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Scott G Pritzlaff,1 Johnathan H Goree,2 Jonathan M Hagedorn,3 David W Lee,4 Kenneth B Chapman,5 Sandy Christiansen,6 Andrew Dudas,7 Alexander Escobar,8 Christopher J Gilligan,9 Maged Guirguis,10 Amitabh Gulati,11 Jessica Jameson,12 Christopher J Mallard,13 Melissa Murphy,14 Kiran V Patel,15 Raj G Patel,16 Samir J Sheth,17 Stephanie Vanterpool,18 Vinita Singh,19 Gregory Smith,2 Natalie H Strand,20 Chau M Vu,21 Tolga Suvar,22 Krishnan Chakravarthy,23 Leonardo Kapural,24 Michael S Leong,25 Timothy R Lubenow,22 Alaa Abd-Elsayed,26 Jason E Pope,21 Dawood Sayed,27 Timothy R Deer28 1Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA; 2Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 3Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Mayo Clinic, Rochester, MN, USA; 4Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA; 5The Spine & Pain Institute of New York, New York, NY, USA; 6Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA; 7Mays & Schnapp Neurospine and Pain, Memphis, TN, USA; 8Department of Anesthesiology, University of Toledo, Toledo, OH, USA; 9Division of Pain Medicine, Brigham and Women’s Hospital Harvard Medical School, Boston, MA, USA; 10Division of Pain Management, Ochsner Health, New Orleans, LA, USA; 11Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA; 12Axis Spine Center, Coeur D’Alene, ID, USA; 13Department of Anesthesiology, University of Kentucky, Lexington, KY, USA; 14North Texas Orthopedics and Spine Center, Grapevine, TX, USA; 15Department of Anesthesiology and Pain Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA; 16Capitol Pain Institute, Austin, TX, USA; 17Interventional Pain Management, Sutter Health, Roseville, CA, USA; 18Department of Anesthesiology, University of Tennessee, Knoxville, TN, USA; 19Department of Anesthesiology, Emory University, Atlanta, GA, USA; 20Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA; 21Evolve Restorative Center, Santa Rosa, CA, USA; 22Department of Anesthesiology and Pain Medicine, Rush University Medical Center, Chicago, IL, USA; 23Coastal Pain and Spinal Diagnostics Medical Group, San Diego, CA, USA; 24Carolinas Pain Institute, Winston-Salem, NC, USA; 25Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA; 26Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; 27Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas, Kansas City, KS, USA; 28The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Scott G Pritzlaff, University of California, Davis, 4860 Y Street, Suite 3020, Sacramento, CA, 95817, USA, Tel +1 916 734-6824, Fax +1 916 734-6827, Email spritzlaff@ucdavis.eduAbstract: The need to be competent in neuromodulation is and should be a prerequisite prior to completing a fellowship in interventional pain medicine. Unfortunately, many programs lack acceptable candidates for these advanced therapies, and fellows may not receive adequate exposure to neuromodulation procedures. The American Society of Pain and Neuroscience (ASPN) desires to create a consensus of experts to set a minimum standard of competence for neurostimulation procedures, including spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRG-S), and peripheral nerve stimulation (PNS). The executive board of ASPN accepted nominations for colleagues with excellence in the subject matter of neuromodulation and physician education. This diverse group used peer-reviewed literature and, based on grading of evidence and expert opinion, developed critical consensus guides for training that all accredited fellowship programs should adopt. For each consensus point, transparency and recusal were used to eliminate bias, and an author was nominated for evidence grading oversight and bias control. Pain Education and Knowledge (PEAK) Consensus Guidelines for Neuromodulation sets a standard for neuromodulation training in pain fellowship training programs. The consensus panel has determined several recommendations to improve care in the United States for patients undergoing neuromodulation. As neuromodulation training in the United States has evolved dramatically, these therapies have become ubiquitous in pain medicine. Unfortunately, fellowship programs and the Accreditation Council for Graduate Medical Education (ACGME) pain program requirements have not progressed training to match the demands of modern advancements. PEAK sets a new standard for fellowship training and presents thirteen practice areas vital for physician competence in neuromodulation.Keywords: neuromodulation, pain education, spinal cord stimulation, dorsal root ganglion stimulation, peripheral nerve stimulation, fellowship training

