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

A Financial Conditions Index for the United States

The financial crisis of 2007-09 has highlighted the importance of developments in financial conditions for real economic activity. The authors estimate the effect of current and past shocks to financial variables on U.S. GDP growth by constructing two growthbased financial conditions indexes (FCIs) that measure the contribution to quarterly (annualized) GDP growth from financial conditions. One FCI is constructed using a structural vector-error correction model and the other is constructed using a large-scale macroeconomic model. The authors' results suggest that financial factors subtracted around 5 percentage points from quarterly annualized real GDP growth in the United States in 2008Q4 and 2009Q1 and should subtract another 5 percentage points from growth in 2009Q2. Moreover, to assess the effect of financial shocks in terms of policy interest rate equivalent units, the authors convert the effect of financial developments on growth into the number of basis points by which the federal funds rate has been tightened. The authors show that the tightening of financial conditions since mid-2007 is equivalent to about 300 basis points of tightening in terms of the federal funds rate. Thus, the aggressive monetary easing undertaken by the Federal Reserve over the financial crisis has not been sufficient to offset the tightening of financial conditions. Finally, in a key contribution to the literature, the authors assess the relationship between financial shocks and real activity in the context of the zero lower bound. They find that the effect of the tightening of financial conditions on GDP growth in the current crisis may have been amplified by as much as 40 per cent due to the fact that policy interest rates reached the zero lower bound.Business fluctuations and cycles; Monetary conditions index; Monetary and financial indicators; Recent economic and financial developments

Different chemometric approaches to optimize the assay of St. John's Wort active ingredients

In this paper, we describe the optimization procedure for the quantitative assay of naphthodianthrones in St. John's Wort dry extract by reversed phase liquid chromatography. Lately, a project for European Pharmacopoeia monograph including an HPLC assay for the active moieties in St. John's Wort dry extract was published with a view to provoking reactions from other researchers. We therefore decided to use different chemometric approaches to evaluate the influence of both analytical and preparative factors to demonstrate the robustness of the optimized method. An asymmetric screening design was built in order to evaluate the weight of each level for each factor – the sonication duration, the light exposure duration, the flow rate and the type of column – on the response: the total hypericin content. Considering the results so obtained, we were compelled to modify some parameters. Thus we built a screening design to apprehend the reliability of the new sample pre-treatment process, the interpretation and identification of active factors were performed according to various methods. We used a third chemometric approach: a sequential bifurcation to check out the method's robustness. In a second step, an eluent compatible with Mass Spectrometry detection was determined by a combined design. To cope with both separation and analysis time, desirability functions were used. Optimal conditions are finally given by ternary system at an optimized temperature (40°C) and all the naphthodianthrones are separated in 10min on conventional endcapped octadecyl silica gel column

Déploiement du programme français dit « Staff d’évaluation des pratiques professionnelles » sur l’iatrogénie médicamenteuse de patients âgés institutionnalisés au sein d’établissements d’hébergement pour personnes âgées dépendantes

