Gender Biases in Estimation of Others' Pain

"You sure she's not making this up?": A qualitative investigation of stigma toward adults with borderline personality disorder in physical healthcare settings

Borderline personality disorder (BPD) is associated with pervasive stigma that contributes to several consequences, such as inaccessible and inadequate healthcare. Existing literature concerning the experiences of BPD stigma within healthcare settings predominantly centers on mental healthcare contexts. However, individuals with BPD also present with elevated physical disabilities and health concerns, demonstrating a need for regular contact with medical professionals to manage and coordinate physical healthcare. The current qualitative study analyzes the dynamics of stigma and consequences in medical settings for physical healthcare among individuals diagnosed with BPD. Community adults (N = 16, Mage = 29.50, 44% cisgender women) provided qualitative responses describing their experiences with stigma in medical settings other than for mental health purposes. The inductive thematic analysis generated six key themes: (1) Dismissal and Misattribution of Physical Symptoms, (2) Delayed or Inappropriate Medical Diagnosis and Intervention, (3) Communication and Advocacy Challenges, (4) Invalidation of Emotional Well-Being and Distress, (5) Self-Harm Stigma, and (6) Presumed Drug-Seeking Behavior. This article demonstrates the persistent and complex role of stigma across physical healthcare settings for individuals with BPD, affecting their physical and mental healthcare outcomes. It also identifies areas for future research and improvement and offers insights to ameliorate these issues.

Race and gender biases in assessing pain intensity and medication needs among Chinese observers

Introduction

Pain-related decision-making can be influenced by the caregiver and sufferer's demographic factors, such as race and gender, which are commonly considered individually. However, such factors may influence pain assessment interdependently based on caregivers' stereotypical beliefs.

Objectives

This study investigated how sufferers' race and gender affect Chinese observers' evaluations of pain intensity and medication needs and the associations with the observers' race and gender-related stereotypical beliefs.

Methods

One hundred sixty-two Chinese participants completed a pain facial expression rating task assessing the level of pain intensity and the extent to which they believe the sufferer needs pain medication for East Asian, White, and Black sufferers, followed by a battery of questionnaires measuring their gender and race role expectation of pain.

Results

Chinese observers were more stringent on East Asians' pain intensity and needs for medication than Whites and Blacks'. However, when Black and East Asian sufferers were perceived to have a similar level of pain, East Asians were more likely to receive medication than Blacks, which is partly due to the observers' stereotypical beliefs that Blacks would have a speedier recovery than East Asians.

Conclusions

Our results provided evidence that in addition to the in-versus-out-group preferences, one's sociocultural-related stereotypical beliefs can account for racial disparities in pain-related decision-making.

A database of naturalistic expressive faces for studying high arousal states

Recent studies comparing behavior to different sets of facial stimuli have highlighted a need to employ more naturalistic, genuine facial expressions in cognitive research. To address this need, we identified and selected a large set of highly expressive face stimuli from the public domain, and used these stimuli to test whether participants can recognise when others are experiencing pain from their facial behaviour. After identifying 315 expressive faces to represent the kinds of facial behaviours often seen in three distinct contexts (i.e., injury-related, loss-related and victory-related), we ran six behavioural ratings tasks to characterise these faces along six dimensions; level of arousal, emotional valence, level of physical pain, attractiveness, familiarity, and perceived gender. The results indicate that injury-related expressions are recognised as lower in emotional valence than victory-related expressions, and higher in psychological arousal than both victory- and loss-related expressions. Overall, these findings suggest that the intense, energetic expressions of people in competitive situations are not rendered ambiguous to third parties by increased arousal. These results validate the use of naturalistic facial expressions in studies of non-verbal, injury-related behaviours and their recognition in forensic and clinical settings. PERSPECTIVE: Here we created and validated a large set of visual stimuli, which have been made available to the scientific community. Our results demonstrate that among high-arousal states, expressions related to feelings of intense pain and injury are visually distinct from expressions related to loss or triumph. Thus, the Wild Faces Database - High Arousal States (WFD-HAS) extension provides an important tool for understanding how we recognise injury-related facial expressions in the real world.

Gendered dimension of chronic pain patients with low and middle income: A text mining analysis

METHODS

This is a mixed-method study using individual interviews (duration between 40-60 minutes) of 181 CNCP patients (71% females) in a tertiary Pain Care Unit, and applying the text mining methodology. Incomes (low or middle) and gender roles (productive vs. reproductive)".

RESULTS

Gender differences were identified in the words used to describe pain impact in working and social life, domestic responsibilities, and family relationships. Albeit having similar CNCP severity and interference, women were on average 8 years older, compared to men, with longer referral time from Primary Care, less retired but more homemakers, showing a greater impact on their mental health. The most discriminating word explaining pain impact for CNCP women was "husband", for men was "work", especially among middle income groups. The way men, with a productive gender role, talked about the impact of CNCP in their lives stressed the word "work". In contrast, men with reproductive roles stressed the words "chores, family or limited" as women with low-income did. Only low-income men used the word "help". The text mining analysis indicates a discrepant distribution of men and women into traditional gender social roles that are consistent with stereotypical traits and may have an impact on pain care. There is a need of an intersectional perspective as part of pain assessment, to develop novel self-management interventions for men and women.

Disparities, Inequities, and Injustices in Populations With Pain: Nursing Recommendations Supporting ASPMN's 2024 Position Statement

The American Society for Pain Management Nursing (ASPMN) upholds the principle that all persons with pain have equal rights to evidence-based, high quality pain assessment, management, and treatment. This practice recommendation's goals are to 1) summarize known pain-related disparities, inequities, and injustices among commonly marginalized and at risk groups, 2) offer recommendations to ascertain that just and equitable pain care is provided to all people, and 3) outline a call to action for all nurses to embrace diversity, equity, inclusion, and a sense of belonging in order to mitigate pain-related disparities, inequities, and injustices within clinical environments and the nursing profession. This paper provides background and rationale for the 2024 ASPMN position statement on disparities, inequities and injustices in people with pain.

Sex Disparities in Opioid Prescription and Administration on a Hospital Medicine Service

INTRODUCTION

Decisions to prescribe opioids to patients depend on many factors, including illness severity, pain assessment, and patient age, race, ethnicity, and gender. Gender and sex disparities have been documented in many healthcare settings, but are understudied in inpatient general medicine hospital settings.

OBJECTIVE

We assessed for differences in opioid administration and prescription patterns by legal sex in adult patient hospitalizations from the general medicine service at a large urban academic center.

DESIGNS, SETTING, AND PARTICIPANTS

This study included all adult patient hospitalizations discharged from the acute care inpatient general medicine services at the University of California, San Francisco (UCSF) Helen Diller Medical Center at Parnassus Heights from 1/1/2013 to 9/30/2021.

MAIN OUTCOME AND MEASURES

The primary outcomes were (1) average daily inpatient opioids received and (2) days of opioids prescribed on discharge. For both outcomes, we first performed logistic regression to assess differences in whether or not any opioids were administered or prescribed. Then, we performed negative binomial regression to assess differences in the amount of opioids given. We also performed all analyses on a subgroup of hospitalizations with pain-related diagnoses.

RESULTS

Our study cohort included 48,745 hospitalizations involving 27,777 patients. Of these, 24,398 (50.1%) hospitalizations were female patients and 24,347 (49.9%) were male. Controlling for demographic, clinical, and hospitalization-level variables, female patients were less likely to receive inpatient opioids compared to male patents (adjusted OR 0.87; 95% CI 0.82, 0.92) and received 27.5 fewer morphine milligram equivalents per day on average (95% CI - 39.0, - 16.0). When considering discharge opioids, no significant differences were found between sexes. In the subgroup analysis of pain-related diagnoses, female patients received fewer inpatient opioids.

CONCLUSIONS

Female patients were less likely to receive inpatient opioids and received fewer opioids when prescribed. Future work to promote equity should identify strategies to ensure all patients receive adequate pain management.

