Brit J Hosp Med
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This article outlines the growing demand for surgical services globally, both in developing and developed countries. The implications of this increasing demand are explored, with particular attention focused on the enduring burden of perioperative complications. The role of critical care in ensuring the safe delivery of surgical services is also examined. Solutions to the 'surgical epidemic' are proposed including the role of perioperative medicine in reconfiguring services to provide safe surgical care.
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Both arthroscopic and open surgery of the shoulder are associated with significant postoperative pain. Use of opioids can result in adverse systemic effects, so a multi-modal analgesic approach and complementary analgesic techniques should be considered to minimize the postoperative opioid requirement. ⋯ However, interscalene block is associated with hemidiaphragmatic paresis which is a substantial risk in patients with serious pulmonary pathology who could otherwise benefit most from a regional technique and the avoidance of opioids. Local infiltration analgesia, and suprascapular nerve block with or without axillary nerve block, have not been consistently shown to be superior to or as effective as interscalene block and there is insufficient evidence to support the use of supraclavicular block over interscalene block.
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In principle the whole human proteome is available for the generation of recombinant proteins and glycoproteins that may serve as drugs (biologics). Endogenous human proteins and glycoproteins are structurally heterogeneous but are recognized as self by the immune system; however, recombinant protein and glycoprotein molecules are necessarily produced in heterologous systems and may include structural variants that are non-self and potentially immunogenic. ⋯ A particular concern is the structure of oligosaccharides attached by the hamster and murine cell lines that provide the dominant production platform. Critical structure and function properties that contribute to optimization of therapeutic potential are illustrated through recombinant erythropoietin and antibody therapeutics.