Pain physician
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Comparative Study Clinical Trial
Comparative evaluation of the accuracy of benzodiazepine testing in chronic pain patients utilizing immunoassay with liquid chromatography tandem mass spectrometry (LC/MS/MS) of urine drug testing.
Eradicating or appreciably limiting controlled prescription drug abuse, such as opioids and benzodiazepines, continues to be a challenge for clinicians, while providing needed, proper treatment. Detection of misuse and abuse is facilitated with urine drug testing (UDT). However, there are those who dispute UDT's diagnostic accuracy when done in the office (immunoassay) and claim that laboratory confirmation using liquid chromatography tandem mass spectrometry (LC/MS/MS) is required in each and every examination. ⋯ Clinicians should feel comfortable conducting in-office UDT immunoassay testing. The present study shows that it is reliable, expedient, and fiscally sound for all involved. In-office immunoassay testing compares favorably with laboratory testing for benzodiazepines, offering both high specificity and agreement. However, clinicians should be vigilant and wary when interpreting results, weighing all factors involved in their decision.
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Pain associated with complex regional pain syndrome (CRPS) is frequently excruciating and intractable. The use of botulinum toxin for relief of CRPS-associated pain has not been well described. ⋯ Intramuscular injection of botulinum toxin A in the upper limb girdle muscles was beneficial for short term relief of pain caused by CRPS in this retrospective case series. The incidence of complications was low (2.7%).
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Review Comparative Study
The impact of comparative effectiveness research on interventional pain management: evolution from Medicare Modernization Act to Patient Protection and Affordable Care Act and the Patient-Centered Outcomes Research Institute.
The Patient-Centered Outcomes Research Institute (PCORI) was established by the Affordable Care Act of 2010 to promote comparative effectiveness research (CER) to assist patients, clinicians, purchasers, and policy-makers in making informed health decisions by advancing the quality and relevance of evidence concerning the manner in which diseases, disorders, and other health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed through research and evidence synthesis. The development of PCORI is vested in the Medicare Modernization Act (MMA) and the American Recovery and Reinvestment Act (ARRA). The framework of CER and PCORI describes multiple elements which are vested in all 3 regulations including stakeholder involvement, public participation, and open transparent decision-making process. ⋯ Further, stakeholders in PCORI are not scientists, are not balanced, and will set an agenda with an ultimate problem of comparative effectiveness and PCORI that it is not based on medical science, but rather on political science and not even under congressional authority, leading to unprecedented negative changes to health care. Thus, PCORI is operating in an ad hoc manner that is incompatible with the principles of evidence-based practice. This manuscript describes the framework of PCORI, and the role of CER and its impact on interventional pain management.
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Post-dural puncture headache (PDPH) is the most common complication of procedures in which the dura mater is penetrated. ⋯ The use of fine gauge pencil-point needles may reduce the incidence of PDPH. The technique of repeated caudal saline injections is easy, rapid, and effective in providing the patient with almost immediate headache relief. In cases where this treatment fails, a blood patch should be considered. Observations from this study suggest that randomized, controlled, double-blind studies may be warranted.
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Case Reports
Peripheral nerve stimulation of the thoracic paravertebral plexus for chronic neuropathic pain.
Persistent post surgical pain is reported in 70% of patients following thoracotomy and mastectomy. This pain is often neuropathic in nature and occasionally it is refractory to traditional medical and interventional management. Neurostimulation of peripheral nerves can be a highly effective clinical modality for the management of neuropathic pain. ⋯ The limitations include only 2 case reports, considered as the lowest level of evidence available in the era of evidence-based medicine, and lack of utilization of multiple other modalities of treatments utilized in managing neuropathic pain. In conclusion, these cases demonstrate the effectiveness of peripheral nerve stimulation of the thoracic paravertebral plexus in the long-term management of refractory neuropathic pain. They also serve to underline the importance of clinical awareness in order to improve patient safety.