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

Utilisation des paramétres physiques pour la caractérisation de la véraison des baies de raisin

National audienc

Fermeté et maturation du raisin. Définition et évolution de différents paramètres rhéologiques au cours de la maturation

National audienc

Firmness and grape berry maturation. Definition of different rheological parameters during the ripening

Mechanical properties of Shiraz and Gamay grape berries were studied in relation with their maturity state using the PenelaupTM rheometer. The analysis of the constrains registered during berry crushing with the flat tool of the device, up to the pellicular tearing, allowed the definition of different rheological parameters and the characterisation of mechanical behaviour of grape and its evolution with the degree of ripening. The analysis of the deformability curves shows, independently of the cultivar, that berry behaviour is not elastical except for some berries at the beginning and at the end of the ripening. This behaviour can be characterised by two indexes expressing the curvature sense of deformability curves, the curvature degree in a way reflecting the turgescence state of the grape. Berry firmness was also considered in two different ways: the initial firmness which represents the elasticity coefficient of the fruit at the beginning of the deformation, and the bursting firmness which can be considered as the pellicular elasticity coefficient. Others parameters, as the pellicular strength which can be expressed from the value of the displacement at berry bursting and the energy used for the deformation were also defined. The evolution of these different parameters during ripening confirms that berry softening at the véraison time depends on the cultivar and on environmental conditions as the vintage. The analysis of the evolutions also indicates that pellicular strength is maximum at this crucial period of berry development

Prévention et traitement du rejet vasculaire chronique par le sirolimus et le mycophénolate mofétil dans un modèle de greffe aortique chez le primate

L'objectif de cette étude était d'évaluer l'effet du Sirolimus (SRL) dans la prévention du rejet vasculaire chronique (RCV) et du Mycophénolate Mofétil (MMF) dans le traitement des lésions avancées de RCV. Une allogreffe aortique a été effectuée chez 18 primates appariés (compatibles ABO, MLR discompatibles). Six primates étaient non traités, 6 étaient traités par le SRL depuis J0, et 6 autres primates étaient traités par le MMF à partir de J45. Le suivi était de 105 jours. La progression des lésions de RCV était e valuée par échographie intra-vasculaire en mesurant l'aire intimale (IA). Chez les primates traités par le SRL, IA était significativement plus faible que chez les contrôles. Chez les animaux traités par MMF, il n'y avait pas de différence significative de IA à J105 avec le groupe contrôle. Une corrélation significative était retrouvée entre la dose de MMF et le degré d'inhibition des lésions de RCV (r = 0.88, P = 0.0015). Le SRL donné en monothérapie est capable de prévenir le RCV chez les primates. En cas de bonne tolérance du MMF à dose élevée, un effet thérapeutique était observé.Graft vascular disease (GVD) remains the primary cause of immunologic graft failure. In this study we investigate whether Sirolimus (SRL) prevents the development of GVD in non-human primate (NHP)and whether delayed treatment with Mycophenolate Mofetil (MMF) halts progression of GVD. Infrarenal aortic segments were exchanged between MLR-mismatched, blood group-compatible NHPs (n = 18). Six NHPs were controls, 6 were treated with SRL starting on day 0, and 6 were treated with MMF starting on day 45. Follow-up was 105 days. Severity of GVD was determined every 3 weeks by intravascular ultrasound (IVUS). In grafts from SRL-treated NHPs, intimal area (IA) were significantly lower than for controls. In MMF-treated NHPs, IA was not significantly different than in the controls. A significant correlation between MMF tolerated dose and the inhibition of progression of IV was found (r = 0.88, P = 0.0015).We show that SRL monotherapy prevented GVD in NHP aortic allograft recipients, suggesting the value of SRL for controlling GVD in clinical transplantation. When high MMF doses were tolerated, MMF slowed progression of GVD.TOULOUSE3-BU Sciences (315552104) / SudocSudocFranceF

Modélisation probabiliste de la qualité d'un vignoble et modélisation déterministe de la qualité d'un vin : premières approches

UMR AGAP - équipe DAAV (Diversité, adaptation et amélioration de la vigne)Evaluer de façon objective la qualité d'un vignoble n’est pas toujours simple. Nous avons conçu un modèle probabiliste qui prend en compte les paramètres définissant le statut de la vigne avec leurs interactions associées. Basé sur un réseau bayésien défini par des experts, il utilise un logiciel de calcul d’inférences. Les données ont été recueillies auprès d’experts pour chaque variable du réseau. Ainsi, 661 cépages ont été évalués et ces résultats sont utilisés par le système. Aucun modèle probabiliste similaire n’avait été développé auparavant. Ce système devrait faciliter l’évaluation de l’impact probable des choix et des décisions des vignerons sur la qualité des vignes à planter dans n’ importe quelle partie du monde.[br/]Prédire la qualité d'un vin est une tâche complexe étant donné le grand nombre de facteurs à prendre en compte simultanément et leurs interactions. Ce travail est une première approche déterministe. Il utilise un ensemble très important de données recueillies dans un vignoble ainsi que l’expertise associée à ces données pendant plusieurs décennies. Dans cette approche, nous avons utilisé les méthodes de l’algèbre linéaire pour représenter la qualité du vin à travers plusieurs sous-modèles. Créé pour les situations étudiées (Châteauneuf du Pape, Côtes du Rhône, Rasteau), ce modèle d'experts n’est pas directement applicable à d'autres situations maispourra servir de référence pour d'autres étude

Randomized study of reduced-intensity chemotherapy combined with imatinib in adults with Ph-positive acute lymphoblastic leukemia.

In this study, we randomly compared high doses of the tyrosine kinase inhibitor imatinib combined with reduced-intensity chemotherapy (arm A) to standard imatinib/hyperCVAD (cyclophosphamide/vincristine/doxorubicin/dexamethasone) therapy (arm B) in 268 adults (median age, 47 years) with Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL). The primary objective was the major molecular response (MMolR) rate after cycle 2, patients being then eligible for allogeneic stem cell transplantation (SCT) if they had a donor, or autologous SCT if in MMolR and no donor. With fewer induction deaths, the complete remission (CR) rate was higher in arm A than in arm B (98% vs 91%; P = .006), whereas the MMolR rate was similar in both arms (66% vs 64%). With a median follow-up of 4.8 years, 5-year event-free survival and overall survival (OS) rates were estimated at 37.1% and 45.6%, respectively, without difference between the arms. Allogeneic transplantation was associated with a significant benefit in relapse-free survival (hazard ratio [HR], 0.69; P = .036) and OS (HR, 0.64; P = .02), with initial white blood cell count being the only factor significantly interacting with this SCT effect. In patients achieving MMolR, outcome was similar after autologous and allogeneic transplantation. This study validates an induction regimen combining reduced-intensity chemotherapy and imatinib in Ph+ ALL adult patients and suggests that SCT in first CR is still a good option for Ph+ ALL adult patients. This trial was registered at www.clinicaltrials.gov as #NCT00327678

J Am Soc Nephrol

Shiga toxin-related hemolytic uremic syndrome (STEC-HUS) is a serious condition, characterized by multiorgan thrombotic microangiopathy, mainly affecting children. Renal involvement is severe, with approximately half of patients requiring dialysis. So far, no specific treatment has been proven efficient in STEC-HUS. The use of eculizumab, a monoclonal antibody inhibiting terminal complement complex, has demonstrated remarkable success in atypical hemolytic uremic syndrome, but its use in uncontrolled studies to treat STEC-HUS has yielded inconsistent results. In this Phase 3 randomized, placebo-controlled trial in 100 pediatric patients with STEC-HUS, the findings did not show efficacy of eculizumab during the acute phase of the disease. However, the results indicated a reduction of renal sequelae in eculizumab-treated patients at 1-year follow-up. Larger prospective studies would be needed to further explore eculizumab as a potential treatment. Shiga toxin-related hemolytic uremic syndrome (STEC-HUS) in children is a severe condition, resulting in approximately 50% of patients requiring RRT. Furthermore, at least 30% of survivors experience kidney sequelae. Recently, activation of the complement alternative pathway has been postulated as a factor in STEC-HUS pathophysiology, leading to compassionate use of eculizumab, a monoclonal antibody inhibiting the terminal complement complex, in affected patients. Given the lack of therapy for STEC-HUS, a controlled study of eculizumab efficacy in treating this condition is a priority. We conducted a Phase 3 randomized trial of eculizumab in children with STEC-HUS. Patients were randomly assigned in a 1:1 ratio to receive either eculizumab or placebo during 4 weeks. Follow-up lasted for 1 year. The primary end point was RRT duration <48 hours after randomization. Secondary endpoints included hematologic and extrarenal involvement. Baseline characteristics were similar among the 100 patients who underwent randomization. The rate of RRT <48 hours did not differ significantly between the two groups (48% in the placebo versus 38% in the eculizumab group; P = 0.31) or in the course of ARF. The two groups also exhibited similar hematologic evolution and extrarenal manifestations of STEC-HUS. The proportion of patients experiencing renal sequelae at 1 year was lower in the eculizumab group than in the placebo group (43.48% and 64.44%, respectively, P = 0.04). No safety concern was reported. In pediatric patients with STEC-HUS, eculizumab treatment does not appear to be associated with improved renal outcome during acute phase of the disease but may reduce long-term kidney sequelae. EUDRACT (2014-001169-28) ClinicalTrials.gov ( NCT02205541 )