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

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Parameter sensitivity analysis and prediction error in a field-scale NO3-N modelling

The hydrologic and nitrate (NO3-N) leaching dynamics of a maize field were respectively modelled with DRAINMOD and DRAINMOD-N. Experimental data of a 3-year period were available for model calibration and evaluation. Data from the first two years were used for model calibration whilst data from the remaining year were used for an initial evaluation. Data collected before the 3-year experiment, during a 23-year period, were used for further “backward” (in time) evaluation. The hydrologic module was calibrated through a trial and error approach. The NO3-N leaching module was calibrated and evaluated with a Monte Carlo simulations based approach. Nine parameters describing the leaching process were studied. In total, 10,000 parameter sets were tried out. The analysis revealed an acceptable prediction of the observed drainage and NO3-N leaching time series throughout both the 3-year experimental period as well as the prior 23-year “backward” evaluation period. Nevertheless, the analysis revealed that no single set of optimal parameter values could be identified. It was found that the model performance is only sensitive to the rate of denitrification. Narrow NO3-N prediction intervals were obtained, even in the longer 23-year (“backward”) evaluation period. Apparently, the behavioural DRAINMOD-N simulations were able to acceptably reproduce the limited to moderate NO3-N leaching fluctuations that occur in the modelled system

Impacts of climate change on the municipal water management system in the Kingdom of Bahrain: Vulnerability assessment and adaptation options

An assessment of the vulnerability of the municipal water management system to the impacts of climate change in the Kingdom of Bahrain, manifested by the increase in demands due to increase in temperatures, is conducted using a dynamic mathematical model representing the water sector in the kingdom. The model is developed using WEAP software and was calibrated and validated by historical matching utilizing data for the period 2000–2012. The model is used in the evaluation of the municipal water sector performance in terms of municipal water demands and their associated cost without and with climate change impacts scenarios for the period 2012–2030. The impact of climate change on the municipal water system is quantified as the difference between the two scenarios in three selected cost indicators: financial (production, conveyance and distribution costs), economic (natural gas asset consumption by desalination plants), and environmental (CO2 emissions by desalination plants). The vulnerability assessment indicated that the current municipal water management system in Bahrain is generally inefficient and associated with relatively high costs, which are expected to increase with time under the current policies and management approach focusing on supply-side management. The increase in temperature will increase these already high costs, and would exacerbate the water management challenges in Bahrain. However, these mounting challenges also present an opportune moment for Bahrain to review its current water resources management approaches and practices and to integrate climate change adaptation measures into its water planning and policies. In order to build an adaptive management capacity of the municipal water management system in Bahrain, a number of management interventions are proposed and evaluated, individually and combined, for their effectiveness in enhancing the efficiency of the management system using the developed dynamic model. These are: reduction of the leakage percentage in the municipal water distributions network and reducing per capita water consumption by raising water awareness among consumers and installing water saving devices in residential units. The evaluation results indicate that there is a large potential for reducing the municipal water demand and its associated cost, especially when all the three are combined; by the year 2030 it is estimated that the cumulative financial saving would be about US$ 2.9 Billion, the cumulative reduction in CO2 emission would be about 19.7 Million tons, and the preservation of the kingdom’s limited natural gas reserves would be about 4 Billion m3. In addition, a major reduction in desalination brine discharge to the marine environment and reduction of generated wastewater and their associated collection and treatment cost could be achieved from the implementation of these interventions. Adopting such management interventions will not only enhance the efficiency of the municipal water management system, but it will also help the Kingdom in its efforts in reducing its greenhouse gasses emissions. It is recommended that similar climate change vulnerability and adaptation analysis is extended to the whole water sector in Bahrain to include other major water consuming sectors (i.e., agricultural, industrial, and tourism sectors) and their sources of water (i.e., groundwater and wastewater) in Bahrain. Keywords: Desalination, CO2 emissions, Natural gas consumption, WEAP modeling, Awareness, Water saving devices, Distribution network leakag

Comparison between thoracoscopic pleural cryobiopsy and conventional forceps biopsy in diagnosis of exudative pleural effusion: Assiut University experience

