Minimally-invasive pain management techniques in palliative care

Pain is a common source of suffering for seriously ill patients. Typical first-line treatments consist of lifestyle modifications and medication therapy, including opioids. However, medical treatments often fail or are associated with limiting systemic toxicities, and more targeted interventional approaches are necessary. Herein, we present options for minimally invasive techniques for the alleviation of pain in palliative patients from a head-to-toe approach, with a focus on emerging therapies and advanced techniques. Head and neck: image-guided interventions targeted to sympathetic ganglia of the head and neck, such as sphenopalatine ganglion (SPG) and stellate ganglion, have been shown to be effective for some forms of sympathetically-maintained and visceral pain. Interventions targeting branches of cranial nerves and upper cervical nerves, such as the glossopharyngeal nerve (GPN), are options in treating somatic head and face pain. Abdominal and Pelvic: sympathetic blocks, including celiac plexus, inferior hypogastric, and ganglion impar can relieve visceral abdominal and pelvic pain. Spine and somatic pain: fascial plane blocks of the chest and abdominal wall and myofascial trigger point injections can be used for somatic pain indications. Cementoplasties, such as kyphoplasty and vertebroplasty, are used for pain related to bony metastases and compression fractures. Tumor ablative techniques can also be used for lytic lesions of the bone. Spinal cord stimulation (SCS), intrathecal drug delivery systems (IDDS), and cordotomy have also been used successfully in patients requiring advanced options, such as those with significant spinal, ischemic, or visceral pain

GRIT: Women in Medicine Leadership Conference Participants’ Perceptions of Gender Discrimination, Disparity, and Mitigation

Objective: To assess demographic characteristics and perceptions of female physicians in attendance at a medical conference for women with content focused on growth, resilience, inspiration, and tenacity to better understand major barriers women in medicine face and to find solutions to these barriers. Patients and Methods: A Likert survey was administered to female physicians attending the conference (September 20 to 22, 2018). The survey consisted of demographic data and 4 dimensions that are conducive to women’s success in academic medicine: equal access, work-life balance, freedom from gender biases, and supportive leadership. Results: All of the 228 female physicians surveyed during the conference completed the surveys. There were 70 participants (31.5%) who were in practice for less than 10 years (early career), 111 (50%) who were in practice for 11 to 20 years (midcareer), and 41 (18.5%) who had more than 20 years of practice (late career). Whereas participants reported positive support from their supervisors (mean, 0.4 [SD 0.9]; P<.001), they did not report support in the dimensions of work-life balance (mean, −0.2 [SD 0.8]; P<.001) and freedom from gender bias (mean, −0.3 [SD 0.9]; P<.001). Conclusion: Female physicians were less likely to feel support for work-life balance and did not report freedom from gender bias in comparison to other dimensions of support. Whereas there was no statistically significant difference between career stage, trends noting that late-career physicians felt less support in all dimensions were observed. Future research should explore a more diverse sample population of women physicians

Novel loci for adiponectin levels and their influence on type 2 diabetes and metabolic traits: A multi-ethnic meta-analysis of 45,891 individuals

Circulating levels of adiponectin, a hormone produced predominantly by adipocytes, are highly heritable and are inversely associated with type 2 diabetes mellitus (T2D) and other metabolic traits. We conducted a meta-analysis of genome-wide association studies in 39,883 individuals of European ancestry to identify genes associated with metabolic disease. We identified 8 novel loci associated with adiponectin levels and confirmed 2 previously reported loci (P = 4.5×10−8- 1.2 ×10−43). Using a novel method to combine data across ethnicities (N = 4,232 African Americans, N = 1,776 Asians, and N = 29,347 Europeans), we identified two additional novel loci. Expression analyses of 436 human adipocyte samples revealed that mRNA levels of 18 genes at candidate regions were associated with adiponectin concentrations after accounting for multiple testing (p<3×10−4). We next developed a multi-SNP genotypic risk score to test the association of adiponectin decreasing risk alleles on metabolic traits and diseases using consortia-level meta-analytic data. This risk score was associated with increased risk of T2D (p = 4.3×10−3, n = 22,044), increased triglycerides (p = 2.6×10−14, n = 93,440), increased waist-to-hip ratio (p = 1.8×10−5, n = 77,167), increased glucose two hours post oral glucose tolerance testing (p = 4.4×10−3, n = 15,234), increased fasting insulin (p = 0.015, n = 48,238), but with lower in HDL- cholesterol concentrations (p = 4.5×10−13, n = 96,748) and decreased BMI (p = 1.4×10−4, n = 121,335). These findings identify novel genetic determinants of adiponectin levels, which, taken together, influence risk of T2D and markers of insulin resistance