Prevalence of pain phenotypes and co-morbidities of chronic pain in Parkinson's Disease

OBJECTIVE

The prevalence of chronic pain in Parkinson's disease (PD) in neurology practices ranges from 24 % to 83 %. To determine whether this prevalence is accurate across patients with PD, we leveraged data from electronic medical records in 80 inpatient and outpatient general practice settings.

METHODS

We explored the prevalence of chronic pain in patients with PD relative to age and sex-matched controls in a large international database with electronic medical records from over 250 million patients (TriNetX Cambridge, MA, USA). We described demographics, co-morbid conditions and medication differences between patients with PD and without PD who have chronic pain.

RESULTS

Extracted data included 4510 patients with PD and 4,214,982 age-matched control patients without Parkinson's Disease. A chronic pain diagnosis was identified in 19.3 % of males and 22.8 % of females with PD. This differed significantly from age-matched patients without PD who had a significantly lower prevalence of chronic pain 3.78 % and 4.76 %. Significantly more PD patients (both male and females) had received tramadol, oxycodone, and neuropathic agents (p<0.001) than patients without PD. Females with PD more often received anti-depressants than males with PD (p<0.05), corresponding with a significantly higher prevalence of depression.

CONCLUSION

Chronic pain in patients with PD is five times as common as in age-matched controls in general practice settings. Patients with PD have a greater prevalence of comorbid conditions that affect development of chronic pain. Whether the pain or the PD is causative to those conditions remains to be elucidated.

Medical student perceptions of gender and pain: a systematic review of the literature

BACKGROUND

Gender bias exists in healthcare and affects how pain is assessed and managed. This bias affects patient outcomes and their trust in healthcare professionals. We also know that future clinicians develop their attitudes early in training. Medical school is therefore an opportunity to shape the values of future doctors and to combat systemic gender bias in healthcare. This systematic review aims to explore medical student perceptions of the relationship between patients' gender and their pain, so that recommendations can be made for developing medical education.

METHODS

Embase, MEDLINE, PsychINFO, LILACS, Global Index Medicus, PakMediNet and ERIC were searched for articles relating to medical student perceptions of gender and pain, with no geographical or language limitations. Quality was assessed using the Medical Education Research Study Quality Index and the Critical Appraisal Skills Programme checklist.

RESULTS

Nine publications were identified, two qualitative and seven quantitative. All studies had methodological limitations. Many different study designs were used, although most involved simulated patients. All studies referred to gender as binary. Multiple studies found that women's pain is more likely to be underestimated by medical students and that the patient's gender drives different approaches during clinical history taking, examination and management in these simulated situations. Only one study found no effect of patients' gender on students' perception of their pain.

CONCLUSIONS

Whilst there is a paucity of high-quality studies in this area, patients' gender was found to affect how their pain is perceived by medical students. No studies explored where students' attitudes towards gender and pain arise from, and few involved 'real life situations'. We propose that further work into medical student perceptions in 'real situations' is needed. This will help to inform how undergraduate medical education can be developed to tackle gender bias, and ultimately improve outcomes for patients.

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Addressing Psychosocial Care Needs in Women with Peripheral Artery Disease

PURPOSE OF REVIEW

Peripheral artery disease (PAD) is a growing global epidemic. Women with PAD are at elevated risk of experiencing psychosocial stressors that influence the diagnosis, management, and course of their illness due to unique sex- and gender-based factors.

RECENT FINDINGS

We review existing evidence for increased psychosocial risk in women with PAD with a focus on mood disorders, chronic stress, pain experiences, substance use disorders, health behaviors and illness perceptions, and healthcare access. We discuss how these factors exacerbate PAD symptomatology and lead to adverse outcomes. Existing gaps in women's vascular care are reviewed and potential solutions to bridge these gaps through psychosocial care integration are proposed. Current care paradigms for women's vascular care do not adequately screen for and address psychosocial comorbidities. Clinician education, integration of evidence-based psychological care strategies, implementation of workflows for the management of individuals with PAD and mental health comorbidities, reform to reimbursement structures, and further advocacy are needed in this space. This review provides a construct for integrated behavioral health care for women with PAD and advocates for further integration of care.

Spine Pain

OBJECTIVE

Spine pain is one of the most common presenting concerns in health care settings. This article reviews clinical strategies for evaluating and managing patients with spine pain.

LATEST DEVELOPMENTS

Minimally invasive interventional procedures, virtual reality, predictive analytics, neuromodulation, and other evolving technologies are significantly impacting the management of spine pain. Advances in modern pain science have also led to effective skills and treatment strategies, including patient interviews and queries for insight regarding pain, education, and cognitive restructuring, and adjusting the timing of examination (after reeducation) and examination techniques to encourage the experience of movement in the absence of assumed tissue damage. An evolving understanding of the influence of patient-centric thoughts, framing, emotional status, and cognitive restructuring's influence on the brain's response to perceived threat are important aspects of spine pain management.

ESSENTIAL POINTS

The correlation of clinical presentations with structural abnormalities is necessary but insufficient to evaluate and manage spine pain. Modern pain science acknowledges pain as a subjective experience but recognizes a critical distinction between tissue damage, nociception, and the experience of pain. What and how we communicate with patients, as well as evolving neuromodulation technologies, augment conventional approaches.

Gender Differences in Perceptions of Psoriatic Arthritis Disease Impact, Management, and Physician Interactions: Results from a Global Patient Survey

INTRODUCTION

We evaluated the impact of gender on disease severity, health-related quality of life (HRQoL), treatment management, and patient-healthcare professional (HCP) interactions from the perspectives of patients with psoriatic arthritis (PsA).

METHODS

Data were collected from a global online patient survey conducted by The Harris Poll (November 2, 2017 to March 12, 2018). Eligible patients were aged ≥ 18 years, with a self-reported diagnosis of PsA for > 1 year, had visited a rheumatologist/dermatologist in the past 12 months, and had reported previously using ≥ 1 conventional synthetic or biologic disease-modifying antirheumatic drug. Data were stratified by gender and analyzed descriptively, inferentially by binomial (chi-square) tests, and by multivariate logistic regression models.

RESULTS

Data from 1286 patients who participated were included: 52% were female, 48% were male. Varying perceptions of disease severity between males and females were indicated by differences in symptoms leading to a diagnosis of PsA, and in symptoms reported despite treatment; more females than males reported joint tenderness, skin patches/plaques, and enthesitis. More females than males reported a major/moderate impact of PsA on their physical activity and emotional/mental well-being. Reasons for switching medication differed between genders, with more females switching because they perceived their medication to not be effective enough related to their joint symptoms. More females than males were very satisfied with their communication with their rheumatologist and were more likely to discuss the impact of PsA on their daily lives, their treatment satisfaction, and treatment goals with their rheumatologist.

CONCLUSIONS

Patients' perceptions of the impact of PsA on HRQoL, treatment management, and interactions with HCPs varied between males and females. More females than males reported major/moderate physical and emotional impacts of PsA. When treating patients, it is important for HCPs to consider the potential impact of gender on patients' experience of PsA and its symptoms. Graphical plain language summary available for this article.

