The Need to Say More: A Qualitative Analysis of Added Free Text to Chronic Pain Patient Intake Packages.

BACKGROUND: Many outpatient chronic pain clinics administer extensive patient intake questionnaires to understand patients' pain and how it impacts their lives. At our institution's pain clinic, many patients include free text in these predominantly closed-ended questionnaires, but little is known about the content categories included in this free text. AIM: This study examined free text entries on chronic pain patient intake questionnaires. METHOD: We analyzed 270 occurrences of free text across 43 patient intake questionnaires of people living with chronic pain using a qualitative content analytic approach. RESULTS: We identified two overarching thematic categories of free text: (1) what they say (characterizes the topic of the free text); and (2) why they say it (characterizes perceived limitations of the patient intake questionnaire format). We also documented the frequency highlighting how often themes and their associated sub-themes (detailed below) were indicated. Within the What they say category, three main themes emerged: (1) health (34.9%; e.g., pain); (2) health service use (27.9%; e.g., medication); and (3) psychosocial factors (20.9%; e.g., relationships). Within the Why they say it category, four main themes emerged: (1) adding information (86.0%; e.g., elaborates/contextualizes); (2) narrow response options (65.1%; e.g., varies); (3) problems with the question (18.6%; e.g., not applicable); and (4) response error (4.7%; e.g., answers incorrectly/misinterprets question). CONCLUSIONS: People living with chronic pain appear motivated to add additional, unprompted information to their patient intake questionnaires. The results from this study may inform changes to chronic pain patient intake questionnaires which could facilitate improvements in chronic pain patient-health care provider communication.

Demographic and clinical characteristics of free-text writers in chronic pain patient intake questionnaires.

BACKGROUND: Chronic pain is a prevalent and burdensome problem within the Canadian health care system, where the gold standard treatment occurs at multidisciplinary pain facilities. Patient intake questionnaires (PIQs) are standard practice for obtaining health information, with many patients including free-text (e.g., writing in margins of questionnaires) on their PIQs. AIMS: This study aims to quantitatively examine whether and how patients who include free-text on PIQs differ from those who do not. METHODS: We retrospectively analyzed 367 PIQs at a Canadian pain facility in Winnipeg, Canada. Patients were categorized into free-text (i.e., any text response not required in responding to questions) or no free-text groups. Groups were compared on sociodemographics, pain, health care utilization, and depressive symptoms with independent samples t-tests and chi-square analyses. RESULTS: Patients with free-text compared to those without had more sources of pain (6.66 vs. 4.63), longer duration of pain (123.2 months vs. 68.1 months), and a greater proportion of past pain conditions (66.3% vs. 55.2%). Additionally, they had tried more treatments for their pain, had seen more specialists, had tried more past medications, were currently on more medications, and had undergone more tests. No differences were identified for depressive symptoms across groups. CONCLUSIONS: This study is the first to examine patient and health-related correlates of free-text on PIQs at a Canadian pain facility. Results indicate that there are significant differences between groups on pain and health care utilization. Thus, patients using free-text may require additional supports and targeted interventions to improve patient-physician communication and patient outcomes.

Contexte: La douleur chronique est un problème répandu et pénible dans le système des soins de santé au Canada, où le traitement de référence se produit dans un centre multidisciplinaire de la douleur. Les formulaires d'admission du patient sont une pratique courante pour obtenir des renseignements sur la santé, et de nombreux patients y incluent du texte libre (en écrivant, par exemple, dans les marges du formulaire).Objectifs: Cette étude vise àexaminer quantitativement si et comment les patients qui incluent du texte libre sur leur formulaire d'admission diffèrent de ceux qui ne le font pas.Méthodes: Nous avons analysé rétrospectivement 367 formulaires d'admission dans un centre canadien de traitement de la douleur à Winnipeg, au Canada. Les patients ont été classés en deux groupes : avec texte libre (c'est-à-dire ayant inscrit une réponse sous forme de texte non requis au moment de répondre aux questions) ou sans texte libre. Les groupes ont été comparés en ce qui concerne les critères sociodémographiques, la douleur, l'utilisation des soins de santé et les symptômes dépressifs, à l'aide de tests t et chi carré pour échantillons indépendants.Résultats: Les patients avec texte libre par rapport à ceux sans texte libre avaient plus de sources de douleur (6,66 comparativement à 4,63), une plus longue durée de la douleur (123,2 mois comparativement à 68,1 mois) et une plus grande proportion de douleur par le passé (66,3 % comparativement à 55,2 %). De plus, ils avaient essayé d'autres traitements pour leur douleur, avaient vu plus de spécialistes, avaient essayé plus de médicaments par le passé, prenaient à ce moment plus de médicaments et avaient subi plus de tests. Aucune différence n'a été recensée pour les symptômes dépressifs entre les groupes.Conclusions: Cette étude est la première à examiner les corrélats liés au patient et à la santé de l'existence de texte libre sur les formulaires d'admission dans un centre de traitement de la douleur au Canada. Les résultats indiquent qu'il existe des différences importantes entre les groupes en ce qui concerne la douleur et l'utilisation des soins de santé. Ainsi, les patients utilisant le texte libre peuvent avoir besoin de soutien additionnel et d'interventions ciblées pour améliorer la communication patient-médecin et les résultats du patient.

