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

Peripheral microangiopathy in patients with precapillary pulmonary hypertension: correlation with cardiac function and patients’ functional capacity

Precapillary pulmonary hypertension is a rare, heterogenous disease of pulmonary vasculature haemodynamically characterized by an increased mean pulmonary arterial pressure > 25mmHg and low pulmonary capillary wedge pressure 25mmHg και χαμηλή πίεση ενσφήνωσης των πνευμονικών τριχοειδών < 15mmHg. Σκοπός της παρούσας μελέτης είναι η διερεύνηση της παρουσίας περιφερικής μικροαγγειοπάθειας σε ασθενείς με προτριχοειδική πνευμονική υπέρταση (πΠΥ) με τη χρήση βιντεοτριχοειδισκόπησης ονύχων άνω άκρων, της ύπαρξης ομοιοτήτων και διαφορών στο πρότυπο τριχοειδοσκόπησης μεταξύ των διαφόρων υποκατηγοριών της πΠΥ και η αναζήτηση τυχόν συσχετίσεων μεταξύ τριχοειδοσκοπικών παραμέτρων και δεικτών καρδιακής λειτουργίας στους ασθενείς με πΠΥ. Πρόκειται για μία προοπτική μελέτη παρατήρησης ασθενών μαρτύρων που διεξήχθη στην ΄Δ Παθολογική Κλινική και στην Ά Καρδιολογική Κλινική του ΑΠΘ. Υψηλής ευκρίνειας βιντεοτριχοειδοσκόπηση άνω άκρων πραγματοποιήθηκε σε ασθενείς με πΠΥ, υγιείς μάρτυρες και μάρτυρες με συστηματικό σκληρόδερμα (ΣΣ) χωρίς πνευμονική αρτηριακή υπέρταση (ΠΑΥ), παράλληλα με την αξιολόγηση των λειτουργικών, ηχωκαρδιογραφικών, αιμοδυναμικών και αιματολογικών παραμέτρων των ασθενών. Συνολικά, 63 ενήλικες ασθενείς με πΠΥ [14 με ΙΠΑΥ, 17 με σύνδρομο Eisenmenger, 18 ασθενείς με ΠΑΥ που οφείλεται σε νόσημα συνδετικού ιστού (ΝΣΙ), 14 με χρόνια θρομβοεμβολική πνευμονική υπέρταση (ΧΘΠΥ)], ηλικίας 55,5 ± 15,8 ετών, 30 υγιείς μάρτυρες και 14 ασθενείς με ΣΣ χωρίς ΠΑΥ και χωρίς σημαντική πνευμονική ίνωση, σταθμισμένοι ως προς την ηλικία και το φύλο συμπεριελήφθησαν στην ανάλυση. Η πλειονότητα των τριχοειδοσκοπικών παραμέτρων (πυκνότητα τριχοειδών, διαστάσεις τριχοειδών, μορφολογία τριχοειδών) ήταν μη φυσιολογικές στο σύνολο των ασθενών με πΠΥ σε σχέση με τους υγιείς μάρτυρες. Η πλειοψηφία των ασθενών με πΠΥ παρουσίασαν ήπιου βαθμού τριχοειδοσκοπικές αλλοιώσεις και μη ειδικό πρότυπο τριχοειδοσκόπησης. Οι ασθενείς με ΙΠΑΥ, ΧΘΠΥ και σύνδρομο Eisenmenger παρουσίασαν παρόμοια χαρακτηριστικά τριχοειδοσκόπησης με ελάχιστες διαφορές μεταξύ τους. Οι ασθενείς με ΠΑΥ-ΣΣ είχαν σημαντικά μειωμένη πυκνότητα τριχοειδών σε σχέση με τους ασθενείς με άλλη ΠΑΥ-ΝΣΙ και τους μάρτυρες με ΣΣ χωρίς ΠΑΥ. Ο λογάριθμος του ΝΤ-proBNP συσχετίστηκε αρνητικά με την τριχοειδική πυκνότητα σε ασθενείς με μη κυανωτική πΠΥ και θετικά με τον αριθμό των ανώμαλων τριχοειδών αγγείων ανά χιλιοστό στο σύνδρομο Eisenmenger. Επίσης, στο σύνδρομο Eisenmenger παρατηρήθηκε αρνητική συσχέτιση της διαμέτρου της αγκύλης των τριχοειδών με τον κορεσμό οξυγόνου στο αρτηριακό αίμα και θετική συσχέτιση με τα επίπεδα αιμοσφαιρίνης. Ομοίως, αρνητική γραμμική συσχέτιση βρέθηκε μεταξύ του κορεσμού του αρτηριακού οξυγόνου στην ηρεμία και της τριχοειδικής πυκνότητας σε ασθενείς με ΧΘΠΥ. Τέλος, ο εκτιμώμενος δείκτης σπειραματικής διήθησης (eGFR) συσχετίστηκε με τις ανωμαλίες του σχήματος των τριχοειδών των ονύχων στο σύνδρομο Eisenmenger και με τη μειωμένη τριχοειδική πυκνότητα στην ΠΑΥ-ΝΣΙ που αντικατοπτρίζουν δύο διαφορετικές πτυχές της συστηματικής μικροαγγειοπάθειας που μπορεί να υπάρχει στην ΠΑΥ. Η καινοτομία της παρούσας μελέτης εδράζεται στο γεγονός ότι μελέτησε και ανέδειξε ποσοτικές και ποιοτικές τριχοειδοσκοπικές μεταβολές στην κοίτη του όνυχα, σε ένα μεγάλο φάσμα ασθενών με πΠΥ, ως ένδειξη της ύπαρξης περιφερικής μικροαγγειοπάθειας παράλληλα με την πνευμονική μικροαγγειοπάθεια. Παράλληλα, ανέδειξε την παρουσία συσχετίσεων μεταξύ ποσοτικών τριχοειδοσκοπικών χαρακτηριστικών και αναίμακτων λειτουργικών, βιοχημικών, ηχωκαρδιογραφικών αλλά και αιμοδυναμικών δεικτών της καρδιακής και της νεφρικής λειτουργίας, γεγονός που μας επιτρέπει να υποθέτουμε την πιθανή αλληλοεξάρτηση της περιφερικής μικροαγγειοπάθειας με τη βαρύτητα της πνευμονικής υπέρτασης σε αυτούς τους ασθενείς. Περισσότερες προοπτικές μελέτες απαιτούνται για την επιβεβαίωση των ευρημάτων μας

