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In the United States, the prevalence of pregnancy-related deaths has risen significantly over the past 20 years. Pregnant women at high risk for peripartum complications should undergo anesthesia consultation before delivery so that a management plan can be created between the obstetrician, anesthesiologist, and patient to ensure optimal outcomes for both the mother and newborn. However, few hospitals outside of major, urban, academic medical centers have dedicated anesthesiologists specially trained in obstetric anesthesia and the resources available to expedite optimization of high-risk parturient comorbidities. Telemedicine is a valuable tool by which evaluation, triaging, and multidisciplinary coordination can be provided for high-risk obstetric patients living in remote or rural communities without access to specialized, maternal care medical facilities. This review examines the existing literature regarding telemedicine use in preoperative anesthesia and antenatal obstetrics and identifies areas for future research. Furthermore, the benefits and potential barriers of implementing a telemedicine program specifically dedicated to obstetric anesthesia are discussed.

The use of opioid analgesics for pain management has increased dramatically over the past decade, with corresponding increases in negative sequelae including overdose and death. Physicians, policymakers, and researchers are focused on finding ways to decrease opioid use and overdose. This crisis calls for a coordinated response that includes the entire healthcare sector. In this work, the authors lay out a blueprint for such a response at the level of the academic medical center. The proposed model is a comprehensive opioid overdose prevention, response, and education program to evaluate, monitor, and address prescription opioid-related adverse events and addiction among all patients within a healthcare system. The approach includes three inter-related elements: (1) creation of an organizational structure that is subdivided into subcommittees to facilitate cross-functional collaboration and implementation. These subcommittees will focus on Research and Design, Implementation, Advisory, and Compliance with the recommendation. (2) Development of an effective communication plan throughout the institution to enable the organization to function seamlessly and efficiently as a single unit, (3) development of a data tracking and reporting system that intended to have a 360° view of all aspects of opioid prescription and downstream patient outcomes. The most effective response system will require an organizational structure that facilitates the ad hoc constitution of cross-functional teams with members drawn from all levels of the organizational hierarchy (executive leadership to frontline staff). Such a structure provides the teams with immediate solutions as developed by the frontline staff and authority to remove institutional barriers that may delay or limit the successful implementation. The model described was developed in our institution by a cross-functional team that included members from the Johns Hopkins School of Medicine and Johns Hopkins University Carey Business School, Department of Operations Management. The multidisciplinary nature of collaboration allowed us to develop a model for an immediate institution-wide response to the opioid crisis, and one that other healthcare organizations could adopt with local modification as a template for execution. The model also meant to serve as a template for an institutional rapid-response that can be seamlessly implemented during any future drug-related crisis or epidemic.

Purpose of review Antenatal anesthesia clinics remain uncommon despite the rising incidence of maternal morbidity and mortality in the United States. The purpose of the present review is to outline the major considerations and challenges surrounding antenatal anesthetic evaluation. Recent findings Data from the general surgical population would suggest a mortality benefit associated with preoperative anesthesia evaluation, although no such data exists in the obstetric population.Robust systems for case ascertainment and referral are needed. Recent publications on obstetric comorbidity indices may provide useful tools to ascertain high-risk parturients for a referral to antenatal obstetric anesthesiology clinics and higher levels of maternal care. Major obstetric organizations have identified and laid out criteria for maternal level of care. Anesthesiology resources also play a role in these designations and can help triage patients to facilities with appropriate resources. Summary Obstetric anesthesiologists have a critical role not only in preoperative patient optimization but also in coordinating multidisciplinary care for optimal patient outcomes.

