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

Sarco-IO : étude des facteurs de risque associés à la survenue d'une infection opportuniste chez les patients porteurs de sarcoïdose/thèse présentée pour le diplôme d'État de docteur en médecine, diplôme d'État, mention médecine interne

Médecine interneUn nombre important d'infections opportunistes (IO) chez les patients atteints de sarcoïdose a été décrit dans la littérature médicale jusqu'à présent, mais sans explication claire. Nous avons réalisé une revue de la littérature médicale sur la base de données Medline via PubMed incluant tous les cas d'IO à l'exclusion de l'aspergillose et de la tuberculose et une étude rétrospective par le biais d'un appel à observations d'IO chez des patients atteints de sarcoïdose à travers la France. Dans notre revue de la littérature, un total de 181 IO ont été identifiées. Les IO les plus fréquemment rapportées étaient des cryptococcoses (N=84 ; 42%). 49 patients ont été inclus dans l'étude et comparés à une population de 136 patients témoins atteints de sarcoïdose et sans IO. Les lymphadénopathies périphériques (OR=3.45 [1.59;7.54], p=0.002), la splénomégalie (OR=8.80 [2.12;46.3], p=0,003), l’atteinte pulmonaire parenchymateuse (OR=6.57 [2.98;16.2], p-0.001), l’atteinte du système nerveux central (OR=8.48 [2.28;42.4], p=0.001), l’utilisation de corticostéroïdes (OR=10.1 [4.43;26.5], p-0.001) ou de cyclophosphamide et d’anti TNFα (respectivement OR=9.00 [1.92 ;70.0] et OR=7.37 [1.46 ;59.0]) étaient statistiquement associés à un risque accru d'IO. Les IO dans la sarcoïdose surviennent ainsi chez des patients dont la maladie est plus sévère et plus souvent traités par immunosuppresseurs. La différence en termes de présentation clinique initiale pourrait s’expliquer par une susceptibilité intrinsèque accrue de certains patients au développement d’infections opportunistesA significant number of opportunistic infections (OIs) in patients with sarcoidosis have been described in the medical literature to date, but without clear explanation. We performed a review of the medical literature on the Medline database via PubMed including all cases of OIs excluding aspergillosis and tuberculosis and a retrospective study through a call for observations of OIs in sarcoidosis patients across France. In our literature review, a total of 181 OIs were identified. The most frequently reported OIs were cryptococcosis (N=84; 42%). 49 patients were included in the study and compared to a population of 136 control patients with sarcoidosis and no OI. Peripheral lymphadenopathy (OR=3.45 [1.59;7.54], p=0.002), splenomegaly (OR=8.80 [2.12;46.3], p=0.003), parenchymal lung involvement (OR=6.57 [2.98;16.2], p-0.001), central nervous system involvement (OR=8.48 [2. 28;42.4], p=0.001), corticosteroid use (OR=10.1 [4.43;26.5], p-0.001) and cyclophosphamide and anti TNFα (OR=9.00 [1.92;70.0] and OR=7.37 [1.46;59.0], respectively) were statistically associated with an increased risk of OI. OIs in sarcoidosis thus occur in patients with more severe disease and more often treated with immunosuppressants. The difference in initial clinical presentation could be explained by an increased intrinsic susceptibility of some patients to the development of opportunistic infection

Challenging Mimickers in the Diagnosis of Sarcoidosis: A Case Study

Sarcoidosis is a systemic granulomatous disease of unknown cause characterized by a wide variety of presentations. Its diagnosis is based on three major criteria: a clinical presentation compatible with sarcoidosis, the presence of non-necrotizing granulomatous inflammation in one or more tissue samples, and the exclusion of alternative causes of granulomatous disease. Many conditions may mimic a sarcoid-like granulomatous reaction. These conditions include infections, neoplasms, immunodeficiencies, and drug-induced diseases. Moreover, patients with sarcoidosis are at risk of developing opportunistic infections or lymphoma. Reliably confirming the diagnosis of sarcoidosis and better identifying new events are major clinical problems in daily practice. To address such issues, we present seven emblematic cases, seen in our department, over a ten-year period along with a literature review about case reports of conditions misdiagnosed as sarcoidosis

Diagnosing Hemophagocytic Lymphohistiocytosis with Machine Learning: A Proof of Concept

