8 research outputs found
Sounds Local, 1996 November 09
No full textInterview with Native American author Susan Power, a member of the Dakota, on growing up in two cultures and becoming a writer, ahead of her reading in Bryan Auditorium of Morton Hall at UNC Wilmington; Interview with director Grenoldo Fraizer on the play, Blessed Assurance, presented by Tapestry Theatre Company and on stage at the Scottish Rite Temple; Romeo and Juliet (film) review by WHQR's film commentator, Steve Taylor; Interview with Wilmington chapter member and ceremony organizer Colonel Roger Raines on the Military Order of World Wars, in conjunction with local organizations, celebrating the Massing of the Colors on Veterans Day at St. Paul's Episcopal Church; Overview of upcoming events on the cultural calendar
School-based interventions TO Prevent Dating and Relationship Violence and Gender-Based Violence: STOP-DRV-GBV systematic review
No full textBackground
Schools have a duty of care to prevent violence between students but a significant amount of dating and relationship violence and gender-based violence occurs in schools. These are important public health issues with important longitudinal consequences for young people.
Objectives
To understand functioning and effectiveness of school-based interventions for the prevention of dating and relationship violence and gender-based violence.
Review methods
We undertook a mixed-methods systematic review to synthesise different types of evidence relating to school-based interventions for the prevention of dating and relationship violence and gender-based violence to understand if, how and in what ways these interventions are effective.
We searched 21 databases and 2 trial registers and undertook forwards and backwards citation chasing, author contact and other supplementary search methods. Searches identified all literature published to June 2021. All screening was undertaken in duplicate and independently, and we quality appraised all included studies.
Results
We included 247 reports (68 outcome evaluations, 137 process evaluations). Synthesis of intervention components produced an intervention typology: single-component, curricular, multicomponent, and multilevel programmes. Synthesis of intervention theories suggested that interventions aiming to increase students’ sense of school belonging and sense of safety in the school building could encourage increased learning of prosocial skills and increased prosocial peer norms, and so potentially reducing dating and relationship violence and gender-based violence. Synthesis of factors affecting delivery highlighted school organisation and leaders who believed in the importance of addressing dating and relationship violence/gender-based violence, along with time and resources to deliver the interventions. The ease with which the intervention could be delivered and modified was also important.
Meta-analysis found stronger evidence for intervention effectiveness in reducing dating and relationship violence than for gender-based violence, with significant long-term impacts on dating and relationship violence victimisation and perpetration, and some evidence that interventions in high-income countries could be effective for reducing victimisation and perpetration of gender-based violence in the long-term. Impacts on knowledge and attitudes were primarily short-term. Network meta-analysis did not suggest superiority of any intervention type. Moderation evidence suggested interventions reduced dating and relationship violence perpetration in boys more than girls, but reduced gender-based violence perpetration more in girls. Metaregression by intervention component did not explain heterogeneity in effectiveness, but qualitative comparative analysis suggested that reducing perpetration was important to reducing victimisation, and that perpetration could be reduced via focus on interpersonal skills, guided practice and (for gender-based violence) implementation of social structural components.
Limitations
Despite an exhaustive search, trials may have been missed and risk of publication bias was high for several analyses.