ABSTRACT: Background: COVID-19 initially caused less severe outbreaks in many low- and middle-income countries (LMIC) compared with many high-income countries, possibly because of differing demographics, socioeconomics, surveillance, and policy responses. Here, we investigate the role of multiple factors on COVID-19 dynamics in the Philippines, a LMIC that has had a relatively severe COVID-19 outbreak. Methods: We applied an age-structured compartmental model that incorporated time-varying mobility, testing, and personal protective behaviors (through a “Minimum Health Standards” policy, MHS) to represent the first wave of the Philippines COVID-19 epidemic nationally and for three highly affected regions (Calabarzon, Central Visayas, and the National Capital Region). We estimated effects of control measures, key epidemiological parameters, and interventions. Findings: Population age structure, contact rates, mobility, testing, and MHS were sufficient to explain the Philippines epidemic based on the good fit between modelled and reported cases, hospitalisations, and deaths. The model indicated that MHS reduced the probability of transmission per contact by 13-27%. The February 2021 case detection rate was estimated at ~8%, population recovered at ~9%, and scenario projections indicated high sensitivity to MHS adherence. Interpretation: COVID-19 dynamics in the Philippines are driven by age, contact structure, mobility, and MHS adherence. Continued compliance with low-cost MHS should help the Philippines control the epidemic until vaccines are widely distributed, but disease resurgence may be occurring due to a combination of low population immunity and detection rates and new variants of concern.

