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

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Electrochemical treatment of wastewater charged with emerging pollutants using innovative and cost controlled anodes

De nos jours, la contamination des eaux par les résidus de médicaments représente une grande menace pour l’écosystème. Face à cette situation, la dépollution des eaux usées par les procédés d'oxydation avancée est une des solutions pour contourner ce problème. Dans le cadre de cette thèse, l’oxydation anodique a été utilisée comme technique de traitement électrochimique pour la dégradation de l’ampicilline. Des anodes à base d’oxydes métalliques ont été développées sur des substrats en acier inoxydable au moyen de différentes techniques de dépôt : électrodéposition et méthode sol-gel spin-coating et dip-coating. L’introduction d’une couche interne ainsi que le dopage de la couche externe modifient les propriétés morphologiques, structurales et électrochimiques de l’anode et contribuent à améliorer son activité électrocatalytique. De plus, l’augmentation de la surface active par le développement d’anodes sur des substrats grilles ou par la photostructuration de la couche interne ont permis d’obtenir une efficacité optimale de dégradation de l’ampicilline à plus faible coût.Nowadays, the contamination of water by drug residues represents a real threat to the ecosystem. Faced with this situation, the depollution of wastewater by advanced oxidation processes is one of the solutions to overcome this problem. In this thesis, anodic oxidation was used as an electrochemical treatment technique for the degradation of ampicillin. Metal oxide anodes have been developed on stainless steel substrates using different deposition techniques: electrodeposition and sol-gel spin-coating and dip-coating. The introduction of an inner layer as well as doping the outer layer modify the morphological, structural and electrochemical properties of the anode and contribute to improving its electrocatalytic activity. Moreover, the increase of the active surface by the development of anodes on grid substrates or by photostructuring the inner layer allowed to obtain an optimal efficiency of ampicillin degradation at lower cost

Traitement électrochimique des eaux usées chargées en polluants émergents utilisant des anodes innovantes à coût maîtrisé

Nowadays, the contamination of water by drug residues represents a real threat to the ecosystem. Faced with this situation, the depollution of wastewater by advanced oxidation processes is one of the solutions to overcome this problem. In this thesis, anodic oxidation was used as an electrochemical treatment technique for the degradation of ampicillin. Metal oxide anodes have been developed on stainless steel substrates using different deposition techniques: electrodeposition and sol-gel spin-coating and dip-coating. The introduction of an inner layer as well as doping the outer layer modify the morphological, structural and electrochemical properties of the anode and contribute to improving its electrocatalytic activity. Moreover, the increase of the active surface by the development of anodes on grid substrates or by photostructuring the inner layer allowed to obtain an optimal efficiency of ampicillin degradation at lower cost.De nos jours, la contamination des eaux par les résidus de médicaments représente une grande menace pour l’écosystème. Face à cette situation, la dépollution des eaux usées par les procédés d'oxydation avancée est une des solutions pour contourner ce problème. Dans le cadre de cette thèse, l’oxydation anodique a été utilisée comme technique de traitement électrochimique pour la dégradation de l’ampicilline. Des anodes à base d’oxydes métalliques ont été développées sur des substrats en acier inoxydable au moyen de différentes techniques de dépôt : électrodéposition et méthode sol-gel spin-coating et dip-coating. L’introduction d’une couche interne ainsi que le dopage de la couche externe modifient les propriétés morphologiques, structurales et électrochimiques de l’anode et contribuent à améliorer son activité électrocatalytique. De plus, l’augmentation de la surface active par le développement d’anodes sur des substrats grilles ou par la photostructuration de la couche interne ont permis d’obtenir une efficacité optimale de dégradation de l’ampicilline à plus faible coût

Elaboration of Highly Modified Stainless Steel/Lead Dioxide Anodes for Enhanced Electrochemical Degradation of Ampicillin in Water

Lead dioxide-based electrodes have shown a great performance in the electrochemical treatment of organic wastewater. In the present study, modified PbO2 anodes supported on stainless steel (SS) with a titanium oxide interlayer such as SS/TiO2/PbO2 and SS/TiO2/PbO2-10% Boron (B) were prepared by the sol–gel spin-coating technique. The morphological and structural properties of the prepared electrodes were characterized by scanning electron microscopy (SEM), energy-dispersive X-ray spectroscopy (EDX), and X-ray photoelectron spectroscopy (XPS). It was found that the SS/TiO2/PbO2-10% B anode led to a rougher active surface, larger specific surface area, and therefore stronger ability to generate powerful oxidizing agents. The electrochemical impedance spectroscopy (EIS) measurements showed that the modified PbO2 anodes displayed a lower charge transfer resistance Rct. The influence of the introduction of a TiO2 intermediate layer and the boron doping of a PbO2 active surface layer on the electrochemical degradation of ampicillin (AMP) antibiotic have been investigated by chemical oxygen demand measurements and HPLC analysis. Although HPLC analysis showed that the degradation process of AMP with SS/PbO2 was slightly faster than the modified PbO2 anodes, the results revealed that SS/TiO2/PbO2-10%B was the most efficient and economical anode toward the pollutant degradation due to its physico-chemical properties. At the end of the electrolysis, the chemical oxygen demand (COD), the average current efficiency (ACE) and the energy consumption (EC) reached, respectively, 69.23%, 60.30% and 0.056 kWh (g COD)−1, making SS/TiO2/PbO2-10%B a promising anode for the degradation of ampicillin antibiotic in aqueous solutions

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

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research