Testing the feasibility of a clinical trial comparing a pre-surgery medication cocktail and nerve-numbing injections for pain management after minimally invasive shoulder surgery

ISRCTN	ISRCTN14069845
DOI	https://doi.org/10.1186/ISRCTN14069845
ClinicalTrials.gov (NCT)	Nil known
Clinical Trials Information System (CTIS)	Nil known
Protocol serial number	PJT-156259
Sponsor	Canadian Institutes of Health Research
Funder	Canadian Institutes of Health Research

Submission date: 18/12/2018
Registration date: 03/01/2019
Last edited: 13/08/2025

Recruitment status: Recruiting
Overall study status: Ongoing
Condition category: Musculoskeletal Diseases

Prospectively registered

Protocol

Statistical analysis plan

Results

Individual participant data

Record updated in last year

Plain English summary of protocol

Background and study aims
Pain after surgery occurs in four out of every five patients and is a major public health concern. The goal of this pilot study is to evaluate if a larger randomized controlled trial (RCT) addressing pain management after surgery is possible. Other objectives are to: 1) identify solutions to challenges that may arise in conducting the study, and 2) obtain some data to determine how many patients will be needed for the larger RCT. We chose to study patients undergoing shoulder surgery since it is a common surgery associated with fairly severe pain that is poorly controlled with current opioid-based regimens.

Who can participate?
Adults who are 18 years or older and having shoulder surgery for rotator cuff injury or shoulder instability.

What does the study involve?
The study involves receiving one of two treatments that are routinely used at the participating hospitals. Patients will be randomized to receive: 1) a nerve block, or 2) a combination of pain medications before surgery plus the nerve block.

What are the possible benefits and risks of participating?
We cannot guarantee that there is any personal benefit to participating in the study, i.e. that one treatment is better than the other. However, participants will have the opportunity to contribute to research in pain management. As all the study interventions are routinely used at the participating sites, the risks of this study are the same as the risks assumed when undergoing this surgery without participating in the study. We have reduced some risk by excluding people who are unlikely to benefit or at high risk of certain adverse events.

Where is the study run from?
Patients will be recruited from St. Mary's Hospital.

When is the study starting and how long is it expected to run for?
April 2018 to March 2027

Who is funding the study?
This study is funded by the Canadian Institutes of Health Research.

