ORIGINAL ARTICLE � HIP - ANESTHESIA
A randomized controlled trial of postoperative analgesia following
total knee replacement: transdermal Fentanyl patches
versus patient controlled analgesia (PCA)
M. J. Hall1 • S. M. Dixon2 • M. Bracey3 • P. MacIntyre4 • R. J. Powell3 •
A. D. Toms3
Received: 13 November 2014 / Accepted: 12 February 2015 / Published online: 11 March 2015
� Springer-Verlag France 2015
Abstract
Background This randomized controlled trial compared a
standard patient controlled analgesic (PCA) regime with a
transdermal and oral Fentanyl regime for post-operative
pain management in patients undergoing total knee
replacement.
Methods One hundred and ninety-six patients undergoing
total knee replacement were recruited. Pre- and post-op-
eratively Visual Analogue Score (VAS), Oxford Knee
Score, Health Anxiety and Depression Score and Brief Pain
Inventory Score were completed. According to the day 1,
VAS score patients were randomly allocated to either a
PCA regime or a Fentanyl transdermal/oral regime. Patient
reported outcomes were measured until the patients were
discharged.
Results The results demonstrate that in terms of analgesic
effect, day of discharge and side effect profile the two
regimes are comparable.
Conclusions We conclude that a Fentanyl transdermal
regime provides adequate analgesic effect comparable to a
standard PCA regime in conjunction with a low side effect
profile. Using a transdermal analgesic system provides ef-
ficient continuous delivery enabling a smooth transition
from hospital to home within the first week. Transdermal
Fentanyl provides an alternative analgesic regime that can
provide an equivalent analgesic effect so as to enable a
satisfactory outcome for the patient in terms of function
and pain.
Level of evidence II.
Keywords Total knee replacement � Post-operative
analgesia � Patient controlled analgesia � Fentanyl patches
Introduction
Knee replacement surgery has proved a successful and
cost-effective method for relieving pain and restoring
function in patients with osteoarthritis [1]. However, pain
management after knee replacement surgery remains a
significant problem, with patients reporting this as a major
concern prior to surgery [2]. Implementing relevant pre-
operative screening methods may facilitate the identifica-
tion of individuals at high risk of experiencing high post-
operative pain [3]. Despite recent advances in the aetiology
of pain, improved pain treatments and the development of
clinical guidelines for pain assessment, the under-treatment
of post-operative pain remains a challenge to both surgeon
and anaesthetist. Recent studies have clearly demonstrated
that patient satisfaction following total knee replacement is
multifactorial with the most significant predictor of dis-
satisfaction being a painful total knee replacement [1].
Providing effective pain relief in the post-operative pe-
riod is essential to enable early mobili.
Preemptive Analgesia for Attenuation of Postoperative Pain in Patients Underg...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Preemptive Analgesia for Attenuation of Postoperative Pain in Patients Underg...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Running head: POSTOPERATIVE PAIN 1
POSTOPERATIVE PAIN 3
Postoperative Pain after Reconstructive Surgery
Carla S. Garcia
Nicole Wertheim College of Nursing and Health Sciences
Author Note
Carla S. Garcia, Nicole Wertheim College of Nursing and Health Sciences, Florida International University
Correspondence concerning this article should be addressed to Carla Garcia, Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL 33199. Contact: [email protected]
Abstract
Postoperative pain is common for most patients who have undergone reconstructive surgery after a burn. The American Society of Pain (ASP) has devised methods of dealing with postoperative pain since most patients report the incident and only half of them were reported to have recovered from it. The use of local anesthetic-based peripheral regional analgesic technique is an efficient way of reducing postoperative pain, as well as the multi-modal approach for pain management, which has been used for patients after a forty-eight-hour post operative period. The American Society of Regional Anesthesia (ASRA) has approved these methods, and through research, has prepared organizational plans that assist surgical and outpatients with postoperative pain management. Measures such as preoperative education, preoperative pain management and pharmacological and non-pharmacological modalities have been recommended. Evidence shows that multi-modal methods of dealing with postoperative pain have been used for most of the cases. This paper will explore the evidence of postoperative pain management after burn reconstruction surgery and include the comparison between the uses of local anesthetic to the use of multi-modal methods in dealing with postoperative pain. In adition, the paper will look at the use of these postoperative methods both in the United States of America (USA) and other countries, and how these methods impact patient outcome.
Keywords: Evidence-Based, Research, Nursing Research, Postoperative, Patient Response.
Significance and Background
Burn reconstruction is a common experience for patients both in the USA and other countries in the world. Postoperative pain is expected after a burn reconstruction, hence the incorporation of methods such as the use of local anesthesia and multi-modal techniques in dealing with pain are recommended. The inquiry is whether the use of local anesthetics is more effective than the multi-modal method in dealing with postoperative pain in adult patients recovering from reconstructive surgery within a forthy-eight-hour time frame.
During a study composed of members of the ASP with help from the American Society of Anesthesiologists (ASA), they assembled in a meeting where members with expertise in anesthesia or.
Running head: POSTOPERATIVE PAIN 1
POSTOPERATIVE PAIN 3
Postoperative Pain after Reconstructive Surgery
Carla S. Garcia
Nicole Wertheim College of Nursing and Health Sciences
Author Note
Carla S. Garcia, Nicole Wertheim College of Nursing and Health Sciences, Florida International University
Correspondence concerning this article should be addressed to Carla Garcia, Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL 33199. Contact: [email protected]
Abstract
Postoperative pain is common for most patients who have undergone reconstructive surgery after a burn. The American Society of Pain (ASP) has devised methods of dealing with postoperative pain since most patients report the incident and only half of them were reported to have recovered from it. The use of local anesthetic-based peripheral regional analgesic technique is an efficient way of reducing postoperative pain, as well as the multi-modal approach for pain management, which has been used for patients after a forty-eight-hour post operative period. The American Society of Regional Anesthesia (ASRA) has approved these methods, and through research, has prepared organizational plans that assist surgical and outpatients with postoperative pain management. Measures such as preoperative education, preoperative pain management and pharmacological and non-pharmacological modalities have been recommended. Evidence shows that multi-modal methods of dealing with postoperative pain have been used for most of the cases. This paper will explore the evidence of postoperative pain management after burn reconstruction surgery and include the comparison between the uses of local anesthetic to the use of multi-modal methods in dealing with postoperative pain. In adition, the paper will look at the use of these postoperative methods both in the United States of America (USA) and other countries, and how these methods impact patient outcome.
Keywords: Evidence-Based, Research, Nursing Research, Postoperative, Patient Response.
Significance and Background
Burn reconstruction is a common experience for patients both in the USA and other countries in the world. Postoperative pain is expected after a burn reconstruction, hence the incorporation of methods such as the use of local anesthesia and multi-modal techniques in dealing with pain are recommended. The inquiry is whether the use of local anesthetics is more effective than the multi-modal method in dealing with postoperative pain in adult patients recovering from reconstructive surgery within a forthy-eight-hour time frame.
During a study composed of members of the ASP with help from the American Society of Anesthesiologists (ASA), they assembled in a meeting where members with expertise in anesthesia or.
Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain ...Nelson Hendler
The Pain Validity Test can predict which patient will have abnormal medical test results with 95% accuracy, and surgical abnormalities with 94% accuracy. This on-line questionnaire takes only 5 minutes of staff time to administer, and takes only 15 minutes of patient time.Results are available immediately. This test can be used to document "medical necessity" for insurance pre-authorization for testing and surgery.
Physician-Pharmacist Comanagement of Postoperative Pain in Egyptian Patients:...iosrphr_editor
Introduction:Patientcontrolled analgesia (PCA) is an interactive method of self drug administrationthat requires proper education to ensure safe and effective use. Morphine is the most popular opioid used for postoperative pain management using PCA; however it has many adverse effects. Nalbuphine, a mixed opioid agonist antagonist, is known to be safer than morphine. Ketorolac produce excellent analgesia when used alone or with opioids. Multimodal analgesicapproach using morphine or nalbuphine combined with ketorolac for PCA administration has not been compared before. The study aimed to compare the clinical efficacy, adverse effects of multimodal analgesia using PCA and the effect of patient education regarding PCA use on patients' outcomes. Patients and methods: AdultEgyptian patients ASA I and II whounderwent different surgical procedures were selected and randomized either to receive PCA of morphine or nalbuphine combined with ketorolac. Patients from each drug group were further randomly selected to receive additional preoperative PCA education beside the usual care for pain management. Visual analogue scale (VAS), hemodynamic parameters,adverse effects and patient satisfaction were compared between groups. Results: Of the total of 60 patients enrolled, 45 patients completed the study: 22 patients for morphine group(M) and 23 for nalbuphine group (N). VAS score was significantly lower in group(M)than group (N)at certain time points. Nalbuphineshowed a significant lower incidence of itching than morphine(P: 0.03*). Pain control and overall satisfactionswerebetter in the intervention groups (M2, N2) than in the control groups (M1, N1). Conclusion:Morphine coadministerd with ketorolac provides more potent analgesia than with nalbuphine. Preoperative patient education regarding PCA is crucial for proper postoperative pain control.
To improving postoperative pain management, we need to;
- Always applies multi-modal analgesia. (get the advantages of multimodal analgesia)
- Implementation of the existing EB regarding the use of non-opioid + opioid on as needed basis.
- Use available specific evidence for optimizing multimodal pain management procedure (PROSPECT Web site).
Evaluating the Effectiveness of Current Pain Management StrategiesWellbe
Pain management of orthopedic surgery patients is being impacted by the changes in health care regulation and reimbursement. There is a need for safer, more effective pain management pathways that can provide opportunities for early discharge without increasing the risk of readmissions or compromising outcomes.
Current pain management strategies for joint replacements, spine surgery and outpatient knee and shoulder procedures will be examined from clinical, safety, satisfaction and cost perspectives. The process of implementing and evaluating these pathways will also be discussed.
Nina Whalen will demonstrate how she evaluated, developed and improved pain management pathways for patients. These pathways include:
– Multimodal pain management for total joint and spine
– Peripheral nerve block utilization for inpatients and outpatients
– Customized pain pathways for special populations
– The use of intraoperative tissue infiltration with medications as a primary pain management strategy in joint replacement surgery
About The Speaker:
Nina Whalen, RN, APN-C, has over 30 years of experience as a nurse practitioner in orthopedic medicine. She has been involved in every phase of patient care at both the clinic and tertiary care levels. In the 1990’s she created and worked in a nurse practitioner hospital program at Presbyterian St Luke’s hospital that provided 24 hour coverage for the needs of hospitalized orthopedic surgery patients. She has worked in research and has co-authored publications in the areas of sports medicine and total joint. She is currently the manager of clinical outcomes at OrthoIndy Hospital (formerly Indiana Orthopaedic Hospital) which is a 38 bed, physician owned, orthopedic specialty hospital in Indianapolis.
Laparoscopic administration of bupivacaine at the uterosacral ligaments during benign laparoscopic androbotic hysterectomy: a randomized controlled trial
Les NVPO sont un événement fréquent en post-anesthésie puisqu'ils touchent environ un tiers des patients. Les différents scores et prophylaxies utilisées bien que souvent efficaces ne closent pas le chapitre de leur prévention. La gabapentine, antivonvusilvant, a montré par ailleurs son effet analgésique en post-opératoire.
Plus récemment, la gabapentine a montré un effet anti-émétique lorsqu'elle était administrée en prévention dans la chimiothérapie du cancer du sein.
