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

On the capacity of DS/CDMA cellular systems employing power control and adaptive transmission rate

grantor: University of TorontoThe capacity of a CDMA network is an extremely important issue in terms of its economic viability. This capacity is strongly dependent on the control of various interference factors. The most important of these factors is that of power control. In a cellular network the received signal strength depends on three propagation loss factors: free space loss (a function of distance), shadowing, and multi-path propagation. If the mobile's received power at the base station with which it is communicating is constant, then the power control is said to be perfect. The multipath fading will have no effect on the system capacity when power control (PC) is perfect and the system has only one cell. In multiple cell systems, however, tracking the multipath fading of users in other cells increases the intracell interference and hence reduces the system capacity. In this thesis, we investigate the system capacity of DS/CDMA systems under perfect power control when the fading channel consists of 'M' equal strength resolvable Rayleigh paths. We investigate the effect of changing the number of the fading resolvable paths on the system capacity. The effect of soft handoff and the effect of limiting the maximum increase in power to compensate for multipath fading are also determined. If there is a line of sight between the mobile and the base station, less deep fades will be encountered and the system capacity will be higher. Thus, we find the system capacity for the case of Rician/Rayleigh fading channels. If we assume the users to be of data type, then during low fade periods, the transmission rate can be decreased instead of increasing the transmitted power. This results in lowering the user's transmission rate but reduces the interference. We show that such a scheme can result in a considerable increase in the system total average transmission rate. It is known that the required signal to interference ratio (SIR) is a function of the user's velocity where slow moving users require a lower SIR. By equalizing the received power from all users, slow users performance will be better than fast users. To guarantee that all users performance is acceptable, the performance of fast users is investigated when determining the system capacity. We propose a scheme where the required signal power from a user is determined according to its velocity. This lowers the powers of slow users and hence reduces interference which increases the capacity. The error in the received signal power is usually modeled as a lognormal variable with a standard deviation that is a function of the user velocity. We show a large difference in this standard deviation depending on whether or not the user's power is controlled by the base station where the interference is measured or by a different base station. We use the error statistics to investigate the system Erlang capacity and investigate the system performance when the transmission rate of data users is determined according to the number of users in the system. The effect of imperfect power control on such an adaptive rate scheme is also investigated.Ph.D

Rectus femoris and vastus intermedius thickness measurement by ultrasound before and after anterior cruciate ligament reconstruction in athletes

Abstract Background Most anterior cruciate ligament (ACL) injuries which are common in violent sports require anterior cruciate ligament reconstruction (ACLR) to restore knee joint stabilization. Rectus femoris (RF) and vastus intermedius (VI) weakness are among the notable changes after ACLR. This weakness can be hazardous to the patient as it could decrease functional activity and thus increases the chances of re-injury. The objectives of the current study were to measure the (RF) thickness, (VI) thickness and the total (RF + VI) thickness on (ACL) reconstructed limb and the non-reconstructed limb of athletes using ultrasound and to compare the results pre-operatively and 6–8 months post-operative. Results The reconstructed limb showed a significant decrease in (RF), (VI) and the total thickness in the 1st, 2nd and 3rd measurements compared to that of non- reconstructed limb post-operatively. In both limbs, the decrease of (VI) thickness was significantly higher than (RF) thickness in the 1st, 2nd and 3rd measurements (p < 0.001, p < 0.001 and p < 0.001 respectively). Conclusions Ultrasound can be used to assess quadriceps atrophy (including the individual muscles) found after ACLR. Ultrasound is an affordable and easily available modality as compared to MRI and CT scans for the assessment of RF and VI muscle weakness in athletes with ACLR during the rehabilitation period and can guide selective rehabilitation protocols if wasting is identified early

CASE REPORT PEER REVIEWED | OPEN ACCESS International Journal of Case Reports and Images (IJCRI) Myxoedema: A rare cause of massive ascites Myxoedema: A rare cause of massive ascites Article ID: Z01201701CR10748RF *********

International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties. Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations. IJCRI publishes ABSTRACT Myxoedema ascites is a rare condition with a known incidence of 4% which makes it in the bottom of the list of causes of ascites, that is why diagnosis is often delayed and physicians usually do not put it in the preliminary differential diagnosis of a case of ascites. We here report a case of Ascites due to hypothyroidism which markedly improved after thyroxin therapy. To our knowledge, this makes it the first case reported in Egypt with myxoedema ascites. Myxoedema ascites is characterized by the dramatic response to replacement therapy. The message to be taken is that myxoedema is a rare cause of massive ascites but should be evaluated if suspected since the condition is easily controlled by medical treatment. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol

Prognostic significance of MGMT promoter methylation in Egyptian GBM patients: A single-institution experience

Background: Glioblastoma Multiforme (GBM) is the highest-mortality tumor of the central nervous system. Epigenetic silencing of the MGMT gene by promoter methylation is associated with loss of MGMT expression and deficiency in MGMT mediated DNA repair, which is affiliated with improved survival in patients treated with alkylating agents such as TMZ. Purpose: This is a retrospective work, studying the MGMT promoter status in a group of GBM patients; correlating this status to time to progression (TTP) and overall survival (OS). Methods: Thirty-nine patients with GBM, treated in Kasr El-Ainy Center of Clinical Oncology and Nuclear Medicine (NEMROCK) between January 2014 and January 2015, were included in our study. The QIAamp DNA FFPE Tissue Kit (Qiagen, USA) was used for genomic DNA extraction from Formalin-fixed paraffin-embedded tumor tissues of the 39 patients. Bisulfite modification of DNA was performed for detecting methylation in MGMT promoter using EpiTect Bisulfite Kit (Qiagen, USA). Specific primers were used to match methylated & un-methylated DNA that was visualized by loading its PCR products in gel electrophoresis system. All statistical analyses were carried out using SPSS version 20.0. Results:  The mean age for our patients was 48 years; with a male to female ratio of 1.3:1. MGMT promoter methylation was found in 27 patients (69.2%) compared to 12 (30.8%) with un-methylation. TMZ was received in 71.8 % (28) of our patients throughout their treatment. The median OS for all patients was 20.03 months; while the median TTP 15.03 was months. Although the OS was statistically significantly higher for patients with methyalted promoter (p-value = 0.004) compared to un-methylated group; yet the TTP difference did not reach a statistical significant value (p-value = 0.048). Conclusions:  The epigenetic silencing of the MGMT gene by promoter methylation has been associated with longer OS & TTP in patients with GBM. Key words: GBM, Epigenetic silencing, Un-methylation, Overall survival