Who is the main contact?
Dr. Ana Velly
ana.velly@mcgill.ca

Contact information

Dr Ana Velly
Scientific

3755 Cote Ste Catherine, Suite A.017
Montreal
H3T1E2
Canada

ORCID ID	0000-0003-3125-1884

Study information

Primary study design	Interventional
Study design	Interventional pilot randomized parallel trial
Secondary study design	Randomised parallel trial
Study type	Participant information sheet
Scientific title	Optimizing pain management: a pilot randomized trial in patients undergoing arthroscopic shoulder surgery
Study objectives	Current study hypothesis as of 09/01/2025: This trial is an exploratory pilot study to test the feasibility for a future pragmatic trial – this is the primary outcome. We are collecting pilot data on the interventions on post-operative pain only as a secondary outcome, and preliminary data suggests that PMC may reduce pain intensity at 24 hours post-surgery, and possibly reduce routine opioid use as compared to PMC+Block. Therefore, the hypotheses are: Primary hypothesis: The future pragmatic RCT is feasible. Primary hypothesis for the future definitive RCT: PMC+Block will reduce pain intensity at 24 hours post-surgery compared to Block alone; and will reduce the need for rescue opioid medication. Previous study hypothesis: This trial is an exploratory pilot study to test the feasibility for a future pragmatic trial – this is the primary outcome. We are collecting pilot data on the interventions on post-operative pain only as a secondary outcome, and preliminary data suggests that PMC may reduce pain intensity at 24 hours post-surgery, and possibly reduce routine opioid use as compared to PMC+Block. Therefore, the hypotheses are: Primary hypothesis: The future pragmatic RCT is feasible. Primary hypothesis for the future definitive RCT: PMC will reduce pain intensity at 24 hours post-surgery compared to either PMC+Block or Block alone; and will reduce the need for rescue opioid medication.
Ethics approval(s)	1. Approved 25/02/2020, Health Canada, ref: HC6-24-c235630 2. Approved 18/08/2020, St. Mary's Hospital ERB, ref: SMHC-19-03
Health condition(s) or problem(s) studied	Rotator cuff pathology or shoulder instability
Intervention	Current interventions as of 04/07/2025: Consenting patients will be randomly assigned to receive one of two study interventions: Block, or PMC+Block. PMC Group: Pregabalin: 25mg at night on the 5th day prior to surgery, 25mg BID on the 4th day prior to surgery, 50 mg BID on the 3rd day prior to surgery, 75 mg BID on the 2nd and 1st day prior to surgery. In our pilot data (Section 3.5), 75 mg BID appeared effective and it is less likely to create adverse events. If patients do not tolerate the 75mg dose (e.g. sedation), we will use the greatest tolerable dose. Non-steroidal anti-inflammatory drugs: Celecoxib 100 mg PO BID starting 5 days prior to surgery. In case of contra-indication or intolerance, Naproxen EC 500 mg PO BID for 5 days will be used. Block Group: Interscalene Block. An anesthesiologist experienced in providing nerve blocks will administer a preoperative single-shot interscalene block, approximately 1 hour prior to the start of surgery. Either ropivacaine or bupivacaine in a volume of 5-15 ml, and a concentration of 0.5%, with no adjuvants, will be used. We will not use continuous interscalene block due to logistical challenges. Duration of the treatment. For the PMC and PMC+Block groupsgroup, they will receive the PMC 5 days prior to their surgery date. The duration of treatment for these groups is thus 5 days. The Block group will receive their treatment right before their surgery – the duration of treatment is therefore 1 day. Following that, all groups will receive the same, standard postoperative treatment. All participants will have their last follow-up assessment performed at 6 months post-surgery. The time points for follow-ups are at 6 hours, 24 hours, 7 days, 2 and 6 months post-surgery. Randomization. We will apply stratified randomization of patients by surgeon using random number generation by an independent third party. To improve blinding, distinct evaluators will be making assessments. A research assistant will assess POP intensity and research nurses will assess pain medication and adverse events. Further, we will ask patients not to disclose their treatment. However, we recognize that the evaluators may be unblinded if patients disclose their treatment (see Section 7.1). We will also blind the supervising statistician to prevent biases during the analysis (e.g., model selection, and handling of missing data). Wash-out period. There is no wash-out period in this parallel RCT, and there are 3 treatment groups. _____ Previous interventions as of 09/01/2025: Consenting patients will be randomly assigned to receive one of two study interventions: Block, or PMC+Block. PMC Group: Pregabalin: 25mg at night on the 5th day prior to surgery, 25mg BID on the 4th day prior to surgery, 50 mg BID on the 3rd day prior to surgery, 75 mg BID on the 2nd and 1st day prior to surgery. In our pilot data (Section 3.5), 75 mg BID appeared effective and it is less likely to create adverse events. If patients do not tolerate the 75mg dose (e.g. sedation), we will use