Assessing Gender Differences in Neuropathic Pain Management: Findings from a Real-Life Clinical Cross-Sectional Observational Study

Introduction: Neuropathic pain is defined as pain induced by a lesion or disease of the somatosensory nervous system. Pharmacological and non-pharmacological treatments are frequently employed. In the current clinical investigation, we assessed the effects of sex on the safety and effectiveness of medications used to treat neuropathic pain. Methods: We conducted a prospective analysis between 1 February 2021 and 20 April 2024, involving patients with neuropathic pain referred to the Ambulatory of Pain Medicine of "Renato Dulbecco" University Hospital in Catanzaro (Calabria, Italy). Patients over 18 years old with signs of neuropathic pain (Douleur Neuropathique en 4 questionnaire ≥ 4) were included. Exclusion criteria comprised patients with Alzheimer's disease; patients with nociplastic or nociceptive pain; and patients with neoplasms. Patients with fewer than two accesses to ambulatory care were excluded, as were those who did not sign the informed consent. Clinical data were collected from each enrolled patient and subsequently analyzed, considering clinical outcomes. Sex and gender differences in efficacy were estimated using multivariate linear modeling and propensity-score matching. Results: During the study, 531 patients were screened, and 174 were enrolled (33.5%, mean age 61.5 ± 13.1; 64 males and 110 females, mean age 60.6 ± 13.4 and 61.96 ± 13.0) in accordance with the inclusion and exclusion criteria. Only minor differences in treatment prescription were observed based on age, body mass index, and comorbidities. Smoking, sex, educational level, and body mass index did not induce a significant change in pain perception. Males required slightly higher, though not significantly, doses of drugs for pain control than females. The treatment was not significantly more effective for females than for males. Females did not exhibit a significantly lower number of adverse drug reactions compared to males. Conclusions: The current study found that there are no appreciable differences between the sexes when it comes to the treatment of neuropathic pain.

Documenting Race and Gender Biases in Pain Assessment and a Novel Intervention Designed to Reduce Biases

Disparities in pain care are well-documented such that women and people of color have their pain undertreated and underestimated compared to men and White people. One of the contributors of the undertreatment of pain for people of color and women may be the inaccurate assessment of pain. Understanding the pain assessment process is an important step in evaluating the magnitude of and intervening on pain disparities in care. In the current work, we focus on documenting intersectional race and gender biases in pain assessment and present the results of a novel intervention for reducing these biases. Across 3 studies (N = 532) and a mini meta-analysis using real videotaped people in pain as stimuli, we demonstrate that observers disproportionately underestimated women of color's pain compared to all other groups (men of color, White women, and White men). In study 3 (N = 232), we show that a novel intervention focused on behavioral skill building (ie, practice and immediate feedback) significantly reduced observers' pain assessment biases toward marginalized groups compared to all other types of trainings (raising awareness of societal biases, raising awareness of self-biases, and a control condition). While it is an open question as to how long this type of intervention lasts, behavioral skills building around assessing marginalized people's pain more accurately is a promising training tool for health care professionals. PERSPECTIVE: This article demonstrates the underestimation of pain among people of color and women. We also found support that a novel intervention reduced observers' pain assessment biases toward marginalized groups. This could be used in medical education or clinical care to reduce intersectional pain care disparities.

Racial Bias in Pediatric Pain Perception

Racial disparities in pediatric pain care are prevalent across a variety of health care settings, and likely contribute to broader disparities in health, morbidity, and mortality. The present research expands on prior work demonstrating potential perceptual contributions to pain care disparities in adults and tests whether racial bias in pain perception extends to child targets. We examined the perception and hypothetical treatment of pain in Black and White boys (experiment 1), Black and White boys and girls (experiment 2), Black and White boys and adult men (experiment 3), and Black, White, Asian, and Latinx boys (experiment 4). Across this work, pain was less readily perceived on Black (vs White) boys' faces-though this bias was not observed within girls. Moreover, this perceptual bias was comparable in magnitude to the same bias measured with adult targets and consistently predicted bias in hypothetical treatment. Notably, bias was not limited to Black targets-pain on Hispanic/Latinx boys' faces was also relatively underperceived. Taken together, these results offer strong evidence for racial bias in pediatric pain perception. PERSPECTIVE: This article demonstrates perceptual contributions to racial bias in pediatric pain recognition. Participants consistently saw pain less readily on Black boys' faces, compared with White boys, and this perceptual bias consistently predicted race-based gaps in treatment. This work reveals a novel factor that may support pediatric pain care disparities.

Exploring the perceptions of senior medical students on gender and pain: a qualitative study of the interplay between formal and hidden curricula

OBJECTIVE

Explore the perceptions of senior medical students on the relationship between gender and pain and examine how formal and hidden curricula in medical education shape their experiences.

DESIGN

We conducted a cross-sectional qualitative interview study, using individual semistructured interviews and adhering to interpretative description methodology. We used Braun and Clarke's reflexive approach to thematic analysis to analyse our data.

SETTING

Six medical schools across the UK. Data collection occurred between the autumn of 2022 and the spring of 2023.

PARTICIPANTS

14 senior (penultimate or final year) medical students.

RESULTS

We created three themes, which describe key educational forces shaping students' experiences of the relationship between gender and pain. These are (1) the sociocultural influencer, (2) the pedagogical influencer and (3) the professorial influencer. Our findings highlight the influence of both wider societal norms and students' own identities on their experiences. Further, we explore the nature and detrimental role of formal curricular gaps, and negative role modelling as a key mechanism by which a hidden curriculum relating to gender and pain exerts its influence.

CONCLUSIONS

These findings have several educational implications, including the need for a more holistic, person-centred approach to pain management within medical school curricula. Additionally, we recommend the creation of reflective spaces to engage students in critical thinking around bias and advocacy from the early stages of their training. We present actionable insights for medical educators to address issues of gender bias and pain management.

Invalidation by medical professionals in post-treatment Lyme disease

Patients with post-treatment Lyme disease (PTLD) report negative perceptions of care and significant invalidation from medical professionals. However, the relationship of invalidation to illness severity has not been examined, nor have risk factors for invalidation been identified. This cross-sectional study enrolled 80 patients who met stringent criteria for PTLD. We examined correlations between the Illness Invalidation Inventory and measures of symptom severity, quality of life, and trust in physicians. To study the relationship between invalidation and potential demographic and clinical factors, we generated simple unadjusted and multivariate adjusted linear regression models. We found that higher 'lack of understanding' and 'discounting' subscale scores of the Illness Invalidation Inventory were significantly positively correlated with higher symptom severity, lower quality of life, and lower trust in physicians. In adjusted linear regression models, older age (lack of understanding: β = - 0.17, p = 0.008, discounting: β = - 0.19, p = 0.001, every 10 years) and male gender (lack of understanding: β = - 0.49, p = 0.016, discounting: β = - 0.51, p = 0.006) were associated with less invalidation. We also identified receiving an alternative diagnosis for PTLD as a mediator in the relationship between gender and invalidation. Based on our findings, we hypothesize that reducing invalidation within the clinical encounter could positively affect illness burden and quality of life for patients with PTLD.

Sex bias in pain management decisions

In the pursuit of mental and physical health, effective pain management stands as a cornerstone. Here, we examine a potential sex bias in pain management. Leveraging insights from psychological research showing that females' pain is stereotypically judged as less intense than males' pain, we hypothesize that there may be tangible differences in pain management decisions based on patients' sex. Our investigation spans emergency department (ED) datasets from two countries, including discharge notes of patients arriving with pain complaints (N = 21,851). Across these datasets, a consistent sex disparity emerges. Female patients are less likely to be prescribed pain-relief medications compared to males, and this disparity persists even after adjusting for patients' reported pain scores and numerous patient, physician, and ED variables. This disparity extends across medical practitioners, with both male and female physicians prescribing less pain-relief medications to females than to males. Additional analyses reveal that female patients' pain scores are 10% less likely to be recorded by nurses, and female patients spend an additional 30 min in the ED compared to male patients. A controlled experiment employing clinical vignettes reinforces our hypothesis, showing that nurses (N = 109) judge pain of female patients to be less intense than that of males. We argue that the findings reflect an undertreatment of female patients' pain. We discuss the troubling societal and medical implications of females' pain being overlooked and call for policy interventions to ensure equal pain treatment.

Using case vignettes to study the presence of outcome, hindsight, and implicit bias in acute unplanned medical care: a cross-sectional study

BACKGROUND AND IMPORTANCE

Various biases can impact decision-making and judgment of case quality in the Emergency Department (ED). Outcome and hindsight bias can lead to wrong retrospective judgment of care quality, and implicit bias can result in unjust treatment differences in the ED based on irrelevant patient characteristics.

OBJECTIVES

First, to evaluate the extent to which knowledge of an outcome influences physicians' quality of care assessment. Secondly, to examine whether patients with functional disorders receive different treatment compared to patients with a somatic past medical history.