Dissociation as a Transdiagnostic Indicator of Self-Injurious Behavior and Suicide Attempts: A Focus on Posttraumatic Stress Disorder and Borderline Personality Disorder.

Dissociative symptoms and suicidality are transdiagnostic features of posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD). The primary objective of this study was to examine associations between dissociation (i.e., depersonalization and derealization) and suicidality (i.e., self-harm and suicide attempts) among individuals with PTSD and BPD. We analyzed data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III; N = 36,309). The Alcohol Use Disorder and Associated Disabilities Interview Schedule for DSM-5 was used to assess lifetime PTSD and BPD. Estimated rates of self-harm among individuals who endorsed dissociation were 15.5%-26.2% for those with PTSD and 13.7%-23.5% for those with BPD, and estimates of suicide attempts among individuals who endorsed dissociation were 34.5%-38.1% for those with PTSD and 28.3%-33.1% for those with BPD. Multiple logistic regressions were conducted to examine the associations between dissociation (derealization, depersonalization, and both) and both self-harm and suicide attempts among respondents with PTSD and BPD. The results indicated that dissociation was associated with self-harm and suicide attempts, especially among individuals with BPD, aORs = 1.39-2.66; however, this association may be driven in part by a third variable, such as other symptoms of PTSD or BPD (e.g., mood disturbance, PTSD or BPD symptom severity). These results may inform risk assessments and targeted interventions for vulnerable individuals with PTSD, BPD, or both aimed at mitigating the risk of self-harm and suicide.

Brain BOLD MRI O2 and CO2 stress testing: implications for perioperative neurocognitive disorder following surgery.

BACKGROUND: Mechanical ventilation to alter and improve respiratory gases is a fundamental feature of critical care and intraoperative anesthesia management. The range of inspired O2 and expired CO2 during patient management can significantly deviate from values in the healthy awake state. It has long been appreciated that hyperoxia can have deleterious effects on organs, especially the lung and retina. Recent work shows intraoperative end-tidal (ET) CO2 management influences the incidence of perioperative neurocognitive disorder (POND). The interaction of O2 and CO2 on cerebral blood flow (CBF) and oxygenation with alterations common in the critical care and operating room environments has not been well studied. METHODS: We examine the effects of controlled alterations in both ET O2 and CO2 on cerebral blood flow (CBF) in awake adults using blood oxygenation level-dependent (BOLD) and pseudo-continuous arterial spin labeling (pCASL) MRI. Twelve healthy adults had BOLD and CBF responses measured to alterations in ET CO2 and O2 in various combinations commonly observed during anesthesia. RESULTS: Dynamic alterations in regional BOLD and CBF were seen in all subjects with expected and inverse brain voxel responses to both stimuli. These effects were incremental and rapid (within seconds). The most dramatic effects were seen with combined hyperoxia and hypocapnia. Inverse responses increased with age suggesting greater risk. CONCLUSIONS: Human CBF responds dramatically to alterations in ET gas tensions commonly seen during anesthesia and in critical care. Such alterations may contribute to delirium following surgery and under certain circumstances in the critical care environment. TRIAL REGISTRATION: ClincialTrials.gov NCT02126215 for some components of the study. First registered April 29, 2014.

