Nevin Manimala

Pain Physician. 2026 May;29(3):269-279.

ABSTRACT

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) affects approximately 50% of patients who receive chemotherapy. CIPN often results in dose reductions, therapy discontinuation, and long-term neurological impairment. Despite existing studies, identifying high-risk populations remains challenging, particularly in patients with diabetes, diabetic neuropathy, and those undergoing corticosteroid therapy.

OBJECTIVES: We sought to evaluate the key risk factors associated with CIPN by analyzing patient demographics, comorbidities, and chemotherapy regimens, with a specific focus on diabetes-related variables in order to inform early identification and prevention strategies.

STUDY DESIGN: Retrospective, single-center, observational cohort study.

SETTING: Academic tertiary care cancer center.

METHODS: Adult patients who received chemotherapy between January 2016 and December 2023 were identified through electronic medical records. Patients with CIPN were defined by the International Classification of Disease, Tenth Revision G62.0 diagnosis code (drug-induced polyneuropathy) and an associated diagnosis of “painful peripheral neuropathy.” Extracted data included demographics (age, body mass index [kg/m2], race/ethnicity), clinical variables (alcohol use, corticosteroid use, diabetes-related factors), and chemotherapy regimen details. Descriptive statistics, Wilcoxon rank sum, c2/Fisher’s exact tests, and multivariable logistic regression were performed. Institutional review board (IRB) approval was obtained (IRB exemption #2024-0139).

RESULTS: Among 36,949 patients, significant CIPN risk factors included older age (40-80 years, P < 0.0001), women (odds ratio [OR] 1.89; P < 0.0001), non-Hispanic/non-Latino ethnicity (OR 1.29; P < 0.0001), and corticosteroid use (OR 2.01; P < 0.0001). African American patients had lower odds of CIPN than White patients (OR 0.78; P < 0.0001). Diabetic neuropathy was strongly associated with increased CIPN risk (OR 5.35; P < 0.0001). Alcohol use was inversely associated with CIPN (OR 0.75; P < 0.0001). Several chemotherapy agents also showed significant associations.

LIMITATIONS: Our study is limited by its retrospective design, potential misclassification bias in CIPN diagnosis, and reliance on electronic medical records. Alcohol use data were frequently missing or unspecified, limiting interpretation.

CONCLUSIONS: Key CIPN risk factors include age, race/ethnicity, corticosteroid use, and diabetic neuropathy. Alcohol use appeared inversely associated with CIPN, though causality remains unclear. Individualized patient assessments and proactive management strategies may help reduce CIPN incidence and improve outcomes in patients with cancer who are receiving chemotherapy.

PMID:42263313

Pain Physician. 2026 May;29(3):E217-E227.

ABSTRACT

BACKGROUND: Degenerative disc disease is a leading cause of low back pain. Conservative treatments like pain medication and exercise therapy have shown mixed results, while procedures like fusion surgery carry risks such as adjacent segment disorder and surgical morbidity. Therefore, there is a critical need for treatments that bridge the gap between conservative care and surgery.

OBJECTIVE: To assess the efficacy of intradiscal hydrogel implantation compared with sham treatment of intradiscal injection of saline in patients with chronic discogenic low back pain.

STUDY DESIGN: Prospective, double-blind, randomized, controlled, multicenter trial.

SETTING: Two tertiary interventional pain care centers in Switzerland and in the Netherlands.

METHODS: Forty-nine patients with chronic discogenic low back pain unresponsive to conservative treatment were randomized to receive either intradiscal hydrogel implantation or a sham treatment. Control Group patients could cross over to hydrogel treatment after 6 months. The primary outcome was pain improvement at 6 months. Secondary outcomes included disability, quality of life, employment status, Patient Global Impression of Change score, analgesic use, disc space height, and disc degeneration. Adverse events were continually assessed.

RESULTS: At 6 months postprocedure, the Hydrogel Group patients had improved pain scores compared to Control Group patients, though not statistically significant (P = 0.070). Six out of 24 patients in the Hydrogel Group reported much improvement on their Patient Global Impression of Change scores, compared to 0 out of 25 in the Control Group (P = 0.008). Within-group disability improvements were statistically significant in the Hydrogel Group but not in the Control Group. No significant differences were found between groups in disability, quality of life, or employment status. Only one serious adverse event was reported-a patient from the Hydrogel Group was hospitalized due to a possible exacerbation of low back pain 6 days postprocedure.

