Noninvasive Bioelectronic Treatment of Postcesarean Pain: A Randomized Trial
1. In this randomized, sham-controlled clinical trial, the use of Transcutaneous Electrical Nerve Stimulation (TENS) for inpatient postcesarean pain resulted in a decrease in inpatient opioid use and significantly fewer opioid prescriptions at discharge.
2. These results did not come at the expense of longer hospital stays, and there was a significant difference in self-reported pain between the sham product and TENS machine.Â
Evidence Rating Level: 1 (Excellent)
Cesarean sections are among the most commonly performed surgical procedures in North America. Thus, pain control following such a procedure is an important topic, particularly in mothers who have a previous substance use disorder and those who are breastfeeding. The vast majority of post-cesarean pain regimens include systemic opioids which are not without side-effects, and several million unused opioid tablets remain unaccounted for as a result of patients being sent home with prescriptions they do not use. Transcutaneous electrical nerve stimulation (TENS) has shown promise as an adjunct therapy and the current study sought to evaluate the value of this adjunct in reducing inpatient opioid consumption. This triple-blind, sham-controlled randomized clinical trial assigned 67 postcesarean patients to the functional TENS device, while 67 were assigned to an identical-appearing sham device. The primary outcome, inpatient opioid use postpartum, was significantly reduced in the experimental group (a 47% reduction; p = .046), and did not report significantly higher pain scores than those using the sham device with opioids. Patients in the TENS device group reported a mean Brief Pain Inventory (BPI) score of 3.59 compared to 4.46 in the sham group (p = .004). Another primary outcome, the frequency of discharge opioid prescriptions, was significantly lower for the TENS group (median difference 7.5 morphine milligram equivalents [MME]; p <.001). Twenty-five percent of the experimental group and ten percent of the sham group were discharged without any opioids whatsoever (p = .03). Finally, there were no adverse treatment events in either group, nor were there differences in hospital stays or rates of infection. While the study may be limited in the fact that 19 percent of participants did not attend their 6-week postpartum visits, its overall findings suggest that TENS is potentially capable of reducing the opioid burden on new mothers in the post-cesarean period.Â
1. This retrospective cohort study found that increased (Neutrophil + monocyte)/lymphocyte ratio (NMLR) at ICU admission with diagnosis of sepsis resulted in significantly increased 30-day mortality.
2. NMLR was found to be an independent prognostic predictor of 30-day mortality in septic ICU patients at admission.Â
Evidence Rating Level: 2 (Good)
The identification of valuable prognostic factors for sepsis could aid in reducing the burden of this important, life-threatening condition. The literature has indicated that the measurement of blood cell ratios could be valuable in the prognostication of sepsis. The ratio of the sum of neutrophil and monocyte counts, to the lymphocyte counts (NMLR) is believed to have prognostic value as it relates to the inflammatory and immune responses in different conditions, including hepatocellular carcinoma, multiple myeloma, and myocardial infarction. The current study sought to correlate NMLR values at time of admission to the intensive care unit (ICU) to 30-day mortality. Data from 7292 participants were included in the study (median age, 67.82 years), of which, 1601 died within 30 days of ICU discharge. It was found that the non-surviving group had significantly higher NMLR values at admission than the surviving group (12.24 [6.44, 23.67] versus 8.71 [4.81, 16.26], p < .001). Further univariate (HR, 1.0092; 95% CI, 1.0074–1.0111; P < 0.001) and multivariate analyses (HR, 1.0036; 95% CI, 1.0008–1.0064; P = 0.011) confirmed NMLR as an independent prognostic predictor of 30-day mortality for sepsis patients. Other factors that constituted the multivariable-adjusted Cox regression included platelet count, anion gap, WBC, diastolic blood pressure, mean blood pressure, heart rate, Sequential Organ Failure Assessment (SOFA) score, chloride, creatinine, potassium levels, and the presence of obstructive pulmonary disease. When dividing the population into higher NMLR (> 9.482) and lower (< 9.482) groups, survival was significantly reduced in the higher NMLR group (p < .0001). This indicated that low NMLR below 9.482 could be a protective factor against 30-day mortality to sepsis. Future studies should corroborate these results while analyzing serial NMLR values throughout ICU admission (not solely initial values), and the use of NMLR as a directive measure for predicting septic shock and the requirement for vasopressors should be further elucidated.Â
1. This retrospective study found that in patients initially presenting with acute appendicitis with appendicolithiasis, the length of hospital stay, age above 65 or between 18-25, hypertension, elevated BMI, and hyponatremia at initial presentation were all predictors of in-hospital appendiceal perforation.
