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

Los vasos capilares mallados encontrados en imágenes de banda estrecha sin aumento óptico identifican efectivamente la neoplasia colorrectal: una validación norteamericana de la experiencia japonesa

15 páginasBackground The presence of meshed capillary (MC) vessels is highly sensitive (96%) and specific (92%) for diagnosing colorectal neoplasia on colonoscopy by using narrow-band imaging (NBI) with optical magnification, which is not available in North America. However, the efficacy of NBI to identify an MC pattern without optical magnification has not been determined. Objective To determine the diagnostic capabilities of NBI colonoscopy without optical magnification in differentiating neoplastic from non-neoplastic colorectal polyps by using the MC pattern. Design Retrospective comparison of prospectively collected colorectal polyp data. Setting Large, academic medical center. Patients This study involved 126 consecutive colorectal polyps (median size 3 mm) that were found in 52 patients (33 men) with a median age of 59.5 years. Intervention All lesions identified by white-light colonoscopy were prospectively diagnosed in real-time by using the MC pattern as determined on high-definition NBI, with 1.5× zoom but without true optical magnification, and then endoscopically excised. Surgical pathology was used as the criterion standard. Main outcome measurements Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of identifying neoplastic polyps were calculated. Results NBI without optical magnification was found to have a sensitivity of 93%, specificity of 88%, positive predictive value of 90%, negative predictive value of 91%, and diagnostic accuracy of 91% when all polyp sizes were considered. For lesions ≤5 mm, sensitivity was 87%, specificity was 93%, positive predictive value was 89%, negative predictive value was 91%, and diagnostic accuracy was 90%. Limitations Single-center, single-endoscopist experience. Conclusion Use of the MC pattern on NBI colonoscopy without optical magnification effectively distinguishes neoplastic from non-neoplastic colorectal polyps. NBI colonoscopy without optical magnification for neoplastic polyp diagnosis appears to be comparable with NBI with optical magnification when the MC pattern is used. A large, prospective trial is needed for further validation.Fondo La presencia de vasos capilares mallados (MC) es muy sensible (96 %) y específica (92 %) para diagnosticar neoplasia colorrectal en la colonoscopia mediante el uso de imágenes de banda estrecha (NBI) con aumento óptico, que no está disponible en América del Norte. Sin embargo, no se ha determinado la eficacia de NBI para identificar un patrón de MC sin aumento óptico. Objetivo Determinar las capacidades diagnósticas de la colonoscopia NBI sin aumento óptico para diferenciar los pólipos colorrectales neoplásicos de los no neoplásicos mediante el uso del patrón MC. Diseño Comparación retrospectiva de datos de pólipos colorrectales recopilados prospectivamente. Configuración Gran centro médico académico. Pacientes Este estudio involucró 126 pólipos colorrectales consecutivos (tamaño medio 3 mm) que se encontraron en 52 pacientes (33 hombres) con una edad media de 59,5 años. Intervención Todas las lesiones identificadas mediante colonoscopia de luz blanca se diagnosticaron prospectivamente en tiempo real utilizando el patrón MC determinado en NBI de alta definición, con zoom de 1,5x pero sin aumento óptico real, y luego se extirparon endoscópicamente. La patología quirúrgica se utilizó como estándar de criterio. Mediciones de resultados principales Se calcularon la sensibilidad, la especificidad, el valor predictivo positivo, el valor predictivo negativo y la precisión para identificar pólipos neoplásicos. Resultados Se encontró que la NBI sin aumento óptico tiene una sensibilidad del 93 %, una especificidad del 88 %, un valor predictivo positivo del 90 %, un valor predictivo negativo del 91 % y una precisión diagnóstica del 91 % cuando se consideraron todos los tamaños de pólipos. Para lesiones ≤5 mm, la sensibilidad fue del 87 %, la especificidad del 93 %, el valor predictivo positivo del 89 %, el valor predictivo negativo del 91 % y la precisión diagnóstica del 90 %. Limitaciones Experiencia de un solo centro, un solo endoscopista. Conclusión El uso del patrón MC en la colonoscopia NBI sin aumento óptico distingue de manera eficaz los pólipos colorrectales neoplásicos de los no neoplásicos. La colonoscopia NBI sin aumento óptico para el diagnóstico de pólipos neoplásicos parece ser comparable con la NBI con aumento óptico cuando se usa el patrón MC. Se necesita un gran ensayo prospectivo para una mayor validación