Diabetic Neuropathy: Pathophysiology Review.

PURPOSE OF REVIEW: Diabetic neuropathy is a debilitating complication of diabetes mellitus that affects millions of individuals worldwide. It is characterized by nerve damage resulting from prolonged exposure to high blood glucose levels. Diabetic neuropathy may cause a range of symptoms, including pain, numbness, muscle weakness, autonomic dysfunction, and foot ulcers, potentially causing significant impairment to the quality of life for those affected. This review article aims to provide a comprehensive overview of the pathophysiology of diabetic neuropathy. The etiology of diabetic neuropathy will be discussed, including risk factors, predisposing conditions, and an overview of the complex interplay between hyperglycemia, metabolic dysregulation, and nerve damage. Additionally, we will explore the molecular mechanisms and pathways of diabetic neuropathy, including the impact of hyperglycemia on nerve function, abnormalities in glucose metabolism, the role of advanced glycation end products (AGEs), and inflammatory and immune-mediated processes. We will provide an overview of the various nerve fibers affected by diabetic neuropathy and explore the common symptoms and complications associated with diabetic neuropathy in the pain medicine field. RECENT FINDINGS: This review highlights advances in understanding the pathophysiology of diabetic neuropathy as well as reviews potential novel therapeutic strategies and promising areas for future research. In conclusion, this review article aims to shed light on the pathophysiology of diabetic neuropathy, its far-reaching consequences, and the evolving strategies for prevention and management. In understanding the mechanisms of diabetic neuropathy and the ongoing research in this area, healthcare professionals can better serve patients with diabetes, ultimately improving well-being and reducing complications.

The Role of Orthoses in Chronic Axial Spinal Conditions.

PURPOSE OF REVIEW: Bracing represents a prevalent conservative, non-surgical approach used in the management of chronic spinal conditions such as spondylosis, degenerative disc disease, and spondylolisthesis. A wide variety of orthoses are available to aid in addressing cervical, thoracic, lumbar, thoracic, and SI joint pain. In this review, we aim to comprehensively examine brace types with their current applications and implications of usage. RECENT FINDINGS: There are multiple cervical bracing options, such as soft and rigid collars, to assist in managing acute trauma and chronic degenerative conditions. The review highlights the nuanced decision-making process between hard and soft collars based on the severity of bone or ligamentous injury and neurological findings. Orthoses for low back pain are commonly used. The review highlights the challenges of chronic neck and lower back pain, emphasizing the importance of clinicians exploring all treatment strategies including braces which can improve function and reduce pain.

Cervical Spinal Cord Stimulation: A Review.

PURPOSE OF REVIEW: This literature review critically examines existing studies on cervical spinal cord stimulation (cSCS) for the treatment of chronic pain. The objective is to evaluate the current evidence, identify knowledge gaps, and collate data to inform clinical decision-making and suggest future research avenues. The review covers indications, contraindications, surgical and anesthetic approaches, trials, efficacy, and complications of cSCS. RECENT FINDINGS: Recent advancements highlight the evolving role of cSCS in chronic pain management. New neuromodulation techniques involve optimal placement of leads based on the pain's innervation level, maximizing therapeutic outcomes. Contemporary studies underscore the broadening benefits of cSCS, including enhanced functional abilities and sleep quality. However, alongside these innovations come challenges; emerging data bring attention to complications such as hardware issues and infections. Significantly, modern research emphasizes the crucial role of accurate patient selection, factoring in prior therapy responses and comprehensive evaluations. cSCS emerges as a promising tool for chronic pain management, with benefits beyond mere pain relief. As surgical techniques, patient selection criteria, and postoperative care refine, the potential of cSCS expands to benefit a broader patient demographic. However, further comprehensive research is necessary to enhance its application, validate its role earlier in treatment, and ultimately ameliorate the lives of those with chronic pain.

Current Review of Regenerative Medicine Therapies for Spine-Related Pain.

PURPOSE OF REVIEW: Persistent spinal pain syndromes are pervasive and lead to functional impairment, increased healthcare utilization, potential disability, and high societal costs. Spinal (cervical, thoracic, lumbar, and sacroiliac joint) pain includes mechanical, degenerative, inflammatory, oncologic, and infectious etiologies. Regenerative medicine is a novel biotechnology targeting mechanical, degenerative, and inflammatory conditions believed to cause pain. Preparations including platelet-rich plasma, mesenchymal stem cells (adipose tissue and bone marrow aspirate concentrates), and growth factors are derived from an autologous donor. The goal of intervention through guided injection of the regenerative media is to reduce inflammation and reverse the degenerative cascade in hopes of restoring normal cellular composition (physiologic homeostasis) and anatomical function to improve pain and function. The authors review limited research supporting the use of platelet-rich plasma injections for facet joint arthropathy and sacroiliac joint pain compared to traditional steroid treatments, as well as the use of platelet rich plasma or mesenchymal stem cells for lumbar discogenic and radicular pain. RECENT FINDINGS: Current evidence to support regenerative medicine for spine-related pain is limited. Although several studies demonstrated a reduction in pain, many of these studies had a small number of participants and were case series or prospective trials. Regenerative medicine treatments lack evidence for the treatment of spine-related pain. Large randomized controlled trials are needed with consistent study protocols to make further recommendations.

Mechanism of Action of Temporary Peripheral Nerve Stimulation.

PURPOSE OF REVIEW: Peripheral nerve stimulation (PNS) refers to the technique of utilizing electrical stimulation of peripheral nerves to inhibit the transmission of pain signals. PNS is used to treat chronic intractable pain and post-surgical or post-traumatic pain alongside a variety of other pain conditions, including headaches, facial pain, pelvic and urogenital pain, chest wall pain, residual limb or phantom limb pain, and back pain. RECENT FINDINGS: More recently, PNS has been used temporarily for periods of time less than 60 days to treat acute post-surgical pain. Peripheral nerve stimulation is believed to be effective due to its effects on both central and peripheral pathways. Centrally, it is proposed that the electrical pulses of PNS inhibit alpha-delta and C fibers, which decreases pain signaling in the higher centers of the central nervous system. Peripherally, gate theory is applied as it is theorized that PNS downregulates inflammatory mediators, endorphins, and neurotransmitters associated with pain signaling to decrease the transmission of efferent nociception and reduce pain sensations.

Addressing Bias in Acute Postoperative Pain Management.

PURPOSE OF REVIEW: This review evaluates disparities in acute postoperative pain management with regard to gender, race, socioeconomic status, age, and language. Strategies for addressing bias are also discussed. RECENT FINDINGS: Inequities in acute postoperative pain management may lead to longer hospital stays and adverse health outcomes. Recent literature suggests that there are disparities in acute pain management related to patient gender, race, and age. Interventions to address these disparities are reviewed but require further investigation. Recent literature highlights inequities in postoperative pain management, particularly in relation to gender, race, and age. There is a need for continued research in this area. Strategies such as implicit bias training and using culturally competent pain measurement scales may help reduce these disparities. Continued efforts by both providers and institutions to address and eliminate biases in postoperative pain management are needed to ensure better health outcomes.

Job Satisfaction Among Pain Medicine Physicians in the US.

Purpose: Data are lacking on the factors that contribute to job satisfaction among pain medicine physicians. We sought to determine how sociodemographic and professional characteristics relate to job satisfaction among pain medicine physicians. Methods: In this nationwide, multicenter, cross-sectional observational study, an electronic questionnaire related to job satisfaction was emailed in 2021 to pain medicine physicians who were members of the American Society of Anesthesiologists or the American Society of Pain and Neuroscience. The 28-item questionnaire asked physicians about sociodemographic and professional factors. Eight questions related to job satisfaction were based on a 10-point Likert scale, and 1 question was a binary (yes/no) variable. Differences in responses based on sociodemographic and professional factors were assessed with the Kruskal-Wallis rank sum test for Likert scale questions and with the Pearson χ2 test for yes/no questions. Results: We determined that several variables, including gender, parental status, geographic location, specialty, years of practice, and volume of patients, are associated with pain medicine physicians' outlook on job satisfaction. Overall, 74.9% of respondents surveyed would choose pain medicine as a specialty again. Conclusion: High rates of poor job satisfaction persist among pain medicine physicians. This survey study identified several sociodemographic and professional factors that are associated with job satisfaction among pain medicine physicians. By identifying physicians at high risk for poor job satisfaction, healthcare leadership and occupational health agencies can aim to protect physicians' well-being, enhance working conditions, and raise awareness about burnout.

Cannabis for the Treatment of Fibromyalgia: A Systematic Review.

Fibromyalgia is a common disease syndrome characterized by chronic pain and fatigue in conjunction with cognitive dysfunction such as memory difficulties. Patients currently face a difficult prognosis with limited treatment options and a diminished quality of life. Given its widespread use and potential efficacy in treating other types of pain, cannabis may prove to be an effective treatment for fibromyalgia. This review aims to examine and discuss current clinical evidence regarding the use of cannabis for the treatment of fibromyalgia. An electronic search was conducted on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus using Medical Subject Heading (MeSH) terms on all literature published up to October 2022. A follow-up manual search included a complete verification of relevant studies. The results of four randomized controlled trials (RCTs) and five observational studies (a total of 564 patients) that investigated the effects of cannabis on fibromyalgia symptoms were included in this review. Of the RCTs, only one demonstrated that cannabinoids did not have a different effect than placebo on pain responses. Overall, this analysis shows low-quality evidence supporting short-term pain reduction in people with fibromyalgia treated with cannabinoid therapeutics. Although current evidence is limited, medical cannabis appears to be a safe alternative for treating fibromyalgia.

Women Authorship Trends in the Highest-Impact Anesthesiology Journals from 2005 to 2021.

Background: Although women and men have matriculated into medical schools in similar proportions since the 1980s, recent data indicate that anesthesiology is lagging in gender equity, especially in academic leadership roles.1,2 As promotion in academic medicine is strongly influenced by publications, understanding whether a lack of women authorship is contributing to this gender gap is crucial.3,4 This article aims to assess how woman authorship trends have changed in the last 16 years, including during the COVID-19 pandemic. Materials and Methods: The five highest impact journals in anesthesia were identified as Journal of Clinical Anesthesia, British Journal of Anaesthesia, Anesthesiology, PAIN, and Regional Anesthesia & Pain Medicine. Number of total authors, including women, men, and unknown gender authors as well as incidence of woman first and/or last author, was documented from articles published in 2005, 2010, 2015, 2020, and 2021. Results: This analysis shows that women are gaining representation in anesthesia publications. Overall, there was a statistically significant increase in the total number of women authors and women first and last authorship. However, as of 2021, women still only represented ∼40% of total and first authors and ∼24% of last authors. In addition, increase in first/last woman authorship was not present in all journals when stratified. Conclusion: These journal differences may suggest the editorial evaluation process as a potential source of gender bias. There was a statistically significant relationship between women senior authors and articles with 50% or more women authors, indicating that woman mentorship is contributing to closing equity gap. These data present a starting point for further investigations into gender disparities within anesthesia to continue the forward progression for women in academic medicine.

Analysis of Gender-Based Authorship Trends in Leading Pain-Medicine Journals Over 10 Years.

Authorship of peer-reviewed publications is important for academic rank, promotion, and national reputation. In pain medicine, limited information is available for authorship trends for women as compared with men. The objective of this study was to describe trends of female authorship data in the 5 pain journals with the highest impact factors over a 10-year period. We analyzed data for January, April, and October in 2009, 2014, and 2019. For each article, the following information was recorded: journal name, journal month, journal year, article title or article PMCID, total authors, total female authors, total male authors, total authors of unknown gender, presence or absence of a female first author, and presence or absence of a female last/senior author. Authorship for 924 articles was reviewed. When a man was senior author, women were first author on only 27.9% of articles (P<.001). A woman was 2 times as likely (57.2%) to be first author when a woman was the senior author (P<.001), pointing to the potential impact of female senior authors. An article with 50% or more female authors was 76.4% more likely to have a female senior author (P<.001). The results demonstrate the influence of a senior female author on the likelihood of an article's having a female first author. When men were the senior authors, women were half as likely to be first authors. The total number of female authors changed very little between 2009 and 2019.

Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience.

Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from - unfortunately, there is no consensus on which treatments are "better" and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.

Perioperative Management of Calciphylaxis: Literature Review and Treatment Recommendations.

Calciphylaxis is a serious and rare medical condition that leads to substantial clinical manifestations including pain, creating perioperative and treatment challenges. No standard treatment protocol exists nor are comprehensive guidelines available for perioperative management of patients with calciphylaxis. In this review, we evaluate existing literature (January 2000 to May 2021) with the aim to offer guidance for treating patients with this challenging disease through the perioperative period. Although no therapies are currently considered standard for treating calciphylaxis, multiple interventions are available for improving symptoms. Preoperative and intraoperative management involves monitoring and optimizing patient comorbid conditions and any possible electrolyte imbalances. Postoperative management can be challenging when potential calciphylaxis triggers are indicated, such as warfarin and corticosteroids. In addition, poor wound healing and difficult pain control are common. Therefore, a multifactorial approach to controlling postoperative pain is recommended that includes the use of nerve blocks, renal-sparing opioids, benzodiazepines, and/or ketamine. We present preoperative, intraoperative, and postoperative recommendations for treating calciphylaxis with levels of evidence when appropriate.

Interventional Treatment Modalities for Chronic Abdominal and Pelvic Visceral Pain.

PURPOSE OF REVIEW: Chronic abdominal and pelvic visceral pain is an oftentimes difficult to treat pain condition that requires a multidisciplinary approach. This article specifically reviews the interventional treatment options for pain resulting from visceral abdominal and pelvic pain. RECENT FINDINGS: Sympathetic nerve blocks are the main interventional option for the treatment of chronic abdominal and pelvic visceral pain. Initially, nerve blocks are performed, and subsequently, neurolytic injections (alcohol or phenol) are longer term options. This review describes different techniques for sympathetic blockade. Neuromodulation is a potential option via dorsal column stimulation or dorsal root ganglion stimulation. Finally, intrathecal drug delivery is sometimes appropriate for refractory cases. This paper will review interventional options for the treatment of chronic abdominal and pelvic visceral pain.

Parental leave policy information during residency interviews.

BACKGROUND: During interviews, medical students may feel uncomfortable asking questions that might be important to them, such as parental leave. Parental leave policies may be difficult for applicants to access without asking the program director or other interviewers. The goal of this study is to evaluate whether parental leave information is presented to prospective residents and whether medical students want this information. METHODS: Fifty-two program directors (PD's) at 3 sites of a single institution received a survey in 2019 to identify whether parental leave information is presented at residency interviews. Medical students received a separate survey in 2020 to identify their preferences. Fisher exact tests, Pearson χ2 tests and Cochran-Armitage tests were used where appropriate to assess for differences in responses. RESULTS: Of the 52 PD's, 27 responded (52%) and 19 (70%) indicated that information on parental leave was not provided to candidates. The most common reason cited was the belief that the information was not relevant (n = 7; 37%). Of the 373 medical students, 179 responded (48%). Most respondents (92%) wanted parental leave information formally presented, and many anticipated they would feel extremely or somewhat uncomfortable (68%) asking about parental leave. The majority (61%) felt that these policies would impact ranking of programs "somewhat" or "very much." CONCLUSIONS: Parental leave policies may not be readily available to interviewees despite strong interest and their impact on ranking of programs by prospective residents.

