Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

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 (beta 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

The social and economic impacts of geothermal development in Hawaii

"Work done under a grant from the U.S. Department of Energy by contract (#3415609) through the Lawrence Livermore Laboratory of the University of California.

The POETICs of industrial carbon dioxide emissions in Japan: an urban and institutional extension of the IPAT identity

<p>Abstract</p> <p>Background</p> <p>This study applies the POETICs framework (population, organization, environment, technology, institutions and culture) to an analysis of industrial carbon dioxide emissions in Japanese cities. The inclusion of institutional variables in the form of International Council for Local Environmental Initiatives membership, ISO 14001 implementation, and non-profit sector activity addresses the ecological limitations of the often used IPAT (impact = population × affluence × technology) approach.</p> <p>Results</p> <p>Results suggest the weak existence of an environmental Kuznets curve, in which the wealthiest cities are reducing their emissions through increased efficiency. Significant institutional impacts are also found to hold in the predicted directions. Specifically, panel and cross-sectional regressions indicate that membership in the International Council for Local Environmental Initiatives and non-profit organizational presence have negative effects on industrial carbon dioxide emissions.</p> <p>Conclusion</p> <p>The presence of institutional drivers at the city level provides empirical support for the POETICs rubric, which recasts the ecological framing of the IPAT identity in a more sociological mold. The results also indicate that Japanese civil society has a role to play in carbon mitigation. More refined studies need to take into consideration an expanded set of methods, drivers, and carbon budgets, as applied to a broader range of cases outside of Japan, to more accurately assess how civil society can bridge the issue of scale that separates local level policy concerns from global level climate dynamics.</p

MULTI-LEVEL POLICY COALITIONS AN INTERPRETATIVE MODEL OF WATER CONFLICTS IN THE AMERICAS

ABSTRACT This article proposes an analytical approach to conflicts and policy-making related to urban water management based on multi-level policy coalitions. This is necessary to articulate four main issues. First, the repositioning of social and political struggles for access to water, along with policy variables. Second, the analysis of the effects of ecological transition, including climate change. Third, the reincorporation of these struggles and challenges in a multi-level approach. Finally, the enquiry into the apparent contradiction, in contemporary policymaking. The article proposes a definition of multi-level coalitions as collective preference systems that influence the content of policies (ideas/advocacy, decisions, policy tools) and their implementation, groups of actors that arise from engagement in policy issues. In the first section, the article presents the objectives of research on urban water management in the Americas, within the framework of which this analytical approach by multi-level coalitions is fashioned. In the second section, the article details four analytical issues. In the third section, it gives a definition of multi-level coalitions