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Alaa Abd-Sayed,1 Kenneth Fiala,1 Jacqueline Weibstein,2 Pooja Chopra,3 Christopher Lam,4 Hemant Kalia,5 Navdeep Jassal,6 Amitabh Gulati,7 Dawood Sayed,4 Timothy Deer8 1Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792-3272, USA; 2Napa Valley Orthopedic Medical Group, Napa, CA, 94558, USA; 3Bux Pain Management, Danville, KY, 40422, USA; 4Department of Anesthesiology, University of Kansas, Kansas City, KS, 66160, USA; 5Rochester Regional Health, Rochester, NY, 14626, USA; 6Excel Pain and Spine, Lakeland, FL, 33805, USA; 7Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, NY, NY, 10604, USA; 8Department of Anesthesiology, University of West Virginia, Charleston, WV, 25301, USACorrespondence: Alaa Abd-Sayed, Email alaaawny@hotmail.comBackground: The use of intrathecal drug delivery for chronic and cancer pain medicine has been established for decades. However, optimization and utilization of this technique still lag behind other modalities for pain control. Some of this may be due to variability of surgical technique, medication usage and education. It is currently unclear on whether or not practitioners follow available algorithms for the use of intrathecal drug delivery systems.Methods: A survey developed by the American Society of Pain and Neuroscience (ASPN) was sent to its members via email using the cloud-based SurveyMonkey. After 30 days of being available, 159 different providers responded to the survey that consisted of 31 various multiple choice and free response questions. Each question was not required and the number of responses to each varied from 128 to 159.Results: Approximately 9% of those who successfully received and opened the email containing the survey responded, likely due to a small number of providers working with intrathecal drug delivery systems. Eighty-six of respondents practice medicine in the United States, and 87% of the respondents were attending physicians. A majority of respondents, approximately 74%, were board certified in pain medicine with 69% of respondents being train in anesthesiology. The first and second most used medications for intrathecal pump trial were morphine and fentanyl, respectively. Most respondents, approximately 96%, provide pre-operative/intra-operative antibiotics. The most common first-choice medication for implanted intrathecal pumps was also morphine with the most common implanted location being the abdomen.Conclusion: Interestingly, there is currently fairly substantial variation in the way providers utilize intrathecal pump delivery for both chronic and cancer pain. There is variation from the training background of the providers providing care, to the pre-implantation trial medications, to where the pump is implanted for each patient, to if the patient has the option to give themselves boluses once implanted. Further research is needed to elucidate current and best practices for intrathecal drug delivery system trials, implantations, and utilization.Keywords: pain management, intrathecal, chronic pain, cancer pain, neuromodulation, analgesia

Abd-Sayed A, Fiala K, Weisbein J, et al. J Pain Res. 2022;15:1305–1314. The authors have advised there is an error in the author list on page 1305. The author name “Alaa Abd-Sayed” should read “Alaa Abd-Elsayed”. The authors apologize for this error.

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Introduction: Tropical myositis - also known as pyomyositis - is a subacute, primary infection of skeletal muscle. Long considered a diagnosis exclusive to tropical climates, recently it has been reported increasingly in historically nontropical climates. We present a case of tropical myositis in Madison, Wisconsin, occurring in a febrile type 1 diabetic patient without travel or known exposure., Case Presentation: A 35-year-old male with a history of von Willebrand disease, type 1 diabetes, and financial insecurity resulting in insulin rationing presented with 2 weeks of generalized weakness. On exam, he had a multitude of large, erythematous "bumps" across his body, which had been increasing in size for more than 2 weeks. His blood glucose was 518, with leukocytosis and labs supportive of diabetic ketoacidosis. Computed tomography revealed extensive intramuscular and subcutaneous abscesses of the left chest, bilateral erector spinae, right gluteal muscles, bilateral thighs, left leg, and left upper and lower arm. Broad-spectrum antibiotics were initiated, as was treatment for diabetic ketoacidosis. Blood and urine cultures revealed oxacillin-susceptible Staphylococcus aureus . After clinical stabilization, he underwent initial incision and drainage of the abscesses. His condition would require 14 more operative incision and drainage procedures and wound closure attempts before he was discharged to a rehab facility after more than a month-long hospitalization., Discussion: Severe tropical myositis is associated with high morbidity and high use of health care resources. The exponential rise in cases in the United States in recent years risks further stressing an already-burdened health care system. We explore potential causes of the increase in cases of tropical myositis in nontropical regions, including increasing rates of diabetes and poverty and climate change. Recent data suggest that the large majority of tropical myositis cases are caused by Panton-Valentine leukocidin toxin-producing Staphylococcus aureus strains. There is a theoretical mitigation of disease severity when patients receive early protein synthesis inhibitor antibiotic treatment, though these findings are limited to case reports and observational studies and lack controlled clinical trials. This case highlights the need for early identification, antibiotic administration, and surgical source control in suspected cases of tropical myositis., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