LIMITATIONS: This trial’s limitations include strict eligibility criteria and questions about the validity of intradiscal saline as a placebo.

CONCLUSIONS: This trial suggests that percutaneous intradiscal hydrogel implantation may reduce chronic discogenic pain and disability, with significant Patient Global Impression of Change improvements, though larger trials are needed to confirm efficacy.

PMID:42263312

Pain Physician. 2026 May;29(3):E209-E216.

ABSTRACT

BACKGROUND: A transversus abdominis plane block provides reliable abdominal wall analgesia, but which adjuvants best sustain its effect remains debated. By facilitating diffusion of local anesthetics, hyaluronidase may improve block quality.

OBJECTIVES: This study evaluated the safety and efficacy of 2 hyaluronidase doses added to bupivacaine for bilateral transversus abdominis plane blocks in patients having a cesarean delivery.

STUDY DESIGN: A prospective, randomized, double-blind, controlled clinical trial.

SETTING: Benha University Hospital, Arab Republic of Egypt, from May 2023 through February 2024.

METHODS: A double-blind, controlled randomized trial was performed with 114 patients having elective cesarean delivery. The patients were allocated equally into 3 arms: Group I (bupivacaine alone), Group II (bupivacaine plus 750 IU hyaluronidase), and Group III (bupivacaine plus 1500 IU hyaluronidase). The time to first rescue analgesia served as the primary outcome. Secondary outcomes encompassed 24-hour morphine requirements, Visual Analog Scale pain score at rest and on coughing, patient satisfaction, hemodynamics, and adverse events. Analyses employed the appropriate statistical tests (parametric or nonparametric), with subsequent post hoc comparisons for significant findings.

RESULTS: Both hyaluronidase groups had significant prolonged analgesia (median 8.1 hours and 9.6 hours) compared to the control group (5.8 hours) (P < 0.001). Morphine requirements over the first postprocedure 24 hours diminished significantly (P < 0.001); Groups II and III had lower pain scores at rest and on coughing between postprocedure hours 2 and 12 (all P < 0.05). Patient satisfaction increased with hyaluronidase (P = 0.0039). No group differences were observed for adverse events, including postoperative nausea and vomiting or local anesthetic toxicity.

LIMITATIONS: This single-center trial with 24-hour follow-up may restrict generalizability and long-term safety assessment; also only 2 hyaluronidase doses were examined.

CONCLUSIONS: Adding hyaluronidase to bupivacaine for transversus abdominis plane block enhances analgesic duration and quality without compromising safety in patients having cesarean delivery. Both high and low doses appear equally effective, suggesting that even lower doses are sufficient for optimal effect.

PMID:42263311

Pain Physician. 2026 May;29(3):251-257.

ABSTRACT

BACKGROUND: The transforaminal epidural steroid injection (TFESI) is a widely used interventional procedure for managing radicular pain. Although TFESI is well established as a safe and effective treatment, patients frequently seek detailed explanations regarding its procedural steps, expected outcomes, and potential risks. Artificial intelligence (AI)-based platforms, particularly large language models (LLMs) such as ChatGPT, have emerged as accessible sources of periprocedural medical information. However, the accuracy, readability, and empathy of AI-generated responses in the context of interventional pain management remain uncertain.

OBJECTIVES: To compare the accuracy and readability of responses generated by ChatGPT and fellowship-trained pain medicine physicians to common patient questions about TFESIs and to assess the potential utility of AI in patient education and periprocedural guidance.

STUDY DESIGN: A cross-sectional comparative study.

METHODS: Twenty frequently asked patient questions about TFESIs were retrospectively identified from pain clinic consultations and submitted individually to ChatGPT-4o and to fellowship-level physicians. Two interventional pain specialists independently evaluated all responses for accuracy and empathy using a 5-point Likert scale; discrepancies were resolved by a third reviewer. Readability was analyzed using the Readable® tool kit across 7 indices: Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGRL), Gunning Fog Index, SMOG Index, Coleman-Liau Index, average word and sentence length, and estimated overall reach.

RESULTS: Both sources delivered highly accurate responses. However, ChatGPT’s answers had significantly lower FRES scores, reflecting reduced reading ease, and higher scores across all other readability indices, indicating greater linguistic complexity and lower accessibility. These responses required a higher level of education to understand. Although empathy scores for ChatGPT were lower than the physicians’, the difference was not statistically significant.

