Milan Stojanović

Abstract Background It is nearly impossible to overestimate the burden of chronic pain, which is associated with enormous personal and socioeconomic costs. Chronic pain is the leading cause of disability in the world, is associated with multiple psychiatric comorbidities, and has been causally linked to the opioid crisis. Access to pain treatment has been called a fundamental human right by numerous organizations. The current COVID-19 pandemic has strained medical resources, creating a dilemma for physicians charged with the responsibility to limit spread of the contagion and to treat the patients they are entrusted to care for. Methods To address these issues, an expert panel was convened that included pain management experts from the military, Veterans Health Administration, and academia. Endorsement from stakeholder societies was sought upon completion of the document within a one-week period. Results In these guidelines, we provide a framework for pain practitioners and institutions to balance the often-conflicting goals of risk mitigation for health care providers, risk mitigation for patients, conservation of resources, and access to pain management services. Specific issues discussed include general and intervention-specific risk mitigation, patient flow issues and staffing plans, telemedicine options, triaging recommendations, strategies to reduce psychological sequelae in health care providers, and resource utilization. Conclusions The COVID-19 public health crisis has strained health care systems, creating a conundrum for patients, pain medicine practitioners, hospital leaders, and regulatory officials. Although this document provides a framework for pain management services, systems-wide and individual decisions must take into account clinical considerations, regional health conditions, government and hospital directives, resource availability, and the welfare of health care providers.

Brain activity was studied with functional magnetic resonance imaging (fMRI) following thermal stimulation. Two groups (n = 6/group) of human male volunteers were given up to four noxious (46 degrees C) and four non-noxious (41 degrees C) stimuli. In the 46 degrees C experiment, positive signal changes were found in the frontal gyri, anterior and posterior cingulate gyrus, thalamus, motor cortex, somatosensory cortex (SI and SII), supplementary motor area, insula, and cerebellum. Low-level negative signal changes appeared in the amygdala and hypothalamus. All regions activated by 46 degrees C were also activated by 41 degrees C. However, except for SI and thalamus, significantly more activation was observed for the 46 degrees C stimulus. A significant attenuation of the signal change was observed by the third stimulus for the 46 degrees C, but not for 41 degrees C experiment. Similar findings were replicated in the second group. These fMRI findings specify differences between somatosensory and pain sensation and suggest a number of rich avenues for future research.

WE studied a patient after amputation of an arm and found that in less than 24 h stimuli applied on the ipsilateral face were referred in a precise, topographically organized, modality-specific manner to distinct points on the phantom. Functional magnetic resonance imaging (fMRI) performed one month later showed that brush-evoked activity in the brain demonstrates objective signal changes which correlate with perceptual changes in the phantom hand. This finding in humans corresponds to the observations of immediate plasticity in cortical pathways described in animals, including primates. The results suggest that reorganization of sensory pathways occurs very soon after amputation in humans, potentially due to the unmasking of ordinarily silent inputs rather than sprouting of new axon terminals.

To determine the clinical factors associated with the success and failure of radiofrequency denervation of the lumbar facet joints.Clinical data were garnered from 3 academic medical centers on 192 patients with low back pain who underwent radiofrequency denervation after a positive response to diagnostic blocks. Success was defined as >/=50% pain relief lasting at least 6 months. Factors evaluated for their association with outcome included duration of pain, opioid use, symptom location, paraspinal tenderness, pain exacerbated by extension/rotation (ie, facet loading), MRI abnormalities, diabetes, smoking, scoliosis, obesity, prior surgery and levels treated.The only factor associated with a successful outcome was paraspinal tenderness. Variables that correlated with treatment failure were 'facet loading,' long duration of pain, and previous back surgery.It is counterproductive to use 'facet loading' as the sole basis for choosing patients for facet interventions. In patients at high risk for treatment failure, taking additional steps to reduce the rate of false-positive screening blocks may improve outcomes.

Occipital neuralgia (ON) is characterized by lancinating pain and tenderness overlying the occipital nerves. Both steroid injections and pulsed radiofrequency (PRF) are used to treat ON, but few clinical trials have evaluated efficacy, and no study has compared treatments. We performed a multicenter, randomized, double-blind, comparative-effectiveness study in 81 participants with ON or migraine with occipital nerve tenderness whose aim was to determine which treatment is superior. Forty-two participants were randomized to receive local anesthetic and saline, and three 120 second cycles of PRF per targeted nerve, and 39 were randomized to receive local anesthetic mixed with deposteroid and 3 rounds of sham PRF. Patients, treating physicians, and evaluators were blinded to interventions. The PRF group experienced a greater reduction in the primary outcome measure, average occipital pain at 6 weeks (mean change from baseline -2.743 ± 2.487 vs -1.377 ± 1.970; P < 0.001), than the steroid group, which persisted through the 6-month follow-up. Comparable benefits favoring PRF were obtained for worst occipital pain through 3 months (mean change from baseline -1.925 ± 3.204 vs -0.541 ± 2.644; P = 0.043), and average overall headache pain through 6 weeks (mean change from baseline -2.738 ± 2.753 vs -1.120 ± 2.1; P = 0.037). Adverse events were similar between groups, and few significant differences were noted for nonpain outcomes. We conclude that although PRF can provide greater pain relief for ON and migraine with occipital nerve tenderness than steroid injections, the superior analgesia may not be accompanied by comparable improvement on other outcome measures.

Study Design. A multicenter, retrospective analysis of cervical epidurograms. Objectives. To determine the effectiveness of the loss of resistance (LOR) technique in identifying the cervical epidural space. To delineate the pattern of epidural contrast spread during cervical epidural steroid injections. Background. Previous studies have shown that if performed without fluoroscopy, the LOR technique can result in inaccurate needle placement in up to 30% of lumbar epidural steroid injections. To date, no study has examined accuracy of LOR technique and pattern of radiographic contrast spread in cervical epidural levels. Methods. Epidurograms of 38 cervical epidural steroid injections in 31 patients were reviewed. The number of LOR attempts and pattern of contrast spread was analyzed. The effects of age, gender, MRI results, previous cervical laminectomy, and the physician’s level of training were correlated with results. Results. The authors found a 53% rate of false LOR during the first attempt to enter the epidural space. Unilateral epidural contrast spread was found in 51% and ventral epidural spread was found in 28% of cases. The average number of cervical vertebral levels covered with 2 mL of contrast was 3.14, with significantly wider spread noted in those patients who had not undergone previous cervical laminectomy. Other variables did not influence the accuracy of needle placement and pattern of epidural contrast spread. Conclusions. The loss of resistance technique may not be an adequate method for ensuring accurate needle placement in blindly performed cervical epidural injections. The use of epidurography can improve the accuracy of needle placement and medication delivery to targeted areas of pathology.

Background context The publication of several recent studies showing minimal benefit for radiofrequency (RF) lumbar zygapophysial (l-z) joint denervation have led many investigators to reevaluate selection criteria. One controversial explanation for these findings is that the most commonly used cutoff value for selecting patients for l-z (facet) joint RF denervation, greater than 50% pain relief after diagnostic blocks, is too low and hence responsible for the high failure rate. Purpose To compare l-z joint RF denervation success rates between the conventional greater than or equal to 50% pain relief threshold and the more stringently proposed greater than or equal to 80% cutoff for diagnostic medial branch blocks (MBB). Study design/setting Multicenter, retrospective clinical data analysis. Patient sample Two hundred and sixty-two patients with chronic low back pain who underwent l-z RF denervation at three pain clinics. Outcome measures Outcome measures were greater than 50% pain relief based on visual analog scale or numerical pain rating score after RF denervation persisting at least 6 months postprocedure, and global perceived effect (GPE), which considered pain relief, satisfaction and functional improvement. Methods Data were garnered at three centers on 262 patients who underwent l-z RF denervation after obtaining greater than or equal to 50% pain relief after diagnostic MBB. Subjects were separated into those who received partial (greater than or equal to 50% but less than 80%) and near-complete (greater than or equal to 80%) pain relief from the MBB. Outcomes between groups were compared with multivariate analysis after controlling for 14 demographic and clinical variables. Results One hundred and forty-five patients obtained greater than or equal to 50% but less than 80% pain relief after diagnostic MBB, and 117 patients obtained greater than or equal to 80% relief. In the greater than or equal to 50% group, success rates were 52% and 67% based on pain relief and GPE, respectively. Among patients who experienced greater than 80% relief from diagnostic blocks, 56% obtained greater than or equal to 50% relief from RF denervation and 66% had a positive GPE. Conclusions Using more stringent pain relief criteria when selecting patients for l-z joint RF denervation is unlikely to improve success rates, and may lead to misdiagnosis and withholding a potentially valuable treatment from good candidates.

Abstract Objective To determine the effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain. Design Comprehensive systematic review. Outcome Measures The primary outcome of interest was the proportion of individuals with reduction of pain by ≥50%. Additional outcomes of interest were a more-than-two-point reduction in pain score, patient satisfaction, functional improvement, decreased use of pain medication, and avoidance of spinal surgery. Results For patients with disc herniations, using the criterion of ≥50% reduction in pain, success rates across included studies (range) were 63% (58–68%) at one month, 74% (68–80%) at three months, 64% (59–69%) at six months, and 64% (57–71%) at one year. For patients with lumbar spinal stenosis, success rates across included studies (range) were 49% (43–55%) at one month, 48% (35–61%) at three months, 43% (33–53%) at six months, and 59% (45–73%) at one year, but there was a lack of corroboration from appropriately controlled studies. Conclusions There is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. There is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis, though small studies suggest a possible benefit. Lumbar transforaminal injection of nonparticulate steroids is as effective as injections with particulate steroids.

