Reoperation Following Primary Greater Occipital Nerve Decompression Surgery: Incidence, Risk Factors and Outcomes.

BACKGROUND: Although nerve decompression surgery is an effective treatment for refractory occipital neuralgia (ON), a proportion of patients experience recurrence of pain and undergo reoperation. This study analyzes the incidence, risk factors, and outcomes of reoperation following primary greater occipital nerve (GON) decompression. METHODS: 215 patients who underwent 399 primary GON decompressions were prospectively enrolled. Data included patient demographics, past medical and surgical history, reoperation rates, intraoperative findings, surgical technique, and postoperative outcomes in terms of pain frequency (days/month), duration (hours/day), intensity (scale 0-10), and migraine headache index (MHI). Bivariate analyses, univariable and multivariable logistic regression analysis was performed. RESULTS: 27 (6.8%) GON decompressions required reoperation with neurectomy at a median follow-up time of 15.5 months (9.8-40.5). Cervical spine disorders on imaging that did not warrant surgical intervention (OR, 4.88; 95% 1.61-14.79; p<0.01) and radiofrequency ablation (RFA) (OR, 4.20; 95% CI, 1.45-15.2; p<0.05) were significantly associated with higher rates of reoperation. At 12 months postoperatively, patients who underwent reoperation achieved similar mean reductions in pain frequency, duration, intensity and MHI, as compared to patients who underwent only primary decompression (p>0.05). CONCLUSION: Patients with ON who have a history of cervical spine disorders or RFA should be counseled that primary decompression has a higher risk of reoperation, but outcomes are ultimately comparable.

Opioid Coprescribing with Sedatives after Implant-Based Breast Reconstruction.

BACKGROUND: Skeletal muscle relaxants and benzodiazepines are thought to mitigate against postoperative muscle contraction. The Centers for Disease Control and Prevention and the Food and Drug Administration warn against coprescribing them with opioids because of increased risks of overdose and death. The authors evaluated the frequency of coprescribing of opioids with skeletal muscle relaxants or benzodiazepines after implant-based reconstruction. METHODS: The authors examined health care claims to identify women (18 to 64 years old) who underwent implant-based breast reconstruction between January of 2008 and June of 2019 to determine the frequency of coprescribing, factors associated with coprescribing opioids and skeletal muscle relaxants or benzodiazepines, and the impact on opioid refills within 90 days of reconstruction. RESULTS: A total of 86.7 percent of women ( n = 7574) who had implant-based breast reconstruction filled an opioid prescription perioperatively. Of these, 27.7 percent of women filled prescriptions for opioids and benzodiazepines, 14.4 percent for opioids and skeletal muscle relaxants, and 2.4 percent for opioids, benzodiazepines, and skeletal muscle relaxants. Risk factors for coprescribing opioids and benzodiazepines included use of acellular dermal matrix, immediate reconstruction, and history of anxiety. Women who filled prescriptions for opioids and skeletal muscle relaxants, opioids and benzodiazepines, and opioids with skeletal muscle relaxants and benzodiazepines were significantly more likely to refill opioid prescriptions, even when controlling for preoperative opioid exposure. CONCLUSIONS: Nearly half of women filled an opioid prescription with a benzodiazepine, skeletal muscle relaxant, or both after implant-based breast reconstruction. Coprescribing of opioids with skeletal muscle relaxants may potentiate opioid use after surgery and should be avoided given the risks of sedation. Identifying strategies that avoid sedatives to manage pain after breast reconstruction is critical to mitigate high-risk prescribing practices. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Innovation in Delivering a Live, Virtual Cadaver Dissection Course.

SUMMARY: The availability of advanced telecommunication technology and the social restrictions introduced by a global pandemic have compelled the medical community to explore new avenues of surgical education. Although cadaver courses have long been a fundamental method for learning surgical anatomy and improving operative preparedness, the COVID-19 pandemic has made traditional dissections less practical. The need for quality virtual learning experiences motivated the authors to design and assess the feasibility of organizing a live, virtual upper extremity peripheral nerve cadaver dissection course. Three phases were critical when developing the course: preplanning, planning, and execution. The success of the live, virtual cadaver dissection depended not only on a detailed curriculum, but the technological audio-video-internet needs to effectively communicate and interact with the viewers. Virtual learning mitigates the risks of in-person dissection courses during a global pandemic and can be enhanced with interactive media (e.g., illustrations and schematics) to augment learning experiences.

Tenosynovitis with Psammomatous Calcifications Masquerading as Pyogenic Flexor Tenosynovitis.

We present a case report examining the clinical management of tenosynovitis with psammomatous calcifications presenting like pyogenic flexor tenosynovitis in a pregnant patient. Discussion details overlapping symptoms, important distinctions on imaging studies and the appropriateness of surgery. Level of Evidence: Level V (Therapeutic).

anem: A Simple Web-Based Platform to Build Stakeholder Understanding of Groundwater Behavior.

Groundwater supports essential societal and ecological functions by acting as a reservoir that buffers against natural variability. Increasing water scarcity and climate variability have resulted in more intensive management of groundwater resources, but groundwater often remains difficult to understand and manage. With this in mind, we develop a simple platform that provides a straightforward, web-based user interface applicable to a wide variety of end-user scenarios. Groundwater behavior is modeled using the method of images in a new R package, anem, which serves as the engine for the web platform, anem-app, produced using R Shiny. Both tools allow users to define aquifer properties and pumping wells, view maps of hydraulic head, and simulate particle tracking under steady-state conditions. These tools have the advantage of being platform independent and open source, so that they are freely available to anyone with a web browser and internet connection (anem-app) or computing platform with R installed (anem). We designed both tools to lower the learning curve and up-front costs to building simple groundwater models. The simplicity of the web application allows exploration of groundwater behavior under various conditions, and should be especially valuable in low-budget applications where advanced analysis may not be practical or necessary. Integration with the R language allows for advanced analysis and deeper exploration of groundwater dynamics. In this manuscript, we describe how anem and anem-app are built in the R environment and demonstrate how they might be used by planners or stakeholders.

Familial Screening for Left-Sided Congenital Heart Disease: What Is the Evidence? What Is the Cost?

Since the American Heart Association's recommendation for familial screening of adults with congenital heart disease for bicuspid aortic valve, similar recommendations for other left-sided heart defects, such as hypoplastic left heart syndrome (HLHS), have been proposed. However, defining at-risk populations for these heart defects based on genetics is less straightforward due to the wide variability of inheritance patterns and non-genetic influences such as environmental and lifestyle factors. We discuss whether there is sufficient evidence to standardize echocardiographic screening for first-degree relatives of children diagnosed with HLHS. Due to variations in the inclusion of cardiac anomalies linked to HLHS and the identification of asymptomatic individuals with cardiac malformations, published studies are open to interpretation. We conclude that familial aggregation of obstructive left-sided congenital heart lesions in families with history of HLHS is not supported and recommend that additional screening should adopt a more conservative definition of what truly constitutes this heart defect. More thorough consideration is needed before embracing familial screening recommendations of families of patients with HLHS, since this could inflict serious costs on healthcare infrastructure and further burden affected families both emotionally and financially.