ID: 218414 Queen Mary University London Postgraduate Certification in Neuromodulation- Accreditation in Neuromodulation

Introduction: There is a distinct unmet need in structured, curriculum based, unbiased education in neuromodulation. Current teaching is through sporadic industry workshops, cadaver courses and peer proctorship. The COVID pandemic has created a unique opportunity where online platforms have enabled education to be delivered remotely in both synchronous and asynchronously. The William Harvey Research Institute, Queen Mary University, London, UK have initiated University based accreditation- Post Graduate Certificate in neuromodulation (PGCert) that provides candidate a qualification in one academic year through part-time study. Method(s): The program underwent rigorous staged university approval process (figure 1). To ensure market feasibility, two short proof of concept CPD programs "Executive Education in Neuromodulation (EEPIN)" were delivered in 2021. These courses attracted 87 candidates across Australia, Singapore, India, Germany, Poland, Czech Republic, Ireland, and UK. The faculty includes key opinion leaders that will deliver the program ensuring the candidates gain academic background and specialist skills to understand safe practice of neuromodulation. The PGCert advisory board has been established to ensure strict governance in terms of content and unbiased delivery confirming ACCME guidance. In order to obtain PGCert, candidates are required to complete 4 x 15 credit modules (60 credits). The four modules include Anatomy & Neurophysiology;Patient care and Procedurals skills;Devices and available technology;Intrathecal drug delivery for cancer and non-cancer pain. The modular nature of the program is designed to provide cumulative knowledge, from basic science to clinical application in line with the best available evidence. The modules comprise nine lectures, spreading over three consecutive days, followed by a written assignment with 40 direct contact hours in each module. The webpage can be accessed at Results: The anonymous data from EEPIN reported on Likert scale 1-5: Objectives defined 30.6% - 4 and 69.4% -5;Relevance of topics 10.2%- 4 and 89.8% -5;Content of presentations 22.4%- 4 and 77.6% -5;Organization 24.5% -4 and 69.4% -5;Candidate faculty interaction 14.3% -4 and 81.6% -5. 97% of the EEPIN candidates recommended the program to others whilst 81.8% expressed their strong interest to enroll for university-based post graduate qualification if offered. Conclusion(s): This PGcert Neuromodulation is a unique, university accredited program that provides qualification in neuromodulation with access to a flexible online e-learning platform to discuss and exchange ideas, share knowledge in candidate's own time. This will support the ongoing need for formal curriculum-based education in neuromodulation. Disclosure: Kavita Poply, PHD: None, Phillippe Rigoard: None, Jan Kallewaard, MD/PhD: None, FRANK J.P.M. HUYGEN, MD PhD: ABBOTT: Speakers Bureau:, Saluda: Consulting Fee:, Boston Scientific: Consulting Fee:, Grunenthal: Speakers Bureau:, Pfizer: Speakers Bureau:, Ashish Gulve, FRCA, FFPMRCA, FFPMCAI, DPMed, FCARCSI, MD, MBBS: None, Ganesan Baranidharan, FRCA: None, Sam ELDABE, MD, FRCA, FFPMRCA: Medtronic: Consulting Fee:, Medtronic: Contracted Research:, Mainstay Medical: Consulting Fee:, Saluda Medical: Consulting Fee:, Boston Scientific: Contracted Research:, Saluda Medical: Contracted Research:, James Fitzgerald, MA,PhD: St Jude Medical: Consultant: Self, Medtronic: Consulting Fee:, UCB: Contracted Research:, Merck: Contracted Research:, Serge Nikolic, MD: None, Stana Bojanic, BSc MBBS FRCS (SN): Abbott: Contracted Research:, Habib Ellamushi: None, Paresh Doshi, MS MCh: None, Preeti Doshi, MBBS, MD, FRCA: None, Babita Ghai, MBBS, MD, DNB: None, Marc Russo, MD: Presidio Medical: Ownership Interest:, Saluda Medical: Ownership Interest:, Boston Scientific: Contracted Research: Self, Mainstay Medical: Contracted Research: Self, Medtronic: Contracted Research: Self, Nevro: Contracted Research: Self, Saluda Medical: Contracted Research: Self, Presidio Medical: Contracted Research: Self, Freedom Ne ro: Ownership Interest - Own Stocks: Self, Lungpacer: Ownership Interest - Own Stocks: Self, SPR Therapeutics: Ownership Interest - Own Stocks: Self, Lawrence Poree, MD,MPH,PHD: Medtronic: Consulting Fee: Self, Saluda Medical: Contracted Research: Family, Nalu Medical: Contracted Research: Family, Gimer Medical: Consulting Fee: Self, Nalu Medical: Consulting Fee: Self, Saluda Medical: Consulting Fee: Self, Nalu: Ownership Interest:, Saluda Inc: Ownership Interest:, Alia Ahmad: None, Alaa Abd Sayed, MD: Medtronic, Abbott, SPR and StimWave: Consulting Fee:, Salim Hayek, MD,PhD: None, CHRISTOPHER GILLIGAN, MD MBA: Persica: Consulting Fee: Self, Saluda: Consulting Fee: Self, Mainstay Medical: Contracted Research: Self, Sollis Therapeutics: Contracted Research: Self, Iliad Lifesciences, LLC: Owner: individuals with legal ownership in a company:, Vivek Mehta: NoneCopyright © 2023

