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Brothers AW, Pak DJ, Poole NM, Kronman MP, Bettinger B, Wilkes JJ, Carpenter PA, Englund JA, Weissman SJ. Individualized Antibiotic Plans as a Quality Improvement Initiative to Reduce Carbapenem Use for Hematopoietic Cell Transplant Patients at a Freestanding Pediatric Hospital. Clin Infect Dis 2024; 78:15-23. [PMID: 37647637 DOI: 10.1093/cid/ciad518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/15/2023] [Accepted: 08/25/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Providers must balance effective empiric therapy against toxicity risks and collateral damage when selecting antibiotic therapy for patients receiving hematopoietic cell transplant (HCT). Antimicrobial stewardship interventions during HCT are often challenging due to concern for undertreating potential infections. METHODS In an effort to decrease unnecessary carbapenem exposure for patients undergoing HCT at our pediatric center, we implemented individualized antibiotic plans (IAPs) to provide recommendations for preengraftment neutropenia prophylaxis, empiric treatment of febrile neutropenia, and empiric treatment for hemodynamic instability. We compared monthly antibiotic days of therapy (DOT) adjusted per 1000 patient-days for carbapenems, antipseudomonal cephalosporins, and all antibiotics during two 3-year periods immediately before and after the implementation of IAPs to measure the impact of IAP on prescribing behavior. Bloodstream infection (BSIs) and Clostridioides difficile (CD) positivity test rates were also compared between cohorts. Last, providers were surveyed to assess their experience of using IAPs in antibiotic decision making. RESULTS Overall antibiotic use decreased after the implementation of IAPs (monthly reduction of 19.6 DOT/1000 patient-days; P = .004), with carbapenems showing a continuing decline after IAP implementation. BSI and CD positivity rates were unchanged. More than 90% of providers found IAPs to be either extremely or very valuable for their practice. CONCLUSIONS Implementation of IAPs in this high-risk HCT population led to reduction in overall antibiotic use without increase in rate of BSI or CD test positivity. The program was well received by providers.
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Affiliation(s)
- Adam W Brothers
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Daniel J Pak
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Nicole M Poole
- Departments of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Matthew P Kronman
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Brendan Bettinger
- Department of Clinical Analytics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jennifer J Wilkes
- Department of Pediatrics, Division of Hematology/Oncology, University of Washington, Seattle, Washington, USA
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Paul A Carpenter
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Janet A Englund
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Scott J Weissman
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Washington, Seattle, Washington, USA
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Durbhakula S, Toy S, Acosta CA, Barman RA, Kelner AF, Issa MA, Broachwala MY, Marascalchi BJ, Navalgund YA, Pak DJ, Petersen EA, Mehta ND, Moeschler SM, Kohan LR. Needs-based novel digital curriculum for the neuromodulation training deficit: Pain Rounds. Reg Anesth Pain Med 2023; 48:414-419. [PMID: 37055185 PMCID: PMC10359535 DOI: 10.1136/rapm-2023-104480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 03/28/2023] [Indexed: 04/15/2023]
Abstract
This study reports the needs-based development, effectiveness and feasibility of a novel, comprehensive spinal cord stimulation (SCS) digital curriculum designed for pain medicine trainees. The curriculum aims to address the documented systematic variability in SCS education and empower physicians with SCS expertise, which has been linked to utilization patterns and patient outcomes. Following a needs assessment, the authors developed a three-part SCS e-learning video curriculum with baseline and postcourse knowledge tests. Best practices were used for educational video production and test-question development. The study period was from 1 February 2020 to 31 December 2020. A total of 202 US-based pain fellows across two cohorts (early-fellowship and late-fellowship) completed the baseline knowledge assessment, while 122, 96 and 88 participants completed all available post-tests for Part I (Fundamentals), Part II (Cadaver Lab) and Part III (Decision Making, The Literature and Critical Applications), respectively. Both cohorts significantly increased knowledge scores from baseline to immediate post-test in all curriculum parts (p<0.001). The early-fellowship cohort experienced a higher rate of knowledge gain for Parts I and II (p=0.045 and p=0.027, respectively). On average, participants viewed 6.4 out of 9.6 hours (67%) of video content. Self-reported prior SCS experience had low to moderate positive correlations with Part I and Part III pretest scores (r=0.25, p=0.006; r=0.37, p<0.001, respectively). Initial evidence suggests that Pain Rounds provides an innovative and effective solution to the SCS curriculum deficit. A future controlled study should examine this digital curriculum's long-term impact on SCS practice and treatment outcomes.
