Glucagon-like peptide-1 receptor agonists: a narrative review of clinical pharmacology and implications for peri-operative practice.

BACKGROUND: Glucagon-like peptide-1 receptor agonists are used increasingly in the management of patients living with type 2 diabetes mellitus and obesity. In patients using glucagon-like peptide-1 receptor agonists, a key concern in the peri-operative period is the increased risk of pulmonary aspiration due to delayed gastric emptying. This review provides an overview of the pharmacodynamic and pharmacokinetic properties of glucagon-like peptide-1 receptor agonists and the risk of delayed gastric emptying and aspiration. METHODS: We conducted searches of MEDLINE and EMBASE databases of articles published before January 2024 using the keywords and medical subject headings: incretins; glucagon-like peptide-1; GLP-1; glucagon-like peptide-1 receptor agonists; GLP-1 RA; peri-operative period; perioperative; peri-operative; stomach emptying; gastric emptying; pulmonary aspiration; aspiration; food regurgitation; and regurgitation. The evidence was analysed, synthesised and reported narratively. RESULTS: A total of 1213 articles were located after duplicates were removed. Two authors screened the titles and abstracts to identify those studies which assessed specifically the risk of delayed gastric emptying and pulmonary aspiration or regurgitation in the peri-operative period. We searched manually the reference lists of relevant studies to identify any additional case reports. Ten studies were identified. Available evidence was limited to case reports, case series and observational work. CONCLUSIONS: There is insufficient evidence to put forward definitive guidance regarding the ideal cessation period for glucagon-like peptide-1 receptor agonists before elective surgery. Precautionary practice is required until more evidence becomes available. We suggest an individualised, evidence-based approach. In patients living with type 2 diabetes mellitus, there is concern that prolonged cessation before surgery will have a detrimental effect on peri-operative glycaemic control and discussion with an endocrinologist is advised. For patients taking glucagon-like peptide-1 receptor agonists for weight management, these drugs should be withheld for at least three half-lives before an elective surgical procedure.

Food Emulsion Gels from Plant-Based Ingredients: Formulation, Processing, and Potential Applications.

Recent advances in the understanding of formulations and processing techniques have allowed for greater freedom in plant-based emulsion gel design to better recreate conventional animal-based foods. The roles of plant-based proteins, polysaccharides, and lipids in the formulation of emulsion gels and relevant processing techniques such as high-pressure homogenization (HPH), ultrasound (UH), and microfluidization (MF), were discussed in correlation with the effects of varying HPH, UH, and MF processing parameters on emulsion gel properties. The characterization methods for plant-based emulsion gels to quantify their rheological, thermal, and textural properties, as well as gel microstructure, were presented with a focus on how they can be applied for food purposes. Finally, the potential applications of plant-based emulsion gels, such as dairy and meat alternatives, condiments, baked goods, and functional foods, were discussed with a focus on sensory properties and consumer acceptance. This study found that the implementation of plant-based emulsion gel in food is promising to date despite persisting challenges. This review will provide valuable insights for researchers and industry professionals looking to understand and utilize plant-based food emulsion gels.

Adolescent-Caregiver Agreement Regarding the School Bullying and Cyberbullying Involvement Experiences of Adolescents with Autism Spectrum Disorder.

School bullying and cyberbullying victimization and perpetration are prevalent in adolescents with autism spectrum disorder (AASD). However, the levels of adolescent-caregiver agreement regarding the bullying involvement of AASD and the factors associated with these levels remain to be evaluated. In the present study, we evaluated the levels of adolescent-caregiver agreement on the school bullying and cyberbullying involvement experiences of AASD and the factors associated with the levels of agreement. This study included 219 dyads of AASD and their caregivers. The school bullying and cyberbullying involvement experiences of the participating AASD were assessed using the School Bullying Experience Questionnaire and the Cyberbullying Experiences Questionnaire, respectively. Attention-deficit/hyperactivity disorder, oppositional defiant disorder (ODD), depressive and anxiety symptoms, and autistic social impairment were also assessed. AASD and their caregivers had poor to fair levels of agreement regarding the school bullying and cyberbullying victimization and perpetration experiences of AASD. Severe inattention, hyperactivity-impulsivity, ODD, depressive and anxiety symptoms, and autistic social impairment were associated with high levels of adolescent-caregiver agreement. When assessing the bullying involvement experiences of AASD, mental health professionals should obtain information from multiple sources. In addition, the factors influencing the levels of agreement should be considered.