Evidence Rating Level: 2 (Good)
Among the most common surgical pathologies, appendicitis is a condition which, if left untreated, could potentially result in perforation. A subset of patients presenting with appendicitis also present with appendicolithiasis (calcified deposits in the appendix), which increases the risk of a complicated appendicitis and/or perforation. The current retrospective study analyzed the data of patients diagnosed with non-perforated acute appendicitis who also presented with appendicoliths. Researchers analyzed medical records, clinical data, and imaging findings to uncover factors that could predict the risk of appendiceal perforation during the course of the illness. Over 16 percent of patients had in-hospital progression to appendiceal perforation, and results also indicated that length of stay was more than twice as long in patients whose appendicitis perforated (3.0 days versus 1.2 days, p < .001). Patient factors such as age above 65 years or between 18 to 25 years (OR 4.12; 95% CI: 1.36—12.48), hypertension (OR: 3.08; 95% CI: 1.01—8.56), elevated BMI above 30 kg/m2 (OR: 2.78; 95% CI: 1.22—6.04), and hyponatremia (OR: 2.95; 95% CI: 1.19—6.90) were significant predictors of in-hospital appendiceal perforation. Histopathological analyses found that signs of severe acute inflammation and/or micro-abscesses and epithelial damage were significantly more common in patients with appendicoliths compared to those without (p < .05). Time to appendectomy in this study was not a significant contributor to risk of perforation, contrary to previous studies, and no other lab markers, including degree of leukocytosis at presentation, were associated with increased risk for in-hospital perforation. A limitation of this study’s retrospective nature is the inability to quantify the importance of other lab markers such as C-reactive protein levels and hyperbilirubinemia as predictors of appendiceal perforation. However, the employment of histopathological analysis was useful in identifying perforation that was not detected on CT due to limited sensitivity, and this is the first study to investigate factors associated with in-hospital progression to perforation in patients with appendicolithiasis. The results of this study provide insight into the relative risk of appendiceal perforation in hospital for patient with or without appendicolithiasis.Â
Young Adult Physical Activity Trajectories and Midlife Nonalcoholic Fatty Liver Disease
1. This analysis of a population-based cohort found that those who engaged in high and moderate decreasing amounts of vigorous physical activity (VPA) over twenty-five years decreased their relative risk of developing nonalcoholic fatty liver disease (NAFLD) by 41%, emphasizing that vigorous (as opposed to moderate) physical activity in early adulthood provided the most benefit.Â
Evidence Rating Level: 2 (Good)
Chronic liver disease is most commonly attributed to non-alcoholic fatty liver disease (NAFLD) and the current primary therapeutic and preventative recommendations for this condition include lifestyle modification. While physical activity is itself beneficial for NAFLD, this study is one of the first to analyze how different long-term patterns in exercise (i.e., vigorous- versus moderate-intensity) impact NAFLD trajectory. 25-year follow-up data on 2833 racially diverse individuals (followed from the mean age of 25.0 years to 50.1 years) from the Coronary Artery Risk Development in Young Adults (CARDIA) prospective observational cohort were analyzed. Participants self-reported their physical activity patterns at eight timepoints over 25 years and were categorized as either moderate physical activity (MPA) or vigorous physical activity (VPA). Noncontrast computed tomography (CT) measured liver fat at the 25-year mark and liver attenuation was measured (where NAFLD is defined as less than 51 hounsfield units, with moderate-severe NAFLD being less than or equal to 40 hounsfield units). Three MPA trajectories were identified: low stable, low increasing, and moderate increasing MPA. Three VPA trajectories were also identified: low stable, moderate decreasing, and high decreasing. The participants who, over 25 years, demonstrated a moderate decreasing or high decreasing VPA pattern were at significantly lower risk for developing NAFLD in middle age (RRModerate VPA 0.74, 95% CI 0.64-0.85; RRHigh VPA 0.59, 95% CI 0.43-0.80) compared to those with low stable VPA over 25 years, even after adjusting for other covariates. The 41% risk reduction of NAFLD in individuals with high decreasing VPA is substantial. Of note, no statistically significant differences in NAFLD risk were noted between the three MPA trajectories. The results of the current study indicate that moderate to high amounts of VPA in early adulthood are associated with lower NAFLD incidence in late adulthood, and that a dose-dependent relationship between exercise intensity and NAFLD risk could exist. Further research should assess the effects of mixed types of physical activity in the life course on relative risk for developing NAFLD, potentially exploring the optimal duration/type of physical activity for reducing NAFLD risk.Â
1. This cohort study found that compared to reference-matched individuals with put inflammatory bowel disease (IBD), any type of IBD increased 10-year and 25-year risk for arrhythmias including arrival flutter/fibrillation, other supraventricular arrhythmias, and ventricular arrhythmias/cardiac arrest.Â
2. Ulcerative colitis (UC) or unclassified IBD (U-IBD) patients, when matched to their own IBD-free siblings, were more likely to develop atrial fibrillation/flutter, whereas those with Crohn’s disease (CD) were more likely to develop supraventricular arrhythmias and ventricular arrhythmias/cardiac arrest than CD-free siblings.Â
Evidence Rating Level: 2 (Good)
Inflammatory bowel disease (IBD) affects millions worldwide and increases one’s risk for a variety of other health conditions long-term. One such condition that has been elucidated in the literature is cardiovascular disease. However, there is limited research on IBD’s possible association with increased risk for arrhythmias (with the exception of atrial fibrillation). This population-based sibling-controlled cohort study in Sweden analyzed patients with biopsy-confirmed IBD (either ulcerative colitis (UC), Crohn’s disease (CD), or unclassified IBD (IBD-U); N = 83,877) as well as reference-matched individuals and their IBD-free siblings. At a median follow-up of 10 years, results did indicate an increased incidence of any type of arrhythmia (aHRCD of 1.15 (95% CI [1.09, 1.21], P < 0.001); aHRUC of 1.14 (95% CI [1.10, 1.18], P < 0.001); aHRU-IBD 1.30 (95% CI [1.20, 1.41], P < 0.001). At 10 years post-IBD diagnosis, there was one extra arrhythmia per 208 Crohn’s or ulcerative colitis patient, and one extra arhythmia per 81 patients with unclassified IBD compared to reference matched individuals. The differences in arrhythmia incidence between IBD and non-IBD references continued at 25-year follow-up. More specifically, patients with all types of IBD (CD, UC, and U-IBD) were at increased risk for developing atrial flutter/fibrillation (aHRs = 1.12, 1.12, and 1.13, respectively; ps < .05), other supraventricular arrhythmias (aHRs = 1.35, 1.31, and 1.34, respectively; ps < .05), and ventricular arrhythmias/cardiac arrest (aHRs = 1.24, 1.25, and 1.39, respectively; ps < .05). However, there was no significant association between any types of IBD and bradyarrhythmias. Compared to their IBD-free siblings, patients with UC or U-IBD were more likely to develop overall arrhythmias (aHRUC 1.18 (95% CI [1.09, 1.28], P < 0.001); aHRU-IBD 1.19 (95% CI [0.99, 1.42], P = .058) and atrial flutter/fibrillation (aHRUC 1.19 (95% CI [1.09, 1.30], P < 0.001); aHRU-IBD 1.24 (95% CI [1.01, 1.53], P = .044). Those with CD were at increased risk of supraventricular arrhythmias and ventricular arrhythmias/cardiac arrest (aHRCD 1.39 and 1.27, respectively; ps < .05). A lack of data quantifying arrhythmia risk relative to IBD severity should be recognized; whether individuals with more frequent IBD flares and more severe symptoms are at an even higher increased risk is unknown based on these results. However, the overall results of this study should raise awareness for health professionals to the potential increased risk of several types of arrhythmias with IBD.Â
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