Publications by authors named "Patrice Forget"

110 Publications

Metoclopramide and Propofol to Prevent Nausea and Vomiting during Cesarean Section under Spinal Anesthesia: A Randomized, Placebo-Controlled, Double-Blind Trial.

J Clin Med 2021 Dec 26;11(1). Epub 2021 Dec 26.

Department of Emergency, SS.ma Annunziata University Hospital, Via dei Vestini, 66100 Chieti, Italy.

Background: Intra-operative nausea, vomiting and retching (NVR) are frequently associated with subarachnoid anesthesia (SA) in women undergoing cesarean section (CS). In this study performed in women undergoing CS under SA with a risk factor control strategy, we compared saline (placebo), propofol, metoclopramide and both drugs to prevent NVR.

Methods: We recorded NVR events in 110 women undergoing CS who were randomized after umbilical cord clamping to receive saline (S; = 27), metoclopramide 10 mg (M; = 28), propofol 1 mg/kg/h (P; = 27) or both drugs (PM; = 28).

Results: The proportion of women with intra-operative nausea was: S: 17/27 (63%); P: 15/27 (56%); M: 13/28 (46%); PM: 6/28 (21%) ( = 0.012, Cramér's V = 0.31 (large effect). The proportion of women with intra-operative vomiting/retching was: S: 9/27 (33%); M: 7/27 (25%); P: 3/28 (11%); PM 2/28 (7%) ( = 0.049, Cramér's V = 0.26 (medium effect). Post-hoc multiple comparisons revealed a significant reduction in NVR episodes and NRS scores between the PM group and control. Sedation scores did not differ among groups.

Conclusion: In women undergoing CS under SA with a risk factor control strategy, combined propofol and metoclopramide reduce nausea and vomiting.
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http://dx.doi.org/10.3390/jcm11010110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8745529PMC
December 2021

Opioid-free versus opioid-based anesthesia in pancreatic surgery.

BMC Anesthesiol 2022 01 4;22(1). Epub 2022 Jan 4.

Department of Anesthesiology, Université Libre de Bruxelles, CUB Érasme, Brussels, Belgium.

Background: Opioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear.

Methods: Perioperative data from 77 consecutive patients who underwent pancreatic resection were included and retrospectively reviewed. Patients received either an OBA with intraoperative remifentanil (n = 42) or an OFA (n = 35). OFA included a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infiltration and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48 h after extubation, length of stay, adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes.

Results: Compared to OBA, NRS (3 [2-4] vs 0 [0-2], P < 0.001) and opioid consumption (36 [24-52] vs 10 [2-24], P = 0.005) were both less in the OFA group. Length of stay was shorter by 4 days with OFA (14 [7-46] vs 10 [6-16], P < 0.001). OFA (P = 0.03), with postoperative pancreatic fistula (P = 0.0002) and delayed gastric emptying (P < 0.0001) were identified as only independent factors for length of stay. The comprehensive complication index (CCI) was the lowest with OFA (24.9 ± 25.5 vs 14.1 ± 23.4, P = 0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups.

Conclusions: In this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.
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http://dx.doi.org/10.1186/s12871-021-01551-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8725294PMC
January 2022

Postoperative Outcomes Associated With Procedural Sedation Conducted by Physician and Nonphysician Anesthesia Providers: Findings From the Prospective, Observational African Surgical Outcomes Study.

Anesth Analg 2021 Dec 28. Epub 2021 Dec 28.

From the Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town Observatory, South Africa.

Background: There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Nonphysician anesthesia providers are utilized to assist with providing anesthesia and procedural sedation to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by nonphysicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death.

Methods: A secondary analysis of a prospective cohort of inhospital adult surgical patients representing 25 African countries was performed. The primary outcome was a collapsed composite of inhospital severe postoperative complications and death. We assessed the association between receiving procedural sedation conducted by a nonphysician (versus physician) and the composite outcome using logistic regression. We used the inverse probability of treatment weighting propensity score method to adjust for potential confounding variables including patient age, hemoglobin level, American Society of Anesthesiologists (ASA) physiological status, diabetes mellitus, urgency of surgery, severity of surgery, indication for surgery, surgical discipline, seniority of the surgical team, hospital level of specialization, and hospital funding system using public or private funding. All patients who only received procedural sedation for surgery were included.

Results: Three hundred thirty-six patients met the inclusion criteria, of which 98 (29.2%) received sedation from a nonphysician provider. The incidence of severe postoperative complications and death was 10 of 98 (10.2%) in the nonphysician group and 5 of 238 (2.1%) in the physician group. The estimated association between procedural sedation conducted by a nonphysician provider and inhospital outcomes was an 8-fold increase in the odds of severe complications and/or death, with an odds ratio (95% confidence interval [CI]) of 8.3 (2.7-25.6).

