Enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil: a single-centre before-and-after cohort study.

Mortality and morbidity for high-risk surgical patients are often high, especially in low-resource settings. Enhanced peri-operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before-and-after cohort study aimed to assess the effectiveness of a postoperative 48-hour enhanced care pathway for high-risk surgical patients ('high-risk surgical bundle') who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high-risk post-anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in-hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high-risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high-risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30-0.72). The high-risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49-0.80]) and surgical re-interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30-0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high-risk surgical patients in a resource-constrained setting could reduce in-hospital mortality.

Neonatal morphine administration leads to changes in hippocampal BDNF levels and antioxidant enzyme activity in the adult life of rats.

It is know that repeated exposure to opiates impairs spatial learning and memory and that the hippocampus has important neuromodulatory effects after drug exposure and withdrawal symptoms. Thus, the aim of this investigation was to assess hippocampal levels of BDNF, oxidative stress markers associated with cell viability, and TNF-α in the short, medium and long term after repeated morphine treatment in early life. Newborn male Wistar rats received subcutaneous injections of morphine (morphine group) or saline (control group), 5 µg in the mid-scapular area, starting on postnatal day 8 (P8), once daily for 7 days, and neurochemical parameters were assessed in the hippocampus on postnatal days 16 (P16), 30 (P30), and 60 (P60). For the first time, we observed that morphine treatment in early life modulates BDNF levels in the medium and long term and also modulates superoxide dismutase activity in the long term. In addition, it was observed effect of treatment and age in TNF-α levels, and no effects in lactate dehydrogenase levels, or cell viability. These findings show that repeated morphine treatment in the neonatal period can lead to long-lasting neurochemical changes in the hippocampus of male rats, and indicate the importance of cellular and intracellular adaptations in the hippocampus after early-life opioid exposure to tolerance, withdrawal and addiction.

Pain-autonomic interaction after work-induced sleep restriction.

BACKGROUND AND PURPOSE: Poor sleep is commonly associated with alterations in pain perception. However, there is a lack of studies that address work-associated sleep restriction (SR) and changes in non-nociceptive perception and autonomic responses after work-induced SR. METHODS: This study was performed with 19 medical students after a normal-sleep night (NS phase) and after a night shift at the local emergency room (SR phase). We performed clinical assessment, quantitative sensory testing for electrical and temperature sensation, RR interval analysis, and recorded sudomotor skin responses (SSRs). RESULTS: The total mean duration of sleep was 436 ± 18 min in the NS group and 120 ± 28 min in the SR group (P<0.001). The anxiety scores were higher following the SR phase compared with those after the NS phase (P<0.01). After SR, there was a decrease in heat-pain threshold, but neither warm nor electrical thresholds were affected. Following SR, subjects showed higher SSR amplitudes and an increased number of double responses at an interstimulus interval of 2 s. We also observed a moderate inverse correlation between heat-pain thresholds and SSR amplitude (r= -0.46; P<0.01). However, there was no correlation between anxiety scores and SSR parameters. CONCLUSIONS: The effects of SR in the context of work stress on pain are specific and appear unrelated to general changes in sensory perception. Hyperalgesia was associated with abnormal autonomic responses, but not with increased anxiety, which suggests an association between the nociceptive and autonomic nervous systems that is independent of the emotional state.

Cafeteria diet-induced obesity plus chronic stress alter serum leptin levels.

Obesity is a disease that has become a serious public health issue worldwide, and chronic stressors, which are a problem for modern society, cause neuroendocrine changes with alterations in food intake. Obesity and chronic stress are associated with the development of cardiovascular diseases and metabolic disorders. In this study, a rat model was used to evaluate the effects of a hypercaloric diet plus chronic restraint stress on the serum leptin and lipids levels and on the weight of specific adipose tissue (mesenteric, MAT; subcutaneous, SAT and visceral, VAT). Wistar rats were divided into the following 4 groups: standard chow (C), hypercaloric diet (HD), stress plus standard chow (S), and stress plus hypercaloric diet (SHD). The animals in the stress groups were subjected to chronic stress (placed inside a 25 cm × 7 cm plastic tube for 1h per day, 5 days per week for 6 weeks). The following parameters were evaluated: the weight of the liver, adrenal glands and specific adipose tissue; the delta weight; the Lee index; and the serum levels of leptin, corticosterone, glucose, total cholesterol, and triglycerides. The hypercaloric diet induced obesity in rats, increasing the Lee index, weight, leptin, triglycerides, and cholesterol levels. The stress decreased weight gain even in animals fed a hypercaloric diet but did not prevent a significant increase in the Lee index. However, an interaction between the independent factors (hypercaloric diet and stress) was observed, which is demonstrated by the increased serum leptin levels in the animals exposed to both protocols.

Obesity and shift work: chronobiological aspects.

The present review has the objective of summarising chronobiological aspects of shift work and obesity. There was a systematic search in PubMed databases, using the following descriptors: shift work; obesity; biological clock. Shift work is extremely frequent in several services and industries, in order to systematise the needs for flexibility of the workforce, necessary to optimise productivity and business competitiveness. In developing countries, this population represents a considerable contingent workforce. Recently, studies showed that overweight and obesity are more prevalent in shift workers than day workers. In addition, the literature shows that shift workers seem to gain weight more often than those workers submitted to a usual work day. In conclusion, there is considerable epidemiological evidence that shift work is associated with increased risk for obesity, diabetes and CVD, perhaps as a result of physiological maladaptation to chronically sleeping and eating at abnormal circadian times. The impact of shift work on metabolism supports a possible pathway to the development of obesity and its co-morbities. The present review demonstrated the adverse cardiometabolic implications of circadian misalignment, as occurs chronically with shift workers.

Preoperative predictors of moderate to intense acute postoperative pain in patients undergoing abdominal surgery.

BACKGROUND: Pain is a sensory and emotional experience that is influenced by physiologic, sensory, affective, cognitive, socio-cultural, and behavioral factors. Consistent with the perspective to improve the postoperative pain control, the present study has the purpose of assessing the effect of presurgical clinical factors, psychological and demographic characteristics as predictors for reporting moderate to intense acute postoperative pain. METHODS: A prospective cohort study was performed with 346 inpatients undergoing abdominal elective surgery (ASA physical status I-III, age range 18-60 years). The measuring instruments were Pain Visual Analog Scale, the State-Trait Anxiety Inventory, and the Montgomery-Asberg Depression Rating Scale. Multivariate conditional regression modeling was used to determine independent predictors for moderate to intense acute postoperative pain. RESULTS: Moderate to intense acute postoperative pain was associated with status ASA III (odds ratio (OR) = 1.99), age (OR = 4.72), preoperative moderate to intense pain (OR = 2.96), chronic pain (OR = 1.75), high trait-anxiety and depressive mood moderate to intense (OR = 1.74 and OR = 2.00, respectively). Patients undergoing surgery to treat cancer presented lower risk for reporting moderate to intense pain OR = 0.39, as well as those that received the epidural analgesia and multimodal analgesia with systemic opioid (OR = 0.09 and OR = 0.16, respectively). CONCLUSIONS: The identification of predictive factors for intense acute postoperative pain may be useful for designing specific preventive interventions to relieve patient suffering. Especially because few of these variables are accessible for medical intervention, which would improve the clinical outcomes and quality of life of patients at risk of moderate to intense acute postoperative pain.

Effect of pre-operative anxiolysis on postoperative pain response in patients undergoing total abdominal hysterectomy.

In a double blind, placebo-controlled trial, we have assessed the effects of pre-operative anxiolysis on postoperative pain scores in 112 ASA I-II women, aged 18-65 years, scheduled to undergo total abdominal hysterectomy. Subjects were randomly allocated to receive either oral diazepam 10 mg (n=56) or placebo (n=56) pre-operatively. Postoperative anxiety, pain scores, analgesic consumption, and sedation were evaluated at several time points during the first 24 h following surgery. Postoperative pain scores were found to be significantly higher in the diazepam group. Trait and state anxiety showed a significant effect on pain scores, independent of the treatment group. No difference was found between the groups in morphine consumption, but there was a significant reduction in morphine consumption with time.

Sleep disturbances associated with minor psychiatric disorders in medical students.

We performed a cross-sectional study with 342 medical students (age range, 18-35 years) to identify, among a group of sleep disturbances, those which are related to minor psychiatric disorders in this population. The instruments employed for data collection were the self-reporting questionnaire (SRQ-20), the morningness/eveningness questionnaire, the Epworth sleepiness scale, and a general questionnaire regarding demographic characteristics, use of drugs, history of psychopathology, usual fall-asleep time, usual wake-up time, amount of sleep, arousal during the night, and insomnia. We used a logistic regression model to determine independent factors associated with minor psychiatry disorders. Daytime sleepiness [odds ratio (OR), 2.12; 95% CI, 1.21-3.71], arousal [OR, 4.54; 95% CI, 1.97-10.47], insomnia [OR 2.45; 95% CI, 1.32-4.56], and sleeping less than 7 hours per night [OR, 2.02; 95% CI, 1.11-3.67] were associated with minor psychiatric disorders. This group of variables determined a cumulative risk ratio of 5.47 [95% CI, 2.87-10.41] for the main outcome.

