Anjana Kundu

A Review of the Experience, Epidemiology, and Management of Pain among American Indian, Alaska Native, and Aboriginal Canadian Peoples

UNLABELLED Substantial literature suggests that diverse biological, psychological, and sociocultural mechanisms account for differences by race and ethnicity in the experience, epidemiology, and management of pain. Many studies have examined differences between Whites and minority populations, but American Indians (AIs), Alaska Natives (ANs), and Aboriginal peoples of Canada have been neglected both in studies of pain and in efforts to understand its biopsychosocial and cultural determinants. This article reviews the epidemiology of pain and identifies factors that may affect clinical assessment and treatment in these populations. We searched for peer-reviewed articles focused on pain in these populations, using PubMed, CINAHL, Cochrane, and the University of New Mexico Native Health Database. We identified 28 articles published 1990 to 2009 in 3 topic areas: epidemiology of pain, pain assessment and treatment, and healthcare utilization. A key finding is that AI/ANs have a higher prevalence of pain symptoms and painful conditions than the U.S. general population. We also found evidence for problems in provider-patient interactions that affect clinical assessment of pain, as well as indications that AI/AN patients frequently use alternative modalities to manage pain. Future research should focus on pain and comorbid conditions and develop conceptual frameworks for understanding and treating pain in these populations. PERSPECTIVE We reviewed the literature on pain in AI/ANs and found a high prevalence of pain and painful conditions, along with evidence of poor patient-provider communication. We recommend further investigation of pain and comorbid conditions and development of conceptual frameworks for understanding and treating pain in this population.

Enhancing access to cancer education for rural healthcare providers via telehealth.

Healthcare providers serving rural populations face numerous barriers to accessing educational programming. Difficulties accessing continuing professional education contribute to the challenges of providing comprehensive health care in the rural setting. Telehealth can inform and educate rural providers about changes in medicine and evidence-based practices, both of which may help them provide quality care. The Native People for Cancer Control Telehealth Network used telehealth technology to deliver a cancer education series in 2008 and 2009 to Washington and Alaska rural healthcare providers who treated American Indians and Alaska Native people. Customizing presentation content to providers’ educational needs encouraged attendance. Evaluation indicated videoconferencing technology was positively received for delivery of the educational sessions. This series demonstrated videoconferencing was a satisfactory means of delivering real-time, interactive cancer educational programming to providers who might not otherwise have access to such programs.

Role of telehealth/videoconferencing in managing cancer pain in rural American Indian communities

Objectives: This project is aimed at determining the feasibility and effect of using videoconferencing to deliver cancer‐related pain management education and case consultation to health care providers in rural AI/AN communities.

Developing the Native People for Cancer Control Telehealth Network.

OBJECTIVE We aimed to develop a telehealth network to deliver postdiagnosis cancer care clinical services and education to American Indian and Alaska Native patients, their families, and their healthcare providers. We also sought to identify the challenges and opportunities of implementing such a telehealth-based application for this rural and underserved population. MATERIALS AND METHODS We followed a participatory formative evaluation approach to engage all stakeholders in the telehealth network design and implementation. This approach allowed us to identify and address technical and infrastructure barriers, lack of previous experience with telehealth, and political, legal, and historical challenges. RESULTS Between September 2006 and August 2009, nine tribal clinics in Washington and 26 clinical sites in Alaska had participated in the telehealth network activities. Network programming included cancer education presentations, case conferences, and cancer survivor support groups. Twenty-seven cancer education presentations were held, with a total provider attendance of 369. Forty-four case conferences were held, with a total of 129 cases discussed. In total, 513 patient encounters took place. Keys to success included gaining provider and community acceptance, working closely with respected tribal members, understanding tribal sovereignty and governance, and working in partnership with cultural liaisons. CONCLUSION The telehealth network exceeded expectations in terms of the number of participating sites and the number of patients served. Following a participatory formative evaluation approach contributed to the success of this telehealth network and demonstrated the importance of community involvement in all stages of telehealth system design and implementation.

Safety, Tolerability, and Short‐Term Efficacy of Intravenous Lidocaine Infusions for the Treatment of Chronic Pain in Adolescents and Young Adults: A Preliminary Report

OBJECTIVE To provide pediatric care providers with insight into lidocaine infusions for analgesia. AIM This retrospective review was conducted to describe lidocaine infusions for chronic refractory pain within the adolescent and young adult pain population. SETTING Although lidocaine infusions have been used for pain management in adults, their analgesic utility in the adolescent and young adult population is limited and so is the evidence for their efficacy and safety. METHODS After Institutional Board Review approval, a retrospective review of efficacy and safety data for analgesic use of lidocaine was conducted. RESULTS Fifteen patients received 58 infusions with 76% receiving relief where maximum relief was seen among patients with starting pain scores ≥6/10 (mean reduction 2.3 vs. 0.5, P value = 0.006) and when a patient had three or more infusions (mean reduction 1.7 compared with 1.2). No serious side effects were encountered, but only mild or moderate side effects that did not require any intervention. Incidence of tingling or numbness and nausea or vomiting seemed to correlate with total dose of lidocaine per kilogram body weight. Patients reported reduced pain scores (6.3 ± 2.3 to 4.6 ± 2.5 before compared with after the infusion [as mean ± standard deviation]) during 80% of infusions. CONCLUSIONS Our limited experience suggests that lidocaine infusions are well tolerated in the adolescent and young adult pain population, with side effects resolving quickly with interruption or discontinuation of the infusion if necessary. Future studies are warranted to examine safety, efficacy, mechanism of actions, and its long-term impact on a developing central nervous system.

Attitudes, Patterns of Recommendation, and Communication of Pediatric Providers About Complementary and Alternative Medicine in a Large Metropolitan Children’s Hospital

The authors conducted an Email survey of their medical staff to explore the attitudes, patterns of recommendation, and communication of pediatric providers about complementary and alternative medicine (CAM) in a large metropolitan children’s hospital. Two thirds of the respondents reported awareness about their patients’ CAM therapy use (65%) and recommended CAM therapy to their patients (67%). Providers who reported personal use of CAM (71%) were more likely to recommend CAM to their patients compared with those who do not (76% vs 45%; P < .05). One half of pediatric providers reported occasional consultation with their patient’s CAM provider, but bidirectional communication was rare (4%). Specific changes in care based on a CAM provider’s recommendations were also unusual (4%). Despite the positive attitudes about and willingness to recommend CAM by pediatric providers, communication between these clinicians and CAM providers may be less than ideal.

Acupuncture therapy for infants: a preliminary report on reasons for consultation, feasibility, and tolerability

Objectives/aims:  The aim of this retrospective review was to determine the feasibility, safety, and potential therapeutic effects of acupuncture in an inpatient infant population and to obtain data that would support the design of a randomized, controlled trial of acupuncture in infants.

Cost Effectiveness Analysis for Nursing Research

Background:With ever-increasing pressure to reduce costs and increase quality, nurses are faced with the challenge of producing evidence that their interventions and care provide value. Cost effectiveness analysis (CEA) is a tool that can be used to provide this evidence by comparative evaluation of the costs and consequences of two or more alternatives. Objectives:The aim of this article is to introduce the essential components of CEA to nurses and nurse researchers with the protocol of a recently funded cluster randomized controlled trial as an example. Methods:This article provides (a) a description of the main concepts and key steps in CEA and (b) a summary of the background and objectives of a CEA designed to evaluate a nursing-led pain and symptom management intervention in rural communities compared with the current usual care. Discussion:As the example highlights, incorporating CEA into nursing research studies is feasible. The burden of the additional data collection required is offset by quantitative evidence of the given intervention’s cost and impact using humanistic and economic outcomes. At a time when U.S. healthcare is moving toward accountable care, the information provided by CEA will be an important additional component of the evidence produced by nursing research.

Reiki training for caregivers of hospitalized pediatric patients: A pilot program ☆

To explore the feasibility of a Reiki therapy-training program for the caregivers of pediatric medical or oncology inpatients, at a large pediatric hospital, a series of Reiki training classes were offered by a Reiki Master. At completion of the training, an interview was conducted to elicit participants feedback regarding the effectiveness and feasibility of the training program. Seventeen of the 18 families agreed to participate. Most families (65%) attended three Reiki training sessions, reporting that Reiki benefitted their child by improving their comfort (76%), providing relaxation (88%), and pain relief (41%). All caregivers identified becoming an active participant in their childs care as a major gain from participation in the Reiki training. A hospital-based Reiki training program for caregivers of hospitalized pediatric patients is feasible and can positively impact patients and their families. More rigorous research regarding the benefits of Reiki in the pediatric population is needed.

Intractable pruritus after traumatic spinal cord injury.

Abstract Background: This report describes a young woman with incomplete traumatic cervical spinal cord injury and intractable pruritus involving her dorsal forearm. Method: Case report. Findings: Anatomic distribution of the pruritus corresponded to the dermatomal distribution of her level of spinal cord injury and vertebral fusion. Symptoms were attributed to the spinal cord injury and possible cervical root injury. Pruritus was refractory to all treatments, including topical lidocaine, gabapentin, transcutaneous electrical nerve stimulation, intravenous Bier block, stellate ganglion block, and acupuncture. Conclusions: Further understanding of neuropathic pruritus is needed. Diagnostic workup of intractable pruritus should include advanced imaging to detect ongoing nerve root compression. If diagnostic studies suggest radiculopathy, epidural steroid injection should be considered. Because the autonomic nervous system may be involved in complex chronic pain or pruritic syndromes, sympatholysis via such techniques as stellate ganglion block might be effective.