the greatest tolerable dose. Non-steroidal anti-inflammatory drugs: Celecoxib 100 mg PO BID starting 5 days prior to surgery. In case of contra-indication or intolerance, Naproxen EC 500 mg PO BID for 5 days will be used. Block Group: Interscalene Block. An anesthesiologist experienced in providing nerve blocks will administer a preoperative single-shot interscalene block, approximately 1 hour prior to the start of surgery. Either ropivacaine or bupivacaine in a volume of 5-15 ml, and a concentration of 0.5%, with no adjuvants, will be used. We will not use continuous interscalene block due to logistical challenges. Duration of the treatment. For the PMC and PMC+Block groups, they will receive the PMC 5 days prior to their surgery date. The duration of treatment for these groups is thus 5 days. The Block group will receive their treatment right before their surgery – the duration of treatment is therefore 1 day. Following that, all groups will receive the same, standard postoperative treatment. All participants will have their last follow-up assessment performed at 6 months post-surgery. The time points for follow-ups are at 6 hours, 24 hours, 7 days, 2 and 6 months post-surgery. Randomization. We will apply stratified randomization of patients by surgeon using random number generation by an independent third party. To improve blinding, distinct evaluators will be making assessments. A research assistant will assess POP intensity and research nurses will assess pain medication and adverse events. Further, we will ask patients not to disclose their treatment. However, we recognize that the evaluators may be unblinded if patients disclose their treatment (see Section 7.1). We will also blind the supervising statistician to prevent biases during the analysis (e.g., model selection, and handling of missing data). Wash-out period. There is no wash-out period in this parallel RCT, and there are 3 treatment groups. _____ Previous interventions: Consenting patients will be randomly assigned to receive one of three study interventions: PMC, Block, or PMC+Block. PMC Group: Pregabalin: 25mg at night on the 5th day prior to surgery, 25mg BID on the 4th day prior to surgery, 50 mg BID on the 3rd day prior to surgery, 75 mg BID on 2nd and 1st day prior to surgery. In our pilot data (Section 3.5), 75 mg BID appeared effective and it is less likely to create adverse events. If patients do not tolerate the 75mg dose (e.g. sedation), we will use the greatest tolerable dose. Non-steroidal anti-inflammatory drugs: Celecoxib 100 mg PO BID starting 5 days prior to surgery. In case of contra-indication or intolerance, Naproxen EC 500 mg PO BID for 5 days will be used. Block Group: Interscalene Block. An anesthesiologist experienced in providing nerve blocks will administer a preoperative single shot interscalene block, approximately 1 hour prior to the start of surgery. Either ropivacaine or bupivacaine in a volume of 5-15 ml, and a concentration of 0.5%, with no adjuvants will be used. We will not use continuous interscalene block due to logistical challenges. Duration of the treatment. For the PMC and PMC+Block groups, they will receive the PMC 5 days prior to their surgery date. The duration of treatment for these groups is thus 5 days. The Block group will receive their treatment right before their surgery – duration of treatment is therefore 1 day. Following that, all groups will receive the same, standard postoperative treatment. All participants will have their last follow-up assessment performed at 6 months post-surgery. The time points for follow-ups are at 6 hours, 24 hours, 7 days, 2 and 6 months post-surgery. Randomization. We will apply stratified randomization of patients by surgeon using random number generation by an independent third party. To improve blinding, distinct evaluators will be making assessments. A research assistant will assess POP intensity and research nurses will assess pain medication and adverse events. Further, we will ask patients not to disclose their treatment. However, we recognize that the evaluators may be unblinded if patients disclose their treatment (see Section 7.1). We will also blind the supervising statistician to prevent biases during the analysis (e.g., model selection, handling of missing data). Wash-out period. There is no wash-out period in this parallel RCT, and there are 3 treatment groups.
Intervention type	Mixed
Primary outcome measure(s)	Current primary outcome measure as of 09/01/2025: 1. Recruitment and consent: Recruitment rate will be assessed as the number of eligible participants who consent to participate in the study, by month, every month. If patient recruitment is below 25% early in the process, we will develop methods to improve recruitment decreasing the barriers to recruitment. 2. Treatment allocation randomization, blinding: Problems will be summarized through internal communications. We will assess evaluator unblinding after the trial, and whether it was caused by study processes (solutions would be implemented during the pilot trial), active treatment efficacy, or adverse events. 