DESIGN

A web-based cross-sectional study in which physicians received case vignettes with a case description and care provided. Physicians were informed about vignette outcomes in a randomized way (no, good, or bad outcome). Physicians rated quality of care for four case vignettes with different outcomes. Subsequently, they received two more case vignettes. Physicians were informed about the past medical history of the patient in a randomized way (somatic or functional). Physicians made treatment and diagnostic decisions for both cases.

SETTING AND PARTICIPANTS

One hundred ninety-one Dutch emergency physicians (EPs) and general practitioners (GPs) participated.

OUTCOME MEASURES AND ANALYSIS

Quality of care was rated on a Likert scale (0-5) and dichotomized as adequate (yes/no). Physicians estimated the likelihood of patients experiencing a bad outcome for hindsight bias. For the second objective, physicians decided on prescribing analgesics and additional diagnostic tests.

MAIN RESULTS

Large differences existed in rated quality of care for three out of four vignettes based on different case outcomes. For example, physicians rated the quality of care as adequate in 44% (95% CI 33-57%) for an abdominal pain case with a bad outcome, compared to 88% (95% CI 78-94%) for a good outcome, and 84% (95% CI 73-91%) for no outcome ( P  < 0.01). The estimated likelihood of a bad outcome was higher if physicians received a vignette with a bad patient outcome. Fewer diagnostic tests were performed and fewer opioids were prescribed for patients with a functional disorder.

CONCLUSION

Outcome, hindsight, and implicit bias significantly influence decision-making and care quality assessment by Dutch EPs and GPs.

Sex differences in facial expressions of pain: results from a combined sample

ABSTRACT

Facial expressions of pain play an important role in pain diagnostics and social interactions. Given the prominent impact of sex on various aspects of pain, it is not surprising that sex differences have also been explored regarding facial expressions of pain; however, with inconclusive findings. We aim to further investigate sex differences in facial expressions of pain by using a large, combined sample to maximize statistical power. Data from 7 previous studies of our group were merged, combining in total the data of 392 participants (male: 192, female: 200). All participants received phasic heat pain, with intensities being tailored to the individual pain threshold. Pain intensity ratings were assessed, and facial responses were manually analyzed using the Facial Action Coding. To compare facial and subjective responses between sexes, linear mixed-effects models were used, with study ID as a random effect. We found significant sex differences in facial responses, with females showing elevated facial responses to pain, although they received lower physical heat intensities (women had lower pain thresholds). In contrast, pain intensity ratings did not differ between sexes. Additionally, facial and subjective responses to pain were significantly associated across sexes, with females showing slightly stronger associations. Although variations in facial expressions of pain are very large even within each sex, our findings demonstrate that women facially communicate pain more intensively and with a better match to their subjective experience compared with men. This indicates that women might be better in using facial communication of pain in an intensity-discriminative manner.

Sex concordance between physicians and patients and discharge opioid prescribing

Inpatient pain management is challenging for clinicians and inequities are prevalent. We examined sex concordance between physicians and patients to determine if discordance was associated with disparate opioid prescribing on hospital discharge. We examined 15,339 hospitalizations from 2013 to 2021. Adjusting for patient, clinical, and hospitalization-level characteristics, we calculated the odds of a patient receiving an opioid on discharge and the days of opioids prescribed across all hospitalizations and for patients admitted with a common pain diagnosis. We did not find an overall association between physician-patient sex concordance and discharge opioid prescriptions. Compared to concordant sex pairs, patients in discordant pairs were not significantly less likely to receive an opioid prescription (odds ratio: 1.04; 95% confidence interval [CI]: 0.95, 1.15) and did not receive significantly fewer days of opioids (2.1 fewer days of opioids; 95% CI: -4.4, 0.4). Better understanding relationships between physician and patient characteristics is essential to achieve more equitable prescribing.

Patient-Centered Care for Women

Patient-centered care for women acknowledges the unique differences between men and women, considers women's concerns, and allows for a partnership between women and providers.

A multidisciplinary approach on music induced-analgesia differentiated by socio-cultural background in healthy volunteers (MOSART): A cross-over randomized controlled trial protocol

Background

Integrating music into pain treatment demonstrates significant benefits, effectively reducing subjective pain levels and perioperative opioid requirements. Currently, the relationship between the impact of specific types of music and listeners' socio-cultural background is still unclear. This is especially relevant given that sociological research indicates that these factors can have a notable influence on music preference and perception. Current evidence suggests that individuals who choose their own music may experience greater benefits. However, additional research is needed to comprehensively grasp whether the effect of (preferred) music on pain endurance remains consistent across different socio-cultural backgrounds.

Methods

In this study, a collaborative effort between medical and sociological researchers aims to investigate music-induced analgesia differentiated by socio-cultural background in healthy volunteers. Participants (n = 84) will listen to self-, and researcher-chosen music and a podcast as a control condition in a cross-over study design. The primary outcome of this study is pain endurance measured by electric stimuli of increasing intensity. Detailed sociological validated questionnaires will be utilized. Considering the notable influence of educational level on music taste formation found in previous research and its crucial role as a source of socio-cultural differentiation, participants will be stratified based on their level of education.

Discussion

This experimental study represents one of the first efforts to gain a socio-culturally differentiated understanding of the therapeutic potential of music. Consequently, this could pave the way to purposefully and inclusively implement personalized music in healthcare settings.

Comparison of Hospital Mortality and Readmission Rates by Physician and Patient Sex

BACKGROUND

Little is known as to whether the effects of physician sex on patients' clinical outcomes vary by patient sex.

OBJECTIVE

To examine whether the association between physician sex and hospital outcomes varied between female and male patients hospitalized with medical conditions.

DESIGN

Retrospective observational study.

SETTING

Medicare claims data.

PATIENTS

20% random sample of Medicare fee-for-service beneficiaries hospitalized with medical conditions during 2016 to 2019 and treated by hospitalists.

MEASUREMENTS

The primary outcomes were patients' 30-day mortality and readmission rates, adjusted for patient and physician characteristics and hospital-level averages of exposures (effectively comparing physicians within the same hospital).

RESULTS

Of 458 108 female and 318 819 male patients, 142 465 (31.1%) and 97 500 (30.6%) were treated by female physicians, respectively. Both female and male patients had a lower patient mortality when treated by female physicians; however, the benefit of receiving care from female physicians was larger for female patients than for male patients (difference-in-differences, -0.16 percentage points [pp] [95% CI, -0.42 to 0.10 pp]). For female patients, the difference between female and male physicians was large and clinically meaningful (adjusted mortality rates, 8.15% vs. 8.38%; average marginal effect [AME], -0.24 pp [CI, -0.41 to -0.07 pp]). For male patients, an important difference between female and male physicians could be ruled out (10.15% vs. 10.23%; AME, -0.08 pp [CI, -0.29 to 0.14 pp]). The pattern was similar for patients' readmission rates.

LIMITATION

The findings may not be generalizable to younger populations.

CONCLUSION

The findings indicate that patients have lower mortality and readmission rates when treated by female physicians, and the benefit of receiving treatments from female physicians is larger for female patients than for male patients.

PRIMARY FUNDING SOURCE

Gregory Annenberg Weingarten, GRoW @ Annenberg.

Social cues influence perception of others' pain

BACKGROUND

Accurately perceiving other people's pain is important in both daily life and healthcare settings. However, judging other's pain is inherently difficult and can be biased by various social and cultural factors. Here, we examined whether perception of others' pain and pain management recommendations are socially influenced by seeing the opinions of other raters.

METHODS

In Experiment 1 (N = 50), participants rated pictures depicting injured hands or feet of pre-selected high, medium and low intensities. Each picture was preceded by cues indicating ratings of 10 previous participants. Cues were randomized to indicate low (SocialLOW) or high (SocialHIGH) pain judgements and were not predictive of actual normative pain intensity. In Experiment 2 (N = 209), participants viewed facial video clips of patients with chronic shoulder pain making painful movements. They estimated patients' pain intensity and provided pain management recommendations.