Cette étude est une méta-analyse des essais randomisés de la gabapentine en prévention des NVPO. Elle conclut à son efficacité, efficacité d'autant plus marquée que le propofol n'est pas utilisé comme agent d'induction et/ou d'entretien.
· Describe strategies to build rapport with inmates and offenders .docxgerardkortney
· Describe strategies to build rapport with inmates and offenders in a correctional treatment or supervision program.
· Describe the effect of group dynamics on facilitating programs.
· Describe techniques for establishing a therapeutic environment.
Generalist Case Management
Woodside and McClam
https://phoenix.vitalsource.com/books/9781483342047/pageid/44
https://phoenix.vitalsource.com/#/books/9781323128800
https://phoenix.vitalsource.com/#/books/9781483342047
https://phoenix.vitalsource.com/#/books/9781133795247
https://phoenix.vitalsource.com/#/books/1259760413
Use book and two outside sources.
At least 100 words per question
THANKS
1 The Role of the Correctional Counselor CHAPTER OBJECTIVES After reading this chapter, you will be able to: 1. Identify the functions and parameters of the counseling process. 2. Discuss the competing interests between security and counseling in the correctional counseling process. 3. Know common terms and concerns associated with custodial corrections. 4. Understand the role of the counselor as facilitator. 5. Identify the various personal characteristics associated with effective counselors. 6. Be aware of the impact that burnout can have on a counselor’s professional performance. 7. Identify the various means of training and supervision associated with counseling. PART ONE: A BRIEF INTRODUCTION TO COUNSELING AND CORRECTIONS There are many myths concerning the concept of counseling. Although the image of the counseling field has changed dramatically over the past two or three decades, much of society still views counseling and therapy as a mystic process reserved for those who lack the ability to handle life issues effectively. While the concept of counseling is often misunderstood, the problem is exacerbated when attempting to introduce the idea of correctional counseling. Therefore, the primary goal of this chapter is to provide a working definition of correctional counseling that includes descriptions of how and when it is carried out. In order to understand the concept of correctional counseling, however, the two words that derive the concept must first be defined: “corrections” and “counseling.” In addition, a concerted effort is made to identify the myriad of legal and ethical issues that pertain to counselors working with offenders. It is very difficult to identify a single starting point for the counseling profession. In essence, there were various movements occurring simultaneously that later evolved into what we now describe as counseling. One of the earliest connections to the origins of counseling took place in Europe during the Middle Ages (Brown & Srebalus, 2003). The primary objective was assisting individuals with career choices. This type of counseling service is usually described by the concept of “guidance.” In the late 1800s Wilhelm Wundt and G. Stanley Hall created two of the first known psychological laboratories aimed at studying and treating individuals with psychological and e.
· Debates continue regarding what constitutes an appropriate rol.docxgerardkortney
· Debates continue regarding what constitutes an appropriate role for the judiciary. Some argue that federal judges have become too powerful and that judges “legislate from the bench.”
1. What does it mean for a judge to be an activist?
2. What does it mean for a judge to be a restrainist?
· Although conservatives had long complained about the activism of liberal justices and judges, in recent years conservative judges and justices have been likely to overturn precedents and question the power of elected institutions of government.
3. When is judicial activism appropriate? Explain.
· To defenders of the right to privacy, it is implicitly embodied in the Constitution in the First, Fourth, Fifth, Ninth, and Fourteenth Amendments. To opponents, it is judge-made law because there is no explicit reference to it under the Constitution. The right to privacy dates back to at least 1890, when Boston attorneys Samuel Warren and Louis Brandeis equated it with the right to be left alone from journalists who engaged in yellow journalism.
4. In short, do you believe a right to privacy exists in the federal Constitution. Why or why not?
.
More Related Content
Similar to ORIGINAL ARTICLE HIP - ANESTHESIAA randomized controlled.docx
Running head: POSTOPERATIVE PAIN 1
POSTOPERATIVE PAIN 3
Postoperative Pain after Reconstructive Surgery
Carla S. Garcia
Nicole Wertheim College of Nursing and Health Sciences
Author Note
Carla S. Garcia, Nicole Wertheim College of Nursing and Health Sciences, Florida International University
Correspondence concerning this article should be addressed to Carla Garcia, Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL 33199. Contact: [email protected]
Abstract
Postoperative pain is common for most patients who have undergone reconstructive surgery after a burn. The American Society of Pain (ASP) has devised methods of dealing with postoperative pain since most patients report the incident and only half of them were reported to have recovered from it. The use of local anesthetic-based peripheral regional analgesic technique is an efficient way of reducing postoperative pain, as well as the multi-modal approach for pain management, which has been used for patients after a forty-eight-hour post operative period. The American Society of Regional Anesthesia (ASRA) has approved these methods, and through research, has prepared organizational plans that assist surgical and outpatients with postoperative pain management. Measures such as preoperative education, preoperative pain management and pharmacological and non-pharmacological modalities have been recommended. Evidence shows that multi-modal methods of dealing with postoperative pain have been used for most of the cases. This paper will explore the evidence of postoperative pain management after burn reconstruction surgery and include the comparison between the uses of local anesthetic to the use of multi-modal methods in dealing with postoperative pain. In adition, the paper will look at the use of these postoperative methods both in the United States of America (USA) and other countries, and how these methods impact patient outcome.
Keywords: Evidence-Based, Research, Nursing Research, Postoperative, Patient Response.
Significance and Background
Burn reconstruction is a common experience for patients both in the USA and other countries in the world. Postoperative pain is expected after a burn reconstruction, hence the incorporation of methods such as the use of local anesthesia and multi-modal techniques in dealing with pain are recommended. The inquiry is whether the use of local anesthetics is more effective than the multi-modal method in dealing with postoperative pain in adult patients recovering from reconstructive surgery within a forthy-eight-hour time frame.
During a study composed of members of the ASP with help from the American Society of Anesthesiologists (ASA), they assembled in a meeting where members with expertise in anesthesia or.
Running head: POSTOPERATIVE PAIN 1
POSTOPERATIVE PAIN 3
Postoperative Pain after Reconstructive Surgery
Carla S. Garcia
Nicole Wertheim College of Nursing and Health Sciences
Author Note
Carla S. Garcia, Nicole Wertheim College of Nursing and Health Sciences, Florida International University
Correspondence concerning this article should be addressed to Carla Garcia, Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL 33199. Contact: [email protected]
Abstract
Postoperative pain is common for most patients who have undergone reconstructive surgery after a burn. The American Society of Pain (ASP) has devised methods of dealing with postoperative pain since most patients report the incident and only half of them were reported to have recovered from it. The use of local anesthetic-based peripheral regional analgesic technique is an efficient way of reducing postoperative pain, as well as the multi-modal approach for pain management, which has been used for patients after a forty-eight-hour post operative period. The American Society of Regional Anesthesia (ASRA) has approved these methods, and through research, has prepared organizational plans that assist surgical and outpatients with postoperative pain management. Measures such as preoperative education, preoperative pain management and pharmacological and non-pharmacological modalities have been recommended. Evidence shows that multi-modal methods of dealing with postoperative pain have been used for most of the cases. This paper will explore the evidence of postoperative pain management after burn reconstruction surgery and include the comparison between the uses of local anesthetic to the use of multi-modal methods in dealing with postoperative pain. In adition, the paper will look at the use of these postoperative methods both in the United States of America (USA) and other countries, and how these methods impact patient outcome.
Keywords: Evidence-Based, Research, Nursing Research, Postoperative, Patient Response.
Significance and Background
Burn reconstruction is a common experience for patients both in the USA and other countries in the world. Postoperative pain is expected after a burn reconstruction, hence the incorporation of methods such as the use of local anesthesia and multi-modal techniques in dealing with pain are recommended. The inquiry is whether the use of local anesthetics is more effective than the multi-modal method in dealing with postoperative pain in adult patients recovering from reconstructive surgery within a forthy-eight-hour time frame.
During a study composed of members of the ASP with help from the American Society of Anesthesiologists (ASA), they assembled in a meeting where members with expertise in anesthesia or.
Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain ...Nelson Hendler
The Pain Validity Test can predict which patient will have abnormal medical test results with 95% accuracy, and surgical abnormalities with 94% accuracy. This on-line questionnaire takes only 5 minutes of staff time to administer, and takes only 15 minutes of patient time.Results are available immediately. This test can be used to document "medical necessity" for insurance pre-authorization for testing and surgery.
Physician-Pharmacist Comanagement of Postoperative Pain in Egyptian Patients:...iosrphr_editor
Introduction:Patientcontrolled analgesia (PCA) is an interactive method of self drug administrationthat requires proper education to ensure safe and effective use. Morphine is the most popular opioid used for postoperative pain management using PCA; however it has many adverse effects. Nalbuphine, a mixed opioid agonist antagonist, is known to be safer than morphine. Ketorolac produce excellent analgesia when used alone or with opioids. Multimodal analgesicapproach using morphine or nalbuphine combined with ketorolac for PCA administration has not been compared before. The study aimed to compare the clinical efficacy, adverse effects of multimodal analgesia using PCA and the effect of patient education regarding PCA use on patients' outcomes. Patients and methods: AdultEgyptian patients ASA I and II whounderwent different surgical procedures were selected and randomized either to receive PCA of morphine or nalbuphine combined with ketorolac. Patients from each drug group were further randomly selected to receive additional preoperative PCA education beside the usual care for pain management. Visual analogue scale (VAS), hemodynamic parameters,adverse effects and patient satisfaction were compared between groups. Results: Of the total of 60 patients enrolled, 45 patients completed the study: 22 patients for morphine group(M) and 23 for nalbuphine group (N). VAS score was significantly lower in group(M)than group (N)at certain time points. Nalbuphineshowed a significant lower incidence of itching than morphine(P: 0.03*). Pain control and overall satisfactionswerebetter in the intervention groups (M2, N2) than in the control groups (M1, N1). Conclusion:Morphine coadministerd with ketorolac provides more potent analgesia than with nalbuphine. Preoperative patient education regarding PCA is crucial for proper postoperative pain control.
To improving postoperative pain management, we need to;
- Always applies multi-modal analgesia. (get the advantages of multimodal analgesia)
- Implementation of the existing EB regarding the use of non-opioid + opioid on as needed basis.
- Use available specific evidence for optimizing multimodal pain management procedure (PROSPECT Web site).
Evaluating the Effectiveness of Current Pain Management StrategiesWellbe
Pain management of orthopedic surgery patients is being impacted by the changes in health care regulation and reimbursement. There is a need for safer, more effective pain management pathways that can provide opportunities for early discharge without increasing the risk of readmissions or compromising outcomes.
Current pain management strategies for joint replacements, spine surgery and outpatient knee and shoulder procedures will be examined from clinical, safety, satisfaction and cost perspectives. The process of implementing and evaluating these pathways will also be discussed.
Nina Whalen will demonstrate how she evaluated, developed and improved pain management pathways for patients. These pathways include:
– Multimodal pain management for total joint and spine
– Peripheral nerve block utilization for inpatients and outpatients
– Customized pain pathways for special populations
– The use of intraoperative tissue infiltration with medications as a primary pain management strategy in joint replacement surgery
About The Speaker:
Nina Whalen, RN, APN-C, has over 30 years of experience as a nurse practitioner in orthopedic medicine. She has been involved in every phase of patient care at both the clinic and tertiary care levels. In the 1990’s she created and worked in a nurse practitioner hospital program at Presbyterian St Luke’s hospital that provided 24 hour coverage for the needs of hospitalized orthopedic surgery patients. She has worked in research and has co-authored publications in the areas of sports medicine and total joint. She is currently the manager of clinical outcomes at OrthoIndy Hospital (formerly Indiana Orthopaedic Hospital) which is a 38 bed, physician owned, orthopedic specialty hospital in Indianapolis.
