Patients' Experience With Opioid Pain Medication After Discharge From Surgery: A Mixed-Methods Study.

BACKGROUND: Decreasing the number of prescription opioids has been a leading strategy in combating the opioid epidemic. In Vermont, statewide and institutional policies have affected prescribing practices, resulting in a 40% decrease in postoperative opioid prescribing. The optimal approach to postoperative opioid prescribing remains unknown. In this study, we describe patients' experience with pain control 1 wk after discharge from surgery. MATERIALS AND METHODS: We assessed patients' experience using a telephone questionnaire, 1-wk after discharge after undergoing common surgical procedures between 2017 and 2019 at an academic medical center (n = 1027). Scaled responses regarding pain control, opioids prescribed, and opioids used (response rate 96%) were analyzed using a mixed-methods approach; open-ended patient responses to questions regarding whether the number of opioids prescribed was "correct" were analyzed using qualitative content analysis. RESULTS: One week after discharge, 96% of patients reported that their pain was well controlled. When asked whether they received the correct number of opioid pills postoperatively, qualitative analysis of patient responses yielded the following six themes: (1) I had more than I needed, but not more than I wanted; (2) Rationed medication; (3) Medication was not effective; (4) Caution regarding risks of opioids; (5) Awareness of the public health concerns; and (6) Used opioids from a prior prescription. CONCLUSIONS: Patient-reported pain control after common surgical procedures was excellent. However, patients are supportive of receiving more pain medications than they actually use, and they fear that further restrictions may prevent them or others from managing pain adequately. Understanding the patients' perspective is important for surgical education and improving discharge protocols.

Comparative analysis of vestibular ecomorphology in birds.

The bony labyrinth of vertebrates houses the semicircular canals. These sense rotational accelerations of the head and play an essential role in gaze stabilisation during locomotion. The sizes and shapes of the semicircular canals have hypothesised relationships to agility and locomotory modes in many groups, including birds, and a burgeoning palaeontological literature seeks to make ecological interpretations from the morphology of the labyrinth in extinct species. Rigorous tests of form-function relationships for the vestibular system are required to support these interpretations. We test the hypothesis that the lengths, streamlines and angles between the semicircular canals are related to body size, wing kinematics and flying style in birds. To do this, we applied geometric morphometrics and multivariate phylogenetic comparative methods to a dataset of 64 three-dimensional reconstructions of the endosseous labyrinth obtained using micro-computed tomography scanning of bird crania. A strong relationship between centroid size of the semicircular canals and body size indicates that larger birds have longer semicircular canals compared with their evolutionary relatives. Wing kinematics related to manoeuvrability (and quantified using the brachial index) explain a small additional portion of the variance in labyrinth size. We also find strong evidence for allometric shape change in the semicircular canals of birds, indicating that major aspects of the shape of the avian labyrinth are determined by spatial constraints. The avian braincase accommodates a large brain, a large eye and large semicircular canals compared with other tetrapods. Negative allometry of these structures means that the restriction of space within the braincase is intense in small birds. This may explain our observation that the angles between planes of the semicircular canals of birds deviate more strongly from orthogonality than those of mammals, and especially from agile, gliding and flying mammals. Furthermore, we find little support for relationships between labyrinth shape and flying style or wing kinematics. Overall, our results suggest that the topological problem of fitting long semicircular canals into a spatially constrained braincase is more important in determining the shape of the avian labyrinth than the specifics of locomotory style or agility. Our results tentatively indicate a link between visual acuity and proportional size of the labyrinth among birds. This suggests that the large labyrinths of birds compared with other tetrapods may result from their generally high visual acuities, and not directly from their ability to fly. The endosseous labyrinths of extinct birds and their close dinosaurian relatives may allow broad inferences about flight or vision, but so far provide few specific insights into detailed aspects of locomotion.

Synthetic microbiology in sustainability applications.