Conclusions
This is the most comprehensive systematic review of school-based interventions for dating and relationship violence and gender-based violence to date. It is clear that the prevention of dating and relationship violence and gender-based violence in schools will require longer-term investment to show benefit
Comunicação e gestão de obras: a dinâmica textos/conversações baseado no estudo de dois empreendimentos habitacionais
No full textTese (doutorado) - Universidade Federal de Santa Catarina, Centro Tecnológico, Programa de Pós-Graduação em Engenharia Civil, Florianópolis, 2010Nos últimos anos, tem ocorrido um intenso debate na literatura da área da construção, em relação a teorias que permitam compreender o que é e como se desenvolve a gestão de obras. Nesse debate, o tema comunicação tem se destacado. De forma a contribuir com essa discussão e considerada a importância dos programas habitacionais, a tese teve como objetivo elaborar uma estrutura teórica que descreve a relação entre a gestão de obras e o processo de comunicação, no contexto de empreendimentos residenciais financiados. Apesar de haver uma discussão recente que considera a comunicação na gestão de obras, o trabalho reconhece e apresenta uma concepção diferenciada para a relação entre esses dois fenômenos, considerada mais adequada, para explicar a inter-relação entre comunicação e gestão de obras. A partir de uma revisão na área de conhecimento da comunicação organizacional, verificaram-se concepções importantes que permitem ampliar e incluir elementos ainda não explorados nas abordagens e propostas recentes para a gestão de obras. Nessa perspectiva, se desenvolveu uma compreensão da relação entre gestão de obras e comunicação como um processo de organização das ações da obra, em que um conjunto de agentes representantes de diferentes níveis hierárquicos se coorientam em torno de um objeto comum, por meio da construção e trasmissão de significados e alinhamento das intenções, através da dinâmica contínua de tradução de textos em conversações e de conversações em textos. Essa concepção é empregada em um contexto da construção civil, a execução de empreendimentos habitacionais financiados, através de dois estudos de caso longitudinais. Nesses estudos são descritos os processos de comunicação, observados como um discurso, manifestado em textos e conversações, antes e durante a execução das obras. Como resultado final é apresentado um modelo específico, que no caso de obras habitacionais financiadas, demonstra a existência de particularidades dos programas de financiamento, que influenciam o processo de comunicação, através da criação e transferência de significados específicos na dinâmica textos/conversações, associados ao processo de formatação do empreendimento e à liberação dos recursos ao longo da execução da construção
Conditional strategies to study gene function during gonadal development in mammals.
No full textSexual development in mammals involves a complex cascade of genetic events. These begin with a cell fate decision, whether to make Sertoli or follicle cells, that gives rise to the development of a male or female gonad, which is controlled by the testis-determining gene Sry. Following the expression of Sry, genes involved in the male pathway act to reinforce and maintain testis-specific cell fate decisions, as well as to repress the female pathway. Sox9 becomes rapidly upregulated after the onset of Sry expression, and is expressed in Sertoli cells throughout life. From mutation studies, SOX9 is known to be essential for male development in humans and to initiate Sertoli cell differentiation in mice. However, the function of SOX9 after sex determination and the reason for its maintenance in Sertoli cells remains unknown. In order to understand the function of Sox9 in the fetal and adult mouse testis, new tools have been generated to control gene activity in a conditional manner. This thesis mainly describes strategies to control either deletion of misexpression of Sox9. To make the tools useful at different