Blood lead levels in an endangered vulture decline following changes in hunting activity.

Lead ammunition stands out as one of the most pervasive pollutants affecting wildlife. Its impact on bird populations have spurred efforts for the phase-out of leaded gunshot in several countries, although with varying scopes and applications. Ongoing and future policy changes require data to assess the effectiveness of adopted measures, particularly in the current context of biodiversity loss. Here, we assessed the long-term changes in blood lead (Pb) levels of Egyptian vultures from the Canary Islands, Spain, which have been severely affected by Pb poisoning over the past two decades. During this period, the reduction in hunting pressure and changes in legislation regarding firearms usage for small game hunting likely contributed to a decrease in environmental Pb availability. As anticipated, our results show a reduction in Pb levels, especially after the ban on wild rabbit hunting with shotgun since 2010. This effect was stronger in the preadult fraction of the vulture population. However, we still observed elevated blood Pb levels above the background and clinical thresholds in 5.6% and 1.5% of individuals, respectively. Our results highlight the positive impact of reducing the availability of Pb from ammunition sources on individual health. Nonetheless, the continued use of Pb gunshot remains an important source of poisoning, even lethal, mainly affecting adult individuals. This poses a particular concern for long-lived birds, compounding by potential chronic effects associated with Pb bioaccumulation. Our findings align with recent studies indicating insufficient reductions in Pb levels among European birds of prey, attributed to limited policy changes and their uneven implementation. We anticipated further reductions in Pb levels among Egyptian vultures with expanded restrictions on hunting practices, including a blanket ban on Pb shot usage across all small game species.

Pentobarbital intoxication as a potential underlying cause for electrocution in a bearded vulture.

A bearded vulture (Gypaetus barbatus) found dead in northern Spain presented external lesions consistent with electrocution as the cause of death. During forensic examination, macroscopic lesions suggested potential comorbidity, so samples were collected for molecular and toxicological analyses. Gastric content and liver were analysed for toxic substances, and pentobarbital (a common pharmaceutical used for euthanasia in domestic animals) was detected at a concentration of 37.3 and 0.05 µg/g, respectively. Other toxicological, viral and endoparasite analyses (avian malaria, avian influenza and flaviviruses) were negative. Thus, although the cause of death was electrocution, pentobarbital intoxication likely impaired the equilibrium and reflexes of the individual, possibly causing the bird to contact energized wires that it would not have otherwise. These results underline the importance of comprehensive analysis of forensic cases of wildlife deaths and reveal barbiturate poisoning as an additional threat for the conservation of the bearded vulture in Europe.

Impact of the novel powered circular stapler on risk of anastomotic leakage in colorectal anastomosis: a propensity score-matched study.

BACKGROUND: Several risk factors for anastomotic leakage (AL) following colorectal surgery have been described. Improvement in devices for performing anastomosis is a modifiable factor that could reduce AL rates. The aim of this study was to assess the impact of technical improvements in the Echelon Circular™ powered stapler (ECPS) on the left-sided colorectal AL rate compared to current manual circular staplers (MCS). METHODS: A cohort study was carried out on consecutive patients between January 2017 and February 2020 in whom left-sided stapled colorectal anastomosis above 5 cm from anal verge was performed. The primary end point was the risk of AL depending on the type of circular stapler used. The ECPS cases were matched to MCS cases by propensity score matching to obtain comparable groups of patients. RESULTS: Two hundred seventy-nine patients met the inclusion criteria. A MCS anastomosis was performed in 218 patients and ECPS anastomosis in 61 (21.9%). Overall, AL was observed in 25 (9%) cases. Factors significantly associated with AL were American Society of Anesthesiologists score (p = 0.025) and type of circular stapler used (p = 0.021). After adjusting the cases with propensity score matching (119 cases MCS versus 60 ECPS), AL was observed in 14 (11.8%) patients in MCS group and in 1 (1.7%) patient in the ECPS group (p = 0.022). AL in the MCS group required reoperation in seven cases (5.8%), the remaining seven patients were treated conservatively. The patient in the ECSP group required an urgent Hartmann's procedure CONCLUSIONS: The ECPS device could have a positive impact by reducing AL rates in left-sided colorectal anastomosis. Multicenter controlled trials are needed for stronger evidence to change practice.

Bryophytes are predicted to lag behind future climate change despite their high dispersal capacities.

