Prevention of Perioperative Abdominal Migraine in a Patient Undergoing Spinal Fusion: A Case Report.

Abdominal migraine is a variant of migraine headaches characterized by episodic attacks of severe abdominal pain with migrainous features, including anorexia, nausea, vomiting, and pallor. It is more commonly diagnosed in children rather than adults. We describe a 74-year-old patient with progressively worsening back pain, severe neurogenic claudication, and a history of opioid-triggered abdominal migraine. As a precautionary measure, a perioperative opioid-sparing treatment plan was devised to prevent abdominal migraine while the patient underwent elective lumbar fusion surgery. Opioid-sparing treatment plans may enable similar patients to undergo surgery without experiencing perioperative abdominal migraines.

Effects of implantation of a deep brain stimulation device on patient weight in Parkinson's disease and essential tremor.

OBJECTIVE: Deep brain stimulation (DBS) is a well-established therapy for treating neurological movement disorders. Some patients who have received DBS therapy have noticed significant weight gain. Further investigation into correlations between patient characteristics and weight gain following DBS device implantation, which the authors here have done, will provide physicians with useful clinical information. METHODS: The authors performed a retrospective study of patients with Parkinson's disease (PD) and essential tremor (ET) who had received DBS therapy in the period from 2012 to 2017. Patient weights had been recorded preoperatively and at 3, 6, and 12 months postoperatively. These data were used to compare patient characteristics, including diagnosis, body mass index (BMI), sex, levodopa equivalent dose (LED), and change in Unified Parkinson's Disease Rating Scale (UPDRS) score. For PD patients, a quantile multivariate regression analysis was used to examine whether significant correlations existed between several of these patient characteristics, as well as age and weight gain following implantation. RESULTS: PD patients had gained a significant amount of weight at 3 months (mean [SE] 2.66 [0.428] kg, p < 0.001), 6 months (3.64 [0.492] kg, p < 0.001), and 12 months (4.18 [0.540] kg, p < 0.001) after DBS placement. Patients who had undergone subthalamic nucleus (STN) DBS device placement gained, on average, more weight than the patients with globus pallidus internus (GPi) placement at both 6 months (mean 2.558 [1.020] kg, p = 0.01) and 12 months (2.358 [1.130] kg, p = 0.04). BMI in the STN cohort was greater than that in the GPi cohort at 6 months (mean difference [SE] 2.60 [1.127] kg/m2, p = 0.02) and at 12 months (2.36 [1.112] kg/m2, p = 0.04). A reduction in LED was negatively correlated with weight change at 6 months (r = -0.33, p < 0.001) and 12 months (r = -0.41, p < 0.001). There was no weight gain correlated with DBS therapy for ET. CONCLUSIONS: PD patients experienced a significant change in weight over time after DBS therapy, whereas ET patients did not. PD patients with an STN target site experienced greater weight gain, on average, than those with a GPi target site. Furthermore, there was a significant increase in BMI at 6 and 12 months in patients with an STN target compared to that in patients with a GPi target. PD patients whose LED was reduced after DBS gained more weight at 6 and 12 months after surgery than the patients whose LED was kept at the same level or increased.

Evaluation of a Novel Surgical Skills Training Course: Are Cadavers Still the Gold Standard for Surgical Skills Training?

BACKGROUND: An increasing body of literature describing use of high-fidelity surgical training models is challenging long-held dogma that cadavers provide the best medium for postgraduate surgical skills training. The purpose of this study was to describe a surgical skills course comprising entirely synthetic training models developed by resident and attending neurosurgeons and to evaluate their perceptions of the overall usefulness of this course and its usefulness compared with cadaveric courses. METHODS: Ten high-fidelity neurosurgical training models were developed. A neurosurgical skills course for residents was structured to include 7 spinal and 3 cranial learning stations, each with its own model and assigned attending expert. Resident and attending neurosurgeons were asked to complete surveys on their overall impressions of the course and models and on workload comparisons between models and real cases. Student t tests were used for statistical comparisons. RESULTS: Survey responses were collected from 9 of 16 participating residents (56.3%) and 3 of 10 attending neurosurgeons (30.0%). Both groups believed that the course was very helpful overall to resident education. Respondents furthermore believed that the course was more helpful overall than cadaveric courses. Task load index testing showed no significant workload difference between models and real cases (P ≥ 0.17), except in temporal demand (P < 0.001). CONCLUSIONS: Resident and attending neurosurgeons subjectively believe that high-fidelity synthetic models were superior to cadavers as a surgical skills teaching platform. This study raises the question of whether cadavers should remain the gold standard for surgical skills courses. Expanded use of these teaching models and further study are warranted.

A case of a positive coccidioides stool culture in an immunocompetent patient with disseminated coccidioidomycosis.

Coccidioidomycosis (CM) is an infection caused by the coccidioides fungus. The spectrum of the disease ranges from a mild upper respiratory illness to severe disseminated infection that could affects the bones, joints, skin, central nervous system, and the gastrointestinal tract. Previous reports of a positive stool culture in the setting of disseminated CM are extremely rare. Herein, we describe a case of a 43-year-old immunocompetent patient with disseminated CM and evidence of positive coccidioides stool culture.

A framework for "driving under the influence of drugs" policy for the opioid using driver.

