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

Non-puerperal uterine inversion associated with adenosarcoma of the uterus: A case report

Introduction: Uterine inversion is an uncommon condition characterized by the invagination of the fundus of the uterus through the vagina and is extremely rare in non-pregnancy settings. Non-puerperal uterine inversion is usually precipitated by tumours exerting traction force on the fundus of the uterus, turning the uterus partially or completely inside out. It is most frequently associated with benign tumours such as submucosal leiomyomas; however, malignant tumours are a rare association. Case Presentation: A 67-year-old woman, G18P18, presented to the emergency department with a bleeding mass that had acutely prolapsed out of the vagina. She had a two-year history of postmenopausal bleeding but had not sought medical advice. She underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Pathological evaluation revealed an adenosarcoma of the uterine fundus, measuring 6 cm in its largest diameter, which invaded the myometrium only superficially. The patient recovered well from the operation with no complications and was referred to an oncologist for further treatment. A computerized tomography scan with intravenous contrast showed no evidence of metastasis. Conclusion: Uterine sarcoma is a malignant tumour of the uterus that typically presents with vaginal bleeding, and rarely as prolapsed uterine inversion. Uterine inversion rarely occurs outside the puerperal setting; however, when it does occur, the possibility of an underlying malignancy should not be neglected. Keywords: Uterine sarcoma, Non-puerperal uterine inversion, Adenosarcoma of the uteru