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Frontiers in Endocrinology 2024The baseline urinary albumin/creatinine ratio (uACR) has been proven to be significantly associated with the risk of major adverse cardiac events (MACE). However, data...
OBJECTIVE
The baseline urinary albumin/creatinine ratio (uACR) has been proven to be significantly associated with the risk of major adverse cardiac events (MACE). However, data on the association between the longitudinal trajectory patterns of uACR, changes in glycated hemoglobin A1c (HbA1c), and the subsequent risk of MACE in patients with diabetes are sparse.
METHODS
This is a retrospective cohort study including 601 patients with type 2 diabetes mellitus (T2DM; uACR < 300 mg/g) admitted to The First Hospital of Shanxi Medical University and The Second Hospital of Shanxi Medical University from January 2015 to December 2018. The uACR index was calculated as urinary albumin (in milligrams)/creatinine (in grams), and latent mixed modeling was used to identify the longitudinal trajectory of uACR during the exposure period (2016-2020). The deadline for follow-up was December 31, 2021. The primary outcome was the MACE [a composite outcome of cardiogenic death, hospitalization related to heart failure (HHF), non-fatal acute myocardial infarction, non-fatal stroke, and acute renal injury/dialysis indications]. The Kaplan-Meier survival analysis curve was used to compare the risk of MACE among four groups, while univariate and multivariate Cox proportional hazards models were employed to calculate the hazard ratio (HR) and 95% confidence interval (CI) for MACE risk among different uACR or HbA1c trajectory groups. The predictive performance of the model, both before and after the inclusion of changes in the uACR and HbA1c, was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC).
RESULTS
Four distinct uACR trajectories were identified, namely, the low-stable group (uACR = 5.2-38.3 mg/g, = 112), the moderate-stable group (uACR = 40.4-78.6 mg/g, = 229), the high-stable group (uACR = 86.1-153.7 mg/g, = 178), and the elevated-increasing group (uACR = 54.8-289.4 mg/g, = 82). In addition, five distinct HbA1c trajectories were also identified: the low-stable group (HbA1c = 5.5%-6.8%, = 113), the moderate-stable group (HbA1c = 6.0%-7.9%, = 169), the moderate-decreasing group (HbA1c = 7.4%-6.1%, = 67), the high-stable group (HbA1c = 7.7%-8.9%, = 158), and the elevated-increasing group (HbA1c = 8.4%-10.3%, = 94). Compared with the low-stable uACR group, patients in the high-stable and elevated-increasing uACR groups were more likely to be older, current smokers, and have a longer DM course, higher levels of 2-h plasma glucose (PG), HbA1c, N-terminal pro-B-type natriuretic peptide (NT-proBNP), uACR, and left ventricular mass index (LVMI), while featuring a higher prevalence of hypertension and a lower proportion of β-receptor blocker treatment ( < 0.05). During a median follow-up of 45 months (range, 24-57 months), 118 cases (19.6%) of MACE were identified, including 10 cases (1.7%) of cardiogenic death, 31 cases (5.2%) of HHF, 35 cases (5.8%) of non-fatal acute myocardial infarction (AMI), 18 cases (3.0%) of non-fatal stroke, and 24 cases (4.0%) of acute renal failure/dialysis. The Kaplan-Meier survival curve showed that, compared with that in the low-stable uACR group, the incidence of MACE in the high-stable (HR = 1.337, 95% CI = 1.083-1.652, = 0.007) and elevated-increasing (HR = 1.648, 95% CI = 1.139-2.387, = 0.009) uACR groups significantly increased. Similar results were observed for HHF, non-fatal AMI, and acute renal injury/dialysis indications ( < 0.05). The multivariate Cox proportional hazards models indicated that, after adjusting for potential confounders, the HRs for the risk of MACE were 1.145 ( = 0.132), 1.337 ( = 0.007), and 1.648 ( = 0.009) in the moderate-stable, high-stable, and elevated-increasing uACR groups, respectively. In addition, the HRs for the risk of MACE were 1.203 ( = 0.028), 0.872 ( = 0.024), 1.562 ( = 0.033), and 2.218 ( = 0.002) in the moderate-stable, moderate-decreasing, high-stable, and elevated-increasing groups, respectively. The ROC curve showed that, after adding uACR, HbA1c, or both, the AUCs were 0.773, 0.792, and 0.826, which all signified statistically significant improvements ( = 0.021, 0.035, and 0.019, respectively).
CONCLUSION
A long-term elevated uACR is associated with a significantly increased risk of MACE in patients with diabetes. This study implies that regular monitoring of uACR could be helpful in identifying diabetic patients with a higher risk of MACE.
Topics: Humans; Male; Female; Retrospective Studies; Diabetes Mellitus, Type 2; Middle Aged; Albuminuria; Creatinine; Aged; Glycated Hemoglobin; Longitudinal Studies; Risk Factors; Prognosis; Biomarkers; Cohort Studies; Follow-Up Studies
PubMed: 38745945
DOI: 10.3389/fendo.2024.1355149 -
The Journal of the American Academy of... May 2024Mental illnesses are well-known factors that contribute to poor outcomes among total hip arthroplasty (THA) patients. However, a dichotomized mental illness diagnosis...
Positive Deviance and Exploring the Role of Mental Health on Early Postoperative Recovery After Total Hip Arthroplasty: A Retrospective Analysis Using the PROMIS-10 Global Health.
INTRODUCTION
Mental illnesses are well-known factors that contribute to poor outcomes among total hip arthroplasty (THA) patients. However, a dichotomized mental illness diagnosis may not reflect the complex biopsychosocial factors contributing to a patient's health. Investigating patients who achieve positive outcomes despite having risk factors, known as positive deviants, may help identify protective characteristics and decrease health disparities among this growing population of patients. Using preoperative Mental Health T-scores (MHT) from the PROMIS-10 Global Health questionnaire among patients with a mental illness diagnosis, the purpose of this study was to explore whether patients with above-average MHT, or positive deviants, experienced a different immediate postoperative recovery path compared with patients with below-average MHT.
METHODS
This was a retrospective chart review of patients undergoing elective primary THA. Patients with a formal diagnosis of a mental health condition were divided based on their MHT (above average [AA] >50, average [A] 40 to 50, below average [BA] <40). Postsurgical parameters included total opioid consumption, self-reported pain scores, and discharge disposition.
RESULTS
A total of 299 patients were analyzed. After controlling for length of stay and type of mental illness, patients in the AA-MHT and A-MHT groups used 33.8 and 29.8 morphine milligram equivalents less than patients in the BA-MHT group during the inpatient stay, respectively. Patients in the AA-MHT group reported a 1.0 lower pain with activity score at discharge compared with patients in the BA-MHT group.
DISCUSSION
The intersection between patients with a mental illness in need of a THA is becoming more commonplace. Data suggest that patients with a mental illness who report AA-MHT on the PROMIS-10 Global Health questionnaire may represent positive deviants or those with a more positive in-hospital recovery path compared with those patients with BA-MHT.
LEVEL OF EVIDENCE
Diagnostic study-retrospective cohort study.
PubMed: 38739867
DOI: 10.5435/JAAOS-D-23-01230 -
European Journal of Orthopaedic Surgery... May 2024Appropriate management of acute postoperative pain is critical for patient care and practice management. The purpose of this study was to determine whether postoperative...
PURPOSE
Appropriate management of acute postoperative pain is critical for patient care and practice management. The purpose of this study was to determine whether postoperative pain score correlates with injury severity in tibial plateau fractures.
METHODS
A retrospective review of prospectively collected data was completed at a single academic level one trauma center. All adult patients treated operatively for tibial plateau fractures who did not have concomitant injuries, previous injury to the ipsilateral tibia or knee joint, compartment syndrome, inadequate follow-up, or perioperative regional anesthesia were included (n = 88). The patients were split into groups based on the AO/OTA fracture classification (B-type vs C-type), energy mechanism, number of surgical approaches, need for temporizing external fixation, and operative time as a proxy for injury severity. The primary outcome measure was the visual analog scale (VAS) pain score (average in the first 24 h, highest in the first 24 h, two- and six-week postoperative appointments). Psychosocial and comorbid factors that may affect pain were studied and controlled for (history of diabetes, neuropathy, anxiety, depression, PTSD, and previous opioid prescription). Additionally, opioid use in the postoperative period was studied and controlled for (morphine milligram equivalents (MME) administered in the first 24 h, discharge MME/day, total discharge MME, and opioid refills).
RESULTS
VAS scores were similar between groups at each time point except the two-week postoperative time point. At the two-week postoperative time point, the absolute difference between the groups was 1.3. The groups were significantly different in several injury and surgical variables as expected, but were similar in all demographic, comorbid, and postoperative opioid factors.
CONCLUSIONS
There was no clinical difference in postoperative pain between AO/OTA 41B and 41C tibial plateau fractures. This supports the idea of providers uncoupling nociception and pain in postoperative patients. Providers should consider minimizing extended opioid use, even in more severe injuries.
PubMed: 38739294
DOI: 10.1007/s00590-024-03972-0 -
Urologic Oncology May 2024The effect of individual non-narcotic analgesics in cystectomy enhanced recovery after surgery (ERAS) is unknown. Additionally, many non-narcotic medications are...