LIMITATIONS: This study assessed a single AI platform (ChatGPT-4o). Accuracy and empathy ratings were performed subjectively by 2 pain specialists, which might have limited generalizability. Additionally, AI-generated responses can vary with software updates, reducing reproducibility across time.

CONCLUSION: ChatGPT provides accurate information regarding TFESIs but demonstrates lower readability and a less empathetic tone than answers given by fellowship-trained physicians. With targeted improvements in clarity and patient-centered communication, AI holds potential as a useful adjunct in patient education and clinical support.

PMID:42263306

Pain Physician. 2026 May;29(3):E139-E149.

ABSTRACT

BACKGROUND: Opioid-free anesthesia (OFA) is becoming increasingly common, yet its effects on early postoperative recovery remain unclear.

OBJECTIVE: Our study assessed the effect of OFA on postoperative recovery compared to opioid-based anesthesia (OBA).

STUDY DESIGN: Systematic review and meta-analysis.

METHODS: We searched MEDLINE, the Cochrane Library, Embase, BIOSIS, and Web of Science concluding on December 19, 2024, for randomized controlled trials comparing OFA and OBA in adults (≥ 18 years). Data were extracted, and risk of bias was assessed using the Cochrane RoB 2.0 tool (The Nordic Cochrane Centre for The Cochrane Collaboration). The primary outcome was recovery quality at postoperative 24 hours. Random-effects meta-analyses were conducted. Evidence certainty was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Our meta-analysis was registered with PROSPERO (ID CRD42024621490).

RESULTS: Sixteen trials with a total of 1,968 patients were included in our meta-analysis. OFA was statistically significance associatedwith an improved Quality of Recovery (QoR)-40 score (mean difference 6.33; 95% CI, 3.48-9.17; very low certainty) and QoR-15 score at postoperative 24 hours (mean difference 10; 95% CI, 2.25-17.74; low certainty) compared to OBA. OFA was a statistical significance associated with a reduced risk of postoperative nausea and vomiting, as well as a shorter stay in the postanesthesia care unit. OFA did not reduce postoperative pain and extubation time.

LIMITATIONS: Our meta-analysis has high heterogeneity, with a predominance of women and middle-aged populations in the included studies. Additionally, side effects related to OFA were not analyzed.

CONCLUSIONS: Our systematic review and meta-analysis concluded that it is uncertain whether OFA is superior to OBA in improving postoperative recovery quality. However, OFA leads to a statistically significant reduction in the incidence of postoperative nausea and vomiting. The evidence was primarily drawn from small trials involving elective surgeries. While our results support using OFA, larger and high-quality studies are needed to validate its effect on postoperative recovery quality.

PMID:42263301

Cancer Nurs. 2026 May 4. doi: 10.1097/NCC.0000000000001584. Online ahead of print.

ABSTRACT

BACKGROUND: Yoga-based breathing exercises (pranayama) can be effective in improving symptoms such as pain, fatigue, and insomnia, and increasing self-efficacy after colorectal cancer surgery.

OBJECTIVE: To evaluate the effects of pranayama on pain, fatigue, insomnia, and self-efficacy after colorectal cancer surgery.

METHODS: This study was a randomized controlled trial comparing a yoga-based breathing intervention to a usual care control group. Participants who were taking the same type and dosage of postsurgical pain medication and not taking sleeping pills were randomly assigned to groups. This study was conducted with 80 adult patients with a recent diagnosis of colorectal cancer who were scheduled for surgical resection. The intervention group performed pranayama twice a day in the evening before surgery and for 7 days after surgery.

RESULTS: In the intervention group, fatigue decreased (P = .012, η2 = 0.055) and sleep quality improved more (P = .033, η2 = 0.043) compared with the control group. Although pain levels decreased over time in the intervention group compared with the control group, this change was not statistically significant (P = .185, η2 = 0.021). Similarly, self-efficacy showed an upward trend in the intervention group; however, this increase was not statistically significant (P = .126, η2 = 0.026).

CONCLUSIONS: Pranayama may be effective in reducing postsurgical fatigue and insomnia and improving self-efficacy.

IMPLICATIONS FOR PRACTICE: These findings support the integration of pranayama into holistic perioperative care as a complementary approach to managing postsurgical symptoms such as fatigue and insomnia.

