The Neurostimulation Appropriateness Consensus Committee (NACC) Recommendations for Infection Prevention and Management.

INTRODUCTION: The use of neurostimulation for pain has been an established therapy for many decades and is a major tool in the arsenal to treat neuropathic pain syndromes. Level I evidence has recently been presented to substantiate the therapy, but this is balanced against the risk of complications of an interventional technique. METHODS: The Neurostimulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society convened an international panel of well published and diverse physicians to examine the best practices for infection mitigation and management in patients undergoing neurostimulation. The NACC recommendations are based on evidence scoring and peer-reviewed literature. Where evidence is lacking the panel added expert opinion to establish recommendations. RESULTS: The NACC has made recommendations to improve care by reducing infection and managing this complication when it occurs. These evidence-based recommendations should be considered best practices in the clinical implantation of neurostimulation devices. CONCLUSION: Adhering to established standards can improve patient care and reduce the morbidity and mortality of infectious complications in patients receiving neurostimulation.

Intrathecal granuloma in a patient receiving high dose hydromorphone.

Intrathecal granuloma formation has commonly been described with morphine therapy. It has been suggested that a high concentration of intrathecal morphine may be responsible for this complication. Much less commonly, intrathecal hydromorphone has been associated with intrathecal granuloma formation. In the current case we report the evaluation and management of an intrathecal granuloma in a patient receiving a relatively high concentration of intrathecal hydromorphone. A nonsurgical, conservative approach to management involves stopping the infusion and observing the patient for improvement as the granuloma mass often slowly resolves once the infusion is stopped. Cessation of the infusion or addition of clonidine to the IDDS admixture in conjunction with close clinical monitoring may be reasonable treatment options in patients with an asymptomatic or mildly symptomatic inflammatory mass. In the current study, rapidly declining neurologic function with a confirmed inflammatory mass adherent to the spinal canal necessitated urgent surgical intervention. Though use of intrathecal hydromorphone still represents an off label application, this opiate is commonly employed as an alternative first line analgesic agent. This case report highlights the potential of high-dose and high infusate concentration intrathecal hydromorphone to form an inflammatory granuloma.

Medical students' attitudes toward pain before and after a brief course on pain.

The effectiveness of a brief clinical and basic science seminar on pain for 1st year medical students was examined by comparing attitudes about pain prior to the seminar to attitudes 5 months after the seminar. The 6-h course combined written materials conveying facts about behavioral, social and biological aspects of pain with clinical observations of an acute and a chronic pain treatment team. Examination of responses to a questionnaire assessing attitudes toward pain patients revealed that medical students have limited personal experience with pain and medications for pain, and limited knowledge about pain. Pre-course attitudes toward pain patients were dominated by perceived negative characteristics of pain patients and the belief that working with such patients is difficult. Attitudes measured 5 months after the course reflected increased complexity, greater emphasis that pain is real and not imaginary, and stronger belief that working with pain patients is rewarding. Five months after the seminar, students reported more accurate estimates of the frequency of problems with addiction stemming from acute pain treatment and exaggerated the prevalence of pain problems in the society. The importance of integrating clinical and basic science experiences in order to influence long-term clinical attitudes and produce lasting changes in clinically relevant knowledge is discussed.