Residency, Stanford University School of Medicine, Anesthesia (2024)
Internship, Stanford University School of Medicine, Medicine (2021)
MD, Stanford University School of Medicine, Clinical Research (2020)
BA, Harvard College, Human Developmental and Regenerative Biology, Secondary in Global Health and Health Policy (2014)
Role of peripheral nerve stimulation in treating chronic neuropathic pain: an international focused survey of pain medicine experts.
Regional anesthesia and pain medicine
2023; 48 (6): 312-318
Interventional pain management (IPM) options for refractory neuropathic pain (NP) have recently increased with availability of peripheral nerve stimulation (PNS) equipment and expertise. Given a lack of high-quality evidence and guidelines on this topic, we sought to understand the perception of physicians with expertise in treating NP regarding IPM and the role of PNS. We emailed a survey in March 2022 to international NP experts including pain medicine physicians, researchers, and leaders of 11 professional pain societies. No representatives from vendors of PNS systems were included in the design of the survey nor as respondents. Among 24 respondents (67% of those contacted), the distal common peroneal, tibial, and sural nerves were most frequently targeted (60%) with PNS. Persistent postsurgical pain of more than 3 months was the most common indication for PNS (84%). The aggregate NP treatment algorithm in order of median rank was non-opioid medications as first line, IPM including epidural/perineural steroid injections tied with transcutaneous electrical nerve stimulation as second line, pulsed radiofrequency (RF) tied with RF ablation/denervation as third line, temporary then permanent PNS as fourth line, followed by spinal cord stimulation, opioids, cryoablation, botulinum, peripheral nerve field stimulation, intrathecal targeted drug delivery, and others. Before offering PNS, 12 respondents (50%) indicated their preference for trialing non-neuromodulation treatments for 1-3 months. Twenty-two respondents (92%) agreed PNS should be offered early in the treatment of neuropathic pain. The most common barriers to PNS use were cost, lack of high-quality evidence in support of its use, lack of exposure to PNS in training programs, and lack of familiarity with the use of ultrasound guidance. PNS appears to have an increasing role in the treatment of NP but more research is needed on the outcomes of PNS to elucidate its role.
View details for DOI 10.1136/rapm-2022-104073
View details for PubMedID 37080584
Application of the novel Nalu Neurostimulation System for peripheral nerve stimulation.
Peripheral nerve stimulation is an established treatment modality for chronic neuropathic pain. Over the last decade, with the advent of innovative devices and delivery platforms, peripheral nerve stimulation has evolved from invasive open surgeries to image-guided, minimally invasive percutaneous procedures. The authors hereby present a novel device, the Nalu Neurostimulation System(Nalu Medical, CA, USA), which has established its advantages in providing predictable and reliable peripheral nerve stimulation therapy for chronic neuropathic pain management. This novel device is effective in treating chronic pain conditions such as post-herniorrhaphy pain syndrome, intercostal neuralgia, post-laminectomy syndrome, and complex regional pain syndromeand holds great promise for the treatment of peripheral neuropathic pain.
View details for DOI 10.2217/pmt-2021-0050
View details for PubMedID 35946308
Considerations in Permanent Implantation of Peripheral Nerve Stimulation (PNS) for Chronic Neuropathic Pain: An International Cross Sectional Survey of Implanters.
Pain practice : the official journal of World Institute of Pain
INTRODUCTION: Novel minimally invasive short-term and long-term peripheral nerve stimulation (PNS) systems have revolutionized targeted treatment of chronic neuropathic pain. We present an international survey of PNS-implanting pain physicians to assess what factors they consider when offering permanent PNS.METHODS: This cross-sectional study consisted of a survey (Qualtrics) that was distributed to PNS-implanting physicians in a device supplier's entire email database on November 13, 2020, with 3 weeks of response time. Physicians' contact information in the form of their email addresses had been previously collected by the supplier upon device distribution with permission to use survey responses for research.RESULTS: Of 2,032 database physicians, 40 physicians representing 37 institutions responded to the survey. The most common application of PNS was mononeuropathic pain (57%). The most frequently targeted nerve was the suprascapular nerve (29%). 14% of physicians reported 81-100% of their implants were dual-lead. The representative physicians ranged broadly in their most frequently-targeted nerves. Although mononeuropathic pain was the most common indication for PNS, there was still varied response regarding other indications such as CRPS and post-surgical chronic pain.CONCLUSION: In context of a low response rate, identifying such factors can help update the prevailing treatment algorithm for interventional therapies, assist pain physicians in better identifying which patients are the best candidates for PNS, and inform future clinical trial design on PNS efficacy.
View details for DOI 10.1111/papr.13105
View details for PubMedID 35178863
Evidence for Continuing Buprenorphine in the Perioperative Period.
The Clinical journal of pain
OBJECTIVES: Given there are conflicting recommendations for the perioperative management of buprenorphine, we conducted a retrospective cohort study of our surgery patients on buprenorphine whose baseline dose had been preoperatively continued, tapered or discontinued.METHODS: With IRB approval, we reviewed charts from January 1, 2013 to June 30, 2016 of patients on buprenorphine who had received elective surgery at Stanford Healthcare. Our primary outcome of interest was the change in pain score, defined as mean postoperative pain score - preoperative pain score. We also collected data on patients' tapering procedure and any postoperative non-buprenorphine opioid requirements.RESULTS: Out of approximately 1200 patients on buprenorphine, 121 had surgery of which 50 were admitted and included in the study. Perioperative continuation of transdermal buprenorphine resulted in a lower change in pain score postoperatively (0.606±0.878) than discontinuation (4.83±1.23, P=0.012). Among sublingual patients, there was no difference in the change in pain score between those who were tapered to a non-zero dose versus discontinued (P=0.55). Continuation of sublingual buprenorphine resulted in fewer non-buprenorphine scheduled opioid prescriptions than its taper or discontinuation (P=0.028). Finally, tapers were performed with great variability in the tapering team and rate of taper.DISCUSSION: Based on our findings, we implemented a policy at our institution for the continuation of perioperative buprenorphine whenever possible. Our work reveals crucial targets for the education of perioperative healthcare providers and the importance of coordination amongst all perioperative services and providers.
View details for DOI 10.1097/AJP.0000000000000858
View details for PubMedID 32520814
Feasibility and Safety of Intrathoracic Biopsy and Repeat Biopsy for Evaluation of Programmed Cell Death Ligand-1 Expression for Immunotherapy in Non-Small Cell Lung Cancer
2018; 287 (1): 326–32
Purpose To determine feasibility and safety of biopsy and repeat biopsy for assessment of programmed cell death ligand-1 (PD-L1) status. Materials and Methods This retrospective analysis reviewed 101 patients who underwent transthoracic core needle biopsy for the KEYNOTE-001 (MK-3475) clinical trial of pembrolizumab, an antiprogrammed cell death-1 therapy for non-small cell lung cancer, from May 2012 to September 2014. Sixty-one male patients (mean age, 66.1 years; range 36-83 years) and 40 female patients (mean age, 66.8 years; age range, 36-90 years) were included. Data collected included population characteristics, treatment history, target location, size, and depth from pleura. Adequacy of the tissue sample for diagnostic testing and rates of biopsy-related complications were assessed. Statistical analysis was performed by using univariate and multivariate generalized linear models to determine significant risk factors for biopsy complications. Results A total of 110 intrathoracic biopsies were performed, and 101 (91.8%) were performed as repeat biopsies subsequent to a previous percutaneous or bronchoscopic biopsy or previous surgical biopsy or resection. More than 84.5% (93 of 110) of biopsies were performed in patients who had undergone previous local or systemic therapy. Specimens were adequate for evaluation of PD-L1 expression in 96.4% of biopsies. Procedure-related complications occurred in 28 biopsies (25.4%); pneumothorax was most common (22.7%). Overall mean number of core needle biopsy samples obtained was 7.9 samples. Conclusion Image-guided transthoracic core needle biopsy is an effective method for obtaining tissue for PD-L1 expression analysis. © RSNA, 2017.
View details for DOI 10.1148/radiol.2017170347
View details for Web of Science ID 000427992600040
View details for PubMedID 29232184