Microorganisms are a promising means to address many societal sustainability challenges owing to their ability to thrive in diverse environments and interface with the microscale chemical world via diverse metabolic capacities. Synthetic biology can engineer microorganisms by rewiring their regulatory networks or introducing new functionalities, enhancing their utility for target applications. In this Review, we provide a broad, high-level overview of various research efforts addressing sustainability challenges through synthetic biology, emphasizing foundational microbiological research questions that can accelerate the development of these efforts. We introduce an organizational framework that categorizes these efforts along three domains - factory, farm and field - that are defined by the extent to which the engineered microorganisms interface with the natural external environment. Different application areas within the same domain share many fundamental challenges, highlighting productive opportunities for cross-disciplinary collaborations between researchers working in historically disparate fields.

LanTERN: A Fluorescent Sensor That Specifically Responds to Lanthanides.

Lanthanides, a series of 15 f-block elements, are crucial in modern technology, and their purification by conventional chemical means comes at a significant environmental cost. Synthetic biology offers promising solutions. However, progress in developing synthetic biology approaches is bottlenecked because it is challenging to measure lanthanide binding with current biochemical tools. Here we introduce LanTERN, a lanthanide-responsive fluorescent protein. LanTERN was designed based on GCaMP, a genetically encoded calcium indicator that couples the ion binding of four EF hand motifs to increased GFP fluorescence. We engineered eight mutations across the parent construct's four EF hand motifs to switch specificity from calcium to lanthanides. The resulting protein, LanTERN, directly converts the binding of 10 measured lanthanides to 14-fold or greater increased fluorescence. LanTERN development opens new avenues for creating improved lanthanide-binding proteins and biosensing systems.

Solution Focused Brief Therapy Telemental Health Suicide Intervention.

One of the innumerable impacts of the coronavirus has been the change in how individuals provide services. For mental health providers, the pandemic required a sudden shift from in person to online service delivery. As therapists learn and embrace a new modality for providing therapy, crisis situations may present with some anxiety. With the pandemic increasing crisis situations for so many individuals, and teletherapy as a mode of service delivery being unlikely to go away after the pandemic, therapists require support in navigating crises situations online, in a medium that feels like the therapist has less control with their clients due to being in different physical locations. The authors believe that regardless of the primary model(s) therapists utilize in session, solution-focused brief therapy is an integrative model that uniquely captures client's resources and reasons for living and when clients are in crisis. The purpose of this paper is to present recommendations for applying solution-focused language in teletherapy practice, to provide ethical, evidenced based care for clients in crisis. A clinical vignette is used to illustrate the application of solution focused brief therapy for working with clients in crisis. Future directions and limitations are discussed.

Opioid Use and Associated Patient Satisfaction With Pain Control After Endoscopic Surgery and Robotic-Assisted Radical Prostatectomy.

OBJECTIVE: To evaluate patient reported measures in patients undergoing endourologic procedures and robotic assisted radical prostatectomy (RARP) to demonstrate the efficacy of non-opioid postoperative pain management strategies. MATERIALS AND METHODS: A prospective cohort study performed at an academic medical center included a patient telephone questionnaire and chart review. Opioid prescriptions, opioid use, and patient reported outcomes were recorded. Bivariate analyses were used to compare patients who did and did not use opioids in the RARP cohort while overall trends were reported for the endourologic procedures. RESULTS: Of the 68 patients undergoing endoscopic intervention, 14 (21%) were prescribed an opioid and 6 (9%) reported any opioid use. 58 (85%) reported their pain was very well or well controlled while 9 reported their pain was poorly controlled. 59 (87%) were satisfied or very satisfied with their pain control. Fifty-three (93%) of the 57 patients undergoing RARP received an opioid prescription and only 23 reported any opioid use. All but 1 patient reported that their pain was well or very well controlled and almost all (54) of the patients were satisfied with their level of pain control. 36 (63%) reported their pain was less than expected while only 7 (12%) reported it was more than expected. CONCLUSION: Most patients undergoing endourologic procedures do not use postoperative opioids and report favorable outcomes regarding their pain control. Similarly, after RARP, most patients do not use opioids even when they are prescribed and are satisfied with their pain control.