Association between intraoperative oliguria and postoperative acute kidney injury in non-cardiac surgical patients: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis aimed to evaluate the association between intraoperative oliguria and the risk of postoperative acute kidney injury (AKI) in patients undergoing non-cardiac surgery. METHODS: The MEDLINE and EMBASE databases were searched up to August 2022 for studies in adult patients undergoing non-cardiac surgery, where the association between intraoperative urine output and the risk of postoperative AKI was assessed. Both randomised and non-randomised studies were eligible for inclusion. Study selection and risk of bias assessment were independently performed by two investigators. The risk of bias was evaluated using the Newcastle-Ottawa scale. We performed meta-analysis of the reported multivariate adjusted odds ratios for the association between intraoperative oliguria (defined as urine output < 0.5 mL/kg/hr) and the risk of postoperative AKI using the inverse-variance method with random effects models. We conducted sensitivity analyses using varying definitions of oliguria as well as by pooling unadjusted odds ratios to establish the robustness of the primary meta-analysis. We also conducted subgroup analyses according to surgery type and definition of AKI to explore potential sources of clinical or methodological heterogeneity. RESULTS: Eleven studies (total 49,252 patients from 11 observational studies including a post hoc analysis of a randomised controlled trial) met the selection criteria. Seven of these studies contributed data from a total 17,148 patients to the primary meta-analysis. Intraoperative oliguria was associated with a significantly elevated risk of postoperative AKI (pooled adjusted odds ratio [OR] 1.74; 95% confidence interval [CI] 1.36-2.23, p < 0.0001, 8 studies). Sensitivity analyses supported the robustness of the primary meta-analysis. There was no evidence of any significant subgroup differences according to surgery type or definition of AKI. CONCLUSIONS: This study demonstrated a significant association between intraoperative oliguria and the risk of postoperative AKI, regardless of the definitions of oliguria or AKI used. Further prospective and multi-centre studies using standardised definitions of intraoperative oliguria are required to define the thresholds of oliguria and establish strategies to minimise the risk of AKI.

Effects of transcranial direct current stimulation on improving performance of delayed- reinforcement attentional set-shifting tasks in attention-deficit/hyperactivity disorder rat model.

Behavioral flexibility (or set-shifting), which is regulated by the prefrontal cortex (PFC), is often impaired in patients with attention-deficit/hyperactivity disorder (ADHD), which is characterized by poor inhibitory control and reinforcement learning. Transcranial direct current stimulation (tDCS) has been proposed as a means of noninvasive brain stimulation and a potential therapeutic tool for modulating behavioral flexibility. Animal studies can pave the way to know if tDCS application can potentially benefit rule- and goal-based activities in ADHD. Spontaneously hypertensive rats (SHRs) and inbred Wistar-Kyoto (WKY) rats were used as an animal model of ADHD and controls, respectively, and their strategy set-shifting abilities, including initial discrimination, set-shifting, and reversal learning tasks under 0-s or 15-s reinforcer delivery delay conditions, were evaluated. The tDCS treatment had a limited effect on the performance of the SHRs and WKY rats in initial discrimination task under 0-s delay condition. Under the 15-s delay condition, the SHRs had longer lever-press reaction times and/or more trial omissions than the WKY rats did when completing set-shifting and reversal-learning tasks. Among the SHRs, tDCS treatment improved the rats' reaction times and/or reduced their trial omissions in the set-shifting and reversal-learning tasks. Although tDCS may improve delayed reinforcement learning set-shifting performance in SHRs, further studies are required to clarify the responsible mechanism.

Mother-Child Interaction of Boys With ADHD: A Behavioral Observation Study.

PURPOSE: Investigate the quality of mothers' interactions with children with ADHD and a marginal disturbance in socioemotional competence (MDSC). RESEARCH METHODS: A total of 49 mother-boy dyads were included, and we observed their communication on neutral and conflict topics for children with ADHD and MDSC, children with ADHD alone, and children with typical development (TD). The Chinese version of the Specific Affect Coding System 20-code was used to examine the affective presentation in communication. RESULTS: Mothers of children with ADHD and MDSC had less negative disengagement affect compared with those of children with ADHD alone. Boys with ADHD and MDSC and boys with TD had constant positive engagement between neutral and conflict conditions in parent-child interaction. Boys with ADHD and MDSC had significantly less positive affect and more neutral affect than children with ADHD only. CONCLUSIONS AND IMPLICATIONS: Boys with ADHD and MDSC and their mothers had worse quality of observed mother-child communication than children with ADHD only and their mothers.