Conclusions: The modest number of observations in this secondary data analysis suggests that shifting the task of procedural sedation from physicians to nonphysicians to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer.
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http://dx.doi.org/10.1213/ANE.0000000000005819DOI Listing
December 2021

Prescribing and deprescribing opioids.

Authors:
Patrice Forget

Pain 2022 01;163(1):1-2

Institute of Applied Health Sciences, Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom.

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http://dx.doi.org/10.1097/j.pain.0000000000002299DOI Listing
January 2022

Opioid treatment for non-cancer pain: we need a comprehensive approach.

Authors:
Patrice Forget

BMJ 2021 12 13;375:n3045. Epub 2021 Dec 13.

University of Aberdeen, Aberdeen AB25 2ZD, UK.

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http://dx.doi.org/10.1136/bmj.n3045DOI Listing
December 2021

Mortality by opioid poisoning in children and teenagers and opioid prescriptions.

BMC Pediatr 2021 Dec 13;21(1):569. Epub 2021 Dec 13.

Institute of Applied Health Sciences, Epidemiology group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen; Department of Anaesthesia, NHS Grampian, Aberdeen, AB25 2ZD, UK.

Background: No comparisons between mortality from opioids in children and teenagers and opioid prescription patterns have been made in England.

Aim: To investigate if an association exists between mortality rates from opioid poisoning in persons aged 19 years old and under and community opioid prescription in England.

Methods: A retrospective analysis was undertaken for 2016 to 2019, comparing community opioid prescriptions and mortality rates from opioid poisoning.

Results: The number of opioid prescriptions decreased over the study period (- 2.4%, p < 0.001). Most deaths due to opioid poisoning in children and teenagers were seen in those under one year old and those aged between 15 and 19 years old (Kruskal-Wallis: p = 0.12; Dunn's test: p = 0.01). Deaths in all age ranges did not change significantly (Poisson Regression Analysis: p > 0.05).

Conclusion: Despite the reduction in community opioid prescriptions, there was no decrease in the number of deaths in children and teenagers due to opioid poisoning.
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http://dx.doi.org/10.1186/s12887-021-03061-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8667418PMC
December 2021

To what extent are we confident that tapentadol induces less constipation and other side effects than the other opioids in chronic pain patients? a confidence evaluation in network meta-analysis.

Br J Pain 2021 Nov 3;15(4):380-387. Epub 2020 Aug 3.

Anesthesiology and Perioperative Medicine, Acute and Chronic Pain Therapy, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium.

Background: A confidence evaluation helps to make informed decisions about the results of meta-analyses. The goal of this work is to perform a confidence evaluation of results of a network meta-analysis (NMA) on the digestive side effects of tapentadol in patients with chronic pain.

Methods: An updated search in PubMed/Medline and Web of Science search until March 2020 was done to perform pairwise meta-analyses with NMA using random-effect models and confidence in network meta-analysis (CiNeMA) for the confidence analysis.

Results: Twenty-five studies were included in the final analyses. Pairwise and indirect comparisons showed a reduced risk of constipation with tapentadol compared to oxycodone. The confidence evaluation did not raise any concerns in terms of confidence for the oxycodone versus tapentadol comparisons. The oxycodone-naloxone versus tapentadol comparisons showed some concerns, particularly in terms of imprecision and incoherence. Regarding the overall risk of any side effects, the confidence evaluation showed a major concern regarding imprecision, but not for the comparison between tapentadol and oxycodone. However, this comparison showed a major heterogeneity.

Discussion And Conclusions: A confidence evaluation in meta-analysis on the effect of tapentadol compared to other opioids in chronic pain showed possible imprecision, heterogeneity and/or incoherence. However, with a high level of confidence, tapentadol was associated with a lower incidence of constipation than oxycodone. Confidence analyses can help to get more information from meta-analyses.
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http://dx.doi.org/10.1177/2049463720945289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8611300PMC
November 2021

Perioperative NSAIDs and Long-Term Outcomes After cancer Surgery: a Systematic Review and Meta-analysis.

Curr Oncol Rep 2021 11 8;23(12):146. Epub 2021 Nov 8.

School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill Health Campus, Aberdeen, AB25 2ZD, UK.

Purpose Of Review: This review investigated the use of perioperative non-steroidal anti-inflammatory drugs (NSAIDs) and long-term outcomes in cancer surgery patients, and whether this is dependent on cancer type, type of NSAID and timing of administration.

