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

QRS fragmentation versus QRS prolongation in predicting right ventricular enlargement and dysfunction in children and adults with repaired Tetralogy of Fallot

Patients with repaired Tetralogy of Fallot (rTOF) have risks of late life-threatening sequelae, including right ventricular (RV) dilation and failure, arrhythmias, and sudden death. QRS prolongation is a well-known ECG predictor of these outcomes but has poor sensitivity for mortality. Growing evidence demonstrates QRS fragmentation (fQRS) as a better prognostic marker for mortality in adults with rTOF, though the two markers have not been directly compared as correlates for CMR abnormalities. Additionally, fQRS has never been studied in pediatric TOF. This single institution retrospectively reviewed 138 CMRs in rTOF patients (median age 21.7 years) who had a corresponding 12-lead ECG within 1 year. fQRS was defined as ≥3 R-waves/notches in the R/S complex (>2 in right bundle branch block) in ≥2 contiguous leads. QRS prolongation was defined as QRS ≥160 ms. Nearly half (46%) the sample had fQRS (42.1% of pediatric subgroup), and 26% had QRS prolongation. Both markers were significantly associated with reduced RV ejection fraction (EF%) (p < 0.01) and larger RV end-diastolic volumes (p < 0.01). QRS prolongation alone predicted lower LV EF% (p = 0.02). Regression analyses showed both QRS prolongation (p < 0.01) and fQRS (p < 0.01) independently associated with reduced RV EF%; QRS prolongation alone predicted RV dilation (p < 0.01). We concluded that both QRS prolongation and fQRS are equivalent as significant markers of RV dysfunction in rTOF patients. QRS prolongation may be a better surrogate for RV dilation specifically. fQRS was frequently seen in children with rTOF and was significantly associated with similar late structural sequelae

Phenotypic scores for disease severity (DS) at LSU, UFL and MN locations and phenotypic scores for infection reaction (IR) and coefficient of infection (CI) at LSU and UFL locations in the RIL population.

The y-axis in each plot represents the number of lines from the population that display scores shown in the x-axis, while locations are shown on the right y-axis; LSU = Louisiana State University Central Research Station in Baton Rouge, LA, UFL = University of Florida crown rust field nursery in Gainesville, FL, MN = University of Minnesota Matt Moore buckthorn nursery in Saint Paul, MN. Mean score of the parents is indicated in the legend.</p

Fig 1 -

Avena strigosa primary leaf infection type (IT) phenotypes inoculated with two Pca races TTTG and QTGB and shown 14 dpi; A. Susceptible parent, PI573582, with IT 4 B and C. PI 258731 carrying resistance with two different IT: “; N” (TTTG) and “0N” (QTRG).</p

Fig 3 -

a. Genetic linkage map of Pc (TTTG) resistance constructed with Illumina 6K SNPs and oat F5:6 RILs derived from a cross between PI 258731 and PI 573582. The flanking SNP markers are highlighted in red color. b. Genetic linkage map of Pc (QTRG) resistance constructed with Illumina 6K SNPs and oat F5:6 RILs derived from a cross between PI 258731 and PI 573582. The flanking SNP markers are highlighted in red color.</p