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

Prevalence, Antibiotic Sensitivity Testing and Molecular Characterization of Virulence and Antimicrobial Resistance Genes in Clostridium perfringens in Fish

Fish is one of the most widely advertised foods, and Egypt is now recognized as a significant global fish producer. Human and animal intestinal illnesses and significant histotoxic illnesses are caused by foodborne microorganisms as Clostridium perfringens (C. perfringens). This study was directed to monitor the prevalence, antibiotic susceptibility testing, detection of some virulence and antibiotic resistance genes of multidrug-resistant C. perfringens recovered from fish. A total of 300 samples were collected from gills and intestine of Catfish, Tilapia and Dennis.  Bacteriological examination was conducted, the obtained C. perfringens strains were tested for antibiogram, PCR screening of virulence and antibiotic resistance genes. The investigated samples showed C. perfringens prevalence of 48.3%. C. perfringens isolates were resistant to several antibiotics as clindamycin (90%), cefprozil (80%), novobiocin (80%), aztreonam (80%) and erythromycin (80%). While, isolates were sensitive to nalidixic acid (90%), ofloxacin (90%), chloramphenicol (90%) and rifampicin (80%). Multidrug-resistant (MDR) C. perfringens was detected in 80% of tested strains. PCR proved that the obtained C. perfringens strains were carrying the virulence genes: cpa, cpb and cpe in a prevalence of 60%, 40% and 10%, respectively. As well, bla and ermB antibiotic resistance genes were detected in C. perfringens strains in a prevalence of 100% for both genes. In conclusion, C. perfringens isolated from fish was multidrug- resistant (MDR) bacteria and was harbored cpa, cpb and cpe virulence genes and bla and ermB antibiotic resistance genes. The development of MDR C. perfringens is conceived as a public health threat

Prevalence, Antibiotic Sensitivity Testing and Molecular Characterization of Virulence and Antimicrobial Resistance Genes in Clostridium perfringens in Fish

Fish is one of the most widely advertised foods, and Egypt is now recognized as a significant global fish producer. Human and animal intestinal illnesses and significant histotoxic illnesses are caused by foodborne microorganisms as Clostridium perfringens (C. perfringens). This study was directed to monitor the prevalence, antibiotic susceptibility testing, detection of some virulence and antibiotic resistance genes of multidrug-resistant C. perfringens recovered from fish. A total of 300 samples were collected from gills and intestine of Catfish, Tilapia and Dennis.  Bacteriological examination was conducted, the obtained C. perfringens strains were tested for antibiogram, PCR screening of virulence and antibiotic resistance genes. The investigated samples showed C. perfringens prevalence of 48.3%. C. perfringens isolates were resistant to several antibiotics as clindamycin (90%), cefprozil (80%), novobiocin (80%), aztreonam (80%) and erythromycin (80%). While, isolates were sensitive to nalidixic acid (90%), ofloxacin (90%), chloramphenicol (90%) and rifampicin (80%). Multidrug-resistant (MDR) C. perfringens was detected in 80% of tested strains. PCR proved that the obtained C. perfringens strains were carrying the virulence genes: cpa, cpb and cpe in a prevalence of 60%, 40% and 10%, respectively. As well, bla and ermB antibiotic resistance genes were detected in C. perfringens strains in a prevalence of 100% for both genes. In conclusion, C. perfringens isolated from fish was multidrug- resistant (MDR) bacteria and was harbored cpa, cpb and cpe virulence genes and bla and ermB antibiotic resistance genes. The development of MDR C. perfringens is conceived as a public health threat

Molecular Characterization of Virulence Genes among MDR and XDR Avian Pathogenic E. coli