Diagnosis of Posterior and Combined-Type Shoulder Instability: A 10-Year Cross-sectional Study From a Single Military Base.

Background: Large variations exist in the reported frequency and etiology of posterior and combined shoulder instability in the active-duty military population. Purpose: To compare imaging and clinical examination findings as well as reoperation rates between active-duty military patients who underwent surgery for anterior, posterior, and combined-type shoulder instability. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review was conducted on patients treated surgically for shoulder instability from a single military base from January 2010 to December 2019. Each case was characterized as isolated anterior, isolated posterior, or combined, according to arthroscopic findings. Information was collected on patient characteristics, history of trauma, time to surgery, associated pathological findings, and survivorship at a minimum 2-year follow-up. Results: Overall, 416 patients (n = 394 men; n = 22 women), with a mean age of 29.1 years, underwent primary shoulder stabilization surgery during the study period. There were 158 patients (38%) with isolated anterior instability, 139 (33%) with isolated posterior instability, and 119 (29%) with combined instability. A history of trauma was more prevalent with isolated anterior instability (129 [81.7%]) than with either isolated posterior (95 [68.4%]) or combined instability (73 [61.3%]) (P = .047 and P = .001, respectively). Patients with anterior instability were significantly more likely to be diagnosed on the preoperative physical examination when compared with patients with posterior instability (93% vs 79.1%; P < .001) or combined instability (93% vs 75.6%; P < .001) and were also more likely to have a discrete labral tear detected on a preoperative magnetic resonance arthrogram than patients with posterior instability (82.9% vs 63.3%; P < .001). There was no significant difference in the rate of medical discharge or recurrent instability requiring reoperation between groups. Conclusion: The study findings indicated that young, active-duty military patients are at increased risk for isolated posterior and combined-type shoulder instability, with posterior and combined instability collectively accounting for over 60% of instability cases in this cohort. Orthopaedic surgeons should be aware of instability when evaluating and treating young, active-duty military patients with shoulder pain, even in the absence of diagnostic physical examinations or imaging findings.

"Every time the phone rings, my heart stops": Mothers' emotional responses to having a young adult child with a substance use disorder.

When a young adult develops a substance use disorder (SUD), a parent often assumes a caregiving role, and experiences burdens associated with this off-time life event (Kaur et al., 2018). Mothers and children reciprocally influence one another's emotional processes, impacting proximal process (Bronfenbrenner & Evans, 2000; Bronfenbrenner & Morris, 1998). The study purpose was to develop a theory of mothers' experiences of having a young adult child with a SUD. We conducted 14 semi-structured interviews with mothers who sought support from an online forum for parents of individuals with a SUD. We analyzed responses using Strauss and Corbin's (1990) grounded theory and identified three core categories that focused on participants' shift from approaching their child from a stance of anxiety and attempts to control their substance use, to anger, and, finally, acceptance of their loved one's autonomy. Findings imply the importance of mothers' treatment involvement, and specialized services for mothers.

Patient Factors Associated with High Opioid Consumption after Common Surgical Procedures Following State-Mandated Opioid Prescription Regulations.

