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      The Polyanalgesic Consensus Conference (PACC): Recommendations on Intrathecal Drug Infusion Systems Best Practices and Guidelines.

      1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40
      Neuromodulation : journal of the International Neuromodulation Society
      Wiley
      Chronic pain, consensus, fixed rate pump, intrathecal drug delivery, neuropathic pain, nonmalignant pain, opioid, programmable pump, psychological evaluation, safety

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          Abstract

          Pain treatment is best performed when a patient-centric, safety-based philosophy is used to determine an algorithmic process to guide care. Since 2007, the International Neuromodulation Society has organized a group of experts to evaluate evidence and create a Polyanalgesic Consensus Conference (PACC) to guide practice.

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          Most cited references202

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          Relationship between Nonmedical Prescription-Opioid Use and Heroin Use

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            Is Open Access

            A new look at cerebrospinal fluid circulation

            According to the traditional understanding of cerebrospinal fluid (CSF) physiology, the majority of CSF is produced by the choroid plexus, circulates through the ventricles, the cisterns, and the subarachnoid space to be absorbed into the blood by the arachnoid villi. This review surveys key developments leading to the traditional concept. Challenging this concept are novel insights utilizing molecular and cellular biology as well as neuroimaging, which indicate that CSF physiology may be much more complex than previously believed. The CSF circulation comprises not only a directed flow of CSF, but in addition a pulsatile to and fro movement throughout the entire brain with local fluid exchange between blood, interstitial fluid, and CSF. Astrocytes, aquaporins, and other membrane transporters are key elements in brain water and CSF homeostasis. A continuous bidirectional fluid exchange at the blood brain barrier produces flow rates, which exceed the choroidal CSF production rate by far. The CSF circulation around blood vessels penetrating from the subarachnoid space into the Virchow Robin spaces provides both a drainage pathway for the clearance of waste molecules from the brain and a site for the interaction of the systemic immune system with that of the brain. Important physiological functions, for example the regeneration of the brain during sleep, may depend on CSF circulation.
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              Inspiration is the major regulator of human CSF flow.

              The mechanisms behind CSF flow in humans are still not fully known. CSF circulates from its primary production sites at the choroid plexus through the brain ventricles to reach the outer surface of the brain in the subarachnoid spaces from where it drains into venous bloodstream and cervical lymphatics. According to a recent concept of brain fluid transport, established in rodents, CSF from the brain surface also enters the brain tissue along para-arterial routes and exits through paravenous spaces again into subarachnoid compartments. This unidirectional flow is mainly driven by arterial pulsation. To investigate how CSF flow is regulated in humans, we applied a novel real-time magnetic resonance imaging technique at high spatial (0.75 mm) and temporal (50 ms) resolution in healthy human subjects. We observed significant CSF flow exclusively with inspiration. In particular, during forced breathing, high CSF flow was elicited during every inspiration, whereas breath holding suppressed it. Only a minor flow component could be ascribed to cardiac pulsation. The present results unambiguously identify inspiration as the most important driving force for CSF flow in humans. Inspiratory thoracic pressure reduction is expected to directly modulate the hydrostatic pressure conditions for the low-resistance paravenous, venous, and lymphatic clearance routes of CSF. Furthermore, the experimental approach opens new clinical opportunities to study the pathophysiology of various forms of hydrocephalus and to design therapeutic strategies in relation to CSF flow alterations.
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                Author and article information

                Journal
                Neuromodulation
                Neuromodulation : journal of the International Neuromodulation Society
                Wiley
                1525-1403
                1094-7159
                February 2017
                : 20
                : 2
                Affiliations
                [1 ] Center for Pain Relief, Charleston, WV, USA.
                [2 ] Summit Pain Alliance, Santa Rosa, CA, USA.
                [3 ] Case Western Reserve University, Cleveland, OH, USA.
                [4 ] Anesthesia and Chronic Pain Management, Ephraim McDowell Regional Medical Center, Danville, KY, USA.
                [5 ] Anaesthesia and Pain Management Department, EHC Hosptial, Morges, and CHUV University Hospital, Lausanne, Switzerland.
                [6 ] The James Cook University Hospital, Middlesbrough, UK.
                [7 ] Valencia School of Medicine, Hospital General Universitario, Valencia, Spain.
                [8 ] Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
                [9 ] University of Miami Health System, Miami, FL, USA.
                [10 ] University of Kentucky College of Medicine, UK HealthCare Pain Services, Lexington, KY, USA.
                [11 ] Doleys Clinic, Birmingham, AL, USA.
                [12 ] California Pain Medicine Center, Los Angeles, CA, USA.
                [13 ] Anesthesiology and Pharmacology, University of California, San Diego, CA, USA.
                [14 ] Pain Clinic of Monterey Bay, University of California at San Francisco, San Francisco, CA, USA.
                [15 ] Department of Anesthesia, UC San Diego, San Diego, CA, USA.
                [16 ] Center for the Rehabilitation Pain Syndromes (CRPS) at UCLA Medical Plaza, Los Angeles, CA, USA.
                [17 ] Carolina Pain Institute, Wake Forest Baptist Health, Winston-Salem, NC, USA.
                [18 ] Roswell Park Cancer Institute, SUNY, Buffalo, NY, USA.
                [19 ] Manhattan Spine and Pain Medicine, Lenox Hill Hospital, New York, NY, USA.
                [20 ] St. Luke's University Health Network, Bethlehem, PA, USA.
                [21 ] Mayo Clinic, Rochester, MN, USA.
                [22 ] Bryn Mawr Hospital, Bryn Mawr, PA, USA.
                [23 ] Christiana Hospital, Newark, DE, USA.
                [24 ] Stanford University, Palo Alto, CA, USA.
                [25 ] Marcus Neuroscience Institute, Boca Raton, FL, USA.
                [26 ] Integrated Pain Solutions, Columbus, OH, USA.
                [27 ] Holy Cross Hospital, Fort Lauderdale, Florida, USA.
                [28 ] San Francisco Medical Center, University of California, San Francisco, CA, USA.
                [29 ] Summa Western Reserve Hospital, Cuyahoga Falls, OH, USA.
                [30 ] Hôpital de Zone Morges, Morges, Switzerland.
                [31 ] Fox Chase Pain Management Associates PC, Doylestown, PA, USA.
                [32 ] Center for Relief of Pain, Kansas City, MO, USA.
                [33 ] MossRehab, Elkins Park, PA, USA.
                [34 ] Premier Pain Management Centers, Shrewsbury, NJ, USA.
                [35 ] Johns Hopkins University, Baltimore, MD, USA.
                [36 ] Center for Pain and Supportive Care, Phoenix, AZ, USA.
                [37 ] Alabama Pain Center, Huntsville, AL, USA.
                [38 ] Pacific Pain Treatment Center (ret.), San Francisco, CA, USA.
                [39 ] Vanderbilt University Medical Center, Nashville, TN, USA.
                [40 ] Cleveland Clinic, Cleveland, OH, USA.
                Article
                10.1111/ner.12538
                28042904
                84d5ef28-8560-4943-91d1-0a104a123c7e
                © 2017 International Neuromodulation Society.
                History

                Chronic pain,consensus,fixed rate pump,intrathecal drug delivery,neuropathic pain,nonmalignant pain,opioid,programmable pump,psychological evaluation,safety

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