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

Obeticholic acid for the treatment of non-alcoholic steatohepatitis: interim analysis from a multicentre, randomised, placebo-controlled phase 3 trial

Background Non-alcoholic steatohepatitis (NASH) is a common type of chronic liver disease that can lead to cirrhosis. Obeticholic acid, a farnesoid X receptor agonist, has been shown to improve the histological features of NASH. Here we report results from a planned interim analysis of an ongoing, phase 3 study of obeticholic acid for NASH. Methods In this multicentre, randomised, double-blind, placebo-controlled study, adult patients with definite NASH,non-alcoholic fatty liver disease (NAFLD) activity score of at least 4, and fibrosis stages F2–F3, or F1 with at least oneaccompanying comorbidity, were randomly assigned using an interactive web response system in a 1:1:1 ratio to receive oral placebo, obeticholic acid 10 mg, or obeticholic acid 25 mg daily. Patients were excluded if cirrhosis, other chronic liver disease, elevated alcohol consumption, or confounding conditions were present. The primary endpointsfor the month-18 interim analysis were fibrosis improvement (≥1 stage) with no worsening of NASH, or NASH resolution with no worsening of fibrosis, with the study considered successful if either primary endpoint was met. Primary analyses were done by intention to treat, in patients with fibrosis stage F2–F3 who received at least one dose of treatment and reached, or would have reached, the month 18 visit by the prespecified interim analysis cutoff date. The study also evaluated other histological and biochemical markers of NASH and fibrosis, and safety. This study is ongoing, and registered with ClinicalTrials.gov, NCT02548351, and EudraCT, 20150-025601-6. Findings Between Dec 9, 2015, and Oct 26, 2018, 1968 patients with stage F1–F3 fibrosis were enrolled and received at least one dose of study treatment; 931 patients with stage F2–F3 fibrosis were included in the primary analysis (311 in the placebo group, 312 in the obeticholic acid 10 mg group, and 308 in the obeticholic acid 25 mg group). The fibrosis improvement endpoint was achieved by 37 (12%) patients in the placebo group, 55 (18%) in the obeticholic acid 10 mg group (p=0·045), and 71 (23%) in the obeticholic acid 25 mg group (p=0·0002). The NASH resolution endpoint was not met (25 [8%] patients in the placebo group, 35 [11%] in the obeticholic acid 10 mg group [p=0·18], and 36 [12%] in the obeticholic acid 25 mg group [p=0·13]). In the safety population (1968 patients with fibrosis stages F1–F3), the most common adverse event was pruritus (123 [19%] in the placebo group, 183 [28%] in the obeticholic acid 10 mg group, and 336 [51%] in the obeticholic acid 25 mg group); incidence was generally mild to moderate in severity. The overall safety profile was similar to that in previous studies, and incidence of serious adverse events was similar across treatment groups (75 [11%] patients in the placebo group, 72 [11%] in the obeticholic acid 10 mg group, and 93 [14%] in the obeticholic acid 25 mg group). Interpretation Obeticholic acid 25 mg significantly improved fibrosis and key components of NASH disease activity among patients with NASH. The results from this planned interim analysis show clinically significant histological improvement that is reasonably likely to predict clinical benefit. This study is ongoing to assess clinical outcomes

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

Surface modification of aramid fibres by graphene oxide nano-sheets for multiscale polymer composites

Aramid fibre-graphene oxide (GO) multiscale reinforcement fibres were prepared by a novel technique where a plasma co-polymerized functional primer coating was initially applied on fibres followed by chemically attaching GO unilamellar sheets to the functionalized surface of the fibres. The functionalized fibres were immersed in purified GO aqueous suspensions at 60. °C under two pH conditions (slightly acidic GO suspension at pH. 6 and alkaline ammonia water GO suspension at pH. 9). The multiscale hybrid fibres were characterized by XPS, FTIR, Raman spectroscopy, SEM, AFM and tensile measurements. The fibres treated in alkaline ammonia aqueous suspension showed better strength and adhesion characteristics. The mean tensile strength value for the modified fibres showed an improvement over 7.9% whereas the interfacial shear strength in modified fibre-epoxy model composites, as determined by micro-bond technique, improved by 44.68%. © 2014 Elsevier B.V

Ligustrum lucidum Leaf Extract-Assisted Green Synthesis of Silver Nanoparticles and Nano-Adsorbents Having Potential in Ultrasound-Assisted Adsorptive Removal of Methylene Blue Dye from Wastewater and Antimicrobial Activity

Present study was conducted to investigate the adsorption and ultrasound-assisted adsorption potential of silver nanoparticles (AgNPs) and silver nanoparticles loaded on chitosan (AgCS composite) as nano-adsorbents for methylene blue (MB) removal. AgNPs were synthesized using leaf extract of Ligustrum lucidum, which were incorporated on the chitosan’s surface for modification. UV–Vis Spectroscopy, FTIR, XRD, SEM, and EDX techniques were used to confirm the synthesis and characterization of nanomaterials. Batch adsorption and sono-adsorption experiments for the removal of MB were executed under optimal conditions; for fitting the experimental equilibrium data, Langmuir and Freundlich’s isotherm models were adopted. In addition, the antimicrobial potential of the AgNPs and AgCS were examined against selected bacterial and fungal strains. UV–Vis spectroscopy confirmed AgNPs synthesis from the leaf extract of L. lucidum used as a reducer, which was spherical as exposed in the SEM analysis. The FTIR spectrum illustrated phytochemicals in the leaf extract of L. lucidum functioning as stabilizing agents around AgNPs and AgCS. Whereas, corresponding crystalline peaks of nanomaterial, including a signal peak at 3 keV indicating the presence of silver, were confirmed by XRD and EDX. The Langmuir model was chosen as an efficient model for adsorption and sono-adsorption, which exposed that under optimum conditions (pH = 6, dye initial concentration = 5 mg L−1, adsorbents dosage = 0.005 g, time = 120 min, US power 80 W), MB removal efficiency of AgNPs was >70%, using ultrasound-assisted adsorption compared to the non-sonicated adsorption. Furthermore, AgNPs exhibited promising antibacterial potential against Staphylococcus aureus with the maximum zone of inhibition (14.67 ± 0.47 mm). It was concluded that the green synthesis approach for the large-scale production of metallic nanoparticles is quite effective and can be recommended for efficient and cost-effective way to eradicate dyes, particularly from textile wastewater