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

CSF1 Restores Innate Immunity Following Liver Injury in Mice and Serum Levels Indicate Outcomes of Patients With Acute Liver Failure

Background & Aims: Liver regeneration requires functional liver macrophages, which provide an immune barrier that is compromised after liver injury. The numbers of liver macrophages are controlled by macrophage colony-stimulating factor (CSF1). We examined the prognostic significance of the serum level of CSF1 in patients with acute liver injury and studied its effects in mice. Methods: We measured levels of CSF1 in serum samples collected from 55 patients who underwent partial hepatectomy at the Royal Infirmary Edinburgh between December 2012 and October 2013, as well as from 78 patients with acetaminophen-induced acute liver failure admitted to the Royal Infirmary Edinburgh or the University of Kansas Medical Centre. We studied the effects of increased levels of CSF1 in uninjured mice that express wild-type CSF1 receptor or a constitutive or inducible CSF1-receptor reporter, as well as in chemokine receptor 2 (Ccr2)-/- mice; we performed fate-tracing experiments using bone marrow chimeras. We administered CSF1-Fc (fragment, crystallizable) to mice after partial hepatectomy and acetaminophen intoxication, and measured regenerative parameters and innate immunity by clearance of fluorescent microbeads and bacterial particles. Results: Serum levels of CSF1 increased in patients undergoing liver surgery in proportion to the extent of liver resected. In patients with acetaminophen-induced acute liver failure, a low serum level of CSF1 was associated with increased mortality. In mice, administration of CSF1-Fc promoted hepatic macrophage accumulation via proliferation of resident macrophages and recruitment of monocytes. CSF1-Fc also promoted transdifferentiation of infiltrating monocytes into cells with a hepatic macrophage phenotype. CSF1-Fc increased innate immunity in mice after partial hepatectomy or acetaminophen-induced injury, with resident hepatic macrophage as the main effector cells. Conclusions: Serum CSF1 appears to be a prognostic marker for patients with acute liver injury. CSF1 might be developed as a therapeutic agent to restore innate immune function after liver injury

Productivity and competition in health care markets

Thesis (Ph.D.)--Massachusetts Institute of Technology, Dept. of Economics, c1999.Includes bibliographical references (p. 171-178).This thesis presents three empirical studies based on regulatory and institutional changes in the US hospital and pharmaceutical industries. Chapter 2 reports the results of an empirical study on changes in quality of health care after hospitals have undergone ownership conversions. Theoretical work on not-for-profit institutions has hypothesized that not-for-profit firms exist as a response to high contracting costs in markets with asymmetric information. If a firm knows more than its customers about the quality of the goods or services it sells, then the firm could cut costs by delivering lower-quality goods than it promises. Not-for-profit organizations serve as a solution to this problem by allowing managers to hold the firms in trust for their customers. Using readmission and mortality rates for heart and stroke patients as measures of quality of care, I find increases in mortality rate as well as readmission rate for heart attack patients after not-for-profit to for-profit conversions and after public to not-for-profit conversions. The deterioration in health care quality did not seem to be attributable to changes in the patient pool, but may be associated with changes in the number of procedures performed. The reduction in care for the uninsured after not-for-profit to for-profit hospital conversions may also point to the importance of legal enforcement and oversight as well as private contracts in ownership transfer. Chapter 3 considers altruistic behavior by not-for-profit, for-profit and public hospitals. Economic theories have hypothesized that not-for-profit organizations act in response to insufficient provision of social or collective consumption goods by private for-profit entities or by the government. I find support for not-for-profit hospitals behaving in an altruistic manner. Nevertheless, there is mixed evidence of both pure and impure altruism for not-for-profits. Similarly, public hospitals also exhibit behavior consistent with both pure and impure altruism. During the period of May 1995-June 1997, four former prescription-only drugs (Pepcid, Tagamet, Zantac and Axid) were introduced to the nonprescription market. Chapter 4 reports the impact of these introductions on thirteen similar incumbent products in the nonprescription drug market. I also analyze firms' use of advertising to compete and to increase demand for their products.by Davina C.Y. Ling.Ph.D

Do the Chinese "Keep up with the Jones"?: Implications of peer effects, growing economic disparities and relative deprivation on health outcomes among older adults in China

