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1.  Diet, lifestyle and chronic widespread pain: Results from the 1958 British Birth Cohort Study 
To examine the relationship between diet and lifestyle, and chronic widespread pain (CWP). If persons with CWP have dietary and lifestyle habits consistent with an increased risk of cancer or cardiovascular disease, it may partially explain evidence in the literature suggesting an association between CWP and these diseases.
The 1958 British Birth Cohort Study comprises individuals born in England, Scotland and Wales in the United Kingdom during one week in March 1958. At 45 years of age, pain was recorded using a self-completion questionnaire. CWP was classified using the American College of Rheumatology definition for fibromyalgia. Data were collected on diet and lifestyle at 33 and 42 years of age.
A total of 8572 participants provided pain data at 45 years of age, of whom 12% reported CWP. Women with CWP, compared with those without, reported an unhealthy diet (ie, fruit/vegetable consumption less than once per week [OR 2.0; 95% CI 1.3 to 3.1], and fatty food [OR 1.7; 95% CI 1.1 to 2.7] and chips (french fries) [OR 1.5; 95% CI 1.0 to 2.4] at least once per day) that may have predisposed them to other chronic diseases such as cancer and cardiovascular disease. Women with CWP were also more likely to be unemployed (adjusted OR 1.4; 95% CI 1.1 to 1.8), to have had high physical exertion at work (adjusted OR 1.6; 95% CI 1.2 to 2.2) and elevated body mass index (overweight – adjusted OR 1.5, 95% CI 1.2 to 1.9; obese – adjusted OR 1.8, 95% CI 1.3 to 2.5). Similar relationships between lifestyle (but not diet) and the risk of CWP were identified in men.
The findings for smoking, body mass index and (for women) diet offer support for the hypothesis that lifestyle factors may partially explain the association between CWP and cancer or cardiovascular disease. Prospective studies are necessary to confirm this relationship.
PMCID: PMC3084409  PMID: 21499583
1958 British Birth Cohort; Cancer; Cardiovascular disease; Chronic widespread pain; Diet; Lifestyle; Physical activity
2.  Pain, health-related quality of life and health care utilization after inpatient surgery: A pilot study 
Little is known about pain-related outcomes in surgical inpatients after discharge from the hospital. An ongoing risk and outcomes monitoring system would provide valuable feedback to improve the quality of patient care.
The purpose of the present pilot study was to describe postoperative pain, medication use, health care utilization and health-related quality of life (HRQOL) immediately and four weeks after surgery; merge clinically captured data with Web-based follow-up data; and examine patients’ willingness to complete Web-based health questionnaires.
One hundred two consecutive surgical inpatients were approached for participation. Perioperative data were abstracted from the acute pain management service clinical database and linked to follow-up data captured four weeks postoperatively.
Follow-up questionnaires were completed by 88 participants. Clinical assessment data were successfully linked to Web-based follow-up data. Average pain intensity (3.7) four weeks following discharge fell just short of the acute pain management service active pain score of 3.9. At four weeks, all 88 participants reported significantly impaired HRQOL, 36 were still taking pain medications and 15 had visited an emergency room. Two-thirds of the participants had access to the Internet at home and approximately one-half were willing to complete on-line health questionnaires.
The study indicates that it is feasible to link clinical and research data, and shows a significant burden of pain and reduced HRQOL in the weeks following discharge. This approach to converting clinically captured data into meaningful information about surgical outcomes is valuable in the development of an ongoing risk and outcomes monitoring system.
PMCID: PMC2585033  PMID: 16511613
Canada; Computerized health data; Health care utilization; Health-related quality of life; Postoperative pain; Prospective study
3.  The epidemiology of chronic pain in Canadian men and women between 1994 and 2007: Results from the longitudinal component of the National Population Health Survey 
The epidemiology of chronic pain is poorly understood due to a paucity of longitudinal studies limiting the ability to develop prevention strategies for a condition resistant to many current therapies.
To identify the incidence of and sociodemographic risk factors for chronic pain in Canadian women and men over a 12-year period.
Using data from the National Population Health Survey, individuals who developed chronic pain, defined as the presence of “usual pain” were identified. The cumulative incidence of chronic pain was calculated separately for men and women followed from 1994 to 2007. Biannual incidence and prevalence estimates of chronic pain were calculated during the same time period. Logistic regression analysis was used to examine predictors of chronic pain in men and women.