Laparoscopic administration of bupivacaine at the uterosacral ligaments during benign laparoscopic androbotic hysterectomy: a randomized controlled trial
Les NVPO sont un événement fréquent en post-anesthésie puisqu'ils touchent environ un tiers des patients. Les différents scores et prophylaxies utilisées bien que souvent efficaces ne closent pas le chapitre de leur prévention. La gabapentine, antivonvusilvant, a montré par ailleurs son effet analgésique en post-opératoire.
Plus récemment, la gabapentine a montré un effet anti-émétique lorsqu'elle était administrée en prévention dans la chimiothérapie du cancer du sein.
Cette étude est une méta-analyse des essais randomisés de la gabapentine en prévention des NVPO. Elle conclut à son efficacité, efficacité d'autant plus marquée que le propofol n'est pas utilisé comme agent d'induction et/ou d'entretien.
· Describe strategies to build rapport with inmates and offenders .docxgerardkortney
· Describe strategies to build rapport with inmates and offenders in a correctional treatment or supervision program.
· Describe the effect of group dynamics on facilitating programs.
· Describe techniques for establishing a therapeutic environment.
Generalist Case Management
Woodside and McClam
https://phoenix.vitalsource.com/books/9781483342047/pageid/44
https://phoenix.vitalsource.com/#/books/9781323128800
https://phoenix.vitalsource.com/#/books/9781483342047
https://phoenix.vitalsource.com/#/books/9781133795247
https://phoenix.vitalsource.com/#/books/1259760413
Use book and two outside sources.
At least 100 words per question
THANKS
1 The Role of the Correctional Counselor CHAPTER OBJECTIVES After reading this chapter, you will be able to: 1. Identify the functions and parameters of the counseling process. 2. Discuss the competing interests between security and counseling in the correctional counseling process. 3. Know common terms and concerns associated with custodial corrections. 4. Understand the role of the counselor as facilitator. 5. Identify the various personal characteristics associated with effective counselors. 6. Be aware of the impact that burnout can have on a counselor’s professional performance. 7. Identify the various means of training and supervision associated with counseling. PART ONE: A BRIEF INTRODUCTION TO COUNSELING AND CORRECTIONS There are many myths concerning the concept of counseling. Although the image of the counseling field has changed dramatically over the past two or three decades, much of society still views counseling and therapy as a mystic process reserved for those who lack the ability to handle life issues effectively. While the concept of counseling is often misunderstood, the problem is exacerbated when attempting to introduce the idea of correctional counseling. Therefore, the primary goal of this chapter is to provide a working definition of correctional counseling that includes descriptions of how and when it is carried out. In order to understand the concept of correctional counseling, however, the two words that derive the concept must first be defined: “corrections” and “counseling.” In addition, a concerted effort is made to identify the myriad of legal and ethical issues that pertain to counselors working with offenders. It is very difficult to identify a single starting point for the counseling profession. In essence, there were various movements occurring simultaneously that later evolved into what we now describe as counseling. One of the earliest connections to the origins of counseling took place in Europe during the Middle Ages (Brown & Srebalus, 2003). The primary objective was assisting individuals with career choices. This type of counseling service is usually described by the concept of “guidance.” In the late 1800s Wilhelm Wundt and G. Stanley Hall created two of the first known psychological laboratories aimed at studying and treating individuals with psychological and e.
· Debates continue regarding what constitutes an appropriate rol.docxgerardkortney
· Debates continue regarding what constitutes an appropriate role for the judiciary. Some argue that federal judges have become too powerful and that judges “legislate from the bench.”
1. What does it mean for a judge to be an activist?
2. What does it mean for a judge to be a restrainist?
· Although conservatives had long complained about the activism of liberal justices and judges, in recent years conservative judges and justices have been likely to overturn precedents and question the power of elected institutions of government.
3. When is judicial activism appropriate? Explain.
· To defenders of the right to privacy, it is implicitly embodied in the Constitution in the First, Fourth, Fifth, Ninth, and Fourteenth Amendments. To opponents, it is judge-made law because there is no explicit reference to it under the Constitution. The right to privacy dates back to at least 1890, when Boston attorneys Samuel Warren and Louis Brandeis equated it with the right to be left alone from journalists who engaged in yellow journalism.
4. In short, do you believe a right to privacy exists in the federal Constitution. Why or why not?
.
· Critical thinking paper · · · 1. A case study..docxgerardkortney
· Critical thinking paper
·
·
· 1.
A case study.
Deborah Shore, aged 45, works for a small corporation in the Research and Development department.
When she first became a member of the department 15 years ago, Deborah was an unusually creative and productive researcher; her efforts quickly resulted in raises and promotions within the department and earned her the respect of her colleagues. Now, Deborah finds herself less interested in doing research; she is no longer making creative contributions to her department, although she is making contributions to its administration.
She is still respected by the coworkers who have known her since she joined the firm, but not by her younger coworkers.
Analyze the case study from the psychoanalytic, learning, and contextual perspectives: how would a theorist from each perspective explain Deborah's development? Which perspective do you believe provides the most adequate explanation, and why?
2. Interview your mother (and grandmothers, if possible), asking about experiences with childbirth. Include your own experiences if you have had children. Write a paper summarizing these childbirth experiences and comparing them with the contemporary experiences described in the text.
3. Identify a "type" of parent (e.g., single parent, teenage parent, low-income parent, dual-career couple) who is most likely to be distressed because an infant has a "difficult" temperament. Explain why you believe that this type of parent would have particular problems with a difficult infant. Write an informational brochure for the selected type of parent. The brochure should include an explanation of temperament in general and of the difficult temperament in particular, and give suggestions for parents of difficult infants.
4. Plan an educational unit covering nutrition, health, and safety for use with preschoolers and kindergartners. Take into account young children's cognitive and linguistic characteristics. The project should include (1) an outline of the content of the unit; and (2) a description of how the content would be presented, given the intellectual abilities of preschoolers. For example, how long would each lesson be? What kinds of pictures or other audiovisual materials would be used? How would this content be integrated with the children's other activities in preschool or kindergarten?
5. Visit two day care centers and evaluate each center using the information from the text as a guide. Request a fee schedule from each center. Write a paper summarizing your evaluation of each center.
Note:
Unless you are an actual potential client of the center, contact the director beforehand to explain the actual purpose of the visit, obtain permission to visit, and schedule your visit so as to minimize disruption to the center's schedule.
6. Watch some children's television programs and advertising, examine some children's toys and their packaging, read some children's books, and listen to some children's recor.
· Coronel & Morris Chapter 7, Problems 1, 2 and 3
· Coronel & Morris Chapter 8, Problems 1 and 2
A People’s History of Modern Europe
“A fascinating journey across centuries towards the world as we experience it today. ... It is
the voice of the ordinary people, and women in particular, their ideas and actions, protests
and sufferings that have gone into the making of this alternative narrative.”
——Sobhanlal Datta Gupta, former Surendra Nath Banerjee
Professor of Political Science, University of Calcutta
“A history of Europe that doesn’t remove the Europeans. Here there are not only kings,
presidents and institutions but the pulse of the people and social organizations that shaped
Europe. A must-read.”
——Raquel Varela, Universidade Nova de Lisboa
“Lively and engaging. William A Pelz takes the reader through a thousand years of
European history from below. This is the not the story of lords, kings and rulers. It is the
story of the ordinary people of Europe and their struggles against those lords, kings and
rulers, from the Middle Ages to the present day. A fine introduction.”
——Francis King, editor, Socialist History
“This book is an exception to the rule that the winner takes all. It highlights the importance
of the commoners which often is only shown in the dark corners of mainstream history
books. From Hussites, Levellers and sans-culottes to the women who defended the Paris
Commune and the workers who occupied the shipyards during the Carnation revolution in
Portugal. The author gives them their deserved place in history just like Howard Zinn did
for the American people.”
——Sjaak van der Velden, International Institute of Social History, Amsterdam
“The author puts his focus on the lives and historical impact of those excluded from
power and wealth: peasants and serfs of the Middle Ages, workers during the Industrial
Revolution, women in a patriarchic order that transcended different eras. This focus not
only makes history relevant for contemporary debates on social justice, it also urges the
reader to develop a critical approach.”
——Ralf Hoffrogge, Ruhr-Universität Bochum
“An exciting story of generations of people struggling for better living conditions, and for
social and political rights. ... This story has to be considered now, when the very notions of
enlightenment, progress and social change are being questioned.”
——Boris Kagarlitsky, director of Institute for globalization studies and social
movements, Moscow, and author of From Empires to Imperialism
“A splendid antidote to the many European histories dominated by kings, businessmen
and generals. It should be on the shelves of both academics and activists ... A lively and
informative intellectual tour-de-force.”
——Marcel van der Linden, International Institute of Social History, Amsterdam
A People’s History
of Modern Europe
William A. Pelz
First published 2016 by Pluto Press
345 Archway Road, London N6 5AA
www.pluto.
· Complete the following problems from your textbook· Pages 378.docxgerardkortney
· Complete the following problems from your textbook:
· Pages 378–381: 10-1, 10-2, 10-16, and 10-20.
· Pages 443–444: 12-7 and 12-9.
· Page 469: 13-5.
· 10-1 How would each of the following scenarios affect a firm’s cost of debt, rd(1 − T); its cost of equity, rs; and its WACC? Indicate with a plus (+), a minus (−), or a zero (0) whether the factor would raise, lower, or have an indeterminate effect on the item in question. Assume for each answer that other things are held constant, even though in some instances this would probably not be true. Be prepared to justify your answer but recognize that several of the parts have no single correct answer. These questions are designed to stimulate thought and discussion.
Effect on
rd(1 − T)
rs
WACC
a. The corporate tax rate is lowered.
__
__
__
b. The Federal Reserve tightens credit.
__
__
__
c. The firm uses more debt; that is, it increases its debt ratio.
__
__
__
d. The dividend payout ratio is increased.
__
__
__
e. The firm doubles the amount of capital it raises during the year.
__
__
__
f. The firm expands into a risky new area.
__
__
__
g. The firm merges with another firm whose earnings are countercyclical both to those of the first firm and to the stock market.
__
__
__
h. The stock market falls drastically, and the firm’s stock price falls along with the rest.
__
__
__
i. Investors become more risk-averse.
__
__
__
j. The firm is an electric utility with a large investment in nuclear plants. Several states are considering a ban on nuclear power generation.
__
__
__
· 10-2 Assume that the risk-free rate increases, but the market risk premium
· 10-16COST OF COMMON EQUITY The Bouchard Company’s EPS was $6.50 in 2018, up from $4.42 in 2013. The company pays out 40% of its earnings as dividends, and its common stock sells for $36.00.
· a. Calculate the past growth rate in earnings. (Hint: This is a 5-year growth period.)
· b. The last dividend was D0 = 0.4($6.50) = $2.60. Calculate the next expected dividend, D1, assuming that the past growth rate continues.