Purpose Common performance metrics for outpatient clinics define the time between patient arrival and entry into an examination room as “waiting time.” Time spent in the room is considered processing time. This characterization systematically ignores time spent in the examination room waiting for service. If these definitions are used, performance will consistently understate total waiting times and overstate processing times. Correcting such errors will provide a better understanding of system behavior. Methods and materials In a radiation oncology service in an urban academic clinic, we collected data from a patient management system for 84 patients with 4 distinct types of visits: consultations, follow-ups, on-treatment visits, and nurse visits. Examination room entry and exit times were collected with a real-time location system for relevant care team members. Novel metrics of clinic performance were created, including the ratio of face time (ie, time during which the patient is with a practitioner) to total cycle time, which we label face-time efficiency. Attending physician interruptions occurred when the attending is called out of the room during a patient visit, and coordination-related delays are defined as waits for another team member. Results Face-time efficiency levels for consults, follow-ups, on-treatment visits, and nurse visits were 30.1%, 22.9%, 33.0%, and 25.6%, respectively. Attending physician interruptions averaged 6.7 minutes per patient. If these interruptions were eliminated, face-time efficiencies would rise to 33.2%, 29.2%, 34.4%, and 25.6%, respectively. Eliminating all coordination-related delays would increase these values to 41.3%, 38.9%, 54.7%, and 38.7%, respectively. Conclusions A real-time location system can be used to augment a patient management system and automate data collection to provide improved descriptions of clinic performance.

Background Traditional spinal cord stimulation (SCS) requires that paresthesia overlaps chronic painful areas. However, the new paradigm high-frequency SCS (HF-SCS) does not rely on paresthesia. Study design A review of preclinical and clinical studies regarding the use of paresthesia-free HF-SCS for various chronic pain states. Methods We reviewed available literatures on HF-SCS, including Nevro's paresthesia-free ultra high-frequency 10 kHz therapy (HF10-SCS). Data sources included relevant literature identified through searches of PubMed, MEDLINE/OVID, and SCOPUS, and manual searches of the bibliographies of known primary and review articles. Outcome measures The primary goal is to describe the present developing conceptions of preclinical mechanisms of HF-SCS and to review clinical efficacy on paresthesia-free HF10-SCS for various chronic pain states. Results HF10-SCS offers a novel pain reduction tool without paresthesia for failed back surgery syndrome and chronic axial back pain. Preclinical findings indicate that potential mechanisms of action for paresthesia-free HF-SCS differ from those of traditional SCS. Conclusions To fully understand and utilize paresthesia-free HF-SCS, mechanistic study and translational research will be very important, with increasing collaboration between basic science and clinical communities to design better trials and optimize the therapy based on mechanistic findings from effective preclinical models and approaches. Future research in these vital areas may include preclinical and clinical components conducted in parallel to optimize the potential of this technology.

This chapter describes two major payment models relevant to the diagnosis and treatment of spine pain. The first is the assessment of the actual outcomes of care delivered, with emphasis on patient-reported outcomes such as pain and functional capacity (“outcomes-based”). The second comprises aggregated past observations in patient groups comparable to the current patient scheduled to receive a treatment (“evidence-based”). Payment decisions are then based upon whether differences were observed in the outcomes of treatment and control groups in the prior studies, preferably conducted as prospective randomized controlled trials. In practice, these two approaches are linked: evidence is typically gathered to assess specific outcomes, and findings of effects upon outcomes contribute to selecting one among many possible treatments and strategies to monitor that treatment’s effectiveness. We further describe a widely used computerized adaptive testing instrument (the Patient-Reported Outcomes Information System, “PROMIS”). We note actions underway by the US Federal insurance system to apply financial, merit-based performance incentives (“MIPS”) to encourage systematic collection and comparisons of treatment outcomes in a range of patient care settings. We conclude by touching on blockchain technology, an innovation that may grow in importance in health care by virtue of its facilitation of collection and pooling of individual patients’ detailed characteristics, care received, and outcomes achieved while maintaining their anonymity.

