Elevated CO2 concentration increases maize growth under water deficit or soil salinity but with a higher risk of hydraulic failure.

Climate change presents a challenge for plants to acclimate their water relations under changing environmental conditions, and may increase the risks of hydraulic failure under stress. In this study, maize plants were acclimated to two different CO2 concentrations ([CO2]; 400 ppm and 700 ppm) while under either water stress (WS) or soil salinity (SS) treatments, and their growth and hydraulic traits were examined in detail. Both WS and SS inhibited growth and had significant impacts on hydraulic traits. In particular, the water potential at 50% loss of stem hydraulic conductance (P50) decreased by 1 MPa in both treatments at 400 ppm. When subjected to elevated [CO2], the plants under both WS and SS showed improved growth by 7-23%. Elevated [CO2] also significantly increased xylem vulnerability (measured as loss of conductivity with decreasing xylem pressure), resulting in smaller hydraulic safety margins. According to the plant desiccation model, the critical desiccation degree (time×vapor pressure deficit) that the plants could tolerate under drought was reduced by 43-64% under elevated [CO2]. In addition, sensitivity analysis showed that P50 was the most important trait in determining the critical desiccation degree. Thus, our results demonstrated that whilst elevated [CO2] benefited plant growth under WS or SS, it also interfered with hydraulic acclimation, thereby potentially placing the plants at a higher risk of hydraulic failure and increased mortality.

Lesions to both somatic and affective pain pathways lead to decreased salience network connectivity.

Human pain is a salient stimulus composed of two main components: a sensory/somatic component, carrying peripheral nociceptive sensation via the spinothalamic tract and brainstem nuclei to the thalamus and then to sensory cortical regions, and an affective (suffering) component, where information from central thalamic nuclei is carried to the anterior insula, dorsal anterior cingulate cortex and other regions. While the sensory component processes information about stimulus location and intensity, the affective component processes information regarding pain-related expectations, motivation to reduce pain and pain unpleasantness. Unlike investigations of acute pain that are based on the introduction of real-time stimulus during brain recordings, chronic pain investigations are usually based on longitudinal and case-control studies, which are limited in their ability to infer the functional network topology of chronic pain. In the current study, we utilized the unique opportunity to target the CNS's pain pathways in two different hierarchical locations to establish causality between pain relief and specific connectivity changes seen within the salience and sensorimotor networks. We examined how lesions to the affective and somatic pain pathways affect resting-state network topology in cancer patients suffering from severe intractable pain. Two procedures have been employed: percutaneous cervical cordotomy (n = 15), hypothesized to disrupt the transmission of the sensory component of pain along the spinothalamic tract, or stereotactic cingulotomy (n = 7), which refers to bilateral intracranial ablation of an area in the dorsal anterior cingulate cortex and is known to ameliorate the affective component of pain. Both procedures led to immediate significant alleviation of experienced pain and decreased functional connectivity within the salience network. However, only the sensory procedure (cordotomy) led to decreased connectivity within the sensorimotor network. Thus, our results support the existence of two converging systems relaying experienced pain, showing that pain-related suffering can be either directly influenced by interfering with the affective pathway or indirectly influenced by interfering with the ascending spinothalamic tract.

Stomatal responses in grapevine become increasingly more tolerant to low water potentials throughout the growing season.

The leaf of a deciduous species completes its life cycle in a few months. During leaf maturation, osmolyte accumulation leads to a significant reduction of the turgor loss point (ΨTLP ), a known marker for stomatal closure. Here we exposed two grapevine cultivars to drought at three different times during the growing season to explore if the seasonal decrease in leaf ΨTLP influences the stomatal response to drought. The results showed a significant seasonal shift in the response of stomatal conductance to stem water potential (gs ~Ψstem ), demonstrating that grapevines become increasingly tolerant to low Ψstem as the season progresses in coordination with the decrease in ΨTLP . We also used the SurEau hydraulic model to demonstrate a direct link between osmotic adjustment and the plasticity of gs ~Ψstem . To understand the possible advantages of gs ~Ψstem plasticity, we incorporated a seasonally dynamic leaf osmotic potential into the model that simulated stomatal conductance under several water availabilities and climatic scenarios. The model demonstrated that a seasonally dynamic stomatal closure threshold results in trade-offs: it reduces the time to turgor loss under sustained long-term drought, but increases overall gas exchange particularly under seasonal shifts in temperature and stochastic water availability. A projected hotter future is expected to lower the increase in gas exchange that plants gain from the seasonal shift in gs ~Ψstem . These findings show that accounting for dynamic stomatal regulation is critical for understanding drought tolerance.

