A Systematic Guideline by the ASPN Workgroup on the Evidence, Education, and Treatment Algorithm for Painful Diabetic Neuropathy: SWEET

Introduction

Painful diabetic neuropathy (PDN) is a leading cause of pain and disability globally with a lack of consensus on the appropriate treatment of those suffering from this condition. Recent advancements in both pharmacotherapy and interventional approaches have broadened the treatment options for PDN. There exists a need for a comprehensive guideline for the safe and effective treatment of patients suffering from PDN.

Objective

The SWEET Guideline was developed to provide clinicians with the most comprehensive guideline for the safe and appropriate treatment of patients suffering from PDN.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations for PDN. A multidisciplinary group of international experts developed the SWEET guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Meeting Abstracts, and Scopus to identify and compile the evidence for diabetic neuropathy pain treatments (per section as listed in the manuscript) for the treatment of pain. Manuscripts from 2000-present were included in the search process.

Results

After a comprehensive review and analysis of the available evidence, the ASPN SWEET guideline was able to rate the literature and provide therapy grades for most available treatments for PDN utilizing the United States Preventive Services Task Force criteria.

Conclusion

The ASPN SWEET Guideline represents the most comprehensive review of the available treatments for PDN and their appropriate and safe utilization.

Informed Consent for Spine Procedures: Best Practice Guideline from the American Society of Pain and Neuroscience (ASPN)

Introduction

The evolution of treatment options for painful spinal disorders in diverse settings has produced a variety of approaches to patient care among clinicians from multiple professional backgrounds. The American Society of Pain and Neuroscience (ASPN) Best Practice group identified a need for a multidisciplinary guideline regarding appropriate and effective informed consent processes for spine procedures.

Objective

The ASPN Informed Consent Guideline was developed to provide clinicians with a comprehensive evaluation of patient consent practices during the treatment of spine pathology.

Methods

After a needs assessment, ASPN determined that best practice regarding proper informed consent for spinal procedures was needed and a process of selecting faculty was developed based on expertise, diversity, and knowledge of the subject matter. A comprehensive literature search was conducted and when appropriate, evidence grading was performed. Recommendations were based on evidence when available, and when limited, based on consensus opinion.

Results

Following a comprehensive review and analysis of the available evidence, the ASPN Informed Consent Guideline group rated the literature to assist with specification of best practice regarding patient consent during the management of spine disorders.

Conclusion

Careful attention to informed consent is critical in achieving an optimal outcome and properly educating patients. This process involves a discussion of risks, advantages, and alternatives to treatment. As the field of interventional pain and spine continues to grow, it is imperative that clinicians effectively educate patients and obtain comprehensive informed consent for invasive procedures. This consent should be tailored to the patient's specific needs to ensure an essential recognition of patient autonomy and reasonable expectations of treatment.

Best Practice Guidelines on the Diagnosis and Treatment of Vertebrogenic Pain with Basivertebral Nerve Ablation from the American Society of Pain and Neuroscience

Chronic low back pain is a worldwide leading cause of pain and disability. Degenerative disc disease has been the presumptive etiology in the majority of cases of chronic low back pain (CLBP). More recent study and treatments have discovered that the vertebral endplates play a large role in CLBP in a term defined as vertebrogenic back pain. As the vertebral endplates are highly innervated via the basivertebral nerve (BVN), this has resulted in a reliable target in treating patients suffering from vertebrogenic low back pain (VLBP). The application of BVN ablation for patients suffering from VLBP is still in its early stages of adoption and integration into spine care pathways. BVN ablation is grounded in a solid foundation of both pre-clinical and clinical evidence. With the emergence of this therapeutic option, the American Society of Pain and Neuroscience (ASPN) identified the need for formal evidence-based guidelines for the proper identification and selection of patients for BVN ablation in patients with VLBP. ASPN formed a multidisciplinary work group tasked to examine the available literature and form best practice guidelines on this subject. Based on the United States Preventative Task Force (USPSTF) criteria for grading evidence, gives BVN ablation Level A grade evidence with high certainty that the net benefit is substantial in appropriately selected individuals.

