Management Prescriptions