Opioid prescriptions in the surgical setting have been implicated as contributors to the opioid epidemic. The authors hypothesized that a multidisciplinary approach to perioperative pain management for patients on chronic opioid therapy could decrease postoperative opioid requirements while reducing postoperative pain scores and improving functional outcomes. Therefore, a Perioperative Pain Program (PPP) for chronic opioid users was implemented. This study presents outcomes from the first 9 months of the PPP. Sixty-one patients met the inclusion criteria. Opioid consumption in morphine milligram equivalent (MME) was calculated and physical and health status of patients was assessed with the Brief Pain Inventory, Short-Form McGill Pain Questionnaire, and Short Form-12. Preliminary results showed significant reduction in MME, improved pain scores, and improved function for surgical patients on chronic opioids. PPP effectively reduced opioid usage without negatively influencing patient-reported outcomes, such as physical pain score assessment and health-related quality of life.

An assessment of the emission of combustible gases in developing countries requires reliable analytical realtime monitors that can rapidly screen them with minimal handling. Considering the expensive nature of monitoring environmental pollutants, chemical sensors are expected to play a pivotal role in measuring and recording environmental data. The Drager X am 5000 was used to report emission levels of combustible gases in this study, namely; nitrogen dioxide (NO2), sulphur dioxide (SO2) and carbon monoxide (CO) at traffic and practising waste dumpsite in Freetown, the main city of Sierra Leone. Hourly average values for the three pollutants were recorded in the morning, afternoon and evening periods, respectively. The range of values were 18 - 76 ppb for NO2, 211 - 506 ppb for SO2 and 11 - 14 ppm for CO at traffic site; and 6 - 16 ppb for NO2, 118 - 276 ppb for SO2 and 8 - 15 ppm for CO at the dumpsite, respectively. There were significantly high hourly variations for NO2 and SO2 at the traffic site and for CO and SO2 at the dumpsite. Evidence of peak values showed emission levels that were considered dangerous for human exposure. This pilot study revealed that combustible gases released in certain areas of the capital city are a concern for both public health officials and environmental advocates.

Introduction Neurostimulation involves the implantation of devices to stimulate the brain, spinal cord, or peripheral or cranial nerves for the purpose of modulating the neural activity of the targeted structures to achieve specific therapeutic effects. Surgical placement of neurostimulation devices is associated with risks of neurologic injury, as well as possible sequelae from the local or systemic effects of the intervention. The goal of the Neurostimulation Appropriateness Consensus Committee (NACC) is to improve the safety of neurostimulation. Methods The International Neuromodulation Society (INS) is dedicated to improving neurostimulation efficacy and patient safety. Over the past two decades the INS has established a process to use best evidence to improve care. This article updates work published by the NACC in 2014. NACC authors were chosen based on nomination to the INS executive board and were selected based on publications, academic acumen, international impact, and diversity. In areas in which evidence was lacking, the NACC used expert opinion to reach consensus. Results The INS has developed recommendations that when properly utilized should improve patient safety and reduce the risk of injury and associated complications with implantable devices. Conclusions On behalf of INS, the NACC has published recommendations intended to reduce the risk of neurological injuries and complications while implanting stimulators.

According to the US Department of Health and Human Services, roughly 40% of all outpatient visits in the US are made to teaching hospitals. The educational mission of these settings adds stages to the care delivery process and, in some instances leads to a system which is a hybrid between a single and two-server queue. We consider the problem of determining appointment schedules for these settings which explicitly account for the teaching mission, high no-show rate, a blending of patient types, highly variable processing times, processing in multiple stages, processing times that are not independent across stages, and a dynamic policy regarding the involvement of a medical trainee. We formulate the resulting problem and develop structural results. We then use properties of the optimization problem to develop an intuitive Cyclic scheduling approach, which bundles multiple patients into each Cycle. The application of our modeling framework is illustrated for the AMC clinic that motivated this work.

Background One in 16 surgical patients prescribed opioids becomes a long-term user. Overprescribing opioids after surgery is common, and the lack of multidisciplinary procedure-specific guidelines contributes to the wide variation in opioid prescribing practices. We hypothesized that a single-institution, multidisciplinary expert panel can establish consensus on ideal opioid prescribing for select common surgical procedures. Study Design We used a 3-step modified Delphi method involving a multidisciplinary expert panel of 6 relevant stakeholder groups (surgeons, pain specialists, outpatient surgical nurse practitioners, surgical residents, patients, and pharmacists) to develop consensus ranges for outpatient opioid prescribing at the time of discharge after 20 common procedures in 8 surgical specialties. Prescribing guidelines were developed for opioid-naive adult patients without chronic pain undergoing uncomplicated procedures. The number of opioid tablets was defined using oxycodone 5 mg oral equivalents. Results For all 20 surgical procedures reviewed, the minimum number of opioid tablets recommended by the panel was 0. Ibuprofen was recommended for all patients unless medically contraindicated. The maximum number of opioid tablets varied by procedure (median 12.5 tablets), with panel recommendations of 0 opioid tablets for 3 of 20 (15%) procedures, 1 to 15 opioid tablets for 11 of 20 (55%) procedures, and 16 to 20 tablets for 6 of 20 (30%) procedures. Overall, patients who had the procedures voted for lower opioid amounts than surgeons who performed them. Conclusions Procedure-specific prescribing recommendations may help provide guidance to clinicians who are currently overprescribing opioids after surgery. Multidisciplinary, patient-centered consensus guidelines for more procedures are feasible and may serve as a tool in combating the opioid crisis.

Objective Spinal cord stimulation (SCS) has become a widely used treatment option for a variety of pain conditions. Substantial variability exists in the degree of benefit obtained from SCS and patient selection is a topic of expanding interest and importance. However, few studies have examined the potential benefits of dynamic quantitative sensory testing (QST) to develop objective measures of SCS outcomes or as a predictive tool to help patient selection. Psychological characteristics have been shown to play an important role in shaping individual differences in the pain experience and may aid in predicting responses to SCS. Static laboratory pain-induction measures have also been examined in their capacity for predicting SCS outcomes. Methods The current study evaluated clinical, psychological and laboratory pain measures at baseline, during trial SCS lead placement, as well as 1 month and 3 months following permanent SCS implantation in chronic pain patients who received SCS treatment. Several QST measures were conducted, with specific focus on examination of dynamic models (central sensitization and conditioned pain modulation [CPM]) and their association with pain outcomes 3 months post SCS implantation. Results Results suggest few changes in QST over time. However, central sensitization and CPM at baseline were significantly associated with clinical pain at 3 months following SCS implantation, controlling for psycho/behavioral factors and pain at baseline. Specifically, enhanced central sensitization and reduced CPM were associated with less self-reported pain 3 months following SCS implantation. Conclusions These findings suggest a potentially important role for dynamic pain assessment in individuals undergoing SCS, and hint at potential mechanisms through which SCS may impart its benefit.

Supplementary Material, Informed_Consent for An Innovative Perioperative Pain Program for Chronic Opioid Users: An Academic Medical Center’s Response to the Opioid Crisis by Marie N. Hanna, MD, MEHP, Traci J. Speed, MD, PhD, Ronen Shechter, MD, Michael C. Grant, MD, Rosanne Sheinberg, MD, Elizabeth Goldberg, CRNP, Claudia M. Campbell, PhD, Nicholas Theodore, MD, FACS, FAANS, Colleen G. Koch, MD, MS, MBA, and Kayode Williams, MD, MBA in American Journal of Medical Quality

Introduction The International Neuromodulation Society (INS) has determined that there is a need to provide an expert consensus that defines the appropriate use of neuromodulation technologies for appropriate patients. The Neuromodulation Appropriateness Consensus Committee (NACC) was formed to give guidance to current practice and insight into future developments. Methods The INS executive board selected members of the international scientific community to analyze scientific evidence for current and future innovations and to use clinical experience to fill in any gaps in information. The NACC used PubMed and Google Scholar to obtain current evidence in the field and used clinical and research experience to give a more complete picture of the innovations in the field. Results The NACC has determined that currently approved neurostimulation techniques and technologies have expanded our ability to treat patients in a more effective and specific fashion. Despite these advances, the NACC has identified several additional promising technologies and potential applications for neurostimulation that could move this field forward and expand the applicability of neuromodulation. Conclusions The NACC concludes that the field of neurostimulation is an evolving and rapidly changing one that will lead to improved patient access, safety, and outcomes.

