Differences in Swedish and Australian medical student attitudes and beliefs about chronic pain, its management, and the way it is taught

Background and aims: Medical students receive training in the management of chronic pain, but the training is often suboptimal. Considering that the basis for physician’s knowledge is their medical education, it is important to explore the attitudes and beliefs of medical students with respect both to chronic pain management and to their views on current pain education. Therefore, the aim of this study was to compare Swedish and Australian medical student’s attitudes and beliefs about patients with chronic pain, and their perceptions regarding their chronic pain management education. Methods: An online survey was conducted with final year Australian and Swedish medical students from two different universities between December 2016 and February 2017. Attitudes and beliefs towards chronic pain patients were measured using the Health Care Providers’ Pain and Impairment Scale (HC-PAIRS). A thematic analysis was conducted on open end questions regarding their views on their education and important skills for chronic pain management. Results: A total of 57 Swedish and 26 Australian medical students completed the HC-PAIRS scale. The Swedish medical students showed statistically significantly lower total mean HC-PAIRS scores compared to Australian medical students (46 and 51, respectively). Australian students had statistically significantly higher scores than the Swedish students for two of four factors: functional expectations and need for cure, whereas no significant differences were seen for the factors social expectations or for projected cognition. From the open end questions it was evident that final year medical students are knowledgeable about key chronic pain items described in clinical guidelines. However, both cohorts described their chronic pain training as poor and in need of improvement in several areas such as more focus on the biopsychosocial model, working in multidisciplinary teams, seeing chronic pain patients and pharmacological training. Conclusions: Attitudes and beliefs are formed during medical education, and our study exploring attitudes of medical students towards chronic pain and how it is taught have provided valuable information. Our survey provided detailed and cohesive suggestions for education improvement that also are in line with current clinical guidelines. This study indicates that the Swedish final year students have a more positive attitude towards chronic pain patients compared to their Australian counterparts. The majority of students in both cohorts perceived chronic pain management education in need of improvement. Implications: This study highlights several areas of interest that warrant further investigation, for example, the impact of a changed medical curriculum in alignment with these clinical guidelines requested by students in this survey, and correspondingly if their attitudes towards chronic pain patients can be improved through education. Further, we conclude that it would be valuable to align the implementation of the HC-PAIRS instrument in order to achieve comparable results between future studies

Links between traumatic brain injury and ballistic pressure waves originating in the thoracic cavity and extremities

Identifying patients at risk of traumatic brain injury (TBI) is important because research suggests prophylactic treatments to reduce risk of long-term sequelae. Blast pressure waves can cause TBI without penetrating wounds or blunt force trauma. Similarly, bullet impacts distant from the brain can produce pressure waves sufficient to cause mild to moderate TBI. The fluid percussion model of TBI shows that pressure impulses of 15-30 psi cause mild to moderate TBI in laboratory animals. In pigs and dogs, bullet impacts to the thigh produce pressure waves in the brain of 18-45 psi and measurable injury to neurons and neuroglia. Analyses of research in goats and epidemiological data from shooting events involving humans show high correlations (r > 0.9) between rapid incapacitation and pressure wave magnitude in the thoracic cavity. A case study has documented epilepsy resulting from a pressure wave without the bullet directly hitting the brain. Taken together, these results support the hypothesis that bullet impacts distant from the brain produce pressure waves that travel to the brain and can retain sufficient magnitude to induce brain injury. The link to long-term sequelae could be investigated via epidemiological studies of patients who were gunshot in the chest to determine whether they experience elevated rates of epilepsy and other neurological sequelae

The Temporal Development of Fatty Infiltrates in the Neck Muscles Following Whiplash Injury: An Association with Pain and Posttraumatic Stress

