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 (β 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.

Sphenopalatine Ganglion versus Greater Occipital Nerve Blocks in Treating Post-Dural Puncture Headache after Spinal Anesthesia for Cesarean Section: A Randomized Clinical Trial

BACKGROUND

Despite being invasive, with serious complications, epidural blood patch (EBP) is still considered the gold standard therapy for Post Dural Puncture Headache (PDPH). The use of Peripheral nerve blocks for PDPH are studied here.

OBJECTIVES

To investigate the efficacy of sphenopalatine ganglion block (SPGB) and greater occipital nerve block (GONB) to relieve PDPH and its associated symptoms.

STUDY DESIGN

Randomized comparative single-blind trial.

SETTING

A University hospital.

METHODS

Patients who received spinal anesthesia for elective cesarean section, and then developed PDPH during hospitalization or within 5 days after dural puncture were enrolled to receive GONB (n = 47) or SPGB (n = 46) for treatment of PDPH. GONB Group: Patients received bilateral GONB using 3 mL mixture of 2 mL lidocaine 2% plus 1 mL dexamethasone 4 mg on each side of occipital region. SPGB Group: Patients received bilateral SPGB using the same mixture in each nostril. Assessments included Numeric Rating Scale (NRS) for severity of headache at supine and sitting positions, nausea NRS, neck stiffness, need for EBP, and complications.

RESULTS

The supine and sitting headache NRS scores significantly decreased at 30 minutes after blocks and throughout follow-up period in both groups (P < 0.000). Clinically significant drop of NRS to < 4 was reached earlier in GONB group. There was a significant difference between groups after 2 hours in supine and sitting headache NRS scores (P = 0.020 and 0.030, respectively); however, both treatments showed similar effectiveness from the third hour afterwards (P > 0.05). Both techniques were effective in relieving neck stiffness and nausea (P < 0.000), with no adverse effects.

LIMITATIONS

A limitation to this study was the small sample size.

CONCLUSIONS

GONB and SPGB are equally effective in relieving symptoms of PDPH. Both techniques are safe, simple, and less invasive than EBP.

Efficacy and Safety of Intravenous Tramadol versus Intravenous Paracetamol for Relief of Acute Pain of Primary Dysmenorrhea: A Randomized Controlled Trial

INTRODUCTION

Many pharmaceutical, surgical, and complementary medical interventions are used for primary dysmenorrhea treatment. However, no consensus has been reached about the most effective intervention.

OBJECTIVE

To compare the efficacy and safety of IV tramadol versus IV paracetamol in relieving acute pain of primary dysmenorrhea.

METHODS

This randomized controlled trial was conducted in a tertiary referral hospital and included 100 patients between 18 and 35 years old diagnosed with primary dysmenorrhea. Patients received either 1-g paracetamol or 100-mg tramadol in 100-mL normal saline as an IV infusion over 10 min. Pain intensity was measured by using a visual analog scale at 15, 30, 60 min, and 2 h. We recorded drug side effects and requirements for rescue analgesics.

RESULTS

Pain scores were significantly lower in the tramadol group compared with the paracetamol group at 15, 30, 60 min, and 2 h (p < 0.001). Fewer patients in the tramadol group needed rescue analgesics compared with the paracetamol group (p = 0.04). No significant differences were reported in side effects between both groups.

CONCLUSIONS

IV tramadol is superior to IV paracetamol in relieving acute pain of primary dysmenorrhea with a comparable side effect profile.

Computerized motion sensitivity screening tests in a multicountry rural onchocercal community survey in Africa

Purpose:

To determine whether the Wu–Jones Motion Sensitivity Screening Test (MSST) accurately reflects the burden of optic nerve disease in several onchoendemic communities in Africa.

Materials and Methods:

The MSST was used to evaluate subjects in the communities of Raja in Sudan, Bushenyi in Uganda, Morogoro in Tanzania, and Ikon, Olomboro, and Gembu in Nigeria. Motion sensitivity was expressed as a percentage of motion detected in the individual eye, and this was averaged for the community. A perfectly normal eye would detect all motion and score 100%.

Results:

In this study, 3858 eyes of 2072 subjects were tested. The test was completed in 76% of respondents. Acceptability was high. Average test time was 120.4 s. The overall mean motion sensitivity of all eyes tested was 88.49%, ±17.49. Using a cutoff level of 50%, 6.4% of all subjects tested were subnormal. The highest proportion of subnormals recorded was in Morogoro at 12.7%. Severe defects in a community best correlated with optic nerve disease prevalence, while the proportion of the defect from a higher cutoff level best correlated with overall ocular morbidity. A repeat examination in the next 5 years following ivermectin treatment will show the influence, if any, on community-wide MSST performance.