Although epidural steroid injections (ESIs) are a common treatment for chronic pain conditions, it is not clear whether there is consensus on their technical aspects. The current literature suggests that variations in technical aspects may affect ESI outcomes. The goal of the survey was to help establish a standard frame of reference for the performance of ESIs. We analyzed survey results from 68 academic anesthesia programs and 28 private practices in the United States. The main finding in this survey is that there is no clear-cut consensus as to the ideal method to perform ESI. There is a wide variation among individual practices in almost every technical aspect of ESI. Private practices use significantly more fluoroscopy than academic centers. The large difference was found in the cervical region where 73% of private practices and only 39% of academic institutions polled perform the ESIs with fluoroscopic guidance (P = 0.005). A similar discrepancy was found in approaches to the epidural space after laminectomy where 61% of private practices, but only 15% of academic centers, use the transforaminal approach. The study results indicate that there is no consensus, and that there is a wide variation in current practices.

<h3>Background and Objectives:</h3> Since its advent more than 50 years ago, the use of discography has been mired in controversy. The purpose of this review is to provide a clinical overview of lumbar discography and discogenic back pain, with special emphasis on determining the accuracy of discography and whether or not the procedure improves outcomes for surgery. <h3>Methods:</h3> Material for this review was obtained from a MEDLINE search conducted from 1951 thru September 2004, bibliographic references, book chapters, and conference proceedings. <h3>Results:</h3> Based on a large number of comparative studies, plain discography is less accurate than magnetic resonance imaging in diagnosing lumbar herniated nucleus pulposus and comparable or slightly more sensitive in detecting degenerative disc disease. For disc degeneration, CT discography remains the gold standard for diagnosis. There are very few studies comparing surgical outcomes between patients who have undergone preoperative provocative discography and those who have not. What little evidence exists is conflicting. Before disc replacement surgery, approximately half the studies have used preoperative discography. A comparison of outcomes did not reveal any significant difference between the 2 groups but none of the studies was controlled, and they used different outcome measures, follow-up periods, and surgical techniques. Because all intradiscal electrothermal therapy (IDET) studies have used discography before surgery, no conclusions can be drawn regarding its effects on outcome. <h3>Conclusions:</h3> Although discography, especially combined with CT scanning, may be more accurate than other radiologic studies in detecting degenerative disc disease, its ability to improve surgical outcomes has yet to be proven. In the United States and Europe, there are inconsistencies in the use of lumbar discography such that it is routinely used before IDET, yet only occasionally used before spinal fusion.

Spinal cord stimulation is the most common mode of neuromodulation used in managing chronic low back pain. It is minimally invasive and reversible as opposed to nerve ablation. The basic scientific background of the initial spinal cord stimulation trials was based on the gate control theory of Melzack and Wall. It has been demonstrated in multiple studies that dorsal horn neuronal activity caused by peripheral noxious stimuli could be inhibited by concomitant stimulation of the dorsal columns. Various other mechanisms, which may play a significant role in the mechanism of action of spinal cord stimulation, include the suppressive effect of spinal cord stimulation on tactile allodynia, increased dorsal horn inhibitory action of gamma-aminobutyric acid (GABA), prevention or abolition of peripheral ischemia, and effects on human brain activity. Spinal cord stimulation is indicated in low back pain with radiculopathy, failed back surgery syndrome, complex regional pain syndrome, peripheral vascular disease, and ischemic heart disease. There is substantial scientific evidence on the efficacy of spinal cord stimulation for treatment of low back and lower extremity pain of neuropathic nature. Clinical studies revealed a success rate of from 50% to 70% with spinal cord stimulation, with decreased pain intensity scores, functional improvement and decreased medication usage. This review discusses multiple aspects of spinal cord stimulation, including pathophysiology and mechanism of action, rationale, indications, technique, clinical effectiveness, and controversial aspects.

A bi-institutional, retrospective clinical data analysis.To determine risk factors for failure and complications of intradiscal electrothermal therapy, a treatment for discogenic back pain.Intradiscal electrothermal therapy is a relatively new treatment for discogenic back pain. Though previous studies have shown it to be an effective treatment, there are few published studies examining complications and none examining risk factors for failure.The authors treated 79 patients with discogenic back pain using intradiscal electrothermal therapy. Complications were assessed by patient report and, when indicated, further diagnostic testing. Success or failure was determined by visual analogue pain scores at 6-month follow-up. Variables examined for their relationship to failure and complications were age, sex, duration of pain, number of levels heated, smoking history, diabetes, obesity, leg pain, and previous back surgery.Forty-eight percent of patients reported more than 50% pain relief at their 6-month follow-up. There were eight complications (10%), most of which were self-limited and transient. The only risk factor associated with intradiscal electrothermal therapy failure was obesity (P = 0.01). Whereas 54% of nonobese patients reported good pain relief at 6 months, only one out of 10 obese patients had successful intradiscal electrothermal therapy. The obese patients in our study were more likely to have a complication from intradiscal electrothermal therapy than they were to obtain pain relief.The only risk factor found to be associated with IDET outcome was obesity, which was a strong predictor of failure. Obesity should be considered a relative contraindication to performing IDET.

Background.Numerous studies have demonstrated that therapeutic injections carried out to treat a variety of different pain conditions should ideally be performed under radiological guidance because of the propensity for blinded injections to be inaccurate. Although trochanteric bursa injections are commonly performed to treat hip pain, they have never been described using fluoroscopy.Methods.The authors reviewed recorded data on 40 patients who underwent trochanteric bursa injections for hip pain with or without low back pain. The initial needle placement was done blindly, with all subsequent attempts done using fluoroscopic guidance. After bone contact, imaging was used to determine if the needle was positioned on the lateral edge of the greater trochanter (GT). Once this occurred, 1 ml of radiopaque contrast was injected to assess bursa spread.Results.The GT was contacted in 78% of cases and a bursagram obtained in 45% of patients on the first needle placement. In 23% of patients a bursagram was obtained on the second attempt and in another 23% on the third attempt. Four patients (10%) required four or more needle placements before a bursagram was appreciated. Attending physicians obtained a bursagram on the first attempt 53% of the time vs 46% for fellows and 36% for residents (P=0.64). Older patients were more likely to require multiple injections than younger patients.Conclusions.Radiological confirmation of bursal spread is necessary to ensure that the injectate reaches the area of pathology during trochanteric bursa injections. Numerous studies have demonstrated that therapeutic injections carried out to treat a variety of different pain conditions should ideally be performed under radiological guidance because of the propensity for blinded injections to be inaccurate. Although trochanteric bursa injections are commonly performed to treat hip pain, they have never been described using fluoroscopy. The authors reviewed recorded data on 40 patients who underwent trochanteric bursa injections for hip pain with or without low back pain. The initial needle placement was done blindly, with all subsequent attempts done using fluoroscopic guidance. After bone contact, imaging was used to determine if the needle was positioned on the lateral edge of the greater trochanter (GT). Once this occurred, 1 ml of radiopaque contrast was injected to assess bursa spread. The GT was contacted in 78% of cases and a bursagram obtained in 45% of patients on the first needle placement. In 23% of patients a bursagram was obtained on the second attempt and in another 23% on the third attempt. Four patients (10%) required four or more needle placements before a bursagram was appreciated. Attending physicians obtained a bursagram on the first attempt 53% of the time vs 46% for fellows and 36% for residents (P=0.64). Older patients were more likely to require multiple injections than younger patients. Radiological confirmation of bursal spread is necessary to ensure that the injectate reaches the area of pathology during trochanteric bursa injections.

To perform a thorough assessment of the recently published Mint Trials in order to illustrate how to read and analyze a study critically, according to principles of evidence-based medicine.Narrative review.We have applied the recently published guidelines for composing and assessing studies on the treatment of pain to a recently published article describing a large study that claimed its "findings do not support the use of radiofrequency denervation to treat chronic low back pain." These guidelines describe the critical components of a high-quality manuscript that allows communication of all relevant information from authors to readers.Application of evidence-based medicine principles to the publication describing the Mint Trials reveals significant issues with the methodology and conclusions drawn by the authors. A thorough assessment demonstrates issues with inclusion/exclusion criteria, diagnostic block protocols, radiofrequency neurotomy technique, co-interventions, outcome measurement, power analysis, study sample characteristics, data analysis, and loss to follow-up. A failure to definitively establish a diagnosis, combined with use of an inadequate technique for radiofrequency neurotomy and numerous other methodological flaws, leaves the reader unable to draw meaningful conclusions from the study data.Critical analysis, rooted in principles of evidence-based medicine, must be employed by writers and readers alike in order to encourage transparency and ensure that appropriate conclusions are drawn from study data.

Objectives To determine the correlation between magnetic resonance imaging (MRI) pathology and the response to diagnostic facet medial branch block (MBB) and L5 dorsal ramus medial branch block and radiofrequency (RF) denervation of lumbar facet joints. Methods The medical records of 127 consecutive patients who underwent MBB for suspected zygapophysial joint pain were reviewed. The lumbar spine MRI of these patients was systematically graded by 2 musculoskeletal radiologists for loss of disc height, spinal stenosis, facet joint degeneration, and other forms of spinal pathology. Results Patients with central or foraminal spinal stenosis had statistically significant correlation with positive outcome of RF (P=0.02), but not with MBB (P=0.08). The presence of facet joint degeneration or hypertrophy was positively correlated with response to MBB (71% vs. 51%; P=0.04), but not RF. Loss of disc height did not correlate with outcome of MBB (P=0.08) and RF (P=0.29). For other spinal pathology, no significant differences were noted for either the response to diagnostic blocks or the RF denervation. Younger patients were more likely to fail MBB (P<0.01) but not RF denervation (P=0.38). Discussion Whereas some relationships were noted between MRI findings and the response to lumbar facet joint interventions, many of these correlations tended to be weak. However, this study does suggest the possibility that patients with spinal stenosis, often considered an exclusion criterion for facet interventions, may respond to RF denervation of facet joints. Prospective studies are needed to confirm these observations.

