Current and future options for the management of phantom-limb pain

Phantom-limb pain (PLP) belongs among difficult-to-treat chronic pain syndromes. Treatment options for PLP are to a large degree implicated by the level of understanding the mechanisms and nature of PLP. Research and clinical findings acknowledge the neuropathic nature of PLP and also suggest that both peripheral as well as central mechanisms, including neuroplastic changes in central nervous system, can contribute to PLP. Neuroimaging studies in PLP have indicated a relation between PLP and the neuroplastic changes. Further, it has been shown that the pathological neuroplastic changes could be reverted, and there is a parallel between an improvement (reversal) of the neuroplastic changes in PLP and pain relief. These findings facilitated explorations of novel neuromodulatory treatment strategies, adding to the variety of treatment approaches in PLP. Overall, available treatment options in PLP include pharmacological treatment, supportive non-pharmacological non-invasive strategies (eg, neuromodulation using transcranial magnetic stimulation, visual feedback therapy, or motor imagery; peripheral transcutaneous electrical nerve stimulation, physical therapy, reflexology, or various psychotherapeutic approaches), and invasive treatment strategies (eg, surgical destructive procedures, nerve blocks, or invasive neuromodulation using deep brain stimulation, motor cortex stimulation, or spinal cord stimulation). Venues of further development in PLP management include a technological and methodological improvement of existing treatment methods, an implementation of new techniques and products, and a development of new treatment approaches

Methodenhandbuch „Bioenergie als Flexibilitätsoption im Energiesystem”

Bioenergie – das Multitalent mit den vielen verschiedenen Konversionspfaden und Nutzungsmöglichkeiten aus den vielfältigen nachwachsenden Rohstoffen! Wird ihre Rolle im Energiesystem angemessen gewürdigt? Werden ihre Funktion und ihre besonderen Potenziale im Systemzusammenhang realistisch dargestellt und analysiert? Welche Kenngrößen sind zur Abbildung des hochgradig diversen Bioenergieanlagenparks von relevanter Bedeutung für die Systemanalyse? Dies ist ein Ausschnitt der zentralen Fragen, mit denen sich dieses Handbuch aus methodischer Sicht beschäftigt. Im Rahmen des vom BMWi im Programm „Energetische Biomassenutzung“ geförderten Projektes „OptiSys“ (FKZ 03KB129) haben sich die Projektpartner deshalb mit der Frage beschäftigt, wie die Bioenergie im großen Zusammenhang des Energiesystems adäquat beschrieben werden kann bzw. sollte. Im Projekt wurde dazu am Beispiel des Biogas-Sektors in Deutschland untersucht, wie sich die zentralen technischen, ökonomischen und ökologischen Eigenschaften von Biogasanlagen in Anlagenparks und im Energiesystem sinnvoll systematisieren und typisieren las-sen. Darüber hinaus wurde die Einflussstärke der so strukturierten Anlagenparameter auf die Ergebnisse der Modellierung des Energieversorgungssystem Deutschland erarbeitet, um die Relevanz einzelner Parameter herauszuarbeiten und darzustellen. Im Modell wurden sowohl der Strom- und Wärmemarkt als auch der Transportsektor berücksichtigt, wenngleich nicht im identischen Detailierungsgrad. Im Ergebnis halten Sie nun ein Methodenhandbuch in den Händen, aus dem sowohl erfahrene Energiesystemmodellierende als auch Neulinge fundiert und umfangreich in Erfahrung bringen können, wie die Bioenergie im Energiesystemzusammenhang modelliert und analysiert werden kann bzw. sollte. Vom Leser wird dabei kein Expertenwissen zur Bioenergie vorausgesetzt, vielmehr reduziert das Methodenhandbuch das Fachwissen der Biogastechnik auf wenige für die Systemmodellierung relevante Aspekte. Dieses Handbuch soll den Nutzer unterstützen eine bewusste Technologie- und Parameterauswahl für den verwendeten Systemkontext zu treffen und diese auch entsprechend zu kommunizieren. Im Methodenhandbuch werden zum einen allgemein übertragbare Erkenntnisse und Methoden für die Modellierung der Bioenergie formuliert (Teil I) und zum anderen die spezifischen Annahmen aus dem Projekt „OptiSys“ transparent dargestellt (Teil II). Die Verfassenden dieses Methodenhandbuches erheben damit keinen Anspruch auf eine voll-ständige Darstellung aller Facetten der Bioenergie oder auf eine Allgemeingültigkeit der Aussagen zur modelltechnischen Abbildung. Vielmehr geht es um Anregungen, Impulse und Reflexionen bezogen auf das komplexe Themenfeld Bioenergienutzung als Bestandteil der Energiewende. Durch die adäquate Berücksichtigung der Bioenergie sollen die Ergebnisse zukünftiger Systemanalysen belastbarer und die Qualität erhöht werden. Das vorliegende Methodenhandbuch will die im Projekt gewonnenen Erfahrungsschätzen teilen. Ein Beitrag dazu ist sicherlich auch der in Teil II bereitgestellte umfangreiche Datensatz zu den technischen und ökonomischen Parametern der untersuchten Biogaskonzepte

The neurosurgical benefit of contactless in vivo optical coherence tomography regarding residual tumor detection: A clinical study

PurposeIn brain tumor surgery, it is crucial to achieve complete tumor resection while conserving adjacent noncancerous brain tissue. Several groups have demonstrated that optical coherence tomography (OCT) has the potential of identifying tumorous brain tissue. However, there is little evidence on human in vivo application of this technology, especially regarding applicability and accuracy of residual tumor detection (RTD). In this study, we execute a systematic analysis of a microscope integrated OCT-system for this purpose.Experimental designMultiple 3-dimensional in vivo OCT-scans were taken at protocol-defined sites at the resection edge in 21 brain tumor patients. The system was evaluated for its intraoperative applicability. Tissue biopsies were obtained at these locations, labeled by a neuropathologist and used as ground truth for further analysis. OCT-scans were visually assessed with a qualitative classifier, optical OCT-properties were obtained and two artificial intelligence (AI)-assisted methods were used for automated scan classification. All approaches were investigated for accuracy of RTD and compared to common techniques.ResultsVisual OCT-scan classification correlated well with histopathological findings. Classification with measured OCT image-properties achieved a balanced accuracy of 85%. A neuronal network approach for scan feature recognition achieved 82% and an auto-encoder approach 85% balanced accuracy. Overall applicability showed need for improvement.ConclusionContactless in vivo OCT scanning has shown to achieve high values of accuracy for RTD, supporting what has well been described for ex vivo OCT brain tumor scanning, complementing current intraoperative techniques and even exceeding them in accuracy, while not yet in applicability

A prospective international multi-center study on safety and efficacy of deep brain stimulation for resistant obsessive-compulsive disorder

Deep brain stimulation (DBS) has been proposed for severe, chronic, treatment-refractory obsessive-compulsive disorder (OCD) patients. Although serious adverse events can occur, only a few studies report on the safety profile of DBS for psychiatric disorders. In a prospective, open-label, interventional multi-center study, we examined the safety and efficacy of electrical stimulation in 30 patients with DBS electrodes bilaterally implanted in the anterior limb of the internal capsule. Safety, efficacy, and functionality assessments were performed at 3, 6, and 12 months post implant. An independent Clinical Events Committee classified and coded all adverse events (AEs) according to EN ISO14155:2011. All patients experienced AEs (195 in total), with the majority of these being mild (52% of all AEs) or moderate (37%). Median time to resolution was 22 days for all AEs and the etiology with the highest AE incidence was 'programming/stimulation' (in 26 patients), followed by 'New illness, injury, condition' (13 patients) and 'pre-existing condition, worsening or exacerbation' (11 patients). Sixteen patients reported a total of 36 serious AEs (eight of them in one single patient), mainly transient anxiety and affective symptoms worsening (20 SAEs). Regarding efficacy measures, Y-BOCS reduction was 42% at 12 months and the responder rate was 60%. Improvements in GAF, CGI, and EuroQol-5D index scores were also observed. In sum, although some severe AEs occurred, most AEs were mild or moderate, transient and related to programming/stimulation and tended to resolve by adjustment of stimulation. In a severely treatment-resistant population, this open-label study supports that the potential benefits outweigh the potential risks of DBS

The appropriate management of persisting pain after spine surgery: a European panel study with recommendations based on the RAND/UCLA method

Purpose: Management of patients with persisting pain after spine surgery (PPSS) shows significant variability, and there is limited evidence from clinical studies to support treatment choice in daily practice. This study aimed to develop patient-specific recommendations on the management of PPSS. Methods: Using the RAND/UCLA appropriateness method (RUAM), an international panel of 6 neurosurgeons, 6 pain specialists, and 6 orthopaedic surgeons assessed the appropriateness of 4 treatment options (conservative, minimally invasive, neurostimulation, and re-operation) for 210 clinical scenarios. These scenarios were unique combinations of patient characteristics considered relevant to treatment choice. Appropriateness had to be expressed on a 9-point scale (1 = extremely inappropriate, 9 = extremely appropriate). A treatment was considered appropriate if the median score was ≥ 7 in the absence of disagreement (≥ 1/3 of ratings in each of the opposite sections 1–3 and 7–9). Results: Appropriateness outcomes showed clear and specific patterns. In 48% of the scenarios, exclusively one of the 4 treatments was appropriate. Conservative treatment was usually considered appropriate for patients without clear anatomic abnormalities and for those with new pain differing from the original symptoms. Neurostimulation was considered appropriate in the case of (predominant) neuropathic leg pain in the absence of conditions that may require surgical intervention. Re-operation could be considered for patients with recurrent disc, spinal/foraminal stenosis, or spinal instability. Conclusions: Using the RUAM, an international multidisciplinary panel established criteria for appropriate treatment choice in patients with PPSS. These may be helpful to educate physicians and to improve consistency and quality of care. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material. [Figure not available: see fulltext.

Deep brain stimulation versus motor cortex stimulation for neuropathic pain: A minireview of the literature and proposal for future research

The treatment of neuropathic pain remains a public health concern. A growing cohort of patients is plagued by medically refractory, unrelenting severe neuropathic pain that ruins their quality of life and productivity. For this group, neurosurgery can offer two different kinds of neuromodulation that may help: deep brain simulation (DBS) and motor cortex stimulation (MCS). Unfortunately, there is no consensus on how to perform these procedures, which stimulation parameters to select, how to measure success, and which patients may benefit. This brief review highlights the literature supporting each technique and attempts to provide some comparisons and contrasts between DBS and MCS for the treatment of neuropathic pain. Finally, we highlight the current unanswered questions in the field and suggest future research strategies that may advance the care of our patients with neuropathic pain