stages, the tamoxifen-inducible Cre/loxP system was employed. This involves the establishment of two elements: a "Cre-driver" and a ' Sox9-responder". Cre-driver transgenes were made under the control of several gonadal-specific regulatory elements, as well as a strong, ubiquitous promoter. Responder mice allow Cre activated conditional misexpression or deletion of Sox9. Analyses on gonad morphologies and gene expression levels were compared between animals that have altered Sox9 expression and those that have not. The results reveal that Sox9 is necessary and sufficient for the expression of Sfl in the Sertoli cells, and suggest that Sox9 is antagonistic to the ovarian- specific gene Foxl2. The newly established Cre-drivers can also be applied in functional studies involving other genes implicated in sexual development
Brycon costaricensis Angulo & Gracian-Negrete, 2013, new species
No full textBrycon costaricensis, new species Table 1, Figure 2 Brycon guatemalensis (not Regan 1908): Meek, 1914: 108–109 (Costa Rica, Atlantic slope, Limón: Río Costa Rica, Quebrada La Victoria, Río Zent and Río Parismina); Fowler, 1923: 23 (Nicaragua, Atlantic slope: Río Eden and Río Tunky); Hildebrand, 1938: 275 (key), 281–282 (distribution, in part: “ranges on the Atlantic slope from Guatemala to Western Panama ”; Costa Rica and Nicaragua reference); Miller, 1966: 137 (distribution, in part: “Atlantic slope from the Río Grijalva, Tabasco and Chiapas, Mexico southward to eastern Panamá ”; Costa Rica and Nicaragua reference); Bussing, 1976: 158–161 (distribution, in part: Atlantic slope from Guatemala to Western Panama; Costa Rica and Nicaragua reference); Bussing & López, 1977: 16, 20, 24, 27 (Costa Rica, Atlantic slope, Alajuela: Arenal Drainage); Géry, 1977: 339 (distribution, in part: “Central America ”; Costa Rica and Nicaragua reference); Bussing, 1985: 457 (distribution, in part: Atlantic slope from Guatemala to western Panama, with two discontinuities; Costa Rica and Nicaragua reference); Bussing, 1987: 75–76 (distribution, in part: Atlantic slope from Grijalva, Mexico to western Panama, with two discontinuities; Costa Rica and Nicaragua reference); Burcham, 1988: 277–283 (Costa Rica, Atlantic slope, Heredia: La Selva Biological Station, Río Puerto Viejo: alimentation); Ulloa-Rojas et. al, 1989: 128–129 (Costa Rica, Atlantic slope, Alajuela: Arenal Drainage); Bussing, 1993: 779 (Costa Rica, Atlantic slope, Heredia: La Selva Biological Station, Río Puerto Viejo: ecology); Bussing, 1994: 196–198 (Costa Rica, Atlantic slope, Heredia: La Selva Biological Station, Río Puerto Viejo: ecology); Horn, 1997: 259–263 (Costa Rica, Atlantic slope, Heredia: La Selva Biological Station, Río Puerto Viejo: seed dispersion of Ficus glabatra); Bussing, 1998: 92–96 (distribution, in part: Atlantic slope from Grijalva, Mexico to western Panama, with two discontinuities; Costa Rica and Nicaragua reference); Banack et al., 2002: 232, 237, 239 – 241 (Costa Rica, Atlantic slope, Heredia: La Selva Biological Station, Río Puerto Viejo: seed dispersion of Ficus insipida); Drewe et al., 2004: 890–899 (Costa Rica, Atlantic slope, Heredia: La Selva Biological Station, Río Puerto Viejo: gut morphology, alimentation, digestive enzyme activity); Smith & Bermingham, 2005: 1839 (distribution, in part: “San Juan province”; Costa Rica and Nicaragua reference); Molina, 2006: 31–36 (Costa Rica: larval development); Reeves & Bermingham, 2006: 88 (distribution, in part: from “ Costa Rica to Mexico ”; Costa Rica and Nicaragua reference); Herrera- Vásquez et al., 2007: 168 (Costa Rica, Atlantic slope); Espinoza, 2008: 1975 (Costa Rica, Atlantic slope, Alajuela: Caño Crucitas, Quebrada descubrimiento, Río Infiernillo, Quebrada Llano Verde and Quebrada Minas). Holotype. UCR 2936 -01: 128.1 mm SL, Costa Rica, Atlantic slope, Heredia, Sarapiquí drainage, La Virgen de Sarapiquí, Río Sarapiquí, at the Tirimbina Biological Reserve, 149 m, 10 ° 24 ' 56.84 "N, 84 °07' 18.70 "W, C.A. Garita, 25 May 2013. Paratypes. 