Hemophagocytic lymphohistiocytosis is a hyperinflammatory syndrome characterized by uncontrolled activation of immune cells and mediators. Two diagnostic tools are widely used in clinical practice: the HLH-2004 criteria and the Hscore. Despite their good diagnostic performance, these scores were constructed after a selection of variables based on expert consensus. We propose here a machine learning approach to build a classification model for HLH in a cohort of patients selected by glycosylated ferritin dosage in our tertiary center in Lyon, France. On a dataset of 207 adult patients with 26 variables, our model showed good overall diagnostic performances with a sensitivity of 71.4% and high specificity, and positive and negative predictive values which were 100%, 100%, and 96.9%, respectively. Although generalization is difficult on a selected population, this is the first study to date to provide a machine-learning model for HLH detection. Further studies will be required to improve the machine learning model performances with a large number of HLH cases and with appropriate controls

Uveitis as an Open Window to Systemic Inflammatory Diseases

Spondyloarthritis (Spa), Behçet’s disease (BD) and sarcoidosis are major systemic inflammatory diseases worldwide. They are all multisystem pathologies and share a possible ocular involvement, especially uveitis. We hereby describe selected cases who were referred by ophthalmologists to our internal medicine department for unexplained uveitis. Physical examination and/or the use of laboratory and imaging investigations allowed to make a diagnosis of a systemic inflammatory disease in a large proportion of patients. In our tertiary referral center, 75 patients have been diagnosed with Spa (n = 20), BD (n = 9), or sarcoidosis (n = 46) in the last two years. There was a significant delay in the diagnosis of Spa-associated uveitis. Screening strategies using Human Leukocyte Antigen (HLA)-B27 determination and sacroiliac magnetic resonance imaging in patients suffering from chronic low back pain and/or psoriasis helped in the diagnosis. BD’s uveitis affects young people from both sexes and all origins and usually presents with panuveitis and retinal vasculitis. The high proportion of sarcoidosis in our population is explained by the use of chest computed tomography (CT) and 18F-fluorodeoxyglucose positron emission tomography CT that helped to identify smaller hilar or mediastinal involvement and allowed to further investigate those patients, especially in the elderly. Our results confirm how in these sight- and potentially life-threatening diseases a prompt diagnosis is mandatory and benefits from a multidisciplinary approach

Management of Non-Infectious Uveitis, a Selection of Topical Items Updating

First of all, we would like to thank all of the authors for their contributions and the editorial staff who enabled the achievement of this «Diagnosis and Management of Non-infectious Uveitis: Old and New Challenges» Special Issue [...

Sarcoidosis-Related Uveitis: A Review

Sarcoidosis is an inflammatory disease that involves the eyes in 10-55% of cases, sometimes without systemic involvement. All eye structures can be affected, but uveitis is the most common ocular manifestation and causes vision loss. The typical ophthalmological appearance of these uveitis is granulomatous (in cases with anterior involvement), which are usually bilateral and with synechiae. Posterior involvement includes vitritis, vasculitis and choroidal lesions. Tuberculosis is a classic differential diagnosis to be wary of, especially in people who have spent time in endemic areas. The diagnosis is based on histology with the presence of non-caseating epithelioid granulomas. However, due to the technical difficulty and yield of biopsies, the diagnosis of ocular sarcoidosis is often based on clinico-radiological features. The international criteria for the diagnosis of ocular sarcoidosis have recently been revised. Corticosteroids remain the first-line treatment for sarcoidosis, but up to 30% of patients require high doses, justifying the use of corticosteroid-sparing treatments. In these cases, immunosuppressive treatments such as methotrexate may be introduced. More recent biotherapies such as anti-TNF are also very effective (as they are in other non-infectious uveitis etiologies)

Le vieillissement est associé à une altération du déclenchement de la vasodilatation cutanée médiée par TRPV3 : un processus crucial pour l'exposition à la chaleur locale