Haemoptysis in Pulmonary Arterial Hypertension Associated with Congenital Heart Disease: Insights on Pathophysiology, Diagnosis and Management

Haemoptysis represents one of the most severe major bleeding manifestations in the clinical course of pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD). Accumulating evidence indicates that dysfunction of the pulmonary vascular bed in the setting of PAH predisposes patients to increased hemorrhagic diathesis, resulting in mild to massive and life-threatening episodes of haemoptysis. Despite major advances in PAH targeted treatment strategies, haemoptysis is still correlated with substantial morbidity and impaired quality of life, requiring a multidisciplinary approach by adult CHD experts in tertiary centres. Technological innovations in the field of diagnostic and interventional radiology enabled the application of bronchial artery embolization (BAE), a valuable tool to efficiently control haemoptysis in modern clinical practice. However, bleeding recurrences are still prevalent, implying that the optimum management of haemoptysis and its implications remain obscure. Moreover, regarding the use of oral anticoagulation in patients with haemoptysis, current guidelines do not provide a clear therapeutic strategy due to the lack of evidence. This review aims to discuss the main pathophysiological mechanisms of haemoptysis in PAH-CHD, present the clinical spectrum and the available diagnostic tools, summarize current therapeutic challenges, and propose directions for future research in this group of patients

Nailfold Videocapillaroscopy for the Evaluation of Peripheral Microangiopathy in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic and refractory autoimmune joint disease that affects multiple organs. Several methods have been applied for the study of microvascular endothelial dysfunction, which is considered an important component of vascular disease in RA. Implementation of nailfold videocapillaroscopy (NVC) represents a viable choice, as the skin is an easily accessible window for the non-invasive, real-time assessment of subtle microcirculation abnormalities. Although NVC is routinely used in the rheumatology field, especially for the diagnostic workout of Raynaud&rsquo;s phenomenon, accumulating evidence suggests a role in the evaluation of systemic vasculopathy associated with autoimmune rheumatic disorders. The current paper aims to provide an overview of NVC as a valuable clinical aid for the assessment of peripheral microcirculation in RA. Previous studies characterizing the capillaroscopic pattern in RA are summarized, along with associations with disease-related characteristics. Most available reports have mainly focused on the descriptions of non-specific morphological alterations that may reflect endothelial injury over the course of the disease. Still, the exact pattern of structural and functional capillaroscopic alterations and their clinical significance in RA remains a subject of ongoing research

Right Heart Catheterization in Pediatric Pulmonary Arterial Hypertension: Insights and Outcome from a Large Tertiary Center