Introduction: Neuromodulation represents one of the more advanced tools in the armamentarium of pain physicians. To optimize neuromodulation patient selection and management, an institutional interdisciplinary neuromodulation committee was created at each of two academic medical centers (University of California Davis [UCD] and Stanford University). The committee aims to collaboratively optimize neuromodulation candidates, to assess and minimize medical and psychologic risks, and to select the best device given a patient's pain condition. In this study, we present the methods and outcome data of the Neuromodulation Committee at the two institutions., Materials and Methods: After institutional review board approval, we included all adult patients who were evaluated by the Neuromodulation Committee between 2017 and 2020 at two academic pain clinics. Patients with insufficient data were excluded from the study. A retrospective chart review was completed on 385 UCD and Stanford University patient committee reviews. Data collected from the chart review included demographics (age, sex), committee meeting results (proceed with trial/implant or decline), trial success, and implant rate., Results: Of the 385 patients screened, the committees recommended proceeding with an implantable device (peripheral and neuraxial) in 337 patients (87.5%). Of the 278 patients recommended for neuraxial neuromodulation, 131 underwent trials with percutaneous leads (47.1%). Trials were successful (causing a ≥50% reduction in self-reported pain or improved function) in 108 patients (82.4%). The institutions completed 87 implants of 131 trials, representing a trial-to-permanent ratio of 66.4%., Conclusions: The Neuromodulation Committee aims to identify optimal patients for neuromodulation, address procedural challenges, decrease adverse events, provide educational context for trainees, and improve patient-related outcomes. Patients who were recommended for neuromodulation and subsequently underwent intervention had high trial success rates for dorsal root ganglion stimulation and spinal cord stimulation. The findings indicate that such an approach can lead to neuromodulation success, especially at academic centers, by combining the expertise of both medical and psychologic professionals., Competing Interests: Conflict of Interest Scott G. Pritzlaff has had a financial agreement or affiliation with the following commercial interests in the form of consultant: Bioness, SPR Therapeutics, Nalu Medical, EBT Medical; royalties: Oxford University Press, Wolters Kluwer; and research grants; Medtronic, Nevro Corp, and Abbott. Michael Jung, Naileshni Singh, Juliann Cho, Matthew Skoblar, and Manoj Jagtiani reported no conflicts of interest. Michael S. Leong has had a financial agreement or affiliation with the following commercial interests in the form of consultant: Sorrento Therapeutics, and research: Wex Pharmaceuticals. Ravi Prasad has had a financial agreement or affiliation with the following commercial interests in the form of consultant: Menda Health and Nitto Inc. Vafi Salmasi has had a financial agreement or affiliation with the following commercial interests in the form of consultant: Biotronik, Vertos Medical, and AppliedVR., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: The International Neuromodulation Society convened a multispecialty group of physicians and scientists based on expertise with international representation to establish evidence-based guidance on intrathecal drug delivery in treating chronic pain. This Polyanalgesic Consensus Conference (PACC)® project, created more than two decades ago, intends to provide evidence-based guidance for important safety and efficacy issues surrounding intrathecal drug delivery and its impact on the practice of neuromodulation., Materials and Methods: Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when PACC® last published guidelines) to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence is scant., Results: The PACC® examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process., Conclusions: The PACC® recommends best practices regarding intrathecal drug delivery to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate., Competing Interests: Conflict of Interest Alaa Abd-Elsayed is a consultant for Medtronic. Philip Kim reports consulting fees from Medtronic, personal fees from TerSera, outside the submitted work; personal fees from Biotronik and Medtronic on a medical board; reseach support from Biotronik, Medtronic, Boston, Nevro, Saluda, and Cornerloc; and participation in a data safety monitoring board on RTX on Morton neuroma study. Christophe Perruchoud reports consulting fees, honoraria, and participation on a data safety monitoring board or advisory board for Medtronic. Anjum Bux reports personal fees from Flowonix Corp, Boston Scientific, AIS, Medtronic, and Vertos, outside the submitted work. Rui Duarte reports personal fees from Saluda Medical, Boston Scientific, Medtronic, and Mainstay Medical, outside the submitted work. Michael Saulino reports research grants from Medtronic and Flowonix; fellowship support from Medtronic, Piramal, and Saol; Denis Dupoiron reports personal fees from Medtronic and Esteve, outside the submitted work. Dennis Patin consults for Medtronic, Abbott, Boston Scientific, and Nevro. Julie G. Pilitsis reports grants and other from Boston Scientific, Nevro, Abbott, TerSera, and Medtronic; other from Saluda, Aim Medical Robotics, and Karuna Labs; grants from National Institutes of Health (NIH) 2R01CA166379-06; and grants from NIH U44NS115111, outside the submitted work. Lawrence R. Poree reports personal fees from Medtronic and Nalu, and grants and personal fees from Saluda, outside the submitted work. Harry Sukumaran reports personal fees from Abbott, Boston Scientific, and Nevro, and personal fees and nonfinancial support from Vertos Medical, outside the submitted work. Erik Shaw reports support from Pfizer/Lilly for tanezumab articles; consulting fees and/or honoraria from TerSera, Boston Scientific, SPR Therapeutics; participation on a data safety monitoring board or advisory board for Pfizer/Lilly NGF blocker; and stock options from SpineThera and ROM Tech. Tony L. Yaksh reports grants from NIH-National Institute of Neurological Disorders and Stroke (NINDS), other from CODA, IONIS, and Medtronic during the conduct of the study; grants from NIH-NINDS, IONIS, and Medtronic, outside the submitted work. Robert M. Levy is an unpaid and uncompensated consultant for Abbott, Biotronik, Nalu, and Synergia. The remaining authors reported no conflict of interest., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Psychological evaluation is required by insurance companies in the United States prior to proceeding with a spinal cord stimulation or a dorsal root ganglion stimulation trial. Since January 2017, we implemented a Multidisciplinary Team Conference for Neuromodulation in our center to facilitate the collaboration between pain physicians and psychologists and to optimize screening of neuromodulation candidates. This study aims to report the impact of this team conference on improvement of neuromodulation outcome in our center., Methods: Appropriateness of neuromodulation were discussed in the team conference after initial visit with the pain specialist and psychological evaluation. For this study, we prospectively and retrospectively collected data on neuromodulation candidates who went through the team conference and those who did not as controls., Results: We discussed 461 patients in the team conference sessions from January 2017 to July 2023. Out of these, a spinal cord stimulator or a dorsal root ganglion stimulator trial was performed in 164 patients with 80.5% (132 cases) trial success rate leading to 140 implants. Out of these implants, 26 (18.6%) explanted and 21 (15%) required revision in 41 (29.3%) patients. We performed neuraxial neuromodulation trial for 70 patients without going through the team conference from January 2016 to July 2023 with a trial success rate of 45.7% (32 cases). In this group, 7 (21.9%) and 6 (18.8%) patients underwent explant and revision. The differences between the groups were statistically significant for trial success rate (odds ratio of 4.9 with p -value of <0.01) but not for explant (odds ratio of 0.8 with p -value of 0.627) or revision (odds ratio of 0.8 with p -value of 0.595)., Conclusion: Implementing Multidisciplinary Team Conference increased trial success rate in our center. Team conference provides therapeutic benefit for patients, and also provides the opportunity for an educational discussion for trainees., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Salmasi, Rasouli, Kao, Ottestad, Terkawi, Morris, Qian, Coleman, Talavera, Poupore-King, Slater and Leong.)