· c. What is Bouchard’s cost of retained earnings, rs?
· 10-20WACC The following table gives Foust Company’s earnings per share for the last 10 years. The common stock, 7.8 million shares outstanding, is now (1/1/19) selling for $65.00 per share. The expected dividend at the end of the current year (12/31/19) is 55% of the 2018 EPS. Because investors expect past trends to continue, g may be based on the historical earnings growth rate. (Note that 9 years of growth are reflected in the 10 years of data.)
The current interest rate on new debt is 9%; Foust’s marginal tax rate is 40%, and its target capital structure is 40% debt and 60% equity.
· a. Calculate Foust’s after-tax cost of debt and common equity. Calculate the cost of equity as rs = D1/P0 + g.
· b. Find Foust’s WACC
· 12-7SCENARIO ANALYSIS Huang Industries is considering a proposed project whose estimated NPV is $12 million. This estimate assumes that economic conditions wi.
· Consider how different countries approach aging. As you consid.docxgerardkortney
· Consider how different countries approach aging. As you consider different countries, think about the following:
o Do older adults live with their children, or are they more likely to live in a nursing home?
o Are older adults seen as wise individuals to be respected and revered, or are they a burden to their family and to society?
· Next, select two different countries and compare and contrast their approaches to aging.
· Post and identify each of the countries you selected. Then, explain two similarities and two differences in how the countries approach aging. Be specific and provide examples. Use proper APA format and citation. LSW10
.
· Clarifying some things on the Revolution I am going to say som.docxgerardkortney
· Clarifying some things on the Revolution
I am going to say something, and I want you to hear me.
I am a scholar of the Revolution. That's the topic of my dissertation. Please believe me when I say that I know a lot about it.
I also happen to know--and this is well-supported by historians--that the Revolution was a civil war in which, for the first several years, Revolutionaries and Loyalists were evenly matched.
I will repeat that. Evenly matched. Loyalists were not merely too cowardly to fight, and they were not old fogies who hated the idea of freedom. Most had been in the Colonies for generations. Many of them took up arms for their King and their country. And when they lost, you confiscated their homes and they fled with the clothes on their back to Canada, England, and other places of the Empire. Both sides--both sides--committed unspeakable atrocities against civilians whom they disagreed with.
Now, a lot of you love to repeat some very fervent patriotic diatribe about how great the Revolution was. That's not history. That's propaganda. Know the difference.
History has shades of gray. History is complex and ambiguous. Washington, for instance, wore dentures made from the teeth of his slaves. Benjamin Franklin's son was the last royal governor of New Jersey. Did you know that the net tax rate for Americans--they always conveniently leave this out of the textbooks--was between 1.9 and 2.1%, depending on colony.? And that was if they had paid the extra taxes on tea and paper.
And, wait for it, people who support California independence use the same logic and arguments as they did in 1775. Did you know that the Los Angeles and Washington are only a few hundred miles closer than Boston and London? That many of the same issues, point by point, are repeating here in California? So put yourself in those shoes. How many of you would have sided with the Empire (whether American or British) based on the fact that you don't know how this will shake out? Would you call someone who supports Calexit a Patriot? Revolutionary? Nutcase? Who gets to own that word, anyway?
You can choose that you would have supported the revolutionaries--but think. Think about the other side. They matter, and their experiences got to be cleansed out of history to make you feel better about the way the revolutionaries behaved during the War. Acknowledge that they are there, and that their point of view has merit, even if you not agree with it.
· Clarifying Unit III's assignment
I have noticed a few consistent problems with the letter in the Unit III issue. Here are some pointers to make it better.
1. Read the clarifying note I wrote above. Note that the taxes aren't actually as high as you have been led to believe, but the point is that they should not be assigned at all without your consent.
2. Acknowledge that this is a debate, that a certain percentage are radicalized for independence, but there are is also a law-and-order group who find this horrific, and want .
· Chapter 9 – Review the section on Establishing a Security Cultur.docxgerardkortney
· Chapter 9 – Review the section on Establishing a Security Culture. Review the methods to reduce the chances of a cyber threat noted in the textbook. Research other peer-reviewed source and note additional methods to reduce cyber-attacks within an organization.
· Chapter 10 – Review the section on the IT leader in the digital transformation era. Note how IT professionals and especially leaders must transform their thinking to adapt to the constantly changing organizational climate. What are some methods or resources leaders can utilize to enhance their change attitude?
.
· Chapter 10 The Early Elementary Grades 1-3The primary grades.docxgerardkortney
· Chapter 10: The Early Elementary Grades: 1-3
The primary grades are grades 1-3.
Although educational reform has had an effect on all children, it is most apparent in the early elementary years. Reform and change comes from a number of sources and the chapter begins by reminding you of this. Let’s examine a few of these sources...
Diversity. There has been a rise in the number of racial and ethnic minority students enrolled in the nation's public schools; this number will (most likely) continue to rise. Teaching children from different cultures and backgrounds is an important piece to account for when planning curriculum.
Standards. Standards is a reason for reform. We've already looked at standards; these are something you must keep in mind when planning lessons.
Data-Driven Instruction may sound new, but it is not a new concept to you. We’ve done a great deal of discussing the outcomes of test-taking and assessments. You've probably all heard "teaching to the test."
Technology. Today’s students have had much experience with technology, therefore, it’s important to provide them with opportunities to learn with technology. It may take a while for you to be creative and think of ways to use it in your teaching (if you haven’ t been).
Health and Wellness. Obesity is a major concern in this country. Therefore, it is important to make sure that children have the opportunity to be active. Unfortunately, due to the pressure of academics, many schools have been taking physical education/activity time out of the curriculum.
Violence: One issue that I notice this new edition of the text has excluded is violence. However, I think that this topic is important; we need to keep children safe when they are at school. As a result of 9/11 (and, not to mention that many violent events have happened on school campuses in recent years), many school districts now have an emergency system in place that they can easily use if there is any type of incident in which the children’s safety is at risk.
WHAT ARE CHILDREN IN GRADES ONE TO THREE LIKE?
Your text explains that the best way to think of a child’s development during this time is: slow and steady. During this stage, there is not much difference between boys and girls when it comes to physical capabilities. Although it is always important to not stereotype based on one’s gender, it is especially important during these years. These children are also entering into their "tween" years, thus; being sensitive to the children's and parents' needs in regards to such changes is important.
It is important to remember that children in the primary grades are in the Concrete Operations Stage. This stage is children ages 7 to 12. The term operation refers to an action that can be carried out in thought as well as executed materially and that is mentally and physically reversible.
These children are at an age in which they can compare their abilities to their peers. And, therefore, children may develop learned helplessnes.
· Chap 2 and 3· what barriers are there in terms of the inter.docxgerardkortney
· Chap 2 and 3
· what barriers are there in terms of the interpersonal communication model?
Typically, communication breakdowns result from lack of understanding without clarification; often, there wasn't even an attempt at clarification. If barriers to interpersonal communication are not acknowledged and addressed, workplace productivity can suffer.
Language Differences
Interpersonal communication can go awry when the sender and receiver of the message speak a different language -- literally and figuratively. Not everyone in the workplace will understand slang, jargon, acronyms and industry terminology. Instead of seeking clarification, employees might guess at the meaning of the message and then act on mistaken assumptions. Also, misunderstandings may occur among workers who do not speak the same primary language. As a result, feelings may be hurt, based on misinterpretation of words or of body language.
Cultural Differences
Interpersonal communication may be adversely affected by lack of cultural understanding, mis-perception, bias and stereotypical beliefs. Workers may have limited skill or experience communicating with people from a different background. Many companies offer diversity training to help employees understand how to communicate more effectively across cultures and relate to those who may have different background experiences. Similarly, gender barriers can obstruct interpersonal communication if men and women are treated differently, and held to different standards, causing interpersonal conflicts in the workplace.
Personality Differences
Like any skill, some people are better at interpersonal communication than others. Personality traits also influence how well an individual interacts with subordinates, peers and supervisors. Extraversion can be an advantage when it comes to speaking out, sharing opinions and disseminating information. However, introverts may have the edge when it comes to listening, reflecting and remembering. Barriers to interpersonal communication may occur when employees lack self-awareness, sensitivity and flexibility. Such behavior undermines teamwork, which requires mutual respect, compromise and negotiation. Bullying, backstabbing and cut throat competition create a toxic workplace climate that will strain interpersonal relationships.
Generational Differences
Interpersonal communication can be complicated by generational differences in speech, dress, values, priorities and preferences. For instance, there may be a generational divide as to how team members prefer to communicate with one another. If younger workers sit in cubicles, using social networking as their primary channel of communication, it can alienate them from older workers who may prefer face-to-face communication. Broad generalizations and stereotypes can also cause interpersonal rifts when a worker from one generation feels superior to those who are younger or older. Biases against workers based on age can constitute a form of disc.
· Case Study 2 Improving E-Mail Marketing ResponseDue Week 8 an.docxgerardkortney
· Case Study 2: Improving E-Mail Marketing Response
Due Week 8 and worth 160 points
Read the following case study.
A company wishes to improve its e-mail marketing process, as measured by an increase in the response rate to e-mail advertisements. The company has decided to study the process by evaluating all combinations of two (2) options of the three (3) key factors: E-Mail Heading (Detailed, Generic); Email Open (No, Yes); and E-Mail Body (Text, HTML). Each of the combinations in the design was repeated on two (2) different occasions. The factors studied and the measured response rates are summarized in the following table.
Write a two to three (2-3) page paper in which you:
1. Use the data shown in the table to conduct a design of experiment (DOE) in order to test cause-and-effect relationships in business processes for the company.
2. Determine the graphical display tool (e.g., Interaction Effects Chart, Scatter Chart, etc.) that you would use to present the results of the DOE that you conducted in Question 1. Provide a rationale for your response.
3. Recommend the main actions that the company could take in order to increase the response rate of its e-mail advertising. Provide a rationale for your response.
4. Propose one (1) overall strategy for developing a process model for this company that will increase the response rate of its e-mail advertising and obtain effective business process. Provide a rationale for your response.
Your assignment must follow these formatting requirements:
. Be typed, double spaced, using Times New Roman font (size 12), with one-inch margins on all sides; citations and references must follow APA or school-specific format. Check with your professor for any additional instructions.
. Include a cover page containing the title of the assignment, the student’s name, the professor’s name, the course title, and the date. The cover page and the reference page are not included in the required assignment page length.
The specific course learning outcomes associated with this assignment are:
. Build regression models for improving business processes.
. Design experiments to test cause-and-effect relationships in business processes.
. Use technology and information resources to research issues in business process improvement.
. Write clearly and concisely about business process improvement using proper writing mechanics.
Read each discussion 1-4 and then write a 200 word response for each.
With your response, you can either expand on the initial post with similar, formally cited, specific examples or additional information regarding the original example(s) (be sure the additional information isn’t simply a re-statement of what has already been posted) or you can respond with a well-supported (based on formally cited information) counter point.
APA FORMAT
Response should have 1 source for each discussion
1. A message in sports is brought to sports economists in Jeremiah 29:11. This verse states, “For I.
· Briefly describe the technologies that are leading businesses in.docxgerardkortney
· Briefly describe the technologies that are leading businesses into the third wave of electronic commerce.
· In about 100 words, describe the function of the Internet Corporation for Assigned Names and Numbers. Include a discussion of the differences between gTLDs and sTLDs in your answer.
