Does sulfur application continue to reduce cadmium accumulation and increase the seed yield of oilseed rape (Brassica napus L.) at the maturity stage?

BACKGROUND: Oilseed rape requires sulfur (S) fertilization. Cadmium (Cd) differs dramatically in agricultural soils. Rice-oilseed rape rotation distributes widely and contributes the majority of rapeseeds in Asian countries. It was reported that S metabolism was involved in Cd uptake in seedlings of oilseed rape, although the effects of S on Cd accumulation and seed yield at maturity are still unclear. RESULTS: We performed a pot experiment including two Cd rates (0.35 and 10.35 mg kg-1 , as low and high Cd soil) and four S levels (0, 30, 60 and 120 mg kg-1 ). The results showed that low S application (30 mg kg-1 ) resulted in two-fold higher seed-Cd concentration irrespective of soil Cd levels. The responsible mechanism might be that Cd translocation into rapeseeds was involved in sulfate transporters, which could be strongly expressed in shoots and roots when supplying sulfate under S-starvation conditions, but depressed under a S-sufficient environment. For high Cd soil, seed yield decreased by 36%, 48% and 72% at 30, 60 and 120 mg S kg-1 compared to non-S treatment, whereas there were no differences for low Cd soil. Antagonistic effects of S and Cd existed for seed yield according to structure equation model analysis. CONCLUSION: Oilseed rape can be grown in low-Cd fields as a safe food crop with high levels of sulfur fertilizers (>60 mg S kg-1 ). In high-Cd fields, oilseed rape is recommended as a Cd-remediation crop, and rapeseeds should only be used for industrial purposes and not for food. © 2021 Society of Chemical Industry.

Wood Ash Induced pH Changes Strongly Affect Soil Bacterial Numbers and Community Composition.

Recirculation of wood ash from energy production to forest soil improves the sustainability of this energy production form as recycled wood ash contains nutrients that otherwise would be lost at harvest. In addition, wood-ash is beneficial to many soils due to its inherent acid-neutralizing capabilities. However, wood ash has several ecosystem-perturbing effects like increased soil pH and pore water electrical conductivity both known to strongly impact soil bacterial numbers and community composition. Studies investigating soil bacterial community responses to wood ash application remain sparse and the available results are ambiguous and remain at a general taxonomic level. Here we investigate the response of bacterial communities in a spruce forest soil to wood ash addition corresponding to 0, 5, 22, and 167 t wood ash ha-1. We used culture-based enumerations of general bacteria, Pseudomonas and sporeforming bacteria combined with 16S rRNA gene amplicon sequencing to valuate soil bacterial responses to wood ash application. Results showed that wood ash addition strongly increased soil pH and electrical conductivity. Soil pH increased from acidic through neutral at 22 t ha-1 to alkaline at 167 t ha-1. Bacterial numbers significantly increased up to a wood ash dose of 22 t ha-1 followed by significant decrease at 167 t ha-1 wood ash. The soil bacterial community composition changed after wood ash application with copiotrophic bacteria responding positively up to a wood ash dose of 22 t ha-1 while the adverse effect was seen for oligotrophic bacteria. Marked changes in bacterial community composition occurred at a wood ash dose of 167 t ha-1 with a single alkaliphilic genus dominating. Additionally, spore-formers became abundant at an ash dose of 167 t ha-1 whereas this was not the case at lower ash doses. Lastly, bacterial richness and diversity strongly decreased with increasing amount of wood ash applied. All of the observed bacterial responses can be directly explained by the wood ash induced changes in pH, electrical conductivity and the addition of wood ash inherent nutrients.

Phosphate sorption by three potential filter materials as assessed by isothermal titration calorimetry.

Phosphorus eutrophication of lakes and streams, coming from drained farmlands, is a serious problem in areas with intensive agriculture. Installation of phosphate (P) sorbing filters at drain outlets may be a solution. The aim of this study was to improve the understanding of reactions involved in P sorption by three commercial P sorbing materials, i.e. Ca/Mg oxide-based Filtralite-P, Fe oxide-based CFH-12 and Limestone in two particle sizes (2-1 mm and 1-0.5 mm), by means of isothermal titration calorimetry (ITC), sorption isotherms, sequential extractions and SEM-EDS. The results indicate that P retention by CFH is due to surface complexation by rapid formation of strong Fe-P bonds. In contrast, retention of P by Filtralite-P and Limestone strongly depends on pH and time and is interpreted due to formation of calcium phosphate precipitate(s). Consequently, CFH can unambiguously be recommended as P retention filter material in drain outlets, whereas the use of Filtralite-P and Limestone has certain (serious) limitations. Thus, Filtralite-P has high capacity to retain P but only at alkaline pH (pH ≥ 10) and P retention by Limestone requires long-time contact and a high ratio between sorbent and sorbate.