INTRODUCTION
The effect of individual non-narcotic analgesics in cystectomy enhanced recovery after surgery (ERAS) is unknown. Additionally, many non-narcotic medications are associated with side effects pertinent to the cystectomy population. To better understand the actual use and utility of these medications, we sought to characterize the association between non-narcotic medications and milligram morphine equivalent (MME) narcotic score during the postoperative inpatient stay.
METHODS
We reviewed 260 consecutive ERAS cystectomy patients. The MME impact of non-narcotic compliance and cumulative dose of medication received was evaluated separately with general linear models. We also assessed relationship of non-narcotic compliance to patient reported pain score, length of stay (LOS), and time to return of bowel function (ROBF) and performed manual review of postoperative documentation to identify reasons for medication noncompliance.
RESULTS
Compliance with postoperative acetaminophen, gabapentin, and ketorolac was low. There was an inverse relationship between ketorolac dose and MME on postoperative day 1 (-0.026 MME/mg; P = 0.004) and postoperative day 2 (-0.33 MME/mg; P < 0.001). Compliance with ketorolac was associated with lower MME on postoperative day 1 (26.1 MME v. 33.6 MME; P = 0.023). There were no such associations identified with gabapentin or acetaminophen. Gabapentin compliance was associated with earlier ROBF (3.7 days v. 4.3 days; P = 0.006). Ketorolac compliance was associated with lower pain score on POD1 (3.25 VAS v. 4.07 VAS; P = 0.019) and POD2 (3.05 VAS v. 3.85 VAS; P = 0.040) There was no association between medication compliance and LOS. The most common reasons identified for non-compliance with gabapentin and ketorolac were renal function concerns (38% and 40% respectively), bleeding concerns with ketorolac (20%) and concerns for neurologic adverse effect with gabapentin (16%).
CONCLUSION
Compliance with non-narcotic medications in our ERAS cystectomy protocol was poor. There was a modest association with ketorolac and postoperative MME but no association with gabapentin or acetaminophen. Further study will clarify the role of these medications for cystectomy patients. Component specific analysis of protocolized care is valuable and may alter care pathways.
PubMed: 38735799
DOI: 10.1016/j.urolonc.2024.03.007 -
Medicine May 2024After the success of the enhanced recovery after surgery protocol, perioperative care has been further optimized in accelerated enhanced recovery pathways (ERPs), where... (Comparative Study)
Comparative Study
Hyperbaric bupivacaine versus prilocaine for spinal anesthesia combined with total intravenous anesthesia during oncological colon surgery in a 23-hour stay enhanced recovery protocol: A non-randomized study.
After the success of the enhanced recovery after surgery protocol, perioperative care has been further optimized in accelerated enhanced recovery pathways (ERPs), where optimal pain management is crucial. Spinal anesthesia was introduced as adjunct to general anesthesia to reduce postoperative pain and facilitate mobility. This study aimed to determine which spinal anesthetic agent provides best pain relief in accelerated ERP for colon carcinoma. This single center study was a secondary analysis conducted among patients included in the aCcelerated 23-Hour erAS care for colon surgEry study who underwent elective laparoscopic colon surgery. The first 30 patients included received total intravenous anesthesia combined with spinal anesthesia with prilocaine, the 30 patients subsequently included received spinal anesthesia with hyperbaric bupivacaine. Primary endpoint of this study was the total amount of morphine milligram equivalents (MMEs) administered during hospital stay. Secondary outcomes were amounts of MMEs administered in the recovery room and surgical ward, pain score using the numeric rating scale, complication rates and length of hospital stay. Compared to prilocaine, the total amount of MMEs administered was significantly lower in the bupivacaine group (n = 60, 16.3 vs 6.3, P = .049). Also, the amount of MMEs administered and median pain scores were significantly lower after intrathecal bupivacaine in the recovery room (MMEs 11.0 vs 0.0, P = .012 and numeric rating scale 2.0 vs 1.5, P = .004). On the surgical ward, median MMEs administered, and pain scores were comparable. Postoperative outcomes were similar in both groups. Spinal anesthesia with hyperbaric bupivacaine was associated with less opioid use and better pain reduction immediately after surgery compared to prilocaine within an accelerated ERP for elective, oncological colon surgery.
