Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Validation of the capnodynamic method to calculate mixed venous oxygen saturation in postoperative cardiac patients

Abstract Background Cardiac output and mixed venous oxygen saturation are key variables in monitoring adequate oxygen delivery and have typically been measured using pulmonary artery catheterisation. The capnodynamic method measures effective pulmonary blood flow utilising carbon dioxide kinetics in ventilated patients. Combined with breath-by-breath measurements of carbon dioxide elimination, a non-invasive approximation of mixed venous oxygen saturation can be calculated. Methods This study primarily investigated the agreement between mixed venous oxygen saturation calculated using the capnodynamic method and blood gas analysis of mixed venous blood sampled via a pulmonary artery catheter in 47 haemodynamically stable postoperative cardiac patients. Both measurements were synchronised and performed during alveolar recruitment by stepwise changes to the level of positive end-expiratory pressure. Simultaneously, we studied the agreement between effective pulmonary blood flow and thermodilution cardiac output. The Bland–Altman method for repeated measurements and calculation of percentage error were used to examine agreement. Measurements before and after alveolar recruitment were analysed by a paired t test. The study hypothesis for agreement was a limit of difference of ten percentage points between mixed venous oxygen saturation using the capnodynamic algorithm vs. catheter blood gas analysis. Results Capnodynamic calculation of mixed venous saturation compared to blood gas analysis showed a bias of -0.02 [95% CI − 0.96–0.91] % and limits of agreement at 8.8 [95% CI 7.7–10] % and − 8.9 [95% CI -10–− 7.8] %. The percentage error was < 20%. The effective pulmonary blood flow compared to thermodilution showed a bias of − 0.41 [95% CI − 0.55–− 0.28] l.min−1 and limits of agreement at 0.56 [95% CI 0.41–0.75] l.min−1 and − 1.38 [95% CI − 1.57–-1.24] l.min−1. The percentage error was < 30%. Only effective pulmonary blood flow increased by 0.38 [95% CI 0.20–0.56] l.min−1 (p < 0.01) after alveolar recruitment. Conclusions In this study, minimal bias and limits of agreement < 10% between mixed venous oxygen saturation calculated by the capnodynamic method and pulmonary arterial blood gas analysis confirmed the agreement hypothesis in stable postoperative patients. The effective pulmonary blood flow agreed with thermodilution cardiac output, while influenced by pulmonary shunt flow

Effect of Caesalpinia bonduc Polyphenol Extract on Alloxan-Induced Diabetic Rats in Attenuating Hyperglycemia by Upregulating Insulin Secretion and Inhibiting JNK Signaling Pathway

Caesalpinia bonduc has been used in herbal medicines for the treatment of a wide range of diseases from decades. The present study has explored the remedial potential and underlying mechanism of polyphenol extract of Caesalpinia bonduc in alloxanized diabetic rats. HPLC/MS analysis confirmed the presence of phenolics in considerable concentrations in Caesalpinia bonduc extract. Administration of different doses (250 and 500 mg/kg) of CPP extract to hyperglycemic rats for 8 weeks restored blood and serum glucose, insulin, glycosylated hemoglobin, leptin, amylin, and carbohydrate metabolizing enzymes level towards normal compared to alloxanized diabetic group. The effect of CPP extract on various genes such as Pdx-1, Ins-1, ngn-3, GLUT-4, and IRS-1 in insulin signaling pathway and Traf-4, Traf-6, and Mapk-8 in MAPK downstream JNK cascade was examined through qRT-PCR to access the core molecular mechanism involved in CPP-induced recovery of diabetes. Results have revealed that CPP extract reduced oxidative stress in pancreaticβcells by restoring free radical scavenging potential, reducing the mRNA expression of Mapk-8, Traf-4, and Traf-6, and increasing the Pdx-1, Ins-1, ngn-3, GLUT-4, and IRS-1 expression ensuing regeneration ofβcells and subsequent insulin release from pancreas. The results obtained in this study recommend that CPP extract may be a promising therapeutic restorative agent in the treatment of diabetes mellitus.</jats:p

Calibration Estimation of Cumulative Distribution Function Using Robust Measures

Outliers are observations that are significantly different from the other observations in a dataset. These types of observations are asymmetric in nature due to a lack of symmetry. The estimation of the cumulative distribution function (CDF) is an important statistical measure commonly discussed for symmetric datasets. However, the estimation of the CDF in the case of the asymmetric nature of the dataset is not a much-explored topic. In this article, we use calibration methodology with auxiliary information for modifying the traditional stratification weight, and hence, we obtain efficient estimates of the CDF using robust measures, i.e., mid-range and tri-mean, under the different distance functions. A simulation study is carried out to see the performance of proposed and existing estimators using asymmetric real-life datasets

Aseptic meningitis in Kikuchi-Fujimoto Disease - Rare manifestation of a rare disease

Kikuchi-Fujimoto Disease (KFD) is a rare disease marked by necrotizing lymphadenitis, often presenting as unilateral cervical lymphadenopathy, along with various extranodal manifestations such as fever, skin rash, hepatosplenomegaly, and arthritis, etc. KFD is thought to be secondary to either a viral infection or an autoimmune process, however, evidence in favor of both models is scarce and non-definitive. We report a case of a young female who presented with persistent high-grade fever, bilateral cervical and axillary lymphadenopathy, and leukopenia. Excisional biopsy of affected lymph nodes revealed well-circumscribed foci of necrosis with karyorrhectic debris and scattered fibrin deposits characteristic of KFD. The patient was promptly initiated on non-steroidal anti-inflammatory drugs (NSAIDs), however, despite an early improvement in symptoms, the patient soon developed aseptic meningitis, a rare neurological complication of KFD. Intravenous followed by oral corticosteroid therapy reported a good prognosis, with no observable residual neurological deficits. Knowledge of the disease and its complications significantly helped in the avoidance of unnecessary investigations and a delay in treatment

Comparative analysis of TPVB and ESPB for postoperative pain management in thoracic and breast surgeries

Objective This meta-analysis assesses the efficacy and safety of erector spinae block (ESPB) and paravertebral block (PVB) for managing postoperative pain in thoracic and breast surgeries.Design Data from 12 randomized controlled trials (RCTs) published between 2019 and 2022 were included, and selected based on stringent criteria.Setting The RCTs were conducted across various clinical settings, including operating theaters worldwide.Patients The analysis involved 844 patients undergoing thoracic or breast surgery under regional anesthesia, representing diverse health statuses.Interventions Patients received either PVB or ESPB, typically guided by ultrasound, for postoperative pain control.Main Findings PVB demonstrated superior pain management during rest and mobility, requiring fewer additional analgesics than ESPB. Incidences of postoperative nausea and vomiting (PONV) and opioid consumption did not differ significantly between the methods. ESPB showed more effective block placement.Conclusion PVB is preferred for reducing analgesic requirements and managing postoperative pain, especially during rest and activity. ESPB offers advantages in block placement. Surgical type and patient preferences should guide the choice between PVB and ESPB, necessitating further research for optimized clinical application