International audienceSensing temperature is vitally important to adapt our body to environmental changes. Local warm detection is required to initiate regulation of cutaneous blood flow, which is part of the peripheral thermoregulatory mechanisms, and thus avoid damage to surrounding tissues. The mechanisms mediating cutaneous vasodilation during local heat stress are impaired with aging. However, the impact of aging on the ability of the skin to detect subtle thermal changes is unknown. Among heat-activated cation channels, transient receptor potential vanilloid 3 (TRPV3) is a thermosensor predominantly expressed on keratinocytes and involved in local vascular thermoregulatory mechanisms of the skin in young mice. In the present study, using a murine in vivo model of local heat exposure of the skin, we showed that heat-induced vasodilation was reduced in old mice associated with reduced expression of TRPV3 channels. We also found a decrease in expression and activity of TRPV3 channel, as well as reduced TRPV3-dependent adenosine tri-phosphate release in human primary keratinocytes from old donors. This study shows that aging alters the epidermal TRPV3 channels, which might delay the detection of changes in skin temperature, thereby limiting the mechanisms triggered for local vascular thermoregulation in the old skin.La détection de la température est d'une importance vitale pour adapter notre corps aux changements environnementaux. La détection de la chaleur locale est nécessaire pour initier la régulation du flux sanguin cutané, qui fait partie des mécanismes de thermorégulation périphérique, et ainsi éviter d'endommager les tissus environnants. Les mécanismes de médiation de la vasodilatation cutanée lors d'un stress thermique local sont altérés avec le vieillissement. Cependant, l'impact du vieillissement sur la capacité de la peau à détecter de subtils changements thermiques n'est pas connu. Parmi les canaux cationiques activés par la chaleur, le transient receptor potential vanilloid 3 (TRPV3) est un thermo-senseur principalement exprimé par les kératinocytes, et est impliqué dans les mécanismes de thermorégulation vasculaire cutanée locale chez les jeunes souris. Dans la présente étude, nous avons montré que la vasodilatation induite par une chaleur locale était réduite chez les souris âgées, et associée à une réduction de l'expression des canaux TRPV3. Nous avons également constaté une diminution de l'expression et de l'activité du canal TRPV3, ainsi qu'une réduction de la libération d'adénosine tri-phosphate dépendante du TRPV3 dans les kératinocytes primaires humains provenant de donneurs âgés. Cette étude montre que le vieillissement altère les canaux TRPV3 épidermiques, ce qui pourrait retarder la détection des changements de température cutanée, limitant ainsi les mécanismes de déclenchement de la thermorégulation vasculaire locale dans la peau âgée

Evaluation of Glycosylated Ferritin in Adult-Onset Still’s Disease and Differential Diagnoses

Glycosylated ferritin (GF) has been reported as a good diagnostic biomarker for adult-onset Still’s disease (AOSD), but only a few studies have validated its performance. We performed a retrospective study of all adult patients with at least one GF measurement over a 2-year period in one hospital laboratory. The diagnosis of AOSD was based on the expert opinion of the treating physician and validated by two independent investigators. Patients’ characteristics, disease activity, and outcome were recorded and compared. Twenty-eight AOSD and 203 controls were identified. Compared to controls, the mean GF was significantly lower (22.3% vs. 39.3, p < 0.001) in AOSD patients. GF had a high diagnostic accuracy for AOSD, independent of disease activity or total serum ferritin (AUC: 0.674 to 0.915). The GF optimal cut-off value for AOSD diagnosis was 16%, yielding a specificity of 89% and a sensitivity of 63%. We propose a modified diagnostic score for AOSD, based on Fautrel’s criteria but with a GF threshold of 16% that provides greater specificity and increases the positive predictive value by nearly 5 points. GF is useful for ruling out differential diagnoses and as an appropriate classification criterion for use in AOSD clinical trials

Extreme Hyperferritinemia: Causes and Prognosis

The significance of extreme hyperferritinemia and its association with certain diagnoses and prognoses are not well characterized. We performed a retrospective analysis of adult patients with at least one total serum ferritin (TSF) measurement ≥ 5000 µg/L over 2 years, in three university hospitals. Conditions associated with hyperferritinemia were collected, and patients were classified into 10 etiological groups. Intensive care unit (ICU) transfer and mortality rates were recorded. A total of 495 patients were identified, of which 56% had a TSF level between 5000 and 10,000 µg/L. There were multiple underlying causes in 81% of the patients. The most common causes were infections (38%), hemophagocytic lymphohistiocytosis (HLH, 18%), and acute hepatitis (14%). For TSF levels > 10,000 µg/L, there were no solid cancer or hematological malignancy without another cause of hyperferritinemia. Isolated iron-overload syndromes never exceeded TSF levels > 15,000 µg/L. Extreme hyperferritinemia (TSF levels > 25,000 µg/L) was associated with only four causes: HLH, infections, acute hepatitis and cytokine release syndromes. A total of 32% of patients were transferred to an ICU, and 28% died. Both ICU transfer rate and mortality were statistically associated with ferritin levels. An optimized threshold of 13,405 μg/L was the best predictor for the diagnosis of HLH, with a sensitivity of 76.4% and a specificity of 79.3%. Hyperferritinemia reflects a variety of conditions, but only four causes are associated with extreme hyperferritinemia, in which HLH and acute hepatitis are the most common. Extreme hyperferritinemia has a poor prognosis with increased mortality