End-Tidal Hypocapnia Under Anesthesia Predicts Postoperative Delirium.

Background: Postoperative delirium (POD) might be associated with anesthetic management, but research has focused on choice or dosage of anesthetic drugs. We examined potential contributions of intraoperative ventilatory and hemodynamic management to POD. Methods: This was a sub-study of the ENGAGES-Canada trial (NCT02692300) involving non-cardiac surgery patients enrolled in Winnipeg, Canada. Patients received preoperative psychiatric and cognitive assessments, and intraoperatively underwent high-fidelity data collection of blood pressure, end-tidal respiratory gases and anesthetic agent concentration. POD was assessed by peak and mean POD scores using the Confusion Assessment Method-Severity (CAM-S) tool. Bivariate and multiple linear regression models were constructed controlling for age, psychiatric illness, and cognitive dysfunction in the examination of deviations in intraoperative end-tidal carbon dioxide (areas over (AOC) and under the curve (AUC)) on POD severity scores. Results: A total of 101 subjects [69 (6) years of age] were studied; 89 had comprehensive intraoperative hemodynamic and end-tidal gas measurements (data recorded at 1 Hz). The incidence of POD was 11.9% (12/101). Age, cognitive dysfunction, anxiety, depression, and intraoperative end-tidal CO2 (AUC) were significant correlates of POD severity. In the multiple regression model, cognitive dysfunction and AUC end-tidal CO2 (0.67 kPa below median intra-operative value) were the only independent significant predictors across both POD severity (mean and peak) scores. There was no association between cumulative anesthetic agent exposure and POD. Conclusions: POD was associated with intraoperative ventilatory management, reflected by low end-tidal CO2 concentrations, but not with cumulative anesthetic drug exposure. These findings suggest that maintenance of intraoperative normocapnia might benefit patients at risk of POD.

A Novel Stress-Diathesis Model to Predict Risk of Post-operative Delirium: Implications for Intra-operative Management.

Introduction: Risk assessment for post-operative delirium (POD) is poorly developed. Improved metrics could greatly facilitate peri-operative care as costs associated with POD are staggering. In this preliminary study, we develop a novel stress-diathesis model based on comprehensive pre-operative psychiatric and neuropsychological testing, a blood oxygenation level-dependent (BOLD) magnetic resonance imaging (MRI) carbon dioxide (CO2) stress test, and high fidelity measures of intra-operative parameters that may interact facilitating POD. Methods: The study was approved by the ethics board at the University of Manitoba and registered at clinicaltrials.gov as NCT02126215. Twelve patients were studied. Pre-operative psychiatric symptom measures and neuropsychological testing preceded MRI featuring a BOLD MRI CO2 stress test whereby BOLD scans were conducted while exposing participants to a rigorously controlled CO2 stimulus. During surgery the patient had hemodynamics and end-tidal gases downloaded at 0.5 hz. Post-operatively, the presence of POD and POD severity was comprehensively assessed using the Confusion Assessment Measure -Severity (CAM-S) scoring instrument on days 0 (surgery) through post-operative day 5, and patients were followed up at least 1 month post-operatively. Results: Six of 12 patients had no evidence of POD (non-POD). Three patients had POD and 3 had clinically significant confusional states (referred as subthreshold POD; ST-POD) (score ≥ 5/19 on the CAM-S). Average severity for delirium was 1.3 in the non-POD group, 3.2 in ST-POD, and 6.1 in POD (F-statistic = 15.4, p < 0.001). Depressive symptoms, and cognitive measures of semantic fluency and executive functioning/processing speed were significantly associated with POD. Second level analysis revealed an increased inverse BOLD responsiveness to CO2 pre-operatively in ST-POD and marked increase in the POD groups when compared to the non-POD group. An association was also noted for the patient population to manifest leucoaraiosis as assessed with advanced neuroimaging techniques. Results provide preliminary support for the interacting of diatheses (vulnerabilities) and intra-operative stressors on the POD phenotype. Conclusions: The stress-diathesis model has the potential to aid in risk assessment for POD. Based on these initial findings, we make some recommendations for intra-operative management for patients at risk of POD.