteria and were included in the current analysis. Most patients identified as female (96%). Vitamin D (57%), magnesium (54%), omega-3 fish oil (53%), acupuncture by an acupuncturist (53%) or an ND (40%), B12 orally or by injection (40%), and probiotics (40%) were highly utilized treatments. A past/current medical history of digestive complaints (64%) and depression/mental illness (63%) were common comorbidities, alongside a history of arthritic conditions (53%) and anxiety (43%). A family history of arthritic conditions (47%) was also prevalent. The Widespread Pain Index and Symptom Severity tool (43%) was used to assess pain and other symptoms. No adverse effects of treatment were readily identifiable. Conclusion: Findings from this study reveal elements of both consistency and variability in the treatment recommendations from NDs in a teaching clinic environment. Future research that assesses or compares treatment recommendations for FM in other settings may be informative to better understand health services, the nature of individualized care, and patient experiences.

Potential role of blood biomarkers in patients with fibromyalgia: a systematic review with meta-analysis.

ABSTRACT: Fibromyalgia (FM) is a complex chronic pain condition. Its symptoms are nonspecific, and to date, no objective test exists to confirm FM diagnosis. Potential objective measures include the circulating levels of blood biomarkers. This systematic review and meta-analysis aim to review studies assessing blood biomarkers' levels in patients with FM compared with healthy controls. We systematically searched the PubMed, MEDLINE, EMBASE, and PsycINFO databases. Fifty-four studies reporting the levels of biomarkers in blood in patients with FM were included. Data were extracted, and the methodological quality was assessed independently by 2 authors. The methodological quality of 9 studies (17%) was low. The results of most studies were not directly comparable given differences in methods and investigated target immune mediators. Thus, data from 40 studies only were meta-analyzed using a random-effects model. The meta-analysis showed that patients with FM had significantly lower levels of interleukin-1 ß and higher levels of IL-6, IL-8, tumor necrosis factor-alpha, interferon gamma, C-reactive protein, and brain-derived neurotrophic factor compared with healthy controls. Nevertheless, this systematic literature review and meta-analysis could not support the notion that these blood biomarkers are specific biomarkers of FM. Our literature review, however, revealed that these same individual biomarkers may have the potential role of identifying underlying pathologies or other conditions that often coexist with FM. Future research is needed to evaluate the potential clinical value for these biomarkers while controlling for the various confounding variables.

Validity and Diagnosis in Physical and Rehabilitation Medicine: Critical View and Future Perspectives.

ABSTRACT: Obtaining a diagnosis is an essential and integral part of physical and rehabilitation medicine in practice and research. Standardized psychometric properties are required of any classifications, diagnostic criteria, and diagnostic rules used. Physicians and researchers, in physical and rehabilitation medicine, need to understand these properties to determine the accuracy and consistency of their diagnosis. Although chronic musculoskeletal pain disorders are among the highly prevalent disorders seen in physical and rehabilitation medicine, limitations regarding existing diagnostic criteria for chronic musculoskeletal pain disorders still exist. Hence, the quest for developing diagnostic tools for chronic musculoskeletal pain that align with the standard properties remains open. These are discussed with an example for existing diagnostic criteria for fibromyalgia. This article primarily aimed to provide an overview of standard psychometric properties. A secondary aim was to critically appraise the tools currently used to diagnose chronic musculoskeletal pain disorders. The challenges and limitations of existing diagnostic tools are discussed. Potential approaches on how to improve the conceptualization of the construct of musculoskeletal pain disorders are also discussed. Adopting a network perspective, for example, can better constitute the disease instead of a single known underlying etiology for persistent or recurrent pain symptoms.

Standard Psychometric Criteria for Measurements in Physical and Rehabilitation Medicine.

ABSTRACT: Measurements of person's variable, such as behavior, perceptions, or attitudes, are essential to physical and rehabilitation medicine in both clinical practice and research. These measurements are commonly based on cumulative questionnaires and follow special statistical rules, belonging to the domain of psychometrics. Selecting the most appropriate measurement is critical. This article provides an overview of the standard psychometric criteria to consider in measurement selection. The article focuses on the criteria related to the contemporary psychometric approach as it considers the construct, the target population, and the purpose for which measurements are used. Common strategies related to psychometric testing are discussed and applied to critically appraise, as a representative example, one of the most commonly used pain measurements: Brief Pain Inventory. The measurement construct, conceptual framework, target population, purpose, and psychometric properties are highlighted. Observed limitations for its implementation in different settings also are discussed.

