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BackgroundPercutaneous peripheral nerve stimulation is an analgesic technique involving the percutaneous implantation of a lead followed by the delivery of electric current using an external pulse generator. Percutaneous peripheral nerve stimulation has been used extensively for chronic pain, but only uncontrolled series have been published for acute postoperative pain. The current multicenter study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent clinical trial and (2) estimate the treatment effect of percutaneous peripheral nerve stimulation on postoperative pain and opioid consumption.MethodsPreoperatively, an electrical lead was percutaneously implanted to target the sciatic nerve for major foot/ankle surgery (e.g., hallux valgus correction), the femoral nerve for anterior cruciate ligament reconstruction, or the brachial plexus for rotator cuff repair, followed by a single injection of long-acting local anesthetic along the same nerve/plexus. Postoperatively, participants were randomized to 14 days of either electrical stimulation (n = 32) or sham stimulation (n = 34) using an external pulse generator in a double-masked fashion. The dual primary treatment effect outcome measures were (1) cumulative opioid consumption (in oral morphine equivalents) and (2) mean values of the "average" daily pain scores measured on the 0 to 10 Numeric Rating Scale within the first 7 postoperative days.ResultsDuring the first 7 postoperative days, opioid consumption in participants given active stimulation was a median (interquartile range) of 5 mg (0 to 30) versus 48 mg (25 to 90) in patients given sham treatment (ratio of geometric means, 0.20 [97.5% CI, 0.07 to 0.57]; P < 0.001). During this same period, the average pain intensity in patients given active stimulation was a mean ± SD of 1.1 ± 1.1 versus 3.1 ± 1.7 in those given sham (difference, -1.8 [97.5% CI, -2.6 to -0.9]; P < 0.001).ConclusionsPercutaneous peripheral nerve stimulation reduced pain scores and opioid requirements free of systemic side effects during at least the initial week after ambulatory orthopedic surgery.Editor’s perspective

BackgroundPercutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducer needle followed by the delivery of electric current after needle withdrawal. This modality has been used extensively to treat chronic pain, but only small series have been published involving postoperative pain. The ultimate objective of this study is to determine the postoperative effects of percutaneous PNS following moderately to severely painful ambulatory surgery within a real-world clinical practice setting. The primary hypothesis is that surgical pain and opioid consumption during the initial 7 days after surgery will be reduced by percutaneous PNS compared with usual and customary analgesia (dual primary outcome measures).DesignA multicenter pragmatic effectiveness trial. We are randomizing participants having painful orthopedic surgical procedures of the upper and lower extremity to receive 14 days of either 1) electrical stimulation or 2) sham in a double-masked fashion. End points are being assessed at various time points over 12 postoperative months.SummaryThe postoperative experience will be much improved if percutaneous PNS provides potent analgesia while concurrently decreasing opioid requirements following painful surgery. Because this modality can be administered for up to 60 days at home, it may provide postoperative analgesia that outlasts surgical pain yet has relatively few risks and, unlike opioids, has no systemic side effects or potential for abuse, addiction, and overdose. Percutaneous PNS has the potential to revolutionize postoperative analgesia as it has been practiced for the past century. This study will inform key stakeholders regarding an evidence-based nonpharmacologic approach to the management of postoperative pain.

Freshwater ecosystems are threatened by climate change and invasive species. Amphibians are important members of freshwater communities and are susceptible to negative effects of climate change and invasion. Furthermore, both climate change and invasion can influence density of amphibian larvae at the microhabitat scale because of larval clustering. To understand the effects of climate change and invasion on Pacific Chorus Frog Pseudacris regilla (Baird and Girard, 1852) larvae, a 2 × 2 × 2 factorial experiment was carried out with a climate treatment (future/historical; simulated as changes in both temperature and hydroperiod), indirect exposure to the invasive Brook Stickleback Culaea inconstans (Kirtland, 1840) fish (chemical cues present/absent), and conspecific density (conspecific present/absent). We measured tadpole survival and development rate along with variables related to body shape, including mass, growth, growth rate, body mass index, tail fin depth, tail muscle depth, tail muscle width, and rear limb length. We assessed the effects of 3 common and important stressors (climate, invasive species, and density) alone and in combination with the other stressors to explore their interactions. Climate change, as simulated by our study, had large effects on Pacific Chorus Frog tadpole development and body shape. Brook Stickleback chemical cues had smaller but important effects on body shape and development rate when combined with additional stressors. Competition because of presence of a conspecific tadpole also reduced survival and had large effects on body shape. Pairwise interactions were largely additive or antagonistic. Three-way stressor interactions were most often antagonistic, resulting in less-than-additive effects of the 3 stressors together. However, 3 synergistic 3-way emergent interactions were detected. When all 3 stressors were present, development rate was faster than expected but rear limb length and tail muscle width were smaller than expected. Our results illustrate that climate change and conspecific density have wide-ranging effects on amphibian growth, development, and morphology—effects which may carry over into the terrestrial stage and reduce fitness. Furthermore, our findings reveal complex stressor interactions that were not predictable from single stressor effects or pairwise stressor effects, illustrating the difficulty in predicting multiple stressor interactions in freshwater systems. [ABSTRACT FROM AUTHOR]

