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

Aortailiak Anevrizma İçin İnternal İliak Arter Oklüzyonu İle Endovasküler Aort Onarımı

Endovasküler aort onarımı (EVAR) yapılan aorto iliak anevrizma hastaları, endogra ı external iliak artereuzattıktan sonra tip II endoleak oluşumunu önlemekiçin vaskuler plak ile internal iliak arter tıkanması vestent gre le kaplanmasını gerektirir.Bununla birlikteinternal iliak arter oklüzyonu pelvik iskemi nedeniylekalça kaldikasyonuna ve diğer çeşitli sekellere nedenolmaktadır.A.iliaca externa ve A.iliaca interna arasında anastomazoluşturan arterler A. gluteainferior,a.circum exa femoris medialis,A.perforans ve A.iliaca externanın A.epigastrıca inferior dalı ile A. iliaca internanın A.obturatarıos dalı arasındadır.Özellikle A. glutea superıor ve a.glutea inferior arterarasında ki bağlantının herhangi bir nedenle tıkanmasıpelvik kladikasyona neden olmaktadır.Kliniğimize de bilinen ht+ astım + mevcut 75 yaşındahasta epigastrik ağrı nedeniyle başvurdu. Çekilen Bt anjiyogra de abdominal arter en geniş yerinde 57 mm, SolA. iliaca en geniş yerinde 59 mm anevrizma mevcuttu.Tip 2 endoleak gelişmemesi açısından endovaskülergre imizi yerleştirmeden önce sol internal iliac artervaskuler plak ile kapatıldı.Daha sonra bifükarsyonlumoduler endovaskuler gre imiz implante edidi. Komplikasyon gelişmedi. Kontrollerinde herhangi bir şikayetiolmadı</p

Idiyopatik Renal Arteriyovenöz Fistül

Kazanılmış, idiyopatik ve doğuştan olarak sınıflanan arteriyovenöz fistüller böbreklerde nadir görülen ve genelde parankim içinde olan lezyonlardır.Renal arteriyovenöz fistül insidansı değişkendir.Doğal renallerde %0,3-%1,9,renal transplantlılarda %6-8 olarak tahmin edilmektedir.Vakaların %70 iyatrojenik ve %20 si konjenitaldir.Arteriyovenözfistüllerin tedavinde ki en büyük endikasyon yüksek debili kalpyetmezliğine neden olmasıdır. Bu vakada da kalp yetmezliğinin tedavisi amacıyla arteriyovenöz fistül kapatılması yapılmıştır.53 yaşında erkek hasta karın ağrısı ve uzun süredir devam eden nefes darlığı şikayetiyle başvurdu. Hastanın yapılan muayanesinde batında devamlı üfürüm tespit edilmesi üzerine Çekilen BT anjiyografide sağ renal ven belirgin geniş olup,arteriyal fazda dolum göstermektedir.İnferior vena kavaya boşalmaktadır. Bu özelliklerin sağ renal arter ve renal ven arasında A-V fistülle uyumlu olarak değerlendirilmiştir.Hasta mevcut kliniği ile A-V fistül kapatılmak üzere işleme alındı. 10 mm vasküler plug implante edildi. Hastanın takibinde çekilen BT de A-V fistülün tamamen kapandığı gösterildi.</p

Endothelial Progenitor Cells and NADPH Oxidase Enzyme Activity in the Development of an Aortic Aneurysm.

INTRODUCTION: Endothelial progenitor cells (EPCs) and nicotinamide adenine dinucleotide phosphate (NADPH) oxidase enzyme activity may affect the vessel wall and have a role in development of aortic aneurysms. EPCs originate from hematopoietic stem cells and can be enumerated from peripheral blood samples by flow cytometry. In this study, we aimed to evaluate the relation of EPC number and NADPH oxidase enzyme activity in the development of thoracic aortic aneurysm (TAA). METHODS: Patients with TAA (n=30) and healthy individuals without TAA (control, n=10) were included in our study. Characterization and enumeration of EPC from peripheral blood samples were performed by flow cytometry with panels including markers of EPCs (CD34/CD133/CD309/CD146/CD144). Additionally, NADPH oxidase enzyme activity (capacity) was also measured by the dihydrorhodamine 123 (DHR 123) test. RESULTS: The enumeration of EPC with CD34+/CD146+ marker showed that the number of mean EPC/106 cells was increased in the patient group (41.5/106 cells), but not in the control group (20.50/105 cells) (P<0.01). Additionally, patients with TAA presented significantly lower NADPH oxidase activity by DHR assay than healthy controls (mean stimulation index: 60.40± 7.86 and 75.10±5.21, respectively) (P<0.01). CONCLUSION: Our results showed that the number of EPCs is significantly higher in aortic aneurysm patients and may have a role in disease progression. The crosstalk between NADPH oxidase enzyme capacity and EPC number may be useful as a parameter to explain the clinical progression of TAA

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit