Optimal Frequency in Repetitive Transcranial Magnetic Stimulation for the Management of Chronic Pain: A Network Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: Repetitive Transcranial Magnetic Stimulation (rTMS) has been shown to be effective for pain modulation in a variety of pathological conditions causing neuropathic pain. The purpose of this study is to conduct a network meta-analysis (NMA) of randomized control trials to identify the most optimal frequency required to achieve chronic pain modulation using rTMS. METHODS: A comprehensive search was conducted in electronic databases to identify randomized controlled trials investigating the efficacy of rTMS for chronic pain management. A total of 24 studies met the inclusion criteria, and a NMA was conducted to identify the most effective rTMS frequency for chronic pain management. RESULTS: Our analysis revealed that high frequency rTMS (20 Hz) was the most effective frequency for chronic pain modulation. Patients treated with 20 Hz had lower pain levels than those treated at 5 Hz (mean difference [MD] = -3.11 [95% confidence interval {CI}: -5.61 - -0.61], P = 0.032) and control (MD = -1.99 [95% CI: -3.11 - -0.88], P = 0.023). Similarly, treatment with 10 Hz had lower pain levels compared to 5 Hz (MD = -2.56 [95% CI: -5.05 - -0.07], P = 0.045) and control (MD = -1.44 [95% CI: -2.52 - -0.36], P = 0.031). 20 Hz and 10 Hz were not statistically different. CONCLUSIONS: This NMA suggests that high frequency rTMS (20 Hz) is the most optimal frequency for chronic pain modulation. These findings have important clinical implications and can guide healthcare professionals in selecting the most effective frequency for rTMS treatment in patients with chronic pain.

Prediction Models for Successful External Cephalic Version: An Updated Systematic Review.

OBJECTIVE: To review the decision aids currently available or being developed to predict a patient's odds that their external cephalic version (ECV) will be successful. STUDY DESIGN: We searched PubMed/MEDLINE, Cochrane Central, and ClinicalTrials.gov from 2015 to 2022. Articles from a pre-2015 systematic review were also included. We selected English-language articles describing or evaluating models (prediction rules) designed to predict an outcome of ECV for an individual patient. Acceptable model outcomes included cephalic presentation after the ECV attempt and whether the ECV ultimately resulted in a vaginal delivery. Two authors independently performed article selection following PRISMA 2020 guidelines. Since 2015, 380 unique records underwent title and abstract screening, and 49 reports underwent full-text review. Ultimately, 17 new articles and 8 from the prior review were included. Of the 25 articles, 22 proposed one to two models each for a total of 25 models, while the remaining 3 articles validated prior models without proposing new ones. RESULTS: Of the 17 new articles, 10 were low, 6 moderate, and 1 high risk of bias. Almost all articles were from Europe (11/25) or Asia (10/25); only one study in the last 20 years was from the United States. The models found had diverse presentations including score charts, decision trees (flowcharts), and equations. The majority (13/25) had no form of validation and only 5/25 reached external validation. Only the Newman-Peacock model (United States, 1993) was repeatedly externally validated (Pakistan, 2012 and Portugal, 2018). Most models (14/25) were published in the last 5 years. In general, newer models were designed more robustly, used larger sample sizes, and were more mathematically rigorous. Thus, although they await further validation, there is great potential for these models to be more predictive than the Newman-Peacock model. CONCLUSION: Only the Newman-Peacock model is ready for regular clinical use. Many newer models are promising but require further validation. KEY POINTS: · 25 ECV prediction models have been published; 14 were in the last 5 years.. · The Newman-Peacock model is currently the only one with sufficient validation for clinical use.. · Many newer models appear to perform better but await further validation..

Improving visualization of the cervix during pelvic exams: A simulation using a physical model of the speculum and human vagina as a steppingstone to reducing disparities in gynecological cancers.