Discusses the positive effects of cooperative learning on students' academic achievement, attitudes toward each other, and social and affective development. Describes two cooperative learning techniques with broad utility and adaptability: the jigsaw strategy and student teams achievement division. (SV)

Climate change and invasive species threaten many ecosystems, including surface freshwater systems. Increasing temperatures and reduced hydroperiod due to climate change may promote the persistence of invasive species and facilitate new invasions due to potentially higher tolerance to environmental stress in successful invaders. Amphibians demonstrate high levels of plasticity in life history characteristics, particularly those species which inhabit both ephemeral and permanent water bodies. We tested the influence of two projected effects of climate change (increased temperature and reduced hydroperiod) on Pacific chorus frog (Pseudacris regilla) tadpoles alone and in combination with the presence of tadpoles of a wide-spread invasive amphibian, the American bullfrog (Lithobates catesbeianus). Specifically, we explored the effects of projected climate change and invasion on survival, growth, mass at stage 42, and development rate of Pacific chorus frogs. Direct and indirect interactions between the invasive tadpole and the native tadpole were controlled via a cage treatment and were included to account for differences in presence of the bullfrog compared to competition for food resources and other direct effects. Overall, bullfrogs had larger negative effects on Pacific chorus frogs than climate conditions. Under future climate conditions, Pacific chorus frogs developed faster and emerged heavier. Pacific chorus frog tadpoles developing in the presence of American bullfrogs, regardless of cage treatment, emerged lighter. When future climate conditions and presence of invasive American bullfrog tadpoles were combined, tadpoles grew less. However, no interaction was detected between climate conditions and bullfrog presence for mass, suggesting that tadpoles allocated energy towards mass rather than length under the combined stress treatment. The maintenance of overall body condition (smaller but heavier metamorphs) when future climate conditions overlap with bullfrog presence suggests that Pacific chorus frogs may be partially compensating for the negative effects of bullfrogs via increased allocation of energy towards mass. Strong plasticity, as demonstrated by Pacific chorus frog larvae in our study, may allow species to match the demands of new environments, including under future climate change. [ABSTRACT FROM AUTHOR]

Background: Studies have found that diffuse pain, indicative of central sensitization, portends poor interventional outcomes. Multiple chemical sensitivities are associated with signs of central sensitization. We sought to prospectively determine whether hypersensitivity reactions (HR) were associated with epidural steroid injection (ESI) outcomes.Methods: HR were classified as immune-related or non-immune-related and categorized by number (0=low, 1 or 2=intermediate, ≥3=high). The primary outcome measure was mean reduction in average leg pain score 1 month post-procedure. A positive outcome was defined as a two-point or greater decrease in average leg pain accompanied by satisfaction 1 month post-procedure.Results: The mean number of immune-mediated and non-immune-mediated HR were 0.6±1.2 and 0.8±1.4, respectively. Individuals in the high (n=24) total HR group had a mean reduction in average leg pain of 0.1±2.7, compared with those in the low (n=61; 1.8±2.1, p=0.025) and intermediate groups (n=52; 1.6±3.1, p=0.060). For back pain and categorical successful outcome, those with fewer HR experienced greater benefit. There were no differences in outcomes when patients were stratified by immune-related HR. Among participants in the low, intermediate and high non-immune-mediated HR groups, the mean reductions in average leg pain scores were 1.7±2.5, 1.6±3.0, and -0.2±2.3, respectively (p = 0.002). 51%, 35%, and 12% of people with low, intermediate and high numbers of non-immune-mediated HR experienced a positive categorical outcome, respectively (p=0.007).Conclusions: Non-immune-related HR were inversely correlated with some ESI outcome measures. [ABSTRACT FROM AUTHOR]