Objective. Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) are common among US veterans of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND). We postulated that these injuries may modulate pain processing in these individuals and affect their subjective pain levels. Design. Cross-sectional. Subjects. 310 deployed service members of OEF/OIF/OND without a lifetime history of moderate or severe TBI were included in this study. Methods. All participants completed a comprehensive evaluation for Blast Exposure, mTBI, PTSD, and Pain Levels. The Boston Assessment of TBI-Lifetime Version (BAT-L) was used to assess blast exposure and potential brain injury during military service. The Clinician-Administered PTSD Scale (CAPS) characterized presence and severity of PTSD. The Visual Analog Scale (VAS) was used to assess pain intensity over the previous month before the interview, with higher scores indicative of worse pain. Statistical analysis was performed by ANOVA and results were adjusted for co-morbidities, clinical characteristics and demographic data. Results. In comparison to control participants (veterans without mTBI or current PTSD), veterans with both current PTSD and mTBI reported the highest pain intensity levels, followed by veterans with PTSD only (P < 0.0001 and P = 0.0005, respectively). Pain levels in veterans with mTBI only were comparable to control participants. Conclusions. Comorbid PTSD and mTBI is associated with increased self-reported pain intensity. mTBI alone was not associated with increased pain.

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal

Objective. To determine the effectiveness and risks of non–image-guided lumbar interlaminar epidural steroid injections.

In Brief Opioid-induced hyperalgesia, toxicity, and withdrawal are phenomena that may occur with intrathecal opioid infusion. We present a case in which a patient received intrathecal morphine infusion, and then experienced a clinical course that may have involved hyperalgesia, toxicity, and/or withdrawal. The possible differential diagnosis of opioid-induced hyperalgesia, toxicity, and withdrawal, and its implications in clinical pain management, are discussed. This report demonstrates the complexity of treating patients with long-term continuous intrathecal opioids when modest adjustment of the intrathecal cocktail results in a paradoxical clinical course. IMPLICATIONS: This report demonstrates the complexity of treating patients with long-term continuous intrathecal opioids when modest adjustment of the intrathecal cocktail results in a paradoxical clinical course.

The concept of opioid-induced hyperalgesia has recently gained prominence as a contributing factor for opioid tolerance and long-term treatment failure. But whereas the preclinical data for this phenomenon are strong, the mixed clinical data derive primarily from experimental pain models conducted in volunteers and heroin addicts, and nonstandardized clinical stimuli, e.g., surgery. The primary objective of this study is to delineate the effect of opioid dose and treatment duration on pain intensity and unpleasantness ratings following a standardized clinical pain stimulus.Three hundred and fifty-five patients, on a steady regimen of analgesic medications and scheduled for an interventional procedure, received a standardized subcutaneous injection of lidocaine prior to a full dose of local anesthetic. Before and immediately following the injection, subjects were asked to rate pain and unpleasantness intensity on a 0 to 10 numerical rating scale. Subjects were stratified into 6 groups based on opioid dosage. A control group of 27 volunteers who had no pain and were taking no analgesics were also injected.Both opioid dose and duration of treatment directly correlated with pain intensity and unpleasantness scores. Baseline pain intensity was also positively associated with both outcome variables. Gender was found to be associated with pain intensity and unpleasantness, with females scoring higher in both categories than males. Compared with patients not receiving opioid treatment, patients receiving opioid therapy were more likely to rate the standardized pain stimulus as being more unpleasant than painful.The results of this study bolster preclinical and experimental pain models demonstrating enhanced pain perception in subjects receiving opioid therapy. This simple clinical model may provide a useful tool in examining opioid-induced hyperalgesia.

In April 2014, the Food and Drug Administration (FDA) issued a Drug Safety Communication requesting that corticosteroid labeling include warnings that injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death.The International Spine Intervention Society spearheaded a collaboration of more than a dozen other medical societies in submitting the letter below to the FDA on November 7, 2014. We are publishing the letter to ensure that the readership of Pain Medicine is aware of the multisociety support for the safety and effectiveness of these procedures. A special note of thanks to all of the societies who signed on in support of the message.

The purpose of this study was to determine the factors associated with false-positive medial branch blocks (MBB), the nerve blocks used to diagnose facet arthropathy, in soldiers and retirees.The study subjects were 78 patients with chronic low back pain who underwent diagnostic MBB to determine whether or not the facet joints were pain generators. Radiofrequency denervation of these nerves was performed in all patients with positive responses. Patients who failed to obtain pain relief after the blocks (negative blocks) and those who obtained temporary pain relief after MBB but failed radiofrequency denervation (false-positive blocks) then proceeded to undergo discography. Based on patients' responses to diagnostic blocks, discography results, the presence of radicular pain, and previous back surgery, the data were analyzed to determine whether any of these variables correlated with false-positive MBB.The presence of discogenic or radicular pain was not associated with a higher false-positive response rate to MBB. Conversely, the absence of discogenic pain was associated with a higher percentage of false-positive blocks. There was also a trend for patients with previous back surgery to have a higher false-positive rate than those who had not undergone previous surgery.Although a high incidence of epidural and foraminal spread occurs during the performance of MBB, this is unlikely to be a significant cause of false-positive blocks.

Abstract OBJECTIVE The purpose of this study was to assess the predictive value of response to sympathetic blockade (SB) on the success rate of spinal cord stimulation (SCS) in patients with complex regional pain syndrome. METHODS We performed a retrospective study on 23 patients with complex regional pain syndrome who underwent both SB and subsequent SCS trials in the past 3 years at the Massachusetts General Hospital Pain Center, Boston, MA, and Walter Reed Army Medical Center, Washington, DC. Fifteen of these patients underwent permanent placement of an SCS device, and pain relief at 1- and 9-month follow-up was recorded. RESULTS Among the 23 patients included in the study, those having transient pain relief with SB were more likely to have a positive SCS trial: all 13 with positive SB had good pain relief during the trial, compared with only 3 of the 10 with negative SB (100% versus 30%, P &amp;lt; 0.001). Among the 10 patients with negative SB, 7 noted poor pain relief during the trial despite adequate coverage, and they did not undergo placement of a permanent device. Among the patients who underwent permanent placement of an SCS device, those who received good pain relief with SB were more likely to have greater than 50% pain relief at 1-month follow-up (100% versus 33%, P = 0.029) and 9-month follow-up (87.5% versus 33.3%, P = 0.15). CONCLUSION We conclude that patients with good response to SB before SCS are more likely to have a positive response during their SCS trial and long-term pain relief after placement of permanent SCS device.

A prospective pilot study was conducted, attempting to identify objective tests that would help clinicians to assess the efficacy of spinal cord stimulation (SCS) trial preceding permanent device implantation.Four university hospitals in the United States and Israel.Thirteen patients with radicular leg pain due to failed back surgery syndrome (FBSS) or leg pain due to complex regional pain syndrome (CRPS) who were candidates for SCS.PARTICIPANTS underwent a series of quantitative sensory tests prior to, and seven days after the initiation of SCS trial. These tests included: vibration threshold (conducted using the VSA 3000; Medoc Inc., Ramat Ishay, Israel), cold threshold, warm threshold, heat pain threshold, phasic heat pain threshold, tonic heat pain threshold (conducted using the TSA 2001; Medoc Inc.), and electrical pain tolerance at 5, 250 and 2000 Hz (administered using the NerveScan 2000; Neurotron, Inc., Baltimore, MD, USA).Useful data were obtained from 12 patients. The results of the vibration threshold and the tolerance to electrical stimulation at 5 and 250 Hz changed with an SCS trial. These results also correlated with the decision regarding the permanent implantation, which was made independently of them. In contrast, the results of thermal thresholds and tolerance to electrical stimulation at 2000 Hz tests did not change with the SCS trial.Our findings, which agree with those of a few other studies, suggest that the vibration threshold and the tolerance to electrical stimulation at 5 and 250 Hz tests can assist the clinician to select the right patients for permanent stimulation.

The sacroiliac joint is a common source of chronic low back pain. We recently described the use of cooled radiofrequency (RF) electrodes for performing lateral branch neurotomy to treat sacroiliac joint pain. The procedure involves lesioning the lateral branches of the posterior primary rami at S1-S3, and the L5 dorsal ramus (L5DR). While the cooled RF electrode has been adopted as a means for lesioning the lateral branches, conventional RF electrodes are used to lesion the L5DR. The objective of this technical report is to evaluate the acute safety of denervating the L5DR using cooled RF electrode.Electronic chart review was conducted on 100 consecutive RF procedures. Data collected included age, sex, years of pain, body mass index, post-procedural pain, numbness, weakness, and other complications.Of 100 procedures 82 were completed using cooled electrode for sacral lateral branches and L5DR. Of the 82 procedures completed using cooled RF to L5DR, 24 were reported to be of high difficulty and 19 with poor visualization (bowel gas). There were no major complications related to the procedure. Four patients reported increased pain: two from the conventional RF of L5DR group and two from the cooled RF group. All of the pains were transient and returned to the baseline within 6 weeks. There were two patients experiencing localized numbness over the upper medial quadrant of the buttock, both in cooled RF group. There was no reported weakness of the lower extremity. Two patients complained of increased lower back pain and two of prolonged itching.This review demonstrates the acute safety of using cooled RF for L5DR denervation with no report of significant or unusual patient complications. To establish frequency of complication associated with the treatment, a larger registry is required.

Corticosteroid injection for the treatment of pain and inflammation is known to decrease the efficacy of the messenger ribonucleic acid (mRNA) vaccines for coronavirus disease 2019 (COVID-19).There is currently no direct evidence to suggest that a corticosteroid injection before or after the administration of an mRNA COVID-19 vaccine decreases the efficacy of the vaccine.However, based on the known timeline of hypothalamic-pituitary-adrenal (HPA) axis suppression following epidural and intraarticular corticosteroid injections, and the timeline of the reported peak efficacy of the Pfizer-BioNTech and Moderna vaccines, physicians should consider timing an elective corticosteroid injection such that it is administered no less than 2 weeks prior to a COVID-19 mRNA vaccine dose and no less than 1 week following a COVID-19 mRNA vaccine dose, whenever possible.

To develop precise universal standard interventional spine nomenclature for reporting procedural details and anatomy. There is no comprehensive nomenclature of spinal imaging anatomy that can be used for anatomical and procedural reporting. Given this critical lack of unifying terminology, a system of nomenclature was developed de novo by expert consensus, based upon clinical needs, and previously published reports. Nomenclature for anatomical and spine procedural reporting for interlaminar and transforaminal approaches was developed using zones in each view. Separate nomenclature for medial branch procedural reporting and discs and vertebral body location and procedural reporting is also presented. There is a need for a unified anatomical location reporting system in interventional spine. The first step is the development of a precise, simple, and intuitive nomenclature, as reported here. The second is ratification followed by dissemination and adoption in clinical practice.