Conclusion:

A wide range in community scores reflected disease diversity. The MSST appears to be a useful test in community-wide screening and diagnosis as it reflects the general level of ocular pathology and specifically, optic nerve disease.

Comparison of topical lidocaine [2% gel] and injectable lidocaine [2% solution] for incision and curettage of chalazion in Ilorin, Nigeria

AIMS AND OBJECTIVES

To compare the efficacy and side effects profile of topical 2% lidocaine gel with injectable 2% lidocaine solution as local anaesthetics for incision and curettage of chalazion.

PATIENTS AND METHODS

Overa 12 month period, 61 patients with unilateral chalazia who were scheduled for incision and curettage surgery under local anaesthesia were randomized into 2 groups: A & B. Group A received 1.5 ml of injectable lidocaine as local anaesthetic while Group B received 1.5 ml of lidocaine 2% gel topically. The major outcome of interest was pain experienced during anaesthetic administration and surgery.

RESULTS

Mean pain score from anaesthesia administration was significantly higher in the injection group (A = 4.46 vs. B = 0.57), (p = 0.000005). There was a statistically significant difference in mean pain score during incision and curettage with more pain in the gel group (A = 2.84 vs. B = 4.83), (p = 0.0012). However, the mean total pain score (surgery plus anaesthesia) was more in the injection than the gel group (A = 7.3 vs. B = 5.4) (p = 0.0094). The proportions that had no fear for injection were 54.8% in A and 56.7 % in B. Group A had significantly more ptosis than Group B (2.2 vs. 1.4, p = 0.00003,). Bleeding occured in 93.5% in group A while none occurred in Group B (p = 0.000).

CONCLUSION

Lidocaine 2% gel is an effective, safe and convenient alternative to injectable lidocaine 2% as local anaesthetic agent in incision and curettage for Chalazion in this study.

Prevalence and distribution of ocular onchocerciasis in three ecological zones in Nigeria

The African Programme for Onchocerciasis Control (APOC) sponsored a baseline study in Nigeria between 1998 and 1999 on the prevalence and distribution of Onchocerciasis. The randomly selected 1,064 subjects in the baseline study underwent detailed eye examination in Cross River (rain forest), Taraba (savanna) and Kogi (forest-savanna) States. This paper compares and contrasts the public health significance of ocular onchocerciasis in these ecological zones. A blindness prevalence of 2.4% was recorded in the study, onchocerciasis being responsible for 30.2% of the bilaterally blind subjects. Onchocerciasis-induced blindness prevalence was relatively high in the rain forest and forest savanna zones of Cross River and Kogi States, Cross River having the highest site-specific prevalence (50.0%), followed by Kogi (41.7%). Taraba recorded only 27.3%. Other conditions identified included glaucoma, optic nerve disease and cataract rates of which were also found to be high among the population (6.9%, 6.5 % and 8.9% respectively). Anterior segment onchocercal lesions, punctate and sclerosing keratitis were the predominant features of the infection in the savanna zone (14.1% and 6.3% respectively), while posterior segment lesions were much more common in the forest zone. The need to sustain the present efforts to control onchocerciasis through mass ivermectin treatment is recommended.

Assessment of interrelationship between poverty and blindness in Maiduguri, Nigeria

AIMS AND OBJECTIVE

To assess the possible role of poverty as a cause and a consequence of blindness among blind individuals in Maiduguri, Nigeria.

PATIENTS AND METHODS

Eighty-five consenting blind individuals living within 4 wards of Maiduguri had ocular examination to determine the cause of their blindness with a view to determining the avoidable nature (preventable and/or curable, were adequate resources available) of their blindness. A semi-structured questionnaire which captured their demographic data, antecedents of blindness and interventions (medical and rehabilitative) sought, access to welfare support services was also administered. Socio-economic status of the respondents was explored through information sought on educational attainment, employment status, means of livelihood, possession of personal assets, and estimates of monthly income.

RESULTS

Blindness from the main causes were avoidable as they were either curable (cataract 41, 48%) or preventable (xerophthalmia 20, 23.5%; glaucoma 12, 14.1%; and trachoma 5, 5.1%). Only 8.2% of the subjects were employed, majority (75.3%) roamed the streets begging; and 69% lived on less than a dollar a day. Over three-quarters had no access to any form of welfare support. Majority (70.6%) did not have any personal asset. More than two-thirds had no formal education and over three-quarters had no access to health services. CONCLUSIONS & RECOMMENDATION: The avoidable nature of blindness in 78 (90%) of the subjects implicates poverty as a causative factor. In turn, the subjects' subsequent existence in poverty and destitution appear directly related to their blindness. We recommend an effective and comprehensive eye care service, and an intensification of poverty-alleviation measures.

