High-frequency, high-intensity TENS compared to standard treatment with opioids for postoperative pain relief after laparoscopic cholecystectomy: A multicentre randomized controlled trial.

BACKGROUND: Adverse effects of opioids could prolong the duration of stay in the post-anaesthesia care unit (PACU). This study aimed to assess time in the PACU and the pain-relieving effect of high-frequency, high-intensity transcutaneous electrical nerve stimulation (HFHI TENS) versus standard treatment with intravenous (IV) opioids. METHODS: Patients undergoing laparoscopic cholecystectomy at two Swedish hospitals were invited to participate. Patients reporting postoperative pain intensity ≥3 according to the Numeric Rating Scale (NRS) in the PACU were randomized to receive standard treatment with IV opioids or HFHI TENS, administered with an intensity of 40-60 mA for 1 min, repeated once if insufficient pain relief. If NRS remained ≥3 after two TENS stimulation the patients received IV opioids. RESULTS: In total, 163 patients were randomized to receive HFHI TENS (n = 85) or IV opioids (n = 78). There was no difference between the HFHI TENS group versus the opioid group regarding time in the PACU (138 min [SD 69] vs. 142 min [SD 95], mean difference -4.42 [95% CI-30:22], p = 0.74), time to pain relief NRS < 3 (median 10 min) and pain intensity at PACU discharge (NRS 1.7 [SD 1.45] vs. 1.6 [SD 1.20], p = 0.58). In the HFHI TENS group, 39 patients (46%) needed additional treatment with IV opioids. Mean opioid consumption was significantly lower in the HFHI TENS group than in the opioid group (4.5 vs. 11.0 morphine equivalents; p < 0.001). CONCLUSIONS: HFHI TENS may be an opioid-sparing alternative for postoperative pain relief. SIGNIFICANCE STATEMENT: In this multicentre, RCT time in the PACU and the pain-relieving effect of HFHI TENS was compared to standard treatment with IV opioids. There were no differences between the groups regarding time in the PACU, time to pain relief and side effects but opioid consumption in the HFHI TENS group was significantly lower. Both groups reported high satisfaction with pain treatment and care. In summary, HFHI TENS should be considered a safe, fast-onsetting, opioid-sparing option for postoperative pain relief.

Protocol to investigate child abuse in foster care.

Hennepin County Community Services, a large urban agency in the midwestern United States, developed specific procedures for investigating complaints of abuse and neglect of children in foster care in 1980. During the period from May 1980 through November 1981, approximately 125 complaints of abuse and neglect in foster homes were investigated. This article discusses the Protocol, including the institutional abuse meeting, investigation by an independent third party, and statements of finding. Factors that appear to be significant in abusing foster parents are marital status, if the foster parents had children of their own, length of time licensed, and presence of previous complaints. Victims were slightly more likely to be male, aged 4-12. Many victims appeared to have adjusted well to the foster homes. Information is presented on how the abuse was reported. Recommendations include: investigations conducted by an objective third person, commitment of the administration, and enlistment of legal personnel and foster parents during implementation. Also included are prevention of abuse through comprehensive screening and then training of foster parents, social workers' close contact with foster parents and foster children, avoiding high risk placement, forbidding corporal punishment, and sensitizing social workers to abuse-neglect of children in foster care.

Interpretation of the tcPO2 curve in adult patients in an intensive care unit.

From the data collected on 135 adult patients in an intensive care unit the following conclusions of the interpretation of the transcutaneous PO2 curve in this type of patient may be drawn: 1) One to four minutes after the electrode was attached a nadir (= the lowest initial point) was reached and then there was a gradual increase which ended with an initial plateau. This plateau could be predicted from the lowest initial point by adding 30 mm Hg. 2) If the lowest initial point was 35 mm Hg or less, it was expected that the final tcPO2 level would be lower than the actual PaO2. 3) No correlation was seen between the lowest initial point of the tcPO2 curve and the time until the initial plateau was reached. In 75% of the cases the plateau was reached within 20 minutes. 4) A slight positive correlation was found between arterial blood pressure and lowest initial point. The difference between the means of the lowest initial point for a group with blood pressure less than or equal to 90 mm Hg and another group with blood pressure greater than 120 mm Hg was highly significant. 5) Transcutaneous PO2 measurements were more likely to represent the arterial PO2 level if blood pressure was greater than 120 mm Hg than if it was less than or equal to 90 mm Hg. 6) The lower the initial tcPO2 level, the more likely it was that the arterial level was higher than the tcPO2 level (see also point 2). 7) The differences between PaO2 and tcPO2 were independent of the arterial PO2 level. 8) The overall correlation between PaO2 and tcPO2 in this material was 0.91; the slope was 0.90 and the intercept -8 mm Hg. The correlation coefficient within each individual patient was higher. 9) The correlation coefficient between PaO2 and tcPO2 for those patients in whom PaO2 was 60 mm Hg or less was comparatively low. This may be explained by the bad condition of these patients followed by a reduced blood flow. 10) An initial drop in tcPO2 to zero level indicates a reduced peripheral circulation, but this must be suspected when the initial drop is below 35 mm Hg.

Contrast media hyperemia and Doppler measurements in peripheral arterial disease.

The addition of Doppler measurements of ankle/brachial artery pressure ratios just before and after the hyperemia of routine angiography is a simple, quick, and efficient method in the determination of the hemodynamic significance of arterial narrowings. In a series of 21 patients (35 limbs) this test was found to be particularly helpful for those patients who could not undergo stress exercise testing, who had borderline significant physiologic test results, and who had angiographically indeterminate severe vessel narrowings.

Cell-type-specific localization of transforming growth factor-beta 2 and transforming growth factor-beta 1 in the hamster ovary: differential regulation by follicle-stimulating hormone and luteinizing hormone.

Cell-type-specific localization and gonadotropin regulation of transforming growth factor-beta 1 (TGF-beta 1) and transforming growth factor-beta 2 (TGF-beta 2) in the hamster ovary were evaluated immunohistochemically under three conditions: (1) during the estrous cycle (Day 1 = estrus; Day 4 = proestrus); (2) after the blockade of periovulatory gonadotropin surges by phenobarbital, and (3) after FSH and/or LH treatment of long-term hypophysectomized hamsters. Ovarian TGF-beta 1 activity was primarily localized in theca and interstitial cells. The activity increased moderately but significantly after the preovulatory LH surge and reached a peak at 0900 h, Day 2 h; oocytes showed considerable activity. TGF-beta 1 immunoreactivity subsequently fell to low levels in theca-interstitial cells through 0900 h, Day 4. Significant TGF-beta 2 immunoreactivity appeared after the surge, mainly in the granulosa cells of both preantral and antral follicles; a few interstitial cells surrounding preantral follicles showed discrete staining. TGF-beta 2 immunoreactivity in granulosa cells and in interstitial cells next to preantral follicles reached a peak at 0900 h, Day 1, and persisted up to 0900 h, Day 2; oocytes showed no staining. Phenobarbital treatment blocked the appearance of TGF-beta 1 and TGF-beta 2 immunoreactivities at 1600 h, Day 4; however, a rebound in immunoreactivities was observed with the onset of the surge after a 1-day delay. Replacement of LH to long-term hypophysectomized hamsters resulted in a marked increase in TGF-beta 1 immunoreactivity in the interstitial cells, but FSH, although it induced follicular development, did not influence ovarian TGF-beta 1 activity. Treatment with FSH, however, induced a massive increase in TGF-beta 2 immunoreactivity in the granulosa cells of newly developed antral and preantral follicles but not in the interstitial cells; LH, on the other hand, had no significant effect on TGF-beta 2 activity. Treatment with FSH and LH combined resulted in a dramatic increase in TGF-beta 2 immunoreactivity in granulosa and interstitial cells and in TGF-beta 1 in theca and interstitial cells comparable to their peak activity in intact animals. Western analyses substantiated the presence of TGF-beta 1 and TGF-beta 2 in the hamster ovary and the specificity of immunolocalization. These studies, therefore, provide critical evidence that TGF-beta 1 and TGF-beta 2 in the hamster ovary are expressed in specific cell types and that their expression is differentially regulated by LH and FSH, respectively.

The validity of the transcutaneous oxygen tension method in adults.

The transcutaneous oxygen tension (tcPo2) in five healthy subjects and in seven patients was monitored continuously by the technique of Huch, Huch, and Lübbers. The inspired oxygen concentration was varied between 15 and 100%. Once stable tcPo2 recordings were obtained, blood samples were drawn via an indwelling arterial catheter for oxygen tension (Pao2) determination. A comparison between the Pao2 and the tcPo2 values is illustrated graphically. There was a small difference between these values in the healthy subjects, which was attributed to variations in the skin from subject to subject. In the patients, a circulatory factor may have added to differences in the absolute levels. The coefficient of correlation between Pao2 and tcPo2 was in all cases higher than 0.98. In healthy persons, Pao2 may be predicted from tcPo2. In patients, any change in Pao2, due to deterioration or improvement, is manifested in the tcPo2 curve. If one or two arterial blood measurements are performed, low as well as high Pao2 values may be predicted from tcPo2 in patients without gross circulatory impairment.

Effect of respiratory physiotherapy on arterial oxygen tension.

The effect of deep breathing on arterial oxygen tension was investigated in 45 postoperative patients. Arterial oxygen tension was estimated by the transcutaneous oxygen tension method, which allows continuous non-invasive measurement of the arterial oxygen tension changes. Three deep breaths in 1 min, assisted by three respiratory therapy devices, were compared to a standard physiotherapy programme. A peak increase in arterial oxygen tension of 3--4.5 mmHg occurred after 1 min, and significantly increased values were seen for 2--4 min following deep breathing with the three respiratory devices. From the various physiotherapeutic procedures, verbally and manually assisted deep breathing gave a 7 mmHg PO2 peak and significantly increased values for 6 min. The sign mechanism is discussed in the light of the present knowledge of airway closure, which gives a satisfactory explanation of the short-lasting increase in oxygen tension.