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

Evaluation of the effects of an integrated plurilingual didactization of French as a foreign or second language on the performance of Moroccan high school students

L’émergence du concept de plurilinguisme dans le champ de la didactique des langues a donné lieu à des approches dites plurielles ou plurilingues. Les travaux, qui se sont penchés sur la didactisation de ce concept, forment une littérature approfondie et riche. Or, peu d’études se sont intéressées à sa transposition et à ses implications didactiques dans la classe de FLE(S) au lycée.Notre travail vise à transposer les faits plurilingues de cette classe au Maroc à la lumière du concept de plurilinguisme dans la perspective d’aider les apprenants dans l’apprentissage du français en mobilisant leur répertoire sociolangagier. Cela nous a amené à élaborer une Didactisation Intégrée Plurilingue du FLE(S) qui s’est concrétisée sous forme d’une méthode plurilingue.Notre travail vise aussi à analyser et à évaluer les effets de cette méthode sur les performances sociolangagières des apprenants. Pour ce faire, nous avons mené une recherche-action, articulée sur l’analyse du contexte sociolinguistique en question,l’évaluation du programme de français en vigueur, l’élaboration d’une Didactisation Intégrée Plurilingue du FLE(S), et in fine, l'expérimentation de cette didactisation en classe de première dans un lycée au Maroc.Cette recherche s’appuie sur l’observation, la pratique, l’analyse et l’évaluation de trois types de corpus: les données des évaluations de la compétence écrite, les données des questionnaires et les données des grilles d’observation de classe lors de l’expérimentation.The emergence of the concept of plurilingualism in the field of language teaching has given rise to so-called pluralistics or plurilingual approaches. The works, which have focused on the didactization of this concept, form an in-depth and rich literature. However, few studies have focused on its transposition and its didactic implications in the FLE(S) class in high school.Our work aims to transpose the plurilingual facts of this class in Morocco in the light of the concept of plurilingualism with a view to helping learners in learning French by mobilizing their sociolinguistic repertoire. This led us to develop a Plurilingual Integrated Didactization of FLE(S) which materialized in the form of a plurilingual method. Our work also aims to analyze and evaluate the effects of this method on the sociolinguistic performance of learners. To do this, we conducted action research, based on the analysis of the sociolinguistic context in question, the evaluation of the French program in force, the development of an Integrated Plurilingual Didactization of FLE(S), and finally, the experimentation of this didactization in class in a high school in Morocco. This research is based on the observation, the practice, the analysis and the evaluation of three types of corpus: thedata of evaluations of written competence, the data of the questionnaires and the data of the grids of observation of class during experimentation

Heterogeneous satellite-terrestrial technologies: Quality of service and availability testing

Due to rapid and constant evolution of wireless communication technologies, standards, protocols, applications, and systems, it is hard to rely on personal experience to make their selection, design and deployment. Testing helps to determine actual performance and limitations of technologies. Testing is also important to avoid the financial and reputation losses of the company as well as to ensure uninterrupted flow of the information for essential services such as healthcare, airports, railways, and military services. Testing covers many aspects of a communications network, including interoperability, conformance, performance and availability. The end-to-end quality of service management implies that features such as service scalability between different networks have to be available. However, wireless QoS requirements are very diverse due to its seamless applications, and moreover, , differences in QoS properties between both wired and wireless applications have a con siderable effect on the level of user service quality as well as platform and application dimensions of network interoperability. The aim of this paper is to establish the network performance and availability requirements for the integrated use of satellite communication technology together with terrestrial network technology in a particular, niche application area, namely the seamless delivery of educational services in rural and remote areas. The suggested testing programme aims to identify the performance and availability issues for the operation of heterogeneous satellite-terrestrial network technologies

Burden of disease scenarios for 204 countries and territories, 2022–2050: a forecasting analysis for the Global Burden of Disease Study 2021

BackgroundFuture trends in disease burden and drivers of health are of great interest to policy makers and the public at large. This information can be used for policy and long-term health investment, planning, and prioritisation. We have expanded and improved upon previous forecasts produced as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) and provide a reference forecast (the most likely future), and alternative scenarios assessing disease burden trajectories if selected sets of risk factors were eliminated from current levels by 2050.MethodsUsing forecasts of major drivers of health such as the Socio-demographic Index (SDI; a composite measure of lag-distributed income per capita, mean years of education, and total fertility under 25 years of age) and the full set of risk factor exposures captured by GBD, we provide cause-specific forecasts of mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) by age and sex from 2022 to 2050 for 204 countries and territories, 21 GBD regions, seven super-regions, and the world. All analyses were done at the cause-specific level so that only risk factors deemed causal by the GBD comparative risk assessment influenced future trajectories of mortality for each disease. Cause-specific mortality was modelled using mixed-effects models with SDI and time as the main covariates, and the combined impact of causal risk factors as an offset in the model. At the all-cause mortality level, we captured unexplained variation by modelling residuals with an autoregressive integrated moving average model with drift attenuation. These all-cause forecasts constrained the cause-specific forecasts at successively deeper levels of the GBD cause hierarchy using cascading mortality models, thus ensuring a robust estimate of cause-specific mortality. For non-fatal measures (eg, low back pain), incidence and prevalence were forecasted from mixed-effects models with SDI as the main covariate, and YLDs were computed from the resulting prevalence forecasts and average disability weights from GBD. Alternative future scenarios were constructed by replacing appropriate reference trajectories for risk factors with hypothetical trajectories of gradual elimination of risk factor exposure from current levels to 2050. The scenarios were constructed from various sets of risk factors: environmental risks (Safer Environment scenario), risks associated with communicable, maternal, neonatal, and nutritional diseases (CMNNs; Improved Childhood Nutrition and Vaccination scenario), risks associated with major non-communicable diseases (NCDs; Improved Behavioural and Metabolic Risks scenario), and the combined effects of these three scenarios. Using the Shared Socioeconomic Pathways climate scenarios SSP2-4.5 as reference and SSP1-1.9 as an optimistic alternative in the Safer Environment scenario, we accounted for climate change impact on health by using the most recent Intergovernmental Panel on Climate Change temperature forecasts and published trajectories of ambient air pollution for the same two scenarios. Life expectancy and healthy life expectancy were computed using standard methods. The forecasting framework includes computing the age-sex-specific future population for each location and separately for each scenario. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline.FindingsIn the reference scenario forecast, global and super-regional life expectancy increased from 2022 to 2050, but improvement was at a slower pace than in the three decades preceding the COVID-19 pandemic (beginning in 2020). Gains in future life expectancy were forecasted to be greatest in super-regions with comparatively low life expectancies (such as sub-Saharan Africa) compared with super-regions with higher life expectancies (such as the high-income super-region), leading to a trend towards convergence in life expectancy across locations between now and 2050. At the super-region level, forecasted healthy life expectancy patterns were similar to those of life expectancies. Forecasts for the reference scenario found that health will improve in the coming decades, with all-cause age-standardised DALY rates decreasing in every GBD super-region. The total DALY burden measured in counts, however, will increase in every super-region, largely a function of population ageing and growth. We also forecasted that both DALY counts and age-standardised DALY rates will continue to shift from CMNNs to NCDs, with the most pronounced shifts occurring in sub-Saharan Africa (60·1% [95% UI 56·8–63·1] of DALYs were from CMNNs in 2022 compared with 35·8% [31·0–45·0] in 2050) and south Asia (31·7% [29·2–34·1] to 15·5% [13·7–17·5]). This shift is reflected in the leading global causes of DALYs, with the top four causes in 2050 being ischaemic heart disease, stroke, diabetes, and chronic obstructive pulmonary disease, compared with 2022, with ischaemic heart disease, neonatal disorders, stroke, and lower respiratory infections at the top. The global proportion of DALYs due to YLDs likewise increased from 33·8% (27·4–40·3) to 41·1% (33·9–48·1) from 2022 to 2050, demonstrating an important shift in overall disease burden towards morbidity and away from premature death. The largest shift of this kind was forecasted for sub-Saharan Africa, from 20·1% (15·6–25·3) of DALYs due to YLDs in 2022 to 35·6% (26·5–43·0) in 2050. In the assessment of alternative future scenarios, the combined effects of the scenarios (Safer Environment, Improved Childhood Nutrition and Vaccination, and Improved Behavioural and Metabolic Risks scenarios) demonstrated an important decrease in the global burden of DALYs in 2050 of 15·4% (13·5–17·5) compared with the reference scenario, with decreases across super-regions ranging from 10·4% (9·7–11·3) in the high-income super-region to 23·9% (20·7–27·3) in north Africa and the Middle East. The Safer Environment scenario had its largest decrease in sub-Saharan Africa (5·2% [3·5–6·8]), the Improved Behavioural and Metabolic Risks scenario in north Africa and the Middle East (23·2% [20·2–26·5]), and the Improved Nutrition and Vaccination scenario in sub-Saharan Africa (2·0% [–0·6 to 3·6]).InterpretationGlobally, life expectancy and age-standardised disease burden were forecasted to improve between 2022 and 2050, with the majority of the burden continuing to shift from CMNNs to NCDs. That said, continued progress on reducing the CMNN disease burden will be dependent on maintaining investment in and policy emphasis on CMNN disease prevention and treatment. Mostly due to growth and ageing of populations, the number of deaths and DALYs due to all causes combined will generally increase. By constructing alternative future scenarios wherein certain risk exposures are eliminated by 2050, we have shown that opportunities exist to substantially improve health outcomes in the future through concerted efforts to prevent exposure to well established risk factors and to expand access to key health interventions.FundingBill & Melinda Gates Foundation.</p