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

Altered Metabolic Integrity of Corpus Callosum Among Individuals at Ultra High Risk of Schizophrenia and First-Episode Patients

Background: The disconnectivity hypothesis as part of the neurodevelopmental model of schizophrenia states that an abnormality in brain development causing impaired corticocortical or interhemispheric connectivity leads to cognitive deficits and symptoms of the illness. Previous studies showed the altered morphology of corpus callosum in patients with schizophrenia. We investigated the metabolic integrity of corpus callosum of individuals at ultra high risk (UHR) of developing schizophrenia and first-episode patients

Giant tentorial dural arteriovenous fistula treated by a combination of trans-arterial embolization and surgery

Tentorial dural arteriovenous fistulae are uncommon lesions but can be life-threatening. A 34-year-old male presented with intractable headache, seizures, and visual disturbance. Three-dimensional computed tomography (CT) angiography and digital subtraction angiography demonstrated a right tentorial dural arteriovenous fistula supplied by both internal and external carotid systems and draining into a giant venous ampula. Transarterial embolization of the external carotid feeders with Onyx (TM, ev3, Irvine, CA) was carried out. Postembolization angiography revealed persistence of a portion of the fistula supplied by the temporo-occipital branch of right middle cerebral artery. The patient underwent right temporo-occipital craniotomy, division of the feeders and resection of the entire fistula and coagulation of the leptomeningeal arterialized veins. Complete elimination of the fistula was demonstrated by angiography. Postoperative recovery was uneventful; the patient did not develop any fresh neurologic deficits. We review the relevant literature and discuss the rationale for managing these lesions

An Adult Tracheocele with No Predisposing Factor

Tracheoceles are rare, and usually, they have been described as incidental findings while evaluating patients for other problems. Our patient complained of a mass located in the right supraclavicular region that got larger on coughing and straining; otherwise, he was asymptomatic. His history did not reveal any predisposing factors. Computed tomography showed an air-filled 3x2.5x2 cm mass at the level of the T2-4 vertebrae. Surgical exploration showed an air-filled mass located between the common carotid artery and trachea, communicating with the tracheal lumen via a narrow tract attached to the posterior wall of the trachea. The mass was completely resected, and the defect in the posterior wall was repaired. A literature search revealed only one tracheocele case without any predisposing factors, and our case is a new one. It is different from other tracheocele reports considering the origin side, type, and level of the lesion

Cerebrovascular complications of transorbital penetrating intracranial injuries

BACKGROUND: Cerebrovascular trauma secondary to transorbital intracranial penetrating injury (TIPVI) is rare. Relatively benign initial presentation may mask the underlying life-threatening vascular injury in transorbital intracranial penetrations. The aim of this study was to evaluate clinical features and endovascular treatment of TIPVI. METHODS: Six patients with angiographic documentation of TIPVI in subacute/chronic phase were reviewed retrospectively. Five were treated endovascularly; however endovascular treatment was aborted in one and conservative management was pursued. RESULTS: Except for one case presenting with vision loss and mild stroke, no significant neurologic deficit was present. Vascular lesions included two cases of carotid-cavernous fistulas, three traumatic aneurysms of cavernous carotid, anterior and middle cerebral arteries and a unique case of coalescing cavernous aneurysms following a through-and-through injury in which the aneurysms united within the thrombosed cavernous sinus on follow up. Fistulas were treated with covered stents, aneurysms with parent artery occlusion or flow diverters. All patients had uneventful recoveries. CONCLUSION: TIPVI may present in a delayed fashion after a seemingly benign presentation. A high index of suspicion is critical to rule out TIPVI with vascular imaging. Transcatheter angiographic techniques allow for both diagnosis and treatment of TIPVI with favorable results

Angiographic Morphometry of Internal Carotid Artery Circulation in Turkish Children

AIM: Knowledge of cerebrovascular morphology is integral in planning neuroendovascular interventions, especially for procedures involving placement of stents, flow diverters or stentrievers. There is insufficient data on angiographic normative values of cerebral circulation in the pediatric age group since angiograms are uncommonly performed in children except for arteriovenous malformations in which arterial dimensions are larger than normal. We aimed to measure the diameters of internal carotid circulation (ICC) arteries on digital subtraction angiograms of pediatric patients and determine the growth trends. MATERIAL and METHODS: This is a retrospective cross-sectional study measurements of ICC arteries of 64 pediatric patients (4- 122 months) with retinoblastoma undergoing intra-arterial chemotherapy. RESULTS: Petrous, cavernous, supraclinoid and choroidal segments of internal carotid artery (ICA) and anterior cerebral artery (ACA) diameters had significant correlation with age. Most of the growth was noted in the first 36-48 months of life. Middle cerebral artery (MCA) diameter did not show significant correlation with age. 87% of the adult diameter of the MCA was attained in the first 6 months of life. ICC arteries reached 81% to 99% of adult sizes in the first 48 months of life. On the contrary, the main iliac artery was only 59% of the adult diameter at this age group. CONCLUSION: Use of current intracranial stents in children appears tolerable due to the growth pattern of ICC arteries. Based on this data, the current armamentarium of intracranial stents or stent-like devices is sufficient to cover the need in the pediatric population