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

Gross morphological study of the renal pelvicalyceal patterns in human cadaveric kidneys

Introduction: The knowledge of detailed calyceal anatomy is essential for performing urologic procedures such as percutaneous nephrolithotomy, percutaneous nephrostomy, flexible ureterorenoscopy, endopyelotomy, and retrograde renal surgery. This study was performed to analyze the various patterns of pelvicalyceal system in the South Indian population, and compare these with previously published studies in different populations. Methods: The study was conducted in 100 kidney specimens. Morphologically undamaged kidneys belonging to both sexes were removed en bloc from cadavers and autopsy cases of the Departments of Anatomy and Forensic Medicine, respectively. The specimens were carefully dissected, and the percentage of various patterns was compared with previous studies. Results: The renal pelvis was found to be intrarenal in 79% of the specimens. The most common type of anatomy was a bicalyceal system with two major calyces, one each from the upper and lower poles, with the middle zone drainage dependent on any one or both of them. An interesting and rare variation of extrarenal calyces with the absence of renal pelvis was observed in 1% of the specimens. In addition, the presence of minor calyces opening directly into the renal pelvis was seen in 8% of the specimens. Conclusion: A biclayceal system of drainage with intrarenal pelvis is the most common calyceal pattern in the kidneys. The patterns must be borne in mind while examining a radiological report involving the kidneys

Internal Offloading or Surgical Offloading Adjuvant Techniques in the Reconstruction of Diabetic Plantar First Metatarsal Head Ulcer For Lasting Results

Introduction Management of diabetic foot ulcers (DFUs) is subverted by recurrences. The main cause for the recurrence of DFUs is the failure to recognize and address all the faulty biomechanics precipitating and perpetuating the ulcer. So, we have devised a protocol for treating the diabetic plantar first metatarsal head ulcer (DPFMHUs) incorporating structured internal offloading procedures in conjunction with reconstruction. Aim The aim of this study was to evaluate our protocol in the management of DPFMHUs. Materials and Methods Fifty-one patients (31 males and 20 females) with DPFMHUs were managed with our protocol in this prospective cohort study conducted from March 2015 to March 2020. All the faulty biomechanics were addressed by tailored internal offloading procedure as per the protocol. Results All patients were followed up for an average period of 23.7 months. Early complications were in the form of wound infection (3 patients, 5.9%) and seroma/hematoma (2 patients, 3.9%). Late complication in the form of recurrence was seen only in one patient (1.9%); rest of the patients had no recurrence (98%). Transfer lesions were noted in six patients (11.8%). Conclusion Our tailored protocol, which addresses all the faulty biomechanics associated with the DPFMHU, may be very helpful in preventing the recurrence and to give lasting results. It is imperative to design a tailored internal/surgical offloading procedure for all deforming forces that are responsible for precipitation and perpetuation of DPFMHUs, in addition to like tissue reconstruction

Evaluation of Madras Diabetes Research Foundation-Indian Diabetes Risk Score in detecting undiagnosed diabetes in the Indian population: Results from the Indian Council of Medical Research-INdia DIABetes population-based study (INDIAB-15)

Background & objectives: Screening of individuals for early detection and identification of undiagnosed diabetes can help in reducing the burden of diabetic complications. This study aimed to evaluate the performance of Madras Diabetes Research Foundation (MDRF)-Indian Diabetes Risk Score (IDRS) to screen for undiagnosed type 2 diabetes in a large representative population in India. Methods: Data were acquired from the Indian Council of Medical Research–INdia DIABetes (ICMR–INDIAB) study, a large national survey that included both urban and rural populations from 30 states/union territories in India. Stratified multistage design was followed to obtain a sample of 113,043 individuals (94.2% response rate). MDRF-IDRS used four simple parameters, viz. age, waist circumference, family history of diabetes and physical activity to detect undiagnosed diabetes. Receiver operating characteristic (ROC) with area under the curve (AUC) was used to assess the performance of MDRF-IDRS. Results: We identified that 32.4, 52.7 and 14.9 per cent of the general population were under high-, moderate- and low-risk category of diabetes. Among the newly diagnosed individuals with diabetes [diagnosed by oral glucose tolerance test (OGTT)], 60.2, 35.9 and 3.9 per cent were identified under high-, moderate- and low-risk categories of IDRS. The ROC-AUC for the identification of diabetes was 0.697 (95% confidence interval: 0.684-0.709) for urban population and 0.694 (0.684-0.704) for rural, as well as 0.693 (0.682-0.705) for males and 0.707 (0.697-0.718) for females. MDRF-IDRS performed well when the population were sub-categorized by state or by regions. Interpretation & conclusions: Performance of MDRF-IDRS is evaluated across the nation and is found to be suitable for easy and effective screening of diabetes in Asian Indians

Prevalence of dyslipidemia in urban and rural India: the ICMR-INDIAB study.

AIM: To study the pattern and prevalence of dyslipidemia in a large representative sample of four selected regions in India. METHODS: Phase I of the Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study was conducted in a representative population of three states of India [Tamil Nadu, Maharashtra and Jharkhand] and one Union Territory [Chandigarh], and covered a population of 213 million people using stratified multistage sampling design to recruit individuals ≥20 years of age. All the study subjects (n = 16,607) underwent anthropometric measurements and oral glucose tolerance tests were done using capillary blood (except in self-reported diabetes). In addition, in every 5th subject (n = 2042), a fasting venous sample was collected and assayed for lipids. Dyslipidemia was diagnosed using National Cholesterol Education Programme (NCEP) guidelines. RESULTS: Of the subjects studied, 13.9% had hypercholesterolemia, 29.5% had hypertriglyceridemia, 72.3% had low HDL-C, 11.8% had high LDL-C levels and 79% had abnormalities in one of the lipid parameters. Regional disparity exists with the highest rates of hypercholesterolemia observed in Tamilnadu (18.3%), highest rates of hypertriglyceridemia in Chandigarh (38.6%), highest rates of low HDL-C in Jharkhand (76.8%) and highest rates of high LDL-C in Tamilnadu (15.8%). Except for low HDL-C and in the state of Maharashtra, in all other states, urban residents had the highest prevalence of lipid abnormalities compared to rural residents. Low HDL-C was the most common lipid abnormality (72.3%) in all the four regions studied; in 44.9% of subjects, it was present as an isolated abnormality. Common significant risk factors for dyslipidemia included obesity, diabetes, and dysglycemia. CONCLUSION: The prevalence of dyslipidemia is very high in India, which calls for urgent lifestyle intervention strategies to prevent and manage this important cardiovascular risk factor

Prevalence of dyslipidemia in all the four regions studied.

<p>*p<0.05 and **p<0.001 compared to urban participants; Dyslipidemia was diagnosed using NCEP guidelines – hypercholesterolemia: Total cholesterol (TC) ≥200 mg/dl; hypertriglyceridemia: triglycerides ≥150 mg/dl; low HDL cholesterol: HDL-C <40 (males) and <50 mg/dl (females); high LDL cholesterol: LDL-C ≥130 mg/dl; High total cholesterol: HDL-C ratio ≥4.5; Isolated hypercholesterolemia: TC ≥200 mg/dl and triglycerides <150 mg/dl; Isolated hypertriglyceridemia: serum triglycerides ≥150 mg/dl and TC <200 mg/dl; Isolated low HDL-C: HDL-C ≤40 mg/dl (male) and ≤50 mg/dl (female) without hypertriglyceridemia or hypercholesterolemia.</p

General characteristics of the study subjects based on the presence of dyslipidemia in all the four regions studied.

<p>*p<0.05 and **p<0.001 compared to subjects with no lipid abnormality.</p