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

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

Background 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

Analysis of two dynamic frictionless contact problems for elastic-visco-plastic materials

We consider two mathematical models which describe the contact between an elastic-visco-plastic body and an obstacle, the so-called foundation. In both models the contact is frictionless and the process is assumed to be dynamic. In the first model the contact is described with a normal compliance condition and, in the second one, is described with a normal damped response condition. We derive a variational formulation of the models which is in the form of a system coupling an integro-differential equation with a second order variational equation for the displacement and the stress fields. Then we prove the unique weak solvability of the models. The proofs are based on arguments on nonlinear evolution equations with monotone operators and fixed point. Finally, we study the dependence of the solution with respect to a perturbation of the contact conditions and prove a convergence result

Analyse variationnelle et numérique de quelques problèmes dynamiques en mécanique de contact

L objectif de ma thèse est l étude de quelques problèmes dynamique de contact avec et sans frottement, entre un corps déformable et une fondation. Nous commençons par la présentation des modèles mécaniques, suivie de quelques rappels d analyse fonctionnelle et d équations aux dérivées partielles. Puis, nous réalisons l analyse variationnelle de deux problèmes de contact sans frottement pour des matériaux élasto-visco-plastiques, le contact étant modélisé à l aide d une loi de compliance normale et respectivement à l aide d une loi de réponse normale instantané. Pour ces problèmes nous obtenons des résultats l existence et d unicité de la solution. Par ailleurs, nous analysons numériquement les problèmes de type hyperélastodynamique avec contact et frottement, avec comme principal objectif le respect de la conservation de l énergie lors des impacts. Pour ce faire, nous avons développé une méthode de continuation de Newton à 2 étapes qui est caractérisée par un respect de la condition de contact unilatéral dans la première étape, puis par la prise en compte de la condition de contact persistant dans la deuxième étape. Cette étude est accompagnée par des simulations numériques qui permettent d effectuer une comparaison approfondie entre la méthode développée dans ce travail et deux autres méthodes numériques de type conservation de l énergieThe aim of my thesis is the study of dynamics frictional and frictionless contact problems between a deformable body and a foundation. We present first the mechanical models as well as some preliminaries of functional analysis and partial differential equations. Then we provide the variational analysis of two frictionless contact problems with elasto-visco-plastic materials, the contact being modelled with the normal compliance condition and with the normal damped response condition, respectively. For these problems we obtain existence and uniqueness results of the solution. Next, we analyze numerically hyperelastodynamic frictional contact problems, with the goal to ensure the conservation of energy during the impact. To this end we developed a 2 steps continuation Newton method in which the unilateral contact condition is satisfied in the first step and which takes into account the consistence contact condition in the second step. This study also includes numerical simulations, which allows us to compare the method developed here with two different numerical methods based on the energy conservationPERPIGNAN-BU Lettres-Sc.humaines (661362102) / SudocSudocFranceF

Puiseux series solutions of ODEs

In this article, we will determine Puiseux series solutions of ordinary polynomial differential equations. We also study the binary complexity of computing such solutions. We will prove that this complexity bound is single exponential in the number of terms in the series. Our algorithm is based on a differential version of the Newton-Puiseux procedure for algebraic equations

Implications of left ventricular mass index on early postoperative outcome in patients undergoing aortic valve replacement

Aim of the work: To study the prognostic influence of the preoperative left ventricular mass index (LVMI) on early postoperative outcome in patients undergoing aortic valve replacement (AVR). Patients and methods: We studied 61 patients (41 males and 20 females) who underwent elective AVR for isolated or mixed aortic valve lesions. LVMI was calculated by trans-thoracic echocardiography in all patients. We classified our patients into two groups: group 1 patients had increased LVMI (>134 g/m2 in males and >110 g/m2 in females) and group 2 patients who had normal LVMI. Aortic valve replacement was done in all patients. Results: We found 48 (age 28.4 ± 12 years) patients with increased LVMI (group 1) and 13 (age 27.2 ± 12 years) with normal LVMI (group 2). There was significantly increase in the need of prolonged use of inotropic support (62.5% versus 31%, P value = 0.041), intensive care unit (ICU) stay and post-operative hospital stay (4.02 ± 2.1 versus 2.3 ± 1.8 days, P value = 0.011 and 8.4 ± 2.4 versus 6.6 ± 2.8 days, 0.025 respectively) in group 1 compared with group 2. The occurrence of post operative ventricular arrhythmia and atrial fibrillation (AF) was higher in group 1 but still statistically insignificant. During post operative period two patients died in group 1 and one patient in group 2. Conclusion: The increase of LVMI values is associated with increased in-hospital morbidity in patients undergoing aortic valve replacement