British journal of anaesthesia
Why is this important?
Suspicions that anesthetic technique impacts survival after cancer surgery continues to be both unanswered and psychologically weighty: are anesthetic choices undermining patient survival?
What did they do?
This Taiwanese research group conducted a retrospective cohort-study in a single hospital covering 10 years of elective hepatectomy patients, comparing propofol to desflurane anesthesia. Notably, hepatocellular carcinoma is one of the leading causes of cancer death in Taiwan.
And they found...?
TIVA propofol was associated with a dramatically better survival (hazard ratio 0.57 (0.38-0.59)), even in subgroup analysis dependent on staging.
Although this finding is consistent with other observational studies across a range of cancers, the apparent size of the benefit (50% mortality reduction!) should give us pause.
Given inconsistent findings from a range of similar observational studies, it is unlikely that there is a real treatment effect of this magnitude.
While we await results from well-powered RCTs, the jury is still out on whether anesthesia choices impact any specific cancer surgery...summary
Several randomised controlled trials show that maintenance of labour epidural analgesia with programmed intermittent epidural bolus reduces the maternal motor block compared with maintenance with a continuous infusion. However, these trials were usually restricted to healthy nulliparous parturients. To assess the generalisability of these randomised controlled trials to 'real-world' conditions, we compared maternal motor function (modified Bromage score) over time between healthy nulliparous and parous women using routinely collected quality-control data. ⋯ The results of the randomised controlled trials on a reduced motor block with programmed intermittent epidural bolus seem generalisable to parturients typically not included in these trials.
Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphi-based survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. ⋯ The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.
Over the past decade, the mechanisms underlying placebo effects have begun to be identified. At the same time, the placebo response appears to have increased in pharmacological trials and marked placebo effects are found in neurostimulation and surgical trials, thereby posing the question whether non-pharmacological interventions should be placebo-controlled to a greater extent. In this narrative review we discuss how the knowledge of placebo mechanisms may help to improve placebo control in pharmacological and non-pharmacological trials. ⋯ Finally, we discuss how systematic investigations into placebo mechanisms across various pain conditions and types of treatment are needed in order to 'personalise' the placebo control to the specific pathophysiology and interventions, which may ultimately lead to identification of more effective treatment for pain patients. In conclusion this review shows that it is important to understand how patients' perception and expectations influence the efficacy of active and placebo treatments in order to improve the test of new treatments. Importantly, this applies not only to assessment of drug efficacy but also to non-pharmacological trials on surgeries and stimulation procedures.