Aim: To define the clinical characteristics, hemodynamics, and adverse events for pediatric patients with pulmonary arterial hypertension (PAH) undergoing right heart catheterization (RHC). Methods: The large referral single center data of 591 diagnostic RHC procedures performed between 2005 and 2020 on pediatric PAH patients was retrospectively collected and analyzed. Results: A total of 591 RHC procedures performed on 469 patients with congenital heart disease (CHD)-PAH (median age 8.8 years, 7.9% New York Heart Association (NYHA) class &gt; II, 1.5% with syncope) and 122 patients with idiopathic PAH (median age of 9.0 years, 27.0% NYHA class &gt; II, 27.0% with syncope) were included. Of those, 373 (63.1%) procedures were performed under general anesthesia. Eighteen patients (18/591, 3.0%) suffered adverse events (mainly pulmonary hypertensive crisis, PHC, n = 17) during the RHC procedure, including 14 idiopathic pulmonary arterial hypertension (IPAH) patients and 4 CHD-PAH patients, and one IPAH patient died in hospital 63 hours after RHC. The risk of developing PHC was significantly increased in patients with IPAH (OR = 14.02, 95%CI: 4.49&ndash;43.85, p &lt; 0.001), atrial blood gas pH &lt; 7.35 (OR = 12.504, 95%CI: 3.545&ndash;44.102, p &lt; 0.001) and RAP &gt; 14 mmHg (OR = 10.636, 95%CI: 3.668&ndash;30.847, p &lt; 0.001). Conclusions: RHC is generally a low-risk procedure in pediatric patients with PAH. However, PHC occur in approximately 3% of patients. Therefore, RHC should be performed in a large, experienced referral pediatric cardiology center, especially in pediatric patients with IPAH requiring general anesthesia

Cardiovascular Risk in Systemic Sclerosis

Purpose of reviewSystemic sclerosis (SSc) is a systemic inflammatory, autoimmune disorder characterized by diffuse fibrosis of the skin and visceral organ involvement. Endothelial dysfunction and microvascular injury dominate the pathophysiology and clinical manifestations of the disease, while the impact of macrovascular atherosclerotic disease on cardiovascular (CVD) morbidity and mortality is yet to be established. In this article, we aim to review current knowledge about CVD as well as cardiac complications in SSc and discuss the potentially implicated pathogenetic mechanisms.Recent findingsSystemic inflammation has been identified as an important trigger and contributor for the development and progression of atherosclerosis, closely associated with high cardiovascular mortality in patients with autoimmune disorders, such as rheumatoid arthritis. A close interplay between traditional risk factors and factors related to the disease, including inflammation, endothelial injury, and immune-mediated cytotoxicity, sharing common pathogenetic features with microvasculopathy, may be responsible for large-vessel involvement and promotion of atherosclerosis in SSc. Cardiac complications, including heart failure due to impairment of coronary microcirculation and myocardial fibrosis, are listed among the primary cause of death in SSc. Evaluation of indirect surrogate markers of CVD, namely, arterial stiffness, carotid media thickness, and flow-mediated dilation, in small studies has provided inconsistent results regarding the association between SSc and atherosclerosis, highlighting the need for further research on this field. In this article, we aim to review current knowledge about large-vessel involvement and CVD in SSc and discuss the potentially implicated pathogenetic mechanisms.SummarySSc conveys a higher risk for CVD associated with both vascular and fibrotic complications during the course of the disease. Increasing attention is given on the use of vasodilators, immunosuppressants, and more recently antifibrotic drugs that potentially improve myocardial function and reduce atherosclerotic disease burden

Peripheral microcirculatory abnormalities are associated with cardiovascular risk in systemic sclerosis: a nailfold video capillaroscopy study

Introduction Microvascular dysfunction is the key element in the pathogenesis of systemic sclerosis (SSc), whereas the contribution of large and medium size vessel abnormalities is yet to be established. The aim of the present study is to assess the association between micro- and macrovascular function by utilizing a broad spectrum of assessments of vascular performance. Methods We included consecutive, consenting SSc patients who underwent nailfold video capillaroscopy (NVC) for microcirculation evaluation. Peripheral and central systolic and diastolic blood pressure, carotid intima-media thickness (cIMT), aortic augmentation index (AIx) corrected for a heart rate of 75 beats per minute (AIx-75), and carotid-femoral pulse wave velocity (PWV) were also performed to assess macrovascular function. Cardiovascular risk disease (CVD) algorithms were also calculated and included in the analysis. Results A total of 81 patients (6 males) were studied with mean age 55.44 +/- 13.40 years. Reduced capillary density was inversely correlated with arterial stiffness (Alx-75) and augmentation pressure (r = - 0.262, p = 0.018, and r = - 0.249, p = 0.025 respectively). Alx was significantly lower in the early compared to late pattern (28.24 +/- 11.75 vs 35.63 +/- 10.47, p = 0.036). A significant trend was found among NVC patterns with Alx-75 values being higher with the progression of microangiopathy towards the “late” group (26.36 +/- 10.90 vs 30.81 +/- 11.59 vs 35.21 +/- 7.90, p = 0.027 for trend). Similarly, Framingham risk score and Atherosclerotic Cardiovascular Disease score were progressively higher across the worsening NVC patterns (4.10 +/- 4.13 vs 2.99 +/- 2.72 vs 6.36 +/- 5.65, p = 0.023, and 6.99 +/- 7.18 vs 5.63 +/- 4.41 vs 12.09 +/- 9.90, p = 0.019, respectively, for trends). Finally, QRISK3 (10-year cardiovascular disease risk) and ASCVD (Atherosclerotic Cardiovascular Disease) scores were inversely correlated with the number of capillaries (r = - 0.231, p = 0.048, and r = - 0.260, p = 0.038 respectively). Conclusion These data suggest that CVD risk scores and macrovascular parameters are strongly correlated with microvasculopathy in patients with SSc