Social Media and Professional Conduct (SMART): Best Practice Guidelines from the American Society of Pain and Neuroscience (ASPN)

Social media has revolutionized internet communication and become ubiquitous in modern life. Though it originated as a medium for friendship, social media has evolved into an ideal venue for professional networking, scientific exchange, and brand building. As such, it is a powerful tool with which interventional pain physicians should become familiar. However, given the permanence and visibility of online posts, it is prudent for interventional pain physicians to utilize social media in a manner that is consistent with the ethical and professionalism standards to which they are held by their patients, employers, peers, and state medical boards. While there are extensive publications of professional codes of conduct by medical societies, there is a paucity of literature regarding social media best practices guidelines. Further, to date there have been no social media best practices recommendations specific to interventional pain medicine physicians. While not exhaustive, the aim of this document is to provide recommendations to pain physicians on how to maintain an effective professional and ethical online presence. Specifically, we provide guidance on online persona and professional image, patient–physician interactions online, patient privacy, industry relations, patient education, and brand building.

Hydrogen sulphide: an emerging regulator of plant defence signalling

Hydrogen sulphide (H₂ S), a gaseous signalling molecule in plants, has gained considerable attention in recent years because of its emerging roles in the regulation of plant growth and development and responses to abiotic stressors. Although the involvement of H₂ S in biotic stress is not well documented in the literature, a growing body of evidence indicates its potential role in plant defence, particularly against bacterial and fungal pathogens. Recent reports have suggested that H₂ S participates in plant defence signalling potentially by (1) regulating glutathione metabolism, (2) inducing expression of pathogenesis-related (PR) and other defence-related genes, (3) modulating enzyme activity through post-translational modifications, and (4) interacting with phytohormones such as jasmonic acid, ethylene and auxin. In this review, we discuss the biosynthesis, metabolism and interaction of H₂ S with phytohormones, and highlight evidence gathered so far to support the emerging roles of H₂ S in plant defence against invading pathogens.

Salvage of Failed Lateral Sacroiliac Joint Fusion with a Novel Posterior Sacroiliac Fusion Device: Diagnostic Approach, Surgical Technique, and Multicenter Case Series

Background

Studies have found that up to one-third of patients with LBP have sacroiliac joint (SIJ) dysfunction as a contributing cause. Historically, the management of SIJ dysfunction has been plagued by ineffectiveness or significant morbidity. In 2008, minimally invasive lateral SIJ fusion was developed. While this procedure is a safe and effective treatment, there is still a significant proportion of patients who will not experience therapeutic success. There is a paucity of data in the literature regarding the management of these patients. Recently, a novel posterior sacroiliac joint fusion device has been developed which minimizes complications compared to lateral approaches and may serve to salvage therapeutic failures in this patient population.

Objective

Determine the efficacy and feasibility of a posterior SIJ fusion device as a salvage technique in patients who have not experienced therapeutic success following lateral SIJ fusion.

Design

Multi-center retrospective observational study.

Methods

Patients who had previously undergone lateral SIJ fusion and had persistent LBP were evaluated and diagnosed to have persistent primary SIJ pathology. All patients underwent posterior SIJ fusion utilizing a machined allograft transfixing sacroiliac fusion device. Demographic data and patient reported pain scores were collected.

Results

A total of 7 patients who had undergone lateral SIJ fusion were included in the study and underwent posterior SIJ fusion. The mean patient reported pain improvement following posterior fusion was 80% with an average follow-up time of 10 months. Median morphine milliequivalents were 20 pre-procedure and 0 post-procedure.

Conclusion

We were able to show significant reductions in pain scores and opioid consumption, which suggests that minimally invasive posterior SIJ utilizing a novel implant and technique may be a viable treatment option to salvage pain relief in this patient population. Further, the favorable safety profile of this posterior technique uniquely positions it to be an appropriate first-line surgical therapy.