· In one or two paragraphs, describe how the Internet changed from a government research project into a technology for business users.
· In about 100 words, explain the difference between an extranet and an intranet. In your answer, describe when you might use a VPN in either.
· Define “channel conflict” and describe in one or two paragraphs how a company might deal with this issue.
· In two paragraphs, explain why a customer-centric Web site design is so important, yet is so difficult to accomplish.
· In about two paragraphs, distinguish between outsourcing and offshoring as they relate to business processes.
· In about 200 words, explain how the achieved trust level of a company’s communications using blogs and social media compare with similar communication efforts conducted using mass media and personal contact.
· Write a paragraph in which you distinguish between a virtual community and a social networking Web site
· Write two or three paragraphs in which you describe the role that culture plays in the development of a country’s laws and ethical standards.
QUESTION 1
Lakota peoples of the Great Plains are notably:
nomadic and followed the buffalo herds
Sedentary farmers, raising corn, northern beans, and potatoes
peaceful people who tried to live in harmony with neighboring tribes and the environment
religious and employed a variety of psychoactive plants during religious ceremonies
QUESTION 2
Tribal peoples of the Great Plains experienced greater ease at hunting and warfare after the introduction of:
Hotchkiss guns
smokeless gunpowder
horses
Intertribal powwows
all of the above
QUESTION 3
The Apaches and Navajos (Dine’) of the southwestern region of North America speak a language similar to their relatives of northern California and western Canada called:
Yuman
Uto-Aztecan
Tanoan
Athabaskan
Algonkian
QUESTION 4
The Navajo lived in six or eight-sided domed earth dwellings called:
wickiups
kivas
hogans
roadhouses
sweat lodge
QUESTION 5
Pueblo Indians, such as the Zuni and Hopi tribes, are descendants of the ancient people known as the:
Anasazi
Ashkenazi
Athabaskan
Aztecanotewa
Atlantean
2 points
QUESTION 6
1. Kachinas, or spirits of nature, were believed to:
Assist in the growth of crops and send rain
Help defend the Navajo against all foreign invaders
Provide medical assistance to the Hopi when doctors were not available
Combat evil spirits such as Skin-walkers or Diablitos
All of the above
2 points
QUESTION 7
1. The preferred dwellings among the Lakota Sioux were:
wickiups
adobe pueblos
pit houses
teepees
buffalo huts
2 points
QUESTION 8
1. Native Americansbenef.
· Assignment List· My Personality Theory Paper (Week Four)My.docxgerardkortney
· Assignment List
· My Personality Theory Paper (Week Four)
My Personality Theory Paper (Week Four)
DUE: May 31, 2020 11:55 PM
Grade Details
Grade
N/A
Gradebook Comments
None
Assignment Details
Open Date
May 4, 2020 12:05 AM
Graded?
Yes
Points Possible
100.0
Resubmissions Allowed?
No
Attachments checked for originality?
Yes
Top of Form
Assignment Instructions
My Personality Theory Paper
Instructions:
For this assignment, you will write a paper no less than 7 pages in length, not including required cover and Reference pages, describing a single personality theory from the course readings that best explains your own personality and life choices. You are free to select from among the several theories covered in the course to date but only one theory may be used.
Your task is to demonstrate your knowledge of the theory you choose via descriptions of its key concepts and use of them to explain how you developed your own personality. It is recommended that you revisit the material covered to date to refresh your knowledge of theory details. This is a "midterm" assignment and you should show in your work that you have studied and comprehended the first four weeks of course material. Your submission should be double-spaced with 1 inch margins on all sides of each page and should be free of spelling and grammar errors. It must include source crediting of any materials used in APA format, including source citations in the body of your paper and in a Reference list attached to the end. Easy to follow guides to APA formatting can be found on the tutorial section of the APUS Online Library.
Your paper will include three parts:
I. A brief description of the premise and key components of the theory you selected. You should be thorough and concise in this section and not spend the bulk of the paper detailing the theory, but rather just give enough of a summary of the key points so that an intelligent but uniformed reader would be able to understand its basics. If you pick a more complicated theory, you should expect explaining its premise and key components to take longer than explaining the same for one of the simpler theories but, in either case, focus on the basics and keep in mind that a paper that is almost all theory description and little use of the theory described to explain your own personality will receive a significant point deduction as will the reverse case of the paper being largely personal experience sharing with little linkage to clearly described key theory components.
II. A description of how your chosen theory explains your personality and life choices with supporting examples.
III. A description of the limitations of the theory in explaining your personality or anyone else’s.
NOTE: Although only your instructor will be reading your paper, you should still think about how much personal information you want to disclose. The purpose of this paper is not to get you to share private information, but rather to bring one .
· Assignment List
· Week 7 - Philosophical Essay
Week 7 - Philosophical Essay
DUE: Mar 22, 2020 11:55 PM
Grade Details
Grade
N/A
Gradebook Comments
None
Assignment Details
Open Date
Feb 3, 2020 12:05 AM
Graded?
Yes
Points Possible
100.0
Resubmissions Allowed?
No
Attachments checked for originality?
Yes
Top of Form
Assignment Instructions
Objective: Students will write a Philosophical Essay for week 7 based on the course concepts.
Course Objectives: 2, 3, & 4
Task:
This 4 - 5 full page (not to exceed 6 pages) Philosophical Essay you will be writing due Week 7 is designed to be a thoughtful, reflective work. The 4 - 5 full pages does not include a cover page or a works cited page. It will be your premier writing assignment focused on the integration and assessment relating to the course concepts. Your paper should be written based on the outline you submitted during week 4 combined with your additional thoughts and instructor feedback. You will use at least three scholarly/reliable resources with matching in-text citations and a Works Cited page. All essays are double spaced, 12 New Times Roman font, paper title, along with all paragraphs indented five spaces.
Details:
You will pick one of the following topics only to do your paper on:
· According to Socrates, must one heed popular opinion about moral matters? Does Socrates accept the fairness of the laws under which he was tried and convicted? Would Socrates have been wrong to escape?
· Consider the following philosophical puzzle: “If a tree falls in the forest and there's no one around to hear it, does it make a sound?” (1) How is this philosophical puzzle an epistemological problem? And (2) how would John Locke answer it?
· Evaluate the movie, The Matrix, in terms of the philosophical issues raised with (1) skepticism and (2) the mind-body problem. Explain how the movie raises questions similar to those found in Plato’s and Descartes’ philosophy. Do not give a plot summary of the movie – focus on the philosophical issues raised in the movie as they relate to Plato and Descartes.
· Socrates asks Euthyphro, “Are morally good acts willed by God because they are morally good, or are they morally good because they are willed by God?” (1) How does this question relate to the Divine Command Theory of morality? (2) What are the philosophical implications associated with each option here?
· Explain (1) the process by which Descartes uses skepticism to refute skepticism, and (2) what first principle does this lead him to? (3) Explain why this project was important for Descartes to accomplish.
Your paper will be written at a college level with an introduction, body paragraphs, a conclusion, along with in-text citations/Works Cited page in MLA formatting. Students will follow MLA format as the sole citation and formatting style used in written assignments submitted as part of coursework to the Humanities Department. Remember - any resource that is listed on the Works Cited page must .
· Assignment 3 Creating a Compelling VisionLeaders today must be .docxgerardkortney
· Assignment 3: Creating a Compelling Vision
Leaders today must be able to create a compelling vision for the organization. They also must be able to create an aligned strategy and then execute it. Visions have two parts, the envisioned future and the core values that support that vision of the future. The ability to create a compelling vision is the primary distinction between leadership and management. Leaders need to create a vision that will frame the decisions and behavior of the organization and keep it focused on the future while also delivering on the short-term goals.
To learn more about organizational vision statements, do an Internet search and review various vision statements.
In this assignment, you will consider yourself as a leader of an organization and write a vision statement and supporting values statement.
Select an organization of choice. This could be an organization that you are familiar with, or a fictitious organization. Then, respond to the following:
· Provide the name and description of the organization. In the description, be sure to include the purpose of the organization, the products or services it provides, and the description of its customer base.
· Describe the core values of the organization. Why are these specific values important to the organization?
· Describe the benefits and purpose for an organizational vision statement.
· Develop a vision statement for this organization. When developing a vision statement, be mindful of the module readings and lecture materials.
· In the vision statement, be sure to communicate the future goals and aspirations of the organization.
· Once you have developed the vision statement, describe how you would communicate the statement to the organizational stakeholders, that is, the owners, employees, vendors, and customers.
· How would you incorporate the communication of the vision into the new employee on-boarding and ongoing training?
Write your response in approximately 3–5 pages in Microsoft Word. Apply APA standards to citation of sources.
Use the following file naming convention: LastnameFirstInitial_M1_A3.doc. For example, if your name is John Smith, your document will be named SmithJ_M1_A3.doc.
By the due date assigned, deliver your assignment to the Submissions Area.
Assignment 3 Grading Criteria
Maximum Points
Chose and described the organization. The description included the purpose of the organization, the products or services the organization provides, and the description of its customer base.
16
Developed a vision statement for the organization. Ensured to accurately communicate the goals and aspirations of the organization in the vision statement.
24
Ensured that the incorporation and communication strategy for the vision statement is clear, detailed, well thought out and realistic.
28
Evaluated and explained which values are most important to the organization.
24
Wrote in a clear, concise, and organized manner; demonstrated ethical scholarship in accurate r.
· Assignment 4
· Week 4 – Assignment: Explain Theoretical Perspectives for Real-life Scenarios
Assignment
Updated
Top of Form
Bottom of Form
For each of the following three scenarios, use a chart format to assess how each traditional theoretical perspective would best explain the situation that a social worker would need to address. You may create your charts in Word or another software program of your choice. An example chart follows the three scenarios.
Scenario 1
You are a hospital social worker who is working with a family whose older adult relative is in end-stage renal failure. There are no advanced directives and the family is conflicted over what the next steps should be.
Scenario 2
You are a caseworker in a drug court. Your client has had three consecutive dirty urine analyses. She is unemployed and has violated her probation order.
Scenario 3
You are a school social worker. A teacher sends her 9-year-old student to you because he reports that he has not eaten in 2 days and there are no adults at home to take care of him.
Chart Example:
Your client, an 11-year-old girl, was removed from home because of parental substance abuse. She is acting out in her foster home, disobeying her foster parents and not following their rules.
Theory
Explanation for Scenario – please respond to the questions below in your explanation
Systems Theory
What systems need to be developed or put in place to support the child? Would Child Protective Services need to become involved? What other systems would support her and a successful outcome for being in foster care?
Generalist Theory
What is the best intervention or therapy to use based on this child’s situation? Given her circumstances, how could you best improve her functioning?
Behavioral Theory
What behaviors are being reinforced? What behaviors are being ignored or punished? What would you suggest to maintain this placement? Would this involve working with the foster parents?
Cognitive Theory
How would you help your client to examine her thinking, emotions, and behavior? What would this entail from a cognitive developmental framework?
Support your assignment with a minimum of three resources.
Length: 3 charts, not including title and reference pages
Your assignment should demonstrate thoughtful consideration of the ideas and concepts presented in the course by providing new thoughts and insights relating directly to this topic. Your response should reflect scholarly writing and current APA standards where appropriate. Be sure to adhere to Northcentral University's Academic Integrity Policy.
Assignement 3
State the function of each of the following musculoskeletal system structures: Describe the structures of the musculoskeletal system.
