PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations.

Caesarean section is associated with moderate-to-severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother-child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50-100 µg or diamorphine 300 µg administered pre-operatively; paracetamol; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single-injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non-steroidal anti-inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel-Cohen incision; non-closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.

PAIN OUT: the making of an international acute pain registry.

BACKGROUND: About 240 million patients undergo surgery every year, worldwide. Roughly 50% of these patients report clinically significant pain. Numerous barriers impede provision of adequate management. Lack of evidence about appropriateness and effectiveness of interventions is one. A registry can provide such information, eventually facilitating better management. This paper reports the development and feasibility of PAIN OUT, the first international acute pain registry, established with funds from the European Commission, and presents preliminary analysis to illustrate the nature of investigations that registry data make possible. METHODS: On the first postoperative day, 6347 adult patients undergoing orthopaedic or general surgery, in 11 medical centres in Europe and Israel, provided Patient Reported Outcomes (PROs) using a validated questionnaire. Clinical data were abstracted from the patient's chart. RESULTS: Feasibility worked well. Over a period of 1 year, surveyors accrued targeted data sets and entered them into an online browser. Collaborators could receive online feedback comparing their findings about PROs against anonymized findings from other centres. Missing data for the majority of variables were low. Despite considerable variability between institutions, a large number of patients were treated according to the generic, evidence-based recommendations we assessed. However, this was not sufficient to result in acceptable outcomes for the majority of patients. CONCLUSION: The initial development of PAIN OUT has been achieved. From 2013, it continues as a not-for-profit academic project, open to clinicians and researchers worldwide. The International Association for Study of Pain and PAIN OUT will work together to maintain, disseminate and develop the registry.

Feasibility of international data collection and feedback on post-operative pain data: proof of concept.

Post-operative pain exacts a high toll from patients, families, healthcare professionals and healthcare systems worldwide. PAIN-OUT is a research project funded by the European Union's 7th Framework Program designed to develop effective, evidence-based approaches to improve pain management after surgery, including creating a registry for feedback, benchmarking and decision support. In preparation for PAIN-OUT, we conducted a pilot study to evaluate the feasibility of international data collection with feedback to participating sites. Adult orthopaedic or general surgery patients consented to participate between May and October 2008 at 14 collaborating hospitals in 13 countries. Project staff collected patient-reported outcomes and process data from 688 patients and entered the data into an online database. Project staff in 10 institutions met the enrolment criteria of collecting data from at least 50 patients. The completeness and quality of the data, as assessed by rate of missing data, were acceptable; only 2% of process data and 0.06% of patient-reported outcome data were missing. Participating institutions received access to select items as Web-based feedback comparing their outcomes to those of the other sites, presented anonymously. We achieved proof of concept because staff and patients in all 14 sites cooperated well despite marked differences in cultures, nationalities and languages, and a central database management team was able to provide valuable feedback to all.

Evidence-based management of postoperative pain in adults undergoing open inguinal hernia surgery.

BACKGROUND: Open inguinal hernia repair is associated with moderate postoperative pain, but optimal analgesia remains controversial. The aim of this systematic review was to evaluate the available literature on the management of pain after open hernia surgery. METHODS: Randomized studies, in English, published between January 1966 and March 2009, assessing analgesic and anaesthetic interventions in adult open hernia surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases. In addition to published evidence, clinical practice was taken into account to ensure that the recommendations had clinical validity. RESULTS: Of the 334 randomized studies identified, 79 were included. Quantitative analysis suggested that regional anaesthesia was superior to general anaesthesia for reducing postoperative pain. Spinal anaesthesia was associated with a higher incidence of urinary retention and increased time to home-readiness compared with regional anaesthesia. CONCLUSION: Field block with, or without wound infiltration, either as a sole anaesthetic/analgesic technique or as an adjunct to general anaesthesia, is recommended to reduce postoperative pain. Continuous local anaesthetic infusion of a surgical wound provides a longer duration of analgesia. Conventional non-steroidal anti-inflammatory drugs or cyclo-oxygenase 2-selective inhibitors in combination with paracetamol, administered in time to provide sufficient analgesia in the early recovery phase, are optimal. In addition, weak opioids are recommended for moderate pain, and strong opioids for severe pain, on request.

