Background:Accepting that it is ethical for meat to be consumed as food, then, in any context, religious or secular, it is indefensible for animals to be subjected to undue pain. Animal slaughter must therefore be predicated on the minimization of pain. Nonstun slaughter (NSS) of bovines involves ventral neck incisions, resulting in an abrupt loss of cortical blood flow and causing nearly instantaneous loss of consciousness (LOC). However, some reports have suggested that LOC after NSS is not instantaneous. This paper presents an overview of the neurobiology underlying NSS and a systematic review of the literature on time to LOC in bovines following NSS. Methods:A literature review was conducted across PubMed, Google Scholar, the Cochrane Library, Medline, and the Web of Science, with 3 coauthors independently screening articles to reduce bias. Only original research and review articles specifically addressing time to LOC in bovines after NSS were included; studies not focused on this outcome were excluded. The quality of evidence was ranked based on hierarchy of evidence utilizing predefined criteria. Results:15 studies were identified: 4 high quality, 3 medium quality, and 8 low quality. High-quality evidence consistently indicates that LOC occurs within 10 seconds of NSS of bovines when done correctly with low-stress, ideal slaughterhouse conditions. Clinical Relevance:Our findings provide important insights to optimize NSS practices, promoting animal welfare while maintaining religious requirements.

The diagnosis and understanding of pain is challenging in clinical practice. Assessing pain relies heavily on self-reporting by patients, rendering it inherently subjective. Traditional clinical imaging methods such as computed tomography and magnetic resonance imaging can only detect anatomical abnormalities, offering limited sensitivity and specificity in identifying pain-causing conditions. Radiotracers play a vital role in molecular imaging that aims to identify abnormal biological processes at the cellular level, even in apparently normal anatomical structures. Therefore, molecular imaging is an important area of research as a prospective diagnostic modality for pain-causing pathophysiology. We present a mini review of the current knowledge base regarding radiotracers for identification of pain in vivo. We also describe radiocaine, a novel positron emission tomography imaging agent for sodium channels that has shown great potential for identifying/labeling pain-producing nerves and producing an objectively measurable pain intensity signal.

Introduction:Pain is the leading reason for which people seek medical care in the United States, and chronic pain (CP) affects approximately 50 million people in the US Pain perception is deeply personal, is highly correlated with behavioral and emotional disorders, and is greatly influenced by physiological and environmental factors. The patient-provider relationship can have profound implications for clinical outcomes within the context of treating CP. However, limited access to pain specialists, the complex nature of many CP-causing conditions, the absence of instruments for objective pain measurement, and the need to foster a trust-based patient-provider relationship throughout treatment pose unique challenges.Objective:To support a more optimal CP care delivery system that leverages a healthy therapeutic patient-provider relationship, we systematically gathered deeper knowledge of the behaviors, interpersonal dynamics, home environment, values, and mindsets of people who experience CP.Methods:We employed ethnographic research methods to collect and analyze data on views, habits, strategies, attitudes, and life circumstances of a range of participants living with CP. We aggregated, analyzed, and summarized participant data to identify trends and similarities.Results:Our findings suggest that patients can be broadly categorized into five predominant pain typologies, or "personas", which are characterized by respective symptom durations, care management preferences, values, communication styles, and behaviors.Conclusion:Identifying CP personas may enhance the ability to personalize CP care and help foster more robust therapeutic relationships, which may lead to greater trust, improved patient satisfaction, and better clinical outcomes.

CASE:A 54-year-old woman with chronic lumbar radiculopathy due to grade II spondylolisthesis at lumbar 4 to 5 developed acute cauda equina syndrome (CES) after an elective lumbar decompression, and fusion was delayed because of statewide bans on elective procedures during the pandemic. The diagnosis was made largely through telehealth consultation and eventually prompted urgent neurosurgical intervention. CONCLUSION:This case report illustrates a rare presentation of acute CES and highlights some of the challenges of practicing clinical medicine in the midst of a pandemic.