Although epidural steroid injections (ESIs) are a common treatment for chronic pain conditions, it is not clear whether there is consensus on their technical aspects. The current literature suggests that variations in technical aspects may affect ESI outcomes. The goal of the survey was to help establish a standard frame of reference for the performance of ESIs. We analyzed survey results from 68 academic anesthesia programs and 28 private practices in the United States. The main finding in this survey is that there is no clear-cut consensus as to the ideal method to perform ESI. There is a wide variation among individual practices in almost every technical aspect of ESI. Private practices use significantly more fluoroscopy than academic centers. The large difference was found in the cervical region where 73% of private practices and only 39% of academic institutions polled perform the ESIs with fluoroscopic guidance (P = 0.005). A similar discrepancy was found in approaches to the epidural space after laminectomy where 61% of private practices, but only 15% of academic centers, use the transforaminal approach. The study results indicate that there is no consensus, and that there is a wide variation in current practices.A national survey of practices performing epidural steroid injections was conducted. The purpose was to establish whether consensus exists on technical aspects of this procedure. The study results indicate that there is no consensus, and that there is a wide variation in current practices.

The inability to provide effective postoperative analgesia is one of the major disadvantages of intravenous regional anesthesia (IVRA). We designed a prospective, randomized, double blind study to evaluate the analgesic effectiveness of adding both ketorolac and dexamethasone to lidocaine for IVRA.The study involved 45 patients undergoing ambulatory hand surgery. They were randomly allocated into three groups: Group L, Group LK and Group LDK. Group L received 3 mg x kg-1 lidocaine; Group LK received 3 mg x kg-1 lidocaine + 30 mg ketorolac; and Group LDK received 3 mg x kg-1 lidocaine for IVRA + 8 mg dexamethasone + 30 mg ketorolac for IVRA using a 40 mL solution. Sensory and motor block onset and recovery times were recorded. Tourniquet pain and pain at the operative site were assessed by a visual analog scale. In the first 24 h after surgery, opioid requirements and total analgesic consumption, including side effects, were noted.Sensory and motor block onset and recovery times were similar in all groups. Patients in Groups LK and LDK required less alfentanyl for control of intraoperative and early postoperative pain. Further, patients in Groups LK and LDK reported significantly lower pain scores compared to those in Group L (P<0.001). Patients in Groups LK and LDK required fewer postoperative ketorolac tablets (2.2+/-1.6 and 1.3+/-0.6 tablets, respectively) in the first 24 h after surgery and had significantly longer periods during which they required no analgesics (524 min and 566 min, respectively) compared to those in Group L (3.8+/-1.3 tablets; 122 min, P<0.001).IVRA with lidocaine and with the inclusion of ketorolac and dexamethasone provides effective perioperative analgesia for patients undergoing ambulatory hand surgery, when compared to the use of lidocaine alone or lidocaine with ketorolac IVRA.

Medial branch blocks are an important tool for the diagnosis of facet joint arthropathy. The most commonly used technique involves multiple needle placements, one for each nerve blocked. This multiple needle technique may require a large amount of local anesthetic for anesthetizing the skin, thereby increasing the rate of false-positive blocks.Diagnostic lumbar medial branch blocks are usually performed using multiple needles, one for each branch. The authors describe a different technique using a single needle for all levels. Initially, the needle is directed toward the medial branch located at the level of the affected facet joint in the antero-posterior view. After anesthetizing this nerve with local anesthetic, the same needle is withdrawn to the skin with the tip still in the subcutaneous tissue and repositioned to block the medial branch above, and thereafter below, while continuing to use only the antero-posterior view, thereby using only one entry site.When performed correctly, the single needle technique provides accuracy similar to the more conventional multiple needle approach during the performance of diagnostic facet joint nerve blocks. Because only one skin entry point is needed, however, this technique may afford several advantages over the multiple needle approach. These may include less patient discomfort, less time required and less radiation exposure since only one C-arm position is used, a smaller volume of local anesthetic, and possibly a lower incidence of false-positive blocks.

The word "hiccup" refers to an involuntary, spasmodic contraction of the diaphragm that is followed by the abrupt closure of the glottis to produce the characteristic sound. Among the many documented causes of this occurrence are those due to neurogenic dysfunction. In the past few decades, lidocaine has been shown to be effective in treating a variety of disorders thought to involve neuropathic mechanisms, including seizures, chronic pain, and arrhythmias. We describe a postsurgical patient in whom two successive intravenous infusions of lidocaine, 1.5 mg/kg followed the next day by 0.75 mg/kg, terminated his hiccup twice, whereas multiple other treatments failed to alleviate the problem. Various causes of this phenomenon are discussed, as well as a possible mechanism for the successful treatment.

A retrospective clinical data analysis was performed.To determine the effect of needle insertion site on provocative diskography results, and to ascertain whether performing diskography ipsilaterally to a patient's reported pain leads to a higher rate of false-positives.In certain groups of patients, provocative diskography is associated with a significant false-positive rate, which can lead to misdiagnosis and inappropriate treatment. Although purported by some to be a cause of false-positive diskogram results, the effect of needle insertion site on diskography results has yet to be determined.The charts of 127 patients who underwent diskography were evaluated to determine the relationship between the location of pain, needle insertion site, and diskography results.Performing diskography on the side ipsilateral to a patient's pain did not result in a higher incidence of positive diskogram results.False-positive diskography results are unlikely to result from performing the procedure on the same side as a patient's reported pain.

To implement direct digital imaging (DDI) in subtraction radiography and compare the accuracy of conventional and subtracted DD images in detecting small bone lesions in vitro.Alveolar bone defects were produced in a section of a pig mandible, with slow-speed burs 0.6, 0.7, 0.8, 0.9, 1.0, 1.2, 1.4 mm in diameter. Standardized DD images were subtracted and displayed in black and white, contrast-enhanced and pseudo-colour transformed formats. 370 pairs of slides taken directly from the computer monitor were evaluated by eight observers.The area P(A) under the ROC curve with DDI was 0.67 +/- 0.1. This was significantly lower (p < 0.001) than any of the three modes of subtraction radiography (mean P(A) = 0.88 +/- 0.09). The detection of small lesions (bur diameter 0.6 mm) was significantly better (p < 0.001) with contrast enhancement. Observer agreement was smaller for DDI (chi = 0.22 +/- 0.09) compared with the subtraction images (mean chi 0.64 +/- 0.13) (p < 0.001).The diagnostic characteristics of the DDI system were significantly improved by digital subtraction with image processing.

Inventory optimization in the supply chain is one of the most important goals in logistical business operations given the fact that optimized inventories directly impact the efficiency and profitability of the business.In the contemporary conditions of business processes, the goal of an enterprise's business operations reflects in the maximal reduction in the level of inventories, simultaneously retaining a certain level of services provided, in order for them to become and remain competitive in the market.Understanding the significance of inventories enables optimal uninterrupted business doing, for which reason exactly the ABC-XYZ method, as one of the ways to efficiently manage inventories, is used in this paper.Given the fact that there are limitations to the ABC classification, the limitation to one single criterion and the non-existence of a demand analysis at determining the needed inventories, the problem is overcome by the introduction of the XYZ classification.The merging of the mentioned classifications results in the integrated ABC-XYZ classification model, which can be used, on the basis of a multi-criteria and multidimensional approach, to classify inventories and make a proposal for their optimization.

Abstract Myth Corticosteroid injection for the treatment of pain is known to decrease the efficacy of the adenovirus vector-based vaccines for COVID-19. Fact There is currently no direct evidence to suggest that a corticosteroid injection before or after the administration of an adenovirus vector-based COVID-19 vaccine decreases the efficacy of the vaccine. However, based on the known timeline of hypothalamic-pituitary-adrenal axis suppression following epidural and intraarticular corticosteroid injections, and the timeline of the reported peak efficacy of the Janssen and AstraZeneca vaccines, physicians should consider timing an elective corticosteroid injection such that it is administered no less than 2 weeks prior to and no less than 2 weeks following a COVID-19 adenovirus vector-based vaccine dose, whenever possible. We emphasize the importance of risk/benefit analysis and shared decision making in determining the timing of corticosteroid injections for pain indications in relation to receipt of a COVID-19 vaccine given that patient-specific factors will vary.

Medial branch blocks have been widely described in the literature as a diagnostic tool for facet joint pain. Recently, a new "single-needle' technique was described that is purported to be equally accurate, and in some respects, superior to the standard multiple-needle technique. To date, no studies have been performed that compared these 2 techniques.In a multicenter setting, 24 subjects underwent 2 separate diagnostic medial-branch blocks in a randomized, single-blind crossover comparison of the single-needle and multiple-needle techniques. Multiple variables were compared between the 2 techniques, including procedure-related discomfort, post-procedure pain relief, volume of local anesthetic required, accuracy as determined by final needle position and contrast-media spread, and time needed to perform the procedure.In this pilot study, the single-needle technique resulted in less procedure-related pain (P = .0003), required less superficial local anesthesia (P =.0006), and took less time to complete (P < .0001) than did the multiple-needle approach. With regard to final needle position, contrast spread, and post-procedure pain relief (P = .8), no differences were noted between the 2 techniques.Our results indicate that the single-needle technique takes less time to perform and causes less patient discomfort than does the standard technique but provides the same degree of accuracy. More studies with larger sample sizes are needed to corroborate these results and explore the effect the single-needle approach has on the rate of false-positive medial branch blocks.