Chronic pain is a global healthcare issue impacting all populations across race, gender, socioeconomic status, and location. Worldwide, up to one in five adults experience ongoing pain and another 1 in 10 are diagnosed with chronic pain each year.

OBJECTIVE Quantifying pain intensity is challenging, particularly for patients with chronic pain. The visual analog scale (VAS) is limited by ceiling effects that often leave patients with no ability to quantify worsening pain. The goal of this study was to determine whether the general Labeled Magnitude Scale (gLMS) can be feasibly used to measure pain clinically while overcoming limitations of the VAS. DESIGN Eighty patients (mean age, 53.7 yrs) scheduled for evaluation of a painful complaint were asked to rate their current pain using the gLMS and the VAS. The time necessary to administer the gLMS was recorded to determine feasibility. The difference in rating between the two scales (VAS and gLMS) was the main outcome measure. RESULTS After scaling and rounding off the gLMS scores for direct comparison, it was found that the gLMS scores were significantly lower than the corresponding VAS scores by a mean of 1.78 (P < 0.001). The mean time to administer the gLMS was 2.66 mins. CONCLUSIONS These results suggest that the gLMS has great potential and can be feasibly used to measure pain intensity clinically. The gLMS scores were consistently lower than the VAS scores, thus reducing the ceiling effect and allowing range at the high end of the scale for rating worsening pain.

The clinical manifestations of Marfan syndrome frequently cause pain. This study aimed to characterize pain in a cohort of adults with Marfan syndrome and investigate demographic, physical, and psychological factors associated with pain and pain-related disability. Two hundred and forty-five participants (73% female, 89% non-Hispanic white, 90% North American) completed an online questionnaire assessing clinical features of Marfan syndrome, pain severity, pain-related disability, physical and mental health, depressive symptoms, pain catastrophizing, and insomnia. Eighty-nine percent of respondents reported having pain with 28% of individuals reporting pain as a presenting symptom of Marfan syndrome. Almost half of individuals reported that pain has spread from its initial site. Participants in our study reported poor physical and mental health functioning, moderate pain-related disability, and mild levels of depressive symptoms, sleep disturbances, and pain catastrophizing. Those who identified pain as an initial symptom of Marfan syndrome and those who reported that pain had spread from its initial site reported greater psychological burden compared with those without pain as an initial symptom or pain spreading. Physical health is the largest predictor of pain severity and pain-related disability. While pain catastrophizing and worse mental health functioning are significant correlates of pain severity and pain-related disability, respectively. Pain is a significant and persistent problem in Marfan syndrome and is associated with profound disability and psychological burden. Further studies are indicated to better characterize the directionality of pain, pain-related disability, and psychological burden in Marfan syndrome. © 2016 Wiley Periodicals, Inc.

Peripheral nerve stimulation (PNS) for the treatment of chronic pain has become an increasingly important field in the arena of neuromodulation, given the ongoing advances in electrical neuromodulation technology since 1999 permitting minimally invasive approaches using an percutaneous approach as opposed to implantable systems. Our review aims to provide clinicians with the recent advances and studies in the field, with specific emphasis on clinical data and indications that have been accumulated over the last several years. In addition, we aim to address key basic science studies to further emphasize the importance of translational research outcomes driving clinical management.

