Exploratory evaluation of spinal cord stimulation with dynamic pulse patterns: a promising approach to improve stimulation sensation, coverage of pain areas, and expected pain relief.

Background: The societal burden of chronic pain and the contribution-in-part to the opioid crisis, is a strong motivation to improve and expand non-addictive treatments, including spinal cord stimulation (SCS). For several decades standard SCS has consisted in delivery of tonic pulses with static parameter settings in frequency, pulse width, and amplitude. These static parameters have limited ability to personalize the quality of paresthesia, the dermatomal coverage, and thus may affect SCS efficacy. Further, static settings may contribute to the build-up of tolerance or loss of efficacy of the therapy over time in some patients. Methods: We conducted an acute exploratory study to evaluate the effects of SCS using time-dynamic pulses as compared to time-static (conventional tonic) stimulation pulses, with the hypotheses that dynamic pulse SCS may enable beneficial tailoring of the sensation and the patient's expectation for better pain relief with SCS. During a single clinic visit, consented subjects undergoing a standard SCS trial had their implanted leads temporarily connected to an investigational external stimulator capable of delivering time-static and six categories of time-dynamic pulse sequences, each characterized by continuously varying a stimulation parameter. Study subjects provided several assessments while blinded to the stimulation pattern, including: drawing of paresthesia maps, descriptions of sensation, and ratings for comfort and helpfulness to pain relief. Results: Even without optimization of the field location, a majority of subjects rated sensations from dynamic stimulation as better or equal to that of static stimulation for comfortableness and for helpfulness to pain relief. The initial data showed a gender and/or pain dermatomal location related preference to a stimulation pattern. In particular, female subjects and subjects with pain at higher dermatomes tended to rank the sensation from dynamic stimulation better. Dynamic stimulation produced greater pain coverage without optimization; in 70% (9/13) of subjects, maximal pain coverage was achieved with a dynamic stimulation pattern. There was also greater variety in the words used by patients to describe stimulation sensation in the free text and free form verbal descriptions associated with dynamic stimulation. Conclusions: With the same electrode configuration and comparable parameter settings, acute SCS using dynamic pulses produced more positive ratings, expanded paresthesia coverage, and greater variation in sensation as compared to SCS using static pulses, suggesting that dynamic stimulation has the potential to improve capabilities of SCS for the treatment of chronic pain. Further study is warranted. Trial Registration: This study was registered at ClinicalTrials.gov under ID NCT02988713, November 2016 (URL: https://clinicaltrials.gov/ct2/show/NCT02988713).

A combined planning approach for improved functional and esthetic outcome of bimaxillary rotation advancement for treatment of obstructive sleep apnea using 3D biomechanical modeling.

In recent years, bimaxillary rotation advancement (BRA) has become the method of choice for surgical treatment of obstructive sleep apnea (OSA). As dislocation of the jaw bones affects both, airways and facial contours, surgeons are facing the challenge of finding an optimal jaw position that allows for the reestablishment of normal airway ventilation and esthetic surgical outcome. Owing to the complexity of the facial anatomy and its mechanical behavior, individual planning of surgical OSA treatment under consideration of functional and esthetic aspects presents a challenge that surgeons typically approach in a non-quantitative manner using subjective evaluation and clinical experience. This paper describes a framework for individual planning of OSA treatment using bimaxillary rotation advancement, which relies on computational modeling of hard and soft tissue mechanics. The described framework for simulation of functional and esthetic post-surgery outcome was used in 10 OSA patients. Comparison of the simulation results with post-surgery data reveals that biomechanical simulation provides a reliable estimate for post-surgery facial tissue behavior and antero-posterior airway extension, but fails to accurately describe a surprisingly large lateral stretch of the velopharyngeal region. This discrepancy is traced back to anisotropic effects of pharyngeal muscles. Possible approaches to improving the accuracy of model predictions and defining sharp criteria for optimizing combined OSA planning are discussed.

Spinal Cord Stimulation (SCS) with Anatomically Guided (3D) Neural Targeting Shows Superior Chronic Axial Low Back Pain Relief Compared to Traditional SCS-LUMINA Study.