Xylem conduit deformation across vascular plants: an evolutionary spandrel or protective valve?

The hydraulic system of vascular plants and its integrity is essential for plant survival. To transport water under tension, the walls of xylem conduits must approximate rigid pipes. Against this expectation, conduit deformation has been reported in the leaves of a few species and hypothesized to function as a 'circuit breaker' against embolism. Experimental evidence is lacking, and its generality is unknown. We demonstrated the role of conduit deformation in protecting the upstream xylem from embolism through experiments on three species and surveyed a diverse selection of vascular plants for conduit deformation in leaves. Conduit deformation in minor veins occurred before embolism during slow dehydration. When leaves were exposed to transient increases in transpiration, conduit deformation was accompanied by large water potential differences from leaf to stem and minimal embolism in the upstream xylem. In the three species tested, collapsible vein endings provided clear protection of upstream xylem from embolism during transient increases in transpiration. We found conduit deformation in diverse vascular plants, including 11 eudicots, ginkgo, a cycad, a fern, a bamboo, and a grass species, but not in two bamboo and a palm species, demonstrating that the potential for 'circuit breaker' functionality may be widespread across vascular plants.

Xylem resistance to cavitation increases during summer in Pinus halepensis.

Cavitation resistance has often been viewed as a relatively static trait, especially for stems of forest trees. Meanwhile, other hydraulic traits, such as turgor loss point (Ψtlp ) and xylem anatomy, change during the season. In this study, we hypothesized that cavitation resistance is also dynamic, changing in coordination with Ψtlp . We began with a comparison of optical vulnerability (OV), microcomputed tomography (µCT) and cavitron methods. All three methods significantly differed in the slope of the curve,Ψ12 and Ψ88 , but not in Ψ50 (xylem pressures that cause 12%, 88%, 50% cavitation, respectively). Thus, we followed the seasonal dynamics (across 2 years) of Ψ50 in Pinus halepensis under Mediterranean climate using the OV method. We found that Ψ50 is a plastic trait with a reduction of approximately 1 MPa from the end of the wet season to the end of the dry season, in coordination with the dynamics of the midday xylem water potential (Ψmidday ) and the Ψtlp . The observed plasticity enabled the trees to maintain a stable positive hydraulic safety margin and avoid cavitation during the long dry season. Seasonal plasticity is vital for understanding the actual risk of cavitation to plants and for modeling species' ability to tolerate harsh environments.

Rapid leaf xylem acclimation diminishes the chances of embolism in grapevines.

Under most conditions tight stomatal regulation in grapevines (Vitis vinifera) avoids xylem embolism. The current study evaluated grapevine responses to challenging scenarios that might lead to leaf embolism and consequential leaf damage. We hypothesized that embolism would occur if the vines experienced low xylem water potential (Ψx) shortly after bud break or later in the season under a combination of extreme drought and heat. We subjected vines to two potentially dangerous environments: (i) withholding irrigation from a vineyard grown in a heatwave-prone environment, and (ii) subjecting potted vines to terminal drought 1 month after bud break. In the field experiment, a heatwave at the beginning of August resulted in leaf temperatures over 45 °C. However, effective stomatal response maintained the xylem water potential (Ψx) well above the embolism threshold, and no leaf desiccation was observed. In the pot experiment, leaves of well-watered vines in May were relatively vulnerable to embolism with 50% embolism (P50) at -1.8 MPa. However, when exposed to drought, these leaves acclimated their leaf P50 by 0.65 MPa in less than a week and before reaching embolism values. When dried to embolizing Ψx, the leaf damage proportion matched (percentage-wise) the leaf embolism level. Our findings indicate that embolism and leaf damage are usually avoided by the grapevines' efficient stomatal regulation and rapid acclimation of their xylem vulnerability.

Relationships between xylem embolism and tree functioning during drought, recovery, and recurring drought in Aleppo pine.