Choose your menu wisely: cuisine-associated food-poisoning risks in restaurants in England and Wales.

The food service sector continues to be the most common setting for reported foodborne disease outbreaks in England and Wales. Using restaurant-associated foodborne outbreaks reported in England and Wales from 1992 to 2009, cuisine-specific risk factors were examined. Of 677 restaurant outbreaks, there were 11 795 people affected, 491 hospitalizations, and seven deaths; and Chinese, Indian, British and Italian cuisines were the most commonly implicated (26%, 16%, 13% and 10%, respectively). Salmonella spp. accounted for most outbreaks of all cuisine types, and particularly Chinese (76%, 133/175) and Italian (55%, 38/69). Poultry meat was the most frequently implicated food vehicle in outbreaks associated with Indian (30%), Chinese (21%), and British (18%) cuisines while for Italian cuisine, desserts and cakes were more frequently implicated (33%). Rice dishes were also a common outbreak food vehicle in those restaurants serving Chinese (22%) and Indian (16%) cuisine. Cross-contamination was the biggest contributory factor associated with Chinese (46%), British (33%) and Indian (30%) cuisines whereas inadequate cooking (38%) and use of raw shell eggs in lightly cooked or uncooked food (35%) were more often associated with Italian cuisine. Over the surveillance period, the proportion of Salmonella Enteritidis PT4 outbreaks in restaurants serving Chinese cuisine significantly decreased (P<0.0001) and this was mirrored by an increase in S. Enteritidis non-PT4 outbreaks (P<0.0001). Despite this change in proportion, contributory factors such as cross-contamination have continued to cause outbreaks throughout the 18 years. The results show that by stratifying the risks associated with restaurants by cuisine type, specific evidence of food control failures can be used to target foodborne illness reduction strategies.

A 17-year review of foodborne outbreaks: describing the continuing decline in England and Wales (1992-2008).

Systematic national surveillance of foodborne disease outbreaks effectively serves the development of public health policy on food safety. The Health Protection Agency has maintained a collaborative surveillance system for foodborne outbreaks in England and Wales since 1992. Up to 2008, 2429 foodborne outbreaks were identified, described and analysed for changes over time. Salmonella spp. accounted for half of the outbreaks, although the proportion of these decreased over the surveillance period. Similarly, the proportion of outbreaks caused by Clostridium perfringens decreased, while those attributed to Campylobacter spp. and Vero cytotoxin-producing Escherichia coli O157 increased. Although poultry meat was the most frequently implicated food vehicle in outbreaks followed by miscellaneous foods and red meats, the proportion of outbreaks attributed to meats in fact decreased over time but those linked to miscellaneous foods did not. Over the surveillance period, the proportion of outbreaks linked to eggs and S. Enteritidis non-phage-type 4, particularly in food service establishments, increased, highlighting the importance of this organism/setting/vehicle association. Contributory factors in most outbreaks were cross-contamination, inadequate heat treatment, and inappropriate food storage. This study describes the overall decline in foodborne outbreaks, providing evidence that the introduction and adherence to effective control measures provide the best means of minimizing the risk of foodborne infection.

Patients' assessment of 4-week recovery after ambulatory surgery.

BACKGROUND: patients' own assessment of recovery after ambulatory surgery has not been well studied. The aim was to study patients' self-assessed recovery, the occurrence and time course of post-operative problems in relation to the type of ambulatory surgery. METHODS: a questionnaire was filled in by 355 patients at five time points: pre-operative, first day at home, 1, 2 and 4 weeks post-operatively. Consecutive patients who underwent either inguinal hernia repair (IHR), arthroscopic procedures (AS) or cosmetic breast augmentation (CBA) were included. RESULTS: unplanned return to hospital was rare (3/355). Health care contacts were noted for 9% of the patients during the first week; a total of 70 contacts occurred during the entire period. Pain was the most frequently reported symptom; 40% of the patients reported pain or mobility problems at 1 week, 28% after 2 weeks and 20% after 4 weeks. Pre-operative pain was associated with an increased level of pain during the early post-operative course, in the recovery room and at 1 week post-operatively. IHR was associated with an overall rapid recovery, while AS patients experienced a slower restitution. All AS patients who reported pain after 4 weeks had reported pain problems already pre-operatively. Pain was not present pre-operatively in the CBA group, but was common at 1 and 2 post-operative weeks and was still reported by 11% at 4 weeks. CONCLUSION: self-assessed recovery was found to cover several weeks with procedure-specific recovery patterns. Pain and mobility impairment were still frequently reported 4 weeks post-operatively.

