Effectiveness and safety of extracorporeal shock wave treatment for low back pain：a systematic review and meta-analysis of RCTs

This meta-analysis was designed to assess the effectiveness and safety of extracorporeal shock wave therapy (ESWT) for patients with low back pain (LBP). Pubmed, Embase, Cochrane's library, PEDro (Physiotherapy Evidence Database), China National Knowledge Infrastructure (CNKI), and Wanfang Data were searched until December 2019 to identify studies assessing the effectiveness and safety of EPSW for LBP. The prime outcome is pain intensity measured by Visual Analog Scale (VAS) or numeric rating scale (NRS). Other outcomes included functional status, quality of life, psychological outcomes measured by Oswestry Disability Index (ODI), as well as the adverse events. Mean differences (MD) were calculated for continuous outcomes, while odd ratios (OR) were calculated for binary outcomes. Revman 5.3 software was used for statistical analysis. Five randomized controlled trials (RCTs) were finally included in this meta-analysis. The pooled mean difference in post-treatment pain scores was −2.37 (P ＜0.0001), indicating that post-treatment pain scores was significantly higher by 2.37 in control group than in ESWT group. At a mean follow-up time of 4–6 weeks, the pooled mean difference in ODI scores was −14.10 (P ＜0.00001), indicating that the pooled mean difference of post-treatment ODI scores was 14.10 higher in control group than in ESWT group. The use of ESWT is effective in alleviating pain and improving the general functional state for patients with LBP. However, more evidence was needed to verify its safety.     

Performance of risk prediction models for post-operative mortality in patients undergoing liver resection

BackgroundLiver resection is commonly performed for hepatic tumors, however preoperative risk stratification remains challenging. We evaluated the performance of contemporary prediction models for short-term mortality after liver resection in patients with and without cirrhosis.MethodsThis retrospective cohort study examined National Surgical Quality Improvement Program data. We included patients who underwent liver resections from 2014 to 2019. VOCAL-Penn, MELD, MELD-Na, ALBI, and Mayo risk scores were evaluated in terms of model discrimination and calibration for 30-day post-operative mortality.ResultsA total 15,198 patients underwent liver resection, of whom 249 (1.6%) experienced 30-day post-operative mortality. The VOCAL-Penn score had the highest discrimination (area under the ROC curve [AUC] 0.74) compared to all other models. The VOCAL-Penn score similarly outperformed other models in patients with (AUC 0.70) and without (AUC 0.74) cirrhosis.ConclusionThe VOCAL-Penn score demonstrated superior predictive performance for 30-day post-operative mortality after liver resection as compared to existing clinical standards.     

A Mixed-Methods Study of the Effect of Abdominal Binders on Opioid Use and Postoperative Pain After Cesarean Birth

ObjectiveTo compare levels of postoperative oxycodone use and incisional pain between two randomized groups—an intervention and a control.DesignMixed-methods design; quantitative data achieved via a randomized controlled trial, with qualitative data collected on binder use. The primary variable was oxycodone (in milligrams) required during the first 48 hours after birth, and the secondary variable was incisional pain levels measured on Postoperative Days 1 and 2.SettingAcute-care community hospital in Wheat Ridge, Colorado, and an acute care urban hospital in Denver, Colorado.ParticipantsA total of 220 individuals in the postpartum period after having cesarean birth.Interventions/MeasurementsParticipants were randomized to the intervention group (binder) or the control group (no binder). Data were collected on opioid usage for the first 48 hours. Participants in both groups were asked to rate their incisional pain on Postoperative Day 1 (24 hours after birth) and Postoperative Day 2 (48 hours after birth). Participants in the binder group were also asked to provide feedback on their experience wearing the binder.ResultsA total of 196 participants completed the study. The overall amount of oxycodone taken by individuals in the binder group was lower than that in the control group, but the difference was not statistically significant (p = .10). Pain scores in the binder group were significantly lower on Day 2 compared with the control group (p = .002). The majority of individuals in the binder group provided positive feedback about their experience wearing the binder.ConclusionIndividuals routinely receive medications to assist with pain management postoperatively. Because of growing concerns related to the nation’s opioid addiction crisis, there is interest in using multimodal treatments to achieve adequate pain control for individuals postoperatively. Abdominal binders are a low-cost intervention to assist with pain management and, given the results of this study, seem like a reasonable option to consider.     

Minimally Invasive Treatments for Benign Prostatic Hyperplasia: Systematic Review and Network Meta-Analysis

PurposeTo review and to compare indirectly the outcomes of minimally invasive therapies for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia.Materials and MethodsA literature search via Medline and Cochrane Central databases was completed for randomized control studies published between January 2000 to April 2020 for the following therapies: Rezum, Urolift, Aquablation, and prostatic artery embolization (PAE). Data on the following variables were included: International prostate symptom score (IPSS), maximum urinary flow rate, quality of life, and postvoid residual (PVR). Standard mean differences between treatments were compared through a meta-analysis using transurethral resection of the prostate (TURP) to assess differences in treatment effect.ResultsThere was no significant difference in outcomes between therapies for IPSS at the 3, 6, and 12-month follow ups. Although outcomes for Rezum were only available out to 3 months, there were no consistently significant differences in outcomes when comparing Aquablation versus PAE versus Rezum. TURP PVR was significantly better than Urolift at 3, 6, and 12 months. No significant differences in minor or major adverse events were noted.ConclusionAlthough significant differences in outcomes were limited, Aquablation and PAE were the most durable at 12 months. PAE has been well studied on multiple randomized control trials with minimal adverse events while Aquablation has limited high quality data and has been associated with bleeding-related complications.     

Effect of deuteration on the single dose pharmacokinetic properties and postoperative analgesic activity of methadone

Although methadone is effective in the management of acute pain, the complexity of its absorption-distribution-metabolism-excretion profile limits its use as an opioid of choice for perioperative analgesia. Because deuteration is known to improve the pharmacokinetic, pharmacodynamic and toxicological properties of some drugs, here we characterized the single dose pharmacokinetic properties and post-operative analgesic efficacy of d₉-methadone.The pharmacokinetic profiles of d₉-methadone and methadone administered intravenously to CD-1 male mice revealed that deuteration leads to a 5.7- and 4.4-fold increase in the area under the time-concentration curve and maximum concentration in plasma, respectively, as well as reduction in clearance (0.9 ± 0.3 L/h/kg vs 4.7 ± 0.8 L/h/kg). The lower brain-to-plasma ratio of d₉-methadone compared to that of methadone (0.35 ± 0.12 vs 2.05 ± 0.62) suggested that deuteration decreases the transfer of the drug across the blood-brain barrier. The estimated LD₅₀ value for a single intravenous dose of d₉-methadone was 2.1-fold higher than that for methadone. Moreover, d₉-methadone outperformed methadone in the efficacy against postoperative pain by primarily activating peripheral opioid receptors. Collectively, these data suggest that the replacement of three hydrogen atoms in three methyl groups of methadone altered its pharmacokinetic properties, improved safety, and enhanced its analgesic efficacy.     

Validation of the Modena bleeding score in endoscopic sinus surgery

IntroductionThe Modena bleeding score is a categorical rating scale that allows the assessment of the surgical field in relation to bleeding during endoscopic surgery. It has recently been presented and validated in the field of endoscopic ear surgery by the present authors. The Modena bleeding score provides five grades for rating the surgical field during endoscopic procedures (from grade 1 ? no bleeding to grade 5 ? bleeding that prevents every surgical procedure except those dedicated to bleeding control).ObjectiveThe aim of this study was to validate the Modena bleeding score in the setting of endoscopic sinus surgery.MethodsFifteen three-minute videos of endoscopic sinus surgery procedures (each containing three bleeding situations) were evaluated by 15 specialists, using the Modena bleeding score. Intra and inter-rater reliability were assessed, and the clinical validity of the Modena bleeding score was calculated using a referent standard.ResultsThe data analysis showed an intra-rater reliability ranging from 0.6336 to 0.861. The inter-rater reliability ranged from 0.676 to 0.844. The clinical validity was α = 0.70; confidence limits: 0.64 ? 0.75, corresponding to substantial agreement.ConclusionThe Modena bleeding score is an effective method to score bleeding during endoscopic sinus surgery. Its application in future research could facilitate the performance and efficacy assessment of surgical techniques, materials or devices aimed to bleeding control during endoscopic sinus surgery.     

多元化联合教学模式在超声引导下疼痛介入治疗中的应用

目的探讨多元化联合教学模式在超声引导下疼痛介入治疗教学中的应用效果。方法选择2018年1月至2020年12月在北京大学第三医院疼痛科进修的30名医师作为研究对象,将其分为对照组与观察组;对照组采用常规教学模式;观察组采用多元化联合教学模式,比较两组医师技能考核成绩、教学质量评分和满意度评分。结果观察组医师技能考核成绩优良率为93.3%,高于对照组的73.3%(P<0.05);观察组医师对基础理论知识掌握、临床思维能力的提高、学习兴趣的激发、疾病诊治能力的提高4个方面的评分均高于对照组(P<0.01)。结论多元化联合教学模式可促进超声引导下疼痛介入治疗技能的提高,有利于提高学员的综合临床能力。     

Comparing the rates of low-value back images ordered by physicians and nurse practitioners for Medicare beneficiaries in primary care

BackgroundLittle is known about the extent of ordering low-value services by.PurposeTo compare the rates of low-value back images ordered by primary care physicians (PCMDs) and primary care nurse practitioners (PCNPs).MethodWe used 2012 and 2013 Medicare Part B claims for all beneficiaries in 18 hospital referral ?regions (HRRs) and a measure of low-value back imaging from Choosing Wisely. Models included random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician sex, the emergency department setting, back pain visit volume, organization, and region (HRR).FindingsPCNPs (N = 231) and PCMDs (N = 4,779) order low-value back images at similar rates (NP: all images: 26.5%; MRI/CT: 8.4%; MD: all images: 24.5%; MRI/CT: 7.7%), with no detectable significant difference when controlling for covariates.DiscussionPCNPs and PCMDs order low-value back images at an effectively similar rate.