The cumulative incidence over the 12-year period was 35.6% (women 39.0%; men 32.2%). Women had a higher biannual prevalence, but not incidence, of chronic pain compared with men. In women, being older, having lower education and being widowed, separated or divorced, increased the risk of chronic pain. There were no sociodemographic risk factors for chronic pain in men.
Women had a higher prevalence – but not incidence – of chronic pain compared with men, indicative of longer duration of illness in women. Risk factors also differed according to sex, supporting current literature reporting potentially different mechanisms for men and women. A better understanding of risk factors is necessary to develop population-based preventive interventions. The former can only be achieved with population-based, longitudinal studies.
PMCID: PMC3401087  PMID: 22606681
Chronic pain; General population; Incidence; Predictors; Sociodemographic factors
4.  Leg ulcer nursing care in the community: a prospective cohort study of the symptom of pain 
BMC Nursing  2013;12:3.
Chronic wounds are managed almost entirely by community nurses. Almost all individuals with leg ulcers report acute pain usually related to dressing change. Little is known about pain after healing. The purpose of this study was to explore the course of pain from baseline to time of healing of leg ulcers (venous or mixed etiology). In order to understand this phenomenon and develop implications for nursing practice, objectives included: 1) Measure incidence and prevalence of pain at baseline and healing; 2) Describe characteristics associated with leg ulcer pain at baseline; 3) Identify predictors of leg ulcer pain at healing.
Data were from one randomized controlled trial (2004-2008) of 424 individuals with leg ulcers in the community receiving evidence-informed nursing management. The primary outcome was pain at the time of healing. Predictive factors included demographic, circumstance of living, clinical and ulcer characteristics. Multivariable logistic regression identified the subset of predictors of pain at healing. Odds ratios (OR) and 95% confidence intervals (CI) are reported.
Eighty-two percent of participants reported pain at baseline and 32% at healing. Five percent with no pain at baseline reported pain at healing. Thirty-seven percent reported moderate to severe pain at baseline and 11% at healing. Twenty percent of all those who healed reported pain interfered with work moderately to extremely at time of healing. Being female (OR=1.64, 95% CI 1.00, 2.68, p=0.05), use of short-stretch vs. four-layer bandages (OR=1.73, 95% CI 1.06, 2.82, p=0.03), lower SF-12 PCS (OR=0.97, 95% CI 0.94, 0.99, p=0.02) and MCS (OR=0.98, 95% CI 0.95-1.00, p=0.04) scores, use of non-steroidal anti-inflammatory drugs (OR=2.28, 95% CI 1.06, 4.88, p=0.03), and tender pain (OR=2.17, 95% CI 1.29, 3.66, p=<0.01) were associated with pain at time of healing.
Pain is an issue on admission for chronic wounds and at healing, yet 58% with moderate to severe pain on admission were not taking pain medication(s). Future studies should examine the role of pain at healing and at subsequent ulcer recurrence. Mobility and other factors that may contribute to pain at time of healing should also be assessed. Community nurses are encouraged to consider pain when planning care on admission and also after wound healing, when most patients are discharged from care.
Trial registration, NCT00202267
PMCID: PMC3598712  PMID: 23388350
Pain; Health-related quality of life; Chronic conditions; Leg ulcers; Community care nursing; Longitudinal study, Canada
5.  Gender Differences in the Influence of Social Support on One-Year Changes in Functional Status in Older Patients with Heart Failure 
The purpose of this study was to determine the combined effects of gender and levels of social support on 1-year functional health outcomes in older persons diagnosed with heart failure (HF). Persons ≥ 65 years of age with an acute HF exacerbation (164 females; 271 males) were enrolled and followed for a year. Participants completed baseline and 12-month questionnaires containing clinical and demographic descriptive information and validated self-report measures of: (1) physical functioning (Medical Outcome Study [MOS] SF12 and Kansas City Cardiomyopathy Questionnaire [KCCQ]) and (2) social support (MOS- Social Support Survey). Women were more likely to be single, widowed or divorced, living alone and earning less annual income. At baseline, women reported significantly lower support and physical function scores. However, at 1 year there were no significant gender differences in the proportion of men or women who experienced clinically meaningful functional decline or death across the year of follow-up. In multivariable modeling, men with lower levels of social support were more likely to experience functional decline. This was not the case for women. Our findings suggest that gender-directed strategies to promote optimization of function for both men and women living with HF in their community are warranted.