Pelvic exams are frequently complicated by collapse of the lateral vaginal walls, obstructing the view of the cervix. To overcome this, physicians frequently repurpose a glove or a condom as a sheath placed over the speculum blades to retract the lateral vaginal walls. Despite their regular use in clinical practice, little research has been done comparing the relative efficacy of these methods. Better visualization of the cervix can benefit patients by decreasing examination-related discomfort, improving cancer screening accuracy, and preventing the need to move the examination to the operating room under general anesthesia. This study presents a physical model that simulates vaginal pressure being exerted around a speculum. Using it, we conduct controlled experiments comparing the efficacy of different condom types, glove materials, glove sizes, and techniques to place gloves on the speculum. The results show that the best sheath is the middle finger of nitrile-material gloves. They provide adequate lateral wall retraction without significantly restricting the opening of the speculum. In comparison, condoms provide a smaller amount of retraction due to loosely fitting the speculum. They may still be a reasonable option for a different speculum size. However, vinyl-material gloves are an impractical option for sheaths; they greatly restrict speculum opening, occasionally even breaking the speculum, which overcome its retraction benefits. Glove size, condom brand, and condom material (latex vs polyisoprene) had minimal impact. This study serves as a guide for clinicians as they use easily accessible tools to perform difficult pelvic exams. We recommend that physicians consider nitrile gloves as the preferred option for a sheath around a speculum. Additionally, this study demonstrates proof-of-concept of a physical model that quantitatively describes different materials on their ability to improve cervical access. This model can be used in future research with more speculum and material combinations, including with materials custom-designed for vaginal retraction.

Using a condom or glove to improve pelvic exam visualization: A guide.

Objectives: Pelvic exams are a cornerstone of gynecological care, necessary for both regular screenings and diagnostics. The collapse of lateral vaginal walls during a pelvic exam is a frequently encountered problem in clinical practice. Methods: Practitioners often utilize tools found in a typical clinical setting to counter this issue, such as a condom or glove over the speculum to prevent the lateral vaginal walls collapsing inward and obscuring cervical views. Results: These techniques have been passed down from mentor to mentee over the years, though scarcely described in literature. This article aims to provide instructions on how to use these two methods in clinical practice to improve pelvic exams for the practitioner and the patient. Conclusion: Utilizing a condom or glove to prevent lateral vaginal wall collapse has the potential to improve pelvic exams for both practitioners and patients.

Healthcare Professionals' Views and Perspectives towards Aging.

Improving care for the older population is a growing clinical need in the United States. Ageism and other attitudes of healthcare professionals can negatively impact care for older adults. This study investigated healthcare professionals' (N = 140) views towards aging and characterized a confluence of factors influencing ageism perspectives in healthcare workers using path analysis models. These models proposed relationships between aging anxiety, expectations regarding aging, age, ageism, and knowledge. Aging anxiety had a less critical role in the final model than hypothesized and influenced ageism in healthcare workers through its negative effect (ß = -0.27) on expectations regarding aging. In contrast, aging knowledge (ß = -0.23), age (ß = -0.27), and expectations regarding aging (ß = -0.48) directly and inversely influenced ageism. Increased knowledge about the aging process could lower ageism amongst healthcare professionals and improve care for older adults. The results put forth in this study help to characterize and understand healthcare workers' complex views towards the aging population they often encounter. Moreover, these results highlight the need and utility of leveraging practitioner education for combating ageism in the clinical setting.

Demographic and Geospatial Analysis of Buprenorphine and Methadone Prescription Rates.

Background The medical community continues to seek to understand both the causes and consequences of opioid use disorder (OUD). The recent 2019 public release of the Automation of Reports and Consolidated Orders System (ARCOS) database from the years 2006 to 2012 provides a unique opportunity to analyze a critical period of the opioid epidemic with unprecedented data granularity. Objectives This study aims to use the ARCOS dataset to (1) determine significant contributory variables to opioid overdose death rates, (2) determine significant contributory variables to the relative prescription of buprenorphine and methadone, and (3) evaluate the existence of statistically significant geospatial clusters in buprenorphine and methadone prescription rates. Methods This study utilizes multiple databases, including the Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research (WONDER), the Drug Enforcement Administration (DEA) prescription drug data, and the United States (US) Census demographics, to examine the relationship between the different treatments of OUD. Linear regressions are used to determine significant contributory factors in overdose rate and the buprenorphine-to-methadone ratio. Geospatial analysis is used to identify geographic clusters in opioid overdoses and treatment patterns. Results Methadone prescriptions, racial demographics, and poverty were found to significantly correspond to opioid overdose death rates (p < 0.05). Buprenorphine prescriptions were not found to be significant (p = 0.20). Opioid overdoses, metro character, racial categorization, and education were found to significantly correspond to the ratio of buprenorphine to methadone prescribed (p < 0.05). Cluster analysis demonstrated different geospatial distributions in the prescriptions of buprenorphine and methadone (p < 0.05). Conclusion Historically, methadone prescriptions have been higher in areas with high overdose rates. Buprenorphine and methadone prescribing patterns have historically demonstrated different geographic trends.