Background: The use of compounded topical pain creams has increased dramatically, yet their effectiveness has not been well evaluated.Objective: To determine the efficacy of compounded creams for chronic pain.Design: Randomized controlled trials of 3 interventions. (ClinicalTrials.gov: NCT02497066).Setting: Military treatment facility.Participants: 399 patients with localized pain classified by each patient's treating physician as neuropathic (n = 133), nociceptive (n = 133), or mixed (n = 133).Intervention: Pain creams compounded for neuropathic pain (ketamine, gabapentin, clonidine, and lidocaine), nociceptive pain (ketoprofen, baclofen, cyclobenzaprine, and lidocaine), or mixed pain (ketamine, gabapentin, diclofenac, baclofen, cyclobenzaprine, and lidocaine), or placebo.Measurements: The primary outcome measure was average pain score 1 month after treatment. A positive categorical response was a reduction in pain score of 2 or more points coupled with a score above 3 on a 5-point satisfaction scale. Secondary outcomes included Short Form-36 Health Survey scores, satisfaction, and categorical response. Participants with a positive outcome were followed through 3 months.Results: For the primary outcome, no differences were found in the mean reduction in average pain scores between the treatment and control groups for patients with neuropathic pain (-0.1 points [95% CI, -0.8 to 0.5 points]), nociceptive pain (-0.3 points [CI, -0.9 to 0.2 points]), or mixed pain (-0.3 points [CI, -0.9 to 0.2 points]), or for all patients (-0.3 points [CI, -0.6 to 0.1 points]). At 1 month, 72 participants (36%) in the treatment groups and 54 (28%) in the control group had a positive outcome (risk difference, 8% [CI, -1% to 17%]).Limitations: Generalizability is limited by heterogeneity among pain conditions and formulations of the study interventions. Randomized follow-up was only 1 month.Conclusion: Compounded pain creams were not better than placebo creams, and their higher costs compared with approved compounds should curtail routine use.Primary Funding Source: Centers for Rehabilitation Sciences Research, Defense Health Agency, U.S. Department of Defense. [ABSTRACT FROM AUTHOR]

Historically, war tends to accelerate innovation within military medicine. In this article, the authors argue this truism has recurred in the case of acute and chronic pain management for combatants in the global war on terrorism (GWOT). Advances in regional anesthesia techniques and multimodal acute pain care are highlighted in light of the typical weapons, injuries, and comorbid conditions of the modern combat era. Reported success of providing chronic pain care in the war theater during GWOT is discussed in the context of operational requirements for current and future wars. A description is provided of the Pain Management Task Force (PMTF) and Pain Campaign Plan which was initiated during GWOT. The PMTF effort enhanced pain education and clinical pain care through leadership and organizational changes, which created broader access to pain treatments for patients and more standardized treatment capabilities across the enterprise. [ABSTRACT FROM AUTHOR]

Unlabelled: Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence.Perspective: This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations. [ABSTRACT FROM AUTHOR]

Morphine and other opioid drugs have played a major role in austere environment pain management since the Civil War, particularly in the military. While the pre-eminence and success of such medications is without question, their use is accompanied by significant side effects that are undesirable in the most advanced medical settings, and are potentially devastating in the field environment. Recently, there have been significant improvements in pain care for America's wounded service members, along with a shift in how many care providers view pain management. An increasing number of healthcare providers are seeing pain not merely as a symptom, but as a disease process. In addition to dramatically improving care for wounded service members, the evolution in the military's approach to pain is enhancing care for civilians. [ABSTRACT FROM AUTHOR]

A streamlined genetic algorithm was developed and implemented on a GPU to evaluate low-thrust trajectories of spacecraft propelled by an ion thruster. It was then applied to examine the utility of a specific thruster for an asteroid impact mission. This method was validated by comparing impact speeds of non-thruster results with the DART mission, which does not significantly use the equipped ion thruster. Then, by utilizing the ion thruster for prolonged periods, this model demonstrated the possibility of significant increases in the impact speed and significant decreases in the trip times. This specific test case was used to examine the utility of the model and, by methodically varying relevant variables, this article shows the influence of the genetic algorithm on the results. By examining a range of electrical power levels, the results presented here provide hints as to the possible effects of spacecraft design trade-offs on impact speed. The analysis of the effects of the algorithm on the results and the evaluation of thruster operating parameters indicate the applicability of this model to a variety of spaceflight missions. [ABSTRACT FROM AUTHOR]

Discusses computer upgrade tips for the technology teacher. Random Access Memory upgrade procedure; Installation of single-in-line memory modules and dual in-line memory modules; Hard drive upgrade procedure.