Pteridium aquilinum and its ptaquiloside toxin induce DNA damage response in gastric epithelial cells, a link with gastric carcinogenesis.

The multifactorial origin of gastric cancer encompasses environmental factors mainly associated with diet. Pteridium aquilinum-bracken fern-is the only higher plant known to cause cancer in animals. Its carcinogenic toxin, ptaquiloside, has been identified in milk of cows and groundwater. Humans can be directly exposed by consumption of the plant, contaminated water or milk, and spore inhalation. Epidemiological studies have shown an association between bracken exposure and gastric cancer. In the present work, the genotoxicity of P. aquilinum and ptaquiloside, including DNA damaging effects and DNA damage response, was characterized in human gastric epithelial cells and in a mouse model. In vitro, the highest doses of P. aquilinum extracts (40 mg/ml) and ptaquiloside (60 µg/ml) decreased cell viability and induced apoptosis. γH2AX and P53-binding protein 1 analysis indicated induction of DNA strand breaks in treated cells. P53 level also increased after exposure, associated with ATR-Chk1 signaling pathway activation. The involvement of ptaquiloside in the DNA damage activity of P. aquilinum was confirmed by deregulation of the expression of a panel of genes related to DNA damage signaling pathways and DNA repair, in response to purified ptaquiloside. Oral administration of P. aquilinum extracts to mice increased gastric cell proliferation and led to frameshift events in intron 2 of the P53 gene. Our data demonstrate the direct DNA damaging and mutagenic effects of P. aquilinum. These results are in agreement with the carcinogenic properties attributed to this fern and its ptaquiloside toxin and support their role in promoting gastric carcinogenesis.

Degradation and ecotoxicity of the biomedical drug artemisinin in soil.

The plant Artemisia annua L. is cropped in many countries for production of the antimalarial drug artemisinin. Artemisinin is phytotoxic and has insecticidal activity. Large-scale cultivation of A. annua may cause transfer of artemisinin to soil and, hence, may affect both soil organisms and the aquatic environment if the compound is leachable. In the present study, a new method for extraction of artemisinin from soil was developed, and field concentrations and degradation kinetics of artemisinin in sandy and loamy soils were measured. The soil concentrations in a Danish A. annua field were up to 11.7 mg/kg. The degradation kinetics could be modeled as the sum of two first-order reactions, a fast initial degradation followed by a reaction that was 11- to 25-fold slower. It took at least 35 d before artemisinin could not be detected (<0.36 mg/kg) at 20 degrees C, classifying artemisinin as being relatively persistent in the environment. Combined with its water solubility of 49.7 +/- 3.7 mg/L, this makes it potentially leachable. In soil, artemisinin repelled the earthworm (Eisenia fetida; the 10 and 50% effect concentrations [EC10s and EC50s, respectively] were 5.24 +/- 2.64 and 21.57 +/- 4.73 mg/kg, respectively) and inhibited growth of lettuce (Lactuca sativa L.; EC50, 2.48 mg/kg). Springtails (Folsomia candida) were not affected in the tested concentration range of 1 to 100 mg/kg. Artemisinin had toxicity to the freshwater algae (Pseudokirchneriella subcapitata; EC50, 0.24 +/- 0.01 mg/L) and duckweed (Lemna minor; EC50, 0.19 +/- 0.03 mg/L) similar to that of the commercial herbicide atrazine. Based on the presented data, the risks of adverse environmental effects because of cultivation of A. annua are high and comparable to those when using commercial pesticides.

Degradation and sorption of 2-propenyl and benzyl isothiocyanate in soil.

Isothiocyanates of natural origin produced by the hydrolysis of plant-produced glucosinolates have the potential to control soil pests, but getting sufficiently high isothiocyanate concentrations in soil is difficult. Furthermore, the isothiocyanates have proven toxic to a wide range of organisms and hence may also harm nontarget organisms. Knowledge of the sorption and degradation of the isothiocyanates is essential to optimize the use of natural isothiocyanates for pest control while minimizing the environmental impact. We have conducted studies on the sorption and degradation of two isothiocyanates of natural origin, 2-propenyl isothiocyanate and benzyl isothiocyanate. The experiments show the isothiocyanates degrade very quickly (t(1/2) = 0.93-4.25 h) in a 1:1 soil water slurry at 25 degrees C and they are sorbed by the organic matter in soil. From an environmental point of view, a fast degradation is desirable, but if the natural isothiocyanates are to be utilized for pest control, a fast degradation may imply they are not present long enough to have the desired effect on pests.