Development and Initial Evaluation of Psychometric Properties of a Pain Competence Assessment Tool (PCAT).

Competency-based education is now considered the best approach for pain educational programs provided for pre and postgraduate healthcare providers (HCPs). To demonstrate learners' progression, an assessment tool that aligns with this educational approach and targets different HCPs is needed. A Pain Competence Assessment Tool (PCAT) was developed based on the pain management core competencies that align with the International Association for the Study of Pain interprofessional pain curriculum. The PCAT is an online competency-based assessment tool for HCPs that consists of 5 case scenarios followed by 17 key-feature questions. HCPs and trainees completed the PCAT through a series of studies to assess its psychometric properties. The preliminary evaluation suggested that the PCAT had adequate content validity. Apart from 6 questions, the PCAT questions demonstrated homogeneity and acceptable reliability, and substantial stability. No ceiling or floor effect was found. A significant difference was detected between the HCPs' and trainees' scores. The PCAT scores strongly correlated with other variables reflecting different competence levels. The PCAT scores showed significant changes in the baseline scores compared to scores after attending an educational intervention. The PCAT offers a first-of-its-kind tool for assessing HCPs' competence (ie, knowledge and its application) in managing chronic pain. Future research is needed for further validation and adaptation of the PCAT. PERSPECTIVE: The Pain Competence Assessment Tool (PCAT) offers a first-of-its-kind tool for assessing clinicians' core competencies that overlap between different professions and support the clinicians' capacity to successfully manage chronic pain in the real world focusing on the patient-centered perspective rather than the profession-specific perspective.

Re-Examining Myofascial Pain Syndrome: Toward Biomarker Development and Mechanism-Based Diagnostic Criteria.

PURPOSE OF REVIEW: We discuss the need for a mechanism-based diagnostic framework with a focus on the development of objective measures (e.g., biomarkers) that can potentially be added to the diagnostic criteria of the syndrome. Potential biomarkers are discussed in relation to current knowledge on the pathophysiology of myofascial pain syndrome (MPS), including alterations in redox status, inflammation, and the myofascial trigger point (MTrP) biochemical milieu, as well as imaging and neurophysiological outcomes. Finally, we discuss the long-term goal of conducting a Delphi survey, to assess the influence of putative MPS biomarkers on clinician opinion, in order to ultimately develop new criteria for the diagnosis of MPS. RECENT FINDINGS: Myofascial pain syndrome (MPS) is a prevalent healthcare condition associated with muscle weakness, impaired mood, and reduced quality of life. MPS is characterized by the presence of myofascial trigger points (MTrPs): stiff and discrete nodules located within taut bands of skeletal muscle that are painful upon palpation. However, physical examination of MTrPs often yields inconsistent results, and there is no gold standard by which to diagnose MPS. The current MPS diagnostic paradigm has an inherent subjectivity and the absence of correlation with the underlying pathophysiology. Recent advancements in ultrasound imaging, systemic biomarkers, MTrP-specific biomarkers, and the assessment of dysfunction in the somatosensorial system may all contribute to improved diagnostic effectiveness of MPS.

Elicitation of stakeholder viewpoints about medical cannabis research for pain management in critically ill ventilated patients: A Q-methodology study.

OBJECTIVES: To determine acceptability of medical cannabis research in critically ill patients. DESIGN: Q-methodology survey. SETTING: Convenience sample of healthcare providers and the general public were recruited at an acute care community hospital in Ontario, Canada. PARTICIPANTS: In the first phase, 63 respondents provided 197 unique viewpoints in response to a topic statement about medical cannabis use in critically ill patients. Twenty-five viewpoints were selected for the q-sample. In the second phase, 99 respondents ranked these viewpoints according to an a priori quasi normal distribution ranging from +4 (most agree) to -4 (least agree). Factor analysis was combined with comments provided by survey respondents to label and describe the extracted factors. RESULTS: The factor labels were hoping and caring (factor 1), pragmatic progress (factor 2), and cautious/conservative and protectionist (factor 3). Factor 1 describes a viewpoint of unequivocal support for medical cannabis research in this population with few caveats. Factor 2 describes a viewpoint of cautious support with a need to monitor for unintended adverse effects. Factor 3 describes a viewpoint of ensuring that current analgosedation techniques are optimized before exposing patients to another potentially harmful drug. CONCLUSIONS: Using a q-methodology design, we were able to sample and describe the viewpoints that exist about medical cannabis research in critically ill patients. Three factors emerged that seemed to adequately describe the relative ranking of q-statements by the majority of respondents. Combining the distinguishing statements along with respondent comments allowed us to determine that the majority support medical cannabis research in critically ill patients.