Determinants of Discrepancy in the Left Ventricular Systolic Function Evaluation Between Preoperative and Intraoperative Evaluations

Unexpectedly decreased left ventricular global systolic function can be difficult to manage, even for patients undergoing elective cardiac surgery, and should prompt a multidisciplinary discussion. Therefore, in this review, we discuss the evidence describing key perioperative variables expected to influence left ventricular systolic function to facilitate this discussion.

In vivo delivery aspects of miRNA, shRNA and siRNA

RNA interference (RNAi) is a wondrous phenomenon that silences the expression of targeted genes via distinct messenger RNA degradation pathways. It has the potential as a therapeutic agent for variety of diseases, including viral infections, cancer, and immune diseases. RNAi mainly conducts gene regulation by 3 ways: microRNA, short hairpin RNA, and small interfering RNA. However, in vivo delivery of RNAi therapeutics is restricted because of charge density, molecular weight, and instability in the presence of nucleases. Furthermore, intracellular accumulation and endosomal escape have remained significant barriers in the delivery of these macromolecules. Many viral and nonviral delivery vectors have been thoroughly investigated to overcome these barriers. Researchers have found applications for RNAi in a variety of diseases and, hence, various delivery systems have been explored to satisfy the need. Both local and systemic strategies have been utilized to elicit RNAi's effect and each carries its own therapeutic implications with varying margins of safety. This review is an effort to describe the types of RNAi and their application in a variety of diseases using both local and systemic delivery approaches. It is sure that advancement in this direction will evolve a new landscape for treating a range of diseases.

Development of siRNA lipoplexes for intracellular delivery in lung cancer cells

Lung cancer occurrence throughout the world and its unsatisfactory treatment has drawn significant attention from many medical agencies. A genomic approach utilizing siRNA against target gene may resolve this problem. Present investigation includes siRNA lipoplex formulation and its in-vitro characterisation in lung cancer cell line for intracellular uptake and cytotoxicity. Accumulation of siRNA inside the cell as well as less cytotoxicity of prepared carrier system signifies potential of prepared siRNA lipoplex in the treatment of lung cancer.

Impact of field vaccination with a Theileria annulata schizont cell culture vaccine on the epidemiology of tropical theileriosis

Tropical theileriosis, caused by Theileria annulata, is an important tick-borne disease of cattle. A cell culture attenuated vaccine has been developed in our laboratory by long-term in vitro propagation of the schizont stage of the parasite. A longitudinal study was conducted at selected farms housing indigenous, cross-bred and exotic animals to investigate the effect of vaccination on the epidemiology of the disease. A total of 120 animals in 4 age groups were vaccinated with the vaccine before the onset of disease season. An equal number of age-matched animals were kept as controls at the same sites. Animals were monitored for 14 months at monthly intervals. The 97.5% vaccinated animals showed a rise in antibody titres 1 month post-vaccination, as determined by single dilution ELISA. The 78.3% of non-vaccinated animals became sero-positive over the period of observation. Mean antibody titres were significantly higher in vaccinated than non-vaccinated animals. Cross-bred animals showed higher antibody titres followed by exotic and indigenous animals in both the vaccinated and non-vaccinated groups. However, the antibody titres in animals of different ages were similar. The 36.7% vaccinated and 64.2% non-vaccinated animals became carriers (<0.5% piroplasms in erythrocytes) during the observation period. Clinical cases of theileriosis were recorded only in the non-vaccinated group suggesting that vaccinated animals were sufficiently immune to withstand field tick challenge for at least 14 months.

Effect of vaccination in the field with the Theileria annulata (Hisar) cell culture vaccine on young calves born during the winter season