The neurophysiology of pruritus is incompletely described.[ 1 Wahlgren CF Measurement of itch. Sem Dermatol. 1995; 14: 277-284 Crossref PubMed Google Scholar ]The sensation of itch is defined as an unpleasant sensation associated with the urge to scratch.[ 2 Lorette G Vaillant L Pruritus. Current concepts in pathogenesis and treatment. Drugs. 1990; 39: 218-223 Crossref PubMed Scopus (34) Google Scholar ]The exact mechanism of this condition is not completely understood. However, there is significant overlap between peripheral and central mechanisms associated with pruritus and those involved in the sensation of pain.[ 3 McMahon SB Koltzenburg M Itching for an explanation. Neurology. 1991; 41: 1024-1028 Crossref PubMed Google Scholar ]Activation of free unmyelinated nerve endings of nociceptors is thought to be the mechanism by which itch is produced.[ 4 Yao GL Tohyama M Senba E Histamine-caused itch induces Fos-like immunoreactivity in dorsal horn neurons: effect of morphine pretreatment. Brain Research. 1992; 599: 333-337 Crossref PubMed Scopus (30) Google Scholar ]It is thus not surprising that certain analgesic treatments might also have antipuritic properties.

WE report the occurrence of symptoms of mania related to corticosteroid injection at the celiac plexus for chronic pancreatitis. Corticosteroids are associated with mental status changes, including mania, confusion, depression, hallucinations, and paranoia. 1 The mechanism for these central nervous system (CNS) perturbations is unknown. The literature suggests that mania is second to psychosis as the most common corticosteroid-related mental status change. Although a relation to dose and daily exposure exists, we found no reports of mania related to a single regional steroid injection. 2,3

Prospective clinical data analysis.To determine if heart rate (HR) response correlates with positive discography results.Lumbar discography is a controversial tool for the diagnosis of discogenic low back pain. The subjective nature of discography can make data interpretation difficult, leading to false-positive and false-negative results. HR changes have been found in numerous studies to be a reliable and valid indicator of acute pain. To date, there is no study analyzing the HR response to discography-induced pain.The HR measurements were recorded immediately preceding and after contrast injection into the each disc, and statistically correlated with the provocation of concordant pain, nonconcordant pain, and nonpainful discs.Discography was performed in 26 subjects with low back pain. Among 75 discograms, 26 discs elicited concordant pain, 9 provoked nonconcordant pain, and 40 elicited no pain response. There was no significant change in HR during disc stimulation for negative [no pain response (P=0.19) and nonconcordant (P=0.26)] discograms, whereas positive discograms [concordant pain (numerical rating scale> or =6/10)] were associated with a statistically significant increase in HR (P=0.000002).Lumbar discography induces positive HR response only in positive discograms. Although there is no immediate practical application of these results, 2 implications may deserve future research: (a) correlation of HR response with surgical and intradiscal electrotherapy treatment outcomes; (b) evaluation of HR measurement in cases of false-positive results (concordant pain on discography but no HR response).

Recent LHC results on the appearance of sub-leading flow modes in PbPb collisions at 2.76~TeV, related to initial-state fluctuations, are analyzed and interpreted within the HYDJET++ model. Using the newly introduced Principal Component Analysis (PCA) method applied to two-particle azimuthal correlations extracted from the model calculations, the leading and the sub-leading flow modes are studied as a function of the transverse momentum ($p_{T}$) over a wide centrality range. The leading modes of the elliptic ($v^{(1)}_{2}$) and triangular ($v^{(1)}_{3}$) flow calculated within the HYDJET++ model reproduce rather well the $v_{2}\{2\}$ and $v_{3}\{2\}$ coefficients experimentally measured using the two-particle correlations. Within the $p_{T} \le $~3~GeV/c range where hydrodynamics dominates, the sub-leading flow effects are greatest at the highest $p_{T}$ of around 3~GeV/c. The sub-leading elliptic flow mode ($v^{(2)}_{2}$), which corresponds to $n = 2$ harmonic, has a small non-zero value and slowly increases from central to peripheral collisions, while the sub-leading triangular flow mode ($v^{(2)}_{3}$), which corresponds to $n = 3$ harmonic, is even smaller and does not depend on centrality. For $n = $~2, the relative magnitude of the effect measured with respect to the leading flow mode shows a shallow minimum for semi-central collisions and increases for very central and for peripheral collisions. For $n = $~3 case, there is no centrality dependence. The sub-leading flow mode results obtained from the HYDJET++ model are in a rather good agreement with the experimental measurements of the CMS Collaboration.

Physicians in conventional clinical practice are likely to regard outcome assessment instruments as something of interest only to academics undertaking research studies. Outcome data are typically collected only in the context of research studies, and research grants are required to pay for staff who collect those data. However, in a field with few proven treatments, outcome assessment should not be restricted to funded research studies but should be a matter of personal and professional concern for all clinicians. Formal evidence is lacking about why outcome instruments are not routinely used in conventional practice, but two prominent reasons seem likely. Firstly, physicians may feel that impressions gained in the course of normal practice are sufficient to indicate that they are achieving good outcomes. However, such impressions are likely to be false. Recall bias means that physicians tend to remember only their better outcomes and forget their bad outcomes. Reporting bias means that patients tend to exaggerate their outcomes in order to please, or not offend, their treating doctor. Using validated outcome instruments reduces bias, especially if they are administered by a third party, such as a nurse. Valid outcome instruments provide a permanent record of objective data; and if they are routinely administered, no patient escapes notice. Thereby, a truer picture of outcomes is obtained. The second reason is that instruments take time to administer, and of the plethora of instruments available, there is no consensus as to which should be used. In recent years, leading authorities in pain research have published a sequence of manuscripts that address what outcome data are desirable for studies of pain treatment and what instruments are suitable for collecting those data (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials [IMMPACT] studies) [1]. These studies, however, seem directed to fellow academic researchers. The …

Interventional pain procedures for management of low back pain (LBP) have significantly evolved over the last decade. A major reason for recent advancements could be attributed to the widespread use of image-guided techniques utilizing fluoroscopy and contrast media. This change improved the delivery of medications to the areas of pathology and potentially contributed to better outcomes and decreased complication rates.

Correlations between azimuthal anisotropy Fourier harmonics ${v}_{n}$ ($n=2,3,4$) are studied using the events from PbPb collisions at $\sqrt{{s}_{{}_{\mathrm{NN}}}}=2.76$ TeV generated by the $\text{HYDJET}++$ and multiphase transport (AMPT) models, and compared to the corresponding experimental results obtained by the ATLAS Collaboration. The Fourier harmonics ${v}_{n}$ are measured over a wide centrality range using the two-particle azimuthal correlation method. The slopes of the ${v}_{2}\text{\ensuremath{-}}{v}_{3}$ correlation from both models are in a good agreement with the ATLAS data. The $\text{HYDJET}++$ model predicts a stronger slope for the ${v}_{2}\text{\ensuremath{-}}{v}_{4}$ and ${v}_{3}\text{\ensuremath{-}}{v}_{4}$ correlations than the ones experimentally measured, while the results from the AMPT model are in a rather good agreement with the experimental results. In contrast to the $\text{HYDJET}++$ predictions, the AMPT model predicts a boomeranglike shape in the structure of the correlations as found in the experimental data.

Savremeni uslovi poslovanja proklamovali su informaciono-komunikacione tehnologije (IKT) kao ključne nosioce razvojnih procesa kako u razvijenim zemljama, tako i u zemljama u razvoju. Rapidan porast IKT u prethodnom periodu uticao je na promene u poslovnim odnosima. Privreda je uspostavila nove oblike poslovanja i komuniciranja, dok je upotreba interneta postala neophodnost u svakodnevnom životu stanovništva. Razvoj IKT doprineo je poboljšanju efikasnosti na globalnom nivou. Osim toga, obezbeđen je preduslov za porast inovativnosti i produktivnosti. Tehnološki napredak promenio je život pojedinca, uvodeći ih u informaciono društvo. Na ovaj način ostvaren je ključni preduslov ostvarenja ekonomskog i društvenog razvoja.

Recently, Friedly et al. published a study on the effectiveness of epidural injections of steroids (ESIs) for lumbar spinal stenosis (LSS) [1]. Because of its apparent implications for clinical practice, this study attracted comments both in the professional [2] and lay press [3]. However, the study prompts reflection on a number of issues that extend beyond the conventional appraisal of a study. Those issues pertain to how physicians think about a condition, how it should be treated, and how to best assess the effectiveness of that treatment. The following article addresses those issues in the interest of informing physicians about how contemporary practices are confounded by lack of diagnostic discipline, and how this makes the conduct of controlled trials complicated and, therefore, makes the results difficult to assess. The cardinal issues are the symptoms of LSS; the diagnosis of LSS; the rationale for treatment; the consequent appropriate selection of patients; the outcomes assessment, either in practice or in a study including the reporting of those outcomes; and the need for rigorous control of the technical performance of the therapeutic intervention. Each of these issues has a critical bearing on appraising not only the literature on LSS, but also on how physicians treat this condition in conventional practice. The literature is profuse with heterogeneity in symptomology related to LSS. While there is no consensus in the current literature on acceptable LSS symptoms, the most commonly quoted symptoms are neurogenic claudication, radicular pain, and low back pain (LBP). Additional symptoms commonly mentioned in literature were fatigue and loss of power in the legs, anesthesia, and a feeling of numbness in the sacral dermatomes. In an attempt to achieve consensus, Katz et al. in 1995 published symptoms most strongly associated with the diagnosis of LSS (likelihood ratio ≥ 2), …

To the Editor: Although the Bier block has been used as a treatment for sympathetically-maintained pain (SMP) for many years, the selection of agents remains controversial. Different drug classes have been used, including alpha-adrenergic blockers (guanethidine, reserpine, bretylium), alpha-2 agonists (clonidine), nonsteroidal anti-inflammatory agents (ketorolac, tenoxicam), local anesthetics (lidocaine, prilocaine), and NMDA antagonists (ketamine). To our knowledge the use of labetalol for Bier block has not been reported. We here report a case of complex regional pain syndrome (CRPS) that did not respond to a standard Bier block with bretylium and lidocaine, but responded for 7 years to multiple Bier blocks with labetalol and lidocaine. A 42-year-old man sustained a right fifth metatarsal fracture after a heavy block fell upon his right foot in June 1993. His injury was complicated by osteomyelitis. Following healing, he continued to have persistent sharp, burning pain on the lateral side and dorsum of the right foot. The pain was constantly present, varying in intensity between 7 (0–10 scale) at its worst and 3–4 at its best. The clinical findings were consistent with a CRPS. Before presentation to our service, treatments included seven lumbar sympathetic blocks, each with poor or no pain relief; epidural infusions with bupivacaine and fentanyl, with moderate temporary pain relief; and physical therapy. He had a negative phentolamine infusion test. Multiple oral medication trials, which included opioids (levorphanol, morphine, oxycodone), tramadol and sodium channel blockers (IV lidocaine), failed to relieve his pain. At presentation, his medications included amitriptyline 100 mg daily, clonidine 0.2 mg po three times daily, clonazepam 0.5 mg po three times daily, gabapentin 900 mg po three times daily, and dextromethorphan 90 mg po three times daily. He had no pending litigation, drank alcohol socially, and smoked for 20 years. On physical examination his right foot was mottled, mildly swollen, colder than the left, and had excessive sweating and dystrophic changes of the skin. Significant cold allodynia and pinprick-induced hyperalgesia were present on the lateral and dorsal surfaces. Strength was normal, with mild limitation in range of motion secondary to pain. He walked with crutches and was unable to bear weight on the foot, except for the duration of pain relief gained with Bier block. In contrast to a Bier block with bretylium 120 mg and lidocaine, which did not bring him pain relief except for the short duration of local anesthetic, Bier blocks with the combination of labetalol (20–40 mg) and lidocaine (100–200 mg) gave him complete pain relief for 7 to 10 days. During the past seven years, he has received this block 158 times. Initially, the blocks were performed once each month; during the last 5 years, he has undergone this procedure every two to three weeks. Medical and vascular evaluations have identified no contraindications to these serial Bier blocks. Other treatments, including a spinal cord stimulation trial, have been proposed, but the patient refused because he was satisfied with the current treatment. In order to determine whether the effect of Bier block was mediated through A beta fiber conduction block,1Torebjork H.E. Hallin R.G. Perceptual changes accompanying controlled preferential blocking of A and C fiber responses in intact human skin nerves.Exp Brain Res. 1973; 16: 321-332Crossref PubMed Scopus (235) Google Scholar the patient consented to an ischemic tourniquet block of the right foot, with no medication administered; this caused an exacerbation of pain and allodynia. In addition he underwent a Bier block with normal saline and lidocaine (without labetalol) in a blind manner to test the effects of lidocaine alone and a possible placebo effect. This procedure provided him with only minimal pain relief for a few hours, as compared to more than 7 days for the combination of lidocaine and labetalol. Sympathetically-maintained pain (SMP) may or may not be present in patients with CRPS. The treatment of SMP with a Bier block using guanethidine has been used clinically for many years. Guanethidine's site of action is on noradrenergic ganglionic synapses. Guanethidine is transported across the sympathetic nerve membrane by the same mechanism that transports norepinephrine itself. After uptake, guanethidine replaces norepinephrine, causing a gradual depletion of norepinephrine stores in nerve endings. It has been suspected that repeated Bier blocks with guanethidine might cause permanent damage to the noradernaline reuptake system, as guanethidine accumulates in nerves for a prolonged time.2Hanington-Kiff J.B. Sympathetic nerve blocks in painful limb disorder.in: Wall P.D. Melzack R. Textbook of pain. Churchill Livingstone;, London1994: 1035-1052Google Scholar The clinical effect of guanethidine in cases of SMP has been reported to last days to weeks,2Hanington-Kiff J.B. Sympathetic nerve blocks in painful limb disorder.in: Wall P.D. Melzack R. Textbook of pain. Churchill Livingstone;, London1994: 1035-1052Google Scholar but others failed to observe a long-term pain relief.3Blanchard J. Ramamurthy S. Walsh N. et al.Intravenous regional sympatholysis a double-blind comparison of guanethidine, reserpine, and normal saline.J Pain Symptom Manage. 1990; 5: 357-361Abstract Full Text PDF PubMed Scopus (107) Google Scholar, 4Ramamurthy S. Hoffman J. Guanethidine Study Group. Intravenous regional guanethidine in the treatment of reflex sympathetic dystrophy/causalgia a randomized, double blind study.Anesth Analg. 1995; 81: 718-723Crossref PubMed Google Scholar, 5Kaplan R. Claudio M. Kepes E. Gu X.F. Intravenous guanethidine in patients with reflex sympathetic dystrophy.Acta Anaesthesiol Scand. 1996; 40: 1216-1222Crossref PubMed Scopus (28) Google Scholar Reserpine has also been used for Bier block in cases of SMP. This is a false precursor for dopamine and norepinephrine in the nervous system. Injectable guanethidine and reserpine are not clinically available in the USA and bretylium has been used instead.6Ford S.R. Forrest W.H. Eltherington L. The treatment of reflex sympathetic dystrophy with intravenous regional bretylium.Anesthesiology. 1988; 68: 137-140Crossref PubMed Scopus (29) Google Scholar, 7Hord A.H. Rooks M.D. Stephens B.O. et al.Intravenous regional bretylium and lidocaine for treatment of reflex sympathetic dystrophy a randomized, double-blind study.Anesth Analg. 1992; 74: 818-821Crossref PubMed Google Scholar Initially, bretylium releases norepinephrine from sympathetic ganglia and terminal endings of postganglionic adrenergic neurons. Subsequently, the drug inhibits the release of norepinephrine from adrenergic nerve endings and blocks its reuptake. Bretylium was found effective in the treatment of CRPS.6Ford S.R. Forrest W.H. Eltherington L. The treatment of reflex sympathetic dystrophy with intravenous regional bretylium.Anesthesiology. 1988; 68: 137-140Crossref PubMed Scopus (29) Google Scholar, 7Hord A.H. Rooks M.D. Stephens B.O. et al.Intravenous regional bretylium and lidocaine for treatment of reflex sympathetic dystrophy a randomized, double-blind study.Anesth Analg. 1992; 74: 818-821Crossref PubMed Google Scholar For our patient, the standard bretylium combined with lidocaine did not provide significant pain relief. Ischemic tourniquet block caused an exacerbation of pain, and, therefore, it is unlikely that the pain relief during his numerous Bier blocks was caused by A beta conduction block. Administration of normal saline and local anesthetic alone did not provide long-lasting pain relief. Phentolamine infusion and lumbar sympathetic blocks were ineffective. There are very few reports about the use of drugs with nonselective beta-blocker properties (propranolol) or with combined alpha and beta-blocker potency (labetalol) for CRPS pain. Several patients with causalgia were successfully treated with propranolol.8Simson G. Propranolol for causalgia and Sudeck's atrophy.JAMA. 1974; 227: 327Crossref PubMed Scopus (18) Google Scholar, 9Magee C.P. Grosz H.J. Propranolol for causalgia.JAMA. 1974; 228: 826-827Crossref PubMed Scopus (3) Google Scholar Successful use of IV and PO labetalol for pain was reported in one patient with algodystrophy, a term synonymous with CRPS.10Churcher M.D. Algodystrophy after aortic bifurcation surgery.Lancet. 1984; 2: 131-133Abstract PubMed Scopus (17) Google Scholar Labetalol was also given into the epidural space for treatment of pain in gynecologic cancers.11Margaria E. Gagliardi M. Palieri L. et al.Analgesic effect of peridural labetolol in the treatment of cancer pain.Int J Clin Pharmacol Ther Toxicol. 1983; 21: 47-50PubMed Google Scholar The efficacy of epidural labetalol in pain control was attributed to membrane stabilizing activity (also known as quinidine-like effect or local anesthetic activity), and to beta-blocking effect.11Margaria E. Gagliardi M. Palieri L. et al.Analgesic effect of peridural labetolol in the treatment of cancer pain.Int J Clin Pharmacol Ther Toxicol. 1983; 21: 47-50PubMed Google Scholar However the use of labetalol in the Bier block was never reported. Labetalol is a competitive antagonist of alpha-1 receptors as well as beta-1 and beta-2 receptors. Labetalol's affinity for alpha-receptors is 10 times less than that of phentolamine, but labetalol is alpha-1 selective. Its beta blocking potency is 3 times lower than that of propranolol. The ratio of beta- to alpha-adrenergic blocking potency of labetalol is 3:1 with oral administration and 7:1 with parenteral administration. It is not clear by which mode of action labetalol provided pain relief in our patient. Beta-1 receptors are located in presynaptic adrenergic nerve terminals, whereas beta-2 and alpha-1 receptors are not present in peripheral nerves. Alpha-1 receptors are present on postsynaptic effector cells, especially smooth muscle, and under the pathological condition of SMP, they can be expressed on the peripheral nociceptors. Therefore, a possible explanation of labetalol's efficacy in this patient could be related to the fact that labetalol's beta-1 presynaptic effect inhibits the reuptake of norepinephrine into adrenergic nerve terminals. The inhibition of norepinephrine uptake by labetalol suggests a mechanism somehow similar to that of guanethidine and bretylium, and may account for labetalol's longer lasting analgesic properties. Nevertheless the alpha-1 blocking effect may also provide pain relief by blocking the ongoing activity in peripheral sensitized nociceptors. Another possible explanation might be the local anesthetic activity of labetalol, also known as “membrane stabilizing” effect. This action is the result of sodium channel blockade. The local anesthetic blockade is usually not evident after systemic administration because the plasma concentration is too low. During the Bier block, the concentration of labetalol in the treated extremity is significantly higher, making it possible for labetalol to be clinically effective as sodium channel blocker without eliciting systemic side effects. However, this action alone is unlikely to account for long-lasting pain relief. In summary, this case illustrates the successful and unusual use of labetalol with Bier blocks for CRPS refractory to conventional treatment. The case supports the safety of repeated treatment with Bier blocks in patients with CRPS and also demonstrates a lack of tolerance to this treatment modality. The authors would like to thank the MGH Pain Center, Department of Anesthesia and Critical Care Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.

This chapter aims to portray why and how WBAA, as an organism, organization, entity, agent, actor, network, … produces emergent effects as a regional entity is a Positive Deviance, as recognized in theory, and more specifically within the Problem Driven Iterative Adaptation by Harvard’s Center for International Development. Positive Deviance is one of the core principles in the PDIA strategy—by “creating (and protecting) environments within and across organizations that encourage experimentation and positive deviance.” First we will briefly elaborate on PDIA and its concepts and describe and encode the distinctiveness of WBAA arguing why and how it is a positive deviance for our Balkans. The expected outcome: to inspire leaders, institutions, CSOs, citizens, academia, … to take the regional approach, moves beyond the silos of a country/domain, has functional bridges with developed countries (for knowhow, funding, coopetition, alignment), and shows “how” coopetition within Western Balkans is to be done. If volunteers can do it, others can surely follow.

Heavy quarks are primarily produced via initial hard scatterings, and thus carry information about the early stages of the Quark-Gluon Plasma (QGP). Measurements of the azimuthal anisotropy of the final-state heavy flavor hadrons provide information about the initial collision geometry, its fluctuation, and more importantly, the mass dependence of energy loss in QGP. Due to the larger bottom quark mass as compared to the charm quark mass, separate measurements of charm and bottom hadron azimuthal anisotropy can shed new light on understanding the dependence of the heavy quark and medium interaction. Because of the high branching ratio and large D 0 mass, measurements of D 0 meson coming from bottom hadron decay (nonprompt D 0 ) can cover a broad kinematic range and be a good proxy of the parent bottom hadrons results. In this talk, we report on the prompt D 0 and the first nonprompt D 0 measurements of the azimuthal anisotropy elliptic ( v 2 ) and triangular ( v 3 ) coefficients of nonprompt D 0 in PbPb collisions at √S NN = 5.02 TeV. The measurements are performed as functions of transverse momentum p T , in three centrality classes, from central to midcentral collisions. Compared to the prompt D 0 results, the nonprompt D 0 v 2 flow coefficients are systematically lower but have a similar dependence on p T and centrality. A non-zero v 3 coefficient of the nonprompt D 0 is observed. The obtained results are compared with theoretical predictions. The comparison could provide new constraints on the theoretical description of the interaction between heavy quarks and the medium.

In this work, we report the presence of rapid intra-night optical variations in both -- flux and polarization of the blazar BL Lacertae during its unprecedented 2020--2021 high state of brightness. The object showed significant flux variability and some color changes, but no firmly detectable time delays between the optical bands. The linear polarization was also highly variable in both -- polarization degree and angle (EVPA). The object was observed from several observatories throughout the world, covering in a total of almost 300 hours during 66 nights. Based on our results, we suggest, that the changing Doppler factor of an ensemble of independent emitting regions, travelling along a curved jet that at some point happens to be closely aligned with the line of sight can successfully reproduce our observations during this outburst. This is one of the most extensive variability studies of the optical polarization of a blazar on intra-night timescales.

This video reviews the indications for medial branch blocks and radiofrequency ablation for chronic low back pain from facet joints.

The Spine Intervention Society commends Cuellar et al. on their well-designed study, in which the authors have identified a trend toward harm from discography [ [1] Cuellar J.M. Stauff M.P. Herzog R.J. Carrino J.A. Baker G.A. Carragee E.J. Does provocative discography cause clinically important injury to the lumbar intervertebral disc? A 10-year matched cohort study. Spine J. 2016; 16: 273-280 Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar ]. Patients who had undergone previous discography had a 19% (95% CI 9%–29%) chance of needing surgery, whereas control subjects had a 6% (95% CI 0%–12%) chance. Although these results represent a trend, the confidence intervals overlap. With a number needed to harm of 8 (described as 7.3 by Cuellar et al.), an additional 8,750 yearly spine surgeries would be performed because of discography, but we, as a group of international academic and private practice spinal interventionalists, are not seeing this flood of postdiscography patients with new back pain.

The consensus questions are a testament to the importance of diagnosing and treating cervical facet pain.[1][1] Denervating a painful structure will structurally eliminate or significantly reduce index pain, but only if the innervated structure is a pain source and only if one does a proper job

Study Design. A bi-institutional, retrospective clinical data analysis. Objectives. To determine risk factors for failure and complications of intradiscal electrothermal therapy, a treatment for discogenic back pain. Summary of the Background Data. Intradiscal electrothermal therapy is a relatively new treatment for discogenic back pain. Though previous studies have shown it to be an effective treatment, there are few published studies examining complications and none examining risk factors for failure. Methods. The authors treated 79 patients with discogenic back pain using intradiscal electrothermal therapy. Complications were assessed by patient report and, when indicated, further diagnostic testing. Success or failure was determined by visual analogue pain scores at 6-month follow-up. Variables examined for their relationship to failure and complications were age, sex, duration of pain, number of levels heated, smoking history, diabetes, obesity, leg pain, and previous back surgery. Results. Forty-eight percent of patients reported more than 50% pain relief at their 6-month follow-up. There were eight complications (10%), most of which were self-limited and transient. The only risk factor associated with intradiscal electrothermal therapy failure was obesity (P = 0.01). Whereas 54% of nonobese patients reported good pain relief at 6 months, only one out of 10 obese patients had successful intradiscal electrothermal therapy. The obese patients in our study were more likely to have a complication from intradiscal electrothermal therapy than they were to obtain pain relief. Conclusion. The only risk factor found to be associated with IDET outcome was obesity, which was a strong predictor of failure. Obesity should be considered a relative contraindication to performing IDET.

The logic behind diagnostic blocks is very straightforward. What has not been determined is the way diagnostic blocks can be best used.Philosophical essay.The interventional pain management physician would serve as the diagnostic expert by efficiently determining the source of the patient's pain."The Best Likelihood Scenario" might improve diagnostic accuracy while decreasing societal costs.

Digitalizacija je postala sastavni deo života

The delay-dependent stability problem is investigated for discrete-time neural networks with time-varying delays. A new augmented Lyapunov-Krasovskii functional (LKF) with single and double summation terms and several augmented vectors is proposed by decomposing the time-delay interval into two nonequidistant subintervals to derive less conservative stability conditions. Then, by using Wirtinger-based inequality, reciprocally, and extended reciprocally convex combination lemmas, tight estimations for sum terms in the forward difference of the LKF are given. Several zero equalities are introduced to further relax the existing results. Less conservative stability criteria are proposed in terms of linear matrix inequalities (LMIs). Finally, numerical examples are proposed to show the effectiveness and less conservativeness of the proposed method.

Liposarcoma of a bone is a very rare tumour of the fatty marrow, originating from lipoblasts. Its frequency is 1:1000 of all bone tumours. The long bones and the lower extremities are predominantly affected, equally in males and females between 30 and 70 years of age. In the estimation of its biological behaviour, histological graduation (G), the surgical localization of the tumour (T) and the presence or absence of metastases (M), are very important. A tumour with low grade differentiation, with transosseal propagation and metastases, has a poor prognosis. Surgical resection-amputation, chemotherapy and radiotherapy are the therapeutic methods of choice.Twelve years ago, in a 58-year old man, there was a radiologically diagnosed sarcoma in the lower part of the right femur manifested with painful swelling in that region. The high suprapatellar amputation was done. There was a histologically proved liposarcoma of a high grade of malignancy. According to the therapeutic protocol, chemotherapy and radiotherapy were applied. During the period of 12 years, the patient had a relapse on the stump, metastatic dissemination in the soft tissue of small pelvis twice, once in the left scapular region and in the inguinal lymph nodes, six operations and 8-year accumulation of metastatic deposits in the lung. Now, the patient feels relatively well, mobile, and walks 5 kilometres every day.Unusual behaviour of the liposarcoma of high grade malignancy with which the patient has been living for 12 years, could be explained by the patient's strong immunobiological system in the struggle to retain its vitality and mobility.

McCormick, Zachary L. MD*; Schneider, Byron J. MD†; Smith, Clark C. MD, MPH‡; Duszynski, Belinda S. BS§; Stojanovic, Milan P. MD∥ Author Information

Abstract Field stimulation is a promising new modality being introduced as an option for difficult to treat neuropathic pain. Field stimulation typically refers to stimulation of unnamed nerves, as compared to peripheral nerve stimulation, which is stimulation of specific nerves. Field stimulation can be used in combination with epidural stimulation and is known as a hybrid stimulation. Hybrid stimulation can improve flexibility of stimulation by allowing greater ranges in amplitude independent from one another. This chapter discusses the indications, patient selection, technique, and complications related to field stimulation. Four short case reports discuss the application of field stimulation in a pain practice.

As the RR Lyrae stars evolve on the Hertzsprung-Russell diagram they are believed to become short period Type II Cepheids, known as BL Her type (with a pulsation period from $1$ to $3-8$ days). Assuming that their mass is around $0.5 - 0.6 {\rm M}_{\odot}$, and that they are low metallicity objects, they were thought to belong to the halo of the Milky Way. We investigated seven Galactic short period Type II Cepheids (BL Her, SW Tau, V553 Cen, DQ And, BD Cas, V383 Cyg, and KT Com) in order to establish their membership within the Galactic structure using the kinematic approach. $Gaia$ should provide us with more data needed to conduct the study of the whole sample.

The purpose of this essay is a discussion on relationship between virtue and (personal) happiness in Kant?s practical philosophy, regarding his concept of the greatest good, and postulate of God as an attempt of conciliation of their contradiction. And, against the Vukovic?s claim that Kant in his transcendental philosophy conveyed attributes of God to man, it would be highlighted Kant?s need of postulating God and returning again in the game; against contrary A. Kozev, the concept of Transcendent, being-in-itself, will again be interpreted as the result of Kant?s transcendental position, not as its religious relict. The purpose of all of this is to show that when we put the question of personal faith in the field of transcendental ethics, which is for Kant equivalently to postulate of God (the greatest good), it comes to sort of break through of existentialism into Kant?s transcendental philosophy.