Leaching of cyanogenic glucosides and cyanide from white clover green manure.

Use of crops for green manure as a substitute for chemical fertilizers and pesticides is an important approach towards more sustainable agricultural practices. Green manure from white clover is rich in nitrogen but white clover also produces the cyanogenic glucosides (CGs) linamarin and lotaustralin; CGs release toxic hydrogen cyanide (HCN) upon hydrolysis which may be utilized for pest control. We demonstrate that applying CGs in the form of a liquid extract of white clover to large columns of intact agricultural soils can result in leaching of toxic cyanide species to a depth of at least 1m. Although degradation of the CGs during leaching proceeded with half lives in the interval 1.5-35 h depending on soil characteristics, a fraction of the applied CGs (0.9-3.2%) was recovered in the leachate as either CGs or toxic cyanide species. Detoxification of the HCN formed was rapid in soil and leachate from both sandy and loamy soil. However, 30% of the leachate samples exceeded the EU threshold value of 50 micrgl(-1) total cyanide for drinking water and 85% exceeded the US threshold of 5 micrgl(-1) for cyanide chronic ecotoxicity in fresh water. This study demonstrates that even easily degradable natural products present in crop plants as defense compounds pose a threat to the quality of groundwater and surface waters. This aspect needs consideration in assessment of the risk associated with use of crops as green manure to replace chemical fertilizers and pesticides as well as in genetic engineering approaches to design crops with improved pest resistance.

Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain.

BACKGROUND: The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques were developed to provide recommendations to clinicians in the United States. OBJECTIVE: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. DESIGN: Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes. METHODS: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency for Healthcare Research and Quality (AHRQ) criteria, Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). RESULTS: Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it is moderate in the diagnosis of thoracic facet joint pain. The evidence is strong for lumbar discography, whereas, the evidence is limited for cervical and thoracic discography. The evidence for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies is moderate. The evidence for diagnostic sacroiliac joint injections is moderate. The evidence for therapeutic lumbar intraarticular facet injections is moderate for short-term and long-term improvement, whereas, it is limited for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks is moderate. The evidence for medial branch neurotomy is moderate. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid injections is strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain secondary to lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis is strong. For spinal endoscopic adhesiolysis, the evidence is strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence is moderate for short-term relief and limited for long-term relief. The evidence for radiofrequency neurotomy for sacroiliac joint pain is limited. The evidence for intradiscal electrothermal therapy is moderate in managing chronic discogenic low back pain, whereas for annuloplasty the evidence is limited. Among the various techniques utilized for percutaneous disc decompression, the evidence is moderate for short-term and limited for long-term relief for automated percutaneous lumbar discectomy, and percutaneous laser discectomy, whereas it is limited for nucleoplasty and for DeKompressor technology. For vertebral augmentation procedures, the evidence is moderate for both vertebroplasty and kyphoplasty. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome is strong for short-term relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems is strong for short-term relief and moderate for long-term relief. CONCLUSION: These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines also do not represent a "standard of care."

Sacroiliac joint interventions: a systematic review.