RESULTS

Experiment 1 revealed that perceivers' pain estimates were significantly and substantially higher for stimuli following SocialHIGH than SocialLOW cues (Cohen's d = 1.26, p < 0.001) and paralleled by increased skin conductance responses. Experiment 2 replicated the effect of social cues on pain judgements (d = 0.58, p < 0.001). However, social cues did not influence post-study pain management recommendations, potentially due to memory limitations.

CONCLUSIONS

Together, these studies reveal that judgements of others' pain are robustly modulated by information about others' opinions. Future research could test the prevalence and strength of such effects in clinical settings.

SIGNIFICANCE

The present study shows that even arbitrary opinions of other raters influence the perception of others' pain. This finding adds new insight into the growing evidence of social and cultural biases in pain estimation.

Learning by observing: a systematic exploration of modulatory factors and the impact of observationally induced placebo and nocebo effects on treatment outcomes

Introduction

Observational learning (OL) refers to learning through observing other people's behavior. OL has been suggested as an effective and simple tool to evoke treatment expectations and corresponding placebo and nocebo effects. However, the exact mechanisms by which OL shapes treatment outcomes, its moderating factors and possible areas of application remain unclear. We thus reviewed the existing literature with two different literature searches to answer the following questions: Which influencing factors contribute to OL-induced placebo and nocebo effects (in healthy volunteers and patients) and how large are these effects (search 1)? In which medical fields has OL been used so far to modulate treatment expectancy and treatment outcomes in patients, their caregivers, and at-risk groups (search 2)? We also aimed to explore whether and how the assessment of treatment expectations has been incorporated.

Methods

We conducted two independent and comprehensive systematic literature searches, both carried out on September 20, 2022.

Results

We identified 21 studies that investigated OL-mediated placebo and nocebo effects for pain and itch, the (placebo) efficacy of sham treatment on anxiety, and the (nocebo) induction of medication side effects (search 1). Studies showed that OL can efficiently induce placebo and nocebo effects across different presentation modes, with medium effect sizes on average: placebo effects, d = 0.79 (range: d = -0.36-1.58), nocebo effects, d = 0.61 (range: d = 0.04-1.5). Although several moderating factors have been investigated, their contribution to OL-induced effects remains unclear because of inconsistent results. Treatment expectation was assessed in only four studies. Regarding medical applications of OL (search 2), we found 12 studies. They showed that OL was effectively applied in preventive, therapeutic and rehabilitative interventions and that it was mainly used in the field of psychosomatics.

Discussion

OL effects on treatment outcomes can be both positive and negative. Future research should investigate which individuals would benefit most from OL and how OL can be implemented most effectively to induce placebo and avoid nocebo effects in clinical settings.

Systematic review registration

This work was preregistered at the Center for Open Science as open-ended registration (doi: 10.17605/OSF.IO/FVHKE). The protocol can be found here: https://archive.org/details/osf-registrations-fvhke-v1.

Sex-based Differences in Patient Perspectives and Experiences With Shoulder, Hip, and Knee Arthroplasty

INTRODUCTION

Sex disparities in presentation of osteoarthritis and utilization of joint replacement surgery (JRS) have been demonstrated. The role of patients' unique perspectives on JRS on their treatment decisions is poorly understood.

METHODS

JRS candidates who were offered JRS but declined surgical treatment completed this survey. Survey questions included demographic information, patient experiences and current opinions around JRS, patient experiences with providers, goals and concerns, and barriers to JRS.

RESULTS

More women experience barriers to undergoing JRS compared with men (53% versus 16%; P = 0.014). While both men and women indicated pain relief as their primary goal for treatment, women were significantly more likely to prioritize regaining the ability to complete daily tasks and responsibilities when compared with men (P = 0.007). Both men and women indicated that low symptom severity and nonsurgical treatment options were the reasons for not undergoing JRS (P = 0.455). Compared with men, women trended toward feeling that they were not sufficiently educated about JRS (P = 0.051).

CONCLUSION

Women have unique perspectives and goals for JRS that may pose sex-specific barriers to care. A better understanding of how patients' gendered experiences affect their decision making is necessary to improve treatment of osteoarthritis and decrease disparities in care.

Women's experiences of seeking healthcare for abdominal pain in Ireland: a qualitative study

BACKGROUND

Evidence suggests that women's abdominal pain is more likely to be minimised or dismissed by healthcare professionals than men's. This can have a detrimental impact on health-related outcomes as well as quality of life. The aim of this study was to explore women's experiences of seeking healthcare for abdominal pain in Ireland.

METHOD

A qualitative design and opportunity sampling approach were employed in this study. Fourteen women living in Ireland with experience of seeking healthcare for abdominal pain took part in one-to-one semi-structured interviews via video-conferencing software. Data were analysed using reflexive thematic analysis.

RESULTS

Four themes were constructed from the data: [1] "Just Get on with It" - Normalisation and Invalidation; [2] "Bad Enough"? Costs of (Not) Seeking Help; [3] "Fight Your Case," Fight for Care; and [4] "Out of the Loop" - Systemic Barriers to Care. Perceived invalidation of pain by healthcare professionals was common, as was internalised normalisation of pain. This created challenges when negotiating pain management solutions. Despite functional interference, participants felt their pain needed to reach an extreme level of severity before seeking help. Costs of private healthcare were implicated in delayed help-seeking. Participants felt the onus was on them to fight for care. Social support and information-seeking facilitated participants in this fight while systemic issues were identified as barriers to adequate care. Despite their frustrations, participants expressed empathy for healthcare professionals operating in a flawed system.

CONCLUSIONS

Participants described mostly negative experiences of seeking healthcare for abdominal pain, characterised by dismissal of symptoms and internalisation of normative views of women's pain as less worthy of care. These experiences reinforced participants' views that self-advocacy is essential to access care for their pain. There are systemic issues at play within the Irish healthcare system that limit women's ability to access abdominal pain management support. Education and training for healthcare professionals on the Gender Pain Gap and its implications for patient care, as well as clear referral pathways for women presenting with abdominal pain, may help to ensure more equitable healthcare delivery for individuals with abdominal pain in Ireland.

Sex differences in the pre-hospital ambulance delay, assessment and treatment of patients with acute coronary syndrome: a rapid evidence review

Background

Chest pain is a frequent symptom suffered by adult patients attended by ambulance. Evidence suggests female patients may suffer different symptoms to their male counterparts, potentiating differences in pre-hospital time delays, assessment and treatment.

Objective

To explore the sex differences in the pre-hospital ambulance delay, assessment and treatment of patients with acute coronary syndrome (ACS).

Methods

A rapid evidence review was conducted following the Cochrane rapid review guidelines. MEDLINE and CINAHL Complete were searched via EBSCOhost on 2 February 2023, and reference lists of included studies and reviews were screened. The Joanna Briggs Institute checklist for analytical cross-sectional studies was used to perform critical appraisal, and a narrative synthesis was conducted.

Results

From 216 articles screened, nine were included, representing over 3.1 million patients from five different countries. Female patients were more likely to suffer delays in time to first electrocardiogram (ECG) and delays in transport time to the emergency department by ambulance. Female patients were also less likely to receive an ECG, aspirin, glyceryl trinitrate and other analgesics.

Conclusion

There are sex disparities in the pre-hospital ambulance delay, assessment and treatment of patients with ACS. Future research is urgently needed to fully understand the reasons for these observations.