The extent to which species can balance out the loss of suitable habitats due to climate warming by shifting their ranges is an area of controversy. Here, we assess whether highly efficient wind-dispersed organisms like bryophytes can keep-up with projected shifts in their areas of suitable climate. Using a hybrid statistical-mechanistic approach accounting for spatial and temporal variations in both climatic and wind conditions, we simulate future migrations across Europe for 40 bryophyte species until 2050. The median ratios between predicted range loss vs expansion by 2050 across species and climate change scenarios range from 1.6 to 3.3 when only shifts in climatic suitability were considered, but increase to 34.7-96.8 when species dispersal abilities are added to our models. This highlights the importance of accounting for dispersal restrictions when projecting future distribution ranges and suggests that even highly dispersive organisms like bryophytes are not equipped to fully track the rates of ongoing climate change in the course of the next decades.

Ejercicios de fortalecimiento muscular sobre las habilidades motoras y la fuerza de miembros inferiores en niños y adolescentes con parálisis cerebral: revisión sistemática / Muscular strengthening exercises on motor skills and strength of lower limbs in children and adolescents with cerebral palsy: A systematic review

Objetivos: Identificar los efectos de los ejercicios de fortalecimiento muscular sobre las habilidades motoras y la fuerza de miembros inferiores en niños y adolescentes con parálisis cerebral, así como, conocer las características principales de los ejercicios y de los sujetos, identificar los instrumentos de medición utilizados, y conocer si los cambios en las variables se mantienen en el tiempo. Estrategia de búsqueda: La búsqueda se realizó en las bases de datos de Pubmed, BVS, Cochrane Library, PEDro, WoS, Science Direct y EBSCO entre los meses de noviembre de 2017 y enero de 2018, así como en revistas especializadas. Selección de estudios: Tras el proceso inicial de identificación de estudios, finalmente se seleccionaron 10 estudios que cumplieron los criterios de selección. Síntesis de resultados: Dos estudios presentaron un bajo riesgo de sesgo. Seis de ellos, muestran resultados significativos en las habilidades motoras, dos estudios en la capacidad de caminar y cuatro estudios en la movilidad. También se encontraron diferencias significativas en la fuerza estática y dinámica, en dos y cuatro estudios, respectivamente. Dos estudios no obtienen resultados significativos en la única variable que analizan, y finalmente, en tres estudios, los resultados se mantienen en el tiempo. Conclusiones: Los ejercicios de fortalecimiento parecen mejorar tanto la fuerza como las habilidades motoras, pero sólo existe una fuerte evidencia en la mejora de la fuerza de grupos musculares aislados. Son necesarias más investigaciones con una mayor calidad metodológica para evidenciar de manera más contundente los efectos de los ejercicios de fortalecimiento sobre las dos variables analizadas

Objectives: To identify the effects of muscular strengthening exercises on motor skills and strength of lower limbs in children and adolescents with cerebral palsy, as well as, to discover the main characteristics of these exercises, and of the subjects, to identify the measurement instruments used, and to know if the changes in the variables are maintained over time. Search strategy: The search was carried out in the PubMed, BVS, Cochrane Library, PEDro, WoS, Science Direct and EBSCO, databases between November 2017 and January 2018, as well as in specialised journals. Selection of studies: After the initial process of identifying the studies, 10 of them were finally selected that met the selection criteria. Synthesis of results: Two studies entirely presented a low risk of bias. Six studied showed significant results in motor skills, specifically two on the ability to walk and four studies on mobility. Significant differences were also found in the static and dynamic strength, in two and four studies, respectively. Two studies did not achieve significant results in the only variable analysed, and finally, in three studies the results are maintained over time. Conclusions: Strengthening exercises seem to improve both strength and motor skills, but there is only strong evidence in the improvement of the strength of isolated muscle groups. More research with a higher methodological quality is needed to demonstrate more forcefully the effects of the strengthening exercises on the two variables analysed

Leiomyosarcoma of the breast in a 48-year old male

@#<p style="text-align: justify;">This is a case of a 48-year old male with left-sided 9.0cm x 8.0cm exophytic, foul-smelling, bleeding breast mass. Core needle biopsy revealed a malignant phylloides tumor. He underwent total mastectomy and final histopathology showed a primary breast leiomyosarcoma staining positive for smooth muscle actin. A review of cases of primary breast leiomyosarcoma was done and to date, there are only 70 documented. The treatment of breast sarcomas still follows those strategies for soft tissue sarcomas in other locations. An important prognosticating factor is complete resection on initial treatment. Lymph node metastasis is rare for sarcomas in general.</p><p style="text-align: justify;"> </p>

Is gastrointestinal microbiota relevant for endogenous mercury methylation in terrestrial animals?