Topics: Humans; Anesthesia, Spinal; Bupivacaine; Male; Female; Anesthetics, Local; Colonic Neoplasms; Middle Aged; Aged; Enhanced Recovery After Surgery; Prilocaine; Pain, Postoperative; Length of Stay; Anesthesia, Intravenous; Pain Measurement
PubMed: 38728520
DOI: 10.1097/MD.0000000000037957 -
Anesthesiology and Pain Medicine Feb 2024The objective of this study was to examine analgesia when using perineural dexamethasone compound in an interscalene brachial plexus block following shoulder surgery.
BACKGROUND
The objective of this study was to examine analgesia when using perineural dexamethasone compound in an interscalene brachial plexus block following shoulder surgery.
METHODS
This study was designed as a randomized, double-blind clinical trial. Patients meeting the specified criteria were randomly divided into two groups: The experimental group and the control group, each comprising 30 individuals. Age and gender were matched between the groups. The control group received lidocaine along with 2 cc of 0.5% bupivacaine (20 milligrams) and 2 cc of normal saline; however, the experimental group received lidocaine, along with 2 cc of 0.5% bupivacaine and 2 cc of dexamethasone. Pain levels were assessed using the Visual Analog Scale (VAS), and covariance analysis was applied for data analysis.
RESULTS
The results demonstrated that pain intensity was notably lower in the experimental (dexamethasone) group than in the control group at both the 12-hour group (P < 0.001) and 24-hour (P < 0.001) postoperative marks. Dexamethasone significantly reduced pain among the patients.
CONCLUSIONS
In conclusion, administering dexamethasone to potential candidates for shoulder surgery could lead to prolonged analgesia for up to 24 hours after the surgery. Consequently, this medication can serve as an efficacious analgesic option for pain management in these patients.
PubMed: 38725917
DOI: 10.5812/aapm-142635 -
Anaesthesia May 2024Excessive opioid prescribing following surgery contributes to the growing opioid crisis. Prescribing practices are modifiable, yet data to guide appropriate prescription...
BACKGROUND
Excessive opioid prescribing following surgery contributes to the growing opioid crisis. Prescribing practices are modifiable, yet data to guide appropriate prescription of opioids at surgical discharge remain sparse. This study aimed to evaluate factors associated with opioid consumption following discharge from surgery.
METHODS
An international prospective multicentre cohort study was performed recruiting adult patients undergoing common general, orthopaedic, gynaecological and urological surgery, with follow-up 7 days after discharge. The primary outcome measures were the quantities of prescribed and consumed opioids in oral morphine milligram equivalents. Descriptive and multivariable analyses were performed to investigate factors associated with the primary outcome measures.
RESULTS
This analysis included 4273 patients from 144 hospitals in 25 countries. Overall, 1311 (30.7%) patients were prescribed opioids at discharge. For those patients prescribed opioids, mean (SD) 179 (240) oral morphine milligram equivalents were prescribed, yet only 81 (145) oral morphine milligram equivalents were consumed within the first 7 days after discharge. An increased dose of opioids prescribed at discharge was associated with an increased dose of opioids consumed during the follow-up period (β = 0.33 (95%CI 0.31-0.34), p < 0.001). The risk of prescribing more opioids than patients consumed increased as quantities of opioids prescribed at discharge exceeded 100 oral morphine milligram equivalents, independent of patient comorbidity, procedure and pain. Patients were prescribed more than twice the quantity of opioids they consumed in the first 7 days following discharge from surgery.
CONCLUSIONS
Our data suggest that the current quantities of opioids provided at discharge exceed patient needs and may contribute to increasing community opioid use and circulation.
PubMed: 38721718
DOI: 10.1111/anae.16297 -
Pain Management Nursing : Official... May 2024Postoperative pain and agitation is an ongoing issue among patients undergoing total knee replacement (TKR). Use of complementary therapies such as music may improve...
BACKGROUND
Postoperative pain and agitation is an ongoing issue among patients undergoing total knee replacement (TKR). Use of complementary therapies such as music may improve outcomes when combined with medical therapy.
AIM
The purpose of this quality improvement (QI) initiative was to evaluate postoperative use of classical music among adult patients who have undergone TKR on reported agitation, pain, and opioid use.
DESIGN
A prospective evidence-based QI initiative.
SETTING
A midwestern hospital post-anesthesia care unit.
PARTICIPANTS
Postoperative patients who had undergone TKR.
METHODS
Classical piano music was played postoperatively using an MP3 device. Adult patients who were undergoing TKR were consecutively offered music during their recovery period in the PACU. Agitation was measured using the Richmond Agitation Sedation Score (RASS). Patient perceived pain was measured on a scale of 0-10 with 0 being no pain and 10 being extreme pain. Opioid use was measured using the morphine milligram equivalents (MME).
