Performance enhancement of large scale networks with heterogeneous traffic.

Finally, these findings are applied towards improving the performance of the Differentiated Services architecture by developing a new Refined Assured Forwarding framework where heterogeneous traffic flows share the same aggregate class. The new framework requires minimal modification to the existing Diffserv routers. The efficiency of the new architecture in enhancing the performance of Diffserv is demonstrated by simulation results under different traffic scenarios.This dissertation builds on the notion that segregating traffic with disparate characteristics into separate channels generally results in a better performance. Through a quantitative analysis, it precisely defines the number of classes and the allocation of traffic into these classes that will lead to optimal performance from a latency standpoint. Additionally, it weakens the most generally used assumption of exponential or geometric distribution of traffic service time in the integration versus segregation studies to date by including self-similarity in network traffic.The dissertation also develops a pricing model based on resource usage in a system with segregated channels. Based on analytical results, this dissertation proposes a scheme whereby a service provider can develop compensatory and fair prices for customers with varying QoS requirements under a wide variety of ambient traffic scenarios.This dissertation provides novel techniques for improving the Quality of Service by enhancing the performance of queue management in large scale packet switched networks with a high volume of traffic. Networks combine traffic from multiple sources which have disparate characteristics. Multiplexing such heterogeneous traffic usually results in adverse effects on the overall performance of the network

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