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Affiliation(s)
- Shravani Durbhakula
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Serkan Toy
- Departments of Basic Science Education and Health Systems & Implementation Science, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Carlos A Acosta
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Carey Business School, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ross A Barman
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Mustafa Y Broachwala
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Bryan J Marascalchi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Daniel J Pak
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Erika A Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Neel D Mehta
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Susan M Moeschler
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lynn R Kohan
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
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Robinson CL, Kim RS, Li M, Ruan QZ, Surapaneni S, Jones M, Pak DJ, Southerland W. The Impact of Smoking on the Development and Severity of Chronic Pain. Curr Pain Headache Rep 2022; 26:575-581. [PMID: 35731364 DOI: 10.1007/s11916-022-01060-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to examine the impact of smoking and its role on the development of chronic pain and provide a critical review of recent literature. RECENT FINDINGS Recent studies demonstrate the bidirectional and dependent relationship between smoking and chronic pain. Those who are in pain have a more difficult time in the cessation of smoking as well as an increased sensitivity to pain during abstinence, lower confidence, and higher relapse rates. The fear of pain and the anxiety and depression that abstinence causes results in a grim outcome for long-term cessation. The dependent nature between chronic pain and smoking is affected by numerous variables. Providers should consider a multiprong approach to treating chronic pain and targeting smoking cessation treatment by providing motivational therapy, nicotine replacement, and medication therapies to prevent relapse, and providing those who are more likely to relapse with a higher level of care.
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Affiliation(s)
- Christopher L Robinson
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
| | - Rosa S Kim
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Michael Li
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Qing Zhao Ruan
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Sindhuja Surapaneni
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Mark Jones
- Department of Anesthesia, Weill Cornell Medical College, New York, NY, USA
| | - Daniel J Pak
- Department of Anesthesia, Weill Cornell Medical College, New York, NY, USA
| | - Warren Southerland
- Department of Anesthesia, The Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Aman MM, Mahmoud A, Deer T, Sayed D, Hagedorn JM, Brogan SE, Singh V, Gulati A, Strand N, Weisbein J, Goree JH, Xing F, Valimahomed A, Pak DJ, El Helou A, Ghosh P, Shah K, Patel V, Escobar A, Schmidt K, Shah J, Varshney V, Rosenberg W, Narang S. The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain. J Pain Res 2021; 14:2139-2164. [PMID: 34295184 PMCID: PMC8292624 DOI: 10.2147/jpr.s315585] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/18/2021] [Indexed: 12/17/2022] Open
Abstract
Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.
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Affiliation(s)
- Mansoor M Aman
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Ammar Mahmoud
- Department of Anesthesiology, Division of Pain Medicine, Northern Light Health Eastern Maine Medical Center, Bangor, ME, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Dawood Sayed
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shane E Brogan
- Department of Anesthesiology, Division of Pain Medicine, University of Utah, Salt Lake City, UT, USA
| | - Vinita Singh
- Department of Anesthesiology, Division of Pain Medicine, Emory University, Atlanta, GA, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Jacqueline Weisbein
- Department of Anesthesiology, Chronic Pain Division, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Johnathan H Goree
- Interventional Pain Medicine, Napa Valley Orthopedic Medical Group, Napa, CA, USA
| | - Fangfang Xing
- Swedish Pain Services, Swedish Health Services, Seattle, WA, USA
| | - Ali Valimahomed
- Gramercy Pain Center, Holmdel, NJ, & Advanced Orthopedics Sports Medicine Institute, Freehold, NJ, USA
| | - Daniel J Pak
- Department of Anesthesiology, Division of Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
| | - Antonios El Helou
- Department of Neurosciences, Division of Neurosurgery, The Moncton Hospital, Moncton, NB. Assistant Professor, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | | | - Krishna Shah
- Assistant Professor of Anesthesiology, Baylor St. Luke’s Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Vishal Patel
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Alexander Escobar
- Department of Anesthesiology and Pain Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Keith Schmidt
- AMITA Neurosciences Institute, Comprehensive Pain Management Program, St. Alexius Medical Center, Hoffman Estates, IL, USA
| | - Jay Shah
- SamWell Institute for Pain Management, Colonia, NJ, USA
| | - Vishal Varshney
- Department of Anesthesia, Providence Healthcare, Vancouver, BC, Canada & Department of Anesthesiology, Pharmacology, Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - William Rosenberg
- Center for the Relief of Pain, Midwest Neurosurgery Associates, Kansas City, Missouri, USA
| | - Sanjeet Narang
- Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Hagedorn JM, Layno-Moses A, Sanders DT, Pak DJ, Bailey-Classen A, Sowder T. Overview of HF10 spinal cord stimulation for the treatment of chronic pain and an introduction to the Senza Omnia™ system. Pain Manag 2020; 10:367-376. [DOI: 10.2217/pmt-2020-0047] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Chronic intractable pain affects a significant percentage of the worldwide population, and it is one of the most disabling and expensive health conditions across the globe. Spinal cord stimulation (SCS) has been used to treat chronic pain for a number of years, but high-frequency SCS was not the US FDA approved until 2015. In this review, we describe the history and development of high-frequency SCS and discuss the benefits of the Omnia™ implantable pulse generator. We also provide a thorough literature review of the published work, highlighting the efficacy and safety profiles of high-frequency SCS for the treatment of multiple chronic pain conditions. Lastly, we offer our outlook on future developments with the Omnia SCS system.