One of the most costly diseases is avian colibacillosis. Virulence genes determine E. coli pathogenicity. This study was undertaken to explore the existence of some virulence-associated genes and resistant configurations of Escherichia coli recovered from broiler chicks. Thirteen E. coli isolates were exposed to an investigation of antimicrobial susceptibility profile against 17 antimicrobial agents that exhibited the highest resistance found against amoxicillin, florfenicol, penicillin, amoxicillin clavulanate, tetracycline, meropenem, sulfamethoxazole-trimethoprim, and chloramphenicol in the percentage of 100%, 100%,100%, 92.3%, 76.9%, 69.2%, 61.5%, and 61.5%, respectively while the isolates exhibited highest sensitivity found to fosfomycin, imipenem, azetronam and ciprofloxacine in the percentage of 100%,92.3%,76.9% and 69.2%, respectively. Moreover, the thirteen E. coli isolates were exposed to the revealing of some virulence genes (iss, omp-T, hlyF, iroN, iuta, iucD, papC, cva, astA, tsh, and irp2) by polymerase chain reaction (PCR). The results showed that the percentages rates were 84.6, 76.9, 76.9, 76.9, 61.5, 53.8, 38.4, 30.7, 23, 15.3 and 15.3%, respectively. A significant correlation between most antimicrobial-resistant phenotypes and virulence genes in E. coli isolates. Antimicrobial use in chickens should be reasonable to prevent antibiotic-resistant microorganisms, according to our findings

Molecular Typing of Virulence and Antimicrobial Resistance Genes with Mutation Tracking of gyrA Gene of Fluoroquinolone-Resistant Strains of Campylobacter Isolated from Broiler Chickens

 Campylobacter is the most common bacterial cause of gastroenteritis globally. A total of 182 fully identified strains of Campylobacter species (42 C. coli and 140 C. jejuni) collected from 6 broiler farms were subjected to studying the antimicrobial resistance pattern and molecular typing of virulence (cadF, ctdA, dnaJ waaC,iam, and fla) and antimicrobial resistance genes (blaOXA-61, gyrA, tetA, tetO, and IR) with sequencing of gyrA region of one strain of fluroquinolones resistant C. coli and C. jejuni. The identified isolates were highly resistant to erythromycin and sulfamethoxazole-trimethoprim. Furthermore, both meropenem and imipenem were effective against the recovered isolates. The tested C. jejuni and C. coli strains had 100%, 83.3%, and 83.3% prevalence of cadF, ctdA, and dnaJ virulence genes, respectively, while waaC, iam, and fla genes couldn’t be detected. The blaOXA-61 resistance gene was found in all of the Campylobacter spp. examined. Furthermore, gyrA, tetA, tetO, and IR resistance genes were found in 100%, 83.3%, 83.3%, and 66.7% of the retrieved C. jejuni strains, respectively.  Likewise, resistance genes were found in 83.3%, 83.3%, 83.3%, and 66.7% of the retrieved C. coli strains, respectively. Approximately 58% (7/12) of the Campylobacter spp. recovered were MDR. Furthermore, 50% (3/6) of the C. jejuni strains recovered were MDR, while 66.7% (4/6) of the C. coli isolates recovered were MDR with MARI(0.22-0.55). For detection of mutations of the gyrA gene, the sequence data of two isolates (C. jejuni and C.coli) were analyzed against the reference sequence on the gene bank where the C. jejuni strain had six mutations, while the C. coli strain had twenty-three. The current findings suggest that MDR Campylobacter strains in poultry may be able to transmit highly virulent Campylobacter as a foodborne pathogen

Molecular Typing of Virulence and Antimicrobial Resistance Genes with Mutation Tracking of gyrA Gene of Fluoroquinolone-Resistant Strains of Campylobacter Isolated from Broiler Chickens

 Campylobacter is the most common bacterial cause of gastroenteritis globally. A total of 182 fully identified strains of Campylobacter species (42 C. coli and 140 C. jejuni) collected from 6 broiler farms were subjected to studying the antimicrobial resistance pattern and molecular typing of virulence (cadF, ctdA, dnaJ waaC,iam, and fla) and antimicrobial resistance genes (blaOXA-61, gyrA, tetA, tetO, and IR) with sequencing of gyrA region of one strain of fluroquinolones resistant C. coli and C. jejuni. The identified isolates were highly resistant to erythromycin and sulfamethoxazole-trimethoprim. Furthermore, both meropenem and imipenem were effective against the recovered isolates. The tested C. jejuni and C. coli strains had 100%, 83.3%, and 83.3% prevalence of cadF, ctdA, and dnaJ virulence genes, respectively, while waaC, iam, and fla genes couldn’t be detected. The blaOXA-61 resistance gene was found in all of the Campylobacter spp. examined. Furthermore, gyrA, tetA, tetO, and IR resistance genes were found in 100%, 83.3%, 83.3%, and 66.7% of the retrieved C. jejuni strains, respectively.  Likewise, resistance genes were found in 83.3%, 83.3%, 83.3%, and 66.7% of the retrieved C. coli strains, respectively. Approximately 58% (7/12) of the Campylobacter spp. recovered were MDR. Furthermore, 50% (3/6) of the C. jejuni strains recovered were MDR, while 66.7% (4/6) of the C. coli isolates recovered were MDR with MARI(0.22-0.55). For detection of mutations of the gyrA gene, the sequence data of two isolates (C. jejuni and C.coli) were analyzed against the reference sequence on the gene bank where the C. jejuni strain had six mutations, while the C. coli strain had twenty-three. The current findings suggest that MDR Campylobacter strains in poultry may be able to transmit highly virulent Campylobacter as a foodborne pathogen

