Oncologists referred patients frequently to SPC, but generally late in the disease course for patients with uncontrolled symptoms. Availability of comprehensive SPC, especially for patients receiving chemotherapy, and persisting definitional issues seem to be the main barriers preventing timely referral.

Chronic postsurgical pain (CPSP), an often unanticipated result of necessary and even life-saving procedures, develops in 5–10% of patients one-year after major surgery. Substantial advances have been made in identifying patients at elevated risk of developing CPSP based on perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. The Transitional Pain Service (TPS) at Toronto General Hospital (TGH) is the first to comprehensively address the problem of CPSP at three stages: 1) preoperatively, 2) postoperatively in hospital, and 3) postoperatively in an outpatient setting for up to 6 months after surgery. Patients at high risk for CPSP are identified early and offered coordinated and comprehensive care by the multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physiotherapists. Access to expert intervention through the Transitional Pain Service bypasses typically long wait times for surgical patients to be referred and seen in chronic pain clinics. This affords the opportunity to impact patients’ pain trajectories, preventing the transition from acute to chronic pain, and reducing suffering, disability, and health care costs. In this report, we describe the workings of the Transitional Pain Service at Toronto General Hospital, including the clinical algorithm used to identify patients, and clinical services offered to patients as they transition through the stages of surgical recovery. We describe the role of the psychological treatment, which draws on innovations in Acceptance and Commitment Therapy that allow for brief and effective behavioral interventions to be applied transdiagnostically and preventatively. Finally, we describe our vision for future growth.

Gap junctions (gjs) are increasingly recognized as playing a significant role in seizures. We demonstrate that different types of gap junctional blocking agents reduce the duration of evoked seizure-like primary afterdischarges (PADs) in the rat in vitro CA1 hippocampal pyramidal region, following repetitive tetanization of the Schaffer collaterals. Intracellular acidosis, which is known to block gap junctional communication, decreased the PADs, whereas alkalinization increased the PADs. Cellular excitability was not significantly depressed as determined by input/output relations recorded before and during perfusion of the gj blockers blockers carbenoxolone and sodium propionate. There was a small decrease following 1-octanol perfusion and a large decrease following NH4Cl application. Carbenoxolone diminished PAD duration, but increased neuronal excitability in whole-cell recordings. After robust PADs were established, the expression of several gj proteins including connexins (Cxs) 26, 32, 36, and 43, as measured by Western blotting, was unchanged, although the level of nonphosphorylated Cx43 was decreased. Our data support the concept that blocking gap junctional communication is an anticonvulsant mechanism.

Although POs acknowledge the importance of early referral to SPC for children with cancer, there remain resource and attitudinal barriers to overcome in this regard.

Chronic (18 h) exposure of cultured hippocampal slices to the type-A GABA receptor blocker, bicuculline methiodide (BMI) 10 lM increased the levels of connexin 43 (Cx43) and connexin 32 (Cx32) mRNAs, but not connexin 26 and connexin 36, as demonstrated by RNase protection assays. The levels of Cx43 and Cx32 proteins in membrane fractions detected by western blotting were also significantly increased. Immunoblotting indicated that BMI also promoted a significant expression of the transcription protein c-fos. The rate of fluorescence recovery after photobleaching, an index of gap junctional coupling, was also significantly increased, whereas it was blocked by the gap junctional blocker, carbenoxolone (100 lM). Extracellular recordings in CA1 stratum pyramidale, performed in BMI-free solution, demonstrated that BMIexposed cultures possessed synaptic responses characteristic of epileptiform discharges: (i) significantly greater frequency of spontaneous epileptiform discharges, (ii) post-synaptic potentials with multiple population spikes, and (iii) significantly longer duration of primary afterdischarges. Carbenoxolone (100 lM), but not its inactive analog, oleanolic acid (100 lM), reversibly inhibited spontaneous and evoked epileptiform discharges. The findings of BMI-induced parallel increases in levels of gap junction expression and function, and the increase in epileptiform discharges, which were sensitive to gap junctional blockers, are consistent with the hypothesis that increased gap junctional communication plays an intrinsic role in the epileptogenic process. Keywords: bicuculline, carbenoxolone, connexins, epilepsy, gap junction. Abbreviations used: ACSF, artificial cerebrospinal fluid; AMPA, a-amino-3-hydroxy-5-methyl-4-isoxazole propionate; APV, 2-amino-5-phosphonovaleric acid; BMI, bicuculline methiodide; CNQX, 6-cyano-7-nitroquinoxaline-2,3-dione; CREB, cAMP response element binding protein; Cx, connexin; FRAP, fluorescence recovery after photobleaching; IPSC, inhibitory post-synaptic current; MPP, myelin proteolipid protein; PAD, primary afterdischarge; PPD, pair-pulse depression; Syn, synapsin.

Objective Previous studies regarding patients' end of life (EOL) preparation have focused mainly on practical tasks, such as advance directives. In this study, we investigate the relational and personal aspects of EOL preparation, using a patient‐completed questionnaire, and examine associations with clinician–patient communication (CPC) and other variables. Methods Patients with advanced cancer but with good performance status were recruited from 24 medical oncology clinics, to participate in a cluster‐randomised controlled trial of early palliative care intervention. Measures included the Quality of Life at the End of Life preparation for EOL subscale, and measures of CPC, functional status, comorbidity, spiritual well‐being and symptom severity. Using chi‐squared tests, t‐tests and multivariate regression analyses, we examined the variables associated with preparation for EOL. We also examined the frequency distributions of individual EOL preparation items and used logistic regression to examine their associations with adequacy of CPC. Results In the 469 patients, characteristics associated with better EOL preparation were better CPC, older age, living alone, less symptom burden and better spiritual well‐being. Thirty‐one per cent agreed that they worried ‘quite a bit’ or ‘completely’ about their family's preparation to cope with the future, and 27% agreed that they would be a burden to their family. All preparation items except regrets about life were associated with adequacy of communication. Conclusions A substantial minority of patients with advanced cancer but with good performance status are concerned about EOL preparation, particularly in relation to their families. Better CPC may help patients prepare not only practically but also personally and socially in relation to the dying process and the welfare of their families. Copyright © 2011 John Wiley & Sons, Ltd.

The elements identified support the delivery of quality care. They may act as a guide for those planning to develop PCUs and form the basis for measures of satisfaction with care.

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