ID: 219407 The Cardiac Patient and Neuromodulation, When Anticoagulation Dictates the Intervention

Introduction: Patients with cardiac comorbidities present unique challenges for undergoing interventional pain procedures. Consensus guidelines on safe anticoagulation management are categorized by procedure, patient specific bleeding risk factors, and class of anticoagulation (Table 1, Table 2).1 Specifically, some procedures occur in close proximity to the spinal cord, require large gauge needles and styletted leads, while others are in compressible locations with minimal tissue disruption. Further, pain-induced hypercoagulation increases the risk of thrombo-vascular events.1 This accentuates the importance of interdisciplinary perioperative coordination with the prescribing cardiologist. Case: A 71-year-old male with past-medical-history of CABG, bilateral femoral-popliteal bypass, atrial fibrillation on apixaban and ticagrelor, and multiple cardiac stents presented with intermittent shooting axial back pain radiating to right buttock, lateral thigh, and calf, worsened with activity. MRI demonstrated thoracic myelomalacia, multi-level lumbar disc herniation, and moderate central canal stenosis. An initial multi-model treatment approach utilizing pharmacologic agents, physical therapy, ESI's, and RFA failed to alleviate symptoms. After extensive discussion with his cardiologist, he was scheduled for a three-day SCS trial. Ticagrelor and apixaban were held throughout the 3-day trial and for 5 and 3 days prior, respectively, while ASA was maintained. Successful trial with tip placement at T6 significantly improved function and pain scores (Figure 1). Upon planned percutaneous implant, the cardiologist recommended against surgical implantation and holding anticoagulation. Alternatively, the patient underwent bilateral lumbar medial branch PNS implant with sustained improvement in lower back symptoms. However, he contracted COVID, resulting in delayed lead explanation (>60 days) without complication. Conclusion(s): Interventional pain practice advisories are well established for anticoagulation use in the perioperative period.1,2 However, there is limited high-quality research on the appropriate length to hold anticoagulation prior to surgery for high thrombotic risk patients. Collegial decision making with the cardiologist was required to avoid deleterious procedural complications. However, they may be unfamiliar with the nuances between interventions or between trial and implant. Prospective studies have shown that low risk procedures, such as the PNS, may not require holding anticoagulants.3 Other case data has demonstrated post-SCS epidural hematoma with ASA use after being held for 1-week prior to surgery. Our patient was unable to undergo SCS implant and instead elected for a lower risk procedure with excellent efficacy. 4 However, delayed PNS lead extraction due to COVID19 hospitalization presented further risk of infection and lead fracture.5 PNS may prove to be an appropriate treatment option for patients who are anticoagulated and are not SCS candidates. Disclosure: Elliot Klein, MD,MPH: None, Clarence Kong, MD: None, Shawn Sidharthan, MD: None, Peter Lascarides, DO: None, Yili Huang, DO: NoneCopyright © 2023

ID: 206479 An Evaluation of Psychological Wellbeing in Neuromodulation Patients During a Global Pandemic

Introduction: Bart's Neuromodulation Centre is a center of excellence for research and innovation. In the UK, the NICE 159 guidelines have highlighted the importance of psychological and multidisciplinary assessment to ascertain the suitability of patients for Neuromodulation. The global pandemic of Covid-19 has had far-reaching physical, psychological, and socioeconomic implications. Despite the various limitations of running services during a pandemic, Barts Neuromodulation Centre maintained the importance of multidisciplinary assessment in the selection of patients suitable for this form of therapy. This paper presents psychological wellbeing outcomes of neuromodulation patients during this unprecedented period. Method(s): Data collection was gathered remotely between January 2021 to December 2021.N=178 completed questionnaires. The mean age was 55 years and 63% were female. Data was collected at baseline and in addition, post-implant data was obtained at 1,3,6 and 12 month follow up. As per NHS England outpatient guidance (2020), all data was completed remotely. All collected data was anonymized and data was stored on an encrypted database. Result(s): Results showed a 78% decrease in depression scores from baseline to 2 years+ and a 76% decrease in anxiety scores from baseline to 2 years+. Conclusion(s): The data demonstrates significant improvements in psychological wellbeing as shown in depression and anxiety scores after SCS therapy. Despite the global pandemic, there remains a strong demand for SCS and encouragingly showed significant improvements in psychological wellbeing. It would be useful to explore ways to improve patient compliance and explore broader parameters of outcomes. Disclosure: Angie Alamgir, PHD: None, Serge Nikolic, MD: None, Habib Ellamushi: None, Amin Elyas, FRCS: None, Joanne Lascelles, Clinical nurse specialist: None, Kavita Poply, PHD: None, Sanskriti Sharma: None, Alia Ahmad, MSc: None, Vivek Mehta: NoneCopyright © 2023

ID: 218293 Real World Outcome Data in Pandemic: A Tertiary Care Neuromodulation Centre UK- 12 Months Data

Introduction: Covid-19 was classed as a global pandemic by the World Health Organization (WHO) in March 2020. This had an overwhelming effect on the National Health Services (NHS) in the United Kingdom resulting in the disruption and subsequent prioritization of the elective recovery services. Despite the various limitations of delivering services during a pandemic, Barts Neuromodulation Centre maintained the importance of multidisciplinary assessment in the selection of patients suitable for this form of therapy. We present the data on our continued activity through pandemic, dependent on the performance feasibility. The aim of this effectiveness project was to evaluate the post SCS outcome data during covid-19 pandemic. Method(s): This was a telephone and in person data collection of patient responses to standardized and validated pain outcome questionnaires following SCS implant performed at St Bartholomew's Hospital, London during January-December 2021. Data was collated from a tertiary Neuromodulation center at Barts Health NHS Trust, UK. Patients completed the questionnaires prior to SCS implant and post implant 1, 3, 6, and 12 month follow- up appointments with our neuromodulation specialists Results: Two hundred and fifteen patients underwent face to face or telephonic consultation during January to December 2021 for the follow ups. Total 178 patients registered their responses with F:M being 63%:37% and the average age 55 years. At each time point, the following number of patients completed: baseline n= 52;1 month n= 27;3 months n=28;6-month n= 21 and 12 months, n= 26. We demonstrate that NRS pain scores reduced by 43%, ODI disability improved by 35%, HADS anxiety reduced by 45%, depression reduced by 46%, PSQ sleep improved by 77% and EQ5D quality of life improved by 66% at 12 months when compared to baseline. There were no serious adverse events reported through this time. Conclusion(s): To our knowledge, this is one of the first reported real-world post SCS outcome data of prospective follow ups. We demonstrate safe delivery of services and data collection feasibility through pandemic. Moreover, our patient cohort showed improvement in the all dimensions of chronic refractory pain following SCS therapy despite clinical burden of COVID-19. Disclosure: Alia Ahmad: None, Angie Alamgir, PHD: None, Sanskriti Sharma: None, Joanne Lascelles, Clinical nurse specialist: None, Amin Elyas, FRCS: None, Helen Bonar: None, Serge Nikolic, MD: None, Habib Ellamushi: None, Vivek Mehta: None, Kavita Poply, PHD: NoneCopyright © 2023

Treatment-Resistant Late-Life Depression: A Review of Clinical Features, Neuropsychology, Neurobiology, and Treatment.

Major depression is common in older adults (≥ 60 years of age), termed late-life depression (LLD). Up to 30% of these patients will have treatment-resistant late-life depression (TRLLD), defined as depression that persists despite two adequate antidepressant trials. TRLLD is challenging for clinicians, given several etiological factors (eg, neurocognitive conditions, medical comorbidities, anxiety, and sleep disruption). Proper assessment and management is critical, as individuals with TRLLD often present in medical settings and suffer from cognitive decline and other marks of accelerated aging. This article serves as an evidence-based guide for medical practitioners who encounter TRLLD in their practice.

Neuromodulation and Opioid Use Disorder: Ethical Opportunities for Canada.

Despite increased efforts of government and non-government organisations to intervene via harm reduction and education initiatives, the opioid crisis has continued to worsen and has been exacerbated by the COVID-19 pandemic. In British Columbia, Canada, opioid overdose deaths in 2021 are the highest ever recorded. Neuromodulation procedures such as deep brain stimulation and repetitive transcranial magnetic stimulation have gained traction as treatments for opioid use disorder in various countries such as Germany, the Netherlands, the United States and China. However, these treatment options have been met with apprehension from both clinicians and patients, likely owing to fear, stigma and reluctance to label addiction as a brain disorder. Further complicating this landscape are socio-demographic factors, as marginalised communities are disproportionately burdened by addiction, while having poor access to care and a history of distrust in the health system. This multifactorial challenge involving many sociocultural factors requires culturally sensitive, interdisciplinary approaches to ensure direct-to-brain innovations are implemented ethically and equitably. This review summarises the state of the science for using neuromodulation to treat opioid use disorder, as well as the available ethical discourse surrounding the expansion of clinical trials and eventual widespread clinical implementation. Additional ethics discussions highlight opportunities for the engineering and clinical evolution of neuromodulation for opioid use disorder trials.

Moving to accelerated protocols of tDCS in schizophrenic catatonia: A case report

This is a case report of a 74-year-old woman with catatonic schizophrenia who was treated with transcranial Direct Current Stimulation (tDCS) in place of electroconvulsive therapy (ECT) during the Covid-19 pandemic that impacted access to ECT facilities. In 2021, the exceptional number of patients infected with SARS-Cov-2 led the French public hospital system to adjust its organization, temporarily redirecting anesthetists from ECT departments to ICUs. Our patient, who was hospitalized via the emergency department, presented schizophrenia with catatonic features. Due to the pandemic, ECT, which is considered the gold standard treatment for this condition, was not available. Therefore, tDCS, a neuromodulation technique that doesn't require general anesthesia, was recommended for this patient, and was delivered at the relatively (compared to standard protocols) accelerated rate of five sessions a day, five days a week. This protocol was chosen as accelerated rTMS had been shown to be effective against depression in recent trials (Cole et al. 2021), and one study had also reported this exact protocol as effective and harmless for a patient with schizophrenia (Mondino et al. 2021). The Bush-Francis Catatonia Rating Scale (BFCRS) was used to evaluate the severity of the catatonia. After 49 sessions, the clinical response was meaningful, with a BFCRS score of 16, compared to 36 at baseline. We then moved to five sessions a day, three days a week, and then two days a week. After 80 sessions, we noted the complete disappearance of catatonia (BFCRS = 6). This case provides evidence for the feasibility and tolerability of accelerated tDCS for patients with catatonia. Accelerated tDCS represents a potential alternative to ECT in the treatment of catatonia, and needs further randomized clinical studies to confirm its efficacy. Research Category and Technology and Methods Clinical Research: 9. Transcranial Direct Current Stimulation (tDCS) Keywords: tdcs, catatonia, covid-19, ECTCopyright © 2023