Recent findings suggest that trees can survive high levels of drought-induced xylem embolism. In many cases, the embolism is irreversible and, therefore, can potentially affect post-drought recovery and tree function under recurring droughts. We examined the development of embolism in potted Aleppo pines, a common species in hot, dry Mediterranean habitats. We asked (1) how post-drought recovery is affected by different levels of embolism and (2) what consequences this drought-induced damage has under a recurring drought scenario. Young trees were dehydrated to target water potential (Ψx ) values of -3.5, -5.2 and -9.5 MPa (which corresponded to ~6%, ~41% and ~76% embolism), and recovery of the surviving trees was measured over an 8-months period (i.e., embolism, leaf gas-exchange, Ψx ). An additional group of trees was exposed to Ψx of -6.0 MPa, either with or without preceding drought (Ψx of -5.2 MPa) to test the effect of hydraulic damage during repeated drought. Trees that reached -9.5 MPa died, but none from the other groups. Embolism levels in dying trees were on average 76% of conductive xylem and no tree was dying below 62% embolism. Stomatal recovery was negatively proportional to the level of hydraulic damage sustained during drought, for at least a month after drought relief. Trees that experienced drought for the second time took longer to reach fatal Ψx levels than first-time dehydrating trees. Decreased stomatal conductance following drought can be seen as "drought legacy," impeding recovery of tree functioning, but also as a safety mechanism during a consecutive drought.

The effect of subcutaneous fat and skin-to-lamina distance on complications and functional outcomes of minimally invasive lumbar decompression.

PURPOSE: Minimally invasive lumbar decompression (MIS) in obese pzatients is technically challenging due to the use of longer tube retractors. The purpose of this study was to evaluate the impact of the thickness of the soft tissue and subcutaneous fat on complications, revisions, and patient-reported functional outcomes after MIS. METHODS: This is a retrospective analysis of 148 consecutive patients who underwent minimally invasive lumbar decompression at our institute between 2013 and 2017 and had at least one year of follow-up. Analysis was performed five times, each time the study group was defined by another measure of adiposity: BMI > 30, skin to lamina distance at the site of surgery and at L4 > 6 cm, and subcutaneous fat thickness at the site of surgery and at L4 > 3 cm. Outcomes included intraoperative complications (durotomy or neurological deficit), possibly inadequate decompression (residual disc, reoperation), length of stay, return to the emergency room or readmission, postoperative medical complications, and functional outcomes: visual analog scores for back and leg pain, and Oswestry Disability Index (ODI). RESULTS: Patients with a thicker layer soft tissue had a significantly higher burden of comorbidities than controls, including higher prevalence of cardiovascular disease (p = 0.002), diabetes (p < 0.001), hypertension (p < 0.001) and higher ASA scores (p = 0.002). Nevertheless, there was no significant difference between the patient groups in surgical and medical complications, functional outcomes, and other assessed outcomes. CONCLUSION: Our results indicate that minimally invasive lumbar decompression is safe and effective for patients with a thick layer of soft tissue and subcutaneous fat.

In situ, direct observation of seasonal embolism dynamics in Aleppo pine trees growing on the dry edge of their distribution.

Xylem embolism impairs hydraulic conductivity in trees and drives drought-induced mortality. While embolism has been monitored in vivo in potted plants, and research has revealed evidence of embolism in field-grown trees, continuous in situ monitoring of cavitation in forests is lacking. Seasonal patterns of embolism were monitored in branchlets of Aleppo pine (Pinus halepensis) trees growing in a dry Mediterranean forest. Optical visualization (OV) sensors were installed on terminal branches, in addition to monthly sampling for micro computed tomography scans. We detected 208 cavitation events among four trees, which represented an embolism increase from zero to c. 12% along the dry season. Virtually all the cavitation events occurred during daytime hours, with 77% occurring between 10:00 and 17:00 h. The probability for cavitation in a given hour increased as vapor pressure deficit (VPD) increased, up to a probability of 42% for cavitation when VPD > 5 kPa. The findings uniquely reveal the instantaneous environmental conditions that lead to cavitation. The increased likelihood of cavitation events under high VPD in water-stressed pines is the first empirical support for this long hypothesized relationship. Our observations suggest that low levels of embolism are common in Aleppo pine trees at the dry edge of their distribution.

Seasonal adjustment of leaf embolism resistance and its importance for hydraulic safety in deciduous trees.

