The current state of training in pain medicine fellowships: An Association of Pain Program Directors (APPD) survey of program directors.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education. METHODS: This study involved 56 PDs of ACGME-accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow-up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy. RESULTS: Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry-related and professional society-related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long-term success. Fifty-four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies. CONCLUSION: This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12-month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization.

Chronic Pain Considerations in Patients with Cardiovascular Disease.

Cardiovascular disease affects close to half of the United States population and many of these patients will develop chronic pain syndromes as a result of their disease process. This article provides an overview of several pain syndromes that result, directly or indirectly, from cardiovascular disease including peripheral arterial disease, angina, thoracic outlet syndrome, postamputation pain, complex regional pain syndrome, and poststroke pain. Psychological and medical comorbidities that affect the medical decision-making process in the treatment of chronic pain associated with cardiovascular disease are also discussed.

Inadvertent Intraoperative Defibrillation Secondary to Electrocautery Grounding Pad Placement.

Intraoperative defibrillation secondary to the usage of electrocautery in a patient with a cardiovascular implantable electronic device is a rare occurrence, and below-the-umbilicus electrocautery use causing inadvertent defibrillation is a near-zero risk. Defibrillation secondary to electrodispersive pad (EDP) radiofrequency dispersion has only ever been theorized. In this report, we describe the case of a 67-year-old male with an automatic implantable cardioverter defibrillator (AICD) undergoing a robotic-assisted left anterior total hip arthroplasty for left hip osteoarthritis who experienced inadvertent intraoperative defibrillation concurrent with electrocautery usage. The defibrillations ceased following contralateral EDP repositioning and application of a donut magnet overlying the patient's AICD.

Improvement of Cyclic Vomiting Syndrome with Outpatient Ketamine Infusions.

Cyclic vomiting syndrome (CVS) is a disorder characterized by recurrent flares of nausea and vomiting, often with significant abdominal pain, of several days duration. Although traditional prophylactic and abortive treatments for CVS are often successful, a subset of CVS patients with chronic abdominal pain may not respond as well to standard therapies. This report is the first, to our knowledge, to describe the use of outpatient ketamine infusions as therapy for refractory CVS. We describe a 63-year-old woman with history of CVS who presented with abdominal pain and recurrent episodes of nausea and vomiting. She first received ketamine during an inpatient admission for a CVS flare, with the aim of treating the abdominal pain. Given her improvement, she was offered a series of outpatient ketamine infusions, which led to a significant reduction in her symptoms. Thus, ketamine may be useful as both an abortive and prophylactic therapy in CVS. Prior reports have noted the anti-emetic effects of ketamine in the perioperative setting, and there is emerging evidence for the use of ketamine infusions for the treatment of chronic pain. However, this report is the first to describe ketamine as a potential prophylactic treatment for CVS.

Development and validation of an HPLC-MS/MS method for the analysis of dexamethasone from pig synovial fluid using dried matrix spotting.

BACKGROUND: Dried matrix spot techniques were employed to validate an HPLC-MS/MS assay for the determination of dexamethasone in clear Yorkshire pig synovial fluid using 15 µl of sample. We have adopted the term dried matrix spot to indicate that the techniques used for dried blood spots can be applied to nonblood matrices. The dried matrix spot method employs a color-indicating process developed at Alturas Analytics that enhances the ability to analyze transparent fluids spotted onto collection paper by allowing the analyst to visually verify the location of the dried sample spot. RESULTS: The method was shown to be accurate (±4.3%) and precise (14.2% at the LLOQ and ≤10.0% at all other concentrations) across the dynamic range of the assay. CONCLUSION: The method shows the potential application of dried matrix spot techniques for the analysis of transparent biological fluids.