Sacral neuromodulation remote programming in patients with refractory lower urinary tract dysfunction: China's experience during the COVID-19 pandemic.

Objectives: Sacral neuromodulation is an effective, minimally invasive treatment for refractory lower urinary tract dysfunction. However, regular postoperative programming is crucial for the maintenance of the curative effects of electronic sacral stimulator devices. The outbreak of coronavirus disease 2019 (COVID-19) limited the ability of practitioners to perform traditional face-to-face programming of these stimulators. Therefore, this study aimed to evaluate the application of remote programming technology for sacral neuromodulation during the COVID-19 pandemic in China. Materials and methods: We retrospectively collected data including baseline and programming information of all patients with lower urinary tract dysfunction who underwent sacral neuromodulation remote programming in China after the outbreak of COVID-19 (i.e., December 2019). The patients also completed a self-designed telephone questionnaire on the subject. Results: A total of 51 patients from 16 centers were included. They underwent 180 total remote programming visits, and 118, 2, 25, and 54 voltage, current, pulse width, and frequency adjustments, respectively, were performed. Additionally, remote switching on and off was performed 8 times; impedance test, 54 times; and stimulation contact replacement, 25 times. The demand for remote programming was the highest during the first 6 months of sacral neuromodulation (average, 2.39 times per person). In total, 36 out of the 51 patients completed the questionnaire survey. Of these, all indicated that they chose remote programming to minimize unnecessary travel because they had been affected by COVID-19. The questionnaire also showed that remote programming could reduce the number of patient visits to the hospital, save time, reduce financial costs, and would be easy for patients to master. All surveyed patients indicated that they were satisfied with remote programming and were willing to recommend it to other patients. Conclusion: Remote programming for sacral neuromodulation is feasible, effective, safe, and highly recommended by patients with refractory lower urinary tract dysfunction. Remote programming technology has great development and application potential in the post-pandemic era.

Clinical applications of transcutaneous auricular neurostimulation for opioid use disorder and pain

Symposium title: Addressing chronic pain and the opioid epidemic using auricular neuromodulation Symposium description: Our proposed symposium integrates a diverse group of scientist and clinician experts (Drs. Cunningham, Wilkes, Khodaparast, Badran) who have committed to exploring the anti-nociceptive and opioid sparing effects of auricular neuromodulation to progress toward non-opioid interventions for chronic pain and opioid use disorders. The demand for chronic pain therapies has increased at an unprecedented rate over the last several decades, contributing in part to a surge in prescription and illicit opioid demand. Countless patients were escalated to prolonged, high-dose opioid regimens over years of treatment. By 2014, 5.4% of U.S. adults were estimated to use prescription opioids on a long-term basis. As the harms of opioid proliferation became increasingly clear, a dramatic paradigm shift occurred in which these drugs are now perceived as more dangerous than beneficial for chronic pain. New clinical guidelines highlight the risks of high-dose regimens as well as the limited benefits, particularly insufficient analgesia and hyperalgesia, associated with long-term use. According to this new perspective, the preferred therapeutic modality for many patients is to safely taper, or even completely stop, using opioids. Transcutaneous auricular neurostimulation (tAN) is a novel therapeutic paradigm that includes stimulation of both the auricular branch of the vagus nerve and auriculotemporal nerve (branch of trigeminal). tAN therapy results in clinically significant reductions in opioid withdrawal symptoms associated with opioid detoxification and tapering. Either adjunctive vagal or trigeminal stimulation modulates pain transmission suggesting overlapping common effector pathways, possibly targeting the endogenous opioid system, which could lead to a synergistic therapeutic benefit for pain. This symposium will explore the scientific basis for this hypothesis across targeted and interconnected topics, including fundamental neuropharmacological mechanisms underlying pain and opioids, clinical challenges of tapering opioids, managing opioid withdrawal symptoms with tAN, and the prospects for tAN to deliver a safe alternative treatment option for pain disorders. The United States is experiencing an epidemic for prescription and non-prescription opioids, which have continued to rise since the 1990s. During 2015, approximately 2.1 million people were severely dependent on prescription opioids, and 513,000 on heroin. In 2020, the Centers for Disease Control reported 93,331 substance use overdose deaths. The continuing increase in opioid-related deaths from 2015 (18%) to 2020 (60%) is partly attributed to the mental health crisis during the Covid-19 pandemic. Aside from pain mitigation, individuals with opioid use disorder (OUD) may be motivated to continue drug-seeking by both the positive reinforcement of the euphoric effects of opioids and the negative reinforcement of opioid withdrawal symptoms due to cessation. Alternative approaches for OUD are a major priority for government agencies given the substantial impact on health, social, and economic welfare. Transcutaneous auricular neurostimulation (tAN) is a non-invasive form of vagus and trigeminal neuromodulation that was recently proven to be an efficacious non-pharmacologic based treatment for reducing opioid withdrawal symptoms. In 2021, tAN therapy received FDA clearance as an adjunctive treatment for opioid withdrawal symptoms in adults. tAN therapy was also proven safe and effective in reducing symptoms of neonatal opioid withdrawal syndrome (NOWS) in neonates. tAN as an adjuvant was safe, well-tolerated, while facilitating the successful rapid weaning of oral morphine and decreasing length of stay in the neonatal ICU. Based on these preliminary findings, tAN therapy is currently in two NIH-funded pivotal clinical trials to: 1) evaluate the long-term effects of tAN on opioid use relapse prevention and cravings in adults with OUD, and 2) determine f tAN therapy can reduce withdrawal symptoms and reduce morphine length of treatment for neonates with NOWS. Lastly, we will explore how tAN could be utilized as neuromodulatory approach for opioid sparing, and ultimately pain mitigation. Research Category and Technology and Methods Clinical Research: 12. Vagus Nerve Stimulation (VNS) Keywords: Vagus Nerve Stimulation, Opioid Use Disorder, Pain, NeurostimulationCopyright © 2023