PMID:42263273 | DOI:10.1097/NCC.0000000000001584

Pain. 2026 Jun 5. doi: 10.1097/j.pain.0000000000004028. Online ahead of print.

ABSTRACT

Abbreviated psychotherapies for chronic pain improve access to care by reducing length of treatment and reaching patients outside of chronic pain clinics, such as primary care. However, the evidence for these approaches is limited. We conducted a randomized controlled trial of brief cognitive behavioral therapy for chronic pain (ie, 6, 30-minute sessions of psychoeducation, behavioral and cognitive skills, and relapse prevention delivered individually) with 184 primary care patients with moderate to severe chronic musculoskeletal pain from a Veterans Health Administration medical center. Mean age of the sample was 59 years (SD = 13.3), 84.8% were male, and 77.2% were White. Following baseline, patients were randomized to either brief cognitive behavioral therapy for chronic pain plus usual pain care or usual pain care alone. Assessments were conducted at baseline plus 6 weeks (mid-treatment), 12 weeks (treatment completion), and 24 weeks (3 month post-treatment follow-up) to gather information regarding pain interference (primary outcome), pain intensity, mental health symptoms, quality of life, and social role participation. Results indicated that relative to usual pain care alone, participants who also received behavioral treatment showed statistically greater improvement in pain interference at each time point. Clinically significant improvement in pain interference was reached by mid-treatment with continued improvement at treatment completion and 3-month follow-up among the behavioral treatment group but not the usual pain care group. Behavioral treatment was also associated with improved physical quality of life and sleep quality. This significantly abbreviated behavioral treatment designed for scalability can lead to rapid and sustained improvements in pain outcomes.

PMID:42263268 | DOI:10.1097/j.pain.0000000000004028

JMIR Mhealth Uhealth. 2026 Jun 9;14:e93877. doi: 10.2196/93877.

ABSTRACT

BACKGROUND: Falls among older adults are a growing and costly public health problem that often leads to mobility decline and loss of independence. Although clinical frameworks such as the Centers for Disease Control and Prevention’s (CDC) Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative recommend multifactor screening (gait, balance, strength, fear of falling, and fall history), most wearable fall risk assessment systems rely on a small set of risk factors (typically gait), which creates a gap between clinical practice and automated wearable assessment.

OBJECTIVE: This study aims to evaluate the importance of STEADI-based fall risk factors and provide design guidance for clinically compatible wearable fall risk assessment systems.

METHODS: We created a dataset of 24 older adults (10 low fall risk and 14 high fall risk) from a publicly available plantar pressure dataset of 48 participants by retaining only those with consistent fall risk labels based on both the Berg Balance Scale and the Timed Up and Go test. A total of 18 features were extracted to quantify gait, strength, balance, fear of falling, and fall history. Random forest (RF) models were trained with leave-one-subject-out cross-validation to assess fall risk. Importance of STEADI-based factors was assessed by two methods: (1) estimating Shapley Additive Explanations values based on a single RF model trained on all features; and (2) training 5 separate RF models, each on 1 STEADI factor category, and comparing their fall risk classification accuracies.

RESULTS: In this secondary analysis, the RF model trained on all features achieved a subject-level accuracy of 87.53% (95% CI 75%-100%). Shapley Additive Explanations analysis identified the right foot flat phase ratio (fear of falling feature) as the highest-ranked feature, followed by maximum right forefoot ground reaction force (strength feature), whereas traditional gait features did not appear in the top 10. The 5 separate RF models trained on individual STEADI-based factor categories showed a similar trend in mean participant-level accuracy: fear of falling, 87.59% (95% CI 75%-100%); strength, 79.18% (95% CI 62.5%-95.83%); balance, 70.5% (95% CI 50%-87.5%); gait 70.81% (95% CI 54.17%-87.5%); and fall history 62.37% (95% CI 50%-75.1%). However, paired comparisons did not show statistically significant differences in accuracy between the gait model and the models trained on other factors.

CONCLUSIONS: These preliminary results show that commonly overlooked nongait factors are potentially as informative as gait, although clear superiority was not demonstrated in this dataset. The novel foot flat phase ratio ranked higher than all other evaluated features, which showed the value of domain knowledge-informed feature engineering. These preliminary findings indicate that nongait STEADI factors merit consideration in the design of wearable fall risk assessment systems.

PMID:42263263 | DOI:10.2196/93877

J Food Sci. 2026 Jun;91(6):e71189. doi: 10.1111/1750-3841.71189.