Access to healthcare in general and to pain management care in particular continues to be a significant problem in the United States and globally for several reasons. On the demand side of the equation, as of September 2015 the U.S. population is currently estimated to be 321.7 million, and the U.S. Census Bureau projects that it will increase to around 347.3 million by 2025, representing a growth of approximately 7.4% [1,2]. This population growth reflects a disproportionately higher increase in older adults, i.e., individuals more than 65 years of age (46%), with a relatively lower rise in the number of people under 18 years of age (5%) [3]. The Institute of Health Informatics reports that between 2012 and 2013 office-based demand for specialist care (increased 4.9%) exceeded that for primary care (declined 0.7%) in the same setting [4]. The implication of the effects of population growth for the demand in specialist services such as pain medicine is that demand can be expected to increase proportionately over the next decade. Following the passage of the Patient Protection and Affordable Care Act (ACA) of 2010 and at the behest of the U.S. Department of Health and Human Services (DHHS), in 2011 the Institute of …

Background The medical, social, and economic effects of the teaching mission on delivery of care at an academic medical center (AMC) are not fully understood. When a free-standing private practice ambulatory clinic with no teaching mission was merged into an AMC, a natural experiment was created. The authors compared process measures across the two settings to observe the differences in system performance introduced by the added steps and resources of the AMC's teaching mission. Methods After creating process maps based on activity times realized in both settings, the authors developed discrete-event simulations of the two environments. The two settings were comparable in the levels of key resources, but the AMC process flow included three residents/fellows. Simulation enabled the authors to consider an identical schedule across the two settings. Results Under identical schedules, the average accumulated processing time per patient was higher in the AMC. However, the use of residents allowed simultaneous processing of multiple patients. Consequently, the AMC had higher throughput (3.5 vs. 2.7 patients per hour), higher room utilization (82.2% vs. 75.5%), reduced utilization of the attending physician (79.0% vs. 93.4%), and a shorter average waiting time (30.0 vs. 83.9 min). In addition, the average completion time for the final patient scheduled was 97.9 min less, and the average number of patients treated before incurring overtime was 37.9% greater. Conclusions Although the teaching mission of the AMC adds processing steps and costs, the use of trainees within the process serves to increase throughput while decreasing waiting times and the use of overtime.

Introduction: Collecting a patient’s pain scores and the analgesic effect achieved during spinal cord stimulation (SCS) trials can be difficult, and no standard exists for doing so. We propose a topographical mapping tool that was derived from a patient’s perspective. Case: A 60-year-old man with postherpetic neuralgia (PHN) underwent a SCS trial after conservative treatment failed to relieve his pain. During the SCS trial, with the SCS off and on in five different settings, he recorded pain levels in each of the six different painful zones he identified. The data collected were transferred to a topographical and anatomical map, which helped the physicians to better understand the effects of the SCS at different settings. Ultimately, the data collected by the patient helped the physicians to implant a permanent SCS successfully. Conclusions: Patient pain diaries have been used in pain medicine for years. This particular patient’s collection of pain scores and SCS effects inspired the construction of a more standardized tool for collecting such data during SCS trials. We propose that use of our Topographical Anatomical Neuropathic-pain Guided (TANG) mapping tool will enable physicians to choose SCS lead positions more precisely than is currently possible.

Background Among patients presenting with axial low back pain, facet arthropathy accounts for approximately 10-15% of cases. Facet interventions are the second most frequently performed procedures in pain clinics across the United States. Currently, there are no uniformly accepted criteria regarding how best to select patients for radiofrequency denervation. Methods A randomized, multicenter study was performed in 151 subjects with suspected lumbar facetogenic pain comparing three treatment paradigms. Group 0 received radiofrequency denervation based solely on clinical findings; group 1 underwent denervation contingent on a positive response to a single diagnostic block; and group 2 proceeded to denervation only if they obtained a positive response to comparative blocks done with lidocaine and bupivacaine. A positive outcome was predesignated as > or =50% pain relief coupled with a positive global perceived effect persisting for 3 months. Results In group 0, 17 patients (33%) obtained a successful outcome at 3 months versus eight patients (16%) in group 1 and 11 (22%) patients in group 2. Denervation success rates in groups 0, 1, and 2 were 33, 39, and 64%, respectively. Pain scores and functional capacity were significantly lower at 3 months but not at 1 month in group 2 subjects who proceeded to denervation compared with patients in groups 0 and 1. The costs per successful treatment in groups 0, 1, and 2 were $6,286, $17,142, and $15,241, respectively. Conclusions Using current reimbursement scales, these findings suggest that proceeding to radiofrequency denervation without a diagnostic block is the most cost-effective treatment paradigm.