HD-tDCS in acute and long-term COVID-19

Symposium title: The potential role of tDCS in the management of Post-Acute Sequelae of SARS-COV-2 (PASC) Symposium description: The novel SARS-CoV-2 virus has infected millions of people worldwide. Post-infectious symptoms, referred to as Post-Acute Sequelae of SARS-CoV-2 (PASC), affect a large and growing segment of survivors, lasting months or even years without recovery. With continuous COVID-19 infections, PASC is a growing problem for public health. Therefore, effective and accessible treatment options need to be evaluated urgently. PASC symptoms are multi-systemic and can vary by the individual in clinical presentation, and its underlying pathological mechanisms remain uncharacterized. tDCS is a well-tolerated and extensively characterized noninvasive neuromodulation technique, and is effective in targeting the neuropsychiatric symptoms that define PASC (i.e., fatigue, cognitive, pain, emotional) including in other post-viral conditions. In addition, tDCS may have a larger role in the management of persisting respiratory symptoms. We will provide an overview of the theoretical basis and work to date supporting tDCS as a tool for PASC management, and present initial findings from recently completed and ongoing clinical trials. When COVID-19 first emerged, many researchers were focused on its impact on the lungs. As we have learned more about SARS-CoV-2 and resulting COVID-19, we have discovered that patients present a greater complexity in the context of the neurotrauma and the pulmonary lesions can become an aggravation of the neuroinvasion of the coronavirus and originate from cerebral injury. Recently, it has been suggested that noninvasive brain stimulation could be a valuable tool for the management of the early and postacute phase of patients with COVID-19. This session will present the results of our investigation of the High-definition transcranial direct current stimulation effects during the acute and chronic recovery phase from COVID-19. The prognostic factors and clinical predictors that contribute to greater response to treatment will be presented and directions for future research will be discussed. Research Category and Technology and Methods Clinical Research: 9. Transcranial Direct Current Stimulation (tDCS) Keywords: HD-tDCS, Coronavirus disease, Noninvasive brain stimulation, Long COVID-19Copyright © 2023

Speaker Gender Representation at the North American Neuromodulation Society Annual Meeting (2017-2021): Have We Made Progress in Closing the Gender Gap?

Background: Speaker gender representation at medical conferences is a significant site of gender disparity. Our primary objective was to quantify the proportion of female speakers and compare plenary session opportunities by gender at the North American Neuromodulation Society (NANS) Annual Conference. Methods: Data from the 2017-2021 NANS Annual Conference presentations were abstracted. Primary outcomes included gender composition of speaker slots, gender composition of individual speakers, and comparison of plenary speaker slots by gender. Secondary outcomes included comparisons of session size, age, professional degree, and number of presentations per speaker based on gender. Results: Gender composition of annual speaker slots was (% slots presented by women): 2017:14.6%; 2018:20.5%; 2019:23.5%; 2020:21.0%; 2021:41.4%. Annual gender composition of individual speakers was (% women): 2017:18.7%; 2018:20.6%; 2019:24.6%; 2020:24.9%; 2021:33.8%. Of all speaker slots, the percentage of plenary slots did not differ based on gender, with 11.4% presented by female speakers versus 11.2% presented by male speakers (OR 1.0, 95% CI 0.7-1.5, P=0.893). Compared to male speaker slots, there was an association of lower age (43.9±5.6 vs 50.8±8.9, P<0.001), lower odds of holding a single doctorate degree (OR 0.3, 95% CI 0.2-0.5, P<0.001), and lower odds of holding a dual MD/PhD or DO/PhD degree (OR 0.3, 95% CI 0.1-0.5, P<0.001) in female speaker slots. Compared to male speakers, there was an association of higher number of presentations per female speaker at the 2021 NANS Annual Meeting (2.48±1.60 vs 1.79±1.30, P=0.008). Conclusion: Although the volume of female speaker slots and individual speakers trailed behind their male counterparts, female speaker representation steadily increased at each subsequent annual NANS meeting. We identified no difference in plenary session slots based on gender.