The Relationship Between the Ability to Infer Another's Pain and the Expectations Regarding the Appearance of Pain Facial Expressions: Investigation of the Role of Visual Perception

Although pain is a commonly experienced and observed affective state, it is frequently misinterpreted, which leads to inadequate caregiving. Studies show the ability at estimating pain in others (estimation bias) and detecting its subtle variations (sensitivity) could emerge from independent mechanisms. While estimation bias is modulated by variables such as empathy level, pain catastrophizing tendency, and overexposure to pain, sensitivity remains unimpacted. The present study verifies if these 2 types of inaccuracies are partly explained by perceptual factors. Using reverse correlation, we measured their association with participants' mental representation of pain, or more simply put, with their expectations of what the face of a person in pain should look like. Experiment 1 shows that both parameters are associated with variations in expectations of this expression. More specifically, the estimation bias is linked with expectations characterized by salient changes in the middle face region, whereas sensitivity is associated with salient changes in the eyebrow region. Experiment 2 reveals that bias and sensitivity yield differences in emotional representations. Expectations of individuals with a lower underestimation tendency are qualitatively rated as expressing more pain and sadness, and those of individuals with a higher level of sensitivity as expressing more pain, anger, and disgust. Together, these results provide evidence for a perceptual contribution in pain inferencing that is independent of other psychosocial variables and its link to observers' expectations. PERSPECTIVE: This article reinforces the contribution of perceptual mechanisms in pain assessment. Moreover, strategies aimed to improve the reliability of individuals' expectations regarding the appearance of facial expressions of pain could potentially be developed, and contribute to decrease inaccuracies found in pain assessment and the confusion between pain and other affective states.

A Narrative Review of the Current Research in Cancer-Related Pain Inequities: The Necessity of Applying Intersectionality to Advance Cancer Pain Research

Cancer-related pain has a significant impact on quality of life for patients with cancer. In populations without cancer, there are documented pain inequities associated with minoritized racial and/or ethnic groups, women, and low socioeconomic status. However, our understanding of pain inequities specifically among patients with cancer remains incomplete. We narratively synthesized published quantitative research on cancer-related pain inequities in the US in the past decade. A search identified 17 English-language articles examining pain for patients with various cancer types at different treatment stages. Our review revealed mixed findings comparing cancer-related pain by racial group (e.g., Black vs White) and sex (male vs female), but consistent findings indicating that people with lower (vs higher) socioeconomic status and younger (vs older) patients report more cancer-related pain. Research on cancer pain among sexual and gender minorities remains scant. Key research gaps include a need for more research that incorporates an intersectional perspective by exploring intersecting subgroups and measuring social and structural processes that drive pain inequities. These findings underscore an important need for researchers to use an intersectional approach to cancer pain to help elucidate key populations at-risk for exacerbated cancer-related pain and identify ways to mitigate social and structural processes that drive these inequities.

The role of transcutaneous electrical nerve stimulation for menstrual pain relief: A randomized control trial

BACKGROUND

Abdominal pain due to menses (primary dysmenorrhea) is an extremely pervasive and debilitating symptom affecting up to 90% of menstruating individuals.

OBJECTIVE

The objective of this randomized control trial was to investigate the effect of a commercial transcutaneous electrical nerve stimulation unit, Therabody PowerDot® (Therabody Inc., Los Angeles) on dysmenorrhea compared with non-steroidal anti-inflammatory drug use.

DESIGN

This was a randomized cross-over study.

METHODS

A total of 47 participants agreed to participate in the study, with 34 completing it. Participants completed treatments across three consecutive menstrual cycles in randomized order: single-unit transcutaneous electrical nerve stimulation (Uno), dual unit transcutaneous electrical nerve stimulation (Duo), and non-steroidal anti-inflammatory drug use (Control). Upon onset of dysmenorrhea, participants applied transcutaneous electrical nerve stimulation to their abdomen for a minimum of 30 min. Control participants were instructed to take non-steroidal anti-inflammatory drugs as needed. Surveys were used to record pain before and after treatment. We hypothesized that the PowerDot would decrease self-reported pain scores, and decrease non-steroidal anti-inflammatory drug consumption during menses.

RESULTS

Participants experienced a statistically and clinically significant reduction in pain during the Control (-3.52 ± 1.9), Uno (-2.10 ± 1.6), and Duo (-2.19 ± 1.7) cycles (p < 0.001). The doses of non-steroidal anti-inflammatory drugs consumed during the Control cycle (3.5 ± 2.6), was significantly different as compared with that of Uno (1.5 ± 3.0), or Duo (1.1 ± 2.6) (p = 0.004).

CONCLUSIONS

Use of a commercial transcutaneous electrical nerve stimulation unit results in significant decrease in pain. Although not as robust as the relief in pain induced by non-steroidal anti-inflammatory drugs, the adverse events of transcutaneous electrical nerve stimulation are minimal in comparison. Therefore, transcutaneous electrical nerve stimulation appears to be a viable alternative to pain relief from dysmenorrhea.

CLINICAL TRIAL REGISTRATION

NCT05178589.

Sex Workers in Canada Face Unequal Access to Healthcare: A Systems Thinking Approach

OBJECTIVES

Despite Canada's universal health system, sex workers across the country face an alarmingly high number of barriers when they seek to healthcare services. This has resulted in unmet healthcare needs and substantially poorer health outcomes than the general Canadian population. The objective of this study was to use a systems thinking approach to gain an in-depth understanding of the barriers sex workers face and how access could be improved.

METHODS

The analysis was conducted using a systems thinking methodology, which incorporates systems tools and inquiry processes. The methodology comprised 2 domains of inquiry: (1) Problem Landscape, (2) Solutions Landscape. Systems tools and methods, such as causal loop diagrams, iceberg diagram, and systems mapping, investigated the problem landscape for understanding the interconnected nature of the issue, alongside review of both published and gray literature. An environmental scan explored the current solutions landscape. These methods connected through systemic inquiry processes, including ongoing review and application of diverse perspectives, boundary judgments, interrelationships; enabled gaps and levers of change to be determined.

RESULTS

The main barriers sex workers face are stigma, criminalization, accessibility, and cost of healthcare. The stigma of sex work stems from otherization, paternalism, and moralistic, faith-based beliefs. The barriers unique to sex work are stigma and criminalization; both of which surface as avoidance, dislike, and/or fear of medical professionals. Five gaps each with a lever of change to improve access were identified: (1) Stigma - Collectivization and external collaboration, (2) Criminal status of sex work - Decriminalization, (3) Lack of adequate education - Improved healthcare professional training and anti-discriminatory health policies, (4) Lack of support - Increased community-based healthcare services, (5) Cost of healthcare - Universal coverage of "secondary" healthcare components.

CONCLUSION

Through reducing the stigma surrounding sex work, making changes that improve the healthcare services that sex workers receive, and collaboration between involved parties, sex workers can be prevented from falling through the cracks of the Canadian healthcare system; lessening the health inequities sex workers face and improving their health outcomes.

"Just" a painful period: A philosophical perspective review of the dismissal of menstrual pain

Science and society typically respond to dysmenorrhea-or painful menstrual cramps-as a normal, natural, and inevitable part of menstruation. This normalization has greatly contributed to the systemic dismissal of painful menstrual cramps. Stigma, secrecy, and the expectation to "cope" fuel the normalization of menstrual pain. In this article, I argue that the normalization of menstrual pain restricts the ability to share an excruciating menstrual pain in a way that would otherwise elicit alarm or concern. This can cause clinicians to downgrade menstrual pain, and even menstruating persons to downgrade their own pain. I refer to the dismissal of menstrual pain as an example of a pain-related motivational deficit. A pain-related motivational deficit describes instances in which an utterance fails to motivate due to societal practices and ideas that make it difficult to recognize the import of the embodied experience being shared.

Preoperative Anxiety Impact on Anesthetic and Analgesic Use

Anxiety is a complex emotional state that can arise from the anticipation of a threatening event, and preoperative anxiety is a common experience among adult patients undergoing surgery. In adult patients, the incidence of preoperative anxiety varies widely across different surgical groups, and it can result in a variety of psychophysiological responses and problems. Despite its negative impact, preoperative anxiety often receives insufficient attention in clinical practice. To improve pain management strategies, there is a need for further research on personalized approaches that take into account various factors that contribute to an individual's pain experience. These personalized approaches could involve developing tools to identify individuals who are more likely to experience increased pain and may require additional analgesia. To address this, regular assessments of anxiety levels should be conducted during preoperative visits, and counseling should be provided to patients with high levels of anxiety. Identifying and addressing preoperative anxiety in a timely manner can help reduce its incidence and potential consequences.