Promoting an interprofessional approach to chronic pain management in primary care using Project ECHO.

Chronic pain is a complex multidimensional condition that requires management with multiple professions' expertise. Healthcare training programs tend to adhere to curricula within their own profession with very few interactions with other groups. Project ECHO (Extension for Community Healthcare Outcomes) Chronic Pain and Opioid Stewardship is a model for interprofessional education, using tele-mentoring, case-base discussions and clinically focused presentations. The goal is to improve competency and confidence in managing complex cases in primary care. This qualitative study engaged twenty healthcare practitioners from multiple professions who had participated in ECHO in focus group discussions about managing patients with chronic pain, about their reasons for and the effect of participating in Project ECHO Ontario Chronic Pain/Opioid Stewardship, and about their perspectives on interprofessional care. The results show that participating in ECHO resulted in personal and professional benefit, and increased understanding about their own roles and limitations, as well as other healthcare professionals' roles. The participants described changes in their attitudes toward patients with chronic pain, and their colleagues from other professions. Non-physician participants were more likely to approach physicians to discuss their assessment and diagnosis as well as prescriptions. The interprofessional nature of the program was seen as positive and contributed to perceived changes in practice collaboration. These results show that healthcare professionals from multiple professions expressed mainly positive views of ECHO's emphasis on interprofessional care, with different professions appreciating different aspects of that approach.

Perioperative nutritional prehabilitation in malnourished children with congenital heart disease: A randomized controlled trial.

OBJECTIVE: The poor preoperative nutritional state of children with congenital heart disease (CHD) is often exacerbated postoperatively. The aim of this study was to evaluate the effect of perioperative 1- versus 2-wk nutritional prehabilitation programs on growth and surgical outcomes in malnourished children with CHD. METHODS: Forty malnourished infants scheduled for elective CHD surgery were randomized to receive either 1 or 2 wk of a nutritional prehabilitation program. Pre- and postoperative anthropometric parameters and feeding characteristics, feeding tolerance, duration of mechanical ventilation, intensive care unit (ICU) length of stay (LOS) and total hospital LOS were documented. RESULTS: The 2-wk prehabilitation group showed higher weight-for-age z-score and body mass index than the 1-wk group both preoperatively postnutritional, and postoperatively with significantly higher weight gain postoperatively. The 2-wk prehabilitation group had a shorter duration of postoperative mechanical ventilation, ICU LOS, and total hospital LOS. CONCLUSION: The 2-wk prehabilitation program was associated with better anthropometric measurements, shorter ICU LOS postoperatively, and shorter duration of hospitalization and mechanical ventilation. The preoperative nutritional status of children with CHD had a negative effect on ICU LOS and duration of mechanical ventilation.

Association Between Acute Inflammatory Cells and Mutation in ICAM-1 Gene With Injury Severity and Outcome Among Traumatic Cerebral Hemorrhagic Contusion.