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Affiliation(s)
- Jonathan M Hagedorn
- Department of Anesthesiology & Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Annie Layno-Moses
- Source Healthcare, 2801 Wilshire Blvd, Suite A, Santa Monica, CA 90403, USA
| | - Daniel T Sanders
- Spine Team Texas, 1120 Raintree Circle, Suite 110, Allen, TX 75013, USA
| | - Daniel J Pak
- Pain Medicine Division, New York-Presbyterian Hospital, Weill Cornell Medicine, 1300 York Ave, New York, NY 10065, USA
| | | | - Timothy Sowder
- Department of Anesthesiology, Division of Pain Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
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Tedore TR, Lin HX, Pryor KO, Tangel VE, Pak DJ, Akerman M, Wellman DS, Oden-Brunson H. Dose-response relationship between local anesthetic volume and hemidiaphragmatic paresis following ultrasound-guided supraclavicular brachial plexus blockade. Reg Anesth Pain Med 2020; 45:979-984. [PMID: 33004656 DOI: 10.1136/rapm-2020-101728] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND There is no consensus regarding what volume of local anesthetic should be used to achieve successful supraclavicular block while minimizing hemidiaphragmatic paresis (HDP). This study investigated the dose-response relationship between local anesthetic volume and HDP after ultrasound-guided supraclavicular brachial plexus block. METHODS A dose escalation design was used to define the dose response curve for local anesthetic volume and incidence of HDP in subjects undergoing upper extremity surgery with supraclavicular block as the primary anesthetic. Dosing levels of 5, 10, 15, 20, 25, 30, 35 and 40 mL of local anesthetic were administered in cohorts of three subjects per dose. Diaphragm function was assessed with M-mode ultrasound before and after block. Secondary objectives included assessment of negative inspiratory force (NIF), oxygen saturation, subjective dyspnea and extent of sensory and motor blockade. RESULTS Twenty-one subjects completed the study. HDP was present at all doses, with an incidence of 33% at 5 mL to 100% at 30-35 mL. There was a significant decrease in NIF (7.5 cmH2O, IQR (22,0); p=0.01) and oxygen saturation on room air (1%, IQR (2,0); p=0.01) 30 min postblock in subjects experiencing HDP but not in those without HDP. There was no increase in dyspnea in subjects with or without HDP. No subject required respiratory intervention. Motor and sensory block improved with increasing dose, and subjects with HDP exhibited denser blocks than those without (p<0.01). CONCLUSIONS There is no clinically relevant volume of local anesthetic at which HDP can be avoided when performing a supraclavicular block. In our subject population free of respiratory disease, HDP was well tolerated. TRIAL REGISTRATION NUMBER NCT03138577.
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Affiliation(s)
- Tiffany R Tedore
- Anesthesiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Hannah X Lin
- Anesthesiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Kane O Pryor
- Anesthesiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Virginia E Tangel
- Anesthesiology, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
| | - Daniel J Pak
- Anesthesiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Michael Akerman
- Anesthesiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - David S Wellman
- Orthopedic Surgery, Westchester Medical Center, Valhalla, New York, USA
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Pak DJ, Gruber J, Deer T, Provenzano D, Gulati A, Xu Y, Tangel V, Mehta N. Spinal cord stimulator education during pain fellowship: unmet training needs and factors that impact future practice. Reg Anesth Pain Med 2019; 44:407-414. [DOI: 10.1136/rapm-2018-100065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 09/07/2018] [Indexed: 11/04/2022]
Abstract
Background and objectivesWith a growing need for non-opioid chronic pain treatments, pain physicians should understand the proper utilization of neuromodulation therapies to provide the most comprehensive care. We aimed to identify the unmet training needs that deter physicians from using spinal cord stimulation (SCS) devices.MethodsInternet-based surveys were fielded to fellows enrolled in pain fellowships during the 2016–2017 academic year accredited by the Accreditation Council for Graduate Medical Education and past pain fellows identified through pain medicine societies and SCS manufacturers.ResultsCurrent fellows were more likely to have received SCS training during fellowship compared with past fellows (100.0% vs 84.0%), yet there was variability in fellows’ SCS experiences with a wide range of trials and implants performed. Forty-six percent of current fellows felt there was an unmet training need regarding SCS. Deficiency in SCS case volume was the most common barrier that was noted (38.5%), followed by lack of SCS curriculum (30.8%) and lack of faculty with SCS expertise (23.1%). Lack of training was a predominant reason for past fellows choosing not to use SCS devices postfellowship. The majority of current and past fellows (79.5% and 55.4%, respectively) strongly supported direct training of fellows by SCS manufacturers.ConclusionsWhile SCS training during pain fellowship has become more universal, the experiences that fellows receive are highly variable, and most rely on industry-sponsored programs to supplement training deficiencies. Standardization of SCS procedures may also enable less experienced providers to navigate the SCS treatment algorithm.
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