Women exaggerate, men downplay: Gendered endorsement of emotional dramatization stereotypes contributes to gender bias in pain expectations

The current work tested whether perceivers believe that women, relative to men, are likely to exaggerate versus downplay pain, an effect we refer to as the gender-pain exaggeration bias. The gender-pain exaggeration bias was operationalized as the extent to which perceivers believe women, relative to men, claim more pain than they feel. Across four experiments, we found that women were expected to exaggerate pain more than men and men were expected to downplay pain more than women (Studies 1-4). Further, judgments that women were more emotionally dramatizing than men contributed to this gender-pain exaggeration bias (Studies 2 and 4). We also assessed whether perceiver-level differences in endorsement of gendered emotional dramatization stereotypes (Studies 3-4) moderated this gender-pain exaggeration bias and found that endorsement of gendered emotional dramatization stereotypes moderated this bias. In sum, we document a relative gender-pain exaggeration bias wherein perceivers believe women, relative to men, to be emotionally dramatizing and therefore more likely to exaggerate versus downplay their pain. This bias may lead perceivers to interpret women's, relative to men's, pain reports as overstatements, inauthentic, or dramatized. Thus, the current work may have implications for well-documented biases in perceptions of (i.e., underestimating) and responses to (i.e., undertreating) women's pain.

Stigma and mental health in endometriosis

This review provides an overview of patient experiences of endometriosis, endometriosis-related types and sources of stigma pertaining to menstruation, chronic pain, and infertility, and their impact on patients' mental health with particular implications for patient care. Because endometriosis is a complex disease with multifactorial etiology, complicated pathophysiology, and a spectrum of clinical features, diagnosis of endometriosis is typically a lengthy process, and many patients experience initial misdiagnosis. A hallmark symptom is severe menstrual pain with other symptoms including chronic pelvic pain, dysmenorrhea, and infertility. Prior research documents that the diagnostic odyssey, complex management, disabling and unpredictable nature of the disease, and painful symptom profile affect multiple life domains of patients, resulting in poor physical, social, and psychological functioning and clinically-significant rates of anxiety and depression for many. More recently, stigma has been recognized as a potent contributor to poor mental health in endometriosis patients, but existing research is limited and largely atheoretical. We identify major sources of stigma related to endometriosis, including menstrual stigma, chronic pain stigma, and infertility stigma, and their likely impact on patients and health care provision. An integrative theoretical approach is described to facilitate research on the prevalence and effects of endometriosis stigma and their explanatory mechanisms, highlighting specific well-validated psychological instruments to assess stigma. Implications for patient care are emphasized. Better understanding of stigma and mental health in people with endometriosis will enhance the standard of care for this patient population.

Veterinary education and experience shape beliefs about dog breeds Part 1: Pain sensitivity

Over 95% of veterinarians report believing that dog breeds differ in pain sensitivity. Ratings made by veterinarians differ from those of the general public, suggesting these beliefs may be learned during veterinary training or clinical experiences. Therefore, the current study's primary objective was to evaluate dog breed pain sensitivity ratings during veterinary training and compare these ratings to those of the general public and undergraduates in animal-health related fields. Using an online survey, members of the general public, undergraduates, veterinary students across all four years, and veterinary faculty and staff rated pain sensitivity of 10 different dog breeds, identified only by their pictures. Compared to the general public and undergraduates, veterinary students rated pain sensitivity across breeds of dog more similarly to veterinary faculty and staff. Further, when undergraduates had clinical experience, they also rated certain dog breeds in a similar way to the veterinary students and professionals. Our findings suggest that veterinary education and clinical experiences influence pain sensitivity ratings across dog breeds. Future research should identify how these pain sensitivity beliefs are communicated and whether these beliefs affect recognition and treatment of pain by veterinarians.

Perception of typical migraine images on the internet: Comparison between a metropolis and a smaller rural city in Germany

The medial portrayal of migraine is often stereotypical and inaccurate but reflects how society perceives migraine. The discrepancy between others' views and the reality of affected individuals may negatively affect access to treatment and the disease course of patients with migraine. This study aimed to investigate whether images presented in the media as typical migraine attacks are perceived as realistic and representative by migraine patients in Rostock, a smaller town in rural Germany, and compare the results to those from Berlin, a large metropolis. We performed an online survey in Rostock. Migraine patients were shown ten images of migraine attacks, which were among the most downloaded stock pictures on the internet under the search term "migraine". They rated on a scale of 0-100 to what extent the pictures were realistic for migraine attacks (realism score), representative of their own migraine (representation score), or the society's view of migraine (society score). In addition, we compared our results with a recently published study from the metropolitan region of Berlin. A total of 174 migraine patients completed our survey. Mean (SD) realism, representation, and society scores were 59.9 (17.5), 56.7 (18.3), and 58.4 (17.1) respectively. Images of older patients were perceived as significantly more realistic and representative than those of younger patients (P < .001). Patients in Rostock (rural region) rated the images as significantly more realistic and representative than survey participants in Berlin (metropolis). Migraine patients in a rural region found typical migraine images only moderately realistic and representative but to a higher degree than their counterparts from a metropolis.

Sex-Based Differences in the Utilization of Shoulder, Hip, and Knee Arthroplasty

INTRODUCTION

Studies show that females have a higher prevalence of osteoarthritis, worse symptoms, but lower rates of joint replacement surgery (JRS). The reason for this remains unknown.

METHODS

A database of JRS candidates was created for patients seen in 2019 at an academic center. Demographics, Kellgren-Lawrence grades, symptom duration, visual analogue pain score, Charlson Comorbidity Index, and nonsurgical treatments were collected. Patients who were offered but declined surgery were invited to focus groups. Two independent sample t-tests, Mann-Whitney U tests, and chi-square tests were used for continuous, scored, and categorical variables, respectively, with two-tailed significance <0.05. Qualitative, code-based analysis was performed for the focus groups.

RESULTS

The cohort included 321 patients (81 shoulder, 59 hip, and 181 knee) including 199 females (62.0%). There were no differences in proportions of females versus males who underwent JRS or in nonsurgical treatments. Female shoulder arthritis patients were older, had a higher visual analogue pain score, and had a higher Charlson Comorbidity Index. In focus groups, males prioritized waiting for technology advancements to return to an active lifestyle, whereas females experienced negative provider interactions, self-advocated for treatment, concerned about pain, and believed that their sex affected their treatment.

DISCUSSION

We found equal utilization of JRS at our institution. However, female patients experienced unique barriers to surgery.

Biological postural oscillations during facial expression of pain in virtual characters modulate early and late ERP components associated with empathy: A pilot study

There is a surge in the use of virtual characters in cognitive sciences. However, their behavioural realism remains to be perfected in order to trigger more spontaneous and socially expected reactions in users. It was recently shown that biological postural oscillations (idle motion) were a key ingredient to enhance the empathic response to its facial pain expression. The objective of this study was to examine, using electroencephalography, whether idle motion would modulate the neural response associated with empathy when viewing a pain-expressing virtual character. Twenty healthy young adults were shown video clips of a virtual character displaying a facial expression of pain while its body was either static (Still condition) or animated with pre-recorded human postural oscillations (Idle condition). Participants rated the virtual human's facial expression of pain as significantly more intense in the Idle condition compared to the Still condition. Both the early (N2-N3) and the late (rLPP) event-related potentials (ERPs) associated with distinct dimensions of empathy, affective resonance and perspective-taking, respectively, were greater in the Idle condition compared to the Still condition. These findings confirm the potential of idle motion to increase empathy for pain expressed by virtual characters. They are discussed in line with contemporary empathy models in relation to human-machine interactions.

