Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This
study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical
procedures.
Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and
elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time
in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during
the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after
discharge.
Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at
discharge. Patients reported being in severe pain for 10 (i.q.r. 1–30)% of the first week after discharge and rated satisfaction with
analgesia as 90 (i.q.r. 80–100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated
with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-
effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. −1.52
to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low-
and middle-income countries, patient-reported outcomes did not.
Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects
of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge
analgesia should be adopted routinely

Simple Summary: Little is known about factors contributing to early post-operative morbidity and
mortality in low and middle income countries with a paucity of data limiting global efforts to improve
gynaecological cancer care. In this multicentre, international prospective cohort study of women
undergoing gynaecological oncology surgery, we show that low and middle versus high income
countries were associated with similar post-operative major morbidity. Capacity to rescue patients
from surgical complications is a tangible opportunity for meaningful intervention.
Abstract:
Gynaecological malignancies affect women in low and middle income countries (LMICs) at
disproportionately higher rates compared with high income countries (HICs) with little known about
variations in access, quality, and outcomes in global cancer care. Our study aims to evaluate international
variation in post-operative morbidity and mortality following gynaecological oncology surgery
between HIC and LMIC settings. Study design consisted of a multicentre, international prospective
cohort study of women undergoing surgery for gynaecological malignancies (NCT04579861).
Multilevel logistic regression determined relationships within three-level nested-models of patients
within hospitals/countries. We enrolled 1820 patients from 73 hospitals in 27 countries. Minor
morbidity (Clavien–Dindo I–II) was 26.5% (178/672) and 26.5% (267/1009), whilst major morbidity
(Clavien–Dindo III–V) was 8.2% (55/672) and 7% (71/1009) for LMICs/HICs, respectively. Higher
minor morbidity was associated with pre-operative mechanical bowel preparation (OR = 1.474,
95%CI = 1.054–2.061, p = 0.023), longer surgeries (OR = 1.253, 95%CI = 1.066–1.472, p = 0.006), greater
blood loss (OR = 1.274, 95%CI = 1.081–1.502, p = 0.004). Higher major morbidity was associated
with longer surgeries (OR = 1.37, 95%CI = 1.128–1.664, p = 0.002), greater blood loss (OR = 1.398,
95%CI = 1.175–1.664, p  0.001), and seniority of lead surgeon, with junior surgeons three times more
likely to have a major complication (OR = 2.982, 95%CI = 1.509–5.894, p = 0.002). Of all surgeries,
50% versus 25% were performed by junior surgeons in LMICs/HICs, respectively. We conclude that
LMICs and HICs were associated with similar post-operative major morbidity. Capacity to rescue
patients from surgical complications is a tangible opportunity for meaningful intervention.
Keywords: surgery; gynaecological oncology; morbidity; mortality; collaborative researchSimple Summary: Little is known about factors contributing to early post-operative morbidity and
mortality in low and middle income countries with a paucity of data limiting global efforts to improve
gynaecological cancer care. In this multicentre, international prospective cohort study of women
undergoing gynaecological oncology surgery, we show that low and middle versus high income
countries were associated with similar post-operative major morbidity. Capacity to rescue patients
from surgical complications is a tangible opportunity for meaningful intervention.
Abstract:
Gynaecological malignancies affect women in low and middle income countries (LMICs) at
disproportionately higher rates compared with high income countries (HICs) with little known about
variations in access, quality, and outcomes in global cancer care. Our study aims to evaluate international
variation in post-operative morbidity and mortality following gynaecological oncology surgery
between HIC and LMIC settings. Study design consisted of a multicentre, international prospective
cohort study of women undergoing surgery for gynaecological malignancies (NCT04579861).
Multilevel logistic regression determined relationships within three-level nested-models of patients
within hospitals/countries. We enrolled 1820 patients from 73 hospitals in 27 countries. Minor
morbidity (Clavien–Dindo I–II) was 26.5% (178/672) and 26.5% (267/1009), whilst major morbidity
(Clavien–Dindo III–V) was 8.2% (55/672) and 7% (71/1009) for LMICs/HICs, respectively. Higher
minor morbidity was associated with pre-operative mechanical bowel preparation (OR = 1.474,
95%CI = 1.054–2.061, p = 0.023), longer surgeries (OR = 1.253, 95%CI = 1.066–1.472, p = 0.006), greater
blood loss (OR = 1.274, 95%CI = 1.081–1.502, p = 0.004). Higher major morbidity was associated
with longer surgeries (OR = 1.37, 95%CI = 1.128–1.664, p = 0.002), greater blood loss (OR = 1.398,
95%CI = 1.175–1.664, p  0.001), and seniority of lead surgeon, with junior surgeons three times more
likely to have a major complication (OR = 2.982, 95%CI = 1.509–5.894, p = 0.002). Of all surgeries,
50% versus 25% were performed by junior surgeons in LMICs/HICs, respectively. We conclude that
LMICs and HICs were associated with similar post-operative major morbidity. Capacity to rescue
patients from surgical complications is a tangible opportunity for meaningful intervention.
Keywords: surgery; gynaecological oncology; morbidity; mortality; collaborative research