Background: Chronic pain is a leading cause of disease burden and disability globally. The COVID-19 pandemic catalyzed a major paradigm shift in health care delivery with the universal adoption of telemedicine. Telehealth physical examination is particularly challenging and little guidance is available on this topic. Objectives: We attempt to describe the Point To the Area of Pain (PTAP) test and establish a consensus regarding its utility for musculoskeletal examination (MSK) via telehealth. Study Design: The authors drafted an online survey. Setting: The survey was sent to physicians and nurse practitioners within the authors' respective departments and institutions who routinely use telemedicine to treat pain Methods: Respondents (n = 61) were asked about their primary specialty, comfort level in evaluating patients in pain, use of the PTAP test and its perceived clinical relevance to patient management, and other relevant questions. Results: Respondents were predominantly trained in Physiatry (47.5%), Anesthesiology (23%), Neurology (13.1%) and Family Medicine (11.5%); 67.2% of providers treat pain related diseases > 75% of the time; 50.8% of respondents were "somewhat comfortable" at performing a virtual MSK exam and 29.5% were "not comfortable"; 65.5% utilize the PTAP test and 88.5% agree or strongly agree that this test provides extrinsic clinically relevant information. Limitations: The relatively small number of respondents. Conclusion: PTAP tests should not replace the standard accepted in-person or virtual physical examination in practice, but in the absence of a hands-on exam, the PTAP test is a clear and concise test that can easily be performed in conjunction with other techniques via telehealth, and in the context of assessing pain provides useful clinical information that can help guide medical decision making.

BACKGROUND:Chronic low back pain (CLBP) is an extremely prevalent disease, whose etiology is often multifactorial. Facet joint arthropathy is one of the most common causes of CLBP. Facet joints are innervated by the medial branches of the primary and adjacent level dorsal rami and are, therefore, key potential targets for the symptomatic management of CLBP. A lumbar medial branch nerve block (MBB) procedure is often used to assist in the diagnosis of facet mediated CLBP. For unclear reasons, some patients experience protracted relief of CLBP after diagnostic MBBs alone.OBJECTIVE:To describe the phenomenon of protracted relief of CLBP after diagnostic MBBs and search for predictors of this response.STUDY DESIGN:A retrospective chart review of patients who underwent MBB procedures by a single practitioner, over a 2 year period, was conducted.SETTING:All patients were seen at the Montefiore Multidisciplinary Pain Program, Bronx, NY.METHODS:Data from follow up visits was used to categorize patient's response to MBBs as having no relief (NR), transient relief (TR) or protracted relief (PR). Patient demographics and characteristics were collected, and a multivariate analysis investigating associations with PR was conducted.RESULTS:146 patients met inclusion criteria. 41 patients (28%) had NR, 54 (37%) had TR, and 51 (35%) had PR. CLBP symptom duration of < 6 months (P = 0.013) and unilateral back pain symptoms (P = 0.0253) were significantly associated with PR after MBB.LIMITATION:This is a retrospective study with a relatively small sample size conducted on patients belonging to a single practitioner. Outcomes were based largely on subjective patient satisfaction scores.CONCLUSIONS:In select patients, MBB may produce protracted relief of CLBP symptoms. The authors present distinct hypotheses which may help explain the therapeutic effects of diagnostic MBB procedures.

In recent years, the delivery of health services has undergone a major paradigm shift towards expanded outpatient services and widespread use of telemedicine. Post-herpetic neuralgia (PHN) is a treatment recalcitrant neuropathic pain condition referring to pain persisting more than three months from the initial onset of an acute herpes zoster. QUTENZA® (capsaicin 8% patch) is a single 1-hr localized treatment for PHN and can provide several months of pain relief per application. However, patient access to capsaicin 8% patch is limited due to sensitive handling protocols that require the patch application to occur under physicians or healthcare professionals under the close supervision of a physician. Herein, we describe a successful treatment of PHN at-home, using capsaicin 8% patch, performed under full supervision and instruction from a physician using video telehealth services. SIGNIFICANCE: This is a case report of the successful treatment of post-herpetic neuralgia at-home using Capsaicin 8% patch. The procedure was performed under full supervision and instruction from a physician using video telehealth services. Not only did the patient tolerate the procedure and have significant efficacy, she voiced preference to repeat treatment in this manner versus going back to the office.

When performing lumbar epidural steroid injection on obese patients, needle placement can be challenging due to the difficulty in estimating the appropriate needle length to utilize. Often times, the standard 3.5‐inch Tuohy needle is too short to reach its target. In our case report, a needle‐through‐needle technique was attempted in a lumbar interlaminar epidural steroid injection procedure after the initial needle fell short of the epidural space. To avoid removing the initial needle and restarting the procedure using a longer needle, a 20‐gauge 6‐inch Tuohy needle was inserted into the 17‐gauge 3.5‐inch Tuohy needle, successfully reaching the epidural space. This technique can facilitate quicker needle placement by avoiding the need for restarting the procedure with a longer needle. Thus, procedural time and radiation exposure may be decreased, as may patient discomfort from repeat needle insertions.

BACKGROUND Throughout the COVID-19 pandemic, clinicians have had to think quickly, adapt to changing recommendations sometimes on a daily basis, and have often had to rely on trial-and-error-based treatment protocols under various conditions. As we move on past the apex of the COVID-19 curve, new treatment protocols for the safe reintegration of elective interventional pain procedures into chronic pain practice are needed. METHODS Literature review and description of a model for the safe reintegration of interventional pain procedures. LIMITATIONS A narrative review with paucity of literature. DISCUSSION Herein we describe one such model in the hopes that through similar knowledge sharing, we can draw on others experiences to reach a collective conclusion on the safest, most effective, and efficient way(s) to move forward.