Aim: Novel minimally invasive short-term and long-term peripheral nerve stimulation (PNS) systems have revolutionized targeted treatment of chronic neuropathic pain. We present an international survey of PNS-implanting pain physicians to assess what factors they consider when offering permanent PNS., Methods: This cross-sectional study consisted of a survey (Qualtrics) that was distributed to PNS-implanting physicians in a device supplier's entire email database on November 13, 2020, with 3 weeks of response time. Physicians' contact information in the form of their email addresses had been previously collected by the supplier upon device distribution with permission to use survey responses for research., Results: Of 2032 database physicians, 40 physicians representing 37 institutions responded to the survey. The most common application of PNS was mononeuropathic pain (57%). The most frequently targeted nerve was the suprascapular nerve (29%). 14% of physicians reported 81-100% of their implants were dual-lead. The representative physicians ranged broadly in their most frequently targeted nerves. Although mononeuropathic pain was the most common indication for PNS, there was still varied response regarding other indications such as CRPS and post-surgical chronic pain., Conclusion: In context of a low response rate, identifying such factors can help update the prevailing treatment algorithm for interventional therapies, assist pain physicians in better identifying which patients are the best candidates for PNS, and inform future clinical trial design on PNS efficacy., (© 2022 World Institute of Pain.)

Introduction: The International Neuromodulation Society convened a multispecialty group of physicians based on expertise with international representation to establish evidence-based guidance on the use of neurostimulation in the cervical region to improve outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for an often-overlooked area of neurostimulation practice., Materials and Methods: Authors were chosen based upon their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to the present. Identified studies were graded using the US Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant., Results: The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process., Conclusions: The NACC recommends best practices regarding the use of cervical neuromodulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be utilized as a guide to assist decision making when clinically appropriate., (Copyright © 2021 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.)

Rotating machinery is one of the major components of industries that suffer from various faults due to the constant workload. Therefore, a fast and reliable fault diagnosis method is essential for machine condition monitoring. In this study, noise eliminated ensemble empirical mode decomposition (NEEEMD) was used for fault feature extraction. A convolution neural network (CNN) classifier was applied for classification because of its feature learning ability. A generalized CNN architecture was proposed to reduce the model training time. A sample size of 64×64×3 pixels RGB scalograms are used as the classifier input. However, CNN requires a large number of training data to achieve high accuracy and robustness. Deep convolution generative adversarial network (DCGAN) was applied for data augmentation during the training phase. To evaluate the effectiveness of the proposed feature extraction method, scalograms from related feature extraction methods such as ensemble empirical mode decomposition (EEMD), complementary EEMD (CEEMD), and continuous wavelet transform (CWT) are classified. The effectiveness of scalograms is also validated by comparing the classifier performance using grayscale samples from the raw vibration signals. All the outputs from bearing and blade fault classifiers showed that scalogram samples from the proposed NEEEMD method obtained the highest accuracy, sensitivity, and robustness using CNN. DCGAN was applied with the proposed NEEEMD scalograms to further increase the CNN classifier's performance and identify the optimal number of training data. After training the classifier using augmented samples, the results showed that the classifier obtained even higher validation and test accuracy with greater robustness. The proposed method can be used as a more generalized and robust method for rotating machinery fault diagnosis.

