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

Early mobilisation in critically ill COVID-19 patients: a subanalysis of the ESICM-initiated UNITE-COVID observational study

Background Early mobilisation (EM) is an intervention that may improve the outcome of critically ill patients. There is limited data on EM in COVID-19 patients and its use during the first pandemic wave. Methods This is a pre-planned subanalysis of the ESICM UNITE-COVID, an international multicenter observational study involving critically ill COVID-19 patients in the ICU between February 15th and May 15th, 2020. We analysed variables associated with the initiation of EM (within 72 h of ICU admission) and explored the impact of EM on mortality, ICU and hospital length of stay, as well as discharge location. Statistical analyses were done using (generalised) linear mixed-effect models and ANOVAs. Results Mobilisation data from 4190 patients from 280 ICUs in 45 countries were analysed. 1114 (26.6%) of these patients received mobilisation within 72 h after ICU admission; 3076 (73.4%) did not. In our analysis of factors associated with EM, mechanical ventilation at admission (OR 0.29; 95% CI 0.25, 0.35; p = 0.001), higher age (OR 0.99; 95% CI 0.98, 1.00; p ≤ 0.001), pre-existing asthma (OR 0.84; 95% CI 0.73, 0.98; p = 0.028), and pre-existing kidney disease (OR 0.84; 95% CI 0.71, 0.99; p = 0.036) were negatively associated with the initiation of EM. EM was associated with a higher chance of being discharged home (OR 1.31; 95% CI 1.08, 1.58; p = 0.007) but was not associated with length of stay in ICU (adj. difference 0.91 days; 95% CI − 0.47, 1.37, p = 0.34) and hospital (adj. difference 1.4 days; 95% CI − 0.62, 2.35, p = 0.24) or mortality (OR 0.88; 95% CI 0.7, 1.09, p = 0.24) when adjusted for covariates. Conclusions Our findings demonstrate that a quarter of COVID-19 patients received EM. There was no association found between EM in COVID-19 patients' ICU and hospital length of stay or mortality. However, EM in COVID-19 patients was associated with increased odds of being discharged home rather than to a care facility. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021)

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

CT perfusion in evaluation of post therapy cervical lymphoma

Objective: Compare CT perfusion between responders and non-responders in patients with residual cervical nodes after lymphoma treatment. Subjects and methods: Twenty-seven patients with treated pathologically proved lymphoma were included in this prospective study, divided into two groups: responders (n. 15) and non-responders to treatment (n. 12). Blood flow (BF), blood volume (BV), mean transit time (MTT) and permeability (PS) were determined using CT perfusion. Lymph nodes sizes were measured (short axis). Results: BF, BV and PS were significantly higher in non-responders group [93.3 (65.3–111) ml/min/100 g, 6.3 (5.2–8) ml/100 g and 18.9 (14.5–25.1) ml/min/100 g respectively] as compared to responders group [54 (43.8–77.5) ml/min/100 g, 4.1 (2.2–4.8) ml/100 g and 9.4 (7.5–14.5) ml/min/100 g respectively], [p 0.019, 0.004 and 0.004 respectively]. MTT had a trend to be low in non-responders group, but did not reach statistical significance (p 0.305). Cutoff value for BF, BV and PS was 59.5 ml/min/100 g, 3.6 ml/100 g and 11.1 ml/min/100 g respectively, 92% sensitivity for the three parameters and specificity 67%, 47% and 73% respectively. Lymph node sizes had no relation to the perfusion parameter values. Conclusion: CT perfusion is a functional imaging tool with promising results in differentiating between responders and non-responders in treated lymphoma patients, using BF, BV and PS

The risk of adverse coronary events is higher in patients with severe obstructive sleep apnea following percutaneous coronary intervention