BACKGROUND: The aim of this study was to determine whether spinal cord stimulation (SCS) using 3D neural targeting provided sustained overall and low back pain relief in a broad routine clinical practice population. STUDY DESIGN AND METHODS: This was a multicenter, open-label observational study with an observational arm and retrospective analysis of a matched cohort. After IPG implantation, programming was done using a patient-specific, model-based algorithm to adjust for lead position (3D neural targeting) or previous generation software (traditional). Demographics, medical histories, SCS parameters, pain locations, pain intensities, disabilities, and safety data were collected for all patients. RESULTS: A total of 213 patients using 3D neural targeting were included, with a trial-to-implant ratio of 86%. Patients used seven different lead configurations, with 62% receiving 24 to 32 contacts, and a broad range of stimulation parameters utilizing a mean of 14.3 (±6.1) contacts. At 24 months postimplant, pain intensity decreased significantly from baseline (ΔNRS = 4.2, N = 169, P < 0.0001) and even more in in the severe pain subgroup (ΔNRS = 5.3, N = 91, P < 0.0001). Axial low back pain also decreased significantly from baseline to 24 months (ΔNRS = 4.1, N = 70, P < 0.0001, on the overall cohort and ΔNRS = 5.6, N = 38, on the severe subgroup). Matched cohort comparison with 213 patients treated with traditional SCS at the same centers showed overall pain responder rates of 51% (traditional SCS) and 74% (neural targeting SCS) and axial low back pain responder rates of 41% and 71% in the traditional SCS and neural targeting SCS cohorts, respectively. Lastly, complications occurred in a total of 33 of the 213 patients, with a 1.6% lead replacement rate and a 1.6% explant rate. CONCLUSIONS: Our results suggest that 3D neural targeting SCS and its associated hardware flexibility provide effective treatment for both chronic leg and chronic axial low back pain that is significantly superior to traditional SCS.

Experimental wavelength-division-multiplexed photon-pair distribution.

We have experimentally implemented the distribution of photon pairs produced by spontaneous parametric downconversion through telecom dense-wavelength-division-multiplexing filters. Using the measured counts and coincidences between symmetric channels, we evaluate the maximum fringe visibility that can be obtained with polarization-entangled photons and compare different filter technologies.

Simple performance evaluation of pulsed spontaneous parametric down-conversion sources for quantum communications.

Fast characterization of pulsed spontaneous parametric down conversion (SPDC) sources is important for applications in quantum information processing and communications. We propose a simple method to perform this task, which only requires measuring the counts on the two output channels and the coincidences between them, as well as modeling the filter used to reduce the source bandwidth. The proposed method is experimentally tested and used for a complete evaluation of SPDC sources (pair emission probability, total losses, and fidelity) of various bandwidths. This method can find applications in the setting up of SPDC sources and in the continuous verification of the quality of quantum communication links.

Light localization induced enhancement of third order nonlinearities in a GaAs photonic crystal waveguide.

Nonlinear propagation experiments in GaAs photonic crystal waveguides (PCW) were performed, which exhibit a large enhancement of third order nonlinearities, due to light propagation in a slow mode regime, such as two-photon absorption (TPA), optical Kerr effect and refractive index changes due to free-carriers generated by TPA. A theoretical model has been established that shows a very good quantitative agreement with experimental data and demonstrates the important role that the group velocity plays. These observations give a strong insight into the use of PCWs for optical switching devices.

Numerical analysis of a high-resolution fast tunable filter based on an intracavity Bragg grating.

A fast tunable filtering technique is proposed associating a diffraction grating with an intracavity Bragg grating. The bandwidth and the tuning range of this filter can be easily adapted by changing the diffraction grating's orientation, or its period, and its response is uniform over the whole tuning range. A numerical simulation of the filter response to a Gaussian beam has been developed, and it fits the experimental results allowing a calculation of the performances that could be obtained with more specific elements. For example, using a commercial acousto-optic deflector would allow a separation of 500 frequencies. It would then be possible to have a tuning range of 100 nm with a bandwidth of 0.2 nm for optical telecommunications.

High-efficiency single-mode Raman generation in a liquid-filled photonic bandgap fiber.

Single-spatial-mode Raman generation in an ethanol-filled photonic bandgap fiber is demonstrated. Due to the limited bandwidth of the fiber, the generation is limited to the first Stokes order only, allowing high generated power without any visible decrease of the conversion efficiency. The realization of these two key properties opens the way to the realization of optimized compact nonlinear wavelength converters that will accommodate a large variety of usable liquids.