PMCID: PMC3432365  PMID: 22957296
6.  Additional Support for Simple Imputation of Missing Quality of Life Data in Nursing Research 
ISRN Nursing  2011;2011:752320.
Background. Missing data are a significant problem in health-related quality of life (HRQOL) research. We evaluated two imputation approaches: missing data estimation (MDE) and assignment of mean score (AMS). Methods. HRQOL data were collected using the Medical Outcomes Trust SF-12. Missing data were estimated using both approaches, summary statistics were produced for both, and results were compared using intraclass correlations (ICC). Results. Missing data were imputed for 21 participants. Mean values were similar, with ICC >.99 within both the Physical Component Summary and the Mental Component Summary when comparing the two methodologies. When imputed data were added into the full study sample, mean scores were identical regardless of methodology. Conclusion. Results support the use of a practical and simple imputation strategy of replacing missing values with the mean of the sample in cross-sectional studies when less than half of the required items of the SF-12 components are missing.
PMCID: PMC3236396  PMID: 22191054
7.  The Canadian Bandaging Trial: Evidence-informed leg ulcer care and the effectiveness of two compression technologies 
BMC Nursing  2011;10:20.
Objective: To determine the relative effectiveness of evidence-informed practice using two high compression systems: four-layer (4LB) and short-stretch bandaging (SSB) in community care of venous leg ulcers. Design and Setting: Pragmatic, multi-centre, parallel-group, open-label, randomized controlled trial conducted in 10 centres. Cognitively intact adults (≥18 years) referred for community care (home or clinic) with a venous ulceration measuring ≥0.7cm and present for ≥1 week, with an ankle brachial pressure index (ABPI) ≥0.8, without medication-controlled Diabetes Mellitus or a previous failure to improve with either system, were eligible to participate.
Consenting individuals were randomly allocated (computer-generated blocked randomization schedule) to receive either 4LB or SSB following an evidence-informed protocol. Primary endpoint: time-to- healing of the reference ulcer. Secondary outcomes: recurrence rates, health-related quality of life (HRQL), pain, and expenditures.
424 individuals were randomized (4LB n = 215; SSB n = 209) and followed until their reference ulcer was healed (or maximum 30 months). An intent-to-treat analysis was conducted on all participants. Median time to ulcer healing in the 4LB group was 62 days [95% confidence interval (CI) 51 to 73], compared with 77 days (95% CI 63 to 91) in the SSB group. The unadjusted Kaplan-Meier curves revealed the difference in the distribution of cumulative healing times was not significantly different between group (log rank χ2 = 0.001, P = 0.98) nor ulcers recurrence (4LB, 10.1%; SSB, 13.3%; p = 0.345). Multivariable Cox Proportional Hazard Modeling also showed no significant between-bandage differences in healing time after controlling for significant covariates (p = 0.77). At 3-months post-baseline there were no differences in pain (no pain: 4LB, 22.7%; SSB, 26.7%; p = 0.335), or HRQL (SF-12 Mental Component Score: 4LB, 55.1; SSB, 55.8; p = 0.615; SF-12 Physical Component Score: 4LB, 39.0; SSB, 39.6; p = 0.675). The most common adverse events experienced by both groups included infection, skin breakdown and ulcer deterioration.
The Canadian Bandaging Trial revealed that in the practice context of trained RNs using an evidence-informed protocol, the choice of bandage system (4LB and SSB) does not materially affect healing times, recurrence rates, HRQL, or pain. From a community practice perspective, this is positive news for patient-centred care allowing individual/family and practitioner choice in selecting compression technologies based on circumstances and context.
Trial registration Identifier: NCT00202267
PMCID: PMC3214126  PMID: 21995267
8.  Pain prevalence in nine- to 13-year-old school children 
Despite significant progress in the epidemiology of chronic pain in adults, major gaps remain in our understanding of the epidemiology of chronic pain in children. In particular, the incidence, prevalence and sensory characteristics of many types of pain in Canadian children are unknown.
