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Reflect on 25 Years of ASIPP at Our 25th Anniversary Luncheon, Immediately Following the Raj-Racz Distinguished Lecture Series!







ASIPP has been actively addressing recent coverage issues through letter correspondence to various agencies. The issues and letters include the following: 
 
AIM published new guidelines effective 04/09/2023. Owned by Anthem, Inc (ANTM), the AIM guidelines are utilized by multiple insurers. ASIPP has addressed the guidelines with a comment letter on the guidelines for Appropriate Use Criteria: Interventional Pain Management. Our comments were related to paravertebral facet joint injection/medial branch nerve block/neurolysis/therapeutic facet joint interventions.
 
We are requesting LCD reconsideration requests to all of the Medicare Contractors for the LCD covering Facet Joint Interventions for Pain Management.
 
ASIPP immediate past president, Amol Soin, sent a letter to Cigna on February 7 addressing their Medical Policy Update on Peripheral Nerve Block Procedures (for trigeminal and occipital neuralgia) which considering them experimental, investigational, or unproven, with an efficacy date of April 18th, 2023. In the letter, we ask that the policy update restricting the use of peripheral nerve blocks be re-evaluated and modified. We recommended that these procedures continue to be covered and we find the characterization of these procedures to be experimental or investigational to be inaccurate.




CGS (L39383), Palmetto (L39402), WPS (L39475), NGS (39455), and Noridian (L39462 and L39464) jurisdictions, have issued SI joint injection policies.

Novitas and First Coast Services have not issued their policies nor have they participated in multijurisdictional committee and have not issued a policy. 

You can use this algorithmic approach whenever you see your patients by utilizing these checklists for each patient prior to performing epidural steroid injections and facet joint interventions. 






The Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EUA) for Lucira COVID-19 & Flu Home Test, the first over-the-counter (OTC) at-home diagnostic test that can detect and differentiate between SARS-CoV-2 and influenza viruses in individuals 2 years of age and older.

The Lucira COVID-19 & Flu Home test is a single-use, nucleic acid amplification test intended for individuals with signs and symptoms consistent with a respiratory tract infection, including COVID-19. The at-home test works by swabbing the nasal cavity and swirling the sample in a vial, which is then placed in a test unit. Results are displayed in the test unit within 30 minutes and determine whether an individual is positive or negative for: Influenza A, Influenza B, and COVID-19. Individuals should report all results to their health care provider.

In symptomatic individuals, the Lucira COVID-19 & Flu Home Test was found to correctly identify 99.3% of negative and 90.1% of positive Influenza A samples, 100% of negative and 88.3% of positive COVID-19 samples, and 99.9% of negative Influenza B samples. The FDA is requiring Lucira to continue collecting samples to determine the test’s ability to detect Influenza B in real world settings as there were not enough cases of Influenza B circulating to include in the study; the test was able to identify the virus in contrived specimens.
ABIPP Part I; ABIPP Path - Combined DCCPM/CSM virtual exam; ABIPP Competency Exam in IPM; ABIPP Competency Exam in Regenerative Medicine

ABIPP Part II; ABIPP Competency Exam - Practical Portion; ABIPP Regenerative Medicine Competency Exam - Practical Portion

But panelists raise multiple concerns over phase III trial data

In two somewhat close votes, an FDA panel of outside experts recommended the agency approve Pfizer's respiratory syncytial virus (RSV) vaccine for older adults, despite concerns over the potential risk for Guillain Barré syndrome.
 
By a tally of 7-4 for safety and efficacy (with one abstention in each case), the Vaccines and Related Biological Products Advisory Committee (VRBPAC) said the evidence favors the RSV prefusion F protein vaccine (RSVPreF) -- which carries a proposed trade name of Abrysvo -- for reducing RSV-related lower respiratory tract infections in adults 60 and up.

However, VRBPAC members showed reservations ranging from the largely health study population, rather than the more vulnerable group of older adults who need the vaccine most, to the limited number of events for the main outcomes.
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Drug will be under added scrutiny to make sure it's for "legitimate veterinary use," agency says

The FDA issued an import alert Tuesday to clamp down on the illegal importation of xylazine, an animal tranquilizer showing up more and more in illicit drugs.
 