Given the availability of cameras in mobile phones, drones and Internet-connected devices, facial privacy has become an area of major interest in the last few years, especially when photos are captured and can be used to identify bystanders' faces who may have not given consent for these photos to be taken and be identified. Some solutions to protect facial privacy in photos currently exist. However, many of these solutions do not give a choice to bystanders because they rely on algorithms that de-identify photos or protocols to deactivate devices and systems not controlled by bystanders, thereby being dependent on the bystanders' trust in these systems to protect his/her facial privacy. To address these limitations, we propose FacePET (Facial Privacy Enhancing Technology), a wearable system worn by bystanders and designed to enhance facial privacy. We present the design, implementation, and evaluation of the FacePET and discuss some open research issues. [ABSTRACT FROM AUTHOR]

There are differences in perceptions of safety culture between healthcare leaders and staff. Evidence suggests that an organization's actual safety performance is more closely reflected in staff perceptions suggesting that frontline staff may be more aware than the leadership of actual patient safety challenges within their organization. Closing the perception gap between healthcare leaders and staff is critical to aligning the resources and strategies required to create a true culture of safety.

Background: In recent years, convincing evidence has emerged implicating tumor necrosis factor alpha as a causative factor in radiculopathy and discogenic back pain. But although preliminary open-label studies demonstrated promising results for the treatment of low back pain with tumor necrosis factor-alpha inhibitors, early optimism has been tainted by a controlled study showing no significant benefit in sciatica. To determine whether outcomes might be improved by a more direct route of administration, the authors evaluated escalating doses of intradiscal etanercept in 36 patients with chronic lumbosacral radiculopathy or discogenic low back pain., Methods: A double-blind, placebo-controlled pilot study was conducted whereby six patients received 0.1, 0.25, 0.5, 0.75, 1.0, or 1.5 mg etanercept intradiscally in each pain-generating disc. In each escalating dose group of six patients, one received placebo. A neurologic examination and postprocedure leukocyte counts were performed in all patients at 1-month follow-up visits. In patients who experienced significant improvement in pain scores and function, follow-up visits were conducted 3 and 6 months after the procedure., Results: At 1-month follow-up, no differences were found for pain scores or disability scores between or within groups for any dose range or subgroup of patients. Only eight patients remained in the study after 1 month and elected to forego further treatment. No complications were reported, and no differences were noted between preprocedure and postprocedure leukocyte counts., Conclusions: Although no serious side effects were observed in this small study, a single low dose of intradiscal etanercept does not seem to be an effective treatment for chronic radicular or discogenic low back pain.

Unlabelled: In recent military conflicts the major source of soldier attrition has not been battle injuries but more mundane causes similar to those encountered in civilian life. In an effort to determine the pain conditions affecting soldiers during wartime, we conducted an observational study among 162 soldiers medically evacuated from Operation Iraqi Freedom who were referred to 2 large pain treatment centers located outside the theaters of combat. Fifty-three percent of soldiers presented with either radicular (n = 49) or axial (n = 37) low back pain, with lumbar herniated disk being the most frequently diagnosed condition (24%). The two most implicated etiologies were exacerbation of a previous pain condition treated with surgery (15%) and motor vehicle accidents(12%). Only 17% of patients were injured during battle. Seventy-two percent of soldiers received at least one nerve block/injection, the most common of which was lumbar epidural steroid administration (22%). Nonsteroidal antiinflammatory drugs were prescribed to 56% of patients, opioids to 49%, and some form of alternative therapy to 17%. Among the 49 patients in whom data were available, only 2% returned to combat duty in Iraq. With the exception of battle-related injuries, the pain conditions suffered during modern warfare seem to be similar to those encountered in civilian pain clinics. To improve the return-to-duty rate, better preventive measures and more aggressive treatment conducted in forward-deployed medical units are recommended., Implications: We conducted an observational study at two large military pain treatment centers among soldiers injured in Operation Iraqi Freedom. Fifty-three percent of soldiers presented with low back pain, with lumbar herniated disk being the most common diagnosis. Only 2% of patients returned to combat duty in Iraq. To improve the return-to-duty rate, better preventive measures and more aggressive treatment in forward-deployed medical units are recommended.