FINDINGS
A total of (n=40) patients received music and (n=50) patients received standard care without music. RASS was significantly lower in the music group than in the baseline non-music group X (1, N = 89) = 17.8, p < .001. Patient reported pain scores were significantly lower in the music group, 3.98(SD = 2.71), compared to the baseline non-music group, 6.27(SD = 2.60). Opioid use was also significantly decreased in the music group to MME 9.51(SD = 8.62) compared to the baseline non-music group 13.38 (SD = 9.71).
CONCLUSION
Music is an effective nonpharmacologic intervention in decreasing agitation, pain, and opioid use among patients undergoing TKR. These findings provide evidence for nurses to incorporate music as an adjunctive approach to enhance the patient's experience and improve outcomes.
PubMed: 38719659
DOI: 10.1016/j.pmn.2024.04.009 -
Annals of Surgery May 2024To evaluate the prophylactic effect of Regenerative Peripheral Nerve Interface (RPNI) surgery on pediatric post-amputation pain.
OBJECTIVE
To evaluate the prophylactic effect of Regenerative Peripheral Nerve Interface (RPNI) surgery on pediatric post-amputation pain.
SUMMARY OF BACKGROUND DATA
Chronic post-amputation pain is a debilitating and refractory sequela of limb amputation affecting up to 83% of pediatric patients with limb loss, resulting in disability and decreased quality of life. We postulate that prophylactic RPNI surgery performed during amputation may decrease the incidence of symptomatic neuroma and development of phantom limb pain, as well as limit analgesic use among pediatric patients with limb loss.
METHODS
Retrospective chart review was performed on pediatric patients between the ages of 8 and 21 years who underwent major lower limb amputation with and without RPNI surgery. Documented neuroma and phantom limb pain scores as well as analgesic use was recorded. Narcotic use was converted to milligrams morphine equivalents per day (MME/day) while overall analgesic use was converted to Medication Quantification Scale version III (MQSIII) scores. Analysis was performed using Stata.
RESULTS
Forty-four pediatric patients were identified; 25 RPNI patients and 19 controls. Seventy-nine percent of control patients developed chronic post-amputation pain versus 21% of RPNI patients (P<0.001). Among the patients who developed post-amputation pain, 20% of controls developed clinical neuroma pain, compared to 0% of RPNI patients (P<0.001). Additionally, RPNI patients demonstrated a significant decrease in pain score (P=0.007) and narcotic usage (P<0.01), compared to controls. Overall analgesic use did not vary significantly between groups.
CONCLUSIONS
Prophylactic RPNI surgery shows promise for pediatric patients undergoing major lower limb amputation by preventing both symptomatic neuromas and possibly the development of phantom limb pain.
PubMed: 38716659
DOI: 10.1097/SLA.0000000000006327 -
JBRA Assisted Reproduction May 2024Clinacanthus nutans (C. nutans) is a medicinal herb that most people with diabetes have historically taken. It's a diet high in antioxidants, which are supposed to help...
OBJECTIVE
Clinacanthus nutans (C. nutans) is a medicinal herb that most people with diabetes have historically taken. It's a diet high in antioxidants, which are supposed to help people live longer and be healthier. It is the first study to suggest using C. nutans to enhance the quality of sperm in male mice given a streptozotocin (STZ) injection.
METHODS
Sixty mice were divided into two groups at the age of four weeks: group one was fed a regular diet (n=10), while group two was administered a high-fat diet (n=50) for eight weeks to develop obesity. Obese mice were given 100mg/kg of STZ to produce hyperglycemia with a 20% mortality rate. Then, 40 hyperglycemic mice were separated into two groups: STZ (n=10) and sample (n=30). The treatment groups were administered a methanolic extract of C. nutans leaves by gavage at doses of 150, 300, and 500mg/kg of body weight (n=10) for 4 weeks.
RESULTS
In contrast to the STZ group, there was a substantial (p=0.001) drop in serum blood glucose and total sperm abnormalities in mice at varying doses. Catalase, glutathione s-transferase (GST), and total antioxidant capacity significantly (p=0.001) increased in the STZ mice group at varying doses, but malondialdehyde was reduced. In comparison to STZ mice, testosterone and luteinizing hormone (LH) levels improved in mice treated with extracts of C. nutans at various doses. For all of the following dependent variables, extraction of the leaf at higher concentrations of 500 milligrams/kilogram has better efficacy than 300 and 150 mg/kg after 4 weeks of treatment.
CONCLUSIONS
The research and development of new natural agents to combat oxidative stress-related diseases have sparked a lot of interest. As a result, the potential leaf extract of C. nutans contains anti-hyperglycemic compounds and improves the quality of sperm in male mice.
PubMed: 38712836
DOI: 10.5935/1518-0557.20240010