Skeletal muscle
Tendons
Ligaments
Bone
Cartilage
Describe each of the following types of joints:
Ball-and-socket
Hinge
Pivot
Gliding
Saddle
Condyloid
Newspaper Rubric
CATEGORY
4
3
2
1
Headline & Byline & images
16 points
Article has a .
· Assignment 2 Leader ProfileMany argue that the single largest v.docxgerardkortney
· Assignment 2: Leader Profile
Many argue that the single largest variable in organizational success is leadership. Effective leadership can transform an organization and create a positive environment for all stakeholders. In this assignment, you will have the chance to evaluate a leader and identify what makes him/her effective.
Consider all the leaders who have affected your life in some way. Think of people with whom you work—community leaders, a family member, or anyone who has had a direct impact on you.
· Choose one leader you consider to be effective. This can be a leader you are personally aware of, or someone you don’t know, but have observed to be an effective leader. Write a paper addressing the following:
· Explain how this leader has influenced you and why you think he or she is effective.
· Analyze what characteristics or qualities this person possesses that affected you most.
· Rate this leader by using a leadership scorecard. This can be a developed scorecard, or one you develop yourself. If you use a developed scorecard, please be sure to cite the sources of the scorecard. Once you have identified your scorecard, rate your leader. You decide what scores to include (for example, scale of 1–5, 5 being the highest) but be sure to assess the leader holistically across the critical leadership competencies you feel are most important (for example, visioning, empowering, strategy development and communication).
· Critique this individual’s skills against what you have learned about leadership so far in this course. Consider the following:
· How well does he/she meet the practices covered in your required readings?
· How well has he/she adapted to the challenges facing leaders today?
· If you could recommend changes to his/her leadership approach, philosophy, and style, what would you suggest? Why?
· Using the assigned readings, the Argosy University online library resources, and the Internet including general organizational sources like the Wall Street Journal, BusinessWeek, or Harvard Business Review, build a leadership profile of the leader you selected. Include information from personal experiences as well as general postings on the selected leader from Internet sources such as blogs. Be sure to include 2–3 additional resources not already included in the required readings in support of your leadership profile.
Write a 3–5-page paper in Word format. Apply APA standards to citation of sources. Use the following file naming convention: LastnameFirstInitial_M2_A2.doc.
By the due date assigned, deliver your assignment to the Submissions Area.
Assignment 2 Grading Criteria
Maximum Points
Explained how this leader has been influential and why you think the leader is effective showing analysis of the leader’s characteristics or qualities.
16
Analyzed the characteristics or qualities the leader possesses that have affected you most..
16
Rated your leader using a leadership scorecard and supported your rationale for your rating.
32
Criti.
· Assignment 1 Diversity Issues in Treating AddictionThe comple.docxgerardkortney
· Assignment 1: Diversity Issues in Treating Addiction
The complexities of working with diverse populations in treating disorders, such as addictions, require special considerations. Some approaches work better with some populations than with others. For example, Alcoholics Anonymous (AA) programs are spiritually based and focus on a higher power. Some populations have difficulty with these concepts and are averse to participating in such groups.
Select a population—for example, African Americans; Native Americans; or lesbians, gays, or bisexual individuals. Research your topic by using articles from the supplemental readings for this course or from other resources such as the Web, texts, experience, or other journal articles related to diversity issues and addictions.
Write a three- to five-page paper discussing the following:
· Some specific considerations for working with your chosen population in the area of addiction treatment
· Whether your research indicates that 12-step groups work with this population
· Any special problems associated with this population that make acknowledging the addiction and seeking treatment more difficult
· Any language or other barriers that this population faces when seeking treatment
Prepare your paper in Microsoft Word document format. Name your file M4_A1_LastName_Research.doc, and submit it to the Submissions Area by the due date assigned Follow APA guidelines for writing and citing text.
Assignment 1 Grading Criteria
Maximum Points
Discussed some specific considerations for working with your chosen population in the area of addiction.
8
Discussed whether your research indicates that 12-step groups work with your chosen population.
8
Discussed any special problems associated with this population that make acknowledging the addiction and seeking treatment more difficult .
8
Discussed any language or other barriers that this population faces when seeking treatment.
8
Wrote in a clear, concise, and organized manner; demonstrated ethical scholarship in accurate representation and attribution of sources, displayed accurate spelling, grammar, and punctuation.
4
Total:
36
· M4 Assignment 2 Discussion
Discussion Topic
Top of Form
Due February 9 at 11:59 PM
Bottom of Form
Assignment 2: Discussion Questions
Your facilitator will guide you in the selection of two of the three discussion questions. Submit your responses to these questions to the appropriate Discussion Area by the due date assigned. Through the end of the module, comment on the responses of others.
All written assignments and responses should follow APA rules for attributing sources.
You will be attempting two discussion questions in this module; each worth 28 points. The total number of points that can be earned for this assignment is 56.
Minority Groups
Many minority groups experience stress secondary to their social surroundings. For example, a family living in poverty may face frequent violence. Limited income makes meeting the day-to-day need.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
Digital Tools and AI for Teaching Learning and Research
ORIGINAL ARTICLE HIP - ANESTHESIAA randomized controlled.docx
1. ORIGINAL ARTICLE � HIP - ANESTHESIA
A randomized controlled trial of postoperative analgesia
following
total knee replacement: transdermal Fentanyl patches
versus patient controlled analgesia (PCA)
M. J. Hall1 • S. M. Dixon2 • M. Bracey3 • P. MacIntyre4 • R. J.
Powell3 •
A. D. Toms3
Received: 13 November 2014 / Accepted: 12 February 2015 /
Published online: 11 March 2015
� Springer-Verlag France 2015
Abstract
Background This randomized controlled trial compared a
standard patient controlled analgesic (PCA) regime with a
transdermal and oral Fentanyl regime for post-operative
pain management in patients undergoing total knee
replacement.
Methods One hundred and ninety-six patients undergoing
total knee replacement were recruited. Pre- and post-op-
2. eratively Visual Analogue Score (VAS), Oxford Knee
Score, Health Anxiety and Depression Score and Brief Pain
Inventory Score were completed. According to the day 1,
VAS score patients were randomly allocated to either a
PCA regime or a Fentanyl transdermal/oral regime. Patient
reported outcomes were measured until the patients were
discharged.
Results The results demonstrate that in terms of analgesic
effect, day of discharge and side effect profile the two
regimes are comparable.
Conclusions We conclude that a Fentanyl transdermal
regime provides adequate analgesic effect comparable to a
standard PCA regime in conjunction with a low side effect
profile. Using a transdermal analgesic system provides ef-
ficient continuous delivery enabling a smooth transition
from hospital to home within the first week. Transdermal
Fentanyl provides an alternative analgesic regime that can
provide an equivalent analgesic effect so as to enable a
3. satisfactory outcome for the patient in terms of function
and pain.
Level of evidence II.
Keywords Total knee replacement � Post-operative
analgesia � Patient controlled analgesia � Fentanyl patches
Introduction
Knee replacement surgery has proved a successful and
cost-effective method for relieving pain and restoring
function in patients with osteoarthritis [1]. However, pain
management after knee replacement surgery remains a
significant problem, with patients reporting this as a major
concern prior to surgery [2]. Implementing relevant pre-
operative screening methods may facilitate the identifica-
tion of individuals at high risk of experiencing high post-
operative pain [3]. Despite recent advances in the aetiology
of pain, improved pain treatments and the development of
clinical guidelines for pain assessment, the under-treatment
of post-operative pain remains a challenge to both surgeon
4. and anaesthetist. Recent studies have clearly demonstrated
that patient satisfaction following total knee replacement is
multifactorial with the most significant predictor of dis-
satisfaction being a painful total knee replacement [1].
Providing effective pain relief in the post-operative pe-
riod is essential to enable early mobilisation and reha-
bilitation, minimise immobility-related complications,
maximise functional outcome and reduce hospital stay.
Many different methods of delivering adequate analgesia
are currently employed but one of the most established is
intravenous (IV) patient controlled analgesia (PCA). This
provides the benefit of self-titrated IV opioid medication
& M. J. Hall
[email protected]
1
Yeovil District Hospital, Higher Kingston,
Yeovil BA21 4AT, UK
2
Royal Cornwall Hospital, Truro, UK
3
Royal Devon & Exeter Hospital, Exeter, UK
5. 4
Nelson Bay District Hospital, Nelson, New Zealand
123
Eur J Orthop Surg Traumatol (2015) 25:1073–1079
DOI 10.1007/s00590-015-1621-6
http://crossmark.crossref.org/dialog/?doi=10.1007/s00590-015-
1621-6&domain=pdf
http://crossmark.crossref.org/dialog/?doi=10.1007/s00590-015-
1621-6&domain=pdf
enabling active participation in the patient’s own post-op-
erative management compared to a more generic, orally
delivered analgesia. The disadvantages are the cost of PCA
pumps along with the monitoring required and nursing time
to manage the systems appropriately.
The literature provides no clear answers as to the best
method of post-operative pain relief, with studies showing
PCA [4] and regional techniques [5, 6] both providing good
analgesia to enable rehabilitation. The major drawback of
morphine can be the side effect profile, including nausea,
6. constipation and itching, whereas with regional analgesia
the reliability and duration of action can be problematic.
Fentanyl has formed the mainstay of intra-operative
analgesia and has many beneficial features. In the lozenge
form, it has a very rapid onset and can reach peak activity
within 20 min compared to 40–60 min for oral morphine
[7]. For this reason, the main clinical application of oral
fentanyl lozenges is in the field of oncology for manage-
ment of breakthrough pain.
The aim of this randomized controlled study was to
compare two analgesic regimes, PCA and Fentanyl (in a
transdermal and oral form) and demonstrate that a trans-
dermal Fentanyl patch can provide comparable post-op-
erative analgesia to a standard PCA regime in terms of pain
and side effect profile without compromising rehabilitation
and discharge times. Post-operatively on day 1, we divided
patients into a low and high pain group based on a pain
score to see if this enabled an accurate prediction of pain
7. requirements during the subsequent post-operative period.
Patients and methods
All patients undergoing a unilateral total knee replacement
at the Royal Devon and Exeter Hospital were invited to
take part in the trial, which included all surgeons per-
forming knee replacement surgery within the trust. Patients
were excluded from the study if they were unable to walk
twenty metres or climb three stairs for any reason other
than pain in the affected joint, trauma and refusal or in-
ability to give valid consent. Pre-operatively the study
group completed the Oxford Knee Score (OKS) [17],
Health Anxiety Depression Score (HADS) and Brief Pain
Inventory Score (BPI). Participants in the trial were pre-
scribed paracetamol (1 g QDS), an anti-inflammatory
(Diclofenac 50 mg BD) and oral morphine (10–20 mg two
hourly) as required.
Patients were given a pain diary on day 1 and asked to
score the pain on movement of the limb using a ten-point
8. Visual Analogue Score (VAS). If this score was 6/10 or
more they were entered into the high pain group (HPG),
and less than six entered the low pain group (LPG). An
independent statistician using a sealed envelope technique
carried out randomization of the HPG into the two treat-
ment arms. The LPG remained on the routine analgesic
regime. In the HPG, patients were randomized to either
intravenous morphine administered through a PCA pump,
or a Fentanyl patch with oral Fentanyl in the form of a
lozenge that can be taken two hourly prior to exercise or
for breakthrough pain. The doses of morphine in the PCA
were 1 mg bolus with a 5 min lockout and no 4-h limit or
background infusion. The doses of Fentanyl patch were
12.5 mcg for patients over 65 years and 25 mcg for pa-
tients under 65 years with lozenges up to 400 mcg for
breakthrough pain and up to five 200 mcg lozenges,
whilst waiting for the patch to reach therapeutic plasma
levels. The lozenges were titrated against signs of
9. lightheadedness.