A study to obtain the lifetime and point prevalence of common acute pains, recurrent pain syndromes and chronic pains was conducted in a cohort of 495 school children, nine to 13 years of age, in eastern Ontario.
Children reported their pain experiences and described the intensity, affect and duration of the pains experienced over the previous month by completing the Pain Experience Interview –Short Form.
The majority of children (96%) experienced some acute pain over the previous month, with headache (78%) being most frequently reported. Lifetime prevalence for certain acute pains differed significantly by sex (P<0.05). Fifty-seven per cent of children reported experiencing at least one recurrent pain, while 6% were identified as having had or currently having chronic pain.
The prevalence of acute pain in this Canadian cohort is consistent with international estimates of acute pain experiences (ie, headache) and recurrent pain problems (ie, recurring headache, abdominal pain and growing pains). However, 6% of children reported chronic pain. The self-completed Pain Experience Interview – Short Form provides a feasible administration technique for obtaining population estimates of childhood pain, and for conducting longitudinal studies to identify risk and prognostic factors for chronic pain.
PMCID: PMC2673140  PMID: 17149456
Children; Chronic pain; Cross-sectional study; Epidemiological study; Pain experience interview; Pain prevalence; Recurrent pain
9.  Prevalence and determinants of pain and pain-related disability in urban and rural settings in southeastern Ontario 
Canadian chronic pain prevalence estimates range from 11% to 66%, are affected by sampling and measurement bias, and largely represent urban settings.
To estimate chronic pain prevalence and factors associated with pain in southeastern Ontario, a region with a larger rural than urban residence.
A systematic sampling with a random start was used to contact households. A telephone-administered questionnaire using the Graded Chronic Pain Scale, with questions on health care and medication use, health status, depression and demographics, was administered to consenting adults (18 to 94 years of age; mean age 50.2±16.6 years).
The response rate was 49% (1067 of 2167), with 76% reporting some pain over the past six months. Low pain intensity with low pain interference prevalence was 34% (grade I), high pain intensity with low pain interference was 26% (grade II), and high pain intensity with high pain interference was 17% (grades III and IV). Of those reporting pain, 49% reported chronic pain (ie, pain for a minimum of 90 days over the past six months) representing 37% of the sample. Being female, unmarried, lower income, poorer self-reported health status and rural residence were associated with increasing pain. Once depression was considered in this pain analysis, residence was no longer significant. Lower rates of health care utilization were reported by rural residents. In those reporting the highest pain grades, poor health, greater medication and health care use, depression and more pain sites were associated with higher odds for pain-related disability.
There is an elevated prevalence of pain in this almost equally split rural/urban region. Further examination of health care utilization and depression is suggested in chronic pain prevalence research.
PMCID: PMC2673139  PMID: 17149455
Chronic pain prevalence; Depression; Health care utilization; Rural Canada
11.  Self-reported patient safety competence among Canadian medical students and postgraduate trainees: a cross-sectional survey 
BMJ Quality & Safety  2015;24(2):135-141.
Quality and patient safety (PS) are critical components of medical education. This study reports on the self-reported PS competence of medical students and postgraduate trainees.
The Health Professional Education in Patient Safety Survey was administered to medical students and postgraduate trainees in January 2012. PS dimension scores were compared across learning settings (classroom and clinical) and year in programme.
Sixty-three percent (255/406) of medical students and 32% (141/436) of postgraduate trainees responded. In general, both groups were most confident in their learning of clinical safety skills (eg, hand hygiene) and least confident in learning about sociocultural aspects of safety (eg, understanding human factors). Medical students’ confidence in most aspects of safety improved with years of training. For some of the more intangible dimensions (teamwork and culture), medical students in their final year had lower scores than students in earlier years. Thirty-eight percent of medical students felt they could approach someone engaging in unsafe practice, and the majority of medical students (85%) and postgraduate trainees (78%) agreed it was difficult to question authority.
Our results suggest the need to improve the overall content, structure and integration of PS concepts in both classroom and clinical learning environments. Decreased confidence in sociocultural aspects of PS among medical students in the final year of training may indicate that culture in clinical settings negatively affects students’ perceived PS competence. Alternatively, as medical students spend more time in the clinical setting, they may develop a clearer sense of what they do not know.
PMCID: PMC4316835  PMID: 25605953
Patient safety; Medical education; Health professions education; Graduate medical education

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