Context Exudative pleural effusion is a diagnostic dilemma that includes many steps; one of them is obtaining a definite diagnosis through pleural biopsy. Cryoprobes are being increasingly used for obtaining larger specimens with fewer crush artifacts. However, the safety and feasibility of cryoprobe biopsy compared with standard forceps for pleural biopsy have not been fully assessed. Aims To evaluate the diagnostic value, size, and quality of the specimens obtained by flexible cryoprobe in comparison with those obtained by flexible forceps probe during medical thoracoscopy in patients with exudative pleural effusion and to assess the possible complications from the procedure. Settings and design This interventional prospective study was carried out at the endoscopy unit at Chest Department and Tuberculosis Assiut University Hospital. Patients and methods This study included 60 patients with undiagnosed exudative pleural effusion. Medical thoracoscopy was carried out for all the patients, and pleural biopsies were taken from the parietal pleura using a conventional rigid forceps probe and flexible cryoprobe in the same settings. Results Cryoprobe biopsy established a definite diagnosis in 55/60, with 91.6% diagnostic yield, whereas forceps biopsy had a definite diagnosis in 53/60, with 88.3% diagnostic yield. The size of cryoprobe biopsy was significantly larger in comparison with the forceps biopsy (26.56 ± 22.16 vs. 17.38 ± 12.08 mm2; P<0.001). The depth of pleural biopsy was evaluated by the presence of extrapleural fat cells, which were significantly higher in cryoprobe biopsy in comparison with forceps biopsy [21 (35%) vs. 11 (18.3%); P=0.03]. There were no significant complications or procedure-related deaths. Conclusions Cryobiopsy is a possible safe and effective alternative to conventional forceps probe biopsy in the diagnosis of exudative pleural effusion with a larger, deeper, and less number of biopsies. It was also found that cryoprobe biopsy had a better diagnostic yield, sensitivity, and accuracy

The synthesis of alkylated or acylated nitroarene cyclopentadienylironcomplexes:

Time-dependent oxidation of η6-alkylaniline-η5-cyclopentadienyliron hexafluorophosphates, 17–32, allows for the preparation of nitrobenzene complexes with alkyl 33–48 or keto 49 substituents. Alkylnitroarene complexes are prepared by the oxidation of their corresponding aniline complexes with H2O2 in CF3CO2H for 20 min. An increase in the reaction time to 24 h gives rise to nitroarene complexes with keto substituents in lower yields. The use of nitroarenes as starting materials in the synthesis of alkanoates is of importance since it allows for the preparation of a large number of this class of compounds with a variety of alkyl substituents. Two different approaches have been utilized to allow for the synthesis of alkanoates. The first approach involves nucleophilic aromatic substitution of alkylnitrobenzene complexes with ethyl alkylacetoacetates followed by demetallation to give the alkanoates. This methodology allows for the preparation of these esters with a variety of alkyl substituents in either the meta or para positions. Another route outlines the reaction of phenylsulfonylacetonitrile with nitroarene complexes to prepare alkanoic acid precursors with alkyl substituents in the ortho, meta and para positions. The preparation of a larger pool of nitroarene complexes clearly demonstrates the advantage of using the cyclopentadienyliron arene complexes in the synthesis of alkanoates or their precursors, arylated phenylsulfonylacetonitriles, over traditional synthetic routes

Global Incidence and Risk Factors Associated With Postoperative Urinary Retention Following Elective Inguinal Hernia Repair

Importance Postoperative urinary retention (POUR) is a well-recognized complication of inguinal hernia repair (IHR). A variable incidence of POUR has previously been reported in this context, and contradictory evidence surrounds potential risk factors.Objective To ascertain the incidence of, explore risk factors for, and determine the health service outcomes of POUR following elective IHR.Design, Setting, and Participants The Retention of Urine After Inguinal Hernia Elective Repair (RETAINER I) study, an international, prospective cohort study, recruited participants between March 1 and October 31, 2021. This study was conducted across 209 centers in 32 countries in a consecutive sample of adult patients undergoing elective IHR.Exposure Open or minimally invasive IHR by any surgical technique, under local, neuraxial regional, or general anesthesia.Main Outcomes and Measures The primary outcome was the incidence of POUR following elective IHR. Secondary outcomes were perioperative risk factors, management, clinical consequences, and health service outcomes of POUR. A preoperative International Prostate Symptom Score was measured in male patients.Results In total, 4151 patients (3882 male and 269 female; median [IQR] age, 56 [43-68] years) were studied. Inguinal hernia repair was commenced via an open surgical approach in 82.2% of patients (n = 3414) and minimally invasive surgery in 17.8% (n = 737). The primary form of anesthesia was general in 40.9% of patients (n = 1696), neuraxial regional in 45.8% (n = 1902), and local in 10.7% (n = 446). Postoperative urinary retention occurred in 5.8% of male patients (n = 224), 2.97% of female patients (n = 8), and 9.5% (119 of 1252) of male patients aged 65 years or older. Risk factors for POUR after adjusted analyses included increasing age, anticholinergic medication, history of urinary retention, constipation, out-of-hours surgery, involvement of urinary bladder within the hernia, temporary intraoperative urethral catheterization, and increasing operative duration. Postoperative urinary retention was the primary reason for 27.8% of unplanned day-case surgery admissions (n = 74) and 51.8% of 30-day readmissions (n = 72).Conclusions The findings of this cohort study suggest that 1 in 17 male patients, 1 in 11 male patients aged 65 years or older, and 1 in 34 female patients may develop POUR following IHR. These findings could inform preoperative patient counseling. In addition, awareness of modifiable risk factors may help to identify patients at increased risk of POUR who may benefit from perioperative risk mitigation strategies

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially