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

Performance of the ESHRE/ESGE classification in differentiating anomalies of double uterine cavity in comparison with the ASRM classification

Objective: To compare the performance of the ESHRE/ESGE classification with that of the ASRM classification in differential diagnosis and management of cases with double uterine cavity. Design: Prospective observational study. Setting: Zagazig University hospitals. Materials and methods: During the period from January 2014 to January 2015, women referred for 3D-TVS due to the diagnosis of double uterine cavity (by 2D-TVS or hysteroscopy) were included in the study. 3D-TVS examination was performed for all women between days 14 and 21 of the cycle. The ASRM and ESHRE/ESGE classifications were both applied to differentiate anomalies in the studied cases. Main outcome measures: In the 100 women included in the study, the ASRM classification classified all cases as having congenital uterine anomalies, with septate uterus being the most frequent (49%). The ESHRE/ESGE classification classified 80/100 as having congenital uterine anomalies, with class U2 (septate) being the most frequent (92.5%). Both classifications showed ‘poor’ agreement in the diagnosis of congenital uterine anomalies and ‘moderate’ agreement in the diagnosis of septate uterus (95% CI, 0.315–0.615) and the diagnosis of cases in whom surgical interference (hysteroscopic metroplasty) is indicated (95% CI, 0.433–0.75). However, the frequencies of diagnosis in the last two groups were significantly higher with the ESHRE/ESGE classification. Major conclusions: The new classification of ESHRE/ESGE leads to increased frequency of diagnosis of a septate uterus and, subsequently, more cases will be candidate for hysteroscopic metroplasty

Mechanical induction of labor and ecbolic-less vaginal birth after cesarean section: A cohort study

Objective: During delivery counseling, some women with previous uncomplicated cesarean section (CS) wish mechanical induction of labor (IOL) but they are not accepting the added risk of using ecbolics to induce and/or augment labor. The objective of the study was to assess the safety and efficacy of the isolated use of transcervical Foley's catheter balloon as a mean of mechanical cervical ripening (CR)/IOL and successful ecbolic-less vaginal birth after cesarean section (VBAC). Materials and methods: A cohort study was conducted in two tertiary care maternity hospitals between October 2013 and July 2016 and recruited women with singleton pregnancy and cephalic presentation who had previous one uncomplicated CS and were scheduled for mechanical CR/IOL at term for routine obstetric indications. No ecbolics were used for induction or augmentation of labor as per patients' request. The primary outcome variable was the rate of successful VBAC. Results: 108 Women had a completed trial of mechanical CR/IOL without ecbolics till delivery. Active labor started in 94 women (87%), however only 43 women (39.8%) had successful VBAC. No woman in the study cohort had uterine rupture, scar dehiscence, uterine tachysystole, postpartum hemorrhage and/or puerperal sepsis. No cases were admitted to intensive care units and there were no maternal mortalities. Prior successful VBAC and post-expulsion BS were the only independent predictors for successful VBAC and shorter duration of labor after balloon expulsion. Conclusion: Mechanical IOL with the mere use of transcervical Foley's catheter is a safe and effective method of VBAC in women refusing use of ecbolics