The active role of gastrointestinal microbiota in mercury (Hg) methylation has been investigated in different terrestrial organisms from insects or annelids to rats and mammals, including the human beings. Some findings reveal the animal digestive tracts as new potential niches for Hg methylation especially in terrestrial invertebrates. However, contradictory results have been reported so far and there is still a long way to fully understand how important the MeHg production in this habitat could be, as well as its implications on the toxicity and biomagnification of MeHg within terrestrial food chains. It is important to know what has been studied in the past and discuss the previous results according to the new perspectives opened in this field. Therefore, the aim of this work is to review the present state of knowledge about the potential capability of gastrointestinal microbiota in Hg methylation with special emphasis in terrestrial animals and to propose new approaches profiting the new and powerful molecular and analytical tools.

An In Vitro Evaluation of Biochemical Processes Involved in Lead-Induced Changes on Ram Spermatozoa.

Lead (Pb(2+) ) is a toxic heavy metal which interferes with several physiological processes regulated by Ca(2+) , including those characterized by changes of the membrane stability and the motility of spermatozoa necessary for the fertilization of the oocyte. In this study, ejaculated sperm from six rams (Ovis aries) have been incubated in vitro with or without 50 ng Pb(2+) /ml during 30 min and in the presence or absence of three different potential modulators of the effects of Pb(2+) on changes in the sperm membrane before fertilization: charybdotoxin, quinacrine and staurosporine. Sperm samples incubated with Pb(2+) have shown significant reductions in acrosome integrity and sperm viability and an increase in progressive movement. None of the studied potential modulators had a protective effect against Pb(2+) action. On the contrary, Pb(2+) -incubated sperm in the presence of staurosporine had lower acrosome integrity, and lower sperm viability was observed when spermatozoa were incubated with Pb(2+) + charybdotoxin. Quinacrine was the only tested substance capable of increasing the concentration of Pb(2+) in spermatozoa; thus, the enhancement of Pb(2+) effects produced by staurosporine and charybdotoxin was not produced by an increased uptake of Pb(2+) by spermatozoa. However, the increase of intracellular Pb(2+) in those spermatozoa incubated with quinacrine did not result in an adverse effect on sperm motility or viability although the acrosome integrity was negatively affected.

Mercury and selenium binding biomolecules in terrestrial mammals (Cervus elaphus and Sus scrofa) from a mercury exposed area.

Mercury (Hg) is likely bound to large biomolecules (e.g. proteins) in living organisms, and in order to assess Hg metabolic pathways and possible toxicological effects, it is essential to study these Hg containing biomolecules. However, the exact nature of most metal binding biomolecules is unknown. Such studies are still in their infancy and information on this topic is scarce because the analysis is challenging, mainly due to their lability upon digestion or extraction from the tissue. New analytical methods that allow complex Hg-biomolecules to be analysed intact are needed and only few very recent studies deal with this approach. Therefore, as an initial step towards the characterization of Hg containing biomolecules, an analytical procedure has been optimised using size-exclusion chromatography (SEC) with inductively coupled plasma mass spectrometry (ICP-MS) detection. We applied this technique to elucidate the distribution and elution profile of Hg and Se, and some physiological important elements such as Fe, Ni, Zn and Cu, to assess metal binding profiles in liver and kidney samples of red deer (Cervus elaphus) and wild boar (Sus scrofa) who roam freely within the largest Hg mining district on Earth, Almadén in Spain. Elemental fractionation profiles of the extracts from different tissues were obtained using two different SEC columns (BioSep-SEC-S2000 GL 300-1kDa and Superdex 75 10/300 GL 70-3kDa). Similar profiles of Hg were observed in red deer and wild boar; however, significant differences were evident for liver and kidney. Moreover, the profiles of Se showed a single peak at high-medium molecular weight in all investigated tissues, while co-elution of Hg with Fe, Ni, Zn and Cu was observed.

Tracking pan-continental trends in environmental contamination using sentinel raptors-what types of samples should we use?

Biomonitoring using birds of prey as sentinel species has been mooted as a way to evaluate the success of European Union directives that are designed to protect people and the environment across Europe from industrial contaminants and pesticides. No such pan-European evaluation currently exists. Coordination of such large scale monitoring would require harmonisation across multiple countries of the types of samples collected and analysed-matrices vary in the ease with which they can be collected and the information they provide. We report the first ever pan-European assessment of which raptor samples are collected across Europe and review their suitability for biomonitoring. Currently, some 182 monitoring programmes across 33 European countries collect a variety of raptor samples, and we discuss the relative merits of each for monitoring current priority and emerging compounds. Of the matrices collected, blood and liver are used most extensively for quantifying trends in recent and longer-term contaminant exposure, respectively. These matrices are potentially the most effective for pan-European biomonitoring but are not so widely and frequently collected as others. We found that failed eggs and feathers are the most widely collected samples. Because of this ubiquity, they may provide the best opportunities for widescale biomonitoring, although neither is suitable for all compounds. We advocate piloting pan-European monitoring of selected priority compounds using these matrices and developing read-across approaches to accommodate any effects that trophic pathway and species differences in accumulation may have on our ability to track environmental trends in contaminants.

Differences in the Vulnerability of Waterbird Species to Botulism Outbreaks in Mediterranean Wetlands: an Assessment of Ecological and Physiological Factors.

UNLABELLED: Avian botulism kills thousands of waterbirds every year, including endangered species, but information about the differences between species in vulnerability to botulism outbreaks and the capacity to act as carriers of Clostridium botulinum is still poorly known. Here, we estimated the vulnerability to botulism of 11 waterbird species from Mediterranean wetlands by comparing the number of affected birds with the census of individuals at risk. The capacity of different species to act as carriers was studied by detecting the presence of the C. botulinum type C/D botulinum neurotoxin (BoNT) gene in fecal samples and prey items of waterbirds in the wild and by the serial sampling of cloacal swabs of birds affected by botulism. We found differences among species in their vulnerabilities to botulism, probably related to feeding habits, season of arrival, turnover, and, possibly, phylogenetic resilience. The globally endangered white-headed duck (Oxyura leucocephala) showed mortality rates in the studied outbreaks of 7% and 17% of the maximum census, which highlights botulism as a risk factor for the conservation of the species. Invasive water snails, such as Physa acuta, may be important drivers in botulism epidemiology, because 30% of samples tested positive for the BoNT gene during outbreaks. Finally, our results show that birds may excrete the pathogen for up to 7 days, and some individuals can do it for longer periods. Rails and ducks excreted C. botulinum more often and for longer times than gulls, which could be related to their digestive physiology (i.e., cecum development). IMPORTANCE: Botulism is an important cause of mortality in waterbirds, including some endangered species. The global climate change may have consequences in the ecology of wetlands that favor the occurrence of botulism outbreaks. Here, we offer some information to understand the ecology of this disease that can be useful to cope with these global changes in the future. We have found that some species (i.e., coots and dabbling ducks) are more vulnerable to botulism and have a more relevant role in the onset and amplification of the outbreaks than other species (i.e., flamingos and grebes). Feeding habits can explain these differences in part; in addition to the well-known role of necrophagous fly maggots, we found here that water snails are frequent carriers of Clostridium botulinum This is relevant, because these water snails can thrive in eutrophic and polluted wetlands, exacerbating other changes driven by climate change in wetlands.

Mercury species accumulation and trophic transfer in biological systems using the Almadén mining district (Ciudad Real, Spain) as a case of study.