A recipe for disaster: outbreaks of campylobacteriosis associated with poultry liver pâté in England and Wales.

Despite the frequency of Campylobacter as the principal cause of bacterial gastroenteritis in the UK, outbreaks attributed to this pathogen are rare. One hundred and fourteen general foodborne outbreaks of campylobacteriosis were reported to the Health Protection Agency from 1992 to 2009 with most occurring in food service establishments (64%, 73/114). Poultry meat (38%, 43/114) was the most commonly reported vehicle of infection, of which poultry liver pâté, and undercooking, were strongly associated with this pathogen. Notably, the number of outbreaks of campylobacteriosis linked to consumption of poultry liver pâté in England and Wales increased significantly from 2007 (74% as opposed to 12%, P<0·00001) with a preponderance of these occurring in December. These outbreaks highlight the hazards associated with inappropriate culinary practices leading to undercooking of poultry liver pâté and suggest that improving catering practice is an important last line of defence in reducing exposure to Campylobacter-contaminated products.

Patient assessed health profile: a six-month quality of life questionnaire survey after day surgery.

AIM: Patient assessed quality of life is one of the principal end-points after day surgery. The aim of the present study was to describe the natural course, differences and timing of final evaluation for three common day surgical procedures; inguinal hernia repair (IHR), arthroscopic procedures (AS); and cosmetic breast augmentation (CBA). METHOD: A total of 355 patients prospectively completed an extended eight-item EQ-5D questionnaire (pain, mobility, mood, self-care, activities, sleep, sex, need for analgesic), preoperatively and at one, three and six months postoperatively. RESULTS: Pain and mobility problems were frequently reported prior to surgery among IHR and AS patients, while CBA patients had less deviation from normal in the preoperative health profile. The proportions of patients reporting surgery-related deviations were 35%, 20% and 5% at one, three and six months respectively. After one month, 50% of AS patients still suffered subjective discomfort as compared to 13% and 20% of the IHR and CBA patients, respectively. Pain and ambulation problems were the most common symptoms in all groups. Six months after surgery, 94% of IHR, 89% of AS and 97% of CBA patients were fully recovered. CONCLUSIONS: No major morbidity or severe complications were observed and patients' satisfaction was high overall. We found procedure-specific changes in the postoperative health profile after day surgery. AS patients recovered more slowly compared with IHR and CBA patients. We conclude that time for final evaluation differs significantly between procedures.

A study of depression and anxiety in cancer patients.

The aim of the study was to assess the prevalence of depression and anxiety in cancer patients. A cross sectional case control study design was used. Severely or terminally ill cancer patients and patients suffering from other concomitant illnesses were excluded from the study. Depression and anxiety was assessed on 50 cancer patients (cases) and on 50 healthy individuals (controls). The tools used were Structured Proforma (for recording sociodemographic details and relevant medical history), General Health Questionnaire (GHQ) and Hospital Anxiety and Depression Scale (HADS). A total of 30 (60.0%) were detected as 'cases' or having psychiatric morbidity based on a cutoff score of above 2 on 12 item GHQ. Depression was present in 28.0% of cancer patients whereas 40.0% of cancer patients had anxiety as per HADS.

Postoperative impact of regular tobacco use, smoking or snuffing, a prospective multi-center study.