Objectives: High-frequency and burst stimulation are newer waveforms that have demonstrated promise compared to traditional tonic spinal cord stimulation (SCS), but more studies are needed to compare their effectiveness. We report the study methods for an ongoing, single center, pragmatic randomized clinical trial to compare the effectiveness of high-frequency and burst SCS in patients with chronic back and/or leg pain., Materials and Methods: Participants who are candidates for spinal cord stimulation are enrolled and screened. Participants will be randomly assigned using point-of-care randomization to receive either high-frequency or burst SCS. Data collection will be through Stanford Pain Management Center's learning healthcare system: CHOIR. CHOIR surveys include National Institutes of Health Patient Reported Outcomes Measurement Information System item banks, a body map, questions about pain intensity, pain catastrophizing scale, and questions about patients' pain experience and healthcare utilization. Participants will complete online surveys at baseline and then 1, 3, 6, 12, 18, 24 and 36 months after their device implant. All participants will use our routine process of trial and implant. Reported adverse events are monitored throughout the study. Our primary outcome is change from baseline in pain intensity at 12 months., Results: We hypothesize that high-frequency SCS is more effective than burst SCS in improving pain, physical function and pain interference in participants with chronic low back and/or leg pain., Conclusions: The pragmatic nature of our proposed trial enables us to recruit a larger participant cohort faster and to follow up these participants longer than currently published clinical trials., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This paper presents automated harmonic removal as a desirable solution to effectively identify and discard the harmonic influence over the output signal by neglecting any user-defined parameter at start-up and automatically reconstruct back to become a useful output signal prior to system identification. Stochastic subspace-based algorithms (SSI) methods are the most practical tool due to the consistency in modal parameters estimation. However, it will be problematic when applied to structures with rotating machines and the presence of harmonic excitations. Difficulties arise when automating this procedure without any human interaction and the problem is still unresolved because stochastic subspace-based algorithms (SSI) methods still require parameters (the maximum within-cluster distance) that are compulsory to be defined at start-up for each analysis of the dataset. Thus, the use of image-based feature extraction for clustering and classification of harmonic components and structural poles directly from a stabilization diagram and for modal system identification is the focus of the present paper. As a fundamental necessary condition, the algorithm has been assessed first from computed numerical responses and then applied to the experimental dataset with the presence of harmonic excitation. Results of the proposed approach for estimating modal parameters demonstrated very high accuracy and exhibited consistent results before and after removing harmonic components from the response signal.

Short peripheral catheter (SPC)-related phlebitis can lead to bloodstream infections and affect patients' quality of life. A randomized trial was carried out to evaluate the effectiveness of 2 treatment methods in reducing the incidence of SPC-related phlebitis. The 2 treatment methods differed in terms of the cleansing solution used before insertion and dressing material used after removal. The results demonstrated that the type of cleansing solution and postremoval dressing material did not make a difference in the incidence of phlebitis. Strict adherence to aseptic techniques and prompt removal of the SPC remained the cornerstone in the prevention of phlebitis.

A major issue of machinery fault diagnosis using vibration signals is that it is over-reliant on personnel knowledge and experience in interpreting the signal. Thus, machine learning has been adapted for machinery fault diagnosis. The quantity and quality of the input features, however, influence the fault classification performance. Feature selection plays a vital role in selecting the most representative feature subset for the machine learning algorithm. In contrast, the trade-off relationship between capability when selecting the best feature subset and computational effort is inevitable in the wrapper-based feature selection (WFS) method. This paper proposes an improved WFS technique before integration with a support vector machine (SVM) model classifier as a complete fault diagnosis system for a rolling element bearing case study. The bearing vibration dataset made available by the Case Western Reserve University Bearing Data Centre was executed using the proposed WFS and its performance has been analysed and discussed. The results reveal that the proposed WFS secures the best feature subset with a lower computational effort by eliminating the redundancy of re-evaluation. The proposed WFS has therefore been found to be capable and efficient to carry out feature selection tasks.

Background: In the course of managing preterm labour, increasing trends of total white cell count raises concern for the obstetrician, suggesting a possible underlying infectious aetiology. Although mild leukocytosis is expected in pregnancy, the patterns of increment after corticosteroid administration are not well described beyond animal models and in a small number of human studies., Methods: Seventy-three consecutive patients who required antenatal corticosteroids for either preterm labour or prelabour caesarean section were recruited and given a standard course of 12mg dexamethasone phosphate, twelve hours apart. Venous blood samples were taken before administration, at six hours and 36 hours after the first dose of dexamethasone., Results: The total white count trend was 10.31±2.62 at baseline, 11.44±3.05 at six hours and 12.20±3.49 at 36 hours. Neutrophil-lymphocyte ratio was 3.60±1.31, 8.73±3.63 and 3.24±1.49 respectively, reflecting relative neutrophilia and lymphopenia which normalised by 36 hours., Conclusion: In contrast to previous studies, we found only a slight increment in total white cell count of about 10%. The marginal changes described in our study would not normally raise any clinical concern, although vigilance should be exercised if higher levels were observed.