ATP1A3 encodes the α3 subunit of the sodium-potassium ATPase, one of two isoforms responsible for powering electrochemical gradients in neurons. Heterozygous pathogenic ATP1A3 variants produce several distinct neurological syndromes, yet the molecular basis for phenotypic variability is unclear. We report a novel recurrent variant, ATP1A3(NM_152296.5):c.2324C>T; p.(Pro775Leu), in nine individuals associated with the primary clinical features of progressive or non-progressive spasticity and developmental delay/intellectual disability. No patients fulfil diagnostic criteria for ATP1A3-associated syndromes, including alternating hemiplegia of childhood, rapid-onset dystonia-parkinsonism or cerebellar ataxia-areflexia-pes cavus-optic atrophy-sensorineural hearing loss (CAPOS), and none were suspected of having an ATP1A3-related disorder. Uniquely among known ATP1A3 variants, P775L causes leakage of sodium ions and protons into the cell, associated with impaired sodium binding/occlusion kinetics favouring states with fewer bound ions. These phenotypic and electrophysiologic studies demonstrate that ATP1A3:c.2324C>T; p.(Pro775Leu) results in mild ATP1A3-related phenotypes resembling complex hereditary spastic paraplegia or idiopathic spastic cerebral palsy. Cation leak provides a molecular explanation for this genotype-phenotype correlation, adding another mechanism to further explain phenotypic variability and highlighting the importance of biophysical properties beyond ion transport rate in ion transport diseases., (Published by Oxford University Press on behalf of the Guarantors of Brain 2023.)

Continuous compression implants (nitinol staples) are gaining popularity secondary to their lower profile, less demanding technique, and less surgical dissection. Biomechanical support exists; however, clinical data is limited in the foot/ankle. This study's purpose is to determine the efficacy of nitinol staples to achieve stable, bony healing in Akin osteotomies and examine their clinical outcomes, complications, re-operations, and pain scores. We performed a retrospective chart review on 90 patients (93 osteotomies) who underwent an Akin osteotomy using a nitinol staple over a 2-year period. Radiographs were randomized and independently reviewed by 3 blinded foot and ankle surgeons. Osteotomies were deemed healed if greater than 50% of the osteotomy contained bridging bone, partially healed as less than 50% bridging bone, and nonunion as no healing, broken hardware, or loss of reduction. Visual analog scale pain scores were analyzed. Radiographic union was seen in 98.9% of Akin osteotomies (92/93), with no loss of reduction or broken staples (0/95). Only 3.2% (3/93) of patients returned to the operating room unplanned: 1 infection (1.1%), 1 symptomatic hardware removal (1.1%), and 1 traumatic disruption of fixation (1.1%). Postoperative pain scores were significantly lower than preoperative. Staples are lower profile and technically less demanding compared to headed screws, plates, and tension band constructs. They offer continuous compression of the osteotomy and are rigid enough to maintain reduction. Based on the findings of this paper, the use of staples provides robust and stable fixation for Akin osteotomies and has low complication and high healing rates., (Copyright © 2022 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess the currently available evidence regarding associations between spinal cord stimulator (SCS) lead type, clinical indications for device placement, and interference between SCSs and cardiac pacemakers (CPMs)/implantable cardioverter-defibrillators (ICDs)., Study Design: Review of case reports and original research studies assessing the interference between SCS and CPM/ICD., Materials and Methods: PubMed and Cochrane databases were searched for articles commenting on the interference between SCS and CPM/ICD. The search criteria which generated the greatest number of relevant studies was (spinal cord stimulator AND [pacemaker OR implantable cardioverter defibrillator]). Additional, empiric review was conducted using JSTOR, ScienceDirect, and EBSCOhost databases; however, no additional eligible studies were identified. Data were extracted, summarized into tables, and quantitatively analyzed using LibreTexts and MedCalc software., Results: There was no statistically significant interference observed between SCS and CPM/ICD devices in patients regardless of indication for SCS placement and SCS lead polarity., Limitations: Limited by variability of patient cases and variability in maximum frequency and amplitude of SCS devices tried in individual cases. Also limited by small sample size and the absence of a standard definition for device interference across studies., Conclusions: Interference between cardiac devices and SCSs is a rare occurrence. As there are currently no published guidelines, devices should be interrogated on a case-by-case basis in the SCS trial period (if implanted after cardiac device), during permanent implantation, and during scheduled follow-up visits. Peri-operative testing should include increasing the SCS settings to maximally tolerated levels with cardiac device set at its maximum sensitivity., (Copyright © 2022. Published by Elsevier Inc.)

Introduction: An innovative online course on safe opioid prescribing for pediatric patients was designed by an interprofessional team of experts for an interprofessional target audience of clinicians in Wisconsin., Methods: The 2-hour accredited course included recorded TED Talks-style presentations and interactive patient cases. A total of 227 course completers responded to pre- and posttests and a 20-item Interprofessional Collaborative Competency Attainment Scale (ICCAS). A Fisher exact test was used to compare pre/post first-attempt test responses and a 2-tailed t test compared the before/after ratings of ICCAS statements., Results: Improvement on pre/posttest assessment was not significant. ICCAS showed significant increase of interprofessional competence for each statement., Discussion: Interprofessional learning can be effectively incorporated in opioid-related continuing education., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

Although the number of SARS-CoV-2 new cases may be declining due to the implementation of the vaccine in the USA, there is a rising cohort of people with long-term effects from the virus. These long-term effects include loss of taste, heart palpitations, and chronic pain syndromes. In this commentary, we assess the current literature to appraise the knowledge of long-term COVID-19 effects related to long-term pain syndromes including testicular pain, headache, chronic pain, and chest pain., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Case: This is a case of a 14-year-old female athlete with cuboid syndrome who underwent calcaneocuboid ligament complex reconstruction using a palmaris tendon allograft that was passed through 2 parallel extra-articular dorsoplantar bone tunnels through the calcaneus and cuboid. She returned to high-impact activities within 6 months. Two-and-a-half years postoperative, she continues sports with only minor stints of pain relieved with rest., Conclusion: Consensus regarding surgical treatment of cuboid syndrome has not been reached. This case report highlights a successful surgical technique for calcaneocuboid instability with potential for return to sports. We found 2 similar case reports in the literature., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B667)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Acute inflammatory edema is a noninfectious inflammatory condition of the skin that is commonly seen in critically ill patients. It is characterized by edematous, erythematous, and nontender plaques involving the abdomen and thighs, sparing areas of the skin subject to pressure. Risk factors include fluid overload, hypoalbuminemia, and obesity. Differentiating acute inflammatory edema from cellulitis can be challenging. Supportive care is the mainstay therapy for acute inflammatory edema, with interventions primarily focused on lowering the fluid burden. We report an unusual case of a nonobese patient in the outpatient setting with acute inflammatory edema., (Copyright © 2021 Baylor University Medical Center.)

Eosinophilic annular erythema (EAE) is a rare eosinophilic dermatosis characterized by annular, erythematous papules and plaques commonly found on the trunk and the extremities. There is continued debate on whether EAE is a distinct entity or a clinical polymorphism of Well's syndrome, but it is generally considered a separate entity based on clinical and histopathological differences. We present a case of EAE and discuss the histopathological findings., (Copyright © 2021 Baylor University Medical Center.)