50 specimens (47.8–325.1 mm SL). Costa Rica: UCR 0214-09: 2, 105.0– 132.9 mm SL, Limón, Matina drainage, Quebrada Chocolate, 4.5 km SW of Moin, on road between Limón and Liverpool, 15 m, 9 º 59 '04.99"N, 83 º05' 29.51 "W, W.A. Bussing and S. Salas, 20 October 1967; UCR 0215-02: 3, 96.7–128.8 mm SL, Limón, Parismina drainage, Río Siquirres 4–5 km W of Siquirres on road between Moravia and Siquirres, 240 m, 10 º05'15.00"N, 83 º 32 ' 44.27 "W, H. Nanne, 15 October 1967; UCR 0263-08: 1, 234.0 mm SL, Alajuela, San Carlos drainage, Quebrada Máquina, 4.2 km from Florencia de San Carlos on road between Ciudad Quesada and Muelle de San Carlos, 90 m, 10 º 23 ' 44.99 "N, 84 º 28 ' 39.33 "W, W.A. Bussing, 1 September 1968; UCR 0444- 10: 4, 144.8 – 170.0 mm SL, Limón, Parismina drainage, Quebrada Salsipuedes, 1.5 km E. of Ventiocho Millas on provisional road to Limón, 20 m, 10 º05' 19.99 "N, 83 º 21 ' 44.27 "W, W.A. Bussing, M. Bussing and R. Nishimoto, 17 October 1970; UCR 0843-02: 5, 47.8–114.7 mm SL, Quebrada Santa Rita, from 1 km above to 1.5 km below bridge, 5 km SW Florencia, San Carlos drainage, Alajuela, Costa Rica, 200 m, 10 º 19 ' 24.99 "N, 84 º 31 ' 0.01 "W, J. Prendas, W. González, W. López and M. Murillo, 22 February 1975; UCR 0929–01: 3, 130.6 – 265.1 mm SL, Alajuela, Lago de Nicaragua drainage, Río Zapote 2.6 km S of Canalete, on Upala road, Lago de 85 m, 10 º 49 ' 59.99 "N, 85 º02'09.83"W, W. Bussing, H. Camacho and W. Gonzáles, 17 December 1975; UCR 0948-03: 4, 64.2–99.8 mm SL, Guanacaste, San Carlos drainage, Quebrada Pérez 2.6 km E of Arenal, 522 m, 10 º 28 ' 19.99 "N, 84 º 49 ' 44.27 "W, W.A. Bussing, E. Bussing and W. González, 5 January 1976; UCR 1351 - 19: 1, 151.8 mm SL, Limón, Matina drainage, Río Cuba, on road to Limón, Costa Rica, 15 m, 10 º01'20.00"N, 83 º 13 ' 14.75 "W, W.A. Bussing, 25 September 1981; UCR 1570 -02: 1, 230.0 mm SL, Alajuela, Lago de Nicaragua drainage, source of small stream, 2 km S of Bijagua, 440 m, 10 º 43 '09.99"N, 85 º03' 59.99 "W, W.A. Bussing, Ich. Course, 17 March 1984; UCR 1671 - 01: 3, 84.0– 153.2 mm SL, Guanacaste, San Juan drainage, Tributary of Río Bijagua, 10 º 44 '25.00"N, 85 º03'09.84"W, W.A. Bussing, Ich. Course, 4 May 1985; UCR 1809 -09: 3, 96.2–148.1 mm SL, Limón, Tortuguero drainage, Parque Nacional Tortuguero, Río Agua Fría, 10 º 27 ' 49.99 "N, 83 º 33 ' 59.99 "W, K. Winemiller, 18 June 1985; UCR 1827 -05: 1 (C&S), 73.0 mm SL, Limón, Parismina drainage, Quebrada Herediana, 6 km NW of Siquirres, on road to Guápiles, 10 m, 10 º08'09.99"N, 83 º 33 ' 29.51 "W, W.A. Bussing, Ich. Course, 21 March 1986; UCR 2147 -02: 1, 140.4 mm SL, Alajuela, Lago de Nicaragua drainage, Río Caño Negro, Parque Nacional Volcán Rincón de la Vieja, in the main stream, 310 m, 10 º 47 '45.00"N, 84 º 57 ' 19.68 "W, S. Navarro, L. Villalba and J. Fraizer, 11 March 1989; UCR 2852 -01: 1 (C&S), 75.9 mm SL, Limón, Parismina drainage, Río Pacuare, J. Picado, 13 July 2004. Nicaragua: UCR 0268-01: 3, 72.5–105.5 mm SL, Zelaya, Escondido drainage, Río La Concha (flowing into Río Mico), 18 km W of Ciudad Rama, 150 m, 12 º 10 ' 00.00"N, 84 º 28 ' 39.33 "W, J.D. Villa, 21 April 1968; UCR 0457-02: 7, 67.0– 185.5 mm SL, Chontales, Prinzapolka drainage, Río Yoaya 13.6 km E of Siuna at road, 300 m, 13 º 40 '00.00"N, 84 º 21 ' 44.27 "W, W.A. Bussing and G. Campos, 14 April 1971; UCR 0461- 10: 6, 55.9- 82.9 mm SL, Chontales, Escondido drainage, Río Muhán 17.4 km SE of Villa Somoza at Managua, Rama road, 100 m, 12 º 11 '00.00", 86 º 15 '05.04"W, W.A. Bussing, G. Campos and A. Zepeda, 17 April 1971; UCR 1086 -01: 1, 325.1 mm SL, San Juan drainage, Quebrada Peor es Nada, R. Beatty, 27 April 1976. Diagnosis. Brycon costaricensis differs from all other Central American Brycon species by possessing 49 to 54 scales in the lateral line (vs. 43 to 48 in B. argenteus, 55 to 61 in B. guatemalensis, and more than 64 in B. behreae, B. chagrensis and B. striatulus) and a anal fin notably longer than head, with 33 to 37 total rays (vs. an anal fin about equal to length of head, with 24 to 28 total rays in B. argenteus, B. obscurus, and B. petrosus, the last two