3. Adherence: We will document challenges and the proposed solutions with all participating surgeons through internal communications. Adherence rate will be calculated by number of participants who adhered at least 50% of the medication as prescribed 5 days before surgery divided by the total of participants who received the prescribed medication (PMC+Block groups). If we cannot increase adherence (defined as taking at least 50% of the medication as prescribed 5 days before surgery) to occur in at least 75% of participants, we will consider the definitive trial to be non-feasible. 4. Attrition: Attrition rates will be assessed by the number of patients who consent to participate who remain in the study until the end of the follow-up period. We will assess dropout during the study. We will document challenges and the proposed solutions with all dropouts through internal communications. We consider a dropout rate of ≤ 20% to be the threshold for a feasible future definitive RCT. 5. Response rates to questionnaires and incomplete questionnaires: We will consider 80% as an acceptable threshold. We will ask all non-responders why they did not to respond the questionnaire or the question and use this information to decide how to improve response rates. 6. Time needed to collect data. We will record how long each set of questionnaires requires, and elicit feedback as to its acceptability. If more than 25% of patients consider the time unacceptable, the definitive RCT will focus on the most important data. Previous primary outcome measure: 1. Recruitment and consent: Recruitment rate will be assessed as the number of eligible participants who consent to participate in the study, by month, every month. If patient recruitment is below 25% early in the process, we will develop methods to improve recruitment decreasing the barriers to recruitment. 2. Treatment allocation randomization, blinding: Problems will be summarized through internal communications. We will assess evaluator unblinding after the trial, and whether it was caused by study processes (solutions would be implemented during the pilot trial), active treatment efficacy, or adverse events. 3. Adherence: We will document challenges and the proposed solutions with all participating surgeons through internal communications. Adherence rate will be calculated by number of participants who adhered at least 50% of the medication as prescribed 5 days before surgery divided by the total of participants who received the prescribed medication (PMC and PMC+Block groups). If we cannot increase adherence (defined as taking at least 50% of the medication as prescribed 5 days before surgery) to occur in at least 75% of participants, we will consider the definitive trial to be non-feasible. 4. Attrition: Attrition rates will be assessed by the number of patients who consent to participate who remain in the study until the end of the follow-up period. We will assess dropout during the study. We will document challenges and the proposed solutions with all dropouts through internal communications. We consider a dropout rate of ≤ 20% to be the threshold for a feasible future definitive RCT. 5. Response rates to questionnaires and incomplete questionnaires: We will consider 80% as an acceptable threshold. We will ask all non-responders why they did not to respond the questionnaire or the question and use this information to decide how to improve response rates. 6. Time needed to collect data. We will record how long each set of questionnaires requires, and elicit feedback as to its acceptability. If more than 25% of patients consider the time unacceptable, the definitive RCT will focus on the most important data.
Key secondary outcome measure(s)	1. Cumulative consumption of opioids for pain management. The research nurse/assistant will assess if patients use opioids at 6 h, 1 day, and 1 week after surgery during their follow-ups at these time points. 2. Pain intensity at 1 day post-surgery. This is generally the primary outcome in trials assessing the effectiveness of POP management. We will measure POP intensity using the standardized, validated questionnaire recommended by the APS: “Patient Outcome questionnaire”(POQ). 3. Pain intensity. We will also assess pain intensity at 6 h, 1 week, 2 and 6 months post-surgery using the POQ as above. 4. Supplemental pain management. We will assess if patients received non-opioid supplemental pain management (rescue medication, other treatments) during follow-ups at 6 h, 1 day, 1 week, and 2 and 6 months after surgery, and identify the treatments received. The research nurse/assistant will be responsible for this. 5. Physical Activity. We will use the validated self-assessment portion of the POQ. This questionnaire will be used at 2 and 6 months post-surgery. 6. Frequency of adverse and serious adverse events: Adverse and serious adverse events will be recorded by the research nurse/assistant at 6h, 1 day, and 7 days post-surgery. In addition, the research nurse/assistant will contact the study surgeons weekly to assess any occurrence of serious adverse events. 7. Cost data. We will record the cost of the anesthesiologist’s time, miscellaneous items (e.g., syringes, gauze pads), and medications by region (Ontario and Quebec).
Completion date	01/03/2027