"This action aims to prevent the drug from entering the U.S. market for illicit purposes, while maintaining availability for its legitimate uses in animals," the agency said in a press release.
 
Veterinarians legitimately use drug products containing xylazine to sedate large animals such as horses and deer, but it is not safe for use in people and may cause serious and life-threatening side effects, the FDA noted. However, "it has been identified as a contaminant found in combination with opioids such as illicit fentanyl, and in combination with other illicit products that contain stimulants such as methamphetamine and cocaine. People who use illicit drugs may not be aware of the presence of xylazine."
Resident/Fellow News and Updates





Compassion is borne out of a sense of empathy — the ability to understand and share the feelings of others. Studies on empathy show it to be crucial to quality healthcare and not just for patients.
 
In one study on empathy ratings among doctors, 87% of the public believe that compassion, or a clear and obvious desire to relieve suffering, is the most critical factor when choosing a doctor. In fact, it eclipses travel time, wait time, and cost on the list of sought-after physician features.
 
Wendie Trubow, MD, an ob/gyn in Newton, Massachusetts with over 25 years of experience in the medical field, says empathy has absolutely helped her be a better physician.
 
"Patients consistently mention how grateful they are that someone has listened to them and validated them," she says. "When patients feel heard and validated, they are more likely to communicate openly, and this raises the potential of being able to create treatment plans that they will actually participate in. Ultimately, it enriches patient care."

But large observational study has significant limitations

Vitamin D supplements were linked with lower dementia incidence and longer dementia-free survival, prospective data showed.
 
In a sample of 12,000 older adults, exposure to vitamin D supplementation was associated with a 40% lower dementia incidence rate compared with no exposure (adjusted HR 0.60, 95% CI 0.55-0.65), reported Zahinoor Ismail, MD, of the University of Calgary in Canada and the University of Exeter in England, and co-authors.
 
Results were consistent across three vitamin D formulations, the researchers wrote in Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring. Effects were greater in females, in apolipoprotein E ε4 (APOE4) non-carriers, and in people with normal cognition versus those with mild cognitive impairment.

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A multi-part study reports that erythritol — a sugar alcohol (polyol) increasingly used as an artificial sweetener that is also made in the body — is associated with risk of major adverse cardiovascular events (MACE) and promotes clotting (thrombosis).
 
Erythritol is one of the most widely used artificial sweeteners with rapidly increasing prevalence in processed and "keto-related" foods. Artificial sweeteners are "generally recognized as safe" (GRAS) by the US Food and Drug Administration, so there is no requirement for long-term safety studies, and little is known about the long-term health effects.
 
The current research, published online February 27 in Nature Medicine by Marco Witkowski, MD, and colleagues, had multiple parts.
 
First, in a group of patients undergoing cardiac risk assessment, the researchers found that high levels of polyols, especially erythritol, were associated with increased 3-year risk of MACE, defined as cardiovascular death or nonfatal myocardial infarction (MI) or stroke. 






Health officials are warning that an increase in the drug-resistant form of the bacteria shigella is a "serious public health threat." 
 
The CDC issued the warning Friday about the rise in the problematic infections. Most of them have been seen in men who have sex with men, but a small number have also occurred in women and in young children.
 
The bacteria can be spread in a variety of ways, including changing the diaper of an infected baby, touching your mouth when the bacteria are on your hands, eating or drinking contaminated food or water, or through sexual contact. It's easily transmitted because just a tiny amount of the bacteria is enough to make someone sick.
 
Shigella infection causes diarrhea that can be bloody. Other symptoms are a fever, belly cramping, and the feeling that you have to poop but your bowels are already empty. Most people recover on their own with rest and fluids, and severe cases can need antibiotic treatment. But strains of the bacteria that are resistant to treatment are on the rise.
Pain Medicine Case Reports (PMCR) and Editor-in-Chief Alaa Abd-Elsayed, MD, PhD would like to invite you to submit case reports and case series to the PMCR journal. Your article will be published free of charge.

