The vans will be deployed across different divisions of the province, enabling drug inspectors to examine medicines in markets and other locations.
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Re:Thoracic epidural versus paravertebral blockade for reducing chronic post-thoracotomy pain (TOPIC-2): open label, parallel group, superiority, multicentre, randomised controlled trial
Agreement: I Agree Body: Dear Editor, Shelley and colleagues are to be congratulated on TOPIC-2, which settles the central question of whether paravertebral blockade is superior to thoracic epidural for chronic post-thoracotomy pain: it is not.¹ The authors themselves frame the value of perioperative analgesia as extending beyond pain scores to "facilitating engagement with physiotherapy and early mobilisation after surgery and thereby reducing the risk of postoperative complications, particularly pulmonary complications." From a nursing and enhanced-recovery perspective, it is precisely these downstream, functional consequences—rather than the primary outcome—that should guide technique selection, and two findings deserve more weight than the trial gives them. First, hypotension. The authors report hypotension (systolic <90 mm Hg) in 18% of the epidural group versus 12% with paravertebral blockade (RR 0.66), but dismiss its importance because most episodes were "minor" (thoracic morbidity and mortality grade 1-2) and no difference in cardiovascular or renal complications emerged.¹ A complication-severity scale captures organ harm, not the functional cost nurses actually manage: hypotension and orthostatic intolerance are the most common barrier to day-one sitting and ambulation after thoracic surgery, and a patient who cannot stand is precisely the patient at risk of the pulmonary complications analgesia is meant to prevent. The marginal day-one pain advantage of epidural (7.7 mm, below the 10 mm minimum clinically important difference) may therefore be offset by a mobilisation penalty that TOPIC-2 did not measure. Second, bladder care. The 12% versus 6% excess of urinary retention in the paravertebral group is presented as confounded by the high rate of routine catheterisation in the epidural group (72% v 33%).¹ But this is itself the point: the two arms are not comparable on bladder outcomes, because near-universal indwelling catheterisation in the epidural group both masks retention and constitutes its own burden—an impediment to mobilisation, a catheter-associated urinary tract infection risk, and patient discomfort. In the paravertebral group, by contrast, the 12% retention figure represents clinically evident retention in largely non-catheterised patients, a real nursing workload of bladder re-catheterisation. Enhanced recovery guidelines for lung surgery increasingly recommend avoiding routine urinary catheterisation,² so a technique that commits most patients to a catheter carries a genuine, underweighted cost. Finally, the 19% of patients with moderate-to-severe chronic pain at six months—in both arms—is a figure nurses can put to immediate use in discharge counselling and expectation-setting, and it argues for nurse-led chronic pain follow-up after thoracotomy. Future trials should measure the outcomes that drive day-to-day recovery—mobilisation milestones, catheter days, and catheter-associated infection—rather than leave technique choice to a null primary outcome. References 1 Shelley B, Middleton L, Boyles R, et al. Thoracic epidural versus paravertebral blockade for reducing chronic post-thoracotomy pain (TOPIC-2): open label, parallel group, superiority, multicentre, randomised controlled trial. BMJ 2026;395:e101114. 2 Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg 2019;55:91-115. doi:10.1093/ejcts/ezy301. No competing Interests: Yes The following competing Interests: Electronic Publication Date: Saturday, November 7, 2026 - 06:56 AI use: No, I have not used AI Highwire Comment Subject: Thoracic epidural versus paravertebral blockade for reducing chronic post-thoracotomy pain (TOPIC-2): open label, parallel group, superiority, multicentre, randomised controlled trial Workflow State: Released Full Title: Re:Thoracic epidural versus paravertebral blockade for reducing chronic post-thoracotomy pain (TOPIC-2): open label, parallel group, superiority, multicentre, randomised controlled trial Highwire Comment Response to: Thoracic epidural versus paravertebral blockade for reducing chronic post-thoracotomy pain (TOPIC-2): open label, parallel group, superiority, multicentre, randomised controlled trial Check this box if you would like your letter to appear anonymously:: Last Name: Ma First name and middle initial: Zebo Email: liamma022@gmail.com Address: Shenzhen University General Hospital, No. 1298, Xueyuan Avenue, Shenzhen University, Nanshan District, Shenzhen City, Guangdong Province Occupation: Nurse Other Authors: Huiting Zhang Affiliation: Shenzhen University General Hospital, Shenzhen, China. BMJ: Additional Article Info: Rapid response
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