The Bangladesh Risk of Acute Vascular Events (BRAVE) Study: objectives and design.

During recent decades, Bangladesh has experienced a rapid epidemiological transition from communicable to non-communicable diseases. Coronary heart disease (CHD), with myocardial infarction (MI) as its main manifestation, is a major cause of death in the country. However, there is limited reliable evidence about its determinants in this population. The Bangladesh Risk of Acute Vascular Events (BRAVE) study is an epidemiological bioresource established to examine environmental, genetic, lifestyle and biochemical determinants of CHD among the Bangladeshi population. By early 2015, the ongoing BRAVE study had recruited over 5000 confirmed first-ever MI cases, and over 5000 controls "frequency-matched" by age and sex. For each participant, information has been recorded on demographic factors, lifestyle, socioeconomic, clinical, and anthropometric characteristics. A 12-lead electrocardiogram has been recorded. Biological samples have been collected and stored, including extracted DNA, plasma, serum and whole blood. Additionally, for the 3000 cases and 3000 controls initially recruited, genotyping has been done using the CardioMetabochip+ and the Exome+ arrays. The mean age (standard deviation) of MI cases is 53 (10) years, with 88 % of cases being male and 46 % aged 50 years or younger. The median interval between reported onset of symptoms and hospital admission is 5 h. Initial analyses indicate that Bangladeshis are genetically distinct from major non-South Asian ethnicities, as well as distinct from other South Asian ethnicities. The BRAVE study is well-placed to serve as a powerful resource to investigate current and future hypotheses relating to environmental, biochemical and genetic causes of CHD in an important but under-studied South Asian population.The Gates Cambridge Trust has supported Dr Chowdhury. Epidemiological fieldwork in BRAVE has been supported by grants to investigators at the Cardiovascular Epidemiology Unit, University of Cambridge. The Cardiovascular Epidemiology Unit is underpinned by programme grants from the British Heart Foundation (RG/13/13/30194), the UK Medical Research Council (MR/L003120/1), and the UK National Institute of Health Research Cambridge Biomedical Research Centre. BRAVE has received support for genetic assays from the European Research Council (ERC-2010-AdG-20100317), European Commission Framework 7 (Grant Agreement number: 279233), and the Cambridge British Heart Foundation Centre for Excellence in Cardiovascular Science; We would like to acknowledge the contributions of the following individuals: Cardiology Research Group in Bangladesh Mohammad Afzalur Rahman, Mohammad Abdul Kader Akanda, M Atahar Ali, Mir Jamal Uddin, SM Siddiqur Rahman, Amal Kumar Choudhury, Md. Mamunur Rashid, Nazir Ahmed Chowdhury, Mohammad Abdullahel Baqui, Kajal Kumar Karmoker, Mohammad Golam Azam; Setting up/implementation of fieldwork in Bangladesh Abbas Bhuiya, Susmita Chowdhury, Kamrun Nahar, Neelima Das, Proshon Roy, Sumona Ferdous, Taposh Kumar Biswas, Abu Sadat Mohammad Sayed Sharif, Ranjit Shingha, Rose Jinnath Tomas, Babulal Parshei, Mabubur Rahman, Mohammad Emon Hossain, Akhirunnesa Mily, AK Mottashir Ahmed, Sati Chowdhury, Sushila Roy, Dipak Kanti Chowdhury, Swapan Kumar Roy; Epidemiological/statistical support in Cambridge Stephen Kaptoge, Simon Thompson, Angela Wood, Narinder Bansal, Anna Ramond, Clare Oliver-Williams, Marinka Steur, Linda O’Keeffe, Eleni Sofianopoulou, Setor Kunutsor, Donal Gorman, Oscar H Franco, Malcolm Legget, Pinal Patel, Marc Suhrcke, Sylvaine Bruggraber, Jonathan Powell; Data management Matthew Walker, Steve Ellis, Shawkat Jahangir, Habibur Rahman, Rifat Hasan Shammi, Shafqat Ullah, Mohammad Abdul Matin and Administration Beth Collins, Hannah Lombardi, Binder Kaur, Rachel Henry, Marilena Papanikolaou, Robert Smith, Abdul Wazed, Robert Williams, Julie Jenkins, Keith Hoddy.This is the final published version of the article. It was originally published in the European Journal of Epidemiology (Chowdhury R, et al., European Journal of Epidemiology, 2015, doi:10.1007/s10654-015-0037-2). The final version is available at http://dx.doi.org/10.1007/s10654-015-0037-

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