BACKGROUND: Acute inflammation in the brain after trauma is mediated by acute inflammatory cells (neutrophils) that contributes to ischemic brain damage, neurological deterioration, and poor outcome. Migration of neutrophils to brain is mediated by intercellular adhesion molecule-1 (ICAM-1). The aim was to determine an association between neutrophils counts, ICAM-1 level and mutation in ICAM-1 gene with injury severity and patient's outcome. METHODS: Cross-sectional study was conducted for ninety Sudanese patients presented with traumatic cerebral hemorrhagic contusion to the National Center for Neurological Sciences, Khartoum, Sudan from December 2015 to January 2018. Non-Sudanese patients, and hemorrhagic contusion associated with other type of brain bleeding were excluded in this study. Moreover, 90 apparently healthy individuals were participated as control. RESULTS: Most patients were males (93.3%), their ages ranged from 25 to 44 years, 11.1% of the patients had severe brain injury, 22.2% had brain edema and the mortality rate was 8.9%. Circulatory levels of leukocytes, neutrophil and ICAM-1 among patients who sustained trauma were significantly elevated compared with controls (p = 0.000). The high level of leukocytes and neutrophils counts were significantly associated with ICAM-1pg/mL circulatory level. High levels of leukocytes, neutrophils, and ICAM-1 were documented in severe brain injuries, whereas. high level of ICAM-1 was observed among patients admitted with brain edema. Leukocytes and neutrophils counts were significantly associated with patient outcome. High level of ICAM-1 (304.88 pg/mL) was observed among patients with poor outcome compared to survivals (263.93 pg/mL). The highest circulatory level of ICAM-1 (280.75 pg/mL) was observed among patient having adenine-adenine (AA) mutant homozygous alleles, followed by (272 pg/mL) for guanine-guanine (GG) homozygous alleles, then (245.12 pg/mL) for guanine-adenine (GA) heterozygous alleles. CONCLUSIONS: Mutation in ICAM-1 gene and increased levels of leukocytes, neutrophils and ICAM-1 constitutes important markers for injury severity and patient's outcome.

The Significance of Mutation in IL-1ß Gene and Circulatory Level for Prediction of Trauma Severity and Outcome in Traumatic Cerebral Hemorrhagic Contusion.

BACKGROUND: Traumatic brain injuries (TBIs) is a leading cause of death, disability, and resources consumption. Cerebral hemorrhagic contusions are primary brain lesion and often one of the most visible lesions following TBIs. Interleukin-one beta (IL-1 ß) is pro-inflammatory cytokines it is circulatory level and gene have been implicated in secondary brain injury and worse outcome following TBIs. This study is to determine the significance role of IL-1 ß gene polymorphism (-511C/T) and circulatory level for prediction trauma severity and outcome in traumatic cerebral hemorrhagic contusion. METHODS: The study population includes 90 Sudanese patients with traumatic cerebral hemorrhagic and 90 apparently healthy individuals as control. IL-1ß serum concentration was measured using enzyme-linked immunosorbent assay and IL-1ß gene was genotyped using restriction fragment length polymorphism-polymerase chain reaction. RESULTS: Significant elevation of IL-1ß level was seen among trauma patients compared to control (p-value < 0.001). Although there was no significant association between IL-1ß level with trauma severity or death; IL-1ß level was higher in severe brain injures compared with moderate and mild one, and the mean concentration of IL-1ß was high (18.75 pg/mL) among patient developed poor outcome compared to survivals (15.17 pg/mL). T recessive allele of IL-1 ß gene was detected in 13.3% of participant. The highest circulatory level of IL-1ß (17.8 pg/mL) was observed among patients with TT homozygous alleles. IL-1 ß gene polymorphism was not associated with trauma severity and death. CONCLUSIONS: IL-1ß circulatory level was varied according to trauma severity and highly levels were seen among patients developed unfavorable outcome. IL-1ß -511C/T gene was not associated with trauma severity and outcome.

Does Integrative Medicine Reduce Prescribed Opioid Use for Chronic Pain? A Systematic Literature Review.

BACKGROUND: Chronic pain (CP) is a major public health problem. Many patients with CP are increasingly prescribed opioids, which has led to an opioid crisis. Integrative medicine (IM), which combines pharmacological and complementary and alternative medicine (CAM), has been proposed as an opioid alternative for CP treatment. Nevertheless, the role of CAM therapies in reducing opioid use remains unclear. OBJECTIVES: To explore the effectiveness of the IM approach or any of the CAM therapies to reduce or cease opioid use in CP patients. METHODS: An online search of MEDLINE and Embase, CINAHL, PubMed supp., and Allied and Complementary Medicine Database (AMED) for studies published in English from inception until February 15, 2018, was conducted. The Mixed Methods Appraisal Tool (MMAT) was used to critically appraise selected studies. RESULTS: The electronic search yielded 5,200 citations. Twenty-three studies were selected. Eight studies were randomized controlled trials, seven were retrospective studies, four studies were prospective observational, three were cross-sectional, and one was quasi-experimental. The majority of the studies showed that opioid use was reduced significantly after using IM. Cannabinoids were among the most commonly investigated approaches in reducing opioid use, followed by multidisciplinary approaches, cognitive-behavioral therapy, and acupuncture. The majority of the studies had limitations related to sample size, duration, and study design. CONCLUSIONS: There is a small but defined body of literature demonstrating positive preliminary evidence that the IM approach including CAM therapies can help in reducing opioid use. As the opioid crisis continues to grow, it is vital that clinicians and patients be adequately informed regarding the evidence and opportunities for IM/CAM therapies for CP.

