- Pain Management
Instructor, Anesthesiology, Perioperative and Pain Medicine
Board Certification: Pain Medicine, American Board of Anesthesiology (2012)
Medical Education:Stanford University - CAPS (2004) CA
Board Certification: Anesthesia, American Board of Anesthesiology (2009)
Fellowship:Stanford Pain Management (2009) CA
Residency:Stanford University (2008) CA
Internship:Massachusetts General Hospital (2005) MA
Perioperative interventions to reduce chronic postsurgical pain.
Journal of reconstructive microsurgery
2013; 29 (4): 213-222
Approximately 10% of patients following a variety of surgeries develop chronic postsurgical pain. Reducing chronic postoperative pain is especially important to reconstructive surgeons because common operations such as breast and limb reconstruction have even higher risk for developing chronic postsurgical pain. Animal studies of posttraumatic nerve injury pain demonstrate that there is a critical time frame before and immediately after nerve injury in which specific interventions can reduce the incidence and intensity of chronic neuropathic pain behaviors-so called "preventative analgesia." In animal models, perineural local anesthetic, systemic intravenous local anesthetic, perineural clonidine, systemic gabapentin, systemic tricyclic antidepressants, and minocycline have each been shown to reduce pain behaviors days to weeks after treatment. The translation of this work to humans also suggests that brief perioperative interventions may protect patients from developing new chronic postsurgical pain. Recent clinical trial data show that there is an opportunity during the perioperative period to dramatically reduce the incidence and severity of chronic postsurgical pain. The surgeon, working with the anesthesiologist, has the ability to modify both early and chronic postoperative pain by implementing an evidence-based preventative analgesia plan.
View details for DOI 10.1055/s-0032-1329921
View details for PubMedID 23463498
Test-Retest Reliability of Thermal Temporal Summation Using an Individualized Protocol
JOURNAL OF PAIN
2013; 14 (1): 79-88
Temporal summation (TS) refers to the increased perception of pain with repetitive noxious stimuli. It is a behavioral correlate of wind-up, the spinal facilitation of recurring C-fiber stimulation. In order to utilize TS in clinical pain research, it is important to characterize TS in a wide range of individuals and to establish its test-retest reliability. Building on a fixed-parameter protocol, we developed an individually adjusted protocol to broadly capture thermally generated TS. We then examined the test-retest reliability of TS within-day (intertrial intervals ranging from 2 to 30 minutes) and between-days (intersession interval of 7 days). We generated TS-like effects in 19 of the 21 participants. Strong correlations were observed across all trials over both days (intraclass correlation [ICC] [A, 10] = .97, 95% confidence level [CL] = .94-.99) and across the initial trials between days (ICC [A, 1] = .83, 95% CL = .58-.93). Repeated measures mixed-effects modeling demonstrated no significant within-day variation and only a small (5 out of 100 points) between-day variation. Finally, a Bland-Altman analysis suggested that TS is reliable across the range of observed scores. Without intervention, thermally-generated TS is generally stable within day and between days.Our study introduces a new strategy to generate thermal TS in a high proportion of individuals. This study confirms the test-retest reliability of thermal TS, supporting its use as a consistent behavioral correlate of central nociceptive facilitation.
View details for DOI 10.1016/j.jpain.2012.10.010
View details for Web of Science ID 000314081100009
View details for PubMedID 23273835
Understanding Central Mechanisms of Acupuncture Analgesia Using Dynamic Quantitative Sensory Testing: A Review
EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE
We discuss the emerging translational tools for the study of acupuncture analgesia with a focus on psychophysical methods. The gap between animal mechanistic studies and human clinical trials of acupuncture analgesia calls for effective translational tools that bridge neurophysiological data with meaningful clinical outcomes. Temporal summation (TS) and conditioned pain modulation (CPM) are two promising tools yet to be widely utilized. These psychophysical measures capture the state of the ascending facilitation and the descending inhibition of nociceptive transmission, respectively. We review the basic concepts and current methodologies underlying these measures in clinical pain research, and illustrate their application to research on acupuncture analgesia. Finally, we highlight the strengths and limitations of these research methods and make recommendations on future directions. The appropriate addition of TS and CPM to our current research armamentarium will facilitate our efforts to elucidate the central analgesic mechanisms of acupuncture in clinical populations.
View details for DOI 10.1155/2013/187182
View details for Web of Science ID 000319569800001
View details for PubMedID 23762107
Concealed mothball abuse prior to anesthesia: mothballs, inhalants, and their management
ACTA ANAESTHESIOLOGICA SCANDINAVICA
2005; 49 (1): 113-116
Mothballs are one of a number of volatile compounds including model airplane glue, spray paint, nail polish remover, room fresheners, and gasoline that are intentionally inhaled for the purpose of recreational self-intoxication. Their inhalation produces a rapid 'high' characterized by euphoria and generalized intoxication. Chronic abuse can be associated with significant organ impairment, and, in rare cases, cardiac dysrhythmias and deranged end-tidal gas monitoring. Mothballs contain the aromatic compound naphthalene and/or paradichlorobenzene. Prolonged exposure can cause hepatic failure and severe hemolytic anemia. We present a case of a young adult who initially concealed her chronic mothball inhalation. The literature regarding mothball abuse as well as inhalant abuse relevant to anesthesia is reviewed, and suggestions for the diagnosis and peri-operative management are offered.
View details for DOI 10.1111/j.1399-6576.2004.00510.x
View details for Web of Science ID 000226638800024
View details for PubMedID 15675996
Serotyping of Toxoplasma gondii infections in humans using synthetic peptides
JOURNAL OF INFECTIOUS DISEASES
2003; 187 (9): 1484-1495
To determine whether the characteristics of disease due to Toxoplasma gondii (toxoplasmosis) are dependent on the infecting strain, we have developed an enzyme-linked immunosorbent assay for typing strains that uses infection serum reacted against polymorphic peptides derived from Toxoplasma antigens SAG2A, GRA3, GRA6, and GRA7. Pilot studies with infected mice established the validity of the approach, which was then tested with human serum. In 8 patients who had Sabin-Feldman dye test titers >64 and for whom the infecting strain type was known, the peptides correctly distinguished type II from non-type II infections. ELISA analysis of a second group of 10 infected pregnant women from whom the parasite strain had not been isolated gave a clear prediction of the strain type causing infection. This method should allow statistically significant data to be obtained about whether different strain types cause disease with different characteristics.
View details for Web of Science ID 000182273700017
View details for PubMedID 12717631