Embolism resistance is often viewed as seasonally stable. Here we examined the seasonality in the leaf xylem vulnerability curve (VC) and turgor loss point (ΨTLP ) of nine deciduous species that originated from Mediterranean, temperate, tropical, or sub-tropical habitats and were growing on the Volcani campus, Israel. All four Mediterranean/temperate species exhibited a shift of their VC to lower xylem pressures (Ψx ) along the dry season, in addition to two of the five tropical/sub-tropical species. In three of the species that exhibited VC seasonality, it was critical for avoiding embolism in the leaf. In total, seven out of the nine species avoided embolism. The seasonal VC adjustment was over two times higher as compared with the seasonal adjustment of ΨTLP , resulting in improved hydraulic safety as the season progressed. The results suggest that seasonality in the leaf xylem vulnerability is common in species that originate from Mediterranean or temperate habitats that have large seasonal environmental changes. This seasonality is advantageous because it enables a gradual seasonal reduction in the Ψx without increasing the danger of embolism. The results also highlight that measuring the minimal Ψx and the VC at different times can lead to erroneous estimations of the hydraulic safety margins. Changing the current hydraulic dogma into a seasonal dynamic in the vulnerability of the xylem itself should enable physiologists to understand plants' responses to their environment better.

Facet overhang: A novel parameter in the pathophysiology of multifidus muscle atrophy.

The relationship between degenerative zygapophysial joint (facet) arthropathy and multifidus muscle atrophy has not been rigorously evaluated. The purpose of this study was to determine if specific morphological features of degenerative facet arthropathy are correlated with multifidus muscle atrophy. We retrospectively reviewed medical records and imaging studies of patients with lumbar spinal stenosis. Facet overhang, bridging osteophyte formation, facet effusion, and facet angles were evaluated by univariable and multivariable regression to identify independent associations with deep and superficial parts of the multifidus total cross-sectional area (tCSA), functional cross-sectional area (fnCSA), and fatty infiltration (FI). Facet overhang was classified as severe in 50 females (53.2%) versus 56 males (36.9%) (p = 0.030). Severity of facet overhang and female sex were independently associated with smaller deep part of the multifidus tCSA and fnCSA as well as higher FI, reflecting greater atrophy of the deep region compared to total muscle mass. In comparison, severe facet overhang (p < 0.001; OR = 3.47, 95% CI = 2.13-5.66) and female sex (p < 0.001; OR = 4.19, 95% CI = 2.58-6.79) were independently associated only with higher superficial part of the multifidus FI, reflecting muscle steatosis without significant lean muscle atrophy. In patients with degenerative lumbar spinal stenosis, facet overhang is an independent risk factor for deep part of the multifidus atrophy. Bridging osteophyte formation, facet effusion, and facet angles were not independently associated with deep part of the multifidus atrophy.

An increase in xylem embolism resistance of grapevine leaves during the growing season is coordinated with stomatal regulation, turgor loss point and intervessel pit membranes.

Although xylem embolism resistance is traditionally considered as static, we hypothesized that in grapevine (Vitis vinifera) leaf xylem becomes more embolism-resistant over the growing season. We evaluated xylem architecture, turgor loss point (ΨTLP ) and water potentials leading to 25% of maximal stomatal conductance (gs25 ) or 50% embolism in the leaf xylem (P50 ) in three irrigation treatments and at three time points during the growing season, while separating the effects of leaf age and time of season. Hydraulic traits acclimated over the growing season in a coordinated manner. Without irrigation, ΨTLP , gs25 , and P50 decreased between late May and late August by 0.95, 0.77 and 0.71 MPa, respectively. A seasonal shift in P50 occurred even in mature leaves, while irrigation had only a mild effect (< 0.2 MPa) on P50 . Vessel size and pit membrane thickness were also seasonally dynamic, providing a plausible explanation for the shift in P50 . Our findings provide clear evidence that grapevines can modify their hydraulic traits along a growing season to allow lower xylem water potential, without compromising gas exchange, leaf turgor or xylem integrity. Seasonal changes should be considered when modeling ecosystem vulnerability to drought or comparing datasets acquired at different phenological stages.

Leaf Carbon Export and Nonstructural Carbohydrates in Relation to Diurnal Water Dynamics in Mature Oak Trees.

Trees typically experience large diurnal depressions in water potential, which may impede carbon export from leaves during the day because the xylem is the source of water for the phloem. As water potential becomes more negative, higher phloem osmotic concentrations are needed to draw water in from the xylem. Generating this high concentration of sugar in the phloem is particularly an issue for the ∼50% of trees that exhibit passive loading. These ideas motivate the hypothesis that carbon export in woody plants occurs predominantly at night, with sugars that accumulate during the day assisting in mesophyll turgor maintenance or being converted to starch. To test this, diurnal and seasonal patterns of leaf nonstructural carbohydrates, photosynthesis, solute, and water potential were measured, and carbon export was estimated in leaves of five mature (>20 m tall) red oak (Quercus rubra) trees, a species characterized as a passive loader. Export occurred throughout the day at equal or higher rates than at night despite a decrease in water potential to -1.8 MPa at midday. Suc and starch accumulated over the course of the day, with Suc contributing ∼50% of the 0.4 MPa diurnal osmotic adjustment. As a result of this diurnal osmotic adjustment, estimates of midday turgor were always >0.7 MPa. These findings illustrate the robustness of phloem functioning despite diurnal fluctuations in leaf water potential and the role of nonstructural carbohydrates in leaf turgor maintenance.