Background Spinal cord stimulation is an established treatment option for certain chronic pain conditions which have been previously unresponsive to conservative therapies or potentially for a subset of patients who have not improved following spine surgery. Prior to permanent lead implantation, stimulator lead trials are performed to ensure adequate patient benefit. During these trials, one of the most common complications and reasons for failure is the displacement and migration of the trial leads, resulting in lost therapeutic coverage. Other complications include infection and dislodged bulky dressings. There is a paucity of literature describing an adequate procedural method to prevent these common complications. Objective This study utilizes a series of 19 patients to evaluate a new technique for securing percutaneous spinal cord simulator trial leads, which may minimize dislodgement and migration complications and improve the rate of trial success. Study Design Retrospective case series. Setting New Jersey Medical School, Department of Anesthesiology, Pain Management Division. Methods A retrospective chart review was conducted on 19 consecutive patients undergoing placement of the percutaneous thoracic spinal cord stimulator trial leads for pain associated with lumbar spine pathology over a two-year period (2010–2012). Results Of the 19 patients in our cohort, there was one trial lead displacement, no lead migrations, and no site infections. Thirteen patients went on to permanent lead implantation. This improved trial lead placement technique had a high success rate with a low number of complications. Limitations Small sample size, retrospective case series, and no control group for comparison. Conclusion This case series was able to demonstrate that our described novel spinal cord stimulator trial lead placement and dressing technique can decrease the incidence of lead displacement and migration, thus improving trial success.

Pain medicine is a multidisciplinary field specializing in the diagnosis and treatment of chronic pain anywhere in the body. Neurologists have a long history of contributions to the field of pain medicine, and in our experience, today's generation of aspiring pain neurologists are finding ample opportunities for pain medicine fellowship positions as well as academic and nonacademic pain medicine career opportunities upon graduation. Pain medicine is a rapidly evolving subspecialty that challenges practitioners' cognitive, procedural, psychomotor, and interpersonal skills and offers a desirable work–life balance. Herein the authors provide a general overview of pain medicine as a neurologic subspecialty.

The objective of this study is to provide demographical and clinical descriptions of patients age 65 years old and older who were treated with PNBs at our institution and evaluate the safety and efficacy of this treatment.

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Images from Headache Teaching Images in Headache: Convexity Subarachnoid Hemorrhage in an Octogenarian Jacob R. Hascalovici MD, PhD, Jacob R. Hascalovici MD, PhD Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USASearch for more papers by this authorMellanie V. Springer MD, Mellanie V. Springer MD Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USASearch for more papers by this authorMatthew S. Robbins MD, Matthew S. Robbins MD Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USASearch for more papers by this author Jacob R. Hascalovici MD, PhD, Jacob R. Hascalovici MD, PhD Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USASearch for more papers by this authorMellanie V. Springer MD, Mellanie V. Springer MD Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USASearch for more papers by this authorMatthew S. Robbins MD, Matthew S. Robbins MD Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USASearch for more papers by this author First published: 24 November 2015 https://doi.org/10.1111/head.12733 Conflict of Interests: Drs. Hascalovici and Springer declare no conflicts of interest regarding the research, authorship, and/or publication of this article. Dr. Robbins has received honoraria for educational activities with the American Headache Society, American Academy of Neurology, Medlink, Springer, and book royalties from Wiley. Funding: The authors (JRH, MVS, MSR) received no financial support for the research, authorship, and/or publication of this article. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume56, Issue5May 2016Pages 895-896 RelatedInformation

