ObjectivesAcute pain is a common presenting complaint in health care. Yet, undertreatment of pain remains a prevailing issue that often results in poor short- and long-term patient outcomes. To address this problem, initiatives to improve teaching on pain management need to begin in medical school. In this study, we aimed to describe medical students’ perspectives of their curriculum, comfort levels, and most effective pain teaching modalities.Materials and methodsA cross-sectional, online survey was distributed to medical students at the University of Alberta (Edmonton, Canada) from late May to early July 2015. Data were collected from pre-clerkship (year 1 and 2) and clerkship (year 3 and 4) medical students for demographic characteristics, knowledge, comfort, and attitudes regarding acute pain management.ResultsA total of 124/670 (19.6%) surveys were returned. Students recalled a median of 2 (interquartile range [IQR]=4), 5 (IQR=3.75), 4 (IQR=8), and 3 (IQR=3.75) hours of formal pain education from first to forth year, respectively. Clerkship students were more comfortable than pre-clerks with treating adult pain (52.1% of pre-clerks “uncomfortable” versus 22.9% of clerks, p<0.001), and overall, the majority of students were uncomfortable with managing pediatric pain (87.6% [64/73] pre-clerks and 75.0% [36/48] clerks were “uncomfortable”). For delivery of pain-related education, the majority of pre-clerks reported lectures as most effective (51.7%), whereas clerks chose bedside instruction (43.7%) and small group sessions (23.9%). Notably, 54.2%, 39.6%, and 56.2% of clerks reported incorrect doses of acetaminophen, ibuprofen, and morphine, respectively, for adults. For children, 54.2%, 54.2%, and 78.7% of clerks reported incorrect doses for these same medications.ConclusionMedical students recall few hours of training in pain management and report discomfort in treating and assessing both adult and (more so) pediatric pain. Strategies are needed to improve education for future physicians regarding pain management.

Background Inadequately treated pain is associated with significant morbidity in older adults. We aimed to describe current pain management practices for patients with fragility pelvic fractures, a common emergency department (ED) presentation in older adults. Methods We performed a health records' review of adults ≥ 65 years old who presented to two academic EDs with nonoperative fragility pelvic fractures between 01/2014 and 09/2018. The primary outcome measures were type and timing of analgesic medications. Secondary outcome measures included ancillary service consultation, ED length of stay, admission rate and rate of return to ED at 30 days. Data were reported using descriptive statistics. ResultsWe included 411 patients. The majority were female (339, 82.5%) with mean age 83.9 (SD 8.1) years. Nearly, onethird (130, 31.6%) did not receive any analgesia for their fracture. Analgesia was initiated in 123 (29.9%) patients through paramedic and nursing medical directives; 244 (59.4%) patients received physician-initiated opioids (hydromorphone 228 (55.5%); morphine 28 (6.8%)). Only 23.1% of patients received one or more ancillary services: physiotherapy (10.5%), social work (7.3%), geriatric nurse assessment (14.1%), and homecare (3.9%). Mean ED length of stay was 11.6 (SD 7.1) h; 210 (51.1%) patients were admitted; of those discharged, 45 (22.4%) returned to the ED within 30 days. Conclusion One in three older adults presenting to the ED with nonoperative fragility pelvic fractures receive no analgesia during the course of their prehospital and ED care. Barriers to quality care must be identified and processes implemented to ensure adequate pain management for this population. Keywords Fragility pelvic fracture • Pain • Older • Emergency Department RésuméContexte La douleur insuffisamment traitée est associée à une morbidité importante chez les personnes âgées. Nous voulions décrire les pratiques actuelles de gestion de la douleur chez les patients souffrant de fractures pelviennes de fragilité, une présentation courante des services d'urgence (SU) chez les personnes âgées. Méthodes Nous avons effectué une revue des dossiers médicaux des adultes ≥ 65 ans qui se sont présentés à deux urgences universitaires avec des fractures pelviennes de fragilité non opérées entre 01/2014 et 09/2018. Les principaux critères d'évaluation étaient le type et le moment de la prise de médicaments analgésiques. Les critères d'évaluation secondairesThe results of this study have been accepted for presentation at the

Ongoing studies using genotyping and novel antiplatelet regimens may identify potential strategies to minimize ischemic and bleeding risks concurrently. Until definitive studies demonstrate clear benefit of a personalized approach to P2Y12 inhibitor prescription, the choice of P2Y12 inhibitors should continue to be based on best evidence from previous large clinical trials.

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