Sinus node dysfunction and atrial fibrillation-Relationships, clinical phenotypes, new mechanisms, and treatment approaches.

Although the anatomical basis of the pathogenesis of sinus node dysfunction (SND) and atrial fibrillation (AF) is located primarily in the left and right atria, increasing evidence suggests a strong correlation between SND and AF, in terms of both clinical presentation and formation mechanisms. However, the exact mechanisms underlying this association are unclear. The relationship between SND and AF may not be causal, but is likely to involve common factors and mechanisms, including ion channel remodeling, gap junction abnormalities, structural remodeling, genetic mutations, neuromodulation abnormalities, the effects of adenosine on cardiomyocytes, oxidative stress, and viral infections. Ion channel remodeling manifests primarily as alterations in the "funny" current (If) and Ca2+ clock associated with cardiomyocyte autoregulation, and gap junction abnormalities are manifested primarily as decreased expression of connexins (Cxs) mediating electrical impulse propagation in cardiomyocytes. Structural remodeling refers primarily to fibrosis and cardiac amyloidosis (CA). Some genetic mutations can also cause arrhythmias, such as SCN5A, HCN4, EMD, and PITX2. The intrinsic cardiac autonomic nervous system (ICANS), a regulator of the heart's physiological functions, triggers arrhythmias.In addition, we discuss arrhythmias caused by viral infections, notably Coronavirus Disease 2019 (COVID-19). Similarly to upstream treatments for atrial cardiomyopathy such as alleviating CA, ganglionated plexus (GP) ablation acts on the common mechanisms between SND and AF, thus achieving a dual therapeutic effect.

Effect of Peripheral Neuromodulation on Headache in Post Covid-19 Survivors

Objective: The purpose of present study was to evaluate the impact of peripheral neuromodulation through vagus nerve stimulation on headache in Post COVID-19 survivors. Method(s): Thirty Post COVID-19 survivors from both genders (17 females and 13 males) aged from 20 to 40 years who suffered from Post COVID-19 headache were recruited and randomized into two groups of equal number. Subjects in group A (study group) received transcutaneous vagus nerve stimulation as well as the designed physiotherapy program whereas subjects in group B (control group) underwent placebo transcutaneous vagus nerve stimulation on vagus nerve in addition to the same designed physical therapy program. The treatment was carried-out for 5 sessions each week for four weeks. Visual analogue scale (VAS) was used to measure the intensity of headache pain whereas the headache disability index (HDI) was used to measure the disability resulted from headache. Result(s): The findings showed significant decline in VAS and HDI post treatment in study group (A) and control group (B) in comparison with that pretreatment (p<0.001). Between-group analysis showed no significant difference between the two groups pretreatment (p>0.05), whereas there was significant decline in VAS and HDI in study group in comparison with that of the control group posttreatment (p<0.05). Conclusion(s): peripheral neuromodulation is more effective in managing headache in post COVID-19 survivors. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

Transcutaneous auricular vagus nerve stimulation effects on inflammatory markers and clinical evolution of patients with COVID-19: a pilot randomized clinical trial.

OBJECTIVE: To evaluate the effects of transcutaneous auricular vagus nerve stimulation (taVNS) on inflammatory markers and clinical outcomes in patients with COVID-19. METHODS: A randomized blinded pilot study was carried out with 21 individuals hospitalized with COVID-19 who received 14 sessions of active (a-taVNS) or sham taVNS (s-taVNS). The level of interleukin-6 (IL-6), interleukin-10 (IL-10), cortisol, and C-reactive protein (CRP) in plasma and clinical evolution pre- and post-intervention were evaluated. The memory and attention levels were evaluated 14 days after the end of the treatment. RESULTS: After treatment, significant intragroup differences were found in the CRP (p = 0.01), IL-6 (p = 0.01), and cortisol (p = 0.01) levels; however, in the comparison between the groups, only the CRP level was statistically lower for the a-taVNS (p = 0.04). The impression of improvement in memory and attention was greater in the a-taVNS than in the s-taVNS (p = 0.01, p = 0.04, respectively). There was no difference between the other clinical outcomes. CONCLUSIONS: taVNS is a viable and safe intervention in the acute care of patients with COVID-19, which can modulate their inflammatory profile and improve cognitive symptoms. However, improvements in overall clinical outcomes were not detected. Larger sample sizes and longer follow-ups are needed to confirm the anti-inflammatory and clinical effects of taVNS in patients with COVID-19. TRIALS REGISTRY: The Brazilian Registry of Clinical Trials (RBR-399t4g5).

Is the post-COVID-19 syndrome a severe impairment of acetylcholine-orchestrated neuromodulation that responds to nicotine administration?