BACKGROUND: The sacroiliac joint is a diarthrodial synovial joint with abundant innervation and capability of being a source of low back pain and referred pain in the lower extremity. There are no definite historical, physical, or radiological features to provide definite diagnosis of sacroiliac joint pain, although many authors have advocated provocational maneuvers to suggest sacroiliac joint as a pain generator. An accurate diagnosis is made by controlled sacroiliac joint diagnostic blocks. The sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected cases with chronic low back pain utilizing controlled comparative local anesthetic blocks. Intraarticular injections, and radiofrequency neurotomy have been described as therapeutic measures. This systematic review was performed to assess diagnostic testing (non-invasive versus interventional diagnostic techniques) and to evaluate the clinical usefulness of interventional techniques in the management of chronic sacroiliac joint pain. OBJECTIVE: To evaluate and update the available evidence regarding diagnostic and therapeutic sacroiliac joint interventions in the management of sacroiliac joint pain. STUDY DESIGN: A systematic review using the criteria as outlined by the Agency for Healthcare Research and Quality (AHRQ), Cochrane Review Group Criteria for therapeutic interventions and AHRQ, and Quality Assessment for Diagnostic Accuracy Studies (QUADAS) for diagnostic studies. METHODS: The databases of EMBASE and MEDLINE (1966 to December 2006), and Cochrane Reviews were searched. The searches included systematic reviews, narrative reviews, prospective and retrospective studies, and cross-references from articles reviewed. The search strategy included sacroiliac joint pain and dysfunction, sacroiliac joint injections, interventions, and radiofrequency. RESULTS: The results of this systematic evaluation revealed that for diagnostic purposes, there is moderate evidence showing the accuracy of comparative, controlled local anesthetic blocks. Prevalence of sacroiliac joint pain is estimated to range between 10% and 27% using a double block paradigm. The false-positive rate of single, uncontrolled, sacroiliac joint injections is around 20%. The evidence for provocative testing to diagnose sacroiliac joint pain is limited. For therapeutic purposes, intraarticular sacroiliac joint injections with steroid and radiofrequency neurotomy were evaluated. Based on this review, there is limited evidence for short-term and long-term relief with intraarticular sacroiliac joint injections and radiofrequency thermoneurolysis. CONCLUSIONS: The evidence for the specificity and validity of diagnostic sacroiliac joint injections is moderate. The evidence for accuracy of provocative maneuvers in diagnosis of sacroiliac joint pain is limited. The evidence for therapeutic intraarticular sacroiliac joint injections is limited. The evidence for radiofrequency neurotomy in managing chronic sacroiliac joint pain is limited.

Opioid guidelines in the management of chronic non-cancer pain.

BACKGROUND: Opioid abuse has increased at an alarming rate. However, available evidence suggests a wide variance in the use of opioids, as documented by different medical specialties, medical boards, advocacy groups, and the Drug Enforcement Administration (DEA). OBJECTIVES: The objective of these opioid guidelines by the American Society of Interventional Pain Physicians (ASIPP) is to provide guidance for the use of opioids for the treatment of chronic non-cancer pain, to bring consistency in opioid philosophy among the many diverse groups involved, to improve the treatment of chronic non-cancer pain, and to reduce the incidence of drug diversion. DESIGN: A policy committee evaluated a systematic review of the available literature regarding opioid use in managing chronic non-cancer pain. This resulted in the formulation of the essentials of guidelines, a series of potential evidence linkages representing conclusions, followed by statements regarding relationships between clinical interventions and outcomes. METHODS: Consistent with the Agency for Healthcare Research and Quality (AHRQ) hierarchical and comprehensive standards, the elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentations, formal endorsement by the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), and blinded peer review. Evidence was designated based on scientific merit as Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), or Level V (indeterminate). RESULTS: After an extensive review and analysis of the literature, the authors utilized two systematic reviews, two narrative reviews, 32 studies included in prior systematic reviews, and 10 additional studies in the synthesis of evidence. The evidence was limited. CONCLUSION: These guidelines evaluated the evidence for the use of opioids in the management of chronic non-cancer pain and recommendations for management. These guidelines are based on the best available scientific evidence and do not constitute inflexible treatment recommendations. Because of the changing body of evidence, this document is not intended to be a "standard of care."

Degradation of zearalenone and ochratoxin A in three Danish agricultural soils.

Degradation of two mycotoxins: zearalenone (ZON) produced by species of Fusarium and ochratoxin A (OTA) produced by species of Penicillium were followed in pot experiments using agricultural topsoils from Danish experimental farms: a sandy soil, a sandy clay soil and a gyttja soil with a high content of silt. Experiments with unplanted soil and pots planted with barley were included. Soil samples were withdrawn during a period of 225 days and analysed for the content of OTA and ZON. The degradation of both toxins consisted of an initial fast degradation followed by a slower transformation step and was described well by a sum of two first-order kinetic equations. The decay first-order rate constants for the first step (k1) were in the range 0.73-2.91 d(-1) for OTA and 0.0612-0.108 d(-1) for ZON, respectively. Half-lives (t0.5) for ZON using data from the first phase were between 6.4 and 11 days, whereas the half-lives for OTA were about 0.2-1 day. The slowest degradation was measured in soil rich in clay. After 225 days, neither OTA nor ZON was detected in any of the soil types. Generally, the degradation of ZON and OTA was faster in planted soil than in unplanted soil, probably due to higher microbial activity. Due to the fast degradation of ZON and OTA in surface soil leaching as soluble substances appears to be limited.