ABSTRACT

This study evaluated the growth of Bacillus cereus, Escherichia coli, and Salmonella Typhimurium in commercially available cocoa-flavored plant-based milk alternatives (PBMAs) under different temperatures and examined the influence of product composition on bacterial development. Bacterial populations were monitored over 12 h at 25°C for all strains and additionally at their optimal growth temperatures (30°C for B. cereus, 37°C for E. coli, and S. Typhimurium). The nutritional composition of the PBMAs was analyzed, and principal component analysis (PCA) was performed to identify key compositional factors. Results showed that the increase in E. coli and Salmonella Typhimurium population was significantly higher at 37°C than at 25°C on all cocoa-flavored PBMAs (p < 0.05), whereas for B. cereus, the differences between 25°C and 30°C were relatively small, with statistical significance observed only for Substrate A (p < 0.05). Growth was significantly influenced by bacterial species (MS = 10.49, p < 0.001), substrate composition (MS = 0.48, p < 0.001), and interaction of both these factors (MS = 0.29, p = 0.001). The formulated regression models based on environmental factor (temperature), PCA scores (reflecting substrate composition, particularly protein, fiber, fat, sodium, and energy balance, and for B. cereus also sodium, fiber, and pH-related properties), and time, accurately reproduced bacterial growth (R² = 0.857-0.898), highlighting the combined effects of these factors. By mapping new PBMA formulations onto the tested compositional space, it may also support contamination risk assessment and contribute to ensuring consumer safety. PRACTICAL APPLICATIONS: The findings highlight that cocoa-flavored plant-based milk alternatives can support the growth of microorganisms depending on their composition and storage temperature. Understanding how nutrients such as protein, fiber, fat, and sodium drive microbial proliferation enables manufacturers to optimize formulations for improved microbial safety. The regression models developed can support predictive assessments during product design. These insights can guide industry and regulators in establishing safer handling, storage, and formulation strategies for PBMAs.

PMID:42263222 | DOI:10.1111/1750-3841.71189

BJS Open. 2026 May 12;10(3):zrag063. doi: 10.1093/bjsopen/zrag063.

ABSTRACT

BACKGROUND: Tumour-positive margins after breast-conserving surgery (BCS) for breast cancer increase the risk of local recurrence and require additional therapy. Intraoperative imaging techniques in high-risk patients could improve margin determination. This study describes margin status after BCS in the Netherlands between 2009 and 2022, focusing on trends in surgical margin status and identifying subgroups at higher risk of tumour-positive margins.

METHODS: All patients undergoing BCS for non-metastatic breast cancer in the Netherlands from 2009 to 2022 were selected from the Netherlands Cancer Registry. Data included patient and tumour characteristics, treatment details, and surgical margin status. Descriptive statistics and trend analyses were performed. Univariate and multivariable analyses were performed to identify risk factors and patient subgroups at higher risk of margin involvement. Marginal effects analyses quantified tumour-positive margin risks.

RESULTS: In total, 109 475 women were included in the study. The mean tumour-positive margin rate was 10.8%. An extensively positive margin (> 4 mm involvement) occurred in 3.9% of patients, with a decreasing trend seen until 2013. Risk factors for a positive margin were invasive lobular carcinoma, multifocal disease, clinical tumour (cT) category 2 or 3, and neoadjuvant chemo- or hormonal systemic therapy without pathological complete response (pCR), with odds ratios (ORs) ranging from 1.56 to 2.96. One or more of these risk factors was present in 44 772 patients (40.9% of total cohort). The probability of positive margins increased with the number of risk factors, from 6.8% (no risk factors) to 49.1% (all four risk factors). Preoperative understaging (cT<pathological tumour) was also associated with an increased margin risk (OR 3.69). Two prediction tools were developed based on these outcomes (for total positive margins and for extensively positive margins only).

CONCLUSION: Over the past decade, tumour-positive margin rates in the Netherlands have remained stable at 10.8%. Patients with invasive lobular carcinoma, cT2/3 tumours, multifocal disease, or those receiving neoadjuvant chemotherapy or hormonal systemic therapy without pCR remain at substantially higher risk. There is room for improvement in these patient subgroups, highlighting the need for intraoperative imaging innovations to reduce positive margins.

PMID:42263217 | DOI:10.1093/bjsopen/zrag063