Findings: Perioperative NSAID use was found to be associated with longer disease-free survival (hazard ration, HR = 0.84 (95% CI, 0.73-0.97)) and overall survival (HR = 0.78 (95% CI, 0.64-0.94)). No difference was found between different types of NSAID for disease-free survival, although in overall survival ketorolac use was significant (HR = 0.63 (95% CI, 0.42-0.95)). Analysis on the timing of NSAID administration found no subgroup to be associated with cancer outcomes. The cancer-type analysis found an association with outcomes in breast and ovarian cancers. However, the level of certainty remains very low, mostly due to the heterogeneity and the retrospective nature of most studies. Perioperative NSAID use may be associated with increased disease-free and overall survival after cancer surgery. This may be dependent on the type of cancer and type of NSAID, and further research is needed to support this. These data may inform future prospective trials, which are needed to determine the clinical impact, as well as optimal NSAID regimen.
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http://dx.doi.org/10.1007/s11912-021-01133-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8575753PMC
November 2021

Vasoactive agents in acute mesenteric ischaemia in critical care.  A systematic review.

F1000Res 2021 8;10:453. Epub 2021 Jun 8.

NHS Grampian, Aberdeen, UK.

: Acute mesenteric ischaemia (AMI) is a surgical emergency which has an associated high mortality.  The mainstay of active treatment includes early surgical intervention, with resection of non-viable bowel, and revascularisation of the ischaemic bowel where possible. Due to the physiological insult of AMI however, perioperative care often involves critical care and the use of vasoactive agents to optimise end organ perfusion. A number of these vasoactive agents are currently available with varied mechanism of action and effects on splanchnic blood flow. However, specific guidance on which is the optimal vasoactive drug to use in these settings is limited. This systematic review aimed to evaluate the current evidence comparing vasoactive drugs in AMI. : A systematic search of Ovid Medline, Ovid Embase, Cochrane CENTRAL and the Cochrane Database of Systematic Review was performed on the 5th of November 2020 to identify randomised clinical trials comparing different vasoactive agents in AMI on outcomes including mortality. The search was performed through the Royal College of Surgeons of England (RCSEng) search support library. Results were analysed using the Rayyan platform, and independently screened by four investigators. : 614 distinct papers were identified. After screening, there were no randomised clinical trials meeting the inclusion criteria. : This review identifies a gap in literature, and therefore recommends an investigation into current practice and clinician preference in relation to vasoactive agents in AMI. Multicentre randomised controlled trials comparing these medications on clinical outcomes will therefore be required to address this question.
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http://dx.doi.org/10.12688/f1000research.52782.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8459625.2PMC
November 2021

Recurrence Kinetics after Laparoscopic Versus Open Surgery in Colon Cancer. A Meta-Analysis.

J Clin Med 2021 Sep 15;10(18). Epub 2021 Sep 15.

Epidemiology Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK.

Background: Colorectal cancer (CRC) is a leading cause of mortality worldwide and in the UK. Surgical resection is the main curative treatment modality available and using a laparoscopic vs. an open approach may have a direct influence on the inflammatory response, influencing cancer biology and potentially the recurrence kinetics by promoting cancer growth.

Methods: This systematic review aims to compare laparoscopic with open surgery for the treatment of colon cancer with a specific focus on the moment of the recurrence. We included randomised controlled trials in intended curative surgery for colon cancer in adults.

Interventions: Studies investigating laparoscopic vs. open resection as an intended curative treatment for patients with confirmed carcinoma of the colon. The two co-primary outcomes were the time to recurrence and the overall survival (OS) and disease-free survival (DFS) at three and five years. Meta-analyses were done on the mean differences.

Results: After selection, we reviewed ten randomised controlled trials. Most of the trials did not display a statistically significant difference in either DFS or OS at three or at five years when comparing laparoscopic to open surgery. Groups did not differ for the OS and DFS, especially regarding the time needed to observe the median recurrence rate. The quality of evidence (GRADE) was moderate to very low.

Conclusion: We observed no difference in the recurrence kinetics, OS or DFS at three or five years when comparing laparoscopic to open surgery in colon cancer.
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http://dx.doi.org/10.3390/jcm10184163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8466495PMC
September 2021

Impact of COVID-19 on opioid use in those awaiting hip and knee arthroplasty: a retrospective cohort study.

BMJ Qual Saf 2021 Sep 14. Epub 2021 Sep 14.

Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.

Background: COVID-19 has had a detrimental impact on access to hip and knee arthroplasty surgery. We set out to examine whether this had a subsequent impact on preoperative opioid prescribing rates for those awaiting surgery.

Methods: Data regarding patient demographics and opioid utilisation were collected from the electronic health records of included patients at a large university teaching hospital. Patients on the outpatient waiting list for primary hip and knee arthroplasty as of September 2020 (COVID-19 group) were compared with historical controls (Controls) who had previously undergone surgery. A sample size calculation indicated 452 patients were required to detect a 15% difference in opioid prescription rates between groups.

Results: A total of 548 patients (58.2% female) were included, 260 in the COVID-19 group and 288 in the Controls. Baseline demographics were similar between the groups. For those with data available, the proportion of patients on any opioid at follow-up in the COVID-19 group was significantly higher: 55.0% (143/260) compared with 41.2% (112/272) in the Controls (p=0.002). This remained significant when adjusted for confounding (age, gender, Scottish Index of Multiple Deprivation, procedure and wait time). The proportion of patients on a strong opioid was similar (4.2% (11/260) vs 4.8% (13/272)) for COVID-19 and Controls, respectively. The median waiting time from referral to follow-up was significantly longer in the COVID-19 group compared with the Controls (455 days vs 365 days; p<0.0001).

