Opioid prescribing for acute postoperative pain: an overview of systematic reviews related to two consensus statements relevant at patient, prescriber, system and public health levels.

BACKGROUND: National guidelines for rational opioid prescribing for acute postoperative pain are needed to optimise postoperative pain control and function whilst minimising opioid-related harm. OBJECTIVES: This overview of systematic reviews aims to summarise and critically assess the quality of systematic reviews related to the 20 recommendations from two previously published consensus guideline papers (ten relevant at patient and prescriber levels and ten at a system / Public Health level). It also aims to identify gaps in research that require further efforts to fill these in order to augment the evidence behind creating national guidelines for rational opioid prescribing for acute postoperative pain. METHODS: A systematic database search using PubMed/MEDLINE and Cochrane was conducted in November 2022. Furthermore, reference lists were reviewed. All identified systematic reviews were assessed for eligibility. Data from each study was extracted using a pre-standardised data extraction form. The methodological quality of the included reviews was assessed by two independent reviewers using the AMSTAR 2 checklist. Descriptive synthesis of the results was performed. RESULTS: A total of 12 papers were eligible for analysis. Only eight out of the total 20 prioritised recommendations had systematic reviews that provided evidence related to them. These systematic reviews were most commonly of critically low quality. CONCLUSION: The consensus papers provide guidance and recommendations based on the consensus of expert opinion that is based on the best available evidence. However, there is a lack of evidence supporting many of these consensus statements. Efforts to further analyse interventions that aim to reduce the rates of opioid prescribing and their adverse effects should therefore continue.

Medical Student Perspectives on Undergraduate Oncology Education in the UK.

AIMS: The British Oncology Network for Undergraduate Societies (BONUS) surveyed students who attended an oncology revision day to determine their views on the current quantity, quality and type of curriculum-based oncology teaching they have experienced. MATERIALS AND METHODS: Students attending two BONUS revision days received a questionnaire assessing their experience of oncology teaching within the medical curriculum and interest in pursuing a future career in oncology using a 10-point Likert scale. Data were collected with informed consent to be anonymised and used for research. Student demographics and qualitative and quantitative data about experiences of oncology education were analysed. RESULTS: In total, 451 students registered to attend the revision days. After removal of duplicates, non-responders and non-UK participants, responses from 153 students studying across years 1-6 at 22 UK medical schools were analysed. The mean quantity of oncology lectures students reported receiving was 8.9 hours and the mean quantity of clinic/ward-based oncology teaching was 7.5 hours. Ninety (62.1%) of the 145 students who responded to the relevant question reported that they had received dedicated teaching in oncology. Students who had received dedicated oncology teaching reported a statistically significantly higher mean quality 6.1 (95% confidence interval 5.6-6.5) versus 5.0 (95% confidence interval 4.3-5.5; P = 0.003) and quantity 5.2 (95% confidence interval 4.7-5.6) versus 4.3 (95% confidence interval 3.7-4.9; P = 0.03) of oncology teaching compared with those who had not received this. CONCLUSION: Appropriate oncology education is essential for all medical students due to the high prevalence of cancer. All future doctors need the appropriate knowledge and communication skills to care for cancer patients. Our analysis provides quantitative evidence to support the value of specialist oncology teaching within the medical school curriculum in improving student-reported experience. National student-led revision days and events may widen interest in a future career in oncology and aid collaboration between oncology societies. It is important for the general undergraduate medical curriculum to integrate specialty content. An integrated curriculum should facilitate a holistic approach that spans prevention, screening, treatment and palliation rather than being split by subspeciality.

A theory for the atmospheric energy spectrum: depth-limited temperature anomalies at the tropopause.

The horizontal spectra of atmospheric wind and temperature at the tropopause have a steep -3 slope at synoptic scales, but transition to -5/3 at wavelengths of the order of 500-1,000 km [Nastrom, G. D. & Gage, K. S. (1985) J. Atmos. Sci. 42, 950-960]. Here we demonstrate that a model that assumes zero potential vorticity and constant stratification N over a finite-depth H in the troposphere exhibits the same type of spectra. In this model, temperature perturbations generated at the planetary scale excite a direct cascade of energy with a slope of -3 at large scales, -5/3 at small scales, and a transition near horizontal wavenumber k(t) = f/NH, where f is the Coriolis parameter. Ballpark atmospheric estimates for N, f, and H give a transition wavenumber near that observed, and numerical simulations of the previously undescribed model verify the expected behavior. Despite its simplicity, the model is consistent with a number of perplexing features in the observations and demonstrates that a complete theory for mesoscale dynamics must take temperature advection at boundaries into account.