Biotransformation of 2-benzoxazolinone to 2-amino-(3H)-phenoxazin-3-one and 2-acetylamino-(3H)-phenoxazin-3-one in soil.

An alternative to the use of synthetic pesticides is to exploit the natural defense chemicals produced by cereals. An important class of allelochemicals is cyclic hydroxamic acids and related benzoxazolinones. A prolonged degradation experiment of the allelochemical compound from rye 2-benzoxazolinone (BOA) was carried out for up to 90 d at 15 degrees C at three different concentration levels, 3, 3000, and 30,000 nmol BOA g soil(-1), respectively, in a sandy loam soil. Two main degradation products, 2-amino-(3H)-phenoxazin-3-one (APO) and 2-acetylamino-(3H)-phenoxazin-3-one (AAPO), were identified and quantified by LC-ESI-MS-MS. The half-life of BOA increased with higher levels of BOA added to the soil. Half-lives of BOA, APO, and AAPO were determined by fitting a single first-order model to the degradation data. Half-life of BOA was determined to be 0.6 d in the 3 nmol BOA g soil(-1) treatment. Half-lives of BOA, APO, and AAPO were 3.1, 2.7, and 2.1 d, respectively, in the 3000 nmol BOA g soil(-1) treatment. In the 30,000 nmol BOA g soil(-1) treatment, the half-lives were 31 d for BOA and 45 d for APO. The microbial community structure was not affected by addition of BOA to the soil as investigated by analysis of signature fatty acids. The results suggest that the exploitability of BOA for crop protection is dependent on the existing concentration of BOA in the soil and the timing of incorporation of hydroxamic acid synthesizing crops into the soil.

Information technology in the interventional pain practice: electronic medical records, practice management software, and document management.

Electronic medical records (EMR) can both replace the paper clinical chart and perform scheduling and billing tasks. EMRs are currently used in only a small proportion of medical practices; however, EMR adoption is expected to soar in a few years. Governmental and industry concerns about safety and quality, along with medical practice needs for increased productivity, are fueling this transition. Medical practices are likely to consider transitioning to EMRs. At this point, the marketplace is fragmented in terms of suppliers, and refinement of the software is continuing. Transitioning to an EMR is a step that offers enormous benefits to interventional pain management physicians, in terms of compliance, the ability to maintain quality, and the ability to manage practices, including larger and more complex practices. Transitioning to an EMR is also a major effort in terms of time and expense: the goal is to settle on a specific EMR and continue to use it. This review focuses on (1) why physicians are or are not transitioning to EMRs; (2) the benefits of a transition; and (3) factors to consider in evaluating the various competing software products. Although EMR technology continues to develop, the review also considers areas in which future development is necessary. The most important areas are seen in document management, data input, and outcomes analysis and decision support capability. The EMR market is evolving rapidly. However, this review should in no way serve as an endorsement of any particular system, vendor, or technology.

Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain.

Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain are systematically developed and professionally derived statements and recommendations that assist both physicians and patients in making decisions about appropriate health care in the diagnosis and treatment of chronic or persistent pain. The guidelines were developed utilizing an evidence-based approach to increase patient access to treatment, to improve outcomes and appropriateness of care, and to optimize cost-effectiveness. All types of relevant and published evidence and consensus were utilized. The guidelines include a discussion of their purpose, rationale, and importance, including descriptions of the patient population served, the methodology, and the pathophysiologic basis for intervention. Multiple diagnostic and therapeutic interventional techniques are included in this document. Strong evidence was shown for diagnostic facet joint blocks for the diagnosis of facet joint pain, and lumbar provocative discography for discogenic pain. Moderate evidence was shown for sacroiliac joint blocks in the diagnosis of sacroiliac joint pain, and for transforaminal epidural injections in the preoperative evaluation of patients with negative or inconclusive imaging studies, but with clinical findings of nerve root irritation. Moderate to strong evidence was shown for multiple therapeutic interventional techniques including medial branch blocks and medial branch neurotomy; caudal epidural steroid injections and transforaminal epidural steroid injections; lumbar percutaneous adhesiolysis; and implantable therapies. These guidelines do not constitute inflexible treatment recommendations. It is expected that a provider will establish a plan of care on a case-by-case basis, taking into account an individual patient's medical condition, personal needs, and preferences, and the physician's experience. Based on an individual patient's needs, treatment different from that outlined here could be warranted. These guidelines do not represent "standard of care."

Methods for evidence synthesis in interventional pain management.