Objectif : Dans le cadre d’un stage à thématique optionnelle internationale de l’Université de Montréal se déroulant au Centre hospitalier de Vienne (France), l’objectif du projet est de déployer et d’analyser les résultats du programme « Staff d'évaluation des pratiques professionnelles "Médicaments et personnes âgées"» en établissement d’hébergement pour personnes âgées dépendantes.  Mise en contexte : Le programme consiste à réviser les dossiers médicaux des résidents dans les établissements d’hébergement pour personnes âgées dépendantes. Ces personnes ont été identifiées comme des patients à risque d’iatrogénie médicamenteuse pouvant bénéficier de ce programme. Le but de ce projet est de définir les non-conformités aux référenciels et d’organiser des réunions multidisciplinaires pour discuter des interventions à effectuer. Avec la présence d’une stagiaire en pharmacie, il a été possible de déployer ce programme dans ces unités.  Résultats : La révision des dossiers s’est effectuée dans quatre unités d’hébergement, avec un nombre total de 130 résidents audités et 201 propositions de modifications de traitement. Le programme « Staff d'évaluation des pratiques professionnelles "Médicaments et personnes âgées"» a permis de mettre en évidence principalement deux types de non-conformité aux référentiels. Quarante-neuf pour cent des résidents avaient au moins un médicament potentiellement inapproprié et 65 % avaient une durée non établie pour les traitements aigus. Plus de la moitié des propositions faites aux médecins ont été acceptées (60 %) lors des réunions multidisciplinaires, ce qui souligne l’impact du rôle du pharmacien dans la révision des dossiers- patients.  Conclusion : Ce projet permet de conclure que le programme « Staff d'évaluation des pratiques professionnelles "Médicaments et personnes âgées"» est un excellent complément à l’analyse d’ordonnances faite par le pharmacien lors de la validation. La prochaine étape serait d’évaluer l’impact de ces interventions auprès des résidents.  Abstract  Objective: Within the context of an optional clinical rotation from the Faculty of pharmacy at the University of Montreal that took place at the Centre hospitalier de Vienne, France, the objective of this project is to present and analyze the results of the program entitled “Professional Practices Assessment Meetings-Medications and the Elderly” in residential facilities for dependent elderly people.  Background: The program involves reviewing the charts of residents in residential facilities for dependent elderly persons. They were identified as patients at risk for iatrogenic event from medications who might benefit from this program. The aim of this project was to identify noncompliance with the guidelines and to organize multidisciplinary meetings to discuss the action to be taken to correct them. It was possible to carry out this program at these facilities due to the presence of a pharmacy student.  Results: Chart reviews were conducted at four residential facilities, with a total of 130 residents audited and 201 proposed treatment changes. The Professional Practices Assessment Meetings – Medications and the Elderly program mainly identified two types of noncompliance with the guidelines. Forty-nine percent of the residents had at least one potentially inappropriate medication and 65% had an unspecified duration for an acute treatment. More than half of the proposals made to the physicians were accepted (60%) at the multidisciplinary meetings, which showed the impact of the pharmacist’s role in chart reviews.  Conclusion: This project lead to the conclusion that the Professional Practices Assessment Meetings – Medications and the Elderly program is an excellent complement to the pharmacist’s analysis of prescriptions during validation. The next step would be to assess the impact of these interventions on the residents.

Unique Changes in the Incidence of Acute Chest Syndrome in Children with Sickle-Cell Disease Unravel the Role of Respiratory Pathogens: A Time-Series Analysis

International audienceBackground: Acute chest syndrome (ACS) is a life-threatening complication of sickle-cell disease (SCD). Although respiratory pathogens are frequently detected in children with ACS, their respective role in triggering the disease is still unclear. We hypothesized that ACS incidence followed the unprecedented population-level changes in respiratory pathogens dynamics following the COVID-19-related non-pharmaceutical interventions (NPIs).Research question: What is the respective role of respiratory pathogens in ACS epidemiology?Study design: AND METHODS. We performed an interrupted time-series analysis of patient records from a national hospital-based surveillance system. All children < 18 years of age with SCD hospitalized for ACS in France between January 2015 and May 2022 were included. The monthly incidence of ACS per 1000 children with SCD over time was analyzed using a quasi-Poisson regression model. The circulation of 12 respiratory pathogens in the general pediatric population over the same period was included in the model to assess the fraction of ACS potentially attributable to each respiratory pathogen.Results: Among the 55,941 hospitalizations of children with SCD, 2306 episodes of ACS were included (median [IQR] age, 9 [5-13] years). We observed a significant decrease in ACS incidence after NPI implementation in March 2020 (-29.5%; 95% CI, -46.8% to -12.2%; P = .001) and a significant increase after lifting of the NPIs in April 2021 (24.4%; 95% CI, 7.2% to 41.6%; P = .007). Using population-level incidence of several respiratory pathogens, we found that Streptococcus pneumoniae accounted for 30.9% (95% CI, 4.9% to 56.9%; P = .02) of ACS incidence over the study period and influenza 6.8% (95% CI, 2.3% to 11.3%; P = .004), whereas other respiratory pathogens had only a minor role.Interpretation: NPIs were associated with significant changes in ACS incidence concomitantly with major changes in the circulation of several respiratory pathogens in the general population. This unique epidemiological situation allowed to unravel the contribution of these respiratory pathogens, in particular S. pneumoniae and influenza, to the burden of childhood ACS, highlighting the potential benefit of vaccine prevention in this vulnerable population

Incidence of Acute Chest Syndrome in Children With Sickle Cell Disease Following Implementation of the 13-Valent Pneumococcal Conjugate Vaccine in France

International audienceImportance: Acute chest syndrome (ACS) is one of the leading acute severe complications of sickle-cell disease (SCD). Although Streptococcus pneumoniae (S pneumoniae) is highly prevalent in children with SCD, its precise role in ACS is unclear. The efficacy of 13-valent pneumococcal conjugate vaccine (PCV13) implementation on ACS is still unknown.Objective: To assess the association of PCV13 implementation in the general pediatric population with the incidence of ACS in children with SCD.Design, setting, and participants: This cohort study used an interrupted time-series analysis of patient records from a national hospital-based French surveillance system. All children younger than 18 years with SCD (based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision definition) hospitalized in France between January 2007 and December 2019 were included.Exposures: PCV13 implementation.Main outcomes and measures: Monthly incidence of ACS per 1000 children with SCD over time as analyzed by segmented linear regression with autoregressive error; monthly incidence of hospitalization for vaso-occlusive crisis, asthma crisis, and acute pyelonephritis per 1000 children with SCD over the same period as the control outcomes.Results: Among the 107 694 hospitalizations of children with SCD, 4007 episodes of ACS were included (median [IQR] age, 8 [4-12] years; 2228 [55.6%] boys). PCV13 implementation in 2010 was followed by a significant decrease in the incidence of ACS (-0.9% per month; 95% CI, -1.4% to -0.4%; P < .001), with an estimated cumulative change of -41.8% (95% CI, -70.8% to -12.7%) by 2019. Sensitivity analyses yielded the same results, including the incidence of ACS adjusted for that of vaso-occlusive crisis over time. The results were similar among different age groups. By contrast, no change was found for the 3 control outcomes over the study period.Conclusions and relevance: PCV13 implementation was associated with an important reduction in the incidence of ACS in children with SCD. This vaccine benefit provides new evidence of the key role of S pneumoniae in ACS and should be considered when estimating outcomes associated with current PCVs and the potential benefit of next-generation PCVs in children

The Aquifer-CO2Leak project: Numerical modeling for the design of a CO2 injection experiment in the saturated zone of the Saint-Emilion (France) site

International audienceThe objective of the Aquifer-CO2Leak project is to get insights into carbon dioxide CO2 migration in aquifers within the context of Carbon Capture and Storage (CCS) and to test the different equipment necessary for CO2 monitoring. The underlying idea is to develop an experiment in the saturated zone (phreatic) of the underground limestone quarry located at Gironde department (France). It consists in injecting water, carrying dissolved gases (CO2 and krypton) and a fluorescent molecule, under controlled conditions. In this paper, we present the dimensioning study of the experiment by numerical simulations carried out using the simulator CooresFlow (IFPEN's in-house simulator for reactive transport in porous media). The important experiment parameters (injection flow rate, injected volume, the time to return in system equilibrium and wells location) were successfully estimated. In particular, the variation of species concentration in time and space was simulated and analyzed to define an experimental measurement schedule for the planned survey. Finally, a sensitivity analysis of the uncertain model parameters is presented. We found that the water table level and the dispersivity of the porous medium appear to be the most “sensitive” parameters