BackgroundCurrent literature describes the limits and pitfalls of using opioid pharmacotherapy for chronic pain and the importance of identifying alternatives. The objective of this study was to identify the practical issues patients and providers face when accessing alternatives to opioids, and how multiple parties view these issues.MethodsQualitative data were gathered to evaluate the outcomes of acupuncture and chiropractic (A/C) services for chronic musculoskeletal pain (CMP) using structured interview guides among patients with CMP (n = 90) and primary care providers (PCPs) (n = 25) purposively sampled from a managed care health care system as well as from contracted community A/C providers (n = 14). Focus groups and interviews were conducted patients with CMP with varying histories of A/C use. Plan PCPs and contracted A/C providers took part in individual interviews. All participants were asked about their experiences managing chronic pain and experience with and/or attitudes about A/C treatment. Audio recordings were transcribed and thematically coded. A summarized version of the focus group/interview guides is included in the Additional file 1.ResultsWe identified four themes around opioid use: (1) attitudes toward use of opioids to manage chronic pain; (2) the limited alternative options for chronic pain management; (3) the potential of A/C care as a tool to help manage pain; and (4) the complex system around chronic pain management. Despite widespread dissatisfaction with opioid medications for pain management, many practical barriers challenged access to other options. Most of the participants’ perceived A/C care as helpful for short term pain relief. We identified that problems with timing, expectations, and plan coverage limited A/C care potential for pain relief treatment.ConclusionsThese results suggest that education about realistic expectations for chronic pain management and therapy options, as well as making A/C care more easily accessible, might lead to more satisfaction for patients and providers, and provide important input to policy makers.Trial registrationClinicalTrials.gov NCT01345409, date of registration 28/4/2011Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0566-0) contains supplementary material, which is available to authorized users.

Background: Interprofessional collaborative practice (IPCP) offers great potential to improve healthcare. Increases in IPCP will require educating learners in authentic IPCP settings and will generate opportunities and challenges. Methods: In January 2015, we implemented an IPCP model called Collaborative Care (CC) for hospitalized adult medical patients. We explored learner perspectives regarding their educational experiences. We deductively coded transcripts from semi-structured interviews with medical learners. Data related to educational experiences were thematically analyzed. Results: Twenty-four of 28 (85.7%) medical learners rotating on CC from January to May 2015 completed interviews. Subsequent inductive analysis of these interviews identified four themes: Loss of Educational Opportunities during Rounds, Feelings of Uncertainty during New Situations, Strategies for Adaptation, and Improved Communication with Patients and the Team. Conclusions: Increased implementation of IPCP will lead to a greater number of learners being exposed to authentic IPCP settings and will generate opportunities and challenges. Though learners perceived improved communication skills in an IPCP model, they also described loss of profession-specific learning opportunities and feelings of uncertainty. These findings corroborate the need for novel teaching methods aligned with IPCP clinical learning environments and educational assessment strategies that reflect attainment of both profession-specific and interprofessional competencies.

The conclusion by Shahid and colleagues may be misleading. 1 They suggest that older patients taking inhibitors of the renin-angiotensin-aldosterone system (RAAS) could be at greater risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as well as of a worse outcome of COVID-19.Results of available studies have not supported the hypothesis that patients treated with RAAS inhibitors, either angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), are more susceptible to COVID-19. [2][3][4] Furthermore, the outcome of COVID-19 is not worse in patients treated with either ACE inhibitors or ARBs compared with patients not taking RAAS inhibitors in terms of organ dysfunction, admission to the intensive care unit, need for mechanical ventilation, and death. [2][3][4] Rather, the use of these drugs is associated with a lower probability of severe illness in patients with high-risk underlying conditions, such as diabetes mellitus, type II. 2 It is important to emphasize these points because COVID-19 patients have a background cardiovascular risk due to the high prevalence of coexisting conditions, such as hypertension, diabetes mellitus, type II, coronary heart disease, heart failure, and chronic kidney disease, for which ACE inhibitors and ARBs are a cornerstone of therapy, according to guidelines. 5 Advancing age and the presence of comorbidities stand as independent adverse prognostic factors in COVID-19 patients rather than the exposure to RAAS inhibitors. [2][3][4][5] Concern about the harmful effects of RAAS inhibitors in the setting of SARS-CoV-2 infection and COVID-19 has been raised by results, although conflicting, of experimental studies showing that RAAS inhibitors have the potential to upregulate the expression of ACE2. 6 ACE2 is the major binding receptor for SARS-CoV-2 and is broadly expressed in human tissues, including in the lung alveolar epithelial cells and the respiratory tract (i.e., the main targets for SARS-CoV-2). 7,8 This has been viewed to indirectly support the hypothesis that subjects taking RAAS inhibitors could be more susceptible to SARS-CoV-2 infection. However, on the other hand, ACE2 is a counterregulatory enzyme that inactivates and degrades angiotensin II to angiotensin-1 (1-7), therefore attenuating the vasoconstriction, sodium retention, and pro-oxidant, proinflammatory, profibrotic, prothrombotic, and arrhythmogenic effects driven by angiotensin II. 9 Furthermore, ACE2 is internalized and downregulated after SARS-CoV-2 infection, which could lead to unopposed angiotensin II effects and more severe inflammation and lung injury in COVID-19 patients. 10 Not surprisingly, some experimental studies have highlighted a protective role of ACE2 in models of lung injury and the acute respiratory distress syndrome. 6 In conclusion, under both a clinical and mechanistic point of view, there is no evidence in favor of an adverse effect of RAAS inhibitors, either ACE inhibitors or ARBs, in COVID-19 patients.