Evaluation of an innovative tele-education intervention in chronic pain management for primary care clinicians practicing in underserved areas.

INTRODUCTION: Inadequate knowledge and training of healthcare providers are obstacles to effective chronic pain management. ECHO (extension for community healthcare outcomes) uses case-based learning and videoconferencing to connect specialists with providers in underserved areas. ECHO aims to increase capacity in managing complex cases in areas with poor access to specialists. METHODS: A pre-post study was conducted to evaluate the impact of ECHO on healthcare providers' self-efficacy, knowledge and satisfaction. Type of profession, presenting a case, and number of sessions attended were examined as potential factors that may influence the outcomes. RESULTS: From June 2014 to March 2017, 296 primary care healthcare providers attended ECHO, 264 were eligible for the study, 170 (64%) completed the pre-ECHO questionnaire and 119 completed post-ECHO questionnaires. Participants were physicians (34%), nurse practitioners (21%), pharmacists (13%) and allied health professionals (32%). Participants attended a mean of 15 ± 9.19 sessions. There was a significant increase in self-efficacy (p < 0.0001) and knowledge (p < 0.0001). Self-efficacy improvement was significantly higher among physicians, physician assistants and nurse practitioners than the non-prescribers group (p = 0.03). On average, 96% of participants were satisfied with ECHO. Satisfaction was higher among those who presented cases and attended more sessions. DISCUSSION: This study shows that ECHO improved providers' self-efficacy and knowledge. We evaluated outcomes from a multidisciplinary group of providers practicing in Ontario. This diversity supports the generalisability of our findings. Therefore, we suggest that this project may be used as a template for creating other educational programs on other medical topics.

Long-term opioid use after discharge from inpatient musculoskeletal rehabilitation.

OBJECTIVE: To determine: (i) the prevalence of opioid-naïve patients discharged on opioids from a musculoskeletal rehabilitation inpatient unit; (ii) the prevalence of opioid use 6 months after discharge; and (iii) the efficacy of the Opioid Risk Tool in identifying long-term opioid use. DESIGN: Prospective study. PARTICIPANTS: Sixty-four opioid-naïve patients who were exposed to opioids during admission and who were discharged on an opioid. METHODS: Potentially eligible patients' charts were reviewed. Participants were interviewed during admission to obtain the opioid risk score and contacted 6 months after discharge via a semi-structured telephone interview. RESULTS: Twenty-eight percent of opioid-naïve patients, who were discharged on opioids were still using opioids 6 months after discharge from rehabilitation. There was a trend for higher Opioid Risk Tool scores in those still using opioids than in individuals who were not using opioids at 6 months (p = 0.053). CONCLUSION: Patients who are prescribed opioids during a hospital admission should be screened for risk of opioid misuse. This data suggests that the Opioid Risk Tool could identify a patient's potential for becoming a long-term user of opioids.

Ovarian hormones and chronic pain: A comprehensive review.

Most chronic noncancer pain (CNCP) conditions are more common in women and have been reported to worsen, particularly during the peak reproductive years. This phenomenon suggests that ovarian hormones might play a role in modulating CNCP pain. To this end, we reviewed human literature aiming to assess the potential role of ovarian hormones in modulating the following CNCP conditions: musculoskeletal pain, migraine headache, temporal mandibular disorder, and pelvic pain. We found 50 relevant clinical studies, the majority of which demonstrated a correlation between hormone changes or treatments and pain intensity, threshold, or symptoms. Taken together, the findings suggest that changes in hormonal levels may well play a role in modulating the severity of CNCP conditions. However, the lack of consistency in study design, methodology, and interpretation of menstrual cycle phases impedes comparison between the studies. Thus, while the literature is highly suggestive of the role of ovarian hormones in modulating CNCP conditions, serious confounds impede a definitive understanding for most conditions except menstrual migraine and endometriosis. It may be that these inconsistencies and the resulting lack of clarity have contributed to the failure of hormonal effects being translated into medical practice for treatment of CNCP conditions.