Intracavity gain gratings.

Intracavity gain gratings are theoretically demonstrated to exhibit diffraction efficiencies that are 100 times larger than unity at pump powers substantially below the lasing threshold. Experiments performed using a Nd:YVO4 microlaser pumped below threshold by two interfering Ti:sapphire laser beams are described. Huge enhancement of the diffraction efficiency (5000X) and a large increase of the angular selectivity (10X) are demonstrated despite the angular reduction of the Fabry-Perot cavity finesse. Much better results are expected using gain gratings with larger areas or thinner cavities such as vertical cavity surface-emitting lasers. Such large fan-out values could be very interesting for applications to optical signal processing.

Band-edge-induced Bragg diffraction in two-dimensional photonic crystals.

Two-dimensional photonic crystals composed of two orthogonal volume diffraction gratings have been photogenerated in photopolymers. When the read beam is set at the Bragg angle, the diffraction efficiency of the transmission grating is strongly enhanced at the band edge of the reflection grating recorded in the material. Such a device provides Bragg operation and enhancement of the diffraction efficiency of the thin diffraction grating together with good wavelength selectivity. Such advantages could be interesting for optical signal processing.

Uncertainties associated with incidence estimates of HIV/AIDS diagnoses adjusted for reporting delay and risk redistribution.

Reporting delay occurs frequently in the case surveillance of a disease such as HIV/AIDS. To evaluate the current trend of incidence, it is important to consider incidence estimates adjusted for reporting delays and the uncertainty associated with this adjustment. For a surveillance system in which cases are reported monthly, there is no straightforward method for constructing the confidence interval estimators for annual incidence or incidence for a period longer than a month. This is because the monthly incidence estimators are not independent and the correlations among them are not available. Furthermore, to estimate the incidence for a specific risk, or exposure, group (e.g. men who have sex with men), we also have to consider the uncertainty associated with the counts from cases reported without an identified risk. Cases with no reported risk are assigned proportionally to each risk group on the basis of experience with cases reported initially with no reported risk but reported later with an identified risk. In this article, we introduce a method for combining the uncertainties associated with both reporting delay and risk redistribution. An estimator for the covariance between two incidence estimators is also provided so that we can make pairwise comparisons and discover any significant changes in incidence over time. Results are applied to evaluating the current trends in AIDS incidence among men who have sex with men in the United States.

Stimulated Raman scattering in an ethanol core microstructured optical fiber.

We show that high efficiency stimulated Raman scattering can be obtained using hollow core photonic crystal fiber with the core filled with a low refractive index nonlinear liquid. This new architecture opens new perspectives in the development of nonlinear functions as any kind of nonlinear liquid media can now be used to implement them, with original properties not accessible with silica core fibers.

Uniform response high resolution tunable optical filtering using a grating-assisted acousto-optic device.

A new filtering technique is proposed that associates the high dispersion of standard reflection gratings with the tuning speed of acousto-optic cells. Tuning is performed by adjusting the grating period so that the chosen wavelength is at Bragg resonance. In this way, the selected wavelength always experiences a maximum diffraction efficiency, ensuring good uniformity. Using a commercial acousto-optic modulator, a wavelength selectivity of 0.075 nm is demonstrated together with a uniformity of +/-0.2 dB on a tuning range of 2.2 nm corresponding to N = 30 resolvable frequencies. N > 600 could be obtained with an acousto-optic cell specially designed for this device.

Tying it all together? A competency-based linkage model for family medicine.

Residency faculty in all specialties will be required by the Accreditation Council for Graduate Medical Education (ACGME) to fully implement competencies into residency programs by 2006. Understanding the new requirements is complicated by having several sets of guiding documents from different sources, including the general competencies of the ACGME, the Residency Review Committee for Family Practice requirements, the competencies developed by the Society of Teachers of Family Medicine, and the Recommended Curriculum Guidelines for Family Practice Residents by the American Academy of Family Physicians. A competency linkage model brings together the various guidelines and shows specifically how they are related. This model helps family practice residency faculty better understand the guiding expectations for their programs and develop more appropriate learning objectives and assessment methods.