Survey of postoperative analgesia following ambulatory surgery

Background: The quality of pain relief during the first 48 hours following ambulatory surgery has been poorly documented. This questionnaire study was performed to evaluate the nature and severity of pain after the patient leaves the hospital. Methods: 1100 patients in the age group 5–88 years who underwent ambulatory surgery during a period of 6months were asked to complete a questionnaire 48 h after the end of the operation. In thecase of children, parents were asked to complete a similar questionnaire. The questions were related to pain experienced during the first 48 h after surgery and to the nature andseverity of postoperative complications. Results: A total of 1035 out of the 1100 patients returned the questionnaire, 94.1%. Overall the majority (65%) of patients had only mild pain at home; however, patients undergoing certain types of surgery had moderate-to-severe pain: inguinal hernia surgery (62% patients), orthopaedic surgery (41%), hand surgery (37%) and varicose vein surgery (36%). In these patients the severity of pain did not decrease during the 2-day study period. About 10% patients had more severe pain than they had anticipated, and 20% had difficulty in sleeping at night due to severe pain. Despite this, over 95% of patients were satisfied with man-agement of postoperative pain. Nausea (20%), tiredness (20%) and vomiting (8%) were the commonest complications reported during the first 48 h. A significant association was found between the administration of a general anaesthetic and the incidence of nausea postoperatively. A large number of patients were alone at home after the operation (28.4%); some (3.8%) had no access to a relative or friend in case of need. Conclusion: Our results show that about 35% of day-surgery patients experience moderate-to-severe pain at home in spite of analgesic medication. About 20% of patients had sleep problems due to severe pain. However, only 5% of patients were dissatisfied. Better analgesic techniques are necessary for patients undergoing certain types of surgery. Patient information and follow-up routines need to be improved.     

Verapamil in Idiopathic Ventricular Tachycardia of Right Bundle Branch Block Morphology: Observations During Electrophysiologic and Exercise Testing

Electrophysiologic studies before and after administration of verapamil were performed in three young patients with recurrent sustained ventricular tachycardia (VT) of right bundle branch block morphology. VT was not provoked by maximal treadmill testing in any patient. Electrophysiologic findings at induction of VT suggested reentry in the first patient and triggered automaticity in the second. Findings were inconclusive in the third patient. Intravenous verapamil terminated the VT in all the three cases. Oral verapamil prevented laboratory induction of sustained VT in the latter two patients. However, VT could be provoked during exercise in both while on oral verapamil therapy. These findings suggest that different mechanisms may underlie ventricular tachycardia dependent upon slow-response tissue; the role of oral verapamil in the treatment of such VT needs further investigation.     

Clinical predictors of fibrosis in patients with chronic liver disease

Aliment Pharmacol Ther 31 , 1085–1094

Summary

Background Patients with chronic liver disease and components of metabolic syndrome may be at higher risk for fibrosis. Aim To assess the impact of clinicodemographic factors on hepatic fibrosis in CLD. Methods Of 1028 chronic liver disease patients, 964 were included in the analysis. Extensive clinico‐demographic and histological data were available. Significant baseline fibrosis (METAVIR stage ≥2) and fibrosis progression (increase of ≥1 stage in subsequent biopsy) were compared between groups using univariate and multivariate analyses. Results Compared with HCV and HBV, NAFLD patients were more obese (higher BMI and waist circumference), diabetic, hypertensive and hyperlipidaemic. Significant fibrosis occurred in 55%, 43% and 20% of HCV, HBV and NAFLD, respectively. Factors independently associated with fibrosis in NAFLD included DM, elevated AST and ALT. For viral hepatitis, independent predictors of fibrosis were low platelet count (HBV and HCV), age (HBV) and elevated AST and ALT (HCV). A second biopsy was available for 96 patients with follow‐up of about 4 years. Factors independently associated with progression of fibrosis were HCV infection, higher ALT and lower platelet count. Conclusions Diabetes mellitus is an independent risk factor for fibrosis only in NAFLD. Elevated aminotransferases and/or low platelet counts are independently associated with significant baseline fibrosis or progression of fibrosis, in patients with chronic liver disease.     

Optimization of AV and VV Delays in the Real-World CRT Patient Population: An International Survey on Current Clinical Practice

Background: Cardiac resynchronization therapy (CRT) is an effective treatment for patients suffering from advanced heart failure and electrical dyssynchrony. Limited data suggest that patients may benefit from routine optimization of the atrioventricular (AV) and interventricular (VV) delays; however, there is scarce information available on how and when optimization should be performed.
Objective: The objective of this survey was to characterize the current international standard of care for optimization of the AV and VV delays in CRT devices recipients.
Methods: Centers participating in the Frequent Optimization Survey Using the QuickOpt Method (FREEDOM) study completed surveys probing into their optimization of AV and VV delays procedures. Probes focused on the methods used to optimizing the delays, visits at which optimization of the delays was performed, percentage of patients that underwent optimization, and factors that limited centers from optimizing the CRT systems.
Results: Few of the 118 investigators from 16 countries who responded to the survey routinely optimized the delays in all patients. At follow-up visits and during hospitalizations, a trend was observed to optimize the delays more often in nonresponders than in responders to CRT. Standard echocardiography was the most common method of optimization. Time availability and lack of qualified staff were the main factors limiting the optimization of CRT systems.
Conclusions: In real-world practice, AV and VV optimization was not performed in a high proportion of patients. A less time-consuming and easier optimization method might enable a more systematic optimization of the AV and VV delays at routine follow-up visits in all recipients of CRT systems.     

LOW BIRTH WEIGHT BABIES : INCIDENCE AND RISK FACTORS

In a prospective hospital based study, during the period from Jan 95 to Dec 96, 3100 consecutively delivered live newborns were studied for the incidence of low birth weight neonates and to evaluate the associated risk factors. One thousand fourteen newborns were classified as low birth weight babies. The incidence expressed per 1000 live births was 327 (32.7%). Of these, 815 (80.4%) were small for gestational age neonates and 199 (19.6%) were preterm neonates. Five hundred seventy small for gestational age neonates (70%) were weighing between 2001 to 2500 gms. Mothers belonging to the age group of 19-25 years delivered the maximum number of low birth weight babies (618/1014) and of these 82.8% were small for gestational age neonates. There were 48 neonates with low birth weight born to mothers below the age of 18 years. Primiparous mothers were found to contribute higher number of low birth weight neonates (414/1014). Spacing as a factor did not show any major difference. Two hundred sixty two low birth weight neonates were born to mothers with significant obstetrical problems such as pregnancy induced hypertension, bad obstetrical history and premature rupture of membranes. The incidence of 32.7% of low birth weight babies is high enough to ring alarm bells.     

PREVENTION OF POST-OPERATIVE WOUND INFECTION IN ABDOMINAL OPERATIONS

One hundred patients undergoing abdominal surgery were included in this prospective study. The role of local application of Betadine, use of synthetic sutures, and use of low pressure subcutaneous suction drainage were evaluated in preventing post-operative wound infection. The infection rate was 15 per cent with Betadine, 15.4 per cent with prolene, 20 per cent with subcutaneous suction drainage and 30.8 per cent in the control group.KEY WORDS: Surgical wound infection, Betadine, Sutures, Infection control