species with 48 to 55 and 53 to 58 scales in the lateral line, respectively). The following combination of characters also can separate the species herein described from B. guatemalensis: 5 or 6 rows of scales between lateral line and pectoral fin base (vs. 7 or 8); 9 to 11 (generally 10) rows of scales between lateral line and dorsal fin base (vs. 10 to 12, generally 11); 5 to 7 (generally 6) rows of scales between lateral line and anal fin base (vs. 7 to 9, generally 8); and a elongated and shallow caudal peduncle, whose length is 1.78 to 2.35 times its depth (vs. a short and deep caudal peduncle, whose length is 1.25 to 1.61 times its depth). Description. Morphometric and meristic data are given in Table 1. Body moderately slender, robust and moderately high in specimens above 300.0 mm of SL; largest body height at dorsal-fin level; sloped dorsal profile; head large, slightly acute anteriorly and moderately deep posteriorly, head depth about 64.30 to 79.22 % (71.73 %) of body deep; eye large and snout relatively short and conical, eye diameter about 0.86 to 1.65 (1.27) times snout length; mouth terminal, heterognathous, premaxillary extending slightly ahead of dentary, leaving 2 rows of teeth exposed in advance of it; maxillary almost reaching the middle of the eye, maxillary length about 28.38 to 37.33 % (32.22 %) of head length; lower jaw shorter than upper, leaving 2 rows of teeth exposed in advance of it; premaxillary teeth large, laterally in 2 series, anteriorly more or less definitely in 3 series (the outer series with 8– 10 (9) teeth, the second series with 7–10 (9) teeth and the inner series with 2 largest teeth); maxillary with 9–15 (11) medium sized teeth; dentary with 7–9 (8) large anterior teeth, 7–12 (9) small posterior teeth and 1 tooth at the symphysis, forming the inner row; first gill arch with 13–15 (14) lower gill rakers, 13–15 (14) upper gill rakers and 1 at angle; scales cycloid; lateral line complete from supracleithrum to caudal-fin base and decurved anteriorly; dorsal-fin origin equidistant from snout and base of caudal-fin or scarcely behind of the middle of SL; pectoral-fin longer than pelvic-fin, its length about 1.22 to 1.51 (1.38) times the pelvic-fin length or 0.75 to 1.12 (0.94) times the distance between the pectoral-fin origin and the pelvic-fin origin; anal-fin base almost equal in length that maximum body depth, its length about 0.85 to 1.09 (1.00) times the body depth; caudal peduncle large and shallow, its length about 1.78 to 2.35 (1.98) times its depth; caudal-fin broadly forked. Color in life. See Figure 2 A. Overall coloration silvery, some of the scales with blackish edges, forming vertical streaks; olive dark back and pearl white belly; pinkish, yellowish, olive or bronze color opercular bones (in adults); posterior edge of gill-opening blackish (in adults); paired fins transparent, light pink or reddish (in juveniles), rosy gray or dark (in adults); dorsal and adipose fins light pink, yellowish, reddish (in juveniles), rosy gray or dark (in adults); a more or less distinct blackish spot on the caudal peduncle; tail pale pink, yellowish, reddish (mostly in juveniles) or dark (mostly in adults); anal and caudal fins usually dark-edged. Color in alcohol. See Figure 2 B. Dorso-lateral body surfaces silvery to coppery, dark olive to dark brown dorsally, becoming gradually clear ventrally; posterior edge of gill-opening blackish (in adults); longitudinal stripes, present in some specimens, extending all along the trunk; moderate to darkly pigmentation on paired fins; dorsal and anal fins pale with some dark pigmentation on interradial membranes and distal margins; adipose-fin usually pigmented at the basis; relatively faint, rounded dark area on caudal peduncle; caudal-fin usually dark-edged. Distribution. Brycon costaricensis is known from Wawa basin in northern Nicaragua to Matina basin in southern Costa Rica, Atlantic slope (Figure 3). In addition, since no other Brycon species has been recorded between Cangrejal, Aguán and Patuca basins in central Honduras