Cannabidiol as a treatment for arthritis and joint pain: an exploratory cross-sectional study.

INTRODUCTION: An estimated 54 million Americans currently suffer from debilitating arthritis. Patients who have exhausted conservative measures can be subject to chronic pain and resort to symptomatic management with anti-inflammatories, acetaminophen, and opioids. Cannabidiol (CBD) is a non-psychoactive cannabinoid that has shown promise in preclinical studies to reduce inflammation and pain associated with arthritis. The purpose of this study was to explore patient perceived effects of cannabidiol on symptoms of arthritis. METHODS: A novel anonymous questionnaire was created to evaluate perceived efficacy of cannabidiol for the treatment of arthritis. A self-selected convenience sample (N=428) was recruited through online methods including social media accounts and newsletters (The Arthritis Foundation and Savvy Cooperative) between May 5, 2020, and November 5, 2020. Statistical analysis was performed to determine differences between types of arthritis and improvements in quality-of-life symptoms. Furthermore, a regression analysis was performed to identify variables associated with decreasing or discontinuing other medications. RESULTS: CBD use was associated with improvements in pain (83%), physical function (66%), and sleep quality (66%). Subgroup analysis by diagnosis type (osteoarthritis, rheumatoid, or other autoimmune arthritis) found improvements among groups for physical function (P=0.013), favoring the osteoarthritis group. The overall cohort reported a 44% reduction in pain after CBD use (P<0.001). The osteoarthritis group had a greater percentage reduction (P=0.020) and point reduction (P<0.001) in pain compared to rheumatoid arthritis and other autoimmune arthritis. The majority of respondents reported a reduction or cessation of other medications after CBD use (N=259, 60.5%): reductions in anti-inflammatories (N=129, 31.1%), acetaminophen (N=78, 18.2%), opioids (N=36, 8.6%) and discontinuation of anti-inflammatories (N=76, 17.8%), acetaminophen (N=76, 17.8%), and opioids (N=81, 18.9%). CONCLUSION: Clinicians and patients should be aware of the various alternative therapeutic options available to treat their symptoms of arthritis, especially in light of the increased accessibility to cannabidiol products. The present study found associations between CBD use and improvements in patient's arthritis symptoms and reductions in other medications. Future research should focus on exploring the benefits of CBD use in this patient population with clinical trials.

An Algorithmic Approach to the Physical Exam for the Pain Medicine Practitioner: A Review of the Literature with Multidisciplinary Consensus.

BACKGROUND: Increased utilization of telemedicine has created a need for supplemental pain medicine education, especially for the virtual physical assessment of the pain patient. Traditional clinical training utilizes manual and tactile approaches to the physical examination. Telemedicine limits this approach and thus alternative adaptations are necessary to acquire information needed for sound clinical judgement and development of a treatment plan. Clinical assessment of pain is often challenging given the myriad of underlying etiologies contributing to the sensory experience. The COVID-19 pandemic has led to a dramatic increase in the use of virtual and telemedicine visits, further complicating the ease of assessing patients in pain. The increased reliance on telemedicine visits requires clinicians to develop skills to obtain objective information from afar. While eliciting a comprehensive history and medication assessment are performed in a standard fashion via telemedicine, a virtual targeted physical examination is a new endeavor in our current times. In order to appropriately diagnose and treat patients not directly in front of you, a pivot in education adaptations are necessary. OBJECTIVE: To summarize best care practices in the telemedicine physical exam while presenting an algorithmic approach towards virtual assessment for the pain practitioner. DESIGN: Review of the literature and expert multidisciplinary panel opinion. SETTING: Nationally recognized academic tertiary care centers. SUBJECTS: Multidisciplinary academic experts in pain medicine. METHODS: Expert consensus opinion from the literature review. RESULTS: An algorithm for the virtual physical exam for pain physicians was created using literature review and multidisciplinary expert opinion. CONCLUSIONS: The authors here present simple, comprehensive algorithms for physical exam evaluations for the pain physician stemming from a review of the literature.

Medical Cannabis for Headache Pain: a Primer for Clinicians.

PURPOSE OF REVIEW: Public acceptance of Cannabis sativa L. (cannabis) as a therapeutic option grows despite lags in both research and clinician familiarity. Cannabis-whether as a medical, recreational, or illicit substance-is and has been commonly used by patients. With ongoing decriminalization efforts, decreased perception of harms, and increased use of cannabis in the treatment of symptoms and disease, it is critical for clinicians to understand the rationale for specific therapies and their medical and practical implications for patients. In view of the opioid crisis, overall patient dissatisfaction, and lack of adherence to current chronic pain and headache therapies, this review provides up-to-date knowledge on cannabis as a potential treatment option for headache pain. RECENT FINDINGS: Research into the use of cannabinoids for disease treatment have led to FDA-approved drugs for seizures, nausea, and vomiting caused by cancer chemotherapy; and for decreased appetite and weight loss in people with HIV/AIDS. For a wide variety of conditions and symptoms (including chronic pain), cannabis has gained increasing acceptance in society. The effects of cannabidiol (CBD) and tetrahydrocannabinol (THC) in pain pathways have been significantly elucidated. An increasing number of retrospective studies have shown a decrease in pain scores after administration of cannabinoids, as well as long-term benefits such as reduced opiate use. Yet, there is no FDA-approved cannabis product for headache or other chronic pain disorders. More is being done to determine who is likely to benefit from cannabis as well as to understand the long-term effects and limitations of the treatment. Cannabis can refer to a number of products derived from the plant Cannabis sativa L. Relatively well-tolerated, these products come in different configurations, types, and delivery forms. Specific formulations of the plant have been shown to be an effective treatment modality for chronic pain, including headache. It is important for clinicians to know which product is being discussed as well as the harms, benefits, contraindications, interactions, and unknowns in order to provide the best counsel for patients.

Survey of Pain Medicine Specialists' Familiarity with Migraine Management.

OBJECTIVE: Pain specialists treat patients with headache and interface with those who use opioids more so than neurologists and headache specialists. We assessed the headache medicine knowledge and needs of pain specialists. DESIGN/SETTING: Cross-sectional online survey. SUBJECTS: Members of the American Academy of Pain Medicine. METHODS: Survey was based on a prior survey of primary care providers' knowledge and needs and was iteratively updated by four headache specialists, two with pain medicine affiliations. RESULTS: Of the 105 respondents, 71.4% were physicians, 34.3% were women, and they averaged 20.0 ± 13.6 years in practice. The most common specialty was anesthesia (36.1%, n = 35/97) followed by neurology (14.4%, n = 14/97). About half of providers (55.7%, n = 34/61 and 53.3%, n = 32/60) were familiar with the American Academy of Neurology Guidelines for pharmacological migraine prevention and the Choosing Wisely Campaign recommendations for limiting neuroimaging and opioids. Less than half of all providers (39.7%, n = 23/58) were familiar with the American Headache Society guidelines for emergency management of migraine. Providers were aware of Level A evidence-based nonpharmacological therapies, with over three-fourths recognizing cognitive behavioral therapy (80.7%, n = 50/62) and biofeedback (75.8%, n = 47/62) as evidence-based interventions. About 80% of providers (n = 50/64) estimate making migraine diagnoses in ≤50% of their patients with headache. Providers consider starting preventive headache therapy at 7.1 ± 3.9 days/month and report referring 34.3%±34.2% of patients to behavioral interventions. CONCLUSIONS: Dissemination and implementation of headache guidelines is needed for pain medicine specialists. Providers may need help diagnosing migraine based on currently accepted guidelines and referring for evidence-based behavioral therapies.

Telemedicine During COVID-19 and Beyond: A Practical Guide and Best Practices Multidisciplinary Approach for the Orthopedic and Neurologic Pain Physical Examination.

BACKGROUND: The COVID pandemic has impacted almost every aspect of human interaction, causing global changes in financial, health care, and social environments for the foreseeable future. More than 1.3 million of the 4 million cases of COVID-19 confirmed globally as of May 2020 have been identified in the United States, testing the capacity and resilience of our hospitals and health care workers. The impacts of the ongoing pandemic, caused by a novel strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have far-reaching implications for the future of our health care system and how we deliver routine care to patients. The adoption of social distancing during this pandemic has demonstrated efficacy in controlling the spread of this virus and has been the only proven means of infection control thus far. Social distancing has prompted hospital closures and the reduction of all non-COVID clinical visits, causing widespread financial despair to many outpatient centers. However, the need to treat patients for non-COVID problems remains important despite this pandemic, as care must continue to be delivered to patients despite their ability or desire to report to outpatient centers for their general care. Our national health care system has realized this need and has incentivized providers to adopt distance-based care in the form of telemedicine and video medicine visits. Many institutions have since incorporated these into their practices without financial penalty because of Medicare's 1135 waiver, which currently reimburses telemedicine at the same rate as evaluation and management codes (E/M Codes). Although the financial burden has been alleviated by this policy, the practitioner remains accountable for providing proper assessment with this new modality of health care delivery. This is a challenge for most physicians, so our team of national experts has created a reference guide for musculoskeletal and neurologic examination selection to retrofit into the telemedicine experience. OBJECTIVES: To describe and illustrate musculoskeletal and neurologic examination techniques that can be used effectively in telemedicine. STUDY DESIGN: Consensus-based multispecialty guidelines. SETTING: Tertiary care center. METHODS: Literature review of the neck, shoulder, elbow, wrist, hand, lumbar, hip, and knee physical examinations were performed. A multidisciplinary team comprised of physical medicine and rehabilitation, orthopedics, rheumatology, neurology, and anesthesia experts evaluated each examination and provided consensus opinion to select the examinations most appropriate for telemedicine evaluation. The team also provided consensus opinion on how to modify some examinations to incorporate into a nonhealth care office setting. RESULTS: Sixty-nine examinations were selected by the consensus team. Household objects were identified that modified standard and validated examinations, which could facilitate the examinations.The consensus review team did not believe that the modified tests altered the validity of the standardized tests. LIMITATIONS: Examinations selected are not validated for telemedicine. Qualitative and quantitative analyses were not performed. CONCLUSIONS: The physical examination is an essential component for sound clinical judgment and patient care planning. The physical examinations described in this manuscript provide a comprehensive framework for the musculoskeletal and neurologic examination, which has been vetted by a committee of national experts for incorporation into the telemedicine evaluation.

Modular soft x-ray spectrometer for applications in energy sciences and quantum materials.

Over the past decade, the advances in grating-based soft X-ray spectrometers have revolutionized the soft X-ray spectroscopies in materials research. However, these novel spectrometers are mostly dedicated designs, which cannot be easily adopted for applications with diverging demands. Here we present a versatile spectrometer design concept based on the Hettrick-Underwood optical scheme that uses modular mechanical components. The spectrometer's optics chamber can be used with gratings operated in either inside or outside orders, and the detector assembly can be reconfigured accordingly. The spectrometer can be designed to have high spectral resolution, exceeding 10 000 resolving power when using small source (∼1µm) and detector pixels (∼5µm) with high line density gratings (∼3000 lines/mm), or high throughput at moderate resolution. We report two such spectrometers with slightly different design goals and optical parameters in this paper. We show that the spectrometer with high throughput and large energy window is particularly useful for studying the sustainable energy materials. We demonstrate that the extensive resonant inelastic X-ray scattering (RIXS) map of battery cathode material LiNi1/3Co1/3Mn1/3O2 can be produced in few hours using such a spectrometer. Unlike analyzing only a handful of RIXS spectra taken at selected excitation photon energies across the elemental absorption edges to determine various spectral features like the localized dd excitations and non-resonant fluorescence emissions, these features can be easily identified in the RIXS maps. Studying such RIXS maps could reveal novel transition metal redox in battery compounds that are sometimes hard to be unambiguously identified in X-ray absorption and emission spectra. We propose that this modular spectrometer design can serve as the platform for further customization to meet specific scientific demands.

Managing Chronic Headache Disorders.

Headaches are a very common disorder, more common than asthma and diabetes combined. Migraine is the most common headache disorder, but it remains underdiagnosed and therefore undertreated. The treatment of migraines is divided into acute and prophylaxis. Patients who are experiencing 8 or more headaches a month or those who experience disability with their headaches as determined by the Migraine Disability Assistance Score or MIDAS should be placed on prophylaxis.

The Sphenopalatine Ganglion: Anatomy, Pathophysiology, and Therapeutic Targeting in Headache.

The sphenopalatine ganglion (SPG) has attracted the interest of practitioners treating head and face pain for over a century because of its anatomical connections and role in the trigemino-autonomic reflex. In this review, we discuss the anatomy of the SPG, as well as what is known about its role in the pathophysiology of headache disorders, including cluster headache and migraine. We then address various therapies that target the SPG, including intranasal medication delivery, new SPG blocking catheter devices, neurostimulation, chemical neurolysis, and ablation procedures.

Comparison of infrapatellar and subcutaneous adipose tissue stromal vascular fraction and stromal/stem cells in osteoarthritic subjects.

Since inflammatory mechanisms have been postulated to link obesity to osteoarthritis, the current study evaluated the ratio of immune cells to multipotent stromal cells within the infrapatellar fat pad (IPFP) and subcutaneous adipose tissue (SQ) of the knee; each depot has potential as a source of regenerative cells. The immunophenotypes of stromal vascular fraction (SVF) and adipose-derived stem cells (ASCs) of the IPFP and SQ were determined in tissues from osteoarthritic subjects (n = 7) undergoing total knee replacement. Based on a subset of surface antigens, the immunophenotype of ASCs from SQ of OA subjects was not significantly different from that of relatively healthy and leaner subjects undergoing elective liposuction surgery. Flow-cytometry comparison of SVF cell populations in the IPFP of OA subjects resembled those within the subject's own matched SQ, with the exception of the endothelial marker CD31(+) , which was significantly greater in cells from SQ. In the OA subjects, lower numbers of capillary-like structures and higher numbers of stromal and alkaline phosphatase colony-forming units in the IPFP vs SQ were consistent with this finding; however, ASCs from both depots in OA subjects exhibited comparable adipogenic and osteogenic differentiation potential. Thus, the IPFP contains an ASC and immune cell population similar to that of donor-matched SQ, making it an alternative ASC source for tissue regeneration. Further studies will be needed to determine whether IPFP immune cell infiltrates play an aetiological role in osteoarthritis equivalent to that shown in diabetes associated with obesity.

A portable cryo-plunger for on-site intact cryogenic microscopy sample preparation in natural environments.

We present a modern, light portable device specifically designed for environmental samples for cryogenic transmission-electron microscopy (cryo-TEM) by on-site cryo-plunging. The power of cryo-TEM comes from preparation of artifact-free samples. However, in many studies, the samples must be collected at remote field locations, and the time involved in transporting samples back to the laboratory for cryogenic preservation can lead to severe degradation artifacts. Thus, going back to the basics, we developed a simple mechanical device that is light and easy to transport on foot yet effective. With the system design presented here we are able to obtain cryo-samples of microbes and microbial communities not possible to culture, in their near-intact environmental conditions as well as in routine laboratory work, and in real time. This methodology thus enables us to bring the power of cryo-TEM to microbial ecology.

Post-operative hypertension after total knee arthroplasty and the effects on transfusion rates.

Transfusions are a cause of significant patient morbidity as well as expense. Anesthesia literature has examined controlled intraoperative hypotension as a means for reducing blood loss and transfusions. Our hypothesis is that inversely increased blood pressure post-operatively would then lead to increased blood loss and transfusions.We examined 105 consecutive patients who underwent TKA. We found a significant odds ratio of 1.123 for pre-operative hematocrit. For post-operative blood pressure, we calculated an insignificant odds ratio of 1.007, proving no relationship between post-operative blood pressure and transfusions.This is the first study to examine increased post-operative blood pressure's contribution to transfusion rates. Although we confirmed that low pre-operative hematocrit contributes to increased transfusions, we did not find a relationship between post-operative blood pressure and transfusions.

A beamline for high-pressure studies at the Advanced Light Source with a superconducting bending magnet as the source.

A new facility for high-pressure diffraction and spectroscopy using diamond anvil high-pressure cells has been built at the Advanced Light Source on beamline 12.2.2. This beamline benefits from the hard X-radiation generated by a 6 T superconducting bending magnet (superbend). Useful X-ray flux is available between 5 keV and 35 keV. The radiation is transferred from the superbend to the experimental enclosure by the brightness-preserving optics of the beamline. These optics are comprised of a plane parabola collimating mirror, followed by a Kohzu monochromator vessel with Si(111) crystals (E/DeltaE approximately equal 7000) and W/B4C multilayers (E/DeltaE approximately equal 100), and then a toroidal focusing mirror with variable focusing distance. The experimental enclosure contains an automated beam-positioning system, a set of slits, ion chambers, the sample positioning goniometry and area detector (CCD or image-plate detector). Future developments aim at the installation of a second endstation dedicated to in situ laser heating and a dedicated high-pressure single-crystal station, applying both monochromatic and polychromatic techniques.

Suite of three protein crystallography beamlines with single superconducting bend magnet as the source.

At the Advanced Light Source, three protein crystallography beamlines have been built that use as a source one of the three 6 T single-pole superconducting bending magnets (superbends) that were recently installed in the ring. The use of such single-pole superconducting bend magnets enables the development of a hard X-ray program on a relatively low-energy 1.9 GeV ring without taking up insertion-device straight sections. The source is of relatively low power but, owing to the small electron beam emittance, it has high brightness. X-ray optics are required to preserve the brightness and to match the illumination requirements for protein crystallography. This was achieved by means of a collimating premirror bent to a plane parabola, a double-crystal monochromator followed by a toroidal mirror that focuses in the horizontal direction with a 2:1 demagnification. This optical arrangement partially balances aberrations from the collimating and toroidal mirrors such that a tight focused spot size is achieved. The optical properties of the beamline are an excellent match to those required by the small protein crystals that are typically measured. The design and performance of these new beamlines are described.