Risk factors for postoperative anxiety in adults.

We identified risk factors for postoperative anxiety and quantified their effect on 712 adults between 18 and 60 years of age (ASA I-III physical status) undergoing elective surgery under general anaesthesia, neural blockade or both. The measuring instruments were a structured questionnaire, a pain visual analogue scale, the McGill Pain Questionnaire, the State-Trait Anxiety Inventory, the Montgomery-Asberg Depression Rating Scale, a Self-Reporting Questionnaire-20, and a Self-Perception of Future Questionnaire. Multivariate conditional regression modelling taking into account the hierarchical relationship between risk factors revealed that postoperative anxiety was associated with ASA status III (OR = 1.48), history of smoking (1.62), moderate to intense postoperative pain (OR = 2.62) and high pain rating index (OR = 2.35), minor psychiatric disorders (OR = 1.87), pre-operative state-anxiety (OR = 2.65), and negative future perception (OR = 2.20). Neural block anaesthesia (OR = 0.72), systemic multimodal analgesia (OR = 0.62) and neuroaxial opioids with or without local anaesthesia (OR = 0.63) were found to be protective factors against postoperative anxiety.

Risk factors for preoperative anxiety in adults.

BACKGROUND: Patients who undergo surgery experience acute psychological distress in the preoperative period. The objective of this study was to identify and quantify the effect of risk factors for preoperative anxiety in adults. METHODS: A cross-sectional study was performed with 592 inpatients scheduled for elective surgery. Age ranged from 18 to 60 years (ASA physical status I-III). Demographic information was collected using a structured questionnaire. The measuring instruments were a visual analog scale, the State-Trait Anxiety Inventory; the Montgomery-Asberg Depression Rating Scale, the WHO Self-Reporting Questionnaire-20, and the future self-perception questionnaire. Multivariate conditional regression modeling was used to control confounding factors and to determine independent predictors of preoperative anxiety, taking into account the hierarchical relationship between risk factors. RESULTS: High preoperative anxiety was associated with history of cancer (odds ratio (OR)=2.26) and smoking (OR=7.47), psychiatric disorders (OR=5.93), negative future perception (OR= 2.30), moderate to intense depressive symptoms (3.22), high trait-anxiety (3.83), moderate to intense pain (2.12), medium surgery (OR=1.52), female gender (OR=2.0), ASA category III (OR=3.41), up to 12 years of education (OR=1.36), and more than 12 years of education (OR=1.68). Previous surgery (OR= 0.61) was associated with lower risk for preoperative state-anxiety. CONCLUSIONS: History of cancer and smoking, psychiatric disorders, negative future perception, moderate to intense depressive symptoms, high trait-anxiety, moderate to intense pain, medium surgery, female gender, ASA category III, up to 12 years of education and more than 12 years of education constituted independent risk factors for preoperative state-anxiety. Previous surgery reduced the risk for preoperative anxiety.

Risk factors for postoperative anxiety in children.

BACKGROUND: Anxiety is defined as a set of behavioural manifestations that can be divided into state- and trait-anxiety. State-anxiety is a transitory emotional condition that varies in intensity and fluctuates over time. Trait-anxiety is a personality trait which remains relatively stable over time. The objective of this study was to identify and quantify perioperative risk factors for immediate postoperative anxiety in children. METHODS: A prospective cohort study was performed with 90 schoolchildren, ages ranging from 7 to 13 years old, ASA physical status I-II, submitted to elective surgery. The measuring instruments were verbal scale of pain, visual analogue scale (VAS), Trait-State Anxiety Inventory for Children (STAIC), Trait-State Anxiety Inventory (STAI) for parents, and structured questionnaire. RESULTS: Patients not submitted to analgesic block and patients with moderate and intense pain presented an estimated risk 5- and 13-fold greater for high levels of postoperative state-anxiety, respectively. High levels of preoperative state-anxiety and administration of doses of midazolam less than 0.056 mg x kg(-1) constituted an estimated risk for postoperative state-anxiety of 3- and 4-fold, respectively. A positive history of previous surgery was associated with lower risk for postoperative anxiety. CONCLUSIONS: High levels of preoperative state-anxiety, administration of less than 0.056 mg x kg(-1) of midazolam, absence of analgesic block and presence of moderate and intense postoperative pain constituted risk factors for immediate postoperative state-anxiety in children. Previous surgery reduced the risk for postoperative anxiety.