Based on Mie scattering theory and the assumption that the particle is electrically small in size (k(t)a≪1,k(m)a≪1), an analytic relationship between radial and tangential permittivity parameters has been established for achieving minimal scattering from an arbitrary rotationally uniaxial anisotropic spherical object incident by a plane wave. Analysis of fields in both the far- and near-field zones indicates that the derived relation is not only valid for electrically small particles, but also applicable to larger ones whose sizes are comparable with the free space wavelength after slight adjustments in parameters. Furthermore, it is observed that the dielectric spherical particle of reduced tangential permittivity yields better transparency performance than the design using a plasmonic cover by Alu and Engheta [Phys. Rev. E 72, 016623 (2005)]. As such, particles with carefully engineered radial anisotropy are transparent without using any coating and are ideal for applications with space constraint and stringent transparency criteria.

Ziconotide is a nonopioid analgesic currently indicated as monotherapy, but frequently used in combination with opioids, for the management of severe chronic pain in patients for whom intrathecal (IT) therapy is warranted and who are intolerant of, or whose pain is, refractory to other treatments. There is a paucity of information regarding ziconotide use in patients with complex regional pain syndrome (CRPS). Seven cases in which IT ziconotide was used in patients with CRPS were analyzed. All patients (4 male, 3 female; age range, 14 to 52 years) had experienced inadequate pain relief with multiple conventional and interventional treatments. Three patients received ziconotide monotherapy exclusively; 4 patients received ziconotide monotherapy initially, then combination IT therapy. The mean ziconotide dose was 5.2 mcg/d (range, 0.5 to 13 mcg/d) at initiation and 24.7 mcg/d (range, 0.06 to 146 mcg/d) at the last available assessment. The mean duration of ziconotide therapy was 3.1 years (range, 26 days to 8 years). At ziconotide initiation, the mean visual analog scale (VAS) score was 89.3 mm (range, 75 to 100 mm); VAS scores decreased by a mean of 47.5% (range, 5% to 100%) at last assessment. Of the 5 patients who experienced substantial improvement in pain, edema, skin abnormalities, and/or mobility with ziconotide therapy, 2 have discontinued ziconotide and are pain free. Another patient experienced marked reversal of both edema and advanced skin trophic changes. Adverse events included urinary retention, depression, anxiety, and hallucinations. Adverse events generally resolved spontaneously, with treatment, or with ziconotide discontinuation/dose reduction. Although further studies are required, ziconotide holds promise as an effective treatment for CRPS.

Objective: To determine the analgesic effect and tolerability of a novel needle-free powder lidocaine delivery system in children undergoing venipuncture., Study Design: In this double-blind, placebo-controlled, single-center trial, 306 children age 3 to 18 years were randomized to receive a needle-free powder lidocaine delivery system or matching sham placebo at the back of the hand 2 to 3 minutes before venipuncture. Venipuncture pain was self-reported using the Wong-Baker FACES scale (in 3- to 12-year-olds) and a 100-mm visual analog scale (in 8- to 18-year-olds). Safety was assessed by adverse events, investigator skin site assessments, and children's self-report of the administration comfort of study treatments. Effect sizes were compared by 2-sample t test and Glass's Delta approach., Results: Subjects receiving the needle-free powder lidocaine delivery system exhibited mean pain reductions (effect size) of 33% to 46% relative to sham placebo. Pain reductions were statistically significant for all ages combined and also for the youngest and oldest age strata. Self-reported administration comfort levels were similar in the active system and sham placebo groups. Incidences of adverse events and dermal reactions were low; the most common dermal reaction was mild erythema., Conclusions: The needle-free powder lidocaine delivery system was well tolerated and provided effective local analgesia when administered 2 to 3 minutes before venipuncture.