The impact of mercury (Hg) pollution in the terrestrial environments and the terrestrial food chains including the impact on human food consumption is still greatly under-investigated. In particular, studies including Hg speciation and detoxification strategies in terrestrial animals are almost non-existing, but these are key information with important implications for human beings. Therefore, in this work, we report on Hg species (inorganic mercury, iHg, and monomethylmercury, MeHg) distribution among terrestrial animal tissues obtained from a real-world Hg exposure scenario (Almadén mining district, Spain). Thus, we studied Hg species (iHg and MeHg) and total selenium (Se) content in liver and kidney of red deer (Cervus elaphus; n = 41) and wild boar (Sus scrofa; n = 16). Similar mercury species distribution was found for both red deer and wild boar. Major differences were found between tissues; thus, in kidney, iHg was clearly the predominant species (more than 81%), while in liver, the species distribution was less homogeneous with a percentage of MeHg up to 46% in some cases. Therefore, Hg accumulation and MeHg transfer were evident in terrestrial ecosystems. The interaction between total Se and Hg species has been evaluated by tissue and by animal species. Similar relationships were found in kidney for both Hg species in red deer and wild boar. However, in liver, there were differences between animals. The possible underlying mechanisms are discussed.

Relationship Between Hyperglycemia and Heart Transplant Rejection.

PURPOSE: Hyperglycemia increases risks of kidney and liver transplant rejection. To determine whether perioperative and subsequent glycemic control was associated with increased risk of heart transplant rejection over the year after transplantation, we performed a retrospective analysis of glycemic control and rejection rates in heart transplantation patients. METHODS: Perioperative glucose levels were analyzed in 157 patients undergoing transplantation at Northwestern Memorial Hospital from June 2005 to December 2012 and compared in patients with and without rejection found on routine follow-up biopsy specimens. RESULTS: Grade ≤1R rejection on biopsy was observed in 116 patients and grade ≥2R rejection (grade requiring increased anti-rejection treatment) in 41 patients. Although no significant differences in the preoperative fasting or inpatient mean glucose levels were found, the mean glucose levels from discharge to 1 year trended higher in those with grade ≥2R compared to grade ≤1R (128.8 ± 40.9 versus 142.2 ± 46.6 mg/dL, P = .084). In a multivariable logistic regression model, neither the lowest nor highest quartile of glucose levels had significantly different odds ratios (ORs) for the development of ≥2R compared to the middle 50% glucose levels. Older age (OR 0.96, P = .020) and higher body mass index levels (OR 0.86, P = .004) were significantly associated with lower odds of developing grade ≥2R. CONCLUSIONS: Although the glucose trend regarding rejection was not statistically significant, we cannot exclude the possibility that much higher glucose levels would influence rejection rates.

Respuesta de los autores: «Estudio epidemiológico del dolor en los hospitales públicos andaluces» / Reply to authors: «Epidemiological study about pain in Andalusian public hospitals»

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Estudio epidemiológico del dolor en los hospitales públicos andaluces / Prevalence of pain in Andalusian public hospitals

Objetivo. Conocer la prevalencia del dolor en pacientes médicos y quirúrgicos ingresados en los hospitales de referencia andaluces, así como sus características y los segmentos poblacionales más afectados. Material y método. Estudio epidemiológico multicéntrico transversal realizado simultáneamente sobre la población ingresada de 5 centros hospitalarios. Mediante cuestionario estructurado se investigaron datos demográficos, área de hospitalización, presencia de dolor en el momento de la entrevista y en las 24 h previas, y variables relacionadas con la intensidad del dolor y su tratamiento. Se incluyeron pacientes con edad superior a 18 años, excluyendo pacientes con dificultad para la comprensión del cuestionario, pacientes psiquiátricos y obstétricas. La intensidad del dolor se valoró mediante escala verbal simple. Resultados. Se incluyeron 1.236 pacientes, el 54,2% eran hombres, el 51,1% eran pacientes con edad superior a 65 años y el 69,17% estaban ingresados en áreas médicas. Se objetivó dolor en el 52,9% de los pacientes ingresados en el área quirúrgica frente al 29,4% del área médica. El 19,4% manifestó haber tenido dolor en las últimas 24 h previas a la encuesta (el 57,7% de los pacientes quirúrgicos y el 32% de los médicos; p < 0,005), y el 42,2% en el momento del estudio, siendo este más frecuente en mujeres (52,7%). La incidencia de dolor en movimiento fue superior a la observada en reposo. El valor medio del dolor en reposo fue de 1,8 y 1,4 para los pacientes quirúrgicos y médicos respectivamente (p < 0,01). El valor medio del dolor al movimiento fue de 2,2 y 1,6 para los pacientes quirúrgicos y médicos respectivamente (p < 0,01). El 25,8% de los pacientes quirúrgicos y el 16,5% de los médicos tuvieron dificultad para conciliar el sueño (p < 0,005). El 12,8% de todos los pacientes no tenían pauta analgésica. El 66,2% y el 85,6% de los pacientes quirúrgicos y médicos respectivamente no solicitaron analgésicos (p < 0,005). Los principales medicamentos prescritos fueron los analgésicos metamizol y paracetamol en el 54,4% de los pacientes. Conclusiones. Consideramos que la presencia de dolor en los pacientes ingresados en nuestra población de estudio es alta y que es esencial impulsar las actuaciones necesarias para mejorar el tratamiento del dolor tanto agudo como crónico (AU)

Objective. To determine the prevalence of pain in medical and surgical patients admitted to reference hospitals in Andalusia, as well as their features and the most population groups most affected. Material and methods. A cross-sectional, multicenter epidemiological study was conducted simultaneously on the population admitted to 5 hospitals. Using a structured questionnaire the demographics, hospital area, presence of pain at the time of the interview, and pre- and post-variables related to the intensity of pain and its treatment at 24 h were investigated. All patients over 18 years old were included, except those patients with difficulty in understanding the questionnaire, and psychiatric and obstetric patients. Pain intensity was assessed by simple verbal scale. Results. Of the 1,236 patients included, 54.2% were male, with 51.1% of patients aged 65 years, and 69.17% were admitted to medical areas. Pain was observed in 52.9% of patients admitted to the surgical area compared to 29.4% in the medical area. Of the 19.4% who reported having had pain in the last 24 h prior to the questionnaire, 57.7% of them were surgical patients and 32% were medical, P < .005), and of the 42.2% who had pain at the time of study, 52.7% were female. The incidence of pain on movement was higher than that observed at rest. The mean resting pain was 1.8 and 1.4 for the surgical and medical patients, respectively (P < .01). The mean pain on movement was 2.2 and 1.6 for the surgical and medical patients, respectively (P < .01). More than one quarter (25.8%) of surgical patients and 16.5% of medical patients had difficulty sleeping (P < .005). Some 12.8% of all patients had no analgesic regimen, and 66.2% and 85.6% of surgical and medical patients, respectively, did not request analgesics (P < .005). The main drugs were prescribed paracetamol analgesic and metamizole, and in 54.4% of patients. Conclusions. We believe that the presence of pain in patients admitted to our study population is high and it is essential to encourage an improvement in the pain management of both acute and chronic pain processes (AU)

[Prevalence of pain in Andalusian public hospitals]. / Estudio epidemiológico del dolor en los hospitales públicos andaluces.

OBJECTIVE: To determine the prevalence of pain in medical and surgical patients admitted to reference hospitals in Andalusia, as well as their features and the most population groups most affected. MATERIAL AND METHODS: A cross-sectional, multicenter epidemiological study was conducted simultaneously on the population admitted to 5 hospitals. Using a structured questionnaire the demographics, hospital area, presence of pain at the time of the interview, and pre- and post-variables related to the intensity of pain and its treatment at 24h were investigated. All patients over 18 years old were included, except those patients with difficulty in understanding the questionnaire, and psychiatric and obstetric patients. Pain intensity was assessed by simple verbal scale. RESULTS: Of the 1,236 patients included, 54.2% were male, with 51.1% of patients aged 65 years, and 69.17% were admitted to medical areas. Pain was observed in 52.9% of patients admitted to the surgical area compared to 29.4% in the medical area. Of the 19.4% who reported having had pain in the last 24h prior to the questionnaire, 57.7% of them were surgical patients and 32% were medical, P<.005), and of the 42.2% who had pain at the time of study, 52.7% were female. The incidence of pain on movement was higher than that observed at rest. The mean resting pain was 1.8 and 1.4 for the surgical and medical patients, respectively (P<.01). The mean pain on movement was 2.2 and 1.6 for the surgical and medical patients, respectively (P<.01). More than one quarter (25.8%) of surgical patients and 16.5% of medical patients had difficulty sleeping (P<.005). Some 12.8% of all patients had no analgesic regimen, and 66.2% and 85.6% of surgical and medical patients, respectively, did not request analgesics (P<.005). The main drugs were prescribed paracetamol analgesic and metamizole, and in 54.4% of patients. CONCLUSIONS: We believe that the presence of pain in patients admitted to our study population is high and it is essential to encourage an improvement in the pain management of both acute and chronic pain processes.