Despite well-documented racial disparities in prescribing opioid medications for pain, little is known about whether there are disparities in the monitoring and follow-up treatment of patients who are prescribed opioid medications. We conducted a retrospective cohort study to examine whether there are racial differences in the use of recommended opioid monitoring and follow-up treatment practices. Our sample included 1646 white and 253 black patients who filled opioid prescriptions for noncancer pain for ≥ 90 consecutive days at the Veterans Affairs Pittsburgh Healthcare System pharmacy in fiscal years 2007 and 2008. Several opioid monitoring and follow-up treatment practices were extracted from electronic health records for a 12-month follow-up period. Findings indicated that 26.3% of patients had opioid agreements on file, pain was documented in 71.7% of primary care follow-up visits, urine drug tests were administered to 49.3% of patients, and 21.2% and 4.2% of patients were referred to pain and substance abuse specialists, respectively. Racial differences were observed in several of these practices. In adjusted comparisons, pain was documented less frequently for black patients than for white patients. Among those who had at least 1 urine drug test, black patients were subjected to more tests, especially if they were on higher doses of opioids. Compared with white patients, black patients were less likely to be referred to a pain specialist and more likely to be referred for substance abuse assessment. Addressing disparities in opioid monitoring and follow-up treatment practices may be a previously neglected route to reducing racial disparities in pain management.
The h-index of plastic surgeons seems to correlate with academic rank and has potential as a tool to measure academic productivity within plastic surgery. Plastic surgeons on faculty in integrated plastic surgery programs, those at larger programs, and male plastic surgeons tend to have higher h-indices. The difference between sexes seems to be, at least in part, due to the higher number of men in high academic positions. There does not seem to be a regional difference with regard to h-indices or a difference with regard to departmental status.
Cardiovascular, respiratory, and related disorders (CVRDs) are the leading causes of adult death worldwide, and substantial inequalities in care of patients with CVRDs exist between countries of high income and countries of low and middle income. Based on current trends, the UN Sustainable Development Goal to reduce premature mortality due to CVRDs by a third by 2030 will be challenging for many countries of low and middle income. We did systematic literature reviews of effectiveness and cost-effectiveness to identify priority interventions. We summarise the key findings and present a costed essential package of interventions to reduce risk of and manage CVRDs. On a population level, we recommend tobacco taxation, bans on trans fats, and compulsory reduction of salt in manufactured food products. We suggest primary health services be strengthened through the establishment of locally endorsed guidelines and ensured availability of essential medications. The policy interventions and health service delivery package we suggest could serve as the cornerstone for the management of CVRDs, and afford substantial financial risk protection for vulnerable households. We estimate that full implementation of the essential package would cost an additional US$21 per person in the average low-income country and $24 in the average lower-middle-income country. The essential package we describe could be a starting place for low-income and middle-income countries developing universal health coverage packages. Interventions could be rolled out as disease burden demands and budgets allow. Our outlined interventions provide a pathway for countries attempting to convert the UN Sustainable Development Goal commitments into tangible action.
Background:Standard isolation of adipose stromal vascular fraction (SVF) requires the use of collagenase and is considered more than “minimally manipulated” by current good manufacturing practice requirements. Alternatively, nonenzymatic isolation methods have surfaced using physical forces to separate cells from the adipose matrix. The purpose of this study was to review the literature on the use of mechanical isolation protocols and compare the results. The implication for use as a standard procedure in practice is discussed.Methods:A systematic review of the literature was performed on mechanical isolation of SVF with a search of six terms on PubMed and Medline databases. One thousand sixty-six articles were subject to evaluation by predetermined inclusion and exclusion criteria.Results:Two level 2 evidence articles and 7 in vitro studies were selected. SVF was isolated using automated closed systems or by subjecting the lipoaspirate to centrifugation only or by shaking or vortexing followed by centrifugation. Six articles reported isolation in laboratory settings and three inside the operating room. Stromal vascular cells expressed CD34, and CD44, CD73, CD90, and CD105, and differentiated along adipogenic and osteogenic lineages. When compared with enzymatic methods, mechanical isolation required less time but yielded fewer cells. Both case–control studies reported improved volume retention with cell-supplemented fat grafts for breast reconstruction.Conclusions:Mechanical isolation methods are alternatives to circumvent safety issues posed by enzymatic protocols. However, randomized comparative studies with long-term clinical outcomes using mechanically isolated stromal vascular cells are needed to identify their ideal clinical applications.
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