Following a SARS-CoV-2 infection, many individuals suffer from post-COVID-19 syndrome. It makes them unable to proceed with common everyday activities due to weakness, memory lapses, pain, dyspnea and other unspecific physical complaints. Several investigators could demonstrate that the SARS-CoV-2 related spike glycoprotein (SGP) attaches not only to ACE-2 receptors but also shows DNA sections highly affine to nicotinic acetylcholine receptors (nAChRs). The nAChR is the principal structure of cholinergic neuromodulation and is responsible for coordinated neuronal network interaction. Non-intrinsic viral nAChR attachment compromises integrative interneuronal communication substantially. This explains the cognitive, neuromuscular and mood impairment, as well as the vegetative symptoms, characterizing post-COVID-19 syndrome. The agonist ligand nicotine shows an up to 30-fold higher affinity to nACHRs than acetylcholine (ACh). We therefore hypothesize that this molecule could displace the virus from nAChR attachment and pave the way for unimpaired cholinergic signal transmission. Treating several individuals suffering from post-COVID-19 syndrome with a nicotine patch application, we witnessed improvements ranging from immediate and substantial to complete remission in a matter of days.

Neuromodulation Virtual Care Technology Provides Safe and Effective Drg/Scs Remote Programming: E-Poster Viewing

Introduction: About 20.4% of US adults suffer from chronic pain and need consistent management plans which were disrupted in 2020 with the COVID-19 pandemic.1,2,3 Patients who use programmable neuromodulation devices to treat chronic pain typically require follow-up visits to address changes in symptoms. An FDA-approved teleprogramming platform enables real-time remote programming via mobile devices for movement disorder and chronic pain patients who use neuromodulation devices. The platform eases the burden travel imposed on many patients, allowing physicians to quickly resolve patient symptoms. The Remote Optimization, Adjustment, and Measurement for Chronic Pain Therapy (ROAM-CPT) study is a post-market, prospective, non-randomized, multi-center investigation to determine that the telehealth system meets patients' therapeutic needs safely and effectively. Materials / Methods: 62 consented subjects across 4 sites, with an implanted neuromodulation device, participating in the REALITY study (NCT03876054) were enrolled in ROAM-CPT and were provided access to the telehealth software. A questionnaire designed for both patient and physician was available after each remote session. The primary success rate was determined by the ability to establish an audio-video connection, complete remote programming or device check, and provide patient clinical care similar to an in-patient session. Additionally, the physicians' and patients' preferences, satisfaction, and reduction in the burden of care compared to in-person sessions were determined. Result(s): 15 patients initiated and completed an audio-video session. All physicians' confirmed services are akin to in-person sessions. During the study, 53.3% of the sessions were complex programming (change in three or more parameters), 26.7% simple programming (change in 1-2 parameter), and 20.0% device interrogation. Overall, all surveyed providers preferred remote care and 93.3% (14/15) of subjects did not require additional clinical care services. Of the 15 subjects across 4 sites, all but 1 reported rapid resolution (reduction in pain), preferred remote care to in-patient, and would recommend a remote session. Patients also reported getting faster appointment time as well as saving travel time and resources typically spent towards an in-person session. Discussion(s): The remote neuromodulation technology provides secure audio-video chat connectivity, programming changes such as amplitude, systems check, and session reports. Physicians easily provide patients care using this platform while patients' therapeutic needs were quickly resolved from the comfort of their homes using their mobile devices. Conclusion(s): Teleprogramming provides real-time programming capabilities and optimizes therapy for patients with neurostimulation devices. Learning Objectives: 1. Teleprogramming provides real-time, safe programming that equals an in-person session. No safety concerns were recorded for all 15 session 2. Virtual clinic affords clinicians the ability to provide quick patient care, does not increase the need for additional follow-up. All 15 participating patients reported resolved therapy needs. 14/15 did not require additional follow-up. 3. Physicians and patients both prefer Virtual clinic 4/4 surveyed physicians and 14/15 surveyed patients preferred virtual clinic. Keywords: Teleprogramming, Neuromodulation, Neurosphere, Virtual clinic, Remote programming, Telehealth Copyright © 2022

An Evaluation of Psychological Wellbeing in Neuromodulation Patients during a Global Pandemic: E-Poster Viewing

Introduction: Bart's Neuromodulation Centre is a centre of excellence for research and innovation. In the UK, the NICE 159 guidelines have highlighted the importance of psychological and multidisciplinary assessment to ascertain the suitability of patients for Neuromodulation. It is widely acknowledged that the global pandemic of Covid-19 has had far-reaching physical, psychological and socioeconomic implications. Despite the various limitations of running services during a pandemic, Barts Neuromodulation Centre maintained the importance of multidisciplinary assessment in the selection of patients suitable for this form of therapy. This paper presents psychological wellbeing outcomes of neuromodulation patients during this unprecedented period. Materials / Methods: Data collection was gathered remotely between January 2021 to December 2021.N=178 completed questionnaires. The mean age was 55 years and 63% were female. Data was collected at baseline and in addition, post-implant data was obtained at 1,3,6 and 12 month follow up. As per NHS England outpatient guidance (2020), all data was completed remotely. All collected data was anonymized and data was stored on an encrypted database. Result(s): Graph 1: HADS Depression Scores [Formula presented] Graph 1 demonstates a 78% decrease in depression scores from baseline to 2 years+ Graph 2: HADS Anxiety Scores [Formula presented] Graph 2 demonstrates a 76% decrease in anxiety scores from baseline to 2 years+. Discussion(s): The data demonstrates significant improvements in psychological wellbeing as shown in depression and anxiety scores after SCS therapy. It would be useful to explore ways to improve patient compliance and explore broader parameters of outcomes. Conclusion(s): Despite the global pandemic, there remains a strong demand for SCS and encouragingly showed significant improvements in psychological wellbeing. Learning Objectives: 1. Evaluate clinical outcomes 2. Understand the impact of a global pandemic on clinical outcomes 3. Delivering remote clinical care and data collection. Keywords: Anxiety, depression, Pain, SCS, neuromodulation, LBP Copyright © 2022

Female LUTS adaptations to COVID era: Lessons learned from the ICS TURNOVER (Transition of fUnctional uRology to New COVID ERa).

Introduction: The COVID-19 pandemic has dramatically affected the Female and Functional Urology (FFU) practice, leading to massive waiting lists, while patients' quality of life remains severely impaired. The aim of the present study is to develop consensual recommendations to guide clinicians on the management of FFU patients. The present paper focuses on female LUTS. Methods: The authors used the Delphi methodology to develop a robust survey questionnaire, covering the principal topics in FFU, based on literature review and expert opinions. Regarding female LUTS, a 98-question survey was distributed among FFU specialists to obtain optimized recommendations, under the auspicious of the International Continence Society (TURNOVER, ICS project). A quantitative analysis of the data was performed, categorizing the mean value from 0-10. Consensus achievement was defined as attaining ≥ 70% agreement. Results: 98 ICS members completed the F-LUTS survey. Recommendations for the diagnosis and management of female LUTS are summarized. Video-consultation should be used for initial assessment, sending questionnaires and bladder diaries in advance to the patient to be filled out before the consultation. However, face-to-face visits are mandatory if POP or continuous incontinence are suspected, and prior to any surgical procedure, regardless of the health alert. Moreover, prescribing medications such as anticholinergics or ß 3 agonists in a telemedicine setting is not considered a safe practice. Follow-up teleconsultations can be used to assess the efficacy and treatment-related adverse events.Urodynamic testing should be only performed if consequences on F-LUTS treatment are expected. The study should be postponed until the pandemic local behaviour flattens.Invasive procedures should be postponed during a high alert. In case surgery is scheduled, outpatient clinics and local anaesthesia should be prioritized. Every patient should be screened for SARS-CoV-2 infection before invasive tests or procedures, following local authorities' guidance. Conclusions: During a pandemic, telemedicine offers a novel way of communication, maintaining medical care while preventing viral transmission. Non-urgent procedures should be postponed until the pandemic curve flattens. Ambulatory procedures under regional or local anaesthesia should be prioritized, aiming to reduce bed occupancy and risk of transmission.

Transcutaneous electrical nerve stimulation for at-home treatment of nocturnal enuresis in children: Determining optimal pad placement

Introduction: Nocturnal enuresis (NE) is a common problem encountered in children that can be recalcitrant to currently available treatment options. Neuromodulation techniques are used to treat various urologic disorders but can be limited by convenience and compliance. Transcutaneous electrical nerve stimulation (TENS) is a neuromodulator that can be used at home to treat various conditions. The aim of this study was to determine if TENS can be offered as an effective at-home option that shows durability for NE in children, and to determine which pad placement is the most efficacious. Materials & Methods: A randomized clinical trial including 90 patients aged 5-18 years presenting with monosymptomatic NE was performed. After one month of behavioral therapy, they were treated with TENS therapy after randomization to three groups based on pad placement: suprapubic (SP), parasacral (PS), and ankle/posterior tibial (PT). TENS therapy was performed nightly for one month. Voiding diaries recording the number of wet nights, wet scale severity score (0-3), TENS compliance, quality of life (QOL) questionnaires, and any adverse reactions were collected monthly at baseline, during TENS therapy, and after TENS for durability assessment, and statistically analyzed after study completion. Results: No patient was cured of NE, and our study failed to show a statistical difference between the study arms in enuresis frequency during TENS. The only statistically significant improvement was QOL during TENS therapy (2.95 improvement for the PT group versus 1.2 and 1.5 regression for SP and PS groups, respectively, p=0.003). PT TENS therapy also showed improvements for enuresis frequency with 2.7 less episodes/month (versus 4.1 and 8.2 more episodes/month in the SP and PS groups, respectively, p=0.06) and the severity of wetness each night with a 0.17 improvement (versus 0.06 and 0.13 regression in the SP and PS groups, respectively, p=0.06) after TENS therapy was completed, however these did not meet statistical significance. Patients were compliant with using TENS therapy (90% or more in all groups) and there were no adverse events. Discussion: This study found that patients who used the PT pad placement for TENS showed significant improvements in QOL during therapy, however we were unable to show a significant difference in enuresis frequency during TENS between groups. The major limitation of our study was the high number of patients lost to follow-up during the COVID-19 pandemic. Conclusion: TENS therapy when combined with behavioral techniques can be an easy and safe tool that can be used at home to help treat NE, however, further studies are needed to optimize this type of therapy to show a clinically significant benefit.