Open access journals are freely available online for immediate worldwide open access to the full text of published articles. There is no subscription fee for open access journals. Open access journals are no different from traditional subscription-based journals: they undergo the same peer-review and quality control as any other scholarly journal.

Interested in becoming a member of the PMCR Editorial Board?
Editorial board members are asked to review 2-6 manuscripts per year. Please submit your most up-to-date CV to sgold@asipp.org for consideration.

For more information or to submit your articles, click here.
| CASE REPORT |


Brian Lee, MBA, Jovan George, DO, Briana Novello, DO, and Ravneet Bhullar, MD


Abstract
BACKGROUND: Botulinum toxin injections have been increasingly used in the treatment of different painful conditions, including thoracic outlet syndrome (TOS). Guidelines to manage adverse effects or toxicity from botulinum toxin injections in these cases are not well established.

CASE REPORT: A female patient in her forties with bilateral arm pain secondary to bilateral neurogenic TOS (NTOS) presented to the pain clinic for botulinum toxin injections to the scalene muscles. Several hours after receiving the injections, the patient experienced dysphagia, hoarseness, and facial paresthesia suspicious for botulinum toxicity. She was administered pyridostigmine for symptom management and for approximately one month until symptom resolution.

CONCLUSIONS: To our knowledge, this is the first case report to discuss the presentation of botulinum toxicity and its management following botulinum toxin injections for pain relief in bilateral NTOS. Botulinum toxicity may be managed with pyridostigmine with some benefit, but further research is needed to establish guidelines.

KEY WORDS: Botulinum toxin injection, botulinum toxicity, pyridostigmine, thoracic outlet syndrome

| RANDOMIZED CONTROLLED TRIAL |


Peipei Huang, MD, Wenrui Ma, MD, Yu Wang, MS, Xiaojuan Shi, MS, Jikun Hao, MS, Zhipeng Tu, MD, Fang Xie, MD, Xuan Li, MS, Zhuojing Luo, MD, and Xueyu Hu, MD


Abstract
BACKGROUND: The postsurgical management of patients with ankylosing spondylitis is often only focused on the incision pain, and the pain caused by abdominal skin traction is paid little attention.

OBJECTIVES: To explore the effectiveness of ultrasound-guided transversus abdominis plane block (TAPB) in treating abdominal skin tension pain after kyphosis surgery.

STUDY DESIGN: Randomized controlled trial.

SETTING: This prospective study consecutively enrolled patients scheduled to undergo kyphosis correction surgery at the Department of Orthopedics of Xijing Hospital from March 2021 to December 2021.

METHODS: The patients were randomized 1:1 to the TAPB and control groups. The Visual Analog Scale (VAS) for abdominal pain, Bruggrmann Comfort Scale (BCS), abdominal skin tension blisters, bed rest duration, length of hospitalization, and the use of patient-controlled analgesia pumps (PCAPs) were compared. The primary endpoint was pain alleviation at 24 hours after surgery.

RESULTS: Thirty-one patients were enrolled, without differences between the 2 groups regarding age, body mass index, preoperative kyphosis severity, operation duration, and blood loss. The TAPB group (n = 16) had lower abdominal VAS scores than the control group (n = 15) at 2, 4, 6, 8, and 12 hours after surgery (P < 0.05). The TAPB group had higher BCS scores than the control group at 4, 6, 8, and 12 hours after surgery (P < 0.05). The TAPB group used PCAPs less frequently than the control group after surgery (P < 0.001). The incidence of tension blisters in the TAPB group was numerically lower than that of the control group, but the difference was not statistically significant (18.8% vs 33.3%, P > 0.05).

LIMITATIONS: The sample size of this study is small and a single-center study, there might be data bias.

CONCLUSIONS: In the first 24 hours after severe kyphosis surgery, TAPB can reduce the pain from abdominal skin tension and increase the comfort scores, but its effects on tension blisters remain to be further studied.

KEY WORDS: Kyphosis, abdominal skin traction, abdominal skin pain, tension blisters, anesthesia, transversus abdominis plane block, visual analog scale, Bruggrmann comfort scale

| OPINION SURVEY |


Kai-Uwe Lewandrowski, MD, Joao Paul Bergamashi, MD, Albert E Telfeian, MD, PhD, Paulo Sergio Teixeira de Carvalho, MD, PhD, and Jorge Felipe Ramirez Leon, MD


Abstract
BACKGROUND: The controversy continues on how to best become proficient in contemporary minimally invasive spinal surgery techniques (MISST). Postgraduate training programs typically lag behind the innovation. Other subspecialty spine care providers often compete with spine surgeons particularly when they do not offer the treatments needed by their patients. The public debate centers around who should be taught and credentialed in providing surgical spine care.

OBJECTIVES: The purpose of this study was to conduct an opinion survey amongst spine care providers regarding the learning curve of MISST and which credentialing standards should be established.

SETTING: Surgeon online opinion survey sent by email, and chat groups in social media networks, including WeChat, WhatsApp, and LinkedIn.

METHODS: Surgeons were asked the following questions: 1) Do you think MISS is harder to learn compared to open surgery? 2) Do you perform MISS? 3) What type of MISS do you perform? 4) If you perform endoscopic surgery, which approach(es)/technique(s) do you employ? 5) In your opinion, where does the innovation take place? 6) Where should MISST be taught? 7) Do you think mastering the MISST learning curve and surgeon skill level affect patient outcomes? 8) Which credentialing criteria do you recommend? Demographic data of responding surgeons, including age, postgraduate training and years from graduation, and practice setting, were also obtained. Descriptive statistics were employed to count the responses and compared to the surgeon’s training using statistical package SPSS Version 27.0 (IBM Corporation, Armonk, NY).

RESULTS: The online survey was viewed by 806 surgeons, started by 487, and completed by 272, yielding a completion rate of 55.9%. Orthopedic surgeons comprised 52.6% (143/272) of respondents, followed by 46.7% (127/272) neurosurgeons, and 0.7% pain management physicians (2/272). On average, respondents had graduated from a postgraduate training program 15.43 ± 10.13 years. Nearly all respondents employed MISST (252/272; 92.8%) and thought that proficiency in MISST affects patients’ outcomes (270/272; 98.2%). Some 54.1% (146/270) opined that MISS is more challenging to learn than traditional open spine surgery. Preferred credentialing criteria were 1) number of MISST cases (87.5%; 238/272), b) skill level (69.9%; 190/272), and c) proficiency assessment (59.9%; 163/272). A case log review (42.3%; 116/272) or an oral examination (26.1%; 71/272) was not favored by surgeons. Surgeons reported academia (43.4%; 116/267) and private practice (41.2%; 110/267) as the centers of innovation. Only 15.4% (41/267) of respondents opined that industry was the main driver over innovation.

LIMITATIONS: Geographical and cultural biases may impact the opinions of responding surgeons.

CONCLUSIONS: Respondents preferred case volume, skill level, and proficiency assessment as credentialing criteria. Surgeons expect academic university programs and specialty societies to provide the necessary training in novel MISST while working with governing boards to update the certification programs.

KEY WORDS: Surgeon opinion survey, minimally invasive spinal surgery, learning curve, credentialing, teaching standards



ASIPP is now in collaboration with Curi Medical Liability Program


Since this malpractice insurance program officially launched in November 2018, ASIPP has signed up hundreds of providers with an average savings of 30%. This is professional liability insurance tailored to our specialty and will stand up for us and defend our practices.
 
Curi is a full-service advisory firm that serves physicians and their practices. Their valued advice is grounded in your priorities and elevated in your outcomes. They are driven by a deep understanding of your specific circumstances in medicine, business, and life. To read a few important points to keep in mind about the program, including discounts, administrative defense, cyber coverage, aggressive claims handling, and complimentary risk management CME activities, visit our website.

ASIPP® has formed a partnership with Henry Schein and PedsPal, a national GPO that has a successful history of negotiating better prices on medical supplies and creating value-added services for independent physicians. Working with MedAssets, PedsPal provides excellent pricing on products like contrast media that alleviate some of the financial pressures you experience today.

ASIPP® is now offering our members the benefit of a unique revenue cycle management/ billing service.

We have received a tremendous amount of interest in the ASIPP® billing and coding program.

Click here to learn more about the negotiated rate for practices and more!
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