Mechanism of Action of Peripheral Nerve Stimulation.

PURPOSE OF REVIEW: The number of applications for peripheral nerve stimulation (PNS) in the pain management field is ever-growing. With the increasing number of clinical applications for peripheral nerve stimulation, the purpose of this article is to review the mechanism of action surrounding PNS, the recent literature from January 2018 to January 2021, and pertinent clinical outcomes. RECENT FINDINGS: The authors searched articles identified from PubMed (January 2018-January 2021), Cochrane Central Register of Controlled Trials databases (January 2018-January 2021), and Scopus (January 2018-January 2021) databases, and manually searched references of identified publications. Broad MeSH terms and Boolean operators were queried in each search, including the following terms and their respective synonyms: peripheral nerve stimulation, mechanism of action, biochemical pathway, and pain pathway. 15 consensus articles were selected for in-depth review and inclusion for qualitative analysis. PNS may activate and modulate higher central nervous system (CNS) centers, including the dorsal lateral prefrontal cortex, somatosensory cortex, anterior cingulate cortex, and parahippocampal areas. Neuromodulatory effects from PNS may also extend into the spinal columns. Also, PNS may lead to changes in endogenous neurotransmitters and affect the plasticity of NMDA pathways.

Comprehensive Review of Topical Analgesics for Chronic Pain.

PURPOSE OF REVIEW: Topical analgesics are a non-opioid option for the treatment of chronic pain conditions including neuropathic pain, musculoskeletal pain, and osteoarthritis. There are many topical medications available; however their efficacy is variable. This article reviews the various topical analgesics, their mechanisms of action, and their efficacy. RECENT FINDINGS: Studies have found topical NSAIDs are useful in treating acute musculoskeletal pain syndromes (strains and sprains) and show some efficacy in treating hand and knee osteoarthritis (Derry et al. Cochrane Database Syst Rev 5:CD008609, 2017). Topical capsaicin 8% has been shown to be efficacious in the treatment of postherpetic neuralgia, painful diabetic peripheral neuropathy, and HIV-neuropathy (Derry et al. Cochrane Database Syst Rev 1:CD007393, 2017). Topical lidocaine has been widely studied and found to reduce pain in patients with postherpetic neuralgia (Knezevic et al. Pain Manag 7:537-58, 2017). Although many other topical analgesics are available, there is limited data to support the efficacy of other agents. Topical analgesics are a relatively benign treatment for chronic pain conditions including neuropathic pain, musculoskeletal, and myofascial pain. There is evidence to support the use of topical NSAIDs, high concentration topical capsaicin, and topical lidocaine for various painful conditions.

Interventional Modalities to Treat Complex Regional Pain Syndrome.

PURPOSE OF REVIEW: Complex regional pain syndrome (CRPS) is a debilitating pain condition that often requires a multidisciplinary approach including medication, physical therapy, occupational therapy, psychological therapy, and interventional procedures to restore the patient's quality of life. This article reviews the interventional treatments for pain resulting from CRPS. RECENT FINDINGS: Sympathetic nerve blocks (stellate ganglion and lumbar sympathetic) are the first-line interventional treatment options for patients with CRPS of the upper and lower extremities, respectively. Fluoroscopic techniques for lumbar sympathetic blocks have not significantly changed throughout the years. However, both novel fluoroscopic and ultrasound approaches to stellate ganglion blockade have arisen. In addition, novel neuromodulation therapies to treat CRPS have been developed to include new waveforms with dorsal column stimulation and entirely new nerve targets such as dorsal root ganglion stimulation. This paper will review the latest interventional treatment options available for the treatment of CRPS.