Volume 120, Issue 7

Context Pain is a therapeutic challenge after total knee arthroplasty (TKA), and it could lead to the overuse of opioids. Few methodologically robust clinical studies have been performed to assess the effectiveness of osteopathic manipulative therapy (OMTh; manipulative care performed by non–US-trained osteopaths) for postsurgical pain. Objective To evaluate the effectiveness of standardized preoperative OMTh on early postoperative pain and opioid consumption after TKA. Methods This comparative, nonrandomized study took place from 2013 to 2015 and included patients who had primary unilateral TKA for osteoarthritis in a knee that had not undergone any previous surgery. Patients were divided into 2 consecutive groups: 1 group received traditional preoperative management, and the other group received associated preoperative OMTh (general OMTh [rhythmic mobilization of all the body joints, from the ankles to the skull, using long-lever manipulation] and myofascial relaxation). The primary evaluation criterion was knee pain at rest 1 month after surgery: 0 (no pain) to 100 (the worst imaginable pain). The secondary evaluation criteria were: (1) knee pain while walking 1 month after surgery, (2) average weekly knee pain during the first month after surgery, (3) the presence of night pain and the consumption of sleeping pills and opioids or morphine at least once per week, (4) the International Knee Society scores and the Western Ontario and McMaster University Osteoarthritis index at postoperative 6 months and 1 year. The number of patients needed for a superiority trial was determined. Results No eligible patient refused OMTh when proposed. Seventy patients were evaluated (mean [SD] age, 75 [8] years; 47 women and 23 men). The 2 treatment groups contained 35 patients each. At postoperative month 1, the OMTh group had significantly less pain at rest (mean [SD], 6.8 [6] vs 20.9 [17.3]; P =.00001) and while walking (7.9 [9.4] vs 23.5 [20.6]; P =.0001) compared with the group that received traditional preoperative management. The consumption of opioids during the first postoperative week was significantly lower in the OMTh group ( P =.0001). No statistically significant difference was found in the International Knee Society or Western Ontario and McMaster University Osteoarthritis scores between the 2 groups at 6 months and 1 year of follow-up. Conclusion Standardized preoperative OMTh was found to be effective in reducing pain in the first month after TKA for osteoarthritis and significantly reduced opioid consumption during the first postoperative week.

Context : Patients with diabetes are susceptible to heart failure. Defective mitochondria can cause cardiac damage. Mitochondrial autophagy or mitophagy is a quality control mechanism that eliminates dysfunctional mitochondria through lysosome degradation. Mitophagy is essential for maintaining a pool of healthy mitochondria for normal cardiac function. However, the effect of diabetes on the functional status of cardiac mitophagy remains unclear. Objective: To determine and compare cardiac mitophagy flux between diabetic and nondiabetic mice. Methods: Using a novel dual fluorescent mitophagy reporter termed mt-Rosella , we labeled and traced mitochondrial fragments that are sequestered by the autophagosome and delivered to and degraded in the lysosome. Results: Mitophagic activity was reduced in high-glucose–treated cardiomyocytes and in the heart tissue of type 1 diabetic mice. Conclusions: Mitophagy was impaired in the heart of diabetic mice, suggesting that restoring or accelerating mitophagy flux may be a useful strategy to reduce cardiac injury caused by diabetes.

Context The number of deaths due to opioid overdose has steadily increased in the United States since the early 2000s. The US opioid epidemic calls for an urgent need to evaluate physician prescribing habits. Objective To educate obstetrics and gynecology residents about opioid abuse, the quantity typically prescribed postoperatively, and strategies to decrease adverse outcomes. Methods Obstetrics and gynecology residents at an urban safety-net hospital were given a preintervention evaluation to understand their opioid prescribing patterns and use of resources like prescription drug monitoring programs and opioid risk tool. Residents then attended a didactic session reviewing rates of adverse outcomes from overprescribing, resources to reduce adverse outcomes, and the number of opioids considered appropriate postoperatively. Residents completed an immediate postintervention evaluation to reevaluate prescribing patterns. Results Pre- and postintervention evaluations were completed by 13 residents. In the preintervention evaluation, all participants reported that they would prescribe at least 30 opioid pills for patients after cesarean delivery, but in the postintervention evaluation, none reported that they would prescribe more than 20 opioid pills ( P =<.0001). Similar but less distinct shifts can be seen in laparoscopic hysterectomy and the use of preoperative gabapentinoids (ie, gabapentin and pregabalin). Before the intervention, 7 residents (54%) reported that they currently prescribed 20 opioid pills or more for patients after laparoscopic hysterectomy, whereas after the intervention, 1 resident (7.7%) reported that he or she would prescribe more than 20 opioid pills in ( P =.0382). Before the intervention, 2 residents (15.4%) reported that they would consider gabapentinoids compared with 13 residents (100%) after the intervention. Conclusion Focused opioid education can reduce the intended number of opioid pills prescribed in a postoperative setting. This study highlights the effect that educational curricula can have on physician prescribing patterns to help mitigate the current epidemic and help optimize stepwise multimodal analgesia to avoid overprescribing opioids.

Context Patient care is an essential part of the practice of obstetrics and gynecology, and patient care is directed by clinical practice guidelines. To increase the validity of these guidelines, we must make sure that there is no outside influence by financial conflicts of interest. Objective To investigate the existence of and reporting patterns regarding payments received by contributors to guidelines from the American College of Obstetricians and Gynecologists (ACOG), ACOG executive committee members, and companies making these payments and to examine the compliance of those receiving payments to ACOG's conflict of interest policies. Methods The Center for Medicare and Medicaid's Open Payments database was used to search practice bulletin committee members and practice bulletin collaborators from 2014-2016, as well as current executive committee board members. Open Payments was also used to evaluate companies that provided payments, and amounts were totaled. The main outcome measure was the monetary values of payments received and the compliance with disclosure statements enforced by ACOG. Manufacturer payments to physicians in the database were analyzed descriptively. Results General and research payments were calculated among 65 physicians in the Open Payments database: 44 physician members of both the obstetrics and the gynecology practice bulletin committees, 4 2016 ACOG executive board physician members, and 17 contributing physician authors. Research payments accounted for greater than 78% of all payments. Consulting, travel and lodging, and speaking fees totaled greater than $90,000 and contributed to more than 90% of the total amount of general payments. Food and beverage payments contributed to 10% of all general payments. Three covered members were noncompliant with the financial conflicts of interest guidelines, receiving industry payments exceeding $5000. Conclusion A small number of companies provide the majority of contributions; however, there is no evidence to suggest bias toward manufactures within ACOG practice bulletins. Future investigations into pharmaceutical manufacturer payments, specifically for consulting fees, may be warranted. (Clinical Trial Registry UMIN-CTR, UMIN000029165)

The influenza outbreak that occurred during 1918-1920 was a defining moment in the history of the world and osteopathic medicine. Despite the tremendous loss of human life, osteopathic physicians also observed greater success in the treatment of patients with the disease, in contrast with their allopathic counterparts. Osteopathic physicians also succumbed to the deadly influenza effects while treating patients. A list of osteopathic physicians who died of influenza or related complications during the pandemic, obtained from osteopathic journals from that time, is provided, along with the historical context of the pandemic.

Prostate cancer is the second most common cause of cancer death among US men. Metastasis typically occurs in the bone, lymph nodes, liver, and thorax. This case highlights a patient who was suspected of having prostate cancer several years before presenting to the emergency department with back pain and an umbilical hernia of increasing size. Gross examination revealed fixed masses on the abdominal wall that appeared malignant on computed tomographic imaging. The umbilical mass was a Sister Mary Joseph nodule (SMJN), which is sometimes found in patients with advanced, metastatic abdominal cancer. An SMJN is most commonly suggestive of gastrointestinal or gynecologic cancer, but it is a rarely reported finding in the context of prostate cancer. SMJN is a frequently missed finding that may delay further investigation for malignant neoplasms. This case reinforces the importance of this physical examination finding and provides evidence for adding prostate cancer to the list of possible diagnoses for patients who have an SMJN.

Dysmenorrhea, or painful menstruation, is a common cause of acute pelvic pain that affects approximately two-thirds of women who are postmenarchal in the United States. Dysmenorrhea pain is frequently severe enough to disrupt daily activities and often accompanied by other symptoms, such as diarrhea, nausea, vomiting, headache, and dizziness. Primary dysmenorrhea is likely due to an excess of prostaglandins and is traditionally treated with nonsteroidal anti-inflammatory drugs and hormonal therapy. Secondary dysmenorrhea can have multiple origins and requires targeted therapy. Currently, musculoskeletal dysfunction and psychosocial factors are not listed as causes of secondary dysmenorrhea. The authors present a case in which the cause of secondary dysmenorrhea was thought to be related to both musculoskeletal dysfunction and emotional stress. Osteopathic manipulative treatment and lifestyle changes helped resolve secondary dysmenorrhea.