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

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

Virtual fracture clinics: be vigilant for the ligamentous elbow injury.

The Covid-19 pandemic encouraged remote healthcare and led to dependency on virtual fracture clinics (VFC). VFC are orthopaedic consultant-led clinics where cases are reviewed virtually following referral by emergency department clinicians. Success is contingent on a comprehensive initial history and examination. This pathway has high patient satisfaction rates and cost-saving benefits. However, clinicians must be vigilant for high-energy mechanisms or examination findings suggestive of greater underlying injury. In this case, VFC missed a rare ipsilateral annular ligament injury in a 15-year old with an undisplaced radial neck fracture, following a fall from a horse. This led to radial head dislocation and delayed surgical repair. Untreated, radial head dislocations lead to pain and reduced range of movement. Despite the rarity of this injury pattern, face-to-face orthopaedic examination would have raised concern for significant ligamentous injury. A high-energy mechanism of injury mandates face-to-face senior orthopaedic review to avoid missing serious concomitant injury

Hourly potential evapotranspiration (hPET) at 0.1degs grid resolution for the global land surface from 1981-present

*Work in progress* _This is a subset of the final data, provided for review purposes. It will be expanded in future with the same DOI._ Hourly potential evapotranspiration (PET) product derived from using FAO's Penman-Monteith formulation with hourly climate variables from ERA5-Land. This dataset covers the time period 1981-present at 0.1 degs spatial resolution over the global land area

Hourly potential evapotranspiration (hPET) at 0.1degs grid resolution for the global land surface from 1981-present

*Work in progress* _This is a subset of the final data, provided for review purposes. It will be expanded in future with the same DOI._ Hourly potential evapotranspiration (PET) product derived from using FAO's Penman-Monteith formulation with hourly climate variables from ERA5-Land. This dataset covers the time period 1981-present at 0.1 degs spatial resolution over the global land area

Horizon scan of invasive alien species for the island of Ireland

Ireland, being an island situated on Europe’s western seaboard, has a fewer number of native species than mainland European Union Member States (MS). Increased numbers of vectors and pathways have reduced the island’s biotic isolation, increasing the risk of new introductions and their associated impacts on native biodiversity. It is likely that these risks are greater here than they are in continental Member States, where the native biodiversity is richer. A horizon scanning approach was used to identify the most likely IAS (with the potential to impact biodiversity) to arrive on the island of Ireland within the next ten years. To achieve this, we used a consensus-based approach, whereby expert opinion and discussion groups were utilised to establish and rank a list of 40 species of the most likely terrestrial, freshwater and marine IAS to arrive on the island of Ireland within the decade 2017–2027. The list of 40 included 18 freshwater invaders, 15 terrestrial IAS and seven marine species. Crustacean species (freshwater and marine) were taxonomically dominant (11 out of 40); this reflects their multiple pathways of introduction, their ability to act as ecosystem engineers and their resulting high impacts on biodiversity. Freshwater species dominated the top ten IAS (seven species out of ten), with the signal crayfish (Pacifastacus leniusculus) highlighted as the most likely species to arrive and establish in freshwaters, while roe deer (Capreolus capreolus) (second) and the warm-water barnacle (Hesperibalanus fallax) (fifth), were the most likely terrestrial and marine invaders. This evidence-based list provides important information to the relevant statutory agencies in both jurisdictions in Ireland to prioritise the prevention of the most likely invaders and aid in compliance with legislation, in particular the EU Regulation on Invasive Alien Species (EU 1143/2014). Targeted biosecurity in both jurisdictions is urgently required in order to manage the pathways and vectors of arrival, and is vital to maintaining native biodiversity on the island of Ireland

Preventable hand injuries: A national audit

Summary: Little is known of the scale of avoidable injuries presenting to medical services on a national level in the UK. This study aimed to assess the type and incidence of preventable wrist and hand injuries (as defined by the core research team) at a national level in the UK. 28 UK hospitals undertook a service evaluation of all hand trauma cases presenting to their units over a 2 week period in early 2021 identifying demographical and aetiological information about injuries sustained. 1909 patients were included (184 children) with a median age of 40 (IQR 25-59) years. The commonest five types of injury were fractures of the wrist; single phalangeal or metacarpal fractures; fingertip injuries; and infection, with the most common mechanisms being mechanical falls and manual labour. This is the first extensive survey of preventable hand injuries in the UK, identifying a need for further work into prevention to reduce healthcare burden and cost. 50% of injuries presenting to hand surgeons are preventable, with the most common injuries being single fractures of the wrist, phalanx and metacarpal. Few preventable injuries were related to alcohol or narcotic intoxication. Further research is needed to identify how to initiate injury prevention measures for hand injuries, particularly focussed towards hand fracture prevention