Introduction. Complex regional pain syndrome type I (CRPS I) is a neuropathic pain disorder of unclear etiology. It commonly follows a trivial injury and is characterized by spontaneous pain manifesting regionally that is disproportionate to the inciting event. Associated signs and symptoms include allodynia, hyperalgesia, edema, sudomotor, vasomotor abnormalities, and trophic changes. Although multiple modalities exist to treat CRPS I, significant disability, diminution in quality of life, and reduction in overall health often accompany the syndrome. Case. A case of a 57-year-old man with CRPS I who was treated with spinal cord stimulation (SCS) after failing conservative therapy is presented. One month following treatment, he experienced complete symptom resolution such that stimulation was subsequently discontinued without recurrence over the 1-year follow-up period. Conclusions. To date there is currently no reliably validated “cure” for CRPS. There has only been one recent report where SCS resulted in the complete eradication of the signs and symptoms associated with CRPS. This series involved adolescent girls aged 11–14 years of age, who tend to have a more benign and self-limited treatment course than that seen in adults. This raises the question as to whether a “neural switch” exists, and if so, where it is located. We postulate that the inter-neuronal connections between the central and peripheral nervous systems implicated by the current pathophysiological model is the most plausible site of this “neural switch,” and that reorganization of this interface can account for the ability of SCS to effect a complete “cure” in CRPS.

Recent human and animal studies provide growing evidence that vagal nerve stimulation (VNS) can deliver strong analgesic effects in addition to providing therapeutic efficacy in the treatment of refractory epilepsy and depression. Analgesia is potentially mediated by vagal afferents that inhibit spinal nociceptive reflexes and transmission and have strong anti-inflammatory properties. The purpose of this review is to provide pain practitioners with an overview of VNS technology and limitations. It specifically focuses on clinical indications of VNS for various chronic pain syndromes, including fibromyalgia, pelvic pain, and headaches. We also present potential mechanisms for VNS modulation of chronic pain by reviewing both animal and human studies.

Purpose of review The paper is a critical appraisal of recent advances in the treatment of complex regional pain syndrome. Rapidly changing concepts related to the pathophysiology of this disease has transformed its current management and necessitates an updated review of the literature. Recent findings Chronic regional pain syndrome is a perplexing disease that continues to challenge researchers with respect to its cause and treatment. Recent modification to diagnostic criteria has enabled clinicians to diagnose this disease in a more consistent fashion. Emerging data indicate a possible role of inflammation in the overall pathophysiology and have led to treatment trials with newer anti-inflammatory medications. Certain ‘conventional’ interventional techniques have been recently scrutinized. A few novel therapeutic options like graded imagery are also outlined. Summary Enhanced insight into the pathophysiology of chronic regional pain syndrome has modified current clinical practice and the focus of research. Certain ‘standard’ therapeutic options for chronic regional pain syndrome have failed the test of time while others have prevailed. New options have recently been evaluated and have shown promising early results. Knowledge of recent advances in chronic regional pain syndrome will help pain physicians provide optimal care to these patients.

Background and Objectives Gabapentin is an anticonvulsant that has been shown to be effective in the treatment of neuropathic and inflammatory pain in animal and human studies. The analgesic effect of its perioperative use has not been fully elucidated. Methods This systematic review (meta-analysis) included 12 randomized controlled trials of 896 patients undergoing a variety of surgical procedures that investigated the impact of perioperative administration of gabapentin on postoperative outcome. Results The pooled visual analog scores for pain at 4 hours and 24 hours were significantly less in those patients who received gabapentin (weighted mean difference [WMD] = −1.57; 95% confidence interval [CI], −2.14 to −0.99 and WMD = −0.74; CI, −1.03 to −0.45, respectively). A concomitant decrease in opioid usage by those patients who received gabapentin was also noted (odds ratio [OR] = −17.84; CI, −23.50 to −12.18). Gabapentin administration was associated with sedation and anxiolysis (OR = 3.28; CI, 1.21-8.87) but not associated with a difference in lightheadedness, dizziness, nausea, or vomiting. Conclusions Based on this systematic review, perioperative oral gabapentin is a useful adjunct for the management of postoperative pain that provides analgesia through a different mechanism than opioids and other analgesic agents and would make a reasonable addition to a multimodal analgesic treatment plan.

External anatomic landmarks have traditionally been used to approximate the location of the neck blood vessels to optimize central venous cannulation of the internal jugular vein (IJV) while avoiding the common carotid artery (CCA). Head rotation affects vessel orientation, but most landmark techniques do not specify its optimal degree. We simulated catheter insertion via both an anterior and central approach to the right IJV using an ultrasound probe held in the manner of a syringe and needle in 49 volunteers. Increased head rotation from 0 degrees, 15 degrees, 30 degrees, 45 degrees, and 60 degrees to the left of midline was associated with higher probability of a simulated needle contacting the IJV and the CCA. For both approaches, the risk of CCA contact was10% for head rotations ofor=45 degrees. Increased body surface area (BSA) and body mass index (BMI) were associated with more CCA contact at head rotations of 45 degrees or 60 degrees. To optimize IJV contact while reducing the likelihood of inadvertent contact with the CCA, the head should be rotated no more than 30 degrees in patients with high BMI or BSA, but it may be turned to 60 degrees if BMI or BSA is low.

Objectives This study investigated the effect on patient waiting times, patient/doctor contact times, flow times, and session completion times of having medical trainees and attending physicians review cases before the clinic session. The major hypothesis was that review of cases prior to clinic hours would reduce waiting times, flow times, and use of overtime, without reducing patient/doctor contact time. Design Prospective quality improvement. Setting Specialty pain clinic within Johns Hopkins Outpatient Center, Baltimore, MD, United States. Participants Two attending physicians participated in the intervention. Processing times for 504 patient visits are involved over a total of 4 months. Intervention Trainees were assigned to cases the day before the patient visit. Trainees reviewed each case and discussed it with attending physicians before each clinic session. Primary and Secondary Outcome Measures Primary measures were activity times before and after the intervention. These were compared and also used as inputs to a discrete event simulation to eliminate differences in the arrival process as a confounding factor. Results The average time that attending physicians spent teaching trainees while the patient waited was reduced, but patient/doctor contact time was not significantly affected. These changes reduced patient waiting times, flow times, and clinic session times. Conclusions Moving some educational activities ahead of clinic time improves patient flows through the clinic and decreases congestion without reducing the times that trainees or patients interact with physicians.

The International Neuromodulation Society (INS) has determined that there is a need to provide an expert consensus that defines the appropriate use of neuromodulation technologies for appropriate patients. The Neuromodulation Appropriateness Consensus Committee (NACC) was formed to give guidance to current practice and insight into future developments.The INS executive board selected members of the international scientific community to analyze scientific evidence for current and future innovations and to use clinical experience to fill in any gaps in information. The NACC used PubMed and Google Scholar to obtain current evidence in the field and used clinical and research experience to give a more complete picture of the innovations in the field.The NACC has determined that currently approved neurostimulation techniques and technologies have expanded our ability to treat patients in a more effective and specific fashion. Despite these advances, the NACC has identified several additional promising technologies and potential applications for neurostimulation that could move this field forward and expand the applicability of neuromodulation.The NACC concludes that the field of neurostimulation is an evolving and rapidly changing one that will lead to improved patient access, safety, and outcomes.