Coxiella Endocarditis as the Cause of Recurrent Fever and Brain Abscess in a Patient with Complex Congenital Heart Disease: A Case Report and Literature Review

Introduction. Blood culture-negative infective endocarditis (BCNIE) can present subtly and is associated with a diagnostic delay leading to increased morbidity and mortality. Case Report. We present the case of an 18-year-old male with a history of complex congenital heart disease and 3-year intermittent episodes of fever of unknown origin, who was referred to our hospital for upper and lower extremity focal seizures. Laboratory blood tests were normal, blood cultures were negative, and brain imaging revealed an abscess. Cardiology consultation was requested, and transthoracic echocardiography revealed an intracardiac vegetation. Empiric antibiotic treatment with sultamicillin, gentamycin, and meropenem was initiated. Serology testing was positive for Coxiella burnetii, and the diagnosis of BCNIE was established. The antibiotic course was changed to oral doxycycline for 36 months and led to resolution of IE, with no vegetation detected on TTE after 15 months. Conclusion. BCNIE is a life-threatening disease entity that can lead to severe complications, such as valve regurgitation, emboli, and death. Patients with congenital heart disease are particularly vulnerable to IE. Timely diagnosis and antibiotic management are of paramount importance in order to avoid the potentially fatal sequelae

Epidemiology and management of chronic thromboembolic pulmonary hypertension: experience from two expert centers

Objectives: Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare, distinct pulmonary vascular disease, and therefore, there is a lack of data regarding its clinical presentation, diagnosis, and management at a national basis. We aimed to describe the demographics and management of patients with CTEPH in Northern Greece. Methods: We conducted a retrospective, observational study by a joint collaboration between two pulmonary hypertension expert centers in Greece, and the study included patients diagnosed with CTEPH. The patient population was divided into two groups depending on their operability. Results: Overall, 27 consecutive patients were included (59% female, mean age 59.3±15.1 years). Dyspnea and fatigue were the most common presenting symptoms. History of pulmonary embolism was present in 82%. Of patients, 18 (67%) were assessed as operable, of whom 10 (55%) finally underwent pulmonary endarterectomy (PEA). There were no differences in symptoms, WHO functional class, 6-min walking test distance, and hemodynamics between the operable and nonoperable groups. At the end of follow-up, all non-operable and operable patients who did not receive surgical treatment were treated with at least one pulmonary hypertension-specific drug. Conclusion: This is the first report that presents data of patients diagnosed with CTEPH in Greece. The percentage of patients who underwent surgical treatment is lower but approaches the reported rates in large registries. Considering that PEA is a relatively safe and potentially curative surgical procedure, we emphasize the need for establishing a designated PEA center in Greece. Keywords: Chronic thromboembolic pulmonary hypertension, pulmonary endarterectomy, registry, riocigua

Epidemiology and management of chronic thromboembolic pulmonary hypertension: experience from two expert centers

Objectives: Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare, distinct pulmonary vascular disease, and therefore, there is a lack of data regarding its clinical presentation, diagnosis, and management at a national basis. We aimed to describe the demographics and management of patients with CTEPH in Northern Greece. Methods: We conducted a retrospective, observational study by a joint collaboration between two pulmonary hypertension expert centers in Greece, and the study included patients diagnosed with CTEPH. The patient population was divided into two groups depending on their operability. Results: Overall, 27 consecutive patients were included (59% female, mean age 59.3±15.1 years). Dyspnea and fatigue were the most common presenting symptoms. History of pulmonary embolism was present in 82%. Of patients, 18 (67%) were assessed as operable, of whom 10 (55%) finally underwent pulmonary endarterectomy (PEA). There were no differences in symptoms, WHO functional class, 6-min walking test distance, and hemodynamics between the operable and nonoperable groups. At the end of follow-up, all non-operable and operable patients who did not receive surgical treatment were treated with at least one pulmonary hypertension-specific drug. Conclusion: This is the first report that presents data of patients diagnosed with CTEPH in Greece. The percentage of patients who underwent surgical treatment is lower but approaches the reported rates in large registries. Considering that PEA is a relatively safe and potentially curative surgical procedure, we emphasize the need for establishing a designated PEA center in Greece. Keywords: Chronic thromboembolic pulmonary hypertension, pulmonary endarterectomy, registry, riociguat