Systematic review of pain medicine content, teaching, and assessment in medical school curricula internationally

Introduction: Pain management is a major health care challenge in terms of the significant prevalence of pain and the negative consequences of poor management. Consequently, there have been international calls to improve pain medicine education for medical students. This systematic review examines the literature on pain medicine education at medical schools internationally, with a particular interest in studies that make reference to: a defined pain medicine curriculum, specific pain medicine learning objectives, dedicated pain education modules, core pain topics, medical specialties that teach pain medicine, elective study opportunities, hours allocated to teaching pain medicine during the curriculum, the status of pain medicine in the curriculum (compulsory or optional), as well as teaching, learning, and assessment methods. Methods: A systematic review was undertaken of relevant studies on pain medicine education for medical students published between January 1987 and May 2018 using PubMed, Medline, Excerpta Medica database (EMBASE), Education Resources Information Center (ERIC), and Google Scholar, and Best Evidence Medical Education (BEME) data bases. Results: Fourteen studies met the inclusion criteria. Evaluation of pain medicine curricula has been undertaken at 383 medical schools in Australia, New Zealand, the United States of America (USA), Canada, the United Kingdom (UK), and Europe. Pain medicine was mostly incorporated into medical courses such as anaesthesia or pharmacology, rather than presented as a dedicated pain medicine module. Ninety-six percent of medical schools in the UK and USA, and nearly 80% of medical schools in Europe had no compulsory dedicated teaching in pain medicine. On average, the median number of hours of pain content in the entire curriculum was 20 in Canada (2009), 20 in Australia and New Zealand (2018), 13 in the UK (2011), 12 in Europe (2012/2013), and 11 in the USA (2009). Neurophysiology and pharmacology pain topics were given priority by medical schools in all countries. Lectures, seminars, and case-based instruction were the teaching methods most commonly employed. When it was undertaken, medical schools mostly assessed student competency in pain medicine using written examinations rather than clinical assessments. Conclusions: This systematic review has revealed that pain medicine education at medical schools internationally does not adequately respond to societal needs in terms of the prevalence and public health impact of inadequately managed pain

Pain medicine content, teaching and assessment in medical school curricula in Australia and New Zealand

Background: The objective of pain medicine education is to provide medical students with opportunities to develop their knowledge, skills and professional attitudes that will lead to their becoming safe, capable, and compassionate medical practitioners who are able to meet the healthcare needs of persons in pain. This study was undertaken to identify and describe the delivery of pain medicine education at medical schools in Australia and New Zealand. Method: All 23 medical schools in Australia and New Zealand in 2016 were included in this study. A structured curriculum audit tool was used to obtain information on pain medicine curricula including content, delivery, teaching and assessment methods. Results: Nineteen medical schools (83%) completed the curriculum audit. Neurophysiology, clinical assessment, analgesia use and multidimensional aspects of pain medicine were covered by most medical schools. Specific learning objectives for pain medicine were not identified by 42% of medical schools. One medical school offered a dedicated pain medicine module delivered over 1 week. Pain medicine teaching was delivered at all schools by a number of different departments throughout the curriculum. Interprofessional learning (IPL) in the context of pain medicine education was not specified by any of the medical schools. The mean time allocated for pain medicine teaching over the entire medical course was just under 20 h. The objective structured clinical examination (OSCE) was used by 32% of schools to assess knowledge and skills in pain medicine. 16% of schools were unsure of whether any assessment of pain medicine education took place. Conclusion: This descriptive study provides important baseline information for pain medicine education at medical schools in Australia and New Zealand. Medical schools do not have well-documented or comprehensive pain curricula that are delivered and assessed using pedagogically-sound approaches considering the complexity of the topic, the prevalence and public health burden of pain

Torque magnetometry of perpendicular anisotropy exchange-spring heterostructures

International audienceThe field-induced magnetic configurations in a [Co/Pd]15 /TbFeCo exchange-spring system with perpendicular magnetic anisotropy are studied using torque magnetometry. The experimental results are compared to a 1D micromagnetic simulation. The good agreement between experiments and simulations allows us to deduce the evolution of the in-depth magnetic configuration as a function of the applied field orientation and amplitude. The chirality transition of the interfacial domain wall developing in the structure can also be determined with this technique

Could faults provide conduits for fluid escape? New field data in the vicinity of the Otway International Test Centre

Introduction It is well known that faults affect fluid movement within the subsurface and this can have a host of implications for the measurement, monitoring, and verification of subsurface technologies (e.g., carbon capture and storage (CCS), energy storage, geothermal energy, and radioactive waste disposal). Faults are an important control on the escape of fluids from depth (e.g., Dockrill and Shipton, 2010). It is therefore important to consider the potential effect of faults in the shallow overburden to any future CCS sites. However, there is very little data on fault architecture in shallow sediments, and consequently their effect on fluid flow is far less well understood than flow through faults at hydrocarbon reservoir depths. In early 2024, a novel field trial injection will be conducted at the CO2CRC Otway International Test Centre (OITC), located in southern Victoria, Australia (Figure 1). The injection will involve a small volume of CO2 (~10 t) being injected into the Brumbys Fault, which will be monitored using various surface and downhole monitoring techniques (Tenthorey et al., 2022), to provide data on the transport of CO2 through shallow faults. The 1.2km long Brumbys Fault is hosted in the Miocene Port Campbell Limestone (PCL) carbonate sequence that outcrops across southern Victoria, with varying thickness from ~30m to 270m (Radke et al., 2022). Brumbys Fault has been interpreted as a strike-slip fault, due to its near-vertical dip (~80°), small throw (2-4m), and favorable orientation to the present-day stress (~30° from the maximum horizontal stress) (Feitz et al., 2018). However, there are no convincing surface markers indicating horizontal displacement. To reduce the uncertainty regarding the fault kinematics, we attempt to reconcile the styles of faulting observed in nearby field exposures with the observations made at the OITC boreholes. Method The Port Campbell Limestone is exposed in coastal cliffs, from Childers Cove in the west (38.489101, 142.672736) to Gibson Beach in the east (-38.674070, 143.117769) and inland in Kurdeez quarry (Figure 1). Access to the cliff faces is limited due to the lack of access points and tides, precluding the collection of detailed field data therefore most field observations were made from adjacent cliffs and tourist lookout spots where available. Results Reverse faulting (1-2m throw) was observed along coastal outcrops (Figure 2) in the eastern portion of field area: outcrops examined west of Port Campbell did not exhibit any faulting. Reverse features had a strike ~50-60°, which is consistent with the maximum horizontal stress direction (~142°). There is some evidence of large vertical fractures (10s m vertical extent) that could be associated with strike slip movement, but horizontal offset could not be seen in cliff and quarry outcrops due to limitations is 3D accessibility of features. These features had a strike of either ~105-110° or ~170-175°. Smaller, more localized vertical and sub-vertical fractures striking ~175° are confined to individual layers within the PCL, highlighting the variation in mechanical properties within different sections of the PCL sequence. At Kurdeez quarry, the PCL is significantly less consolidated compared to the coastal outcrops, which is similar to the rock core retrieved from the Brumbys-1, 2 and 3 wells. Spatial variations in diagenetic or depositional history have influenced the mechanical properties of the PCL and may in turn have influenced the fault formation. Conclusions There is a spatial variation in the location and type of faulting in the study area: eastern coastal areas host reverse faulting, whereas western coastal areas and inland areas lack evidence of reverse faulting and are unconsolidated. The PCL is much thicker to the west and north (where it reaches its maximum thickness of ~270m thick), which may explain this spatial variation in deformation style. Further work on the interpretation and characterisation of Brumbys Fault will be necessary before any injection experiment to ensure the fault geometry and fluid flow implications are fully understood

Cargo-Towing Fuel-Free Magnetic Nanoswimmers for Targeted Drug Delivery

Fuel-free nanomotors are essential for future in-vivo biomedical transport and drug-delivery applications. Herein, the first example of directed delivery of drug-loaded magnetic polymeric particles using magnetically driven flexible nanoswimmers is described. It is demonstrated that flexible magnetic nickel–silver nanoswimmers (5–6 μm in length and 200 nm in diameter) are able to transport micrometer particles at high speeds of more than 10 μm s−1 (more than 0.2 body lengths per revolution in dimensionless speed). The fundamental mechanism of the cargo-towing ability of these magnetic (fuel-free) nanowire motors is modelled, and the hydrodynamic features of these cargo-loaded motors discussed. The effect of the cargo size on swimming performance is evaluated experimentally and compared to a theoretical model, emphasizing the interplay between hydrodynamic drag forces and boundary actuation. The latter leads to an unusual increase of the propulsion speed at an intermediate particle size. Potential applications of these cargo-towing nanoswimmers are demonstrated by using the directed delivery of drug-loaded microparticles to HeLa cancer cells in biological media. Transport of the drug carriers through a microchannel from the pick-up zone to the release microwell is further illustrated. It is expected that magnetically driven nanoswimmers will provide a new approach for the rapid delivery of target-specific drug carriers to predetermined destinations

Liver Enzyme Abnormalities and Associated Risk Factors in HIV Patients on Efavirenz-Based HAART with or without Tuberculosis Co-Infection in Tanzania.

To investigate the timing, incidence, clinical presentation, pharmacokinetics and pharmacogenetic predictors for antiretroviral and anti-tuberculosis drug induced liver injury (DILI) in HIV patients with or without TB co-infection. A total of 473 treatment naïve HIV patients (253 HIV only and 220 with HIV-TB co-infection) were enrolled prospectively. Plasma efavirenz concentration and CYP2B6*6, CYP3A5*3, *6 and *7, ABCB1 3435C/T and SLCO1B1 genotypes were determined. Demographic, clinical and laboratory data were collected at baseline and up to 48 weeks of antiretroviral therapy. DILI case definition was according to Council for International Organizations of Medical Sciences (CIOMS). Incidence of DILI and identification of predictors was evaluated using Cox Proportional Hazards Model. The overall incidence of DILI was 7.8% (8.3 per 1000 person-week), being non-significantly higher among patients receiving concomitant anti-TB and HAART (10.0%, 10.7 per 1000 person-week) than those receiving HAART alone (5.9%, 6.3 per 1000 person-week). Frequency of CYP2B6*6 allele (p = 0.03) and CYP2B6*6/*6 genotype (p = 0.06) was significantly higher in patients with DILI than those without. Multivariate cox regression model indicated that CYP2B6*6/*6 genotype and anti-HCV IgG antibody positive as significant predictors of DILI. Median time to DILI was 2 weeks after HAART initiation and no DILI onset was observed after 12 weeks. No severe DILI was seen and the gain in CD4 was similar in patients with or without DILI. Antiretroviral and anti-tuberculosis DILI does occur in our setting, presenting early following HAART initiation. DILI seen is mild, transient and may not require treatment interruption. There is good tolerance to HAART and anti-TB with similar immunological outcomes. Genetic make-up mainly CYP2B6 genotype influences the development of efavirenz based HAART liver injury in Tanzanians

Canadian physiotherapists' views on certification, specialisation, extended role practice, and entry-level training in rheumatology

<p>Abstract</p> <p>Background</p> <p>Since the last decade there has been a gradual change of boundaries of health professions in providing arthritis care. In Canada, some facilities have begun to adopt new arthritis care models, some of which involve physiotherapists (PT) working in extended roles. However, little is known about PTs' interests in these new roles. The primary objective of this survey was to determine the interests among orthopaedic physiotherapists (PTs) in being a certified arthritis therapist, a PT specialized in arthritis, or an extended scope practitioner in rheumatology, and to explore the associated factors, including the coverage of arthritis content in the entry-level physiotherapy training.</p> <p>Methods</p> <p>Six hundred PTs practicing in orthopaedics in Canada were randomly selected to receive a postal survey. The questionnaire covered areas related to clinical practice, perceptions of rheumatology training received, and attitudes toward PT roles in arthritis care. Logistic regression models were developed to explore the associations between PTs' interests in pursuing each of the three extended scope practice designations and the personal/professional/attitudinal variables.</p> <p>Results</p> <p>We received 286 questionnaires (response rate = 47.7%); 258 contained usable data. The average length of time in practice was 15.4 years (SD = 10.4). About 1 in 4 PTs agreed that they were interested in assuming advanced practice roles (being a certified arthritis therapist = 28.9%, being a PT specialized in rheumatology = 23.3%, being a PT practitioner = 20.9%). Having a caseload of ≥ 40% in arthritis, having a positive attitude toward advanced practice roles in arthritis care and toward the formal credentialing process, and recognizing the difference between certification and specialisation were associated with an interest in pursing advanced practice roles.</p> <p>Conclusion</p> <p>Orthopaedic PTs in Canada indicated a fair level of interest in pursuing certification, specialisation and extended scope practice roles in arthritis care. Future research should focus on the effectiveness and cost-effectiveness of the emerging health service delivery models involving certified, specialized or extended scope practice PTs in the management of arthritis.</p

Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

Background: Approximately 450 000 children are born with familial hypercholesterolaemia worldwide every year, yet only 2·1% of adults with familial hypercholesterolaemia were diagnosed before age 18 years via current diagnostic approaches, which are derived from observations in adults. We aimed to characterise children and adolescents with heterozygous familial hypercholesterolaemia (HeFH) and understand current approaches to the identification and management of familial hypercholesterolaemia to inform future public health strategies. Methods: For this cross-sectional study, we assessed children and adolescents younger than 18 years with a clinical or genetic diagnosis of HeFH at the time of entry into the Familial Hypercholesterolaemia Studies Collaboration (FHSC) registry between Oct 1, 2015, and Jan 31, 2021. Data in the registry were collected from 55 regional or national registries in 48 countries. Diagnoses relying on self-reported history of familial hypercholesterolaemia and suspected secondary hypercholesterolaemia were excluded from the registry; people with untreated LDL cholesterol (LDL-C) of at least 13·0 mmol/L were excluded from this study. Data were assessed overall and by WHO region, World Bank country income status, age, diagnostic criteria, and index-case status. The main outcome of this study was to assess current identification and management of children and adolescents with familial hypercholesterolaemia. Findings: Of 63 093 individuals in the FHSC registry, 11 848 (18·8%) were children or adolescents younger than 18 years with HeFH and were included in this study; 5756 (50·2%) of 11 476 included individuals were female and 5720 (49·8%) were male. Sex data were missing for 372 (3·1%) of 11 848 individuals. Median age at registry entry was 9·6 years (IQR 5·8-13·2). 10 099 (89·9%) of 11 235 included individuals had a final genetically confirmed diagnosis of familial hypercholesterolaemia and 1136 (10·1%) had a clinical diagnosis. Genetically confirmed diagnosis data or clinical diagnosis data were missing for 613 (5·2%) of 11 848 individuals. Genetic diagnosis was more common in children and adolescents from high-income countries (9427 [92·4%] of 10 202) than in children and adolescents from non-high-income countries (199 [48·0%] of 415). 3414 (31·6%) of 10 804 children or adolescents were index cases. Familial-hypercholesterolaemia-related physical signs, cardiovascular risk factors, and cardiovascular disease were uncommon, but were more common in non-high-income countries. 7557 (72·4%) of 10 428 included children or adolescents were not taking lipid-lowering medication (LLM) and had a median LDL-C of 5·00 mmol/L (IQR 4·05-6·08). Compared with genetic diagnosis, the use of unadapted clinical criteria intended for use in adults and reliant on more extreme phenotypes could result in 50-75% of children and adolescents with familial hypercholesterolaemia not being identified. Interpretation: Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life

The Pain Medicine Curriculum Framework-structured integration of pain medicine education into the medical curriculum

Medical practitioners play an essential role in preventing pain, conducting comprehensive pain assessments, as well as promoting evidence-based practices. There is a need for the development of innovative, interprofessional and integrated pain medicine curricula for medical students. The Pain Medicine Curriculum Framework (PMCF) was developed to conceptualise a purposeful approach to the complex process of curriculum change and to prioritise the actions needed to address the gaps in pain medicine education. The PMCF comprises four dimensions: (1) future healthcare practice needs; (2) competencies and capabilities required of graduates; (3) teaching, learning and assessment methods; and (4) institutional parameters. Curricula need to meet the requirements of registration and accreditation bodies, but also equip graduates to serve in their particular local health system while maintaining the fundamental standards and values of these institutions. The curriculum needs to connect knowledge with experience and practice to be responsive to the changing needs of the increasingly complex health system yet adaptable to patients with pain in the local context. Appropriate learning, teaching and assessment strategies are necessary to ensure that medical practitioners of the future develop the required knowledge, skills and attitudes to treat the diverse needs of patients\u27 experiencing pain. The historical, political, social and organisational values of the educational institution will have a significant impact on curriculum design. A more formalised approach to the development and delivery of a comprehensive pain medicine curriculum is necessary to ensure that medical students are adequately prepared for their future workplace responsibilities