Background: Up-regulation of heme oxygenase-1 (HO-1) and altered cholesterol (CH) metabolism are characteristic of Alzheimer-diseased (AD) neural tissues. We previously provided evidence of significant HO-1/sterol interactions in vitro (cultured rat astroglia) and in postmortem human AD brain (Religious Orders Study). Methods: The current experiments were designed to further delineate these interactions in vivo by comparing the behavior of HO-1/sterol interactions in two mouse models; (1) a novel HO-1 transgenic mouse (GFAP.HMOX1) engineered to selectively express human HO-1 in the astrocytic compartment and (2) the previously described triple transgenic AD mouse (3xTg-AD). In samples of frontal cortex, total CH, CH precursors and relevant oxysterols were quantified by gas chromatography-mass spectrometry (GC-MS) and HO-1 protein expression was assessed by ELISA. The relationships of HO-1 expression to total CH, CH precursors and total oxysterols were determined for both mouse models using linear regression analysis. Results: HO-1 expression is increased in GFAP.HMOX1 mice relative to wild type and in 11-12-month-old 3xTg-AD mice (with AD-like phenotype) relative to control mice and 5-6-month-old 3xTg-AD mice (no AD-like phenotype). Total oxysterols significantly decreased as HO-1 expression increased in GFAP.HMOX1 mice expressing high levels of HO-1, whereas total oxysterols increased as HO-1 expression increased in aged 3xTg-AD mice. Total CH and total CH precursors increased as HO-1 protein expression increased in 11-12-month-old 3xTg-AD mice relative to 5-6-month old 3xTg-AD mice. Conclusions: Our findings indicate a differential impact of HO-1 on patterns of brain sterol and redox homeostasis that is contingent on the presence or absence of AD-like neuropathology. These data provide fresh insight concerning the regulation of sterol homeostasis within the aging and degenerating CNS which may inform the development of novel therapeutic and preventive strategies for the management of AD and related conditions. (C) 2014 IBRO. Published by Elsevier Ltd. All rights reserved.

Over the past decade, brain sterol homeostasis has become a subject of intense investigation amongst researchers, physicians and pharmaceutical companies as it has been widely implicated in the pathogenesis of neurodegeneration. However, the mechanisms for this relationship remain ill defined. As the average lifespan in North America steadily increases, the number of patients living with degenerative conditions such as Alzheimer's disease is estimated to grow exponentially and rapidly near epidemic proportions. The central nervous system (CNS) is the most cholesterol (CH) dense region in the human body and this sterol and its derivatives are responsible for a wide range of biological functions essential for cell survival, growth and homeostasis. Overexpression of Heme oxygenase-1 (HO-1), a stress enzyme that mediates the catabolism of heme to biliverdin, free iron, and carbon monoxide (CO), is responsible for generation of reactive oxygen species (ROS) in the CNS and has been reported in Alzheimer-diseased (AD) neural tissues. Over the past six years, our laboratory and collaborators have provided evidence of significant HO-1/sterol interactions in vitro (cultured rat astroglia), in post-mortem human AD brain (Religious Orders Study) and in vivo employing a novel HO-1 transgenic mouse (HMOX-1) and a triple transgenic AD mouse model (3xTg-AD). Our findings have consistently implicated HO-1 as a central regulator of sterol homeostasis in CNS across various models of neurodegeneration. The data indicate a differential impact of HO-1 on patterns of brain sterols and oxysterols in accordance with various redox microenvironments and the presence or absence of AD-like pathological brain aging. CNS CH levels may be related to disease progression in Alzheimer's affected neural tissues in a non-linear fashion. We herein describe these novel pathways of neurosterol homeostasis.

BACKGROUND:Up-regulation of heme oxygenase-1 (HO-1) and altered cholesterol (CH) metabolism are characteristic of Alzheimer-diseased (AD) neural tissues. We previously provided evidence of significant HO-1/sterol interactions in vitro (cultured rat astroglia) and in post-mortem human AD brain (Religious Orders Study). METHODS:The current experiments were designed to further delineate these interactions in vivo by comparing the behavior of HO-1/sterol interactions in two mouse models; (1) a novel HO-1 transgenic mouse (GFAP.HMOX1) engineered to selectively express human HO-1 in the astrocytic compartment and (2) the previously described triple transgenic AD mouse (3xTg-AD). In samples of frontal cortex, total CH, CH precursors and relevant oxysterols were quantified by gas chromatography-mass spectrometry (GC-MS) and HO-1 protein expression was assessed by ELISA. The relationships of HO-1 expression to total CH, CH precursors and total oxysterols were determined for both mouse models using linear regression analysis. RESULTS:HO-1 expression is increased in GFAP.HMOX1 mice relative to wild type and in 11-12-month-old 3xTg-AD mice (with AD-like phenotype) relative to control mice and 5-6-month-old 3xTg-AD mice (no AD-like phenotype). Total oxysterols significantly decreased as HO-1 expression increased in GFAP.HMOX1 mice expressing high levels of HO-1, whereas total oxysterols increased as HO-1 expression increased in aged 3xTg-AD mice. Total CH and total CH precursors increased as HO-1 protein expression increased in 11-12-month-old 3xTg-AD mice relative to 5-6-month old 3xTg-AD mice. CONCLUSIONS:Our findings indicate a differential impact of HO-1 on patterns of brain sterol and redox homeostasis that is contingent on the presence or absence of AD-like neuropathology. These data provide fresh insight concerning the regulation of sterol homeostasis within the aging and degenerating CNS which may inform the development of novel therapeutic and preventive strategies for the management of AD and related conditions.