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BACKGROUND: Refractory angina is a severe chronic disease, defined as angina which cannot be controlled by usual treatments for heart disease. This disease is frightening, debilitating, and difficult to manage. Many people suffering refractory have inadequate pain relief, continually revisit emergency departments for help, undergo repeated cardiac investigations, and struggle with obtaining appropriate care. There is no clear framework to help people understand the risks and benefits of available treatment options in Canada. Some treatments for refractory angina are invasive, while others are not covered by provincial health insurance plans. Effective care for refractory angina sufferers in Canada is critically underdeveloped; it is important that healthcare professionals and refractory angina sufferers alike understand the treatment options and their implications. This proposal builds on the recent Canadian practice guidelines for the management of refractory angina. We propose to develop a decision support tool in order to help people suffering from refractory angina make well-informed decisions about their healthcare and reduce their uncertainty about treatment options. METHODS: This project will be conducted in three phases: a) development of the support tool with input from clinical experts, the Canadian refractory angina guidelines, and people living with refractory angina, b) pilot testing of the usability of the tool, and c) formal preliminary evaluation of the effectiveness of the support tool to help people make informed decisions about treatment options. DISCUSSION: A decision support tool for refractory angina is needed and the available data suggest that by developing such a tool, we may be able to help refractory angina sufferers better understand their condition and the effectiveness of available treatment options (in their respective clinical settings) as well as their implications (e.g. risks vs. benefits). By virtue of this tool, we may also be able to facilitate identification and inclusion of patients' values and preferences in the decision making process. This is particularly important as refractory angina is an intractable condition, necessitating that the selected course of treatment be lifelong. This study will yield a much needed patient decision aid for people living with refractory angina and pilot data to support a subsequent effectiveness study.

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OBJECTIVE: Currently, the use of spinal cord stimulation (SCS) therapy is not recommended in pregnancy because the effects of SCS on the pregnancy and developing fetus are unknown. However, many SCS recipients are women of childbearing age who may later become pregnant. The purpose of the present report is to review and summarize the existing literature on the use of SCS therapy during the prenatal period. METHODS: We first present the case of a 38-year-old woman from our center who became pregnant after receiving an SCS implantation. We then provide a synopsis of previous reports that were identified in a literature search. We highlight the key findings from these cases as they relate to the course of pregnancy, fetal development, labor and delivery management, fertility, and technical complications. RESULTS: In our literature review, we identified 12 cases of pregnancy in 8 women. To these we add the present case. CONCLUSIONS: Women of childbearing age who are candidates for SCS implantation should be tested for pregnancy prior to implantation surgery. They also should be informed about the limited state of our scientific knowledge regarding the impact of this technology on reproductive health. For patients already implanted with SCS, decisions about ongoing use in the event of pregnancy should be made on an individual basis after a careful consideration of potential risks and benefits.

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Refractory angina (RFA) is a debilitating disease characterized by cardiac pain resistant to conventional treatments for coronary artery disease including nitrates, calcium-channel and ß-adrenoceptor blockade, vasculoprotective agents, percutaneous coronary interventions, and coronary artery bypass grafting. The mortality rate of patients living with RFA is not known but is thought to be in the range of approximately 3%. These individuals suffer severely impaired health-related quality of life with recurrent and sustained pain, poor general health status, psychological distress, impaired role functioning, and activity restriction. Effective care for RFA sufferers in Canada is critically underdeveloped. These guidelines are predicated upon a 2009 Canadian Cardiovascular Society (CCS) Position Statement which identified that underlying the problem of RFA management is the lack of a formalized, coordinated, interprofessional strategy between the cardiovascular and pain science/clinical communities. The guidelines are therefore a joint initiative of the CCS and the Canadian Pain Society (CPS) and make practice recommendations about treatment options for RFA that are based on the best available evidence. Concluding summary recommendations are also made, giving direction to future clinical practice and research on RFA management in Canada.

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BACKGROUND: The need for intrathecal infusion in a palliative care setting is infrequent. Despite established efficacy, safety and cost effectiveness, this is considered an 'extraordinary measure' in Canada. Patients requiring this approach are not typical palliative care patients, having shorter and more uncertain life expectancies. OBJECTIVES: The present study is a qualitative exploration of the impact of intrathecal pump implantation on cancer patients, and also the impact of the intervention on the staff caring for those patients. METHODS: Palliative care unit patients who received an implanted intrathecal pump or dome catheter for intractable cancer pain participated in multiple semistructured interviews. Doctors and nurses caring for each patient were also interviewed. Interviews were recorded and analyzed for themes. The study terminated when saturation was reached. RESULTS: Six patients participated, with up to three interviews each. Twenty-four staff interviews took place. Patients' hopes and expectations were not always fully met, but the infusions had a profound positive effect on quality of life. Patients expressed anxiety about dependence on the device, and also on a few highly skilled individuals. Staff interviews revealed a significant impact on the 'culture' of the palliative care unit. Clear communication of the rationale for infusion was very important, as was regular education about infusion management. CONCLUSIONS: Implanted intrathecal infusion devices are a necessary part of a tertiary level cancer pain management service for the unfortunate minority with intractable pain. Practical recommendations for care are made for palliative care programs contemplating offering intrathecal infusions.

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