Cooperative Behavior Evokes Interbrain Synchrony in the Prefrontal and Temporoparietal Cortex: A Systematic Review and Meta-Analysis of fNIRS Hyperscanning Studies.

Single-brain neuroimaging studies have shown that human cooperation is associated with neural activity in frontal and temporoparietal regions. However, it remains unclear whether single-brain studies are informative about cooperation in real life, where people interact dynamically. Such dynamic interactions have become the focus of interbrain studies. An advantageous technique in this regard is functional near-infrared spectroscopy (fNIRS) because it is less susceptible to movement artifacts than more conventional techniques like electroencephalography (EEG) or functional magnetic resonance imaging (fMRI). We conducted a systematic review and the first quantitative meta-analysis of fNIRS hyperscanning of cooperation, based on thirteen studies with 890 human participants. Overall, the meta-analysis revealed evidence of statistically significant interbrain synchrony while people were cooperating, with large overall effect sizes in both frontal and temporoparietal areas. All thirteen studies observed significant interbrain synchrony in the prefrontal cortex (PFC), suggesting that this region is particularly relevant for cooperative behavior. The consistency in these findings is unlikely to be because of task-related activations, given that the relevant studies used diverse cooperation tasks. Together, the present findings support the importance of interbrain synchronization of frontal and temporoparietal regions in interpersonal cooperation. Moreover, the present article highlights the usefulness of meta-analyses as a tool for discerning patterns in interbrain dynamics.

Multiple types of harassment victimization in adolescents with autism spectrum disorder: Related factors and effects on mental health problems.

BACKGROUND/PURPOSE: This study examined the prevalence and related factors of multiple (two or three) types of harassment victimization, including school bullying, cyberbullying, and teacher harassment, and their cumulative effects on depression, anxiety, self-esteem, and suicidality in adolescents with autism spectrum disorder (ASD) but without intellectual disability. METHODS: A total of 219 adolescents with ASD but without intellectual disability and their parents participated in this study. Their experiences of school bullying, cyberbullying, and teacher harassment were evaluated. The related factors of multiple types of harassment victimization, including demographic characteristics, socio-communicative skills, comorbid attention-deficit/hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD) symptoms, were examined. Moreover, the effects of multiple types of harassment victimization on depression, anxiety, self-esteem, and suicidality were examined. RESULTS: In total, 20.54% of participants were victims of multiple types of harassment. Hyperactivity or impulsivity and ODD symptoms were positively associated with multiple types of harassment victimization. Adolescents with ASD who experienced multiple types of harassment victimization had higher severities of depression and anxiety and were more likely to have suicidality than nonvictims and those who experienced only one type of harassment victimization. CONCLUSION: Experiencing more than one type of harassment victimization was significantly associated with the development of mental health problems in adolescents with ASD. ODD and hyperactivity/impulsivity symptoms predicted the risk of experiencing multiple types of harassment.

Long-term mental health outcomes of severe burn injury: A 5-year follow-up of the 2015 Formosa Fun Coast Water Park fire disaster.

OBJECTIVE: Severe burn injuries have profound mental health impacts on individuals, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Many burn survivors also report positive psychosocial changes, termed posttraumatic growth (PTG). This study investigated long-term mental health of severe burn injury (i.e., PTSD, MDD, and PTG) and the longitudinal influences of coping strategies and social support. METHODS: Ninety-nine adult burn survivors of the 2015 Formosa Fun Coast Water Park fire disaster participated in the 5-year follow-up (Wave 3, W3), with 93% completing the earlier 2- (Wave 1, W1) and 3-year follow-up (Wave 2, W2). Participants averaged 22.1 years of age at burn, and 62.6% were females. The mean total body surface area burned (TBSA) was 50.3%, with a mean length of hospital stay of 87.6 days. RESULTS: Five years after the 2015 fire disaster, 13.1%, and 14.1% of the survivors met probable DSM-5 PTSD and MDD, while 51.5% reported significant PTG. After controlling for demographic, burn-specific, and baseline outcome variables, avoidance coping at W2 prospectively predicted PTSD and depressive symptoms at W3 (p = .003 and 0.04), with medium-to-large and medium effect sizes (sr2 = 0.10 and 0.05). Approach coping at W2 prospectively predicted PTG at W3 (p = .014), with a medium-to-large effect size (sr2 = 0.07). CONCLUSION: Rates of probable PTSD and MDD were still relatively high in long-term burn survivors. However, PTG continued to be highly prevalent. Our findings highlight the importance of coping in affecting the long-term mental health of severe burn injury.

What has social neuroscience learned from hyperscanning studies of spoken communication? A systematic review.

A growing body of literature examining the neurocognitive processes of interpersonal linguistic interaction indicates the emergence of neural alignment as participants engage in oral communication. However, questions have arisen whether the study results can be interpreted beyond observations of cortical functionality and extended to the mutual understanding between communicators. This review presents evidence from electroencephalography (EEG) and functional near-infrared spectroscopy (fNIRS) hyperscanning studies of interbrain synchrony (IBS) in which participants communicated via spoken language. The studies are classified into: knowledge sharing; turn-taking speech co-ordination; cooperation, problem-solving and creativity; and naturalistic discussion paradigms according to the type of interaction specified in each study. Alignment predominantly occurred in the frontal and temporo-parietal areas, which may reflect activation of the mirror and mentalizing systems. We argue that the literature presents a significant contribution to advancing our understanding of IBS and mutual understanding between communicators. We end with suggestions for future research, including analytical approaches and experimental conditions and hypothesize that brain-inspired neural networks are promising techniques for better understanding of IBS through hyperscanning.

Association between intravenous fluid resuscitation and outcome among patients with suspected infection and sepsis: A retrospective cohort study.

OBJECTIVE: To investigate the association between timing and volume of intravenous fluids administered to ED patients with suspected infection and all-cause in-hospital mortality. METHODS: Retrospective cohort study of ED presentations at four metropolitan hospitals in Sydney, Australia, between October 2018 and May 2019. Patients over 16 years of age with suspected infection who received intravenous fluids within 24 h of presentation were included. RESULTS: During the study period, 7533 patients with suspected infection received intravenous fluids. Of these, 1996 (26.5%) and 231 (3.1%) had suspected sepsis and septic shock, respectively. Each 1000 mL increase in intravenous fluids administered was associated with a reduction in risk of in-hospital mortality (adjusted odds ratio [AOR] 0.87, 95% confidence interval [CI] 0.76-0.99). This association was stronger in patients with septic shock (AOR 0.66, 95% CI 0.49-0.89), and those admitted to intensive care unit (ICU) (AOR 0.74, 95% CI 0.56-0.96). Patients with suspected sepsis and septic shock who received a total volume of >3600 mL had lower in-hospital mortality (AOR 0.44, 95% CI 0.22-0.91; AOR 0.16, 95% CI 0.05-0.57) compared to those administered <3600 mL within the first 24 h of presenting to the ED. There was no association between the time of initiation of fluids and in-hospital mortality among survivors and non-survivors (2.3 vs 2.5 h, P = 0.50). CONCLUSION: We observed a reduction in risk of in-hospital mortality for each 1000 mL increase in intravenous fluids administered in patients with septic shock or admitted to ICU suggesting illness severity to be a likely effect modifier.

Health-related quality of life in mothers of children with attention deficit hyperactivity disorder in Taiwan: The roles of child, parent, and family characteristics.

BACKGROUND: No study has examined how child and maternal psychopathological difficulties and family factors contribute to the health-related quality of life (HRQOL) of mothers of children with attention deficit hyperactivity (ADHD). AIMS: To investigate the impact of children's diagnosis of ADHD, children's and maternal psychopathology and significant sociodemographic variables of the children, parents and family on HRQOL of mothers of children with ADHD and those of children with typical development (TD) in Taiwan. METHODS AND PROCEDURES: Children with ADHD (n = 257) and children with typical development (n = 324) and their mothers were recruited from a psychiatric clinic of a medical center and 10 elementary schools and four high schools in northern Taiwan. Maternal HRQOL was assessed with the World Health Organization Quality of Life - BREF, while the other factors were screened using the Chinese version of the Childhood Autism Spectrum Test for autistic traits, the Swanson, Nolan, and Pelham, version IV scale for ADHD symptoms, the Child Behavior Checklist for behavioral and emotional problems, The Center for Epidemiologic Studies Depression Scale for maternal depression and interpersonal problems, the Adult ADHD Self-report Scale for maternal ADHD symptoms, and the Family APGAR for family support. OUTCOMES AND RESULTS: Mothers of children with ADHD had significantly worse HRQOL in all four domains compared with those of children with typical development. Multiple regressions found that factors consistently related to the HRQOL of mothers of children with ADHD and those of children with TD were maternal depression and perceived family support after controlling for several familial, parental and child variables. HRQOL of mothers of children with ADHD and those of children with TD was more closely related to her own and family factors rather than mother- or teacher-rated ADHD symptoms, clinical diagnosis of ADHD or psychopathology of the child. CONCLUSIONS AND IMPLICATIONS: Screening for maternal HRQOL, depressive symptoms and family support systems and mental health services for mothers of children with ADHD are warranted based on these findings.

Intermittent theta burst stimulation over the posterior superior temporal sulcus for children with autism spectrum disorder: A 4-week randomized blinded controlled trial followed by another 4-week open-label intervention.

LAY ABSTRACT: Intermittent theta burst stimulation is a varied form of repetitive transcranial magnetic non-invasive brain stimulation technique used to treat several neurological and psychiatric disorders. Its feasibility and therapeutic effects on the bilateral posterior superior temporal sulcus in children with autism are unknown. We conducted a single-blind, sham-controlled parallel randomized clinical trial in a hitherto largest sample of intellectually able children with autism (N = 78). Participants randomized to the active group received two-session/week intermittent theta burst stimulation for continuous 8 weeks. Those in the sham group received two-session/week sham stimulations in the first 4 weeks and then active intervention for the following 4 weeks after unblinding. First, we found that continuous 8-week intermittent theta burst stimulation on the bilateral posterior superior temporal sulcus in children with autism is safe and tolerable. Second, we found that 8-week intermittent theta burst stimulation produced greater therapeutic efficacy, although we did not find any significant effects of 4-week intermittent theta burst stimulation on core symptoms and social cognitive performances in autism. Further analysis revealed that participants with higher intelligence and better social cognitive performance, alongside less attention-deficit hyperactivity disorder severity at baseline, were more likely to be responders. This study identified that the factors contribute to responders and the results suggest that longer courses of non-invasive brain stimulation may be needed to produce therapeutic benefits in autism, with consideration of heterogeneous responses.

Contextual Factors Impact the Variability in ADHD Symptoms in Preschoolers with Situational Hyperactivity.

Objective: This study examined preschoolers with teacher-reported or parent-reported situational hyperactivity, and whether they differed in terms of behavioral problems, attentional problems, and parenting perceptions. Method: We used the Conners' Kiddie Continuous Performance Test and the Color Flanker Task to assess 99 preschoolers with pervasive high-ADHD-symptoms (42), school-situational high-ADHD-symptoms (30), or home-situational high-ADHD-symptoms (27), plus 111 preschoolers with pervasive low-ADHD-symptoms. Parents and teachers reported externalizing/internalizing behavioral problems. Parenting perceptions were measured with the Parenting Stress Index-Short Form and a parenting perceptions scale. Results: Preschoolers with school-situational high-ADHD-symptoms had deficits in attentional control. Parents of preschoolers with home-situational high-ADHD-symptoms had higher levels of parental stress and perceived their parenting to be harsher. Preschoolers with pervasive high-ADHD-symptoms had deficits in attentional control, increased parental stress, and parents with harsher parenting perceptions. Conclusion: Preschoolers with situational high-ADHD-symptoms may have different contextual risk factors related to ADHD symptoms reported by parents versus teachers.

Decreased Risk of Influenza in Child and Adolescent Patients with Attention-Deficit Hyperactivity Disorder Following Methylphenidate Treatment: A Nationwide Cohort Study in Taiwan.