Eligibility

Participant type(s)	Patient
Age group	Adult
Lower age limit	18 Years
Upper age limit	64 Years
Sex	All
Target sample size at registration	36
Key inclusion criteria	1. Aged 18 years or older 2. Understand English or French; 3. Undergoing arthroscopic surgery for shoulder rotator cuff pathology or shoulder instability with at least 6 months of symptoms.
Key exclusion criteria	Current participant exclusion criteria as of 09/01/2025: 1. Allergies to any of the following drug combinations: 1.1. pregabalin, or 1.2. both celecoxib and naproxen EC; or 1.3. bupivacaine 2. Allergic-type to reactions to sulfonamides 3. History of asthma, urticaria, or allergic-type reactions after taking Acetylsalicylic Acid (ASA) or other NSAIDs (i.e. complete or partial syndrome of ASA-intolerance-rhinosinusitis, urticaria/angioedema, nasal polyps, asthma); 4. Angioedema 5. Bleeding disorders 6. History of ulcers 7. Inflammatory bowel disease 8. Cerebrovascular disease (including but NOT limited to stroke, cerebrovascular accident, transient ischemic attacks and/or amaurosis fugax) 9. Ischemic heart disease (including but NOT limited to acute myocardial infarction, history of myocardial infarction and/or angina) 10. Congestive heart failure (NYHA II-IV) 11. Liver impairment 12. Renal impairment (Renal impairment is identified by an estimated glomerular filtration rate (eGFR) of less than 60 mL/min per 1.73 m2. This valued is estimated from a calculator found at https://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation) 13. Known hyperkalemia 14. Chronic pulmonary lung disease (COPD) 15. Contraindications to pregabalin, or both celecoxib and naproxen EC; or bupivacaine 16. Current use of high-dose opioids (>60 mg equivalents of morphine), gabapentinoids, antidepressants, antipsychotics, or cannabinoids 17. Cancer 18. Pregnancy or lactation. All females under age 55 get pregnancy tests prior to surgery. If they are pregnant, the surgery is cancelled. This procedure is not specific to this study, but a standard practice for all hospitals before surgery. 19. Frail or debilitated patients 20. Life expectancy of less than one year 21. Those without DSQ (Dossier Santé Québec) or ClinicalConnect (Ontario) access 22. Cannot be randomized to receive an interscalene block 23. Patients who refused to do a blood test. 24. Patients with BMI < 19 will be excluded 25. Unable to communicate in English or French Previous participant exclusion criteria as of 10/01/2022 to 09/01/2025: A potential participant who meets any of the following criteria will be excluded from participation in this study: 1. Allergies to any of the following drug combinations: 1.1. Pregabalin 1.2. Both celecoxib and naproxen EC 1.3. Both ropivacaine and bupivacaine 2. Allergic-type reactions to sulfonamides 3. History of asthma, urticaria, or allergic-type reactions after taking Acetylsalicylic Acid (ASA) or other NSAIDs (i.e. complete or partial syndrome of ASA-intolerance-rhinosinusitis, urticaria/angioedema, nasal polyps, asthma) 4. Angioedema 5. Bleeding disorders 6. History of ulcers 7. Inflammatory bowel disease 8. Cerebrovascular disease (including but NOT limited to stroke, cerebrovascular accident, transient ischemic attacks and/or amaurosis fugax) 9. Ischemic heart disease (including but NOT limited to acute myocardial infarction, history of myocardial infarction and/or angina) 10. Congestive heart failure (NYHA II-IV) 11. Liver impairment 12. Renal impairment (Renal impairment is identified by an estimated glomerular filtration rate (eGFR) of less than 60 mL/min per 1.73 m2. This valued is estimated from a calculator found at https://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation) 13. Known hyperkalemia 14. Chronic pulmonary lung disease (COPD) 15. Contraindications to pregabalin, both celecoxib and naproxen EC, or both ropivacaine and bupivacaine 16. Current use of high-dose opioids (>60 mg equivalents of morphine), gabapentinoids, antidepressants, antipsychotics, or cannabinoids 17. Cancer 18. Pregnancy or lactation. All females under age 55 get pregnancy tests prior to surgery. If they are pregnant, the surgery is cancelled. This procedure is not specific to this study, but a standard practice for all hospitals before surgery. 19. Frail or debilitated patients 20. Life expectancy of less than one year 21. Those without DSQ (Dossier Santé Québec) or ClinicalConnect (Ontario) access 22. Cannot be randomized to receive an interscalene block 23. Patients who refused to do a blood test. _____ Previous exclusion criteria as of 12/05/2021: 1. Allergies to any of the following drug combinations: o pregabalin, or o both celecoxib and naproxen EC; or o both ropivacaine and bupivacaine 2. Allergic-type reactions to sulfonamides 3. History of asthma, urticaria, or allergic-type reactions after taking Acetylsalicylic Acid (ASA) or other NSAIDs (i.e. complete or partial syndrome of ASA-intolerance-rhinosinusitis, urticaria/angioedema, nasal polyps, asthma); 4. Angioedema 5. Bleeding disorders 6. History of ulcers 7. Inflammatory bowel disease 8. Cerebrovascular disease (including but NOT limited to stroke, cerebrovascular accident, transient ischemic attacks and/or amaurosis fugax) 9. Ischemic heart disease (including but NOT limited to acute myocardial infarction, history of myocardial infarction and/or angina) 10. Congestive heart failure (NYHA II-IV) 11. Liver impairment 12. Renal impairment (Renal impairment is identified by an estimated glomerular filtration rate (eGFR) of less than 60 mL/min per 1.73 m2. This valued is estimated from a calculator found at https://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation) 13. Known hyperkalemia 14. Chronic pulmonary lung disease (COPD) 15. Cancer 16. Pregnancy or lactation. All females under age 55 get pregnancy tests prior to surgery. If they are pregnant, the surgery is cancelled. This procedure is not specific to this study, but a standard practice for all hospitals before surgery. 17. Frail or debilitated patients 18. Life expectancy of less than one year 19. Current use of high-dose opioids (>60 mg equivalents of morphine), gabapentinoids, antidepressants, antipsychotics, or cannabinoids 20. Cannot be randomized to receive an interscalene block 21. Contraindications to pregabalin, or both celecoxib and naproxen EC, or both ropivacaine and bupivacaine 22. Those without DSQ (Dossier Santé Québec) or ClinicalConnect (Ontario) access. 23. Patients who refused to do a blood test. _____ Previous exclusion criteria: 1. True allergies or other contraindications to any of the medications used in the study 2. Bleeding disorders 3. History of ulcers 4. History of cancer 5. Life expectancy for less than one year 6. Current use of high-dose opioids (>60 mg equivalents of morphine), gabapentinoids, antidepressants, antipsychotics, or cannabinoids; 7. Patients with chronic pulmonary lung disease (COPD)
Date of first enrolment	01/10/2025
Date of final enrolment	28/02/2026