The responses were monitored of young crossbred calves vaccinated against tropical theileriosis during the winter against a field tick challenge in the disease season. Thirty-eight calves below 2 months of age, born after the end of the disease season, were selected at an organized farm. Twenty-five animals were vaccinated with Theileria annulata (Hisar) cell culture vaccine (developed at CCS HAU Hisar laboratory) after the end of the disease season and 13 calves were kept as non-vaccinated controls. These calves were observed for their susceptibility to theileriosis in the new disease season. There was an increase in antibody titre in 18 of the 25 vaccinated animals one month after vaccination. The antibody titre then declined gradually, but remained higher than those of the non-vaccinated animals at month 0. No fever or other clinical signs of tropical theileriosis were observed in any of the vaccinated animals. Nine out of 25 (36%) vaccinated calves showed occasional piroplasms (<0.5%) in blood smears. All the vaccinated animals withstood the field tick challenge. On the other hand, 9 of the 13 (69%) unvaccinated calves exhibited occasional piroplasms, and included three clinical cases of tropical theileriosis. These observations suggest that young crossbred calves vaccinated with the T. annulata (Hisar) cell culture vaccine at the end of the disease season were relatively resistant during the next disease season.

Validity of self-reports about quality of life among patients with schizophrenia

Lehman's Quality of Life Interview was administered to 22 patients with schizophrenia and their proxies and to 15 patients with cancer and their proxies. The results indicated that there was a discrepancy between responses on global objective and subjective measures for patients with schizophrenia but not for patients with cancer. A discrepancy was also found for the proxies of the patients with schizophrenia but not for the proxies of the patients with cancer. These findings suggest that the discrepancy between subjective and objective indicators of quality of life of patients with schizophrenia signifies a genuine difference rather than an anomaly related to the patient's psychiatric condition.

Cognitive therapy: looking backward, looking forward

This article reviews some of the historical factors associated with the unprecedented strength and popularity of cognitive therapy, and offers predictions for the next half-century of this approach to treatment. It is predicted that the future will bring with it increased demands on cognitive therapy for evaluation of processes of change (including identification of therapeutic specifics and nonspecifics, technical specification of the process of therapy, and examination of therapist and patient predictors of change), and accountability and efficiency in the public and private sectors. With the increase in personal autonomy, globalization, and technology, the demands from the general public also will increase. One possible risk of the trend towards increased technology is that cognitive therapy may become overly technical. Although specific therapy techniques are crucial to delivering effective treatment, it is also the "nonspecifics" of therapy that add to the "art" of psychotherapy. The final challenge of cognitive therapy also may be the most difficult--to continue to be an empirically based science while maintaining its role in the art of healing.

Gynecologic cytology from the perspective of the Laboratory Proficiency Testing Program, Ontario, Canada

The accumulated test results from annual proficiency testing of approximately 150 cytology laboratories during the period 1977-1992 were analyzed. Several features of the test program are presented, including the adaptability of the uniform diagnostic terminology that was in use throughout. Observations include the impact of screening by a technologist; the better diagnostic performance generally, but not exclusively, in larger-volume laboratories; the degree of reproducibility of reporting in the laboratory; the ease of diagnosis in some diagnostic categories; and patterns observed in "false negative" and "false positive" rates. The follow-up analysis of suboptimal performance is recorded, and remedial and educational aspects are emphasized. The impact of levels of performance on the specific population being screened is correlated with the data on laboratory caseloads and with hospital vs. nonhospital laboratories.

Serum gonadotropins and testosterone in infertile patients with varicocele

Serum concentrations of gonadotropins and testosterone in 25 infertile men with varicocele were compared with those in control men and men with idiopathic oligo-azoospermia. No significant difference was found in values of serum follicle-stimulating hormone (FSH) (14.9 +/- 13.6 mIU/ml), luteinizing hormone (LH) (24.9 +/- 19.1 mIU/ml), and testosterone (5.0 +/- 2.1 ng/ml) when the group with varicocele was compared with either the control group (FSH, 7.0 +/- 3.2 mIU/ml; LH, 23.6 +/- 16.0 mIU/ml; testosterone, 5.3 +/- 1.8 ng/ml) or the group with idiopathic oligo-azoospermia (FSH, 23.0 +/- 22.69 mIU/ml; LH, 36.7 +/- 24.1 mIU/ml; testosterone, 5.31 +/- 2.3 ng/ml). However, compared with the control group, there was a significant elevation of serum FSH levels in patients with varicocele whose testicular biopsy score counts were between 1 and 4. The importance of preoperative determination of the serum FSH level is discussed.