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

Assessment of nitrate contamination of karst springs, Bani Kanana, northern Jordan

Contamination of groundwater from point and non-point sources is one of the major problems of water resources in Jordan. Altogether one hundred and six groundwater samples were collected from twenty six karst springs emerging from Umm Rijam aquifer and three wells tapping Amman-Wadi As Sir aquifer, and investigated for NO3 - concentrations. Results showed that NO3 - concentration in spring water ranged from 8 to 192 mg/L with an average of 33 mg/L. Seventy seven percent of the samples collected from the springs had nitrate concentrations exceeding the threshold value of 20 mg/L of anthropogenic source, and eight percent of the samples collected had nitrate concentrations higher than 50 mg/L, the maximum acceptable nitrate concentration for drinking water. About eighty percent of the sampled springs had nitrate concentrations higher than 20 mg/L. The K-means cluster analysis performed on the collected samples revealed the presence of three major clusters. The data were processed for the possible presence of discordant outliers using the unpublished computer program UDASYS by Verma and Díaz-González. There is a wide spatial variation in the nitrate concentration in spring water. Monitoring the water quality of these springs showed that the lowest concentrations of nitrate were found in the wet season (January, February, and December), while the highest concentrations were found in the dry season (August, September). Nitrate concentration in Amman-Wadi As Sir aquifer ranges from <1 mg/L to 19.2 mg/L, with an average of 9.8 mg/L. Untreated domestic wastewater is most probably the major source of the nitrate in the spring water, as the study area is not served with sewer system, and domestic wastewater is collected in cesspools dug in the kartsed Umm Rijam Formation. Moreover, in the area under consideration there are no major industries or intensive agricultural activities. The results of this study are useful to highlight one of the most important environmental problems, namely the degradation of the water quality, and may serve to alert and encourage local and national authorities to take substantial steps and actions to protect and manage water quality.La contaminación del agua subterránea por fuentes puntuales y no puntuales es uno de los mayores problemas para los recursos de agua en Jordania. Se colectaron 106 muestras de agua subterránea de 26 manantiales cársticos que emanan del acuífero Umm Rijam y de tres pozos que drenan el acuífero Amman-Wadi As Sir, y se investigaron sus concentraciones de NO3 -. Los resultados mostraron que la concentración de NO3 - en agua de manantiales está en el rango de 8 mg/L a 192 mg/L, con un promedio de 33 mg/L. Setenta y siete porciento de las muestras colectadas en manantiales tuvieron concentraciones de nitrato que exceden el valor límite de 20 mg/L de fuentes antropogénicas, y ocho porciento de las muestras colectadas tuvieron concentraciones de nitrato mayores que 50 mg/L, la concentración máxima de nitrato permisible para agua potable. Aproximadamente el 8% de los manantiales muestreados tuvieron concentraciones de nitrato mayores que 20 mg/L. El análisis de conglomerados por el método de los centroides (�K-means cluster analysis�) reveló la presencia de tres conglomerados mayores. Los datos fueron analizados por la posible presencia de valores discordantes empleando el programa de cómputo no publicado UDASYS de Verma y Díaz-González. Existe una amplia variación espacial en la concentración de nitrato en agua de manantial. El monitoreo de la calidad del agua de esos manantiales mostró que las concentraciones más bajas de nitrato se encontraron en la estación de lluvias (enero, febrero y diciembre), mientras que las concentraciones más altas se encontraron en la estación seca (agosto y septiembre). La concentración de nitrato en el acuífero Amman-Wadi As Sir varía entre <1 mg/L y 19.2 mg/L, con un promedio de 9.8 mg/L. La fuente más probable de nitrato en los manantiales son las aguas residuales domésticas no tratadas, ya que el área de estudio no cuenta con sistema de drenaje y las aguas residuales domésticas son colectadas en cisternas cavadas en la Formación Umm Rijam afectada por procesos cársticos. Además, en el área no hay industrias grandes o actividades agrícolas intensivas. Los resultados de este estudio son útiles para resaltar uno de los problemas ambientales más importantes como es la degradación de la calidad del agua, y pueden servir como una alerta a las autoridades locales y nacionales para que sean tomados pasos substanciales y acciones para proteger y manejar la calidad del agua

Assessment of nitrate contamination of karst springs, Bani Kanana, northern Jordan

ABSTRACT Contamination of groundwater from point and non-point sources is one of the major problems of water resources i