Healthcare decisions are increasingly being made on research-based evidence, rather than on expert opinion or clinical experience alone. Consequently, the process by which the strength of scientific evidence is evaluated and developed by means of evidence-based medicine recommendations and guidelines has become crucial resulting in the past decade in unprecedented interest in evidence-based medicine and clinical practice guidelines. Systematic reviews, also known as evidence-based technology assessments, attempt to minimize bias by the comprehensiveness and reproducibility of the search for and selection of articles for review. Evidence-based medicine is defined as the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients. Thus, the practice of evidence-based medicine requires the integration of individual clinical expertise with the best available external evidence from systematic research. To arrive at evidence-based medicine decisions all valid and relevant evidence should be considered alongside randomized controlled trials, patient preferences and resources. However, many systematic reviews in interventional pain management fail to follow evidence-based medicine principles. Clinical practice guidelines are systematically developed statements that assist clinicians, consumers and policy makers to make appropriate healthcare decisions. The complex processes of guideline development depend on integration of a number of activities, from collection and processing of scientific literature to evaluation of the evidence, development of evidence-based recommendations or guidelines and implementation and dissemination of the guidelines to relevant professionals and consumers. Guidelines are being designed to improve the quality of healthcare and decrease the use of unnecessary, ineffective or harmful interventions. This review describes various aspects of evidence-based medicine, systematic reviews in interventional pain management, evaluation of the strength of scientific evidence, differences between systematic and narrative reviews, rating the quality of individual articles, grading the strength of the body of evidence and appropriate methods for searching for the evidence.

Guidelines for the use of controlled substances in the management of chronic pain.

Controlled substance abuse has increased at an alarming rate. However, available evidence suggests a wide variance in the use of controlled substances, as documented by different medical specialties, medical boards, advocacy groups, and the Drug Enforcement Administration. The primary objective of controlled substance guidelines by American Society of Interventional Pain Physicians (ASIPP) is to provide guidance for the use of controlled substances for the treatment of chronic pain. It is anticipated that these practical guidelines will improve quality of care, patient access, and quality of life. Additional benefits include improved treatment efficiency and efficacy, and cost containment by improving the risk-benefit ratio of treating patients with chronic pain. Further goals of this manuscript are to bring consistency in opioid philosophy among the many diverse groups involved, to improve the treatment of chronic pain patients with medically appropriate controlled substances, and to reduce the incidence of drug diversion. These guidelines also reinforce the need for systematic evaluation and ongoing care of patients with chronic or persistent pain. ASIPP controlled substance guidelines also provide a discussion of the epidemiology of chronic pain, the role of controlled substances in treating chronic pain, various aspects of drug abuse, pharmacological considerations, clinical effectiveness of controlled substances, options for treatment monitoring and drug testing and a review of terminology used in addiction medicine. These guidelines do not constitute inflexible treatment recommendations. It is expected that a provider will establish a plan of care on a case-by-case basis, taking into account an individual patient's medical condition, personal needs, and preferences, and the physician's experience. Based on an individual patient's needs, controlled substance prescribing and treatment different from that outlined here may be warranted. These guidelines do not represent "standard of care."

Epidural steroids in the management of chronic spinal pain and radiculopathy.

Epidural injections with or without steroids are used extensively in the management of chronic spinal pain. However, evidence is contradictory with continuing debate about the value of epidural steroid injections in chronic spinal syndromes. The objective of this systematic review is to determine the effectiveness of epidural injections in the treatment of chronic spinal pain. Data sources include relevant literature identified through searches of MEDLINE, EMBASE (Jan 1966- Mar 2003), manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings. Both randomized and non-randomized studies were included in the review based on the criteria established by the Agency for Healthcare Research and Quality (AHRQ). Studies were excluded from the analysis if they were simply review or descriptive and failed to meet minimum criteria. The results showed that there was strong evidence to indicate effectiveness of transforaminal epidural injections in managing lumbar nerve root pain. Further, evidence was moderate for caudal epidural injections in managing lumbar radicular pain. The evidence in management of chronic neck pain, chronic low back pain, cervical radiculopathy, spinal stenosis, and post laminectomy syndrome was limited or inconclusive. In conclusion, the evidence of effectiveness of transforaminal epidural injections in managing lumbar nerve root pain was strong, whereas, effectiveness of caudal epidural injections in managing lumbar radiculopathy was moderate, while there was limited or inconclusive evidence of effectiveness of epidural injections in managing chronic spinal pain without radiculopathy, spinal stenosis, post lumbar laminectomy syndrome, and cervical radiculopathy.