Utility and effectiveness of computerised motion sensitivity screening tests in rural onchocercal community survey

BACKGROUND

Non-invasive tool of community diagnosis for onchocercal endemicity needs to be identified and ascertained for their utility and effectivity in order to facilitate the control of onchocerciacis in sub-Saharan Africa

OBJECTIVE

To determine the utility and effectiveness of the Wu-Jones Motion Sensitivity Screening Test (MSST) in detecting optic nerve diseases in onchocercal-endemic rural Africa.

METHODS

MSST was applied to sampled subjects in the selected communities of Raja in Sudan; Bushenyi in Uganda; Morogoro in Tanzania; and of Ikom, Olamaboro and Gashaka in Nigeria. Basically, six points within the central field of vision were repeatedly tested at 1/3 meter from the screen of a laptop computer in a room darkened. Motion sensitivity was expressed as a percentage of motion detected in the individual eye and this was averaged for the community.

RESULTS

A total of 3,858 eyes of 2,072 patients were examined. Seventy-six percent of the subjects completed the test, at an average test time of 120.4 (66.7) seconds. The overall mean motion sensitivity of all eyes tested was 88.49 (17.49%). At a cut-off point of 50%, 6.4% of all subjects tested were subnormal, while at 70% cutoff, 13.3% were subnormal. The highest proportion of 50% cutoff sub-normality was recorded at Morogoro at 12.7%.

CONCLUSION

Motion Sensitivity Screening Test was widely accepted and easily administered to the rural and largely illiterate subjects studied. Our data suggest that the proportion of severe field defects by MSST in a community, with cutoff at 33%, best correlates with optic nerve disease prevalence, while proportion of defect from a higher cut-off level at about 50%, best correlates with overall ocular morbidity.

Familiarity with modern health management trends by West African surgeons

OBJECTIVES

To collate the self-reported assessment of familiarity with some aspects of managerial competencies on the part of some surgeons and their observations on the managerial environment of their health institutions and draw appropriate policy implications.

DESIGN

Cross-sectional study using a structured questionnaire.

SETTING

The study was conducted during the 50th Annual Scientific Conference of the West African College of Surgeons, which was held in Calabar, Nigeria, from 6th to It 12th February 2010.

SUBJECTS

One hundred and ten out of 150 surgeons who were attending the conference returned their filled questionnaires.

RESULTS

Their familiarity with business and financial concepts was lacking on crucial ones related to marketing strategies. Respondent largely found the listed objections to advertisement of medical services as very appropriate. They preferred largely to interact with themselves in professional associations rather than with others in cross-cultural groupings. Funding (66.4%) and political/ethnic influences (43.9%) were rated as impacting very negatively on their health institutions, while the deployment of information communication technology to institutional processes was adjudged to be unsatisfactory.

CONCLUSIONS

Most of the indices of core competencies in modern health leadership and management appeared deficient among our study participants and their health institutions managerial environments were equally deficient. We recommend for a well-focussed short time duration health management course for all physicians particularly specialists.

Causes and prevalence of ocular morbidity among primary school children in Ilorin, Nigeria

OBJECTIVE

To determine the causes and prevalence of ocular morbidity among primary school children in Ilorin, Nigeria.

MATERIALS AND METHODS

A cross sectional survey of primary school children in 10 randomly selected primary schools within Ilorin, Nigeria was carried out between July 2005 and January 2006. Relevant ocular history and basic ocular examinations were carried out on the children that were selected from a multi-stage sampling process.

RESULTS

One thousand three hundred and ninety three pupils were surveyed. There were 689 (49.4%) boys and 704 (50.6%) girls. The age range was between 4 and 15 years. The mean and modal ages were 10.16 SD 2.5 and 10 respectively. Two hundred and seventy seven pupils had ocular pathology giving a prevalence of 19.9%. The two most common ocular disorders found among the pupils were refractive errors and vernal conjunctivitis with prevalence of 6.9% and 6.7% respectively. Others included genetic / congenital / developmental ocular disorders 39 (2.8%), glaucoma / glaucoma suspect 20 (1.4%), ocular infections 18 (1.3%), and ocular trauma 11 (0.8%). More than three-quarters (86.7%) of the causes of visual impairment and blindness among the pupils were avoidable (preventable or treatable).

