Background: Chronic postsurgical pain is a common complication of surgery. The role of psychologic risk factors like depression and anxiety is substantially understudied in cardiac surgery. This study sought to identify perioperative factors associated with chronic pain at 3, 6, and 12 months after cardiac surgery. The authors hypothesize that baseline psychologic vulnerabilities have a negative influence on chronic postsurgical pain. Methods: The authors prospectively collected demographic, psychologic, and perioperative factors in a cohort of 1,059 patients undergoing cardiac surgery at the Toronto General Hospital between 2012 and 2020. Patients were followed and completed chronic pain questionnaires at 3, 6, and 12 months after surgery. Results: The study included 767 patients who completed at least one follow-up questionnaire. The incidence of postsurgical pain (more than 0 out of 10) at 3, 6, and 12 months after surgery was 191 of 663 (29%), 118 of 625 (19%), and 89 of 605 (15%), respectively. Notably, among patients reporting any pain, the incidence of pain compatible with a neuropathic phenotype increased from 56 of 166 (34%) at 3 months to 38 of 97 (39%) at 6 months and 43 of 67 (64%) at 12 months. Factors associated with postsurgical pain scores at 3 months include female sex, pre-existing chronic pain, previous cardiac surgery, preoperative depression, baseline pain catastrophizing scores, and moderate-to-severe acute pain (4 or more out of 10) within 5 postoperative days. Conclusions: Nearly one in three patients undergoing cardiac surgery reported pain at 3 months of follow-up, with approximately 15% reporting persistent pain at 1 yr. Female sex, pre-existing chronic pain, and baseline depression were associated with postsurgical pain scores across all three time periods. Editor’s Perspective: What We Already Know about This Topic: What This Article Tells Us That Is New:

Summary: Background: Delirium is a common and potentially serious complication after major surgery. A previous history of depression is a known risk factor for experiencing delirium in patients admitted to the hospital, but the generalised risk has not been estimated in surgical patients. Methods: We conducted a systematic review and meta‐analysis of studies reporting the incidence or relative risk (or relative odds) of delirium in the immediate postoperative period for adults with pre‐operative depression. We included studies that defined depression as either a formal pre‐existing diagnosis or having clinically important depressive symptoms measured using a patient‐reported instrument before surgery. Multilevel random effects meta‐analyses were used to estimate the pooled incidences and pooled relative risks. We also conducted subgroup analyses by various study‐level characteristics to identify important moderators of pooled estimates. Results: Forty‐two studies (n = 4,664,051) from five continents were included. The pooled incidence of postoperative delirium for patients with pre‐operative depression was 29% (95%CI 17–43%, I ² = 99.0%), compared with 15% (95%CI 6–28%, I ² = 99.8%) in patients without pre‐operative depression and 21% (95% CI 11–33%, I ² = 99.8%) in the cohorts overall. For patients with pre‐operative depression, the risk of delirium was 1.91 times greater (95%CI 1.68–2.17, I ² = 42.0%) compared with patients without pre‐operative depression. Conclusions: Patients with a previous diagnosis of depression or clinically important depressive symptoms before surgery have substantially greater risk of experiencing delirium after surgery. Clinicians and patients should be informed of these increased risks. Robust screening and other risk mitigation strategies for postoperative delirium are warranted, especially for patients with pre‐operative depression.

There is substantial evidence showing that medical student wellness is a worsening problem in Canada. It is apparent that medical students’ wellness deteriorates throughout their training. Medical schools and their governing bodies are responding by integrating wellness into competency frameworks and accreditation standards through a combination of system- and individual-level approaches. System-level strategies that consider how policies, medical culture, and the “hidden curriculum” impact student wellness, are essential for reducing burnout prevalence and achieving optimal wellness outcomes. Individual-level initiatives such as wellness programming are widespread and more commonly used. These are often didactic, placing the onus on the student without addressing the learning environment. Despite significant progress, there is little programming consistency across schools or training levels. There is no wellness curriculum framework for Canadian undergraduate medical education that aligns with residency competencies. Creating such a framework would help align individual- and system-level initiatives and smooth the transition from medical school to residency. The framework would organize goals within relevant wellness domains, allow for local adaptability, consider basic learner needs, and be learner-informed. Physicians whose wellness has been supported throughout their training will positively contribute to the quality of patient care, work environments, and in sustaining a healthy Canadian population. Nous disposons d’un grand nombre de données concrètes démontrant que le bien-être des étudiants en médecine au Canada se détériore tout au long de leur cheminement universitaire et que le problème s’aggrave. Alliant les approches systémique et individuelle, les facultés de médecine et leurs directions réagissent en intégrant le bien-être dans les cadres de compétences et les normes d’agrément. Les stratégies systémiques, qui tiennent compte de l’impact des politiques, de la culture médicale et du « curriculum caché » sur le bien-être des étudiants, sont indispensables pour prévenir l’épuisement professionnel et pour obtenir des résultats optimaux en matière de bien-être. Les initiatives au niveau individuel, comme les programmes axés sur le bien-être, sont de plus en plus répandues. Ces programmes sont souvent didactiques et ils sollicitent l’étudiant sans tenir compte de l’environnement d’apprentissage. Bien que ces initiatives aient marqué des progrès importants, il y a peu d’uniformité entre les programmes des diverses facultés et entre les niveaux de formation. Il n’y a pas de cadre pédagogique pour les programmes d’études de premier cycle axés sur le bien-être au Canada s’alignant aux compétences visées dans les programmes de résidence. La création d’un tel cadre permettrait d’harmoniser les initiatives de niveau individuel et celles de niveau systémique et de faciliter la transition de la faculté de médecine vers la résidence. Il comporterait des objectifs organisés selon les domaines de bien-être pertinents, une souplesse permettant son adaptation aux divers milieux, il tiendrait compte des besoins fondamentaux des apprenants et il serait fondé sur une consultation de ces derniers. Les médecins dont le bien-être a été soutenu tout au long de leur formation contribueront de façon positive à la qualité des soins aux patients, à leur environnement de travail et au maintien d’une population canadienne en bonne santé.