Radiological findings associated with poor recovery following whiplash injury remain elusive. Muscle fatty infiltrates (MFI) in the cervical extensors on magnetic resonance imaging (MRI) in patients with chronic pain have been observed. Their association with specific aspects of pain and psychological factors have yet to be explored longitudinally.44 subjects with whiplash injury were enrolled at 4 weeks post-injury and classified at 6 months using scores on the Neck Disability Index as recovered, mild and moderate/severe. A measure for MFI and patient self-report of pain, loss of cervical range of movement and posttraumatic stress disorder (PTSD) were collected at 4 weeks, 3 months and 6 months post-injury. The effects of time and group and the interaction of time by group on MFI were determined. We assessed the mediating effect of posttraumatic stress and cervical range of movement on the longitudinal relationship between initial pain intensity and MFI. There was no difference in MFI across all groups at enrollment. MFI values increased in the moderate/severe group and were significantly higher in comparison to the recovered and mild groups at 3 and 6 months. No differences in MFI values were found between the mild and recovered groups. Initial severity of PTSD symptoms mediated the relationship between pain intensity and MFI at 6 months. Initial ROM loss did not.MFI in the cervical extensors occur soon following whiplash injury and suggest the possibility for the occurrence of a more severe injury with subsequent PTSD in patients with persistent symptoms

Summary and way forward.

In Nagothu, U. S.; Gosain, A. K.; Palanisami, Kuppannan (Eds.). Water and climate change: an integrated approach to address adaptation challenges. New Delhi, India: Macmilla

Regional variations in diffuse nitrogen losses from agriculture in the Nordic and Baltic regions

This paper describes nitrogen losses from, and the characteristics of. 35 selected catchments (112 to 2000 ha) in the Nordic and Baltic countries. Average annual losses of N in 1994-1997 ranged from 5 to 75 kg ha(-1). Generally, the lowest losses were observed in the Baltic countries and the highest in Norway. The N losses were also characterised by significant within-country and interannual variations, particularly in the Norwegian catchments. An important finding of the study is that the average nutrient losses varied greatly among the catchments studied. The main explanations for this variability were water runoff, fertiliser use (especially the amount of manure), soil type and erosion (including stream bank erosion). However, there were several exceptions, and it was difficult to find general relationships between the individual factors. For example, there was poor correlation between nitrogen losses and surpluses. Therefore, the results suggest that the observed variability in N losses cannot have been due solely to differences in farm management practices, although the studied catchments do include a wide range of nutrient application levels, animal densities and other relevant elements. There is considerable spatial variation in the physical properties (soil. climate, hydrology, and topography) and the agricultural management of the basins, and the interaction between and relative effects of these factors has an important impact on erosion and nutrient losses. In particular, hydrological processes may have a marked effect on N losses measured in the catchment stream water. The results indicate that significant differences in hydrological pathways (e.g. the relationship between fast- and slow-flow processes) lead to major regional differences in N inputs to surface waters and therefore also in the response to changes in field management practices. Agricultural practices such as crop rotation systems, nutrient inputs and soil conservation measuresVytauto Didžiojo universitetasŽemės ūkio akademij

Water allocation with use of the Building Block Methodology (BBM) in the Godavari Basin, India

Access to sufficient quantities of water of acceptable quality is a basic need for human beings and a pre-requisite to sustain and develop human welfare. In cases of limited availability, the allocation of water between different sectors can result in conflicts of interests. In this study, a modified version of the Building Block Methodology (BBM) was demonstrated for allocation of waters between different sectors. The methodology is a workshop-based tool for assessing water allocation between competing sectors that requires extensive stakeholder involvement. The tool was demonstrated for allocation of water in the Sri Ram Sagar water reservoir in the Godavari Basin, Andhra Pradesh, India. In this multipurpose reservoir, water is used for irrigation, drinking water supply and hydropower production. Possible water allocation regimes were developed under present hydrological conditions (normal and dry years) and under future climate change, characterized by more rain in the rainy season, more frequent droughts in the dry season and accelerated siltation of the reservoir, thus reducing the storage capacity. The feedback from the stakeholders (mainly water managers representing the various sectors) showed that the modified version of the BBM was a practical and useful tool in water allocation, which means that it may be a viable tool for application also elsewhere