Background: Chronic pain is a prevalent and debilitating problem for millions of people and spinal cord stimulation (SCS) is one option for treatment. It has been shown to have membrane stabilizing properties and is often used in conjunction with medications that are also believed to offer pain control through membrane stabilization., Objective: The goal of this review is to analyze the effects of SCS combined with medications to evaluate for augmentative therapeutic effect., Setting: Systematic review., Methods: A systematic computerized search of the literature was conducted using PubMed, the Cochrane Library, and EMBASE for articles published in English., Results: We report three articles that discuss the potential for augmentative effects of medication in combination with SCS. Located articles related primarily to SCS combined with Gabapentin, TCA, or SNRI., Limitations: The limited number of articles reflects a need for more investigation in this area., Conclusion: Based on the suspected mechanisms for SCS and neuromodulating medications, there is reason to believe adding these medical therapies may enhance the effects of SCS., (Copyright © 1964–2019 by MedWorks Media Inc, Los Angeles, CA All rights reserved. Printed in the United States.)

Background Medical and traumatic emergencies can be intimidating and stressful. This is especially true for early-career medical personnel.Training providers to respond effectively to medical emergencies before being confronted with a real scenario is limited by unnatural or high-cost training modalities that fail to realistically replicate the stress and gravity of real-world trauma management. Immersive virtual reality (IVR) may provide a unique training solution.  Methods We created a working group of 10 active duty or former military emergency medicine physicians and two technical experts. We hosted 10 meetings to facilitate the development process. The program was developed with financial support from the Telemedicine and Advanced Technology Research Center (TATRC), through the primary vendor Exonicus, Inc, with support from Anatomy Next Inc, and Kitware, Inc. Development was completed using an agile project management style, which allowed our team to review progress and provide immediate feedback on previous milestones throughout its completion. The working group completed the resulting four simulation scenarios to evaluate perceived realism and training potential. Finally, testing of the technology platform off the network in a deployed role 3 was conducted. Results Upon completion, we created four IVR scenarios based on the highest mortality battlefield injuries: hemorrhage, tension pneumothorax, and airway obstruction. The working group unanimously indicated a high level of realism and potential training usefulness. Throughout this process, there have been a number of lessons learned and we present those here to show what we have created as well as provide guidance to others creating IVR training solutions.  Conclusion Our team developed trauma scenarios that, to our knowledge, are the only IVR trauma scenarios to run autonomously without instructor input. Furthermore, we provide a potential template for the creation of future autonomous IVR training programs. This framework may offer a dynamic starting point as more teams seek to leverage the capabilities IVR offers., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Couperus et al.)

Jacquet's erosive dermatitis, or dermatitis syphiloides posterosiva, is classified as a severe irritant dermatitis characterized by erythematous papules and nodules with erosive, punched-out lesions. It can be found in the perineal distribution and is frequently reported in infants over 6 months of age. In adults, it is associated with urinary or fecal incontinence. We present a case of a 21-year-old white woman with a history of chronic umbilical drainage and a 3-year history of a periumbilical rash with red, friable, well-demarcated papules. Biopsy revealed pseudoepitheliomatous hyperplasia with focal epidermal erosion and a superficial perivascular infiltrate of lymphocytes and plasma cells. Our case sheds light on this uncommon diagnosis in an unlikely location.

Purpose of Review: Examining the efficacy of radiofrequency ablation in treating headache conditions., Recent Findings: The efficacy of radiofrequency ablation in treating headache conditions is not well studied. Chronic headache conditions can be difficult to treat with little consensus on management of headaches associated with pericranial neuralgias. In this retrospective study, we found that radiofrequency ablation is an effective and safe treatment for resistant headache conditions. This study is important as it describes a novel treatment for chronic headache which can benefit a large number of patients.

Purpose of Review: To explore the efficacy of radio frequency ablation in treating pain in patients with hardware at site of the procedure., Recent Findings: There is very limited data in literature about this topic. One study performed in 2016 indicated no complications when performing RFA close to hardware in patients with chronic pain conditions. Radiofrequency ablation can be safely and effectively performed close to hardware. While heating of the hardware can happen which can theoretically lead to tissue injury or decreased heat going to target nerve, this does not seem to be of clinical significance. More studies are needed to confirm this finding.

We present the case of a 44-year-old man with a complicated past medical history who presented with presumed sepsis secondary to pneumonia and severe joint pain secondary to gout. Despite an entirely negative infectious workup during his lengthy hospitalization, he developed ulcerated, draining wounds on his hands and feet that were also initially presumed to be infectious. The chalky substance draining from the wounds was eventually evaluated with potassium hydroxide under polarized microscopy and found to have the characteristic negative birefringence of sodium urate crystals. He was treated with steroids after an infectious etiology had been ruled out, and he improved clinically once his uric acid levels began to fall.

A warming climate is expected to have an impact on the magnitude and timing of river floods; however, no consistent large-scale climate change signal in observed flood magnitudes has been identified so far. We analyzed the timing of river floods in Europe over the past five decades, using a pan-European database from 4262 observational hydrometric stations, and found clear patterns of change in flood timing. Warmer temperatures have led to earlier spring snowmelt floods throughout northeastern Europe; delayed winter storms associated with polar warming have led to later winter floods around the North Sea and some sectors of the Mediterranean coast; and earlier soil moisture maxima have led to earlier winter floods in western Europe. Our results highlight the existence of a clear climate signal in flood observations at the continental scale., (Copyright © 2017 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Mohs micrographic surgery is a specialized form of skin cancer surgery in which the Mohs surgeon acts as both surgeon and pathologist. The procedure is characterized by its histopathologic margin control and ability to spare tissue, particularly in cosmetically sensitive locations. Mohs surgery is known for both limiting the size of the final defect and its high cure rate. In this review, the authors highlight indications for the procedure, detail the technique itself, discuss cutaneous tumors for which Mohs micrographic surgery is indicated, and present the economic benefit of Mohs surgery., (Published by Elsevier Inc.)

Dermatophytic pseudomycetoma represents a chronic infection characterized by a tumor-like growth containing dermatophytes arranged as clustered aggregates (grains) within the dermis. In contrast to mycetomas, they lack sinus tracts and are more common in the scalp. We describe a dermatophytic pseudomycetoma arising in the scalp of an 18-year-old African-American woman. Histopathologic examination showed a dense, mixed-cell infiltrate expanding the dermis. Accompanying this infiltrate were numerous grains scattered throughout the dermis. No sinus tracts were identified, but a number of grains were seen in the epidermal surface, admixed with serum crust. Recognition of a dermatophytic infection as a pseudomycetoma on a biopsy is important, as surgery may be required for a successful treatment.

Complex regional pain syndrome (CRPS) is a neurologic disorder that often results in debilitating chronic pain, but the diagnosis may elude providers as it is one of exclusion. A history of trauma may be elucidated. We report a case of CRPS and review the clinical findings, appropriate workup, and treatment options for the patient. The patient we describe went through an extensive workup before receiving the correct diagnosis. Delay in diagnosis leads to prolonged suffering for the patient and, at times, unnecessary invasive debridement procedures. Raising awareness of this entity may help physicians make the correct diagnosis early, as well as initiate a collaborative effort between neurology, anesthesiology, and dermatology to provide the patient the most favorable outcome.

Zinc deficiency may result from either a congenitally inherited defect of zinc absorption or is acquired secondarily from a variety of factors affecting dietary zinc intake, absorption, or loss. We report a case of acquired zinc deficiency secondary to gastric bypass surgery that resulted in vulvar cutaneous manifestations of delayed onset, with failure to clear after oral supplementation with zinc. The patient experienced improvement of symptoms only after administration of intravenous zinc supplementation. Upon review of the current literature, it is thought that the patient's original suboptimal response to oral supplementation and improvement after receiving intravenous zinc were related to the intentional surgical alteration and bypass of the absorptive capacity of the duodenum and jejunum. With the current prevalence of obesity and availability of surgical weight loss therapies, it is important to be mindful of the resulting nutritional deficiencies, their clinical manifestations, and factors affecting the efficacy of therapeutic approaches as seen in this case., (© 2015 Wiley Periodicals, Inc.)