Poster: ECR 2013 / C-1905 / Gallbladder perforation - radiological aspects, types and causes, ultrasound and CT findings by: V. Urban 1, M. Djosev2, T. Nastasic1, B. Begenisic3, N. Terzic3, S. M. Arsenovic1, G. Lukic1, D. Lalosevic1, M. Stojanovic1; 1Belgrade/RS, 2Belgrad/RS, 3Beograd/RS

Od uvođenja rashladnih sredstava HCFC baziranih na R22 traže se rešenja koja će biti trajnijeg karaktera. Prva zamena za HCFC – R22 bazirana na HFC R404A u Evropi je prevaziđena uvođenjem propisa EN 517/2014 (sa važnošću od 1.1.2015) kao naslednika prethodne direktive EN 862/2006. Servisna zabrana rada sa R404A i R507A od 2020. godine u Evropi će otežati serviserima potragu za budućim zamenama i obeležavanjima za šta se treba spremati već danas. Alternative koje su danas predložene za R404A (GWP 3922) jesu: R407A (2107), R407C (1774), R407F(1825), R410A (2088), R442A (1888), R449A (1397), HFO – R452A (2140) i radi poređenja R32 (675). U radu će biti odabrane najperspektivnije alternative i navedene uporedne termodinamičke karakteristike na koje inženjeri koji projektuju sisteme i serviseri u eksploataciji treba da obrate pažnju.

Savremeni uslovi poslovanja

Funkcija nabavke predstavlja

Mössbauer spectra of human liver ferritin and its pharmaceutical analogues Ferrum Lek and Maltofer® measured at various temperatures within the range of 295–83 K were fitted using five quadrupole doublets related to different 57Fe microenvironments in various layers/regions of the ferrihydrite and akaganéite iron cores. The observed anomalous temperature dependences of some Mössbauer parameters were considered as a result of low temperature structural rearrangements in different layers/regions in the iron core.

Introduction Malignant cystic renal tumor is a rare variant of renal malignancy. Cystic neoplasm results from haemorrhage, necrosis and colliquation of a solid tumour or tumour occurring within the wall of a cyst. That pathoanatomic substratum reflects characteristic sonographic features indicating its malignant nature. It is important to distinguish a simple cyst (not requiring surgery) from intracystic malignant lesion because it requires surgery. Case Outline The authors present a 59-year-old woman with a sonographic finding of a simple cyst in the upper pole of the right kidney revealed during gynaecological ultrasonography. Immediately afterwards, the radiologist performed renal sonography and its finding was a cystic lesion suggestive of malignancy. Further evaluation by CT scan showed that the lesion was clearly malignant. After surgery, the histological finding verified cystic renal cancer. Conclusion Ultrasonography may reveal a complex cyst and solid mass but requires an experienced sonographer. Contrast CT scan would be performed to examine the "suspicious" lesion because it clearly shows if a cystic lesion is benign or malignant. .

In Phoniatric Dpt. everyday practice we try to keep specific multidisciplinary approach to the communication disorders, that includes an expert team using modern technology. Over the last six years we have treated 110 singers (3% of all new cases) and the results of their diagnostic and therapeutic management are presented here. There were 67 women and 43 men, 41 were smokers and 69 nonsmokers. The singing genres included 24 pop, 41 folk, 8 ethnic, 29 choral and 8 opera singers. The therapy success was compared with the demographic parameters, level of education and music genres across the subjects. A precise history, clinical examination, endovideolaryngostroboscopy and multidimensional computer analysis of voice and speech was carried out by two phoniatricians, two logopeds, two nurses and one clinical psychologist. Additional consultations were carried out by audiologists, allergists, endocrinologists, chest physicians, gastroenterologists and neurologists where necessary. We suggest that the gold standard is conservative therapy, with phonosurgery if conservative measures fail. We also suggest that an annual systematic examination is optimal in preventing disease in professional singers.

Background and aims: Subcortical white matter (WM) plays an important role in speech production and language processing. Most frequently, cerebral WM lesions are secondary to small vessel disease in patients with vascular risk factors.

Brazil is currently the largest ethanol-biofuel producer worldwide. Ethanol is produced by fermenting the sucrose part of the sugarcane that contains only one third of the sugarcane energy. The rest of the plant is burned to produce energy to run the process and to generate electricity that is sold to the public grid, making the process a net energy producer. This paper evaluates current technology from an energy efficiency point of view and quantifies additional benefits from extra energy generated in during sugarcane processing.

While chronic thoracic pain is less common in comparison to low back pain, it is estimated that 34-42% of patients with upper or mid-back pain have symptoms originating from the thoracic facet joints. Patients who experience short-term pain relief from medial branch blocks may benefit long-term from radiofrequency ablation with subsequent pain reduction and improvement in function. With the patient in the prone position, the vertebral levels are identified under C-arm fluoroscopic guidance. Most complications from thoracic interventions stem from improper placement of the needle, or improper injection of local anesthetic. Less damaging complications include generalized trauma to the surrounding area with hematoma formation. Consistent use of contrast under live fluoroscopic guidance for intra-articular injections to confirm placement is recommended. All procedures should be performed where all measures can be taken to prevent potentially life-threatening complications.

Chronic pain in the cervical region that radiates to the shoulders and upper extremities is a common clinical problem. Van Zundert and colleagues’ article reports a randomized, double-blind trial of pulsed radiofrequency in chronic radicular neck pain patients (23 screened from 256) resulting in a statistically significant short-term efficacy measured as better global perceived effect and a 20-point reduction in a visual Analogue Scale. The trial reports no complications and displays significant reduction in analgesic use 6 months post procedure. This is the third published study highlighting the innovative application of radiofrequency (first to use pulsed radiofrequency) to treat this difficult pain syndrome.

New measurements of anisotropic flow in XeXe collisions at a center-of-mass energy of 5.44 TeV per nucleon pair, collected by the CMS experiment at the LHC, are presented. The ν2, ν3 and ν4 Fourier coefficients of the anisotropic azimuthal distribution are obtained employing three different analysis techniques: two-particle correlations, the scalar product method, and multiparticle cumulants, which have different sensitivities to non-flow and flow fluctuation effects. The results are shown as a function of transverse momentum (pT) for various centrality selections, and compared with corresponding results from PbPb collisions. These new measurements in a smaller nucleus-nucleus system than PbPb provide additional insights into the system-size dependence of the collective flow induced by the dominant collision geometry and its fluctuations. In particular, these results, compared to theoretical predictions and Monte Carlo generators, will provide important details on the system size dependence of the medium response in heavy ion collisions. They also offer a unique opportunity to study the onset of flow from small to large systems.

The LHC results on the sub-leading flow modes in PbPb collisions at 2.76 TeV, related to initial-state fluctuations, are analyzed and interpreted within the HYDJET++ model. Using the newly introduced Principal Component Analysis (PCA) method applied to two-particle azimuthal correlations extracted from the model calculations, the leading and the sub-leading flow modes are studied as a function of the transverse momentum (pT ) over a wide centrality range. The leading modes of the elliptic (v (1) 2 ) and triangular (v 3 (1) 3) flow calculated within the HYDJET++ model reproduce rather well the v 2 {2} and v 3 {2} coeffcients experimentally measured using the two-particle correlations. Within the pT ≤3 GeV/c range where hydrodynamics dominates, the sub-leading flow effects are greatest at the highest pT of around 3 GeV/c. The sub-leading elliptic flow mode (v 2 (2) ), which corresponds to n=2 harmonic, has a small non-zero value and slowly increases from central to peripheral collisions, while the sub-leading triangular flow mode (v 3 (2) ), which corresponds to n =3 harmonic, is even smaller and does not depend on centrality. For n =2, the relative magnitude of the effect measured with respect to the leading flow mode shows a shallow minimum for semi-central collisions and increases for very central and for peripheral collisions. For n =3 case, there is no centrality dependence. The subleading flow mode results obtained from the HYDJET++ model are in a rather good agreement with the experimental measurements of the CMS Collaboration.

Modern hotel organizations invest significant funds to increase quality of service.It is necessary to provide as much comfort as possible to both hotel guests and employees, which includes access to various multimedia services (Internet, VoD, IPTV service, etc.).Unified communications in hotel environment offer a quality solution to the problem of communication across hotel and contribute to the improvement of hotel services, as well as creating a good image.Unified Communications is a collection of applications and devices of the latest generation that allow users to dimension, control and manage calls, messages, data, and software tools from any location, using any device or software interface.Thanks to the diversity in the domain of information exchange, Unified Communications are applicable in almost all types of business environments.The realized technical solution contains the Unify system of the OpenScape Business series as one of the most modern forms of TDM/IP hybrid solutions.The system offers a simple installation, maintenance and upgrade with minimal energy consumption compared to other systems.The problem of transferring multimedia real time signals through the IP network is solved by QoS mechanisms.The project envisages Firewall protection of the internal network on the Juniper Router page, which has all the necessary facilities to connect the hotel to the Internet.The technical solution also envisages the installation of SIP GSM gateway type 2N at a central location, with the possibility of up to 4 SIM cards, for calls to employees on mobile networks, which is considered an optimal solution for the needs of hotels with up to 50 employees.Hotel environment is specific for several reasons.The network structure is, in most cases, subdivided into sub-networks for guests and employees.The functionality of the devices differs, and in each service it is enough to provide only a certain set of functions in order to provide guests with a fast and efficient service.The subnet for the guests is made up of the terminal devices brought by the guests and the terminal equipment owned by hotel.The terminal devices communicate over the Wi-Fi access point in the 2.4 or 5GHz band according to the IEEE 802.11b/g/n and 802.11ac standard with a dual-mode operation.IPTV platform provides highquality IPTV service, but also delivers various additional information that the hotel wants to offer to its guests.The displays enable integration with smartphones and with the rest of the Hotel Systems.The technical solution also includes the installation of Headend having required capacity for receiving a television signal, as well as the installation of wireless telephony servers via DECT technology.Unified communications system in hotel environment has a low maintenance cost, and provides customization to individual customer needs, portable services on every device, and the inclusion of new services that generates additional revenue.The implemented Unified Communications

Documentation of meetings and conferences is performed at most companies by one or more people sitting at a computer and typing what has been said during the meeting. This may lead to typing mistak ...