Productivity versus drought adaptation in olive leaves: Comparison of water relations in a modern versus a traditional cultivar.

The physiological traits that set the tradeoff between productivity and drought adaptation in plants are still under debate. To reveal these traits, we compared the water relations of two olive (Olea europaea) cultivars: "Barnea"-a highly productive modern cultivar; and "Souri"-a drought-adapted traditional cultivar. We hypothesized that Souri has lower hydraulic conductivity and lower hydraulic vulnerability. The hypothesis was tested at the leaf level. The soil volumetric water content (θ), stem water potential (ΨS ), and gas exchange were measured in both cultivars while they dried until a significant reduction in their maximal photochemical potential (Fv /Fm  < 0.6) was obtained. Additionally, pressure-volume relations, leaf hydraulic vulnerability, and the petiole xylem architecture were evaluated. To our surprise, Souri's leaf hydraulic conductivity was more vulnerable to low ΨS , approaching zero at -8 MPa compared with <-10 MPa in "Barnea." At the same time, Souri's higher osmotic content and cell rigidity enabled it to sustain 1.4 MPa lower ΨS , while maintaining near optimal (Fv /Fm ). However, both cultivars significantly reduced their Fv /Fm (<0.6) at the same θ, suggesting that the capability to sustain a low θ is not the issue. Instead, Souri's lower transpiration enabled it to withstand a longer drought while avoiding low θ. Barnea's larger xylem vessels and hydraulic conductivity supported higher stomatal conductance (gs ) and assimilation rate, which nurtured its higher productivity but resulted in quick depletion of θ. These results suggest that hydraulic resistance or the ability to sustain low θ do not set the tradeoff between productivity and drought adaptation in olive leaves.

Long-Term Pain Characteristics and Management Following Minimally Invasive Spinal Decompression and Open Laminectomy and Fusion for Spinal Stenosis.

Background and Objectives: To compare the long-term pain characteristics and its chronic management following minimally invasive spinal (MIS) decompression and open laminectomy with fusion for lumbar stenosis. Materials and Methods: The study cohort included patients with a minimum 5-year postoperative follow-up after undergoing either MIS decompression or laminectomy with fusion for spinal claudication. The primary outcome of interest was chronic back and leg pain intensity. Secondary outcome measures included pain frequency during the day, chronic use of non-opioid analgesics, narcotic medications, medical cannabinoids, and continuous interventional pain treatments. Results: A total of 95 patients with lumbar spinal stenosis underwent one- or two-level surgery for lumbar spinal stenosis between April 2009 and July 2013. Of these, 50 patients underwent MIS decompression and 45 patients underwent open laminectomy with instrumented fusion. In the fusion group, a higher percentage of patients experienced moderate-to-severe back pain with 48% compared to 21.8% of patients in the MIS decompression group (p < 0.01). In contrast, we found no significant difference in the reported leg pain in both groups. In the fusion group, 20% of the patients described their back and leg pain as persistent throughout the day compared to only 2.2% in the MIS decompression group (p < 0.05). A trend toward higher chronic dependence on analgesic medication and repetitive pain clinic treatments was found in the fusion group. Conclusions: MIS decompression for the treatment of degenerative spinal stenosis resulted in decreased long-term back pain and similar leg pain outcomes compared to open laminectomy and instrumented fusion surgery.

Visualizing Embolism Propagation in Gas-Injected Leaves.

Because the xylem in leaves is thought to be at the greatest risk of cavitation, reliable and efficient methods to characterize leaf xylem vulnerability are of interest. We report a method to generate leaf xylem vulnerability curves (VCs) by gas injection. Using optical light transmission, we visualized embolism propagation in grapevine (Vitis vinifera) and red oak (Quercus rubra) leaves injected with positive gas pressure. This resulted in a rapid, stepwise reduction of transmitted light, identical to that observed during leaf dehydration, confirming that the optical method detects gas bubbles and provides insights into the air-seeding hypothesis. In red oak, xylem VCs generated using gas injection were similar to those generated using bench dehydration, but indicated 50% loss of conductivity at lower tension (∼0.4 MPa) in grapevine. In determining VC, this method eliminates the need to ascertain xylem tension, thus avoiding potential errors in water potential estimations. It is also much faster (1 h per VC). However, severing the petiole and applying high-pressure gas could affect air-seeding and the generated VC. We discuss potential artifacts arising from gas injection and recommend comparison of this method with a more standard procedure before it is assumed to be suitable for a given species.

The physiology of drought stress in grapevine: towards an integrative definition of drought tolerance.

Water availability is arguably the most important environmental factor limiting crop growth and productivity. Erratic precipitation patterns and increased temperatures resulting from climate change will likely make drought events more frequent in many regions, increasing the demand on freshwater resources and creating major challenges for agriculture. Addressing these challenges through increased irrigation is not always a sustainable solution so there is a growing need to identify and/or breed drought-tolerant crop varieties in order to maintain sustainability in the context of climate change. Grapevine (Vitis vinifera), a major fruit crop of economic importance, has emerged as a model perennial fruit crop for the study of drought tolerance. This review synthesizes the most recent results on grapevine drought responses, the impact of water deficit on fruit yield and composition, and the identification of drought-tolerant varieties. Given the existing gaps in our knowledge of the mechanisms underlying grapevine drought responses, we aim to answer the following question: how can we move towards a more integrative definition of grapevine drought tolerance?

Swift metabolite changes and leaf shedding are milestones in the acclimation process of grapevine under prolonged water stress.

BACKGROUND: Grape leaves provide the biochemical substrates for berry development. Thus, understanding the regulation of grapevine leaf metabolism can aid in discerning processes fundamental to fruit development and berry quality. Here, the temporal alterations in leaf metabolism in Merlot grapevine grown under sufficient irrigation and water deficit were monitored from veraison until harvest. RESULTS: The vines mediated water stress gradually and involving multiple strategies: osmotic adjustment, transcript-metabolite alteration and leaf shedding. Initially stomatal conductance and leaf water potential showed a steep decrease together with the induction of stress related metabolism, e.g. up-regulation of proline and GABA metabolism and stress related sugars, and the down-regulation of developmental processes. Later, progressive soil drying was associated with an incremental contribution of Ca2+ and sucrose to the osmotic adjustment concomitant with the initiation of leaf shedding. Last, towards harvest under progressive stress conditions following leaf shedding, incremental changes in leaf water potential were measured, while the magnitude of perturbation in leaf metabolism lessened. CONCLUSIONS: The data present evidence that over time grapevine acclimation to water stress diversifies in temporal responses encompassing the alteration of central metabolism and gene expression, osmotic adjustments and reduction in leaf area. Together these processes mitigate leaf water stress and aid in maintaining the berry-ripening program.

An Internet-Based Survey to Assess Clinicians' Knowledge and Attitudes Towards Opioid-Induced Hypogonadism.

BACKGROUND: Long-term opioid therapy for chronic pain management requires regularly assessing and documenting benefits and side effects. Opioid-induced sex hormone disturbances are a complication that needs to be assessed routinely and perhaps not only when suspected. There is abundant literature about its prevalence, clinical consequences, and treatment, yet routine hormone screening and appropriate treatment are seldom performed in pain clinics. Ignorance, skepticism, and/or indifference are possible reasons explaining why opioid-induced hypogonadism (OIH) remains underdiagnosed among chronic pain patients. METHODS: This was an Internet-based survey reaching out to pain clinicians to assess their knowledge and attitudes regarding OIH. RESULTS: A total of 135 responses were received, representing a 23.7% response rate. Analysis of responses showed that 47% of responders were somewhat familiar with this complication, but their knowledge about the prevalence and the time to develop varied. Screening for OIH is ordered based on suspicion of its presence (50%), but not routinely (38%). Lack of knowledge was the most frequent reason adduced for not screening for OIH. Sex-related symptoms and signs are the most relevant reasons leading to suspicion and screening of OIH. Upon laboratory confirmation, most responders refer their patients to endocrinology (82%) for further management since most (60%) believe that testosterone replacement would improve their patients' health. CONCLUSIONS: Knowledge and attitudes towards OIH varied among this population of pain clinicians invited to participate in the research. Lack of knowledge and incertitude seem to impact the attitudes towards screening and treating OIH. Better medical training at undergraduate and postgraduate levels as well as continuous medical education may contribute to raising awareness about this complication and providing early treatment.