Each day until discharge, patients attempted standard
physiotherapy tasks as part of their physiotherapy regime
and then scored their pain using the VAS which is scored
zero to ten (where the lower the score the less the patient’s
pain). Patients were also asked to complete the BPI score
with 1–4 being mild, 4–6 moderate and 7–10 severe pain.
These scores were completed for worst pain, least pain,
average pain, pain currently, pain on activity, pain effect on
mood, pain on walking, pain whilst at work, pain affect on
relations, pain whilst sleeping and pain effect on enjoy-
ment. Pain assessment was carried out on a daily basis until
discharge in the form of a short interview and completion
of the above-mentioned scores. As part of the question-
naires, we recorded the presence of side effects and their
severity and impact on rehabilitation.
For this study, full ethical approval was granted from the
local ethics committee as well as full approval from the
10. Medicines and Healthcare Products Regulatory Agency
(MHRA). Research and Development reference from
Royal Devon and Exeter Hospital: 612163 and Research
Ethics Committee reference: 06/Q2102/57.
Statistical analysis
Based on preliminary data for PCA that we can expect a
15 % reduction in pain worst score after 4 days (which is
what we saw on average), and if there is truly no difference
between the standard and experimental treatment, then 50
patients are required to be 80 % sure that the limits of a
two-sided 90 % confidence interval will exclude a differ-
ence between the standard and experimental group of more
than 30 %.
Continuous outcome data were tested for normality us-
ing the Shapiro Wilks test. If the data were found to be
normally distributed, central tendency was expressed using
means and dispersion using standard deviation. If the data
proved not to be Gaussian, and could not easily be trans-
11. formed, they were summarised using medians and
1074 Eur J Orthop Surg Traumatol (2015) 25:1073–1079
123
interquartile ranges and comparisons were made using
nonparametric tests such as the Mann–Whitney U test.
Confidence intervals were derived wherever possible.
Categorical data were summarised as proportions and
percentages as appropriate with associated confidence in-
tervals. A comparison of time to discharge was analysed
using Kaplan–Meier survival analysis. Repeated con-
tinuous measures such as VAS pain, OKS, BPI elements
and HADS were analysed using repeated measures analysis
of variance provided the basic requirements were met. The
first 5 days of data were included as in subsequent days,
too many patients had been discharged to make analysis
feasible.
Results
12. One hundred and ninety-six patients undergoing unilateral
total knee replacement were recruited into the trial. Of
these 64 subsequently withdrew from the trial after initially
consenting and 25 had incomplete data collection for
analysis and were excluded. This left a total of one hundred
and seven patients in the trial with 69 in the LPG, 38 in the
HPG with sixteen of these receiving Fentanyl patches and
lozenges and 22 receiving a PCA infusion (Fig. 1).
The mean age in the LPG was 68; Fentanyl group 64 and
PCA group 66 years. Patient ages ranged from 41 to
96 years with patients in the LPG tending to be older on
average, but this was not statistically significantly different.
Day of discharge
Kaplan–Meier survivorship analysis comparing the three
groups showed a significant difference in day of discharge
between the three groups. Mean time to discharge was
6.23 days for Fentanyl, 5.95 days for PCA and 4.48 days
in the low pain group (p = 0.007) (Fig. 2).
13. We also analysed the percentage of patients discharged
by day 5. The LPG had the highest rate of discharge
overall, with forty-two (77.8 %) discharged by this time
period. In the HPG, thirteen (68 %) of the PCA group and
7 (5 %) of the Fentanyl group were discharged by day 5;
however, this difference was not significant (p = 0.284).
Pain scores
Pain scores were analysed at day 5 post-operatively as a
large proportion of patients had been discharged after this
time.
Comparison of VAS scores showed that there was no
significant difference in pain scores on movement
(p = 0.317), rest (p = 0.811), worst pain (p = 0.353) and
night (p = 0.730) between the Fentanyl and PCA groups
(see Table 1).
Both HPG groups (Fentanyl and PCA) showed a sig-
nificant reduction, i.e. pain is better, in BPI Worst score,
BPI Average score, BPI Now score, BPI Activity score,
14. BPI Mood score, BPI Walk score, BPI Relations score, BPI
Work score, BPI Sleep score, BPI Enjoy score (see
Table 2). The reduction in all BPI Worst scores was similar
in both of the treatment groups (i.e. fentanyl from 6.81 to
4.22) and PCA from 7.44 to 4.48). BPI (Now) showed a
significant difference between the LPG and HPG
(p 0.001); however, all other modalities of the BPI score
showed no significant difference.
Side effects
Using repeated measures ANOVA showed that the side
effect scores between the Fentanyl and PCA groups were
relatively low (1.271–1.417) and did not vary significantly
across the 4 days. There was no significant difference in
side effect score between the two groups, PCA (mean
1.368) and Fentanyl (mean 1.339) (p = 0.887).
Oxford Knee Scores
Both HPG groups (Fentanyl and PCA) demonstrated a
significant reduction in OKS score (p 0.001). However,
there was no significant difference between the two
15. treatment groups (p = 0.974) (see Table 3). The reduc-
tion in OKS score was similar in both of the treatment
groups, dropping from a mean of 36.9–28.72 in the
Fentanyl group and 37.16–28.58 in the PCA group (see
Table 3).
Anxiety and depression: HADS scores
Both HPG groups (Fentanyl and PCA) demonstrated a
significant reduction in mean HADS score; 10.16–7.91 in
the Fentanyl group and 12.89–7.06 in the PCA group
(p = 0.004). Comparison of HADS Score for the LPG and
HPG showed no significant difference (p = 0.615).
Discussion
The results from this study show that a post-operative
regime of transdermal Fentanyl patches compares to that of
a more conventional PCA regime in terms of analgesic
effect, day of discharge and side effect profile. By using the
VAS score pre-operatively, we showed that patients can be
allocated into a high or low pain group and consequently a
16. Eur J Orthop Surg Traumatol (2015) 25:1073–1079 1075
123
targeted analgesic regime can be implemented to suit the
individuals analgesic requirements.
Over the last decade, the emphasis on peri-operative
pain management in joint replacement surgery has made
significant advances, to the extent that many consider it to
be the most substantial advance in clinical practice [8]. A
4-year follow-up study concluded that pain is a common
persistent problem in the community with a relatively high
incidence and low recovery rate [9]. Ip et al. [10] in a
systematic review found that preexisting pain, anxiety, age
and type of surgery are the most significant factors for the
intensity of post-operative pain with type of surgery, age
and psychological distress, the three most important pre-
dictive factors for analgesic consumption.
It is well established that more than half the numbers of
17. patients undergoing lower limb joint replacement surgery
Assessed for eligibility (n=196)
Excluded (n=90)
♦ Not meeting inclusion criteria (n=26)
♦ Declined to participate (n=64)
♦ Other reasons (n=0)
Analysed (n=14) at day 4
♦ Excluded from analysis (n=0)
Discontinued intervention
(discharged home):-
day 1, n=0
day 2, n=0
day 3, n=1 (1)
day 4, n=1 (2)
day 5, n=1 (3)
day 6, n=6 (9)
day 7, n=4 (10)
(Cumulative totals in brackets)
Allocated to Fentanyl intervention (n=15)
♦ Received allocated intervention (n=15)
♦ Did not receive allocated intervention
(n=0)
Discontinued intervention
(discharged home):-
day 1, n=0)
day 2, n=0)
day 3, n=1 (1)
day 4, n=3 (4)
day 5, n=7 (11)
18. day 6, n=10 (18)
day 7, n=0 (18)
(Cumulative totals in brackets)
Allocated to PCA intervention (n=23)
♦ Received allocated intervention
(n=23)
♦ Did not receive allocated
intervention (n=0)
Analysed (n=19) at day 4
♦ Excluded from analysis (n=0)
Allocation
Analysis
Follow-Up
High pain group.
Randomized (n=38)
Enrollment
Observational group (low pain) (n=68)
Discontinued intervention
(discharged home):-
day 1, n=0
day 2, n=0
day 3, n=3 (3)
day 4, n=20 (23)
day 5, n=27 (50)
day 6, n=5 (55)
19. day 7, n=4 (59)
(Cumulative totals in brackets)
Analysed (n=45) at day 4
♦ Excluded from analysis (n=0)
Fig. 1 Consort diagram of study patients
1076 Eur J Orthop Surg Traumatol (2015) 25:1073–1079
123
receive suboptimal analgesia especially during the initial
post-operative period [8], with patients now well informed
to their pain management and consider it a high priority
[2]. However, the importance of delivering adequate
analgesia reaches beyond that of clinical duty with recog-
nition that inadequate pain management can increase the
possibility of developing a poor outcome. Severe post-op-
erative pain results in longer hospital stay, increased opioid
use with resultant side effects and lower patient mood.
Studies have demonstrated that those patients that receive
suboptimal analgesia post-operative have higher levels of
20. arthrofibrosis and diminished range of motion [5, 11, 12].
In this study, analysis of pre-operative BPI pain score data
demonstratedthattheHPG had a higherpercentage ofpatients
reporting a BPI greater than 5, 61 %, compared to the LPG
which only had 40 %. Early identification of patients likely to
require additional or alternative methods of post-operative
analgesia means maximising rehabilitation enabling
achievement of physiotherapy targets sooner ultimately
Fig. 2 Kaplan–Meier curve of discharge days
Table 1 Mean VAS pain scores for pain on movement, at rest,
worst and at night. A comparison of fentanyl and PCA
interventions in the high
pain group and also a comparison of the high pain group with
the low pain group
Intervention Mean VAS pain score
Day Pain on movement Pain at rest Worst pain Pain at night
High pain group
Fentanyl
1 7.33 5.83 7.92 8.20
2 7.08 5.25 7.33 5.50
3 5.83 4.17 7.25 4.50
21. 4 5.42 3.50 6.25 4.00
5 5.33 3.50 6.67 3.30
PCA
1 7.67 6.58 8.00 7.71
2 7.67 4.58 8.50 4.43
3 6.75 4.33 7.33 5.00
4 6.08 4.17 7.25 3.86
5 5.50 3.50 6.92 2.71
Within subjects comparison
(i.e. changes over time)
F = 4.9 with 4, 88
df, p = 0.001
F = 5.83 with 4, 88
df, p = 0.001
F = 1.94 with 4, 88
df, p = 0.111
F = 17.83 with 4,
88 df, p = 0.001
22. Main effect: comparison
of fentanyl versus PCA
F = 1.05 with 1, 22
df, p = 0.317
F = 0.06 with 1, 22
df, p = 0.811
F = 0.90 with 1, 22
df, p = 0.353
F = 0.12 with 1,
22 df, p = 0.730
Low pain group
1 3.06 1.88 3.77 3.46
2 5.00 2.29 5.41 2.85
3 4.88 1.65 5.53 1.85
4 4.88 1.53 5.77 1.77
5 4.47 1.06 5.88 1.69
Within subjects comparison
(i.e. changes over time)
23. F = 2.17 with 4,
156 df, p = 0.095
F = 6.01 with 4,
156 df, p = 0.001
F = 0.89 with 4,
156 df, p = 0.451
F = 19.97 with 4,
112 df, p 0.001
Main effect: comparison
of LPG with HPG
F = 17.87 with 1,
39 df, p 0.001
F = 29.39 with 1,
39 df, p 0.001
F = 19.87 with 1,
39 df, p 0.001
F = 14.54 with 1,
28 df, p = 0.001
Eur J Orthop Surg Traumatol (2015) 25:1073–1079 1077
123
24. reducing length of stay. In those patients identified as requir-
ing additional analgesic support post-operatively the Fentanyl
transdermal delivery regime has a distinct advantage of pro-
viding a smooth transition to the home environment.