BACKGROUND: Young individuals with attention-deficit hyperactivity disorder (ADHD) may have an elevated risk of influenza because of the difficulty in complying with the behavioral procedures that help protect against influenza. Moreover, the effects of sufficient methylphenidate treatment on influenza have received little attention. OBJECTIVE: This study evaluated the association between ADHD medication usage and influenza and assessed the effect of duration of ADHD treatment on the risk of influenza using a nationwide population-based database. METHODS: This study investigated methylphenidate usage and the risk of influenza among children and adolescents with ADHD. We identified 5259 young individuals aged less than 18 years who were diagnosed as having ADHD between 1996 and 2013 from the National Health Insurance Research Database of Taiwan, and we tested whether methylphenidate use affects influenza risk using Cox proportional hazard models. RESULTS: After controlling for confounding factors, the results indicated that influenza risk significantly reduced in the group of ADHD patients who were prescribed methylphenidate for 90 days and more (hazard ratio [HR]: 0.62, 95% confidence interval [CI]: 0.52-0.75, p<0.001), demonstrating a 38% reduction in the risk of influenza in this group. However, this was not observed in the group of ADHD patients who used methylphenidate for 1-90 days (HR: 0.69, 95% CI: 0.89-1.05, p=0.12). CONCLUSION: The lower incidence of influenza observed in the group prescribed with methylphenidate for a longer period highlights the importance of compliance to medication and psychoeducation with regard to ADHD management.

Validity and Reliability Study of the Chinese (Traditional) Version of the Devereux Early Childhood Assessment for Toddlers (DECA-T).

BACKGROUND: The Devereux Early Childhood Assessment for Toddlers (DECA-T), which is one of the few standardized, norm-referenced behavioral rating scales related to young children's mental health, resilience, and social-emotional development, was developed for toddlers aged between 18 and 36 months. OBJECTIVE: The aim of this study was to test the clinimetric properties of the Chinese (Traditional) version of the DECA-T (C-DECA-T) using a classical test theory analysis and an item response theory analysis. METHODS: Seventy-five community-based toddlers aged from 18 to 36 months and 50 clinic-based participants recruited in hospitals in northern Taiwan participated in this study. Social-emotional competence was assessed by the C-DECA-T and children's behavior problems were rated via the Child Behavior Checklist 1.5 to 5 (CBCL/1.5-5). Homogeneity of the C-DECA-T was assessed by Mokken analysis; sensitivity and specificity were assessed via receiver operating characteristic curve. RESULTS: The results showed the C-DECA-T demonstrated good test-retest reliability (r=0.8) and high internal consistency (Cronbach's alpha = 0.94). Inter-rater reliability between father and mother was fair (ICC = 0.46). Convergent validity of the CBCL/1.5-5 total behavior problems (r=-0.26) demonstrated acceptable psychometric performance. The overall measure of the sampling adequacy of the C-DECA-T assessed by principal component analysis was 0.93. Mokken scale analysis showed the 36-items of the C- DECA-T formed a weak unidimensional scale (Hs =0.35), supporting its construct validity. The area under curve of the C-DECA-T in prediction of social-emotional disturbance was 0.70. The optimal cutoff of the Total Protective Factor score of the C-DECA-T was a T score of 40.1 (T40.1), with a sensitivity of 95% and a specificity of 68%. Item 2 ("show affection for a familiar adult") and item 33 ("calm herself/himself") provide a good amount of information for the assessment of social-emotional strength and needs of a toddler in clinical practice. CONCLUSION: The C-DECA-T showed good psychometric properties. Our findings of high internal consistency of the three subscales and total score of the C-DECA-T suggest symptom manifestation of social-emotional competence and needs in Taiwanese toddlers is not culturally different from American toddlers. The clinimetric properties of the C-DECA-T examined by a classical test theory analysis approach and an item response theory analysis approach suggest that the C-DECA-T is a reliable and valid instrument for measuring social-emotional strength and needs in the population in Taiwan.

Continuous local anaesthetic wound infusion for postoperative pain after midline laparotomy for colorectal resection in adults.

