Evaluation of a Tiered Opioid Prescribing Guideline for Inpatient Colorectal Operations

Background: In light of the opioid epidemic, reducing excess prescription quantities while tailoring to patient need is key. We previously created an opioid prescribing guideline using retrospective institutional data to satisfy the majority of patients’ opioid needs following inpatient colorectal surgery. Objective: This study sought to prospectively validate an institutional prescribing guideline based on previously-defined opioid consumption patterns following inpatient colorectal operations. Methods: We carried out a cohort study comparing opioid prescribing and consumption patterns before (7/18 – 1/19) and after (9/19 – 2/20) adoption of a tiered opioid prescribing guideline for inpatient elective colorectal operations (colectomies, proctectomies, and ostomy reversals) at a single tertiary care medical center. Opioid use was quantified as Equianalgesic 5mg Oxycodone Pills (EOP), and patients were grouped in three tiers based on opioid consumption in the 24-hours prior to discharge: Tier 1 (0 EOP), Tier 2 (0.1-3 EOP), and Tier 3 (\u3e3 EOP). Our guideline recommended maximum prescriptions of 0 EOP for Tier 1, 12 EOP for Tier 2, and 30 EOP for Tier 3. Results: The study included 100 patients before and 101 after guideline adoption. Demographic and operative variables were similar before and after guideline adoption. Guideline adherence was 85%. Overall, there was a 41% reduction in mean prescription quantity and 53% reduction in excess pills per prescription with no change in opioid consumption or refill rates. Conclusion: Adoption of a tiered opioid prescribing guideline significantly reduced opioid prescription quantity with no change in consumption or refill rates. Standardization of discharge prescriptions based on patient consumption in the 24 hours prior to discharge may be an important step towards minimizing excess prescribing

The Interstellar N/O Abundance Ratio: Evidence for Local Infall?

Sensitive measurements of the interstellar gas-phase oxygen abundance have revealed a slight oxygen deficiency ($\sim$ 15%) toward stars within 500 pc of the Sun as compared to more distant sightlines. Recent $FUSE$ observations of the interstellar gas-phase nitrogen abundance indicate larger variations, but no trends with distance were reported due to the significant measurement uncertainties for many sightlines. By considering only the highest quality ($\geq$ 5 $\sigma$) N/O abundance measurements, we find an intriguing trend in the interstellar N/O ratio with distance. Toward the seven stars within $\sim$ 500 pc of the Sun, the weighted mean N/O ratio is 0.217 $\pm$ 0.011, while for the six stars further away the weighted mean value (N/O = 0.142 $\pm$ 0.008) is curiously consistent with the current Solar value (N/O = 0.138$^{+0.20}_{-0.18}$). It is difficult to imagine a scenario invoking environmental (e.g., dust depletion, ionization, etc.) variations alone that explains this abundance anomaly. Is the enhanced nitrogen abundance localized to the Solar neighborhood or evidence of a more widespread phenomenon? If it is localized, then recent infall of low metallicity gas in the Solar neighborhood may be the best explanation. Otherwise, the N/O variations may be best explained by large-scale differences in the interstellar mixing processes for AGB stars and Type II supernovae.Comment: accepted for publication in the Astrophysical Journal Letter

Why Customers Value Mass-customized Products: The Importance of Process Effort and Enjoyment

We test our hypotheses on 186 participants designing their own scarves with an MC toolkit. After completing the process, they submitted binding bids for "their" products in Vickrey auctions. We therefore observe real buying behavior, not merely stated intentions. We find that the subjective value of a self-designed product (i.e., one's bid in the course of the auction) is indeed not only impacted by the preference fit the customer expects it to deliver, but also by (1) the process enjoyment the customer reports, (2) the interaction of preference fit and process enjoyment, and (3) the interaction of preference fit and perceived process effort. In addition to its main effect, we interpret preference fit as a moderator of the valuegenerating effect of process evaluation: In cases where the outcome of the process is perceived as positive (high preference fit), the customer also interprets process effort as a positive accomplishment, and this positive affect adds (further) value to the product. It appears that the perception of the self-design process as a good or bad experience is partly constructed on the basis of the outcome of the process. In the opposite case (low preference fit), effort creates a negative affect which further reduces the subjective value of the product. Likewise, process enjoyment is amplified by preference fit, although enjoyment also has a significant main effect, which means that regardless of the outcome, customers attribute higher value to a self-designed product if they enjoy the process. The importance of the self-design process found in this study bears clear relevance for companies which offer or plan to offer MC systems. It is not sufficient to design MC toolkits in such a way that they allow customers to design products according to their preferences. The affect caused by this process is also highly important. Toolkits should therefore stimulate positive affective reactions and at the same time keep negative affect to a minimum. (authors' abstract

A Na I Absorption Map of the Small-Scale Structure in the Interstellar Gas Toward M15

Using the DensePak fiber optic array on the KPNO WIYN telescope, we have obtained high S/N echelle spectra of the Na I D wavelength region toward the central 27" x 43" of the globular cluster M15 at a spatial resolution of 4". The spectra exhibit significant interstellar Na I absorption at LSR velocities of +3 km/s (LISM component) and +68 km/s (IVC component). Both components vary appreciably in strength on these scales. The derived Na I column densities differ by a factor of 4 across the LISM absorption map and by a factor of 16 across the IVC map. Assuming distances of 500 pc and 1500 pc for the LISM and IVC clouds, these maps show evidence of significant ISM structure down to the minimum scales of 2000 AU and 6000 AU probed in these absorbers. The smallest-scale N(Na I) variations observed in the M15 LISM and IVC maps are typically comparable to or higher than the values found at similar scales in previous studies of interstellar Na I structure toward binary stars. The physical implications of the small and larger-scale Na I features observed in the M15 maps are discussed in terms of variations in the H I column density as well as in the Na ionization equilibrium.Comment: 11 pages, 3 figures, accepted for publication in ApJ Letter

Measuring the Farm Level Impact of Agricultural Loans in Low Income Countries: A Review Article

Billions of dollars are spend worldwide on agricultural credit programs, yet few comprehensive evaluations exist. This paper reviews several methodological issues involved in measuring the farm level impact of agricultural loans. Fungibility of loan funds, farm-household interdependence, and the attribution problem are three issues which are reviewed in detail. A farm resource allocation model is used to analyze expected impact of loans on the farm. Recent descriptive, econometric and mathematical programming studies of loan impact in low income countries are reviewed relative to these issues and the resource allocation model. Suggestions are given for improved research and data collection