Locations

Countries of recruitment

Canada

Study participating centre

St. Mary’s Hospital

3830 Lacombe Avenue
Montreal
H3T 1M5
Canada

Results and Publications

Individual participant data (IPD) Intention to share	Yes
IPD sharing plan summary	Stored in non-publicly available repository
IPD sharing plan	The datasets generated during and/or analysed during the current study will be stored in a non-publicly available repository. (REDCap; https://project-redcap.org/). Data will be collected only after consent from participants is obtained. Only key study staff will have direct access to REDCap and its data. The study staff is permitted access to only the minimum necessary data required to fulfill their role in the study.

Study outputs

Output type	Details	Date created	Date added	Peer reviewed?	Patient-facing?
Participant information sheet	Participant information sheet	11/11/2025	11/11/2025	No	Yes
Protocol file	version 1.11	11/03/2021	04/07/2025	No	No

Additional files

ISRCTN14069845 Protocol v1.11 March 21 2025.pdf: Protocol file

Editorial Notes

13/08/2025: The following changes were made to the trial record:
1. The date of first enrolment was changed from 01/08/2025 to 01/10/2025.
2. The date of final enrolment was changed from 31/12/2025 to 28/02/2026.
3. The IPD sharing plan was added.
04/07/2025: The following changes were made to the trial record:
1. Uploaded protocol (not peer-reviewed) as an additional file.
2. The interventions were changed.
09/01/2025: The following changes were made:
1. The study hypothesis, interventions, primary outcome measure, and participant exclusion criteria were amended.
2. The upper age limit number and unit were added.
3. The recruitment start date was changed from 01/08/2021 to 01/08/2025.
4. The recruitment end date was changed from 31/12/2021 to 31/12/2025.
5. The following centres were removed: Ottawa Hospital and St. Joseph's Health Care London.
6. The plain English summary was updated.
7. The overall study end date was changed from 01/03/2023 to 01/03/2027.
8. The intention to publish date was changed from 01/04/2023 to 01/04/2027.
10/01/2022: The following changes have been made:
1. The overall trial end date has been changed from 30/04/2022 to 01/03/2023.
2. The participant exclusion criteria have been updated.
3. The trial participating centre "Ottawa Hospital" has been added and the trial participating centre "Maisonneuve-Rosemont Hospital" has been removed.
4. The plain English summary has been updated to reflect the changes above.
12/05/2021: The following changes were made to the trial record:
1. The recruitment start date was changed from 15/02/2019 to 01/08/2021.
2. The recruitment end date was changed from 15/08/2019 to 31/12/2021.
3. The overall end date was changed from 31/03/2020 to 30/04/2022.
4. The intention to publish date was changed from 01/01/2021 to 01/04/2023.
5. The ethics approval was added.
6. The exclusion criteria were changed.
7. The trial participating centre Jewish General Hospital was removed.
4. The plain English summary was updated to reflect these changes.