BACKGROUND: Colorectal resection through a midline laparotomy is a commonly performed surgical procedure to treat various bowel conditions. The typical postoperative hospital stay after this operation is 6 to 10 days. The main factors hindering early recovery and discharge are thought to include postoperative pain and delayed return of bowel function.Continuous infusion of a local anaesthetic into tissues surrounding the surgical incision via a multi-lumen indwelling wound catheter placed by the surgeon prior to wound closure may reduce postoperative pain, opioid consumption, the time to return of bowel function, and the length of hospital stay. OBJECTIVES: To evaluate the efficacy and adverse events of continuous local anaesthetic wound infusion for postoperative pain after midline laparotomy for colorectal resection in adults. SEARCH METHODS: We searched the CENTRAL, MEDLINE and Embase databases to January 2019 to identify trials relevant to this review. We also searched reference lists of relevant trials and reviews for eligible trials. Additionally, we searched two clinical trials registers for ongoing trials. SELECTION CRITERIA: We considered randomised controlled trials (including non-standard designs) or quasi-randomised controlled trials comparing continuous wound infusion of a local anaesthetic versus a placebo or a sham after midline laparotomy for colorectal resection in adults. We did not compare continuous local anaesthetic wound infusion to other techniques, such as transverse abdominis plane block or thoracic epidural analgesia. We allowed non-randomised analgesic co-interventions carried out equally in the intervention and control groups. DATA COLLECTION AND ANALYSIS: Two review authors independently identified trials for inclusion and assessed their quality using the Cochrane 'Risk of bias' tool. We extracted data using standardised forms, including pain at rest and on movement (10-point scale), opioid consumption via a patient-controlled analgesia (PCA) system (mg morphine equivalent), postoperative opioid-related adverse events, the time to rescue analgesia, the time to first flatus and to first bowel movement, the time to ambulation, the length of hospital stay, serious postoperative adverse events, and patient satisfaction. We quantitatively synthesised the data by meta-analysis. We summarised and graded the certainty of the evidence for critical outcomes using the GRADEpro tool and created a 'Summary of findings' table. MAIN RESULTS: This review included six randomised controlled trials that enrolled a total of 564 adults undergoing elective midline laparotomy for colorectal resection comparing continuous wound infusion of a local anaesthetic to a normal saline placebo. Due to 23 post-randomisation exclusions, a total of 541 participants contributed data to the analysis of at least one outcome (local anaesthetic 268; control 273). Most participants were aged 55 to 65 years, with normal body mass index and low to moderate anaesthetic risk (American Society of Anesthesiologists class I-III). Random sequence generation, allocation concealment, and blinding were appropriately carried out in most trials. However, we had to downgrade the certainty of the evidence for most outcomes due to serious study limitations (risk of bias), inconsistency, indirectness, imprecision and reporting bias.Primary outcomesOn postoperative day 1, pain at rest (mean difference (MD) -0.59 (from 3.1), 95% confidence interval (CI) -1.12 to -0.07; 5 studies, 511 participants; high-certainty evidence), pain on movement (MD -1.1 (from 6.1), 95% CI -2.3 to -0.01; 3 studies, 407 participants; low-certainty evidence) and opioid consumption via PCA (MD -12 mg (from 41 mg), 95% CI -20 to -4; 6 studies, 528 participants; moderate-certainty evidence) were reduced in the local anaesthetic group compared to the control group.Secondary outcomesThere was a reduction in the time to first bowel movement (MD -0.67 from 4.4 days, 95% CI -1.17 to -0.17; 4 studies, 197 participants; moderate-certainty evidence) and the length of hospital stay (MD -1.2 from 7.4 days, 95% CI -2.0 to -0.3; 4 studies, 456 participants; high-certainty evidence) in the local anaesthetic group compared to the control group.There was no evidence of a difference in any serious postoperative adverse events until hospital discharge (RR 1.04, 95% CI 0.68 to 1.58; 6 studies, 541 participants; low-certainty evidence) between the two study groups. AUTHORS' CONCLUSIONS: After elective midline laparotomy for colorectal resection, continuous wound infusion of a local anaesthetic compared to a normal saline placebo reduces postoperative pain at rest and the length of hospital stay, on the basis of high-certainty evidence. This means we are very confident that the effect estimates for these outcomes lie close to the true effects. There is moderate-certainty evidence to indicate that the intervention probably reduces opioid consumption via PCA and the time to first bowel movement. This means we are moderately confident that effect estimates for these outcomes are likely to be close to the true effects, but there is a possibility that they are substantially different. The intervention may reduce postoperative pain on movement, however, this conclusion is based on low-certainty evidence. This means our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect. There is low-certainty evidence to indicate that the intervention may have little or no effect on the rates of any serious postoperative adverse events until hospital discharge. High-quality randomised controlled trials to evaluate the intervention with a focus on important clinical and patient-centred outcomes are needed.