Conclusion: The work provides evidence of potential for an emerging opioid problem associated with the influence of COVID-19 on elective arthroplasty services. Viable alternatives to opioid analgesia for those with end-stage arthritis should be explored, and prolonged waiting times for surgery ought to be avoided in the recovery from COVID-19 to prevent more widespread opioid use.
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http://dx.doi.org/10.1136/bmjqs-2021-013450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8449843PMC
September 2021

Opioid-free Anesthesia: Comment.

Anesthesiology 2021 10;135(4):751-753

University of Aberdeen, NHS Grampian, Foresterhill, Aberdeen, United Kingdom.

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http://dx.doi.org/10.1097/ALN.0000000000003908DOI Listing
October 2021

Pleth variability index and fluid management practices: a multicenter service evaluation.

BMC Res Notes 2021 Jul 28;14(1):293. Epub 2021 Jul 28.

Institut du Cancer, Montpellier, France.

Objectives: The introduction of a new technology has the potential to modify clinical practices, especially if easy to use, reliable and non-invasive. This observational before/after multicenter service evaluation compares fluid management practices during surgery (with fluids volumes as primary outcome), and clinical outcomes (secondary outcomes) before and after the introduction of the Pleth Variability Index (PVI), a non-invasive fluid responsiveness monitoring.

Results: In five centers, 23 anesthesiologists participated during a 2-years period. Eighty-eight procedures were included. Median fluid volumes infused during surgery were similar before and after PVI introduction (respectively, 1000 ml [interquartile range 25-75 [750-1700] and 1000 ml [750-2000]). The follow-up was complete for 60 from these and outcomes were similar. No detectable change in the fluid management was observed after the introduction of a new technology in low to moderate risk surgery. These results suggest that the introduction of a new technology should be associated with an implementation strategy if it is intended to be associated with changes in clinical practice.
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http://dx.doi.org/10.1186/s13104-021-05705-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8317350PMC
July 2021

Perspectives on pain registries.

Pain 2021 08;162(8):2201-2203

Department of Anaesthesiology and Intensive Care, Jena University Hospital, Jena, Germany.

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http://dx.doi.org/10.1097/j.pain.0000000000002228DOI Listing
August 2021

Statins in Healthy Adults: A Meta-Analysis.

Medicina (Kaunas) 2021 Jun 7;57(6). Epub 2021 Jun 7.

Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, Epidemiology Group, University of Aberdeen, Aberdeen AB25 2ZD, UK.

: In this paper, we investigated the efficacy of statin therapy on cardiovascular disease (CVD) reduction in adults with no known underlying health conditions by undertaking a meta-analysis and systematic review of the current evidence. : We performed a systematic search to identify Primary Prevention Randomized Controlled Trials (RCTs) that compared statins with a control group where CVD events or mortality were the primary end point. Identified RCTs were evaluated and classified into categories depending on relevance in order to determine which type of meta-analysis would be feasible. : No differences were observed between categories with the exception of relative risk for all CVD events combined which showed a 12% statistically significant difference favouring studies which were known to include participants without underlying health conditions. Strong negative correlations between number-need-to-treat (NNT) and LDL-C reduction were observed for all Coronary Heart Disease (CHD) outcomes combined and all CVD outcomes combined. : This project highlights the need for further research on the effects of statins on participants who do not suffer from underlying health conditions, given that no such studies have been conducted.
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http://dx.doi.org/10.3390/medicina57060585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8312228PMC
June 2021

Exploratory Outlier Detection for Acceleromyographic Neuromuscular Monitoring: Machine Learning Approach.

J Med Internet Res 2021 05 31;23(6):e25913. Epub 2021 May 31.

Department of Anesthesiology and Perioperative Medicine, Universitair Ziekenhuis Brussel, Brussel, Belgium.

Background: Perioperative quantitative monitoring of neuromuscular function in patients receiving neuromuscular blockers has become internationally recognized as an absolute and core necessity in modern anesthesia care. Because of their kinetic nature, artifactual recordings of acceleromyography-based neuromuscular monitoring devices are not unusual. These generate a great deal of cynicism among anesthesiologists, constituting an obstacle toward their widespread adoption. Through outlier analysis techniques, monitoring devices can learn to detect and flag signal abnormalities. Outlier analysis (or anomaly detection) refers to the problem of finding patterns in data that do not conform to expected behavior.

