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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Evaluation of negative skin friction effects in pile foundations using 3D nonlinear analysis

The aim of this paper is to evaluate the influence of negative skin friction in pile foundations. Three dimensional nonlinear analyses for a single pile and pile groups were carried out for a specific case and some case studies as well. Contrary to simplified conventional analysis in which the predictions are usually overestimated and could be considered as an upper limit, it was found that the dragload of a pile in a group depends on the surface load, the pile configuration, the pile position in a group, the ultimate skin friction and the interface stiffness. It has been demonstrated that for fixed-head friction pile groups the dragload group effect is significantly greater than in the case of free-head end-bearing pile groups. Moreover, predictions for internal piles have shown considerably smaller dragloads for fixed-head piles, which is in accordance with experimental findings. It has also been demonstrated that when the construction of an embankment precedes the application of the foundation working load, the effect of negative skin friction is considerably smaller than in the reverse case. (c) 2005 Elsevier Ltd. All rights reserved

Response prediction for axially loaded pile groups in clays using 3D nonlinear analysis

The objective of this paper is to quantify the effect of the interaction between the piles of a group under axial loading in clayey soils. Three dimensional parametric nonlinear analysis was carried out for various pile group configurations. Reduction factors for estimating the group bearing capacity are proposed in tabular form while the variation of the stiffness of a group with the settlement level and pile arrangements is illustrated. The validity of a proposed relationship for estimating the response of pile groups is also examined

Introducing the “bleeding team”: Urgent reconstruction of an open fracture in a patient receiving acenocoumarol

Case: An elderly, polytrauma patient receiving vitamin K antagonist (VKA) for atrial fibrillation required immediate surgery for open distal tibial fracture. As the initial reversal with vitamin K and fresh frozen plasma by the trauma team was ineffective, the “Bleeding Team” was convened and administrated the appropriate four-factor prothrombin complex regimen, reversing the VKA in a timely manner. Surgery was performed under peripheral nerve blockade subsequently. The postoperative course of the patient was uneventful. Conclusion: The individualized approach and the multidisciplinary experts’ team guidance is of outmost importance in patients who are treated with anticoagulants and present for nonelective surgery. © 2021 Lippincott Williams and Wilkins. All rights reserved

In-depth bioinformatic study of the cadherin 5 interactome in patients with thoracic aortic aneurysm unveils 8 novel biomarkers

OBJECTIVES: Thoracic aortic aneurysm (TAA) is characterized by the dilation of the aorta and is associated with poor prognosis if not diagnosed and treated early. In this context, the identification of biomarkers regarding the TAA diagnosis, monitoring and prognosis is crucial. The purpose of the current study was to investigate the differential gene expression profile of the cadherin 5 (CDH5 or VE-Cadherin) gene network in patients with TAA, to propose novel biomarkers. METHODS: In silico techniques were used to construct the interactome of the CDH5 network, identify the differentially expressed genes (DEGs) in TAA as compared to healthy controls, and uncover the related molecular functions and the regulating miRNAs. RESULTS: Transcriptomic data of one microarray dataset were included, incorporating 43 TAA and 43 control samples. Eight DEGs were identified; 7 were up-regulated and 1 was down-regulated. A molecular signature of 8 genes (CDH5; Calcitonin Receptor-Like Receptor-CALCRL; Activin A Receptor-Like Type 1-ACVRL1, Tryptophanyl-TRNA Synthetase 1-WARS; Junction Plakoglobin-JUP, Protein Tyrosine Phosphatase Receptor Type J-PTPRJ, Purinergic Receptor P2X 4-P2RX4, Kinase Insert Domain Receptor-KDR) were identified as biomarkers associated with TAA. PTPRJ was associated with excellent discrimination and calibration in predicting TAA presentation. Positive correlations were reported regarding the expression of CDH5-CALCRL, CDH5-ACVRL1, CDH5-WARS and CDH5-PTPRJ. Finally, gene set enrichment analysis indicated the molecular functions and miRNA families (hsa-miR-296-5p, hsa-miR-6836-5p, hsa-miR-6132, hsa-miR-27a-5p and hsa-miR-6773-5p) relevant to the 8 biomarkers. CONCLUSIONS: These outcomes propose an 8-gene molecular panel associated with TAA. © 2021 The Author(s). Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved

Thoracic Epidural Analgesia With Levobupivacaine for 6 Postoperative Days Attenuates Sympathetic Activation After Thoracic Surgery