BACKGROUND: Driving under the influence of drugs (DUID) is a term used to designate the action of driving an automobile after the consumption of drugs or medications other than alcohol that interfere with the capacity to operate a vehicle safely. Unlike recreational drugs, prescription medications pose a unique challenge to those attempting to harness their benefits yet protect the driving public. As studies demonstrate a steady increase in opioid use and abuse in the United States, these same constituencies must regulate a significant percentage of drivers who are under the influence of opioids. OBJECTIVE: This article examines current DUID policy and attempts to present unified suggestions for improvement based on best scientific evidence of opioid-induced psychomotor impairment. STUDY DESIGN: Literature Review METHODS: A literature search was conducted regarding the epidemiology of opioid use and abuse, psychomotor effects of opioids, DUID, and state policy concerning DUID. A total of 23 epidemiological studies, 3 studies on acute psychomotor effects, 32 on chronic psychomotor effects, and selected pertinent law and policy were reviewed. RESULTS: Current state law concerning DUID is variable and often relies on prosecutorial discretion to provide protection of the driving public and prosecution of the truly impaired. LIMITATIONS: The design of various studies included in this review imposes limitations on the epidemiological data extracted. Relationships between opioids and automobile accidents are commonly reviewed in retrospect. The data on opioid-induced psychomotor impairment and its effects on driving an automobile require further direct study to examine current inferences. CONCLUSIONS: A sizable percentage of the driving public has detectable levels of opioids within their bodies. The best available evidence demonstrates psychomotor impairment following acute administration of opioids or an increase in opioid dosage, but impairment diminishes with chronic, stable opioid usage. Policy makers must account for this evidence when balancing the benefit of pain relief against the need for public roadway protection when drafting DUID legislation.

Long-term outcome of epilepsy surgery among 399 patients with nonlesional seizure foci including mesial temporal lobe sclerosis.

OBJECT: The authors reviewed the long-term outcome of focal resection in a large group of patients who had intractable partial nonlesional epilepsy, including mesial temporal lobe sclerosis (MTS), and who were treated consecutively at a single institution. The goal of this study was to evaluate the long-term efficacy of epilepsy surgery and the preoperative factors associated with seizure outcome. METHODS: This retrospective analysis included 399 consecutive patients who underwent epilepsy surgery at Mayo Clinic in Rochester, Minnesota, between 1988 and 1996. The mean age of the patients at surgery was 32 +/- 12 years (range 3-69 years), and the mean age at seizure onset was 12 +/- 11 years (range 0-55 years). There were 214 female (54%) and 185 male (46%) patients. The mean duration of epilepsy was 20 +/- 12 years (range 1-56 years). The preceding values are given as the mean +/- standard deviation. Of the 399 patients, 237 (59%) had a history of complex partial seizures, 119 (30%) had generalized seizures, 26 (6%) had simple partial seizures, and 17 (4%) had experienced a combination of these. Preoperative evaluation included a routine and video-electroencephalography recordings, magnetic resonance imaging of the head according to the seizure protocol, neuropsychological testing, and a sodium amobarbital study. Patients with an undefined epileptogenic focus and discordant preoperative studies underwent an intracranial study. The mean duration of follow up was 6.2 +/- 4.5 years (range 0.6-15.7 years). Seizure outcome was categorized based on the modified Engel classification. Time-to-event analysis was performed using Kaplan-Meier curves and Cox regression models to evaluate the risk factors associated with outcomes. Among these patients, 372 (93%) underwent temporal and 27 (7%) had extratemporal resection of their epileptogenic focus. Histopathological examination of the resected specimens revealed MTS in 113 patients (28%), gliosis in 237 (59%), and normal findings in 49 (12%). Based on the Kaplan-Meier analysis, the probability of an Engel Class I outcome (seizure free, auras, or seizures related only to medication withdrawal) for the overall patient group was 81% (95% confidence interval [CI] 77-85%) at 6 months, 78% (CI 74-82%) at 1 year, 76% (CI 72-80%) at 2 years, 74% (CI 69-78%) at 5 years, and 72% (CI 67-77%) at 10 years postoperatively. The rate of Class I outcomes remained 72% for 73 patients with more than 10 years of follow up. If a patient was in Class I at 1 year postoperatively, the probability of seizure remission at 10 years postoperatively was 92% (95% CI 89-96%); almost all seizures occurred during the 1st year after surgery. Factors predictive of poor outcome from surgery were normal pathological findings in resected tissue (p = 0.038), male sex (p = 0.035), previous surgery (p < 0.001), and an extratemporal origin of seizures (p < 0.001). CONCLUSIONS: The response to epilepsy surgery during the 1st follow-up year is a reliable indicator of the long-term Engel Class I postoperative outcome. This finding may have important implications for patient counseling and postoperative discontinuation of anticonvulsant medications.

Legal pressures and incentives for personalized medicine.

Legal liability has the potential to be a powerful driver pushing implementation of personalized medicine. Individuals injured by adverse drug effects are increasingly likely to bring lawsuits alleging that they have a polymorphism or biomarker conferring susceptibility to the drug that should have been identified and used to alter their drug treatment. Likely targets of such lawsuits include drug manufacturers, third party payors, physicians and pharmacists, of which physicians are most at risk of substantial liability.