Objective: This study was motivated by the development of a smartphone app intended for neuromuscular monitoring based on combined accelerometric and angular hand movement data. During the paired comparison stage of this app against existing acceleromyography monitoring devices, it was noted that the results from both devices did not always concur. This study aims to engineer a set of features that enable the detection of outliers in the form of erroneous train-of-four (TOF) measurements from an acceleromyographic-based device. These features are tested for their potential in the detection of erroneous TOF measurements by developing an outlier detection algorithm.

Methods: A data set encompassing 533 high-sensitivity TOF measurements from 35 patients was created based on a multicentric open label trial of a purpose-built accelero- and gyroscopic-based neuromuscular monitoring app. A basic set of features was extracted based on raw data while a second set of features was purpose engineered based on TOF pattern characteristics. Two cost-sensitive logistic regression (CSLR) models were deployed to evaluate the performance of these features. The final output of the developed models was a binary classification, indicating if a TOF measurement was an outlier or not.

Results: A total of 7 basic features were extracted based on raw data, while another 8 features were engineered based on TOF pattern characteristics. The model training and testing were based on separate data sets: one with 319 measurements (18 outliers) and a second with 214 measurements (12 outliers). The F1 score (95% CI) was 0.86 (0.48-0.97) for the CSLR model with engineered features, significantly larger than the CSLR model with the basic features (0.29 [0.17-0.53]; P<.001).

Conclusions: The set of engineered features and their corresponding incorporation in an outlier detection algorithm have the potential to increase overall neuromuscular monitoring data consistency. Integrating outlier flagging algorithms within neuromuscular monitors could potentially reduce overall acceleromyography-based reliability issues.

Trial Registration: ClinicalTrials.gov NCT03605225; https://clinicaltrials.gov/ct2/show/NCT03605225.
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http://dx.doi.org/10.2196/25913DOI Listing
May 2021

Is multi-source feedback the future of perioperative medicine?

Anaesth Crit Care Pain Med 2021 06 7;40(3):100886. Epub 2021 May 7.

School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.

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http://dx.doi.org/10.1016/j.accpm.2021.100886DOI Listing
June 2021

Propofol for Induction and Maintenance of Anesthesia in Patients With Brugada Syndrome: A Single-Center, 25-Year, Retrospective Cohort Analysis.

Anesth Analg 2021 06;132(6):1645-1653

From the Department of Anesthesiology and Perioperative Medicine and.

Background: Propofol administration in patients with Brugada syndrome (BrS) is still a matter of debate. Despite lacking evidence for its feared arrhythmogenicity, up to date, expert cardiologists recommend avoiding propofol. The main aim of this study is to assess the occurrence of malignant arrhythmias or defibrillations in patients with BrS, during and 30 days after propofol administration. The secondary aim is to investigate the occurrence of adverse events during propofol administration and hospitalization, as the 30-day readmission and 30-day mortality rate.

Methods: We performed a retrospective cohort study on patients with BrS who received propofol anytime from January 1, 1996 to September 30, 2020. Anesthesia was induced by propofol in both groups. In the total intravenous anesthesia (TIVA) group, anesthesia was maintained by propofol, while in the BOLUS group, volatile anesthesia was provided. The individual anesthetic charts and the full electronic medical records up to 30 postprocedural days were scrutinized.

Results: One hundred thirty-five BrS patients who underwent a total of 304 procedures were analyzed. The TIVA group included 27 patients for 33 procedures, and the BOLUS group included 108 patients for 271 procedures. In the TIVA group, the median time of propofol infusion was 60 minutes (interquartile range [IQR] = 30-180). The estimated plasma or effect-site concentration ranged between 1.0 and 6.0 µg·mL-1 for target-controlled infusion (TCI). The infusion rate for manually driven TIVA varied between 0.8 and 10.0 mg·kg-1·h-1. In the BOLUS group, the mean propofol dose per kilogram total body weight was 2.4 ± 0.9 mg·kg-1. No malignant arrhythmias or defibrillations were registered in both groups. The estimated 95% confidence interval (CI) of the risk for malignant arrhythmias in the BOLUS and TIVA groups was 0-0.011 and 0-0.091, respectively.

Conclusions: The analysis of 304 anesthetic procedures in BrS patients, who received propofol, either as a TIVA or as a bolus during induction of volatile-based anesthesia, revealed no evidence of malignant arrhythmias or defibrillations. The present data do not support an increased risk with propofol-based TIVA compared to propofol-induced volatile anesthesia. Prospective studies are needed to investigate the electrophysiologic effects of propofol in BrS patents.
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http://dx.doi.org/10.1213/ANE.0000000000005540DOI Listing
June 2021

What are the impact and the optimal design of a physical prehabilitation program in patients with esophagogastric cancer awaiting surgery? A systematic review.

BMC Sports Sci Med Rehabil 2021 Mar 25;13(1):33. Epub 2021 Mar 25.

Pôle de Neuro Musculo Skeletal Lab, Institut de Recherche Expérimentale et Clinique, Neuro Musculo Skeletal Lab, Université catholique de Louvain, Avenue Mounier 53, bte B1.53.07, 1200, Brussels, Belgium.