and Coco and Ulám basins in northern Nicaragua (Bussing 1998, Matamoros et al. 2009), B. guatemalensis (sensu stricto) should now be considered as restricted from the Grijalva and Usumacinta basins in southern Mexico (Miller et al. 2006) to the Ulúa and Leán basins in northwestern Honduras, in the Atlantic slope, and to the Choluteca basin at the Honduran Pacific slope (Matamoros et al. 2009). Etymology. The specific name, costaricensis, refers to the country of the type locality: Costa Rica, Atlantic slope, Heredia, Sarapiquí drainage, La Virgen de Sarapiquí, Río Sarapiquí. Common names. Machaca, Sábalo, Sabalete, Machaca del Atlántico (Bussing 1998, Angulo in press). Ecological notes. The literature mentioning Brycon guatemalensis should eventually be revised regarding the origin of the material used (see Distribution). Brycon costaricensis inhabits some lakes in Nicaragua and Costa Rica, but it is also abundant in fast-flowing rivers and streams since it is a very strong swimmer (Bussing & López 1977, Bussing 1998). It is found at elevations between 0 and 600 m in lakes, rivers and creeks (Bussing 1998). It tolerates temperatures between 21 and 34 °C (Bussing 1998). Young specimens (less than 80 mm of total length) fed principally on insects while the largest ones (more than 80 mm of total length) consumed a large proportion of allochthonous vegetal matter, principally leaves (Burcham 1988). Horn (1997) and Banack et al. (2002) found that the largest individuals of this species can potentially disperse Ficus spp. (Moraceae) seeds for long distances along watercourses. Drewe et al. (2004) found that largest individuals of B. costaricensis have relatively larger intestines than juveniles specimens, and an ontogenetical change of main gut enzymes, associated with the ontogenetic change in diet (from carnivores to mainly herbivores). In addition, as in the case of B. opalinus (Cuvier 1819), B. costaricensis possesses a large gall bladder, suggesting the importance of the digestion of lipids in these species (Drewe et al. 2004, Gomiero et al. 2008). Burcham (1988) also found that largest individuals of B. costaricensis are present in forest streams and usually absent from deforested areas that indicates that the removal of fruit trees from the banks of small streams leads to their local elimination or to a considerable decrease in their abundance. Regarding the reproductive biology of B. costaricensis, little is known. Bussing (1998) mentions that pairs of this species lay eggs in an excavated nest in the sand substratum of creeks. Additionally, Molina (2006) describes their most relevant larval development characteristics after artificial fertilization of eggs of wild fish. Brycon costaricensis is a delight for sport fisherman because of its fighting nature and the flesh is highly regarded (Bussing 1998). The latter author reported for this species a maximun size of 500 mm and a maximun weight of 4300 g. Remarks. CVA recovered two distinct shape groups along both Canonical Variates (CV) (Figure 4). Brycon guatemalensis and B. costaricensis specimens were evenly distributed among the two groups in CV 1, meanwhile B. costaricensis and B. behreae were likewise distributed among the two groups in CV 2. Both canonical variate axis are significant at the p <.001 level based on the Wilk’s lamda value (the sum of squares within groups divided by the total sum of squares within and between groups). The CV 1 explained 74.82 % of the shape variance. An assignment test performed in CVAgen based on CV 1 determined that all specimens had been correctly assigned to the respective group. Shape differences associated with the CV 1 and CV 2 are shown in Figure 4. Brycon costaricensis, with positive scores on CV 1 (Figure 4 C) and negative scores on CV 2 (Figure 4 D), has slender bodies and caudal peduncles larger and shallower than specimens with negative scores on CV 1 (Figure 4 B) as well as deeper heads, eyes displaced dorsally, anterior fins insertion displaced anteriorly and the posterior end of the supraocipital spine positioned anteriorly and dorsally than specimens with positive scores on CV 2 (Figure 4 E).Published as part of Angulo, Arturo & Gracian-Negrete, Jatziry Marlene, 2013, A new species of Brycon (Characiformes: Characidae) from Nicaragua and Costa Rica, with a key to the lower Mesoamerican species of the genus, pp. 255-266 in Zootaxa 3731 (2) on pages 258-263, DOI: 10.11646/zootaxa.3731.2.6, http://zenodo.org/record/22334
Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries
No full textBackground: 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 sideeffects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β 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 lowand 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
Vorapaxar in the secondary prevention of atherothrombotic events
No full textContains fulltext :
110189.pdf (Publisher’s version ) (Open Access)BACKGROUND: Thrombin potently activates platelets through the protease-activated receptor PAR-1. Vorapaxar is a novel antiplatelet agent that selectively inhibits the cellular actions of thrombin through antagonism of PAR-1. METHODS: We randomly assigned 26,449 patients who had a history of myocardial infarction, ischemic stroke, or peripheral arterial disease to receive vorapaxar (2.5 mg daily) or matching placebo and followed them for a median of 30 months. The primary efficacy end point was the composite of death from cardiovascular causes, myocardial infarction, or stroke. After 2 years, the data and safety monitoring board recommended discontinuation of the study treatment in patients with a history of stroke owing to the risk of intracranial hemorrhage. RESULTS: At 3 years, the primary end point had occurred in 1028 patients (9.3%) in the vorapaxar group and in 1176 patients (10.5%) in the placebo group (hazard ratio for the vorapaxar group, 0.87; 95% confidence interval [CI], 0.80 to 0.94; P<0.001). Cardiovascular death, myocardial infarction, stroke, or recurrent ischemia leading to revascularization occurred in 1259 patients (11.2%) in the vorapaxar group and 1417 patients (12.4%) in the placebo group (hazard ratio, 0.88; 95% CI, 0.82 to 0.95; P=0.001). Moderate or severe bleeding occurred in 4.2% of patients who received vorapaxar and 2.5% of those who received placebo (hazard ratio, 1.66; 95% CI, 1.43 to 1.93; P<0.001). There was an increase in the rate of intracranial hemorrhage in the vorapaxar group (1.0%, vs. 0.5% in the placebo group; P<0.001). CONCLUSIONS: Inhibition of PAR-1 with vorapaxar reduced the risk of cardiovascular death or ischemic events in patients with stable atherosclerosis who were receiving standard therapy. However, it increased the risk of moderate or severe bleeding, including intracranial hemorrhage. (Funded by Merck; TRA 2P-TIMI 50 ClinicalTrials.gov number, NCT00526474.)
Predicting opioid consumption after surgical discharge: a multinational derivation and validation study using a foundation model
No full textOpioids are frequently overprescribed after surgery. We applied a tabular foundation model to predict the risk of post-discharge opioid consumption. The model was trained and internally validated on an 80:20 training/test split of the ‘Opioid PrEscRiptions and usage After Surgery’ (ACTRN12621001451897p) study cohort, including adult patients undergoing general, orthopaedic, gynaecological and urological operations (n = 4267), with external validation in a distinct cohort of patients discharged after general surgical procedures (n = 826). The area under the receiver operator curve was 0.84 (95% confidence interval [CI] 0.81–0.88) at internal testing and 0.77 (95% CI 0.74–0.80) at external validation. Brier scores were 0.13 (95% CI 0.12–0.14) and 0.19 (95% CI 0.17–0.2). Patients with a <50% predicted risk of opioid consumption consumed a median of 0 oral morphine equivalents in the first week after surgery. Applying this model would reduce opioid prescriptions by 4.5% globally, and counterfactual modelling suggests without increasing time in severe pain (−4.3%, 95% CI −17.7 to 8.6)
