Opioid stewardship: a need for opioid discharge guidance: comment on Br J Anaesth 2018 Dec 28

We read with interest the special and insightful article by Soffin and colleagues1 on the prescription opioid crisis. They carefully examine many of the drivers for subsequent opioid dependence after surgery and provide suggestions on how practice can and should be improved. As proponents of enhanced recovery programmes, we acknowledge that with reduced postoperative length of stay, and with the increased utilisation of ambulatory/day surgery, patients are no longer being fully weaned off their analgesics by the time of hospital discharge

Perioperative Opioids - Reclaiming Lost Ground

Opium (poppy tears) has been in use since 3400 BCE, with historical writings recording its sedative, euphoric, and analgesic properties, but it was not until the 19th century that morphine was isolated, paving the way for its therapeutic use. The 20th century witnessed advances in pharmacology and molecular biology, leading to the development of many different types of opioids and the recognition and classification of opioid receptors.Analgesia is fundamental to recovery from surgery, and while opioids continue to be the cornerstone of perioperative analgesia, overreliance on these agents and their many adverse effects has led to a reevaluation of their role in modern perioperative practice. Persistent postoperative opioid use (with disordered substance use at the extreme end of the spectrum) and opioid-induced ventilatory impairment have led to a global opioid crisis that has resulted in more than 100 000 deaths per annum worldwide, a number that rises yearly.1 Persistent postoperative opioid use and opioid-induced ventilatory impairment are exacerbated by other factors, such as nonmedical opioid use and opioid diversion. While the numbers of deaths are clearly not on the scale of the current COVID-19 pandemic, regrettably, there are few signs of measures that will force mortality to recede in the near future. In addition, the financial costs for increased health care and substance use disorder treatment, lost productivity, and criminal justice interventions ran to $150 billion in the US alone in 2015.1 While the opioid epidemic may have originated in the US, it has spread to other areas of the world, with Europe having more than 1.3 million individuals with high-risk opioid use.1 Besides the modifiable risk factors (Box),2 indiscriminate use of opioids has also been fueled by aggressive marketing strategies by pharmaceutical companies and the erroneous impression that consumption of opioids for pain does not lead to substance use disorders

The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist: A Joint Statement by the ERAS^® and ERAS^® USA Societies.

Enhanced recovery after surgery (ERAS) programs are multimodal care pathways designed to minimize the physiological and psychological impact of surgery for patients. Increased compliance with ERAS guidelines is associated with improved patient outcomes across surgical types. As ERAS programs have proliferated, an unintentional effect has been significant variation in how ERAS-related studies are reported in the literature. To improve the quality of ERAS reporting, ERAS <sup>®</sup> USA and the ERAS <sup>®</sup> Society launched an effort to create an instrument to assist authors in manuscript preparation. Criteria to include were selected by a combination of literature review and expert opinion. The final checklist was refined by group consensus. The Societies present the Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist. The tool contains 20 items including best practices for reporting clinical pathways, compliance auditing, and formatting guidelines. The RECOvER Checklist is intended to provide a standardized framework for the reporting of ERAS-related studies. The checklist can also assist reviewers in evaluating the quality of ERAS-related manuscripts. Authors are encouraged to include the RECOvER Checklist when submitting ERAS-related studies to peer-reviewed journals

Beyond surgery: clinical and economic impact of Enhanced Recovery After Surgery programs.

Enhanced Recovery After Surgery (ERAS) is a perioperative management based on multimodality and multidisciplinary work. ERAS has been shown to have important clinical and economic benefits, but its spread remains slow worldwide. This manuscript reviews the overall program benefits and focuses on important aspects for implementation well beyond surgery. Implementation of ERAS pathways improves clinical outcomes and induces substantial economic gains. ERAS is the current surgical revolution

The Performance of Private Equity Funds: Does Diversification Matter?

This paper is the first systematic analysis of the impact of diversification on the performance of private equity funds. A unique data set allows the exact evaluation of diversification across the dimensions financing stages, industries, and countries. Very different levels of diversification can be observed across sample funds. While some funds are highly specialized others are highly diversified. The empirical results show that the rate of return of private equity funds declines with diversification across financing stages, but increases with diversification across industries. Accordingly, the fraction of portfolio companies which have a negative return or return nothing at all, increase with diversification across financing stages. Diversification across countries has no systematic effect on the performance of private equity funds

Consensus on Training and Implementation of Enhanced Recovery After Surgery: A Delphi Study.

Enhanced Recovery After Surgery (ERAS) is widely accepted in current surgical practice due to its positive impact on patient outcomes. The successful implementation of ERAS is challenging and compliance with protocols varies widely. Continual staff education is essential for successful ERAS programmes. Teaching modalities exist, but there remains no agreement regarding the optimal training curriculum or how its effectiveness is assessed. We aimed to draw consensus from an expert panel regarding the successful training and implementation of ERAS. A modified Delphi technique was used; three rounds of questionnaires were sent to 58 selected international experts from 11 countries across multiple ERAS specialities and multidisciplinary teams (MDT) between January 2016 and February 2017. We interrogated opinion regarding four topics: (1) the components of a training curriculum and the structure of training courses; (2) the optimal framework for successful implementation and audit of ERAS including a guide for data collection; (3) a framework to assess the effectiveness of training; (4) criteria to define ERAS training centres of excellence. An ERAS training course must cover the evidence-based principles of ERAS with team-oriented training. Successful implementation requires strong leadership, an ERAS facilitator and an effective MDT. Effectiveness of training can be measured by improved compliance. A training centre of excellence should show a willingness to teach and demonstrable team working. We propose an international expert consensus providing an ERAS training curriculum, a framework for successful implementation, methods for assessing effectiveness of training and a definition of ERAS training centres of excellence

Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines

BackgroundERAS® Society guidelines are holistic, multidisciplinary tools designed to improve outcomes after surgery. The enhanced recovery after surgery (ERAS) approach was initially developed for colorectal surgery and has been implemented successfully across a large number of settings, resulting in improved patient outcomes. As the ERAS approach is increasingly being adopted worldwide and new guidelines are being generated for new populations, there is a need to define an ERAS® Society guideline and the methodology that should be followed in its development.MethodsThe ERAS® Society recommended approach for developing new guidelines is based on the creation of multidisciplinary guideline development groups responsible for defining topics, planning the literature search, and assessing the quality of the evidence.ResultsClear definitions for the elements of an ERAS guideline involve multimodal and multidisciplinary approaches impacting on multiple patient outcomes. Recommended methodology for guideline development follows a rigorous approach with systematic identification and evaluation of evidence, and consensus‐based development of recommendations. Guidelines should then be evaluated and reviewed regularly to ensure that the best and most up‐to‐date evidence is used consistently to support surgical patients.ConclusionThere is a need for a standardized, evidence‐informed approach to both the development of new ERAS® Society guidelines, and the adaptation and revision of existing guidelines

The price of rapid exit in venture capital-backed IPOs

This paper proposes an explanation for two empirical puzzles surrounding initial public offerings (IPOs). Firstly, it is well documented that IPO underpricing increases during “hot issue” periods. Secondly, venture capital (VC) backed IPOs are less underpriced than non-venture capital backed IPOs during normal periods of activity, but the reverse is true during hot issue periods: VC backed IPOs are more underpriced than non-VC backed ones. This paper shows that when IPOs are driven by the initial investor’s desire to exit from an existing investment in order to finance a new venture, both the value of the new venture and the value of the existing firm to be sold in the IPO drive the investor’s choice of price and fraction of shares sold in the IPO. When this is the case, the availability of attractive new ventures increases equilibrium underpricing, which is what we observe during hot issue periods. Moreover, I show that underpricing is affected by the severity of the moral hazard problem between an investor and the firm’s manager. In the presence of a moral hazard problem the degree of equilibrium underpricing is more sensitive to changes in the value of the new venture. This can explain why venture capitalists, who often finance firms with more severe moral hazard problems, underprice IPOs less in normal periods, but underprice more strongly during hot issue periods. Further empirical implications relating the fraction of shares sold and the degree of underpricing are presented