Background: Substantial postoperative complications occur after tumor resection for esophagogastric cancers. Physical prehabilitation programs aim to prepare patients for surgery by improving their functional status with the aim of reducing postoperative complications. This systematic review aims to summarize the effects of physical prehabilitation programs on exercise capacity, muscle strength, respiratory muscle function, postoperative outcomes, and health-related quality of life and to determine the optimal design of such a program to improve these outcomes in esophagogastric cancer patients undergoing tumor resection.

Methods: A systematic literature review was conducted using PubMed, The Cochrane Library, Scopus, and PEDro databases to identify studies evaluating the effects of physical prehabilitation program on exercise capacity, muscle strength, respiratory muscle function, postoperative complications, length of hospital stay, mortality, and health-related quality of life in patients with esophagogastric cancer awaiting surgery. Data from all studies meeting the inclusion criteria were extracted. The quality of each selected study was determined using the Downs and Black checklist.

Results: Seven studies with 645 participants were included. The preoperative exercise program consisted of respiratory training alone in three studies, a combination of aerobic and resistance training in two studies, and a combination of respiratory, aerobic, and resistance training in two studies. Training frequency ranged from three times a day to twice a week and each session lasted between 20 and 75 min. Four studies were of fair quality and three of good quality. Some studies reported improvements in maximal inspiratory pressure, inspiratory muscle endurance, postoperative (pulmonary) complications, and length of hospital stay in the preoperative exercise group compared to the control group.

Conclusion: This systematic review reports the current evidence for physical prehabilitation programs in patients with esophagogastric cancer awaiting surgery. However, due to the limited number of randomized controlled trials, the significant heterogeneity of exercise programs, and the questionable quality of the studies, higher quality randomized controlled trials are needed.

Trial Registration: PROSPERO Registration Number: CRD42020176353 .
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http://dx.doi.org/10.1186/s13102-021-00260-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993458PMC
March 2021

International multicentre observational study to evaluate the association between perioperative red blood cell transfusions and 1-year mortality after major cancer surgery (ARCA-1): study design, statistical analysis plan and study protocol.

BMJ Open 2021 03 18;11(3):e043453. Epub 2021 Mar 18.

Department of Anesthesiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.

Introduction: Blood transfusion is still common in patients undergoing major cancer surgery. Blood transfusion can be associated with poor prognosis in patients with cancer. Perioperative Care in the Cancer Patient -1 (ARCA-1) aims to assess in a large cohort of patients the current incidence, pattern of practice and associations between perioperative blood transfusions and 1-year survival in patients undergoing major cancer surgery.

Methods And Analysis: ARCA-1 is a prospective international multicentre observational study that will include adult patients scheduled to have major cancer surgical procedures with the intention to cure, and an overnight planned hospital admission. The study will be opened for 1 year for enrolment (7 January 2020-7 February 2021). Each centre will enrol patients for 30 days. The primary endpoint of this study is all-cause mortality 1 year after major cancer surgery. Secondary endpoints are rate of perioperative blood product use, cancer-specific mortality at 1 year and PFSs and 30-day morbidity and mortality.

Ethics And Dissemination: This study was approved by the Institutional Review Board at The University of Texas-MD Anderson Cancer Center. The study results will be published in peer-reviewed journals and disseminated at international conferences.

Trial Registration Number: NCT04491409.
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http://dx.doi.org/10.1136/bmjopen-2020-043453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7978332PMC
March 2021

Substance abuse by anaesthesiologists, shouldn't we do more?

Eur J Anaesthesiol 2021 07;38(7):682-683

From the Institute of Applied Health Sciences, Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Department of Anaesthesia, NHS Grampian, Aberdeen (PF), Population and Behavioural Science Division, School of Medicine, University of St Andrews, Fife, UK, International Society of Addiction Medicine (ISAM), Alberta, Canada (AB).

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http://dx.doi.org/10.1097/EJA.0000000000001466DOI Listing
July 2021

High-Dose Spinal Cord Stimulation Reduces Long-Term Pain Medication Use in Patients With Failed Back Surgery Syndrome Who Obtained at Least 50% Pain Intensity and Medication Reduction During a Trial Period: A Registry-Based Cohort Study.

Neuromodulation 2021 Apr 20;24(3):520-531. Epub 2021 Jan 20.

Department of Neurosurgery, Universitair Ziekenhuis Brussel, Jette, Belgium.

Objectives: High-dose spinal cord stimulation (HD-SCS) revealed positive results for obtaining pain relief in patients with failed back surgery syndrome (FBSS). However, it is less clear whether HD-SCS also is able to reduce pain medication use. The aim of this registry-based cohort study is to explore the impact of HD-SCS on pain medication use in FBSS patients.