BACKGROUND: The aim was to study the effects of different tobacco administration routes on pain and post-operative nausea and vomiting (PONV), following three common day surgical procedures: cosmetic breast augmentation (CBA), inguinal hernia repair (IHR) and arthroscopic procedures (AS). We have prospectively investigated the effects of regular tobacco use in ambulatory surgery. METHODS: The 355 allocated patients were followed during recovery and the first day at home. RESULTS: Thirty-two percent of the patients used tobacco regularly, 33% of CBA, 27% of IHR and 34% of AS. Pain was well controlled in the post-anesthesia care unit at rest; during ambulation, 37% of all patients reported VAS>3. Tobacco use had no impact on early post-operative pain. Post-operative nausea was experienced by 30% of patients during recovery while in hospital. On day 1, 14% experienced nausea. We found a significant reduction of PONV among tobacco users (smoking and/or snuffing). Smoking or snuffing reduced the risk of PONV by nearly 50% in both genders on the day of surgery and at the first day at home. The reduction of PONV was equal, regardless of tobacco administration routes. CONCLUSION: We found that regular use of tobacco, both by smoking and snuffing, had a significant effect on PONV during the early post-operative period. Non-tobacco users undergoing breast surgery were found to have the highest risk for PONV. We could not see any influence of nicotine use on post-operative pain. Thus, it seems of value to identify regular tobacco use, not only smoking, as a part of the pre-operative risk assessment.

Survey of Salmonella contamination of edible nut kernels on retail sale in the UK.

Consumption of nut kernels has shown an upward trend due to people's increasing tendency to eat healthy snacks. The purpose of this survey was to establish the microbiological safety of retail edible nut kernel samples of different varieties. Overall Salmonella spp. and Escherichia coli were detected from 0.1% and 0.8% of 2886 edible nut kernels, respectively. S. Senftenberg and S. Tennessee were detected from two pre-packed samples of Brazil nuts (0.4%) and S. Anatum from a pre-packed mixed nuts sample (0.9%; mix: almonds, Brazils, cashews, peanuts, walnuts) indicating a risk to health. The levels of Salmonella ranged from <0.01 to 0.23/g. E. coli at unsatisfactory levels (150/g) was present in another pre-packed Brazils nuts sample (0.2%). E. coli was additionally found at lower levels (range: 3.6-43/g) in Brazils (1.9%), macadamia (1.5%), pistachios (1.1%), walnuts (0.7%), peanuts (0.7%), hazels (0.5%), cashews (0.4%), and almonds (0.3%). Levels of E. coli did not correlate with the presence of Salmonella. The batches contaminated with Salmonella were recalled and Food Standards Agency food alerts were issued to advise against the consumption of the affected products. The presence of Salmonella is unacceptable in ready-to-eat foods and follows that the need for applying good agricultural and hygiene practices and effective decontamination procedures during the production of edible kernels cannot be overemphasized.

Intrauterine insemination practice in the UK.

Intrauterine insemination (IUI) is a recognised treatment for infertility. The overall success rate of IUI remains controversial and depends on several factors. There is a wide variation in the practice of IUI across the country. A postal survey was conducted to determine the attitudes to the factors influencing IUI practice. A questionnaire containing 22 factors was sent to 150 reproductive medicine units in the UK. Practitioners were requested to rate each parameter on the scale of 1-10, where 1 was least important and 10 very important. A total of 101 practitioners replied. Over 50% of the corresponding practitioners were Consultants, 32% were Infertility Nurse Specialists and 12% were other clinicians. The factor with the highest rating was the number of the follicles on the day of human chorionic gonadotrophin (hCG) injection, followed by the size of the follicle and the total sperm count. The fourth critical factor voted was the need for a standardised protocol for all the unit staff. The wide variation in the approach to IUI probably explains the great variance in pregnancy rates. Further properly designed studies are needed to ascertain the role of the factors in determining the success of IUI and the most successful protocols.

Clinical practice and routines for day surgery in Sweden: implications for improvement in nursing interventions.

The purpose of this study was to examine nursing practice in day surgery settings in Sweden. A questionnaire focusing on the routines of the day surgery process of patients in Sweden was administered. Based on these findings, appropriate nursing interventions are outlined and discussed. Day surgery routines were in accordance with general worldwide practice. The study revealed that nursing involvement was rare in the preoperative routine. In addition, the major part of the recovery process, including assessments of discharge eligibility and information about pain management, was managed by PACU nurses. The nurse follow-up revealed a number of subjective queries and symptoms that, in a seemingly easy way, could have been prevented by further perianesthesia/perioperative patient education. There is an obvious place for nursing interventions when the decision for day surgery is taken. These interventions should focus on providing the patient with information before surgery, preoperative patient health screening, and information/education at discharge. Furthermore, nursing interventions should include quality assurance, such as follow-up calls for the evaluation of care, as well as providing information and coaching for the patient at home.