Single shot lymphoscintigraphy in breast cancer: Effective single tracer sentinel node detection protocol with reduction in procedural pain.

PURPOSE: Variation in protocols for axillary sentinel lymph node (SLN) mapping exists. We strive to evaluate the effectiveness of reduction in number of injections on reducing procedural pain, while maintaining nodal detection. METHODS: Over 7 years, the number of periareolar injections performed was reduced stepwise from 4 to 1. This was analyzed for SLN detection and patients' subjective perceived pain. RESULTS: 828 patients with invasive breast cancer who underwent SLN mapping were included. Laterality of breast injection site included 326 (39.4%) in the right breast, 354 (42.8%) in the left breast and 148 (17.9%) in bilateral breasts. In patients who had 4 injection sites in a unilateral breast (n = 143), the reported pain score was 4.3 ± 2.4. Patients with 3 injections (n = 163), 2 injections (n = 163) and 1 injection (n = 211) in a breast reported pain scores of 3.4 ± 2.4, 3.2 ± 2.2, and 2.9 ± 2.6, respectively. In patients who had bilateral sentinel node procedures, those with 4 injections in each breast for a total of 8 injections (n = 37) reported a pain score of 5.7 ± 2.4. Patients with 3 (n = 51), 2 (n = 31) and 1 (n = 39) injection(s) in each breast reported perceived pain of 4.8 ± 2.8, 3.7 ± 2.7 and 3.5 ± 1.9, respectively. Incremental decreased pain scores were achieved with decreasing number of injections (p < 0.001). Nodal detection was maintained. CONCLUSION: A single periareolar subdermal injection site reduces periprocedural pain while maintaining nodal detection.

Migraine Surgery at the Frontal Trigger Site: An Analysis of Intraoperative Anatomy.

BACKGROUND: The development of migraine headaches may involve the entrapment of peripheral craniofacial nerves at specific sites. Cadaveric studies in the general population have confirmed potential compression points of the supraorbital and supratrochlear nerves at the frontal trigger site. The authors' aim was to describe the intraoperative anatomy of the supraorbital and supratrochlear nerves at the level of the supraorbital bony rim in patients undergoing frontal migraine surgery and to investigate associated pain. METHODS: PATIENTS: scheduled for frontal-site surgery were enrolled prospectively. The senior author (W.G.A.) evaluated intraoperative anatomy and recorded variables using a detailed form and operative report. The resulting data were analyzed. RESULTS: One hundred eighteen sites among 61 patients were included. The supraorbital nerve traversed a notch in 49 percent, a foramen in 41 percent, a notch plus a foramen in 9.3 percent, and neither a notch nor a foramen in one site. The senior author noted macroscopic nerve compression at 74 percent of sites. Reasons included a tight foramen in 24 percent, a notch with a tight band in 34 percent, and supraorbital and supratrochlear nerves emerging by means of the same notch in 7.6 percent or by means of the same foramen in 4.2 percent. Preoperative pain at a site was significantly associated with nerve compression by a foramen. CONCLUSIONS: The intraoperative anatomy and cause of nerve compression at the frontal trigger site vary greatly among patients. The authors report a supraorbital nerve foramen prevalence of 50.3 percent, which is greater than in previous cadaver studies of the general population. Lastly, the presence of pain at a specific site is associated with macroscopic nerve compression.

Procedural pain and oral glucose in preterm neonates: brain development and sex-specific effects.

Our objectives were to determine whether procedural pain and glucose exposure are associated with altered structural and functional brain development differently in preterm males and females, and neurodevelopment at 18-month corrected age. Fifty-one very preterm neonates (22 males; median [interquartile range] gestational age 27.6 [2.0] weeks) underwent 3 serial scans including T1-weighted and resting-state functional magnetic resonance imaging (MRI) at median postmenstrual weeks: 29.4, 31.9, and 41.1. Thalamus, basal ganglia, and total brain volumes were segmented. Functional resting-state MRI data were extracted from the independent-components maps. Pain was operationalized as the total number of neonatal intensive care unit-administered invasive procedures. Neurodevelopmental outcomes at 18-month corrected age were assessed with the Bayley Scales of Infant Development, second edition. Generalized estimating equations assessed the association of pain and glucose exposure with brain structural and functional development. More invasive procedures were independently associated with slower growth of thalamic (P < 0.001), basal ganglia (P = 0.028), and total brain volumes (P = 0.001), particularly in females. Similar relationships were observed between glucose exposure and brain volumes. Functional connectivity between thalamus and sensorimotor cortices was negatively associated with number of invasive procedures. Greater procedural pain and higher glucose exposure were related to poorer neurodevelopmental outcomes. These findings suggest that structural and functional brain development is vulnerable to procedural pain. Glucose used for analgesia does not appear to mitigate the adverse impact of pain on brain development. The vulnerability of brain development in females towards early pain is distinct from other neonatal morbidities. The link between pain and glucose with neurodevelopment suggests that these factors have long-lasting impact.