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

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Language Learning Resources on the Internet

Recent developments in computer networking - made possible by the improved accessibility of the Internet, with email and online chat systems - are making a huge impact on Technology Enhanced Language Learning (TELL). For many of us, the Internet is as mysterious as were earlier developments in Computer Assisted Language Learning (CALL) and interactive multimedia. However, we would like to argue in this paper that with the growth of the Internet in education and greater user-friendliness, ease of access for non-computer experts is now more feasible. Specifically, there is a huge range of authentic language resources for TESOL teachers. Internet resources on the World Wide Web are many and varied, and are difficult to describe on the printed page. The Internet itself is a vast worldwide network of computers, first developed for the defence forces in the USA, and then used widely by academics, before spreading throughout all computerised societies. All Australian universities are connected to the Internet, as are many government organisations and businesses, and a rapidly growing number of schools and colleges are also joining in. The exchange of information on the Internet involves millions of computers around the world, many of them connected through home computers using modems on ordinary telephone lines

A strategic approach to QA for transnational education programs

This paper describes the QA best practice model for higher education transnational education (TNE) programs recently developed at Swinburne, and the early stages of its implementation. The framework can be conveniently drawn as a four-box model which integrates planning and QA, and emphasises strategic guidelines and the client perspective, as well as academic and administration guidelines (see Table 1, below). The framework operates within the 'fitness for purpose' QA approach adopted by the Australian Universities Quality Agency (AUQA 2005), and is informed by the new 'Provision of education to international students: code of practice and guidelines for Australian universities' recently published by the Australian Vice-Chancellors’ Committee (AVCC), to which all Australian universities are signatories (AVCC 2005). We were given the opportunity to explore QA models and develop a 'conceptual framework' for TNE programs by the award of research funding from the AVCC offshore quality project to Swinburne University in September 2004. The project was completed and a report submitted to the AVCC in June 2005. The function of the framework is to: integrate TNEP planning and QA from the concept proposal stage provide an overview or map to university TNEP procedures and logistics as a tool for collating information essential to strategic management monitor university compliance on regulatory issues (AUQA, AVCC, host country regulations). The planning and QA framework is being applied to the logistics for transnational education programs (TNEP), in the form of guidelines for TNEP project initiation, project management, and project review. The framework and guidelines are part of Swinburne’s Internationalisation Strategic Plan, and are being developed by the Office of the Pro Vice-Chancellor (International), in consultation with university divisions who are managing TNE programs, and with various academic and administrative committees involved in policy affecting TNE programs. The overall context for the discussion is the effort of universities to become multinational organisations with internationalised staff and students. TNE programs are an increasingly significant factor in this process, given significant growth over the last decade (DFAT 2005, p. 56). In turn, the quality of TNE programs is a key strategic issue, as shown by the recent discussion paper from the Department of Education, Science and Training, with a 'Transnational Quality Strategy' under development this year. The more immediate goal is continuing improvement in planning and logistics for TNE programs, an effort that will always be a work in progress as transnational education rapidly evolves and constantly presents new challenges. To meet these challenges, universities need to overcome deficiencies in strategic planning and quality assurance