Gender and sex bias in prevention and clinical treatment of women's chronic pain: hypotheses of a curriculum development

This discursive paper focuses on undergraduate medical education's role in tackling gender bias in clinical practice, specifically preventing and managing from a non-biomedical perspective chronic pain in women. A preliminary web search of medical schools' curricula was performed to identify programs content related to gender bias in pain management. The web search included 10 universities' websites selected from the top 10 rankings QS Universities Rankings 2022 for medical schools. Additionally, a questionnaire was sent to all deans of the selected academic institutions to explore the curriculum content further. The web search, and the lack of response from the deans, highlighted that relevant curriculum components on gender bias and chronic pain needed to be implemented. Therefore, this paper introduces an innovative curriculum development approach designed by the multi-professional research team to be implemented in medical school programs. This novel educational strategy could also cross-contaminate other healthcare practitioners' university programs and, thus, stimulate an interprofessional debate into fostering inclusiveness and equal opportunities in health.

Equity, Diversity, and Inclusion in anesthesiology: a primer

PURPOSE

This continuing professional development module aims to elucidate the current demographics of anesthesiology in Canada and the experience of anesthesiologists from equity-seeking groups. This module will also identify and describe factors impacting the health care experience of patients from equity-seeking groups who receive perioperative, pain, and obstetric care.

PRINCIPAL FINDINGS

In recent years, discrimination based on sex, gender, race, ethnicity, sexual orientation, ability, other demographic factors, and the intersection of these identities have gained greater attention not only in our society at large but also within medicine and anesthesiology. The stark consequences of this discrimination for both anesthesiologists and patients from equity-seeking groups have become clearer in recent years, although the full scope of the problem is not fully understood. Data regarding the demographics of the national anesthesia workforce are lacking. Literature describing patient perspectives of various equity-seeking groups is also sparse, although increasing. Health disparities impacting people who are racialized, women, LGBTQIA+, and/or living with disability are also present in the perioperative context.

CONCLUSION

Discrimination and inequity persist in the Canadian health care system. It is incumbent upon us to actively work against these inequities every day to create a kinder and more just health care system in Canada.

How Pain-Related Facial Expressions Are Evaluated in Relation to Gender, Race, and Emotion

Inequities in pain assessment are well-documented; however, the psychological mechanisms underlying such biases are poorly understood. We investigated potential perceptual biases in the judgments of faces displaying pain-related movements. Across five online studies, 956 adult participants viewed images of computer-generated faces ("targets") that varied in features related to race (Black and White) and gender (women and men). Target identity was manipulated across participants, and each target had equivalent facial movements that displayed varying intensities of movement in facial action-units related to pain (Studies 1-4) or pain and emotion (Study 5). On each trial, participants provided categorical judgments as to whether a target was in pain (Studies 1-4) or which expression the target displayed (Study 5) and then rated the perceived intensity of the expression. Meta-analyses of Studies 1-4 revealed that movement intensity was positively associated with both categorizing a trial as painful and perceived pain intensity. Target race and gender did not consistently affect pain-related judgments, contrary to well-documented clinical inequities. In Study 5, in which pain was equally likely relative to other emotions, pain was the least frequently selected emotion (5%). Our results suggest that perceivers can utilize facial movements to evaluate pain in other individuals, but perceiving pain may depend on contextual factors. Furthermore, assessments of computer-generated, pain-related facial movements online do not replicate sociocultural biases observed in the clinic. These findings provide a foundation for future studies comparing CGI and real images of pain and emphasize the need for further work on the relationship between pain and emotion.

Supplementary Information

The online version contains supplementary material available at 10.1007/s42761-023-00181-6.

Female reproductive health impacts of Long COVID and associated illnesses including ME/CFS, POTS, and connective tissue disorders: a literature review

Long COVID disproportionately affects premenopausal women, but relatively few studies have examined Long COVID's impact on female reproductive health. We conduct a review of the literature documenting the female reproductive health impacts of Long COVID which may include disruptions to the menstrual cycle, gonadal function, ovarian sufficiency, menopause, and fertility, as well as symptom exacerbation around menstruation. Given limited research, we also review the reproductive health impacts of overlapping and associated illnesses including myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), postural orthostatic tachycardia syndrome (POTS), connective tissue disorders like Ehlers-Danlos syndrome (EDS), and endometriosis, as these illnesses may help to elucidate reproductive health conditions in Long COVID. These associated illnesses, whose patients are 70%-80% women, have increased rates of dysmenorrhea, amenorrhea, oligomenorrhea, dyspareunia, endometriosis, infertility, vulvodynia, intermenstrual bleeding, ovarian cysts, uterine fibroids and bleeding, pelvic congestion syndrome, gynecological surgeries, and adverse pregnancy complications such as preeclampsia, maternal mortality, and premature birth. Additionally, in Long COVID and associated illnesses, symptoms can be impacted by the menstrual cycle, pregnancy, and menopause. We propose priorities for future research and reproductive healthcare in Long COVID based on a review of the literature. These include screening Long COVID patients for comorbid and associated conditions; studying the impacts of the menstrual cycle, pregnancy, and menopause on symptoms and illness progression; uncovering the role of sex differences and sex hormones in Long COVID and associated illnesses; and addressing historical research and healthcare inequities that have contributed to detrimental knowledge gaps for this patient population.

The role of exercise for pain management in adults living with and beyond cancer: a systematic review and meta-analysis

BACKGROUND

Pain is a common side effect of cancer or cancer treatment that negatively impacts biopsychosocial wellbeing and quality of life. Exercise is a potential intervention to manage pain that is safe and has multiple benefits. The objective was to determine the role of exercise in cancer pain management.

METHODS

We completed a systematic review and meta-analysis of exercise interventions in adults with any type or stage of cancer by searching Ovid MEDLINE®, Embase, APA PsycInfo, the Cochrane Central Register of Controlled Trials, CINAHL, and SPORTDiscus. We included experimental and quasi-experimental designs where pain was measured as an outcome. Data synthesis included narrative and tabular summary. A meta-analysis was performed on studies powered to detect the effect of exercise on pain. Study quality was evaluated using the Cochrane risk of bias tool and certainty of evidence was evaluated using the GRADE tool.

RESULTS

Seventy-six studies were included. Studies were predominantly conducted in breast cancer and exercise usually included a combination of aerobic and strength training. Ten studies were included in the meta-analysis demonstrating a significant effect for exercise in decreasing pain (estimated average standard mean difference (SMD) was g =  - 0.73 (95% CI: - 1.16 to - 0.30)); however, the overall effect prediction interval was large. Overall risk of bias for most studies was rated as some concerns and the grading of evidence certainty was low.

CONCLUSION

There are limitations in the evidence for exercise to manage cancer-related pain. Further research is needed to understand the role of exercise in a multimodal pain management strategy.

Patient, family member, and ambulance staff experiences of prehospital acute pain management in adults: A systematic review and meta-synthesis

Background

We aimed to synthesize the qualitative experiences of patients, their family members, and ambulance staff involved in the prehospital management of acute pain in adults and generate recommendations to improve the quality of care.

Methods

A systematic review was conducted following the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines. We searched from inception to June 2021: MEDLINE, CINAHL Complete, PsycINFO and Web of Science (search alerts were screened up to December 2021). Articles were eligible for inclusion if they reported qualitative data and were published in the English language. The Critical Appraisal Skills Program for qualitative studies checklist was used to assess risk of bias, thematic synthesis was performed on included studies and recommendations for clinical practice improvement were generated.

Results

Twenty-five articles were included in the review, representing over 464 patients, family members, and ambulance staff from 8 countries. Six analytical themes and several recommendations to improve clinical practice were generated. Strengthening the patient-clinician relationship by building trust, promoting patient empowerment, addressing patient needs and expectations, and providing a holistic approach to pain treatment is key to improving prehospital pain management in adults. Shared pain management guidelines and training across the prehospital and emergency department intersection should improve the patient journey.

Conclusion

Interventions and guidelines that strengthen the patient-clinician relationship and span the prehospital and emergency department phase of care are likely to improve the quality of care for adults suffering acute pain in the prehospital setting.