CONCLUSION

The sheer magnitude of avoidable causes of visual impairment and blindness in the study underscores the need for effective school eye-health programmes in developing countries.

Appropriateness of ophthalmic cases presenting to a Nigerian tertiary health facility: implications for service delivery in a developing country

OBJECTIVE

To assess whether the ophthalmic cases presenting at a Nigerian tertiary eye unit are appropriate for such level of care and also draw necessary implications for service delivery.

METHODS

Data on 1321 consecutive new patients that presented at the ophthalmic clinic of the University of Teaching Hospital, Ilorin, Nigeria between February and July 2005 were reviewed on demographics, referral routes, and reasons for patronage, diagnoses and disease categories. Information on the general situation of health infrastructures prevailing at the surrounding health facilities was collected from key-informants.

RESULTS

One thousand and ninety-one (82.6%) presented without any referral and 1095 (82.9%) patronized in order to access perceived good quality of eye care service being rendered. However, only a small proportion of their ailments (191, 14.5%) actually required attention at the tertiary level of eye care. The key informants painted a picture of severely-challenged general and health infrastructures particularly at the primary health care facility level.

CONCLUSION

An overwhelming majority of ophthalmic patients directly accessed eye care at the tertiary level, even though most of their ailments could have been satisfactorily treated at the lower facilities of health care were the latter to be functioning optimally. A better coordinated and strengthened health care system, particularly at the primary and secondary health care facilities would ease the burden of inappropriate presentations on tertiary health facilities in Nigeria.

Survey of blindness and low vision in Egbedore, South-Western Nigeria

BACKGROUND

Developing efficient and cost-effective eye care programmes for communities in Nigeria has been hampered by inadequate and inaccurate data on blindness and low vision.

OBJECTIVE

To determine the prevalence and causes of blindness and low vision among adults 50 years and older in South-Western Nigeria in order to develop viable eye care programme for the community.

METHODS

Twenty clusters of 60 subjects of age 50 years and older were selected by systematic random cluster sampling. Information was collected and ocular examinations were conducted on each consenting subject. Data were recorded in specially designed questionnaire and analysed using descriptive statistical methods.

RESULTS

Out of the 1200 subjects enrolled for the study, 1183(98.6%) were interviewed and examined. Seventy five (6.3%)) of the 1183 subjects were bilaterally blind and 223(18.9%) had bilateral low vision according to WHO definition of blindness and low vision. Blindness was about 1.6 times commoner in men than women. Cataract, glaucoma and posterior segment disorders were major causes of bilateral blindness. Bilateral low vision was mainly due to cataract, refractive errors and posterior segment disorders.

CONCLUSION

The prevalence of blindness and low vision in this study population was high. The main causes are avoidable. Elimination of avoidable blindness and low vision calls for attention and commitment from government and eye care workers in South Western Nigeria.

Knowledge and attitude of guardians towards eye health of primary school pupils in Ilorin, Nigeria

OBJECTIVE

To determine guardians' knowledge and attitude towards pupils' eye health and draw implication for designing children-oriented ocular health messages.

METHODS

A survey of 1,393 guardians selected through multistage random sampling in Ilorin, Nigeria. Using structured questionnaire, information sought included guardians' demographic characteristics, relationship to pupils, occupation, awareness of eye specialists, perception of normal vision, pupils' eye complaints, and ways of treating children eye conditions. Data analysis was done with SPSS 12.0.1. The test of significance was performed using Chi square test and significance was taken at p < 0.05.

RESULTS

Guardians comprised 689 (49.4%) males and 704 (50.6%) females, mean age 43.61 SD 11.45. Most (88.54%) were pupils' parents and (11.46%) were relations (n=1,318); (55.15%) were in low-paying occupations (n=1,311); (87.92%) were aware of eye specialists, (12.08%) unaware, (n=1192); (97.27%) adjudged normal vision at least important, (2.73%) not important (n=1,174). Pupils' eye complaints (n=914) included pain (26.04%), itching (24.73%), redness (21.12%), discharge (8.53%), blur vision (8.21%), photophobia (7.33%) and lacrimation (4.05%). Guardians (n=1,069) managed pupils' eye diseases using hospital treatment (61.65%), neglect (21.33%), self medication (9.26%) and traditional medication (7.76%). There were no significant associations between guardians' ways of managing pupils' eye diseases and their views on normal vision (p = 0.940); awareness of eye care specialists (p = 0.952); and economic occupational grouping (p = 0.959).

CONCLUSION

The negative implications of neglecting eye diseases and use of self and harmful traditional eye-medications by some of the guardians need to be discouraged by appropriate eye health education.

Millennium Development Goals: an assessment of awareness and perceptions of attainability by health workers in Owo, Nigeria

AIM

To assess the awareness of the United Nations Millenium Development Goals (MDGs) by some Nigerian health workers and also their perceptions of the attainability of the goals.

SUBJECT AND METHODS

Through the means of a structured questionnaire served on 92 consenting health workers selected by stratified sampling technique ,information regarding their bio data, awareness of the millennium development goals (MDGs), the duration and source of the awareness and their perception of attainability of the goals were obtained. The feasibility of attainment of the goals was rated as: very attainable, attainable, and not attainable.

RESULTS

All the respondents were by then aware of the MDGs. Most of the respondents (57.6%) became aware within the preceding year, i.e., 2006; while only very few (2.2%) had been aware 6-7 years earlier (2000 and 2001). Some respondents (46.7%) got to know of MDGs through their colleagues while others (32.6%) got to know through the print and electronic media. The remaining others (20.7%) were informed through the sensitization efforts of the government and non-government agencies. The highest degree of optimism for the attainment ofMDGs were displayed largely for health related MDGs; i.e., the goals 4, 5 and 6.

CONCLUSIONS & RECOMMENDATIONS

Majority of the respondents were aware of MDGs. Most adjudged the attainment of MDGs feasible. The government and other stake holders should sensitize the populace, strengthen the health system and ensure equitable access to health care.

Perceptions of Nigerian ophthalmologists about traditional eye care practice in Nigeria

This study was designed to determine perceptions of Nigerian ophthalmologists about traditional eye care practice in Nigeria. A semi-structured questionnaire was used to capture relevant information on TECP from some Nigerian ophthalmologists that attended their 32nd annual professional congress in Enugu, Nigeria, from the 4th to 8th September, 2007. One hundred and one ophthalmologists comprising of 41 consultants, 6 diplomates and 54 resident doctors gave their consent and participated in the study by returning their filled questionnaires. Majority of the respondents (66%) reported a significant degree of community acceptance of TECP within their various localities. Most of the respondents (57.6%) were against collaboration with traditional healers. Despite acknowledging a significant degree of community acceptance for TECP, majority of the respondents were against an integration of TECP into the health system, even at the primary eye care level. We recommend that the government, in collaboration with ophthalmologists, evolves a multi-disciplinary agency to 1) regulate and monitor TECP; 2) identify and encourage the useful components of TECP, while at the same time, identify and discourage the harmful aspects including all forms of surgery and couching of the lens; 3) training and retraining of TECP practitioners to enable them become useful members of the primary eye care team.

Evaluation of the oculo-kinetic perimetry glaucoma screening test in a sub-Saharan African setting

BACKGROUND

The oculo-kinetic perimetry glaucoma screening test (OKPGST) simplifies testing for glaucoma. Despite its acceptable degree of efficiency and practicability, its usage in sub-Saharan African appears limited.

OBJECTIVE

To evaluate and compare the oculo-kinetic perimetry glaucoma screening chart against automated perimetry and clinical criteria in screening for glaucoma in a sub-Sahara African setting.

METHODS

In the first stage, the test was conducted on selected eyes with reproducible glaucomatous visual field detects on perimetry with the KOWA AP125 central visual field plotter, and also in their age-matched controls. During the second stage at the rural outreach health posts, patients with clinically diagnosed primary open angle glaucoma (intraocular pressure of > 21mmHg and a cup/disc ratio > 0.5), and their age-matched controls were also screened with the test.

RESULTS

The test was positive in 107 of the 113 eyes with glaucomatous field loss on automated perimetry; and inaccurate in 2 of the 98 control eyes, giving a sensitivity of 94.7%, specificity of 98%, and an efficiency of 96.2%. Among patients with clinically diagnosed glaucoma at the rural health posts, the test was positive in 61 of 65 eyes, while it was inaccurate in 2 of 62 eyes of control patients, giving a sensitivity of 93.8%, specificity 96.8%, and an efficacy of 99.2%.

CONCLUSION

The oculo-kinetic perimetry glaucoma screening test with the KOWA performed well, using the KOWA automated perimeter as a standard. It is a convenient, rapid, reliable and inexpensive screening tool in diagnosing primary open angle glaucoma in rural health establishments where conventional perimeters are lacking.