The current state of training in pain medicine fellowships: An Association of Pain Program Directors (APPD) survey of program directors.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education. METHODS: This study involved 56 PDs of ACGME-accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow-up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy. RESULTS: Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry-related and professional society-related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long-term success. Fifty-four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies. CONCLUSION: This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12-month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization.

Incidentally diagnosed mammary gland tumors are less likely to be malignant than nonincidental mammary gland tumors.

OBJECTIVE: To compare malignancy rates of canine mammary gland tumors diagnosed incidentally and nonincidentally. ANIMALS: 96 female dogs from which mammary gland tumors were removed. METHODS: Medical records of all female dogs from which mammary gland tumors were removed at a privately owned referral institution between 2018 and 2021 were reviewed. Data were obtained on signalment for each dog, histopathologic results for each tumor, and the primary reason for each dog's presentation to the hospital. The proportion of malignant tumors was compared between dogs that were presented with nonincidental MGTs and dogs that were presented for a different primary condition and had incidental MGTs found on examination. RESULTS: A total of 195 tumors were removed from the 96 dogs in this study. In dogs with incidental MGTs, 82 of 88 (93%) tumors were benign and 6 of 88 (7%) were malignant. In dogs with nonincidental MGTs, 75 of 107 (70%) tumors were benign and 32 of 107 (30%) were malignant. Nonincidental MGTs were significantly (OR, 5.83; 95% CI, 2.31 to 14.73; P = .001) more likely to be malignant compared with incidental MGTs. Dogs with nonincidental MGTs were 6.84 times as likely to have a malignant MGT removed compared with dogs with incidental MGTs (OR, 6.84; 95% CI, 2.47 to 18.94; P < .001). The likelihood of malignancy increased by 5% for each 1-kg increase in body weight (OR, 1.05; 95% CI, 1.01 to 1.09; P = .013). Larger tumors were more likely to be malignant than smaller tumors (P = .001). CLINICAL RELEVANCE: Most incidentally diagnosed MGTs are benign and allow for a good prognosis after excision. Small dogs and dogs with MGTs < 3 cm in diameter are the least likely to have a malignancy.

Structural basis of activation and antagonism of receptor signaling mediated by interleukin-27.

Interleukin-27 (IL-27) uniquely assembles p28 and EBI3 subunits to a heterodimeric cytokine that signals via IL-27Rα and gp130. To provide the structural framework for receptor activation by IL-27 and its emerging therapeutic targeting, we report here crystal structures of mouse IL-27 in complex with IL-27Rα and of human IL-27 in complex with SRF388, a monoclonal antibody undergoing clinical trials with oncology indications. One face of the helical p28 subunit interacts with EBI3, while the opposite face nestles into the interdomain elbow of IL-27Rα to juxtapose IL-27Rα to EBI3. This orients IL-27Rα for paired signaling with gp130, which only uses its immunoglobulin domain to bind to IL-27. Such a signaling complex is distinct from those mediated by IL-12 and IL-23. The SRF388 binding epitope on IL-27 overlaps with the IL-27Rα interaction site explaining its potent antagonistic properties. Collectively, our findings will facilitate the mechanistic interrogation, engineering, and therapeutic targeting of IL-27.

Review of Efficacy and Safety of Spinal Cord Stimulation in Veterans.

OBJECTIVES: Spinal cord stimulation (SCS) has been shown to be an effective and safe option to treat patients with intractable pain in the general population. Our study examined the experience of US veterans with SCS. METHODS: We reviewed electronic health records and conducted phone interviews with 65 veterans who had SCS from 2008 to 2020 at the Southeastern Louisiana Veterans Health Care System (SLVHCS). Our primary outcome measure was veteran would recommend SCS to peers. Secondary outcomes were improvements in activities of daily living and ability to decrease opioid pain medications. RESULTS: A majority (77%) of veterans recommended SCS to their peers. Statistical difference was seen in 16 of 18 categories of activities of daily living based on the Pain Outcomes Questionnaire. No permanent neurologic deficits or deaths were associated with SCS use. There were no neurological sequelae. Three patients (5%) developed skin dehiscence postimplant and were treated with explant surgery but all were eager to get a new SCS implanted. CONCLUSION: Veterans at SLVHCS were satisfied with their experience using SCS and few experienced adverse effects.