Sacral insufficiency fractures in the elderly.

Sacral insufficiency fractures are not uncommon in elderly patients. We have diagnosed 20 cases in a five-year period, and have reviewed the clinical records, radiographs, CT and bone scans. We also assessed the degree of osteoporosis by measuring bone density using dual-energy X-ray absorptiometry and bone histomorphometry, and monitored the patients' functional outcome. Bone scans were positive in all 20 patients, CT showed a fracture or sclerosis in 7 of 12 patients and was useful in excluding malignancy. Plain radiographs were the least helpful, showing sclerosis in only 4 of the 20 patients. Involutional osteoporosis with a reduced bone formation rate was the most common underlying cause. Seventeen patients had complete resolution of pain within nine months, and no patient lost independence in daily activities. Increased awareness of these fractures may help to avoid unnecessary investigation and treatment. Bedrest and analgesia followed by rehabilitation provide good relief of symptoms.

Risk factors for hepatitis C virus infection in blood donors: a case-control study.

OBJECTIVE: To investigate risk factors for hepatitis C virus (HCV) infection in Sydney blood donors. DESIGN: Blood donors confirmed to be positive for HCV antibodies were compared with blood donors with a positive result of a screening assay, but whose HCV antibody status had not been confirmed. A questionnaire on sexual, parenteral and other potential risk factors was administered to both groups. SETTING: Blood Transfusion Service in Sydney. PARTICIPANTS: The study enrolled 220 donors who had confirmed HCV infection, and 210 donors who did not. RESULTS: The relative risk associated with injecting drug use was 63 (95% confidence interval, 19-260) when comparison was made with all other donors. Among donors who did not report injecting drug use, a significant, independent increase in risk was found in association with having had a tattoo. Among donors who did not give a history of parenteral exposure, there was a significantly greater risk in people with more than one life-time sexual partner than in those with at most one partner. CONCLUSION: A history of injecting drug use was elicited as the most important risk factor in Sydney blood donors with antibodies to hepatitis C. Having had a tattoo, and an increased number of lifetime sexual partners were also independently associated with HCV infection.

Clinical assessment and incidence of hepatitis C RNA in 50 consecutive RIBA-positive volunteer blood donors.

OBJECTIVES: (i) To assess evidence of liver disease in 50 consecutive volunteer blood donors who were anti-hepatitis C virus (anti-HCV) antibody positive and who were referred to one hepatologist; (ii) to assay for viral RNA in serum in these patients. SETTING: Royal Prince Alfred Hospital, a teaching hospital of the University of Sydney. PATIENTS: Fifty people who were detected by the NSW Red Cross Blood Transfusion Service to be anti-HCV antibody positive and to have a positive result on recombinant immunoblot assay (RIBA) were assessed by one hepatologist for symptoms, signs and biochemical evidence of hepatic dysfunction. These patients were consecutive referrals from this source. Sixteen of these patients also consented to liver biopsy assessment. All patients had serum assayed for viral RNA by polymerase chain reaction with a combination of 3' and 5' primers. RESULTS: The 50 blood donors consisted of 28 men and 22 women, with a mean age of 34.5 years. Forty-six patients were asymptomatic. Only six had a past history of hepatitis while 14 had minor signs of chronic liver disease. In 28, injecting drug use was thought the most likely source of exposure to HCV. The minimal mean time since exposure to HCV in these patients was 8.8 +/- 5.2 years. Eight patients had received a blood transfusion at a mean time of 15.0 +/- 9.8 years from the time of consultation. The mean maximum level of alanine aminotransferase (ALT) in all 50 patients was 102.8 U/L. Five patients had persistently normal ALT levels; another 22 had at least one normal ALT level. Liver biopsies indicated chronic persistent hepatitis in 11 patients, mild chronic active hepatitis in three patients and more severe chronic active hepatitis in one. One patient had cirrhosis on biopsy. Forty-two patients had viral RNA detected in serum. CONCLUSION: Chronic infection with HCV in blood donors was invariably asymptomatic; 78% of patients had no signs of chronic liver disease and 68% had a maximum hepatic transaminase level of less than 100 U/L. Although severe liver disease was seen in two of 16 biopsies, the majority of these patients have mild liver disease despite a mean of about 10 years since exposure to the virus. Eighty-four per cent of patients had evidence of viral RNA in serum.