Background: Previous open-label studies have demonstrated that botulinum toxin type B (BTX-B, Myobloc, Solstice Neurosciences) in doses of up to 3,000 U is safe and effective in the treatment of glabellar wrinkles., Objective: This double-blind, randomized, placebo-controlled, sequential-dose-escalation study evaluated the safety and tolerability of seven BTX-B doses ranging from 250 to 3,000 U in the treatment of subjects with hyperfunctional glabellar lines., Methods: Participants received a single intramuscular treatment of either BTX-B or placebo at five facial sites with a 12-week follow-up period. Primary efficacy outcome measure was the Investigator Global Scale score of subject's glabellar lines at rest and at full frown. Safety was evaluated primarily on the occurrence of adverse events (AEs)., Results: The investigator scores demonstrated a statistically significant increasing dose-response trend in the percentage of subjects with no lines or mild lines at rest from Weeks 1 to 12 (p=.0420) and at full frown from Weeks 1 to 8 (p<.0001). Fifty-one subjects (36.7%) experienced AEs; the most common AE was headache not otherwise specified, experienced by 19 subjects (13.7%)., Conclusions: BTX-B at doses up to 3,000 U was safe and well tolerated in the treatment of hyperfunctional glabellar lines. Treatment with BTX-B reduced hyperfunctional glabellar lines in subjects, and the duration of action appeared to be related to the dose administered. Further studies using higher doses of BTX-B for treatment of glabellar wrinkles are planned.

Safety and efficacy data from a study of slow intrathecal (IT) ziconotide titration for the management of severe chronic pain are presented. Patients randomized to ziconotide (n = 112) or placebo (n = 108) started IT infusion at 0.1 microg/hour (2.4 microg/day), increasing gradually (0.05-0.1 microg/hour increments) over 3 weeks. The ziconotide mean dose at termination was 0.29 microg/hour (6.96 microg/day). Patients' baseline Visual Analogue Scale of Pain Intensity (VASPI) score was 80.7 (SD 15). Statistical significance was noted for VASPI mean percentage improvement, baseline to Week 3 (ziconotide [14.7%] vs. placebo [7.2%; P = 0.036]) and many of the secondary efficacy outcomes measures. Significant adverse events (AEs) reported in the ziconotide group were dizziness, confusion, ataxia, abnormal gait, and memory impairment. Discontinuation rates for AEs and serious AEs were comparable for both groups. Slow titration of ziconotide, a nonopioid analgesic, to a low maximum dose resulted in significant improvement in pain and was better tolerated than in two previous controlled trials that used a faster titration to a higher mean dose.

Background: The surgical cure rate for primary hyperparathyroidismis greater than 95%. For those who have recurrent or persistent disease, preoperative localization improves reoperation success rates. Selective parathyroid venous sampling (SPVS) for intact parathyroid hormone is particularly useful when non-invasive localization techniques are negative or inconclusive., Methods: We present all known cases (n = 13)between 1994 and 2002 who had venous sampling for localization a tour institution prior to reoperation for recurrent or persistent primary hyperparathyroidism. Comparison was made with non-invasive localization procedures. Results of invasive and non-invasive localization were correlated with surgical findings., Results: Of the nine reoperated cases, eight had positive correlations between SPVS and operative findings and histopathology. SPVS did not reveal the parathyroid hormone source in one case with negative non-invasive localization procedures. Comparisons between SPVS,computerized tomography (CT), and parathyroid scintigraphy (MIBI)as expressed in terms of true positive (TP), false positive (FP)and false negative (FN) were: SPVS - TP88.8%, FP 0%, FN 11.1%; CT - TP22.2%, FP 22.2%, FN 55.5%; and MIBI - TP33.3%, FP 0%, FN 66.6%. At least seven of the nine operated cases have been cured; another remained normocalcaemic 2 weeks after subtotal parathyroidectomy., Conclusion: In our institution SPVS has proven to be a valuable tool in cases with recurrent or persistent primary hyperparathyroidism and negative non-invasive localization procedures.

Mexilitine is an anti-arrhythmic agent used to treat neuropathic pain. The drug has a low side-effect profile with gastritis as the predominant complaint. The following two cases suggest that mexilitine can potentially cause persistent ophthalmic changes and should be used with caution in chronic pain patients with preexisting ocular disease.

Intraspinal drug delivery systems are becoming increasingly utilized for the management of patients with pain or spasticity. Numerous potential complications associated with the use of this technology have previously been described in the literature. We have had experience with a new complication of the internal alarm being triggered by the instillation of cold solution into the pump resevoir. This new finding could have implications for patients with respect to unnecessary reevaluations of the pump, or possible premature scheduling of pump replacement surgery.

Intravenous lidocaine is used to treat various neuropathic pain states. Systemic local anesthetics have been reported to cause behavioral alteration via limbic system activation. This case report describes a dramatic behavioral change in a patient receiving intravenous lidocaine and suggests a possible use of lidocaine to discriminate somatic and affective pain characteristics.