Materials And Methods: Data from the Discover registry was used in which the effectiveness of HD-SCS was explored in neurostimulation-naïve FBSS patients as well as in rescue patients. All neurostimulation-naïve FBSS patients positively responded to a four-week SCS trial period in which at least 50% pain relief and 50% medication reduction were obtained. Medication use was measured with the Medication Quantification Scale III (MQS) in 259 patients at baseline and at 1, 3, and 12 months of HD-SCS. Additionally, defined daily doses (DDD) and morphine milligram equivalents (MME) were calculated as well.

Results: One hundred thirty patients reached the visit at 12 months. In neurostimulation-naïve patients, a statistically significant decrease in MQS (χ = 62.92, p < 0.001), DDD (χ = 11.47, p = 0.009), and MME (χ = 21.55, p < 0.001) was found. In rescue patients, no statistically significant improvements were found. In both patient groups, statistically significant reductions in the proportion of patients on high-risk MME doses ≥90 were found over time. At the intraindividual level, positive correlations were found between MSQ scores and pain intensity for back (r = 0.56, r = 0.31, p < 0.001) and leg pain (r = 0.61, r = 0.22, p < 0.001) in neurostimulation-naïve and rescue patients, respectively.

Conclusions: Registry data on HD-SCS in FBSS patients revealed a statistically significant and sustained decrease in pain medication use, not only on opioids, but also on anti-neuropathic agents in neurostimulation-naïve patients, who positively responded to an SCS trial period with at least 50% pain relief and 50% pain medication decrease, but not in rescue patients.
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http://dx.doi.org/10.1111/ner.13363DOI Listing
April 2021

Pain trajectories, progress and perspectives.

Authors:
Patrice Forget

Anaesth Crit Care Pain Med 2021 02 14;40(1):100799. Epub 2021 Jan 14.

Institute of Applied Health Sciences, Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, NHS Grampian, Foresterhill, AB25 2ZD, Aberdeen, United Kingdom. Electronic address:

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http://dx.doi.org/10.1016/j.accpm.2021.100799DOI Listing
February 2021

Multimodal Analgesia for Spine Surgery: Does the Intraoperative Opioid Dose Matter?

Anesth Analg 2021 02;132(2):e27-e28

Department of Anesthesiology and Perioperative Pain Management, The University of Texas MD Anderson Cancer Center, Houston, Texas.

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http://dx.doi.org/10.1213/ANE.0000000000005006DOI Listing
February 2021

Characterization of Preoperative, Postsurgical, Acute and Chronic Pain in High Risk Breast Cancer Patients.

J Clin Med 2020 11 26;9(12). Epub 2020 Nov 26.

Department of Gynecology, Breast Clinic, King Albert II Institute, Cliniques universitaires Saint-Luc, UCLouvain, 1200 Brussels, Belgium.

Background: Pain after breast cancer surgery remains largely unexplained and inconsistently quantified. This study aims to describe the perioperative pain patterns in patients with breast cancer, up to two years after surgery.

Methods: This is a pre-planned sub-study of the Ketorolac in Breast Cancer (KBC) trial. The KBC trial was a multicentre, prospective, double-blind, placebo-controlled, randomised trial of a single dose of 30 mg of ketorolac just before breast cancer surgery, aiming to test its effect on recurrences. This sub-study focuses only on pain outcomes. From 2013 to 2015, 203 patients were randomised to ketorolac ( = 96) or placebo ( = 107). Structured questionnaires were delivered by telephone after one and two years, exploring the presence, location, permanence, and frequency of pain. Patients' perceptions of pain were captured by an open-ended question, the responses to which were coded and classified using hierarchical clustering.

Results: There was no difference in pain between the ketorolac and the placebo group. The reported incidence of permanent pain was 67% and 45% at one and two years, respectively. The largest category was musculoskeletal pain. Permanent pain was mainly described in patients with musculoskeletal pain. The description of pain changed in most patients during the second postoperative year, i.e., moved from one category to another (no pain, permanent, or non-permanent pain, but also, the localisation). This phenomenon includes patients without pain at one year.

Conclusions: Pain is a complex phenomenon, but also a fragile and unstable endpoint. Pain after breast cancer surgery does not necessarily mean breast pain but also musculoskeletal and other pains. The permanence of pain and the pain phenotype can change over time.
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http://dx.doi.org/10.3390/jcm9123831DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759784PMC
November 2020

Determining the Minimal Clinical Important Difference for Medication Quantification Scale III and Morphine Milligram Equivalents in Patients with Failed Back Surgery Syndrome.

J Clin Med 2020 Nov 21;9(11). Epub 2020 Nov 21.

Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Belgium.