Objective: To investigate the impact of 2 postoperative analgesic regimens on heart rate variability in patients who underwent thoracotomy. Design: A prospective, randomized trial. Setting: A single-institutional study in a university hospital. Participants: Fifty patients who underwent thoracotomy under combined general anesthesia and thoracic epidural analgesia divided by a number generator into 2 equal groups (A and B). Interventions: In group A, postoperative analgesia consisted of thoracic epidural analgesia with levobupivacaine for 6 postoperative days. In group B, on the 3rd postoperative day this regimen was changed to patient-controlled intravenous morphine. Heart rate variability recordings were performed on the day before surgery, after the epidural, after operation, and on every postoperative day. Statistical analysis used chi-square and Student t tests (Bonferroni correction). Measurements and Main Results: In both groups, the low-frequency component of the analyzed recordings declined after epidural and after surgery. In group A, the low-frequency component was significantly lower compared with baseline from the 2nd postoperative day onward, whereas in group B it was significantly higher compared with A on the 4th and 6th postoperative days. In both groups, the changes in high frequency were statistically insignificant. Intergroup comparisons of the low-/high-frequency ratio showed statistical difference on the last day of observation. There was no difference between the groups in hemodynamic variables and visual analog scale/10 scores. Conclusions: Postoperatively decreased cardiac sympathetic outflow continues with epidural analgesia, whereas it is abolished by the change to intravenous patient-controlled morphine. (C) 2011 Elsevier Inc. All rights reserved

Translation and cultural adaptation of the greek version of the confusion assessment method diagnostic algorithm and the nursing delirium screening scale and their inter-rater reliability: A prospective cohort study

Aim: The lack of standardized tools limits the diagnosis οf postoperative delirium (POD) in the Greek population. Our aim was the translation and the cultural adaptation of the confusion assessment method (CAM) diagnostic algorithm and the nursing delirium screening scale (nu-DESC) in the Greek surgical population, and the determination of their interrater reliability. Methods: After Ethical approval and registration as a clinical trial (NCT04154176), a prospective cohort study was conducted in the Department of Anesthesiology, University Hospital of Larissa, Greece. Patients at least 60 years old, undergoing elective non-cardiac surgery, under general anesthesia were included. Results: Data from 60 patients, 180 records in total, were analyzed. There was an “almost perfect agreement” between the raters with the use of CAM (Cohen’s Kappa estimate: 0.960; 95 % CI: 0.905-1.000) and nu-DESC (Cohen’s Kappa estimate: 0.981; 95 % CI: 0.944-1.000). The agreement on each specific question of CAM and nu-DESC ranged from “substantial” to “almost perfect agreement”. Based on the CAM, the sensitivity and specificity of nu-DESC were 0.97 (95 % CI: 0.82-1.00) and 0.99 (95 % CI: 0.96-1.00), respectively. The Greek versions of CAM and nu-DESC showed a high inter-rater agreement. Conclusion: With the translation, the cultural adaptation, and the determination of their inter-rater agreement, the CAM diagnostic algorithm and the nu-DESC may serve as reliable instruments for the detection of POD in the Greek population. © 2020, Lithografia Antoniadis I - Psarras Th G.P. All rights reserved

Differences in long-term survival outcomes after coronary artery bypass grafting using single vs multiple arterial grafts: a meta-analysis with reconstructed time-to-event data and subgroup analyses

Objective: We reviewed the available literature on patients with coronary artery disease undergoing isolated coronary artery bypass grafting (CABG) with either single (SAG) or multiple arterial grafting (MAG). Methods: Original research studies that evaluated the long-term survival of MAG versus SAG were identified, from 1995 to 2022. The median overall survival (OS) and event-free OS were the primary endpoints. Comparison of median OS between the right internal mammary artery (RIMA) and radial artery (RA) as a second arterial conduit was the secondary endpoint. Subgroup analyses were performed regarding patients older than 70 years, with diabetes mellitus, and females. A sensitivity analysis was performed with the leave-one-out method. Results: Forty-four studies were included in the qualitative and thirty-nine in the quantitative synthesis. After pooling data from 180 to 459 patients, the MAG group demonstrated a higher OS (HR, 0.589; 95% CI, 0.58–0.60; p < 0.0001) and event-free OS compared with the SAG group (HR, 0.828; 95% CI, 0.80–0.86; p < 0.0001). In addition, RITA was associated with superior OS compared with RA as a second arterial conduit (HR, 0.936; 95% CI, 0.89–0.98; p = 0.009). MAG was also superior to SAG in patients over 70 years, females, and patients with diabetes mellitus. Sensitivity analysis demonstrated a small-size study effect on the female subgroup analysis. Conclusion: The present meta-analysis indicates that MAG is associated with enhanced survival outcomes compared to SAG for patients undergoing isolated CABG. © 2022, The Author(s)