A Case Report of Multimodal Analgesia for the Treatment of Refractory Chronic Nipple Pain.

Chronic nipple pain can be challenging to a multidisciplinary care team. We report a case of a patient who experienced years of ineffective treatment before presenting to the pain management clinic. Upon presentation, the patient was trialed on neuropathic agents, topical pain medications, acupuncture, calcium channel blockers, intercostal nerve blocks, pulsed radiofrequency, and a spinal cord stimulator trial. We report the treatment options and what was ultimately effective to improve pain scores and functionality. Presenting this treatment approach will educate the reader about options for multimodal therapy to avoid delayed treatment for other patients in the future.

A Penny for Your (Sexual) Thoughts: Qualitative Analysis of Women's Self-Described Reactions to Sexual and Nonsexual Stimuli.

Women display a wide range of subjective (self-reported), physiological (genital response), and emotional responses to sexual stimuli. Sexual responses are often assessed using quantitative methodologies; qualitative data can corroborate quantitative data and reveal novel information and avenues for discovery for understanding variations in patterns of sexual response. The current study examined women's (n = 148) responses to various sexual and non-sexual stimuli through open-ended, free response thought journals immediately after watching various neutral (nature themed) and sexually explicit video clips (e.g., solitary masturbation, intercourse). A qualitative content analysis of 842 responses was conducted by five independent coders to determine participants' thoughts immediately after viewing stimuli. Prominent themes included: (1) stimulus appraisals; (2) emotional expressions; and (3) self-reflections and disclosures, which further included participants' sexual-self-disclosures; (4) various degrees of sexual arousal (or lack thereof); and (5) sexual and non-sexual desires. Additional analyses include frequencies and comparisons of specific themes between stimulus types. Findings contribute to understanding cognitive and emotional components of sexual response.

Intraoperative Transesophageal Echocardiography in Management of Acute Type I Aortic Dissection With Malperfusion: A Case Report.

Acute type I aortic dissection is a life-threatening emergency with potentially devastating complications, including end-organ malperfusion. Early detection of malperfusion with intraoperative imaging allows for efficient transition to appropriate interventions. We present a case of a 65-year-old male with acute type I aortic dissection who underwent emergent surgical repair of the aortic root and hemiarch followed by acutely worsening distal malperfusion. The use of intraoperative transesophageal echocardiography played a critical role in visualizing diversion of flow to the false lumen, prompting urgent vascular surgery consultation and life-saving thoracic endovascular aortic repair.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group.

BACKGROUND: The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial. METHODS: In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4-5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement. RESULTS: Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation. CONCLUSIONS: Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group.

BACKGROUND: The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial. METHODS: In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4-5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement. RESULTS: Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation. CONCLUSIONS: Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Not Your Average Mediastinal Mass: A Case of a Large Mediastinal Teratoma in a Patient With a History of Polio Disease.

Mediastinal masses can be challenging to the surgical team and anesthetic considerations vary according to the location, pathology, surgical approach, and patient comorbidities. We report the case of a 21 cm symptomatic intrathoracic teratoma in a postpartum patient with a history of poliomyelitis. Significant challenges were presented for anesthetic induction, potential extracorporeal membrane oxygenation, and the use of neuraxial pain techniques and neuromuscular blockade. This case report demonstrates techniques to safely manage a patient with a large symptomatic mediastinal mass and potential neuromuscular disease.

Opioid Therapy for Chronic Pain: Overview of the 2017 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline.

Description: The US Department of Veterans Affairs (VA) and US Department of Defense (DoD) revised the 2010 clinical practice guideline (CPG) for the management of opioid therapy for chronic pain, considering the specific needs of the VA and DoD and new evidence regarding prescribing opioid medication for non-end-of-life-related chronic pain. This paper summarizes the major recommendations and compares them with the US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids. Patient Population: This Opioid Therapy CPG was developed for VA-DoD service members, veterans, and their families. Methods: The VA/DoD Evidence-Based Practice Work Group convened a VA/DoD guideline renewal development effort and conformed to the guidelines established by the VA/DoD Joint Executive Council (JEC) and VA/DoD Health Executive Council (HEC). The panel developed questions, searched and evaluated the literature, developed recommendations using GRADE methodology, and developed algorithms. Passage of the CARA Act by Congress compelled consideration and comparison with the CDC opioid therapy guideline mid-development. Results: There were 18 recommendations made. This article focuses on guideline development and key recommendations with CDC comparisons taken from four major areas, including: initiation and continuation of opioids;type, dose, follow-up, and taper of opioids;risk mitigation;acute pain. Conclusions: Guideline development and recommendations are presented. There was substantial overlap with the CDC opioid guideline. Additionally, there were items particularly relevant to the VA-DoD, including risk mitigation, suicide prevention, and preventing opioid use disorder in young patients. Our guideline highlights avoiding opioid therapy longer than 90 days as a critical juncture.

Confocal microscope analysis of depth of etch between self-limiting and traditional etchant systems.

OBJECTIVE: To see whether there is an advantage to using a self-limiting phosphoric acid etchant versus a traditional 34% phosphoric acid etchant for bonding by measuring the depth of etch at multiple time intervals. MATERIALS AND METHODS: A total of 25 bovine teeth were mounted and etched on the facial surface with two different etchants: standard 34% phosphoric acid and a self-limiting 35% phosphoric acid etchant at varied time intervals of 15, 30, 60, 90, and 120 seconds. Teeth were scanned using a three-dimensional laser confocal scanning microscope prior to etching and scanned again after etching to determine the depth of enamel etched compared to the baseline enamel surface prior to etching. RESULTS: The 34% phosphoric acid etchant etched significantly deeper than the self-limiting etch. Etch times exceeding 30 seconds also etched significantly deeper for both types of etchant. CONCLUSION: The etch depth of the self-limiting etchant was consistently less than the standard etchant. Both types of etchant etched deeper after 30 seconds, but the depth of etch at 120 seconds was not different than at 60 seconds, indicating that both etchants are somewhat self-limiting in depth. Therefore, there is no advantage to using the self-limiting etchant.