ABSTRACT 
Background: Placenta accreta spectrum (PAS) no longer uncommon in daily obstetrics practice. Incidence of PAS has
increased because of cesarean section pandemic. It is accompanied by acute maternal morbidity and mortality and
long-term complications.  Regarding long-term consequences and quality of life (Qol), little evidence is available.
Objective: The aim of the current work was to evaluate short form (SF)-36 survey in women with PAS.
Patients and methods: A total of 80 women with confirmed diagnosis of PAS were recruited in the study. This study
was conducted in Women Health Center, Assiut University, which is a tertiary care unit, between 2020 and 2021. The
participants were subjected to thorough clinical and obstetric evaluation. SF-36 score was measured in those patients
after 6-8 weeks and 12 months postpartum. 
Results: Mean age of enrolled women was 30.86 (SD 4.68) years with range between 21 and 40 years old. A total of
12 (15%) women were complicated by hysterectomy, 23(28.7%) with bladder injury while just 2 (2.7%) with ureteric
injury. Women with complications had significantly lower baseline vitality and general health and higher baseline
bodily pain higher follow up bodily pain and role of limitation (emotional). Yet, in each separate all domains of SF-36
during follow up. Conclusion: Women after a pregnancy complicated by PAS had significant improvement in SF-36
domains after 1 year follow up. Domains of SF-36 weren’t greatly affected by complications of PAS. Affection of
patient quality of life following PAS should be in consideration.
Keywords: PAS, Qol, Questionnaire, Hysterectomy, SF-36. 

Background: Preeclampsia remains a leading cause of maternal and neonatal morbidity and mortality. It is characterized by
altered local and systemic immune regulation and a rise in proinflammatory cytokines. The inflammasome is a cytosolic protein
complex that mediates innate immune responses through promoting the secretion of interleukin-1beta (IL-1β). This study aimed
to investigate the nucleotide oligomerization domain (NOD)-like receptor family, pyrin domain-containing protein 3, inflammasome
activation in preeclampsia (PE), its relation to IL-1β and their association with PE outcomes.
Methods: Placenta and blood were collected from 25 control pregnant women and 50 preeclamptic women. Pyrin domaincontaining
protein 3 (NLRP3) and IL-1β gene expression were quantified by real-time polymerase chain reaction (PCR).
Results: Placental and blood relative gene expression levels of NLRP3 and IL-1β were significantly higher in mild and severe PE
than in controls. A significantly higher blood expression of NLRP3 was noticed in the low birth weight subgroup compared to the
normal birth weight subgroup (p = 0.03) in the severe PE group. Both biomarkers levels in placenta and blood showed significant
negative correlations with the weight of newborn. The strong positive correlation (p < 0.0001, r = 0.9) between NLRP3 and IL-1β
suggested that IL-1β response mostly depend on NLRP3 inflammasome.
Conclusions: These results suggest the presence of excessive activation of NLRP3 and subsequently increased production of
active IL-1β that may predispose placental inflammation in severe PE and subsequently, low neonatal birth weight and shortened
gestational age.
Keywords: NLRP3 inflammasome; interleukin-1β; preeclampsia; birth weight; innate immunity