The use of Fentanyl in orthopaedic surgery is limited
with its most common usage being in management of
breakthrough pain in the palliative care setting. Fentanyl
patches do add to the total narcotic dosage as well as
providing an alternative route for administration of anal-
gesia. However, concerns over unpredictable delivery and
the potential for adverse effects does deter many centres
from using Fentanyl through this method. Using Fentanyl
ionophoretic transdermal systems, Viscusi et al. [13, 14]
demonstrated pain control equivalent to standard morphine
PCA delivery systems in a variety of post-operative pa-
tients, with no significant difference in side effect profiles.
Analysis of the side effect profile in our study showed
25. similar findings with no significant difference demonstrated
between the Fentanyl group and the PCA group.
From this study, we suggest Fentanyl patches and lozenges
provide a viable alternative to the standard morphine based
regime used in most PCA pumps. Fentanyl in a transdermal
therapeutic system provides several attractive features; firstly
it provides stable plasma concentrations in a relatively short
period of time which are maintained a background steady-
state level, secondly newer formulations are safer and bioe-
quivalent to standard oral preparations. Minville et al. re-
ported on a small group of patients who had a fentanyl patch
applied 10 h prior to total hip arthroplasty. No difference in
respiratory depression was noted between that group and
those who did not receive the patch [15, 16]. However, the
use of fentanyl lozenges in this setting is innovative with the
ability of the oral form of Fentanyl to be rapidly absorbed
through the buccal mucosa providing high plasma levels
rapidly means that its profile is ideally suited to managing
26. breakthrough pain during the post-operative period.
Current trends favour the multimodal approach that
provide adequate analgesia yet minimise opioid-related
Table 2 Mean (and 95 % CI) BPI scores for worst pain and pain
now
Intervention BPI worst BPI now
High pain group
Fentanyl
Pre 6.81 (5.74–7.89) 4.90 (3.46–6.34)
Post 4.22 (3.15–5.3) 2.43 (1.30–3.56)
PCA
Pre 7.44 (6.56–8.33) 5.39 (4.2–6.57)
Post 4.48 (3.59–5.37) 2.55 (1.62–3.48)
Within subjects comparison (i.e. change over time) F = 6.74
with 1, 29 df; p = 0.015 F = 3.27 with 1, 29 df; p = 0.081
Main effect: comparison of fentanyl versus PCA F = 0.682 with
1, 29 df; p = 0.486 F = 0.21 with 1, 29 df; p = 0.653
Low pain group
Pre 10.11 (8.35–11.87) 3.56 (2.87–4.25)
27. Post 6.07 (4.57–7.57) 1.24 (0.8–1.68
Within subjects comparison (i.e. change over time) F = 5.64
with 1, 80 df; p = 0.02 F = 5.38 with 1, 80 df; p = 0.023
Comparison of LPG with HPG F = 2.57 with 1, 80 df; p = 0.113
F = 15.51 with 1, 80 df; p 0.001
A comparison of fentanyl and PCA interventions in the high
pain group and also a comparison of the high pain group with
the low pain group.
Age as a covariate
Table 3 Mean (and 95 % CI) Oxford Knee Score and Hospital
Anxiety and Depression Score
Intervention Pre-OKS Post-OKS Pre-HADS Post-HADS
High pain group
Fentanyl 36.9 (32.61–41.19) 28.72 (25.56–31.89) 10.16 (6.38–
13.95) 7.91 (5.04–10.79)
PCA 37.16 (33.92–40.41) 28.58 (26.19–30.97) 12.89 (9.77–
16.01) 7.06 (4.69–9.43)
Within subjects comparison F = 43.96 with 1, 27 df; p 0.001 F
= 9.93 with 1, 29 df; p = 0.004
Main effect: comparison of fentanyl versus PCA F = 0.001 with
1, 27 df; p = 0.974 F = 0.26 with 1, 29 df; p = 0.615
Low pain group 35.28 (33.34–39.54) 26.70 (25.03–28.37) 10.11
(8.35–11.87) 6.07 (4.57–7.57)
Within subjects comparison F = 4.78 with 1, 78 df; p = 0.032 F
28. = 5.64 with 1, 79 df; p = 0.02
Comparison of LPG with HPG F = 2.57 with 1, 78 df; p = 0.113
F = 1.42 with 1, 79 df; p = 0.237
A comparison of fentanyl and PCA interventions in the high
pain group and also a comparison of the high pain group with
the low pain group.
Age as a covariate
1078 Eur J Orthop Surg Traumatol (2015) 25:1073–1079
123
side effects. From this study, we suggest that the use of
Fentanyl in a transdermal delivery system with oral Fen-
tanyl for breakthrough pain provides equivalent pain re-
lieve compared to the more standard opioid based PCA
systems, which several studies have demonstrated provide
adequate cost-efficient pain relief [2, 4]. However, none of
the theoretical advantages were seen as a practical differ-
ence in our patient group. Early identification of patients
falling into the high pain category means that suitable
analgesic regimes can be planned so as to create an envi-
29. ronment in which both mentally and physically the patient
is able to undertake progressive rehabilitation.
We know that patient expectations correlate highly with
satisfaction and by managing expectations and considering
the mental health of the patient can all help reduce the risk
of overall dissatisfaction. Post-operative pain relief is one
important aspect in the process of undergoing a knee re-
placement with many global factors pertaining to that in-
dividual playing an important role to the overall outcome.
The benefits of splitting patients into low and high pain
groups results means that those patients at risk of devel-
oping severe acute post-operative pain are identified at an
early stage and specific analgesic regime can be imple-
mented so as to manage the pain appropriately in order that
rehabilitation is not compromised. Central to successful
enhanced recovery programs is providing a platform for
patients to mobilise such that they can be discharged safely
with a minimal length of stay. Multi-modal analgesic
30. regimes we feel are therefore a key component to these
programs. Managing patients post-operative analgesia and
pain perception efficiently can result in faster rehabilitation
and ultimately improved functional outcome and patient
satisfaction. This study demonstrates the potential benefits
of multi-modal analgesia in enabling a faster rehabilitation
in the initial post-operative period and ultimately improves
outcomes.
Conflict of interest None.
References
1. Scott CEH, Howie CR, MacDonald D, Biant LC (2010) Pre-
dicting dissatisfaction following total knee replacement. J Bone
Joint Surg (Br) 92-B:1253–1258
2. Kastanias P, Gowans S, Tumber PS, Snaith K, Robinson S
(2010)
Patient-controlled oral analgesia for postoperative pain
management following total knee replacement. Pain Res Manag
J
Can Pain Soc 15(1):11–16
31. 3. Werner MU, Mjobo HN, Nielson PR, Rudin A (2010)
Prediction
of postoperative pain. A systematic review of predictive ex-
perimental pain studies. Anesthesiology 112:1494–1502
4. Hudova J, McNicol E, Quah C, Lau J, Carr DB (2006) Patient
controlled opioid analgesia versus conventional analgesia for
postoperative pain. Cochrane Database Syst Rev 4:48
5. Singelyn FJ, Deyaert M, Joris D et al (1998) Effects of intra-
venous patient-controlled analgesia with morphine, continuous
epidural analgesia and continuous three-in-one block on postop-
erative pain and knee rehabilitation after unilateral total knee
arthroplasty. Anesth Analg 87:88–92
6. Capdevila X, Barthelet Y, Biboulet P et al (1999) Effects of
perioperative analgesic technique on the surgical outcome and
duration of rehabilitation after major knee surgery. Anesthesi-
ology 91:8–15
7. Collins SL, Faura CC, Moore RA, McQuay HJ (1998) Plasma
concentrations after oral morphine: a systematic review. J Pain
32. Syndrome Manage 16:388–402
8. Maheshwari AV, Blum YC, Shekhar L, Ranawat A, Ranawat
C
(2009) Multimodal pain management after total hip and knee
replacement at the Ranawat Orthopaedic Center. Clin Orthop
Relat Res 467:1418–1423
9. Shipton EA, Tait B (2005) Flagging the pain: preventing the
burden of chronic pain by identifying and treating risk factors
in
acute pain -. Eur J Anaesthesiol 22:405–412
10. Ip HYV, Abrishami A, Peng PWH et al (2003) Predictors of
postoperative pain and analgesic consumption. A qualitative
systematic review. Anesthesiology 111:657–677
11. Ranawat CS, Ranawat AS, Mehta A (2003) Total knee
arthro-
plasty rehabilitation protocol: what makes the difference?
J Arthroplasty 18(3 Suppl 1):27–30
12. Lundbald H, Kreicbergs A, Jansson KA (2008) Prediction of
persistent pain after total knee replacement for osteoarthritis.
J Bone Joint Surg 90:166–171
33. 13. Viscusi ER, Siccardi M, Damaraju CV, Hewitt DJ, Kershaw
P
(2007) The safety and efficacy of fentanyl ionophoretic trans-
dermal system compared with morphine intravenous patient-
controlled analgesia for post-operative pain management: an
analysis of pooled data from three randomized, active-
controlled
clinical studies. Pain Med 105(5):1428–1436
14. Viscusi ER, Reynolds L, Chung F, Atkinson LE, Khanna S
(2004) Patient-controlled transdermal fentanyl hydrochloride vs
intravenous morphine pump for postoperative pain. JAMA
291:1333–1341
15. Minville V, Lubrano V, Bounes V et al (2008) Postoperative
analgesia after total hip arthroplasty: patient-controlled
analgesia
versus transdermal fentanyl patch. J Clin Anesth 20:280–283
16. Parvizi J, Miller A, Gandhi K (2011) Multimodal pain
manage-
ment after total joint arthroplasty. J Bone Joint Surg Am
93:1075–1084
34. 17. Dawson J, Fitzpatrick R, Murray D, Carr A (1998)
Questionnaire
on the perception of patients about total knee replacement. J
Bone
Joint Surg 80:63–69
Eur J Orthop Surg Traumatol (2015) 25:1073–1079 1079
123
Copyright of European Journal of Orthopaedic Surgery &
Traumatology is the property of
Springer Science & Business Media B.V. and its content may
not be copied or emailed to
multiple sites or posted to a listserv without the copyright
holder's express written permission.
However, users may print, download, or email articles for
individual use.
A randomized controlled trial of postoperative analgesia
following total knee replacement: transdermal Fentanyl patches
versus patient controlled analgesia
(PCA)AbstractBackgroundMethodsResultsConclusionsLevel of
evidenceIntroductionPatients and methodsStatistical
analysisResultsDay of dischargePain scoresSide effectsOxford
Knee ScoresAnxiety and depression: HADS
scoresDiscussionConflict of interestReferences