What are the health effects of unequal economic growth? What are the health consequences of 'keeping up with the Jones'? Many developed countries (e.g., US and Japan) have experienced significant income growth between 1950s and 2000s but population survey shows that on average the population is not growing more satisfied with life. Theories that attempt to respond to these findings hypothesize that as income grows, people may spend more on conspicuous consumption because they compare themselves with others in their peer groups and care about their position in socio-economic distributions relative to others. Indeed, public health studies have found a relationship between income inequality and adult health outcomes in developed countries. Specifically, there seems to be a correlation between social hierarchy and mortality, as well as a correlation between social hierarchy and morbidity. China is a prime study site due to its growing spatial inequalities in the past decade. Though China has been committed to economic reform, different regions and cities have encountered very disparate rates of development and growth. In this paper, we utilize a set of panel data collected in China (China Health and Nutrition Survey 1989-2004) to examine the effects of peer groups, relative deprivation, and income disparities on individual health outcomes such as the probability of high waist circumference, body mass index categories, probability of hypertension, nutritional intake as well as health behavior such as smoking. We use a combination of multi-level mixed effects modeling as well as factor analysis to examine these effects and find significant and differential effects of income quartiles, peer groups, relative deprivation, and Gini coefficient on health.Economic growth Health Relative deprivation China Elderly

Differences in Nobel laureates across disciplines

Are Economists really different from non-Economists? In this paper, we constructed a data set on Nobel Laureates’ personal life, to investigate if Economists are indeed different by studying their degree of self-interest across disciplines. Our study has made use of the observable characteristics of the Laureates such as the total number of children, year of award, affiliation at time of award, place of birth, scientific age, collaboration between the Laureate and spouse(s) and the number of times spouse(s) mentioned in the Official Biography of the Laureate, which may possibly affect the Laureates’ divorce rates and the acknowledgment of their spouse(s). Our main findings suggest that the total number of children plays an important role in influencing the Laureates’ divorce rates. Contrary to our expectations, Economists are not any more self-interested than Chemists and Physicists in terms of the divorce rates and sharing of credit with their spouse(s).Bachelor of Art

Continuous Flow Aqueous Synthesis of Highly Luminescent AgInS 2 and AgInS 2 /ZnS Quantum Dots

Continuous flow synthesis of semiconductor quantum dots (QDs) holds the promise of being highly reproducible, being scalable, and providing precise control of all reaction parameters. Here, we applied this technique to the aqueous synthesis of the Ag–In–S (AIS) core and AIS/ZnS core/shell QDs and optimized several parameters comprising reaction temperature, pressure, time, nature, and the ratio of precursors. Photoluminescence quantum yield (PLQY) values of 32%/44% (average/best) for the core and 77%/83% for the core/shell system have been obtained in short reaction times (8–15 min). We demonstrate by means of combined structural and optical studies that the high PLQY originates from donor–acceptor pair recombination processes, involving essentially [InAg2+ + 2VAg–] defect complexes whose formation is favored by the large excess of indium used (In:Ag ratio of 4:1), and the low reaction temperature (100–120 °C). The structural disorder is further enhanced during ZnS shell growth, which in addition to surface passivation and removal of nonradiative decay channels leads to the partial diffusion of the added zinc ions into the AIS core and the formation of ZnIn− antisite defects. The presented method provides excellent reproducibility and high scalability, facilitating the large-scale production of highly luminescent AIS/ZnS QDs

Continuous Flow Aqueous Synthesis of Highly Luminescent AgInS 2 and AgInS 2 /ZnS Quantum Dots

Continuous flow synthesis of semiconductor quantum dots (QDs) holds the promise of being highly reproducible, being scalable, and providing precise control of all reaction parameters. Here, we applied this technique to the aqueous synthesis of the Ag–In–S (AIS) core and AIS/ZnS core/shell QDs and optimized several parameters comprising reaction temperature, pressure, time, nature, and the ratio of precursors. Photoluminescence quantum yield (PLQY) values of 32%/44% (average/best) for the core and 77%/83% for the core/shell system have been obtained in short reaction times (8–15 min). We demonstrate by means of combined structural and optical studies that the high PLQY originates from donor–acceptor pair recombination processes, involving essentially [InAg2+ + 2VAg–] defect complexes whose formation is favored by the large excess of indium used (In:Ag ratio of 4:1), and the low reaction temperature (100–120 °C). The structural disorder is further enhanced during ZnS shell growth, which in addition to surface passivation and removal of nonradiative decay channels leads to the partial diffusion of the added zinc ions into the AIS core and the formation of ZnIn− antisite defects. The presented method provides excellent reproducibility and high scalability, facilitating the large-scale production of highly luminescent AIS/ZnS QDs