BACKGROUND: Limited data is available on the impact of obstructive sleep apnea (OSA) or continuous positive airway pressure (CPAP) therapy on coronary events or mortality in patients undergoing percutaneous coronary intervention (PCI). METHODS: From a multispecialty community sleep center, patients undergoing polysomnography (PSG) from 2011 to 2014 were identified. Of these, those who had PCI performed after PSG were included in this analysis. Coronary events (myocardial infarction or redo PCI), mortality or composite endpoint (MI, redo PCI and death) after PCI was compared between those with severe OSA (apnea-hypopnea index [AHI] 330) or non-severe OSA (AHI\u3c30) using Wilcoxon, Chi square test, and Kaplan-Meier analysis. Predictors of composite and individual end points were determined using proportional hazard cox model. RESULTS: The cohort consisted of 222 patients (mean age 63.2±11.3 years, 70% male) of whom 39% had severe OSA, 24% moderate OSA, 28 mild OSA and 9% had no OSA. The composite endpoint after PCI was significantly higher in those with severe OSA, compared to those with non-severe OSA (36% vs 24%, hazard ratio: 1.8, 95% CI: 1.1-2.9; p-value: 0.02, Fig). Multivariate analysis showed severity of OSA, MI and age\u3e65 as independent predictors for composite endpoints. (Fig) CONCLUSIONS: Severe OSA has a negative impact on coronary event rate after PCI. Whether treating OSA with CPAP therapy helps reduce these events needs to be further investigated

Outcome study of the Pipeline Vantage Embolization Device (second version) in unruptured (and ruptured) aneurysms (PEDVU(R) study)

Background The Pipeline Vantage Embolization Device (PEDV) is the fourth-generation pipeline flow diverter for intracranial aneurysm treatment. There are no outcome studies for the second PEDV version. We aimed to evaluate safety and efficacy outcomes. Primary and secondary objectives were to determine outcomes for unruptured and ruptured cohorts, respectively.Methods In this multicenter retrospective and prospective study, we analyzed outcome data from eight centers using core laboratory assessments. We determined 30-day and ≥3-month mortality and morbidity rates, and 6- and 18-month radiographic aneurysm occlusion rates for procedures performed during the period July 2021–March 2023.Results We included 121 consecutive patients with 131 aneurysms. The adequate occlusion rate for the unruptured cohort at short-term and medium-term follow up, and also for the ruptured cohort at short-term follow up, was >90%. Two aneurysms (1.5%) underwent retreatment. When mortality attributed to a palliative case in the unruptured cohort, or subarachnoid hemorrhage in the ruptured cohort, was excluded then the overall major adverse event rate in respective cohorts was 7.5% and 23.5%, with 0% mortality rates for each. When all event causes were included on an intention-to-treat basis, the major adverse event rates in respective cohorts were 8.3% and 40.9%, with 0.9% and 22.7% mortality rates.Conclusions For unruptured aneurysm treatment, the second PEDV version appears to have a superior efficacy and similar safety profile to previous-generation PEDs. These are acceptable outcomes in this pragmatic and non-industry-sponsored study. Analysis of ruptured aneurysm outcomes is limited by cohort size. Further prospective studies, particularly for ruptured aneurysms, are needed

Regional variations in antimicrobial susceptibility of community-acquired uropathogenic Escherichia coli in India: findings of a multicentric study highlighting the importance of local antibiograms

Background: Evidence-based prescribing is essential to optimise patient outcomes in cystitis. This requires knowledge of local antibiotic resistance rates. DASH to Protect Antibiotics (https://dashuti.com/) is a multicentric mentorship programme guiding centres in preparing, analysing and disseminating local antibiograms to promote antimicrobial stewardship in community UTI. Here we map the susceptibility profile of Escherichia coli from 22 Indian centres. Methods: These centres spanned 10 Indian States and three Union Territories. Antibiograms for urinary E. coli from the outpatient departments were collated. Standardisation was achieved by regional online training; anomalies were resolved via consultation with study experts. Data were collated and analysed. Findings: Nationally, fosfomycin, with 94% susceptibility (inter-centre range 83-97%), and nitrofurantoin with 85% susceptibility (61-97%) retained widest activity. Susceptibility rates were lower for co-trimoxazole (49%), fluoroquinolones (31%) and oral cephalosporins (26%). Rates for third- and fourth- generation cephalosporins were 46% and 52%, respectively, with 54% (33-58%) ESBL prevalence. Piperacillin-tazobactam (81%) amikacin (88%), meropenem (88%) retained better activity, but one centre in Delhi recorded only 42% meropenem susceptibility. Susceptibility rates were mostly higher in South, West and Northeast India; centres in the heavily-populated Gangetic plains, across North and Northwest India, had greater resistance. These findings highlight the importance of local antibiograms in guiding appropriate antimicrobial choices. Interpretation: Fosfomycin and nitrofurantoin are the preferred oral empirical choices for uncomplicated E. coli cystitis in India, though elevated resistance in some areas is concerning. Empiric use of fluoroquinolones and third generation cephalosporins is discouraged whereas piperacillin/tazobactam and aminoglycosides remain carbapenem-sparing parenteral agents