Duloxetine in the management of chronic musculoskeletal pain

Chronic musculoskeletal pain is among the most frequent painful complaints that healthcare providers address. The bulk of these complaints are chronic low back pain and chronic osteoarthritis. Osteoarthritis is the most common form of arthritis in the United States. It is a chronic degenerative disorder characterized by a loss of cartilage, and occurs most often in older persons. The management of osteoarthritis and chronic low back pain may involve both nonpharmacologic (eg, weight loss, resistive and aerobic exercise, patient education, cognitive behavioral therapy) and pharmacologic approaches. Older adults with severe osteoarthritis pain are more likely to take analgesics than those with less severe pain. The pharmacologic approaches to painful osteoarthritis remain controversial, but may include topical as well as oral nonsteroidal antiinflammatory drugs, acetaminophen, duloxetine, and opioids. The role of duloxetine for musculoskeletal conditions is still evolving

Managing tribal assets: Developing long term strategic plans: Working paper series--98-01

As Native American tribes move toward self-determination with their governments and self-sufficiency of their peoples, they face daunting problems. Beginning from the status quo of unemployment rates ranging as high as 90%, concomitant social and health issues unseen elsewhere in the U.S., and limited financial assets, tribes need to develop long-term strategic plans. However, traditional economic development models and techniques are of little use in designing these plans. Additionally, some tribes are earning substantial financial assets through gaming operations. Nearly all tribes, however, still face the challenge of using their assets to build vibrant communities after many years of destitution. To this end, the development of a long-term strategic community development plan is called for. The National Executive Education Program for Native American Leadership (NEEPNAL) in conjunction with the Center for American Indian Economic Development (CAIED) has developed a method for aiding tribes to develop such plans. This paper addresses the multiple, difficult issues surrounding development of an effective long-term strategic planning process for productive uses of tribal assets. Further, the NEEPNAL/CAIED method for overcoming these difficulties is presented, with positive examples from tribal experience

Pharmacotherapy for Fibromyalgia

Fibromyalgia (FM) is a chronic disorder characterized by multifocal pain and other associated somatic symptoms including fatigue, insomnia, cognitive/memory problems, and even psychological distress. It appears that 2–4% of the general population suffers from FM. FM negatively impacts the physical functioning of its patients, as evidenced by difficulties with multiple daily activities, as well as affecting emotional health, social functioning, and health related quality of life. This review will discuss the potential theories that possibly contribute to the pathogenesis of FM, although the precise mechanism is unknown. The evolution of the assessment of FM will also be examined, with the waning use of tender point examinations and the appearance of new simple, practical diagnostic criteria. Although non-pharmacologic therapeutic options (exercise, education, cognitive–behavioral therapy) have been shown to be extremely effective in FM, the focus of this article will be on pharmacologic strategies. Non-Food and Drug Administration (FDA) approved as well as FDA approved agents will be presented. Each agent's therapeutic “niche” in FM management will be discussed based on its pharmacologic profile, patient responsiveness, and tolerability. Finally a clinical algorithm will be presented for the step-wise management of pain and other associated symptoms of FM

Safety and efficacy of intrathecal ziconotide in the management of severe chronic pain

Ziconotide is a conopeptide intrathecal (IT) analgesic which is approved by the US Food and Drug Administration (FDA) for the management of severe chronic pain. It is a synthetic equivalent of a naturally occurring conopeptide found in the venom of the fish-eating marine cone snail and provides analgesia via binding to N-type voltage-sensitive calcium channels in the spinal cord. As ziconotide is a peptide, it is expected to be completely degraded by endopeptidases and exopeptidases (Phase I hydrolytic enzymes) widely located throughout the body, and not by other Phase I biotransformation processes (including the cytochrome P450 system) or by Phase II conjugation reactions. Thus, IT administration, low plasma ziconotide concentrations, and metabolism by ubiquitous peptidases make metabolic interactions of other drugs with ziconotide unlikely. Side effects of ziconotide which tend to occur more commonly at higher doses may include: nausea, vomiting, confusion, postural hypotension, abnormal gait, urinary retention, nystagmus/amblyopia, drowsiness/somnolence (reduced level of consciousness), dizziness or lightheadedness, weakness, visual problems (eg, double vision), elevation of serum creatine kinase, or vestibular side effects. Initially, when ziconotide was first administered to human subjects, titration schedules were overly aggressive and led to an abundance of adverse effects. Subsequently, clinicians have gained appreciation for ziconotide’s relatively narrow therapeutic window. With appropriate usage multiple studies have shown ziconotide to be a safe and effective intrathecal analgesic alone or in combination with other intrathecal analgesics

Best Practices for Operations of Satellite Constellations

This paper presents the best practices used by several commercial and government operators of satellite constellations. These best practices were identified through a series of seminars and discussions held at NASA Goddard Space Flight Center (GSFC). The best practices are arrived through many years of experience and improvements made in the operations procedures and the operational systems with the primary drivers as mission safety and cost effectiveness. This paper discusses the operational aspects associated with how different organizations manage complexities of constellation operations. For the purposes of this paper, satellite constellations are groups of similar spacecraft with more than one spacecraft needed to fully accomplish the constellation's missio