Optimal management of perioperative analgesia regarding immediate and short-term outcomes after liver transplantation - A systematic review, meta-analysis and expert panel recommendations.

BACKGROUND: Adequate pain control is essential for patients undergoing liver transplantation (LT). Multiple analgesic strategies have been implemented during the perioperative period. There is no consensus on the optimal perioperative analgesia management. OBJECTIVES: To provide recommendations, on the optimal perioperative analgesia management for LT. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS: A systematic review and meta-analysis following PRISMA guidelines and recommendations using GRADE. Studies describing outcomes, morbidity, mortality, pain scores, intensive care unit and hospital length of stay in patients that received different pain management techniques during and after LT were included (CRD42021243282). RESULTS: One thousand nine hundred ten articles were screened, but only two randomized controlled trials, one prospective and six retrospective studies were included. The opioid-avoidance protocols included, thoracic epidural analgesia (TEA), Transversus Abdominis Plane (TAP) block, as well as other non-opioid analgesics, resulted in improved short-term outcomes. Mortality was reduced in this group versus control cohorts (OR = 0.51; CI 0.14, 1.83; P = 0.350), Time to extubation, and intensive care unit LOS were shorter; pain scores after surgery were lower in opioid-avoidance group (percentage decrease, 35%, 12%, and 55%, respectively). However, hospital LOS was longer (percentage increase 8%). CONCLUSIONS: Opioid-avoidance analgesia management for LT results in improved short-term outcomes. (Quality of Evidence; Moderate to low | Grade of Recommendation; Weak). Medications such as acetaminophen(paracetamol), gabapentin, ketamine, tramadol and local anesthesia may be used instead of, or as adjuncts to opioids for postoperative analgesia. Overall evidence remains weak and more robust studies are required.

Improving a newly adapted teaching and learning approach: Collaborative Learning Cases using an action research / 한국의학교육

PURPOSE: Although medical curricula are now better structured for integration of biomedical sciences and clinical training, most teaching and learning activities still follow the older teacher-centric discipline-specific formats. A newer pedagogical approach, known as Collaborative Learning Cases (CLCs), was adopted in the medical school to facilitate integration and collaborative learning. Before incorporating CLCs into the curriculum of year 1 students, two pilot runs using the action research method was carried out to improve the design of CLCs. METHODS: We employed the four-phase Kemmis and McTaggart's action research spiral in two cycles to improve the design of CLCs. A class of 300 first-year medical students (for both cycles), 11 tutors (first cycle), and 16 tutors (second cycle) were involved in this research. Data was collected using the 5-points Likert scale survey, open-ended questionnaire, and observation. RESULTS: From the data collected, we learned that more effort was required to train the tutors to understand the principles of CLCs and their role in the CLCs sessions. Although action research enables the faculty to improve the design of CLCs, finding the right technology tools to support collaboration and enhance learning during the CLCs remains a challenge. CONCLUSION: The two cycles of action research was effective in helping us design a better learning environment during the CLCs by clarifying tutors' roles, improving group and time management, and meaningful use of technology.