The Medication Quantification Scale III (MQS) is a tool to represent the negative impact of medication. A reduction in medication can serve as an indicator to evaluate treatment success. However, no cut-off value has yet been determined to evaluate whether a decrease in medication is clinically relevant. Therefore, the objective is to estimate the thresholds for the MQS and morphine milligram equivalents (MMEs) that best identify a clinically relevant important improvement for patients. Data from the Discover registry, in which patients with failed back surgery syndrome were treated with high-dose spinal cord stimulation, were used. Patient satisfaction was utilized to evaluate a clinically important outcome 12 months after stimulation. Anchor-based and distribution-based methods were applied to determine the minimal clinical important difference (MCID). Distribution-based methods revealed a value of 4.28 for the MQS and 33.61 for the MME as MCID. Anchor-based methods indicated a percentage change score of 41.2% for the MQS and 28.2% for the MME or an absolute change score of 4.72 for the MQS and 22.65 for the MME. For assessing a treatment outcome, we recommend using the percentage change score, which better reflects a clinically important outcome and is not severely influenced by high medication intake at baseline.
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http://dx.doi.org/10.3390/jcm9113747DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7700681PMC
November 2020

Our project for the Journal(s).

Eur J Anaesthesiol 2021 01;38(1):1-3

From the Université de Paris, AP-HP, Hôpital Cochin, DMU ARME, UMR 1140 ,INSERM, Paris, France.

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http://dx.doi.org/10.1097/EJA.0000000000001396DOI Listing
January 2021

Hysteroscopic Resection for Missed Abortion: Feasibility, Operative Technique and Potential Benefit Compared to Curettage.

Front Surg 2020 8;7:64. Epub 2020 Sep 8.

Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.

To evaluate the feasibility of hysteroscopic resection (HsR) for primary surgical management of missed abortion. Reproductive outcomes and potential benefit of this technique will be compared to traditional dilatation and curettage (D&C). Retrospective cohort study in two Departments (Gynecology and Obstetrics) of a tertiary medical care center (Canadian Task Force classification II-2). Women with first trimester missed abortion. Two techniques were used for the management of missed abortion: ultrasound-guided dilatation and curettage (D&C) and hysteroscopic resection (HsR). We evaluated 358 patients who underwent primary surgical removal of missed abortion. Hundred seventy three patients have been treated by D&C and 185 underwent HsR. In the HsR group, 110 patients (59.5%) have obtained their pregnancy with fertilization (IVF) vs. 7 patients (4.0%) in the D&C group which make the HsR population hypofertile in comparison to the D&C population. The intra- and post-operative complication rates are low and comparable. Intrauterine anomalies were diagnosed during the HsR in 10 patients (5.4%) and could be investigated after the intervention as a possible cause of miscarriage. Because of the difference in term of fertility, the reproductive outcomes have been analyzed by multivariate analysis. The hazard ratio of pregnancy at 6 months, adjusted to the factor IVF for D&C compared to HsR is 0.69 [0.49-0.96] ( = 0.026). That could represent a significant benefit in the particular population followed in IVF, but regarding the retrospective analysis, and the very different population in the two groups, it doesn't allow us to draw any evidence based conclusion. Hysteroscopic resection is a feasible and safe procedure for the management of missed abortion that could increase the diagnosis of uterine abnormalities. With all the limitation of the design of our study, our data seems to show a trend to a potential benefit in term of reproductive outcomes for hypofertile patient undergoing IVF treatment.
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http://dx.doi.org/10.3389/fsurg.2020.00064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505996PMC
September 2020

Persistent postoperative opioid use in Europe: A systematic review.

Eur J Anaesthesiol 2021 May;38(5):505-511

From the Epidemiology group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen (TS, PF) and Department of Anaesthesia, NHS Grampian, Aberdeen, UK (PF).

Background: In the United States, postoperative opioid prescriptions have been implicated in the so-called 'opioid epidemic'. In Europe, the extent of overprescribing or misuse of opioids is not known.

Objectives: To describe the proportion of persistent postoperative opioid use in adults (>18 years) in European countries.

Design: Systematic review of the published data.

Data Sources: We searched the electronic literature databases MEDLINE (Ovid), Embase (Ovid), PubMed/MEDLINE and Scopus.

Eligibility Criteria: Studies describing opioid use in adult patients (>18 years) at least 3 months after surgery.

Results: One thousand three hundred and seven studies were found, and 12 studies were included in this review. The rate of opioid use after 3 to 6 months was extracted from the studies and categorised by the type of surgery. Nine studies investigated opioid use after total hip or total knee arthroplasties (THA and TKA) and reported opioid user rates between 7.9 and 41% after 3 months. In all the included studies, a proportion between 2 and 41% of patients were opioid users 3 months after surgery. The level of evidence varied from high to very low.

Conclusion: To describe persistent opioid use in relation to specific countries or types of surgery is not possible. Because of the wide ranges observed, we can neither confirm nor rule out a possible public health problem linked to the persistent use of opioids in Europe.

Study Registration: PROSPERO: CRD42019154292.
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http://dx.doi.org/10.1097/EJA.0000000000001346DOI Listing
May 2021
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