BACKGROUND: State regulations have decreased prescribed opioids with more than 25% of patients abstaining from opioids. Despite this, 2 distinct populations of patients exist who consume "high" or "low" amounts of opioids. The aim of this study was to identify factors associated with postoperative opioid use after common surgical procedures and develop an opioid risk score. STUDY DESIGN: Patients undergoing 35 surgical procedures from 7 surgical specialties were identified at a 620-bed tertiary care academic center and surveyed 1 week after discharge regarding opioid use and adequacy of analgesia. Electronic medical record data were used to characterize postdischarge opioids, complications, demographics, medical history, and social factors. High opioid use was defined as >75th percentile morphine milligram equivalents for each procedure. An opioid risk score was calculated from factors associated with opioid use identified by backward multivariate logistic regression analysis. RESULTS: A total of 1,185 patients were enrolled between September 2017 and February 2019. Bivariate analyses revealed patient factors associated with opioid use including earlier substance use (p < 0.001), depression (p = 0.003), anxiety (p < 0.001), asthma (p = 0.006), obesity (p = 0.03), migraine (p = 0.004), opioid use in the 7 days before surgery (p < 0.001), and 31 Clinical Classifications Software Refined classifications (p < 0.05). Significant multivariates included: insurance (p = 0.005), employment status (p = 0.005), earlier opioid use (odds ratio [OR] 2.38 [95% CI 1.21 to 4.68], p = 0.01), coronary artery disease (OR 0.38 [95% CI 0.16 to 0.86], p = 0.02), acute pulmonary embolism (OR 9.81 [95% CI 3.01 to 32.04], p < 0.001), benign breast conditions (OR 3.42 [95% CI 1.76 to 6.64], p < 0.001), opioid-related disorders (OR 6.67 [95% CI 1.87 to 23.75], p = 0.003), mental and substance use disorders (OR 3.80 [95% CI 1.47 to 9.83], p = 0.006), headache (OR 1.82 [95% CI 1.24 to 2.67], p = 0.002), and previous cesarean section (OR 5.10 [95% CI 1.33 to 19.56], p = 0.02). An opioid risk score base was developed with an area under the curve of 0.696 for the prediction of high opioid use. CONCLUSIONS: Preoperative patient characteristics associated with high opioid use postoperatively were identified and an opioid risk score was derived. Identification of patients with a higher need for opioids presents an opportunity for improved preoperative interventions, the use of nonopioid analgesic therapies, and alternative therapies.

A harmonised, high-coverage, open dataset of solar photovoltaic installations in the UK.

Solar photovoltaic (PV) is an increasingly significant fraction of electricity generation. Efficient management, and innovations such as short-term forecasting and machine vision, demand high-resolution geographic datasets of PV installations. However, official and public sources have notable deficiencies: spatial imprecision, gaps in coverage and lack of crucial meta data, especially for small-scale solar panel installations. We present the results of a major crowd-sourcing campaign to create open geographic data for over 260,000 solar PV installations across the UK, covering an estimated 86% of the capacity in the country. We focus in particular on capturing small-scale domestic solar PV, which accounts for a significant fraction of generation but was until now very poorly documented. Our dataset suggests nameplate capacities in the UK (as of September 2020) amount to a total of 10.66 GW explicitly mapped, or 13.93 GW when missing capacities are inferred. Our method is applied to the UK but applicable worldwide, and compatible with continual updating to track the rapid growth in PV deployment.

The genetic insulator RiboJ increases expression of insulated genes.

A primary objective of synthetic biology is the construction of genetic circuits with behaviors that can be predicted based on the properties of the constituent genetic parts from which they are built. However a significant issue in the construction of synthetic genetic circuits is a phenomenon known as context dependence in which the behavior of a given part changes depending on the choice of adjacent or nearby parts. Interactions between parts compromise the modularity of the circuit, impeding the implementation of predictable genetic constructs. To address this issue, investigators have devised genetic insulators that prevent these unintended context-dependent interactions between neighboring parts. One of the most commonly used insulators in bacterial systems is the self-cleaving ribozyme RiboJ. Despite its utility as an insulator, there has been no systematic quantitative assessment of the effect of RiboJ on the expression level of downstream genetic parts. Here, we characterized the impact of insulation with RiboJ on expression of a reporter gene driven by a promoter from a library of 24 frequently employed constitutive promoters in an Escherichia coli model system. We show that, depending on the strength of the promoter, insulation with RiboJ increased protein abundance between twofold and tenfold and increased transcript abundance by an average of twofold. This result demonstrates that genetic insulators in E. coli can impact the expression of downstream genes, information that is essential for the design of predictable genetic circuits and constructs.