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

Secure Enhancement for MQTT Protocol Using Distributed Machine Learning Framework

The Message Queuing Telemetry Transport (MQTT) protocol stands out as one of the foremost and widely recognized messaging protocols in the field. It is often used to transfer and manage data between devices and is extensively employed for applications ranging from smart homes and industrial automation to healthcare and transportation systems. However, it lacks built-in security features, thereby making it vulnerable to many types of attacks such as man-in-the-middle (MitM), buffer overflow, pre-shared key, brute force authentication, malformed data, distributed denial-of-service (DDoS) attacks, and MQTT publish flood attacks. Traditional methods for detecting MQTT attacks, such as deep neural networks (DNNs), k-nearest neighbor (KNN), linear discriminant analysis (LDA), and fuzzy logic, may exist. The increasing prevalence of device connectivity, sensor usage, and environmental scalability become the most challenging aspects that novel detection approaches need to address. This paper presents a new solution that leverages an H2O-based distributed machine learning (ML) framework to improve the security of the MQTT protocol in networks, particularly in IoT environments. The proposed approach leverages the strengths of the H2O algorithm and architecture to enable real-time monitoring and distributed detection and classification of anomalous behavior (deviations from expected activity patterns). By harnessing H2O’s algorithms, the identification and timely mitigation of potential security threats are achieved. Various H2O algorithms, including random forests, generalized linear models (GLMs), gradient boosting machine (GBM), XGBoost, and the deep learning (DL) algorithm, have been assessed to determine the most reliable algorithm in terms of detection performance. This study encompasses the development of the proposed algorithm, including implementation details and evaluation results. To assess the proposed model, various evaluation metrics such as mean squared error (MSE), root-mean-square error (RMSE), mean per class error (MCE), and log loss are employed. The results obtained indicate that the H2OXGBoost algorithm outperforms other H2O models in terms of accuracy. This research contributes to the advancement of secure IoT networks and offers a practical approach to enhancing the security of MQTT communication channels through distributed detection and classification techniques

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

Background: Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.Methods: This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.Results: A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 percent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 percent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 percent; however, it was 41 per cent in low-to-middle-compared with 19 per cent in very high-HDI countries.Conclusion: Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761)