In Vitro Micropropagation of Endangered <i>Achillea fragrantissima</i> Forssk. Combined with Enhancement of Its Antihyperglycemic Activity

Achillea fragrantissima Forssk. (Family: Asteraceae) has been used as a natural remedy in the Arabian region for its antihyperglycemic activity. As a result of the intensive demand for this plant in folk medicinal uses, its scarcity has become problematic. This study has explored methods that produce an efficient in vitro culture protocol for the conservation of this plant as well as the enhancement of its hypoglycemic activity. A. fragrantissima cultures on Murashige and Skoog (MS) medium supplemented with 3.6 µM/L of 6-benzyl aminopurine (BAP) for a two month period resulted in maximum in vitro shoot proliferation (12.33 shoots/explant) while MS medium supplemented with 2.4 µM/L 1-naphthalene acetic acid (NAA) provided maximum in vitro adventitious root formation (2.46 roots/shoot tip explant). Callus induction was favored by leaf explants cultured on MS medium and supplemented with 3 µM/L BAP and 3 µM/L IAA media in dark conditions. Further in vivo study of some selected feedings determined that the best hypoglycemic activity was obtained in either indole-3-butyric acid (IBA)-fed plants (24%) or NAA-fed plants (22%). Both treatments enhanced insulin-like activity in STZ-treated diabetic Sprague-Dawley rats when compared with the wild plant (10%). Moreover, the IBA-fed plants showed significant antioxidant activity while the NAA-fed plants inhibited salivary alpha amylase. The framework of this study provides in vitro culture methods that can sustain the cultivation of this over-exploited A. fragrantissima plant as well as increase its antioxidant and insulin-like activities

In Vitro Micropropagation of Endangered Achillea fragrantissima Forssk. Combined with Enhancement of Its Antihyperglycemic Activity

Achillea fragrantissima Forssk. (Family: Asteraceae) has been used as a natural remedy in the Arabian region for its antihyperglycemic activity. As a result of the intensive demand for this plant in folk medicinal uses, its scarcity has become problematic. This study has explored methods that produce an efficient in vitro culture protocol for the conservation of this plant as well as the enhancement of its hypoglycemic activity. A. fragrantissima cultures on Murashige and Skoog (MS) medium supplemented with 3.6 &micro;M/L of 6-benzyl aminopurine (BAP) for a two month period resulted in maximum in vitro shoot proliferation (12.33 shoots/explant) while MS medium supplemented with 2.4 &micro;M/L 1-naphthalene acetic acid (NAA) provided maximum in vitro adventitious root formation (2.46 roots/shoot tip explant). Callus induction was favored by leaf explants cultured on MS medium and supplemented with 3 &micro;M/L BAP and 3 &micro;M/L IAA media in dark conditions. Further in vivo study of some selected feedings determined that the best hypoglycemic activity was obtained in either indole-3-butyric acid (IBA)-fed plants (24%) or NAA-fed plants (22%). Both treatments enhanced insulin-like activity in STZ-treated diabetic Sprague-Dawley rats when compared with the wild plant (10%). Moreover, the IBA-fed plants showed significant antioxidant activity while the NAA-fed plants inhibited salivary alpha amylase. The framework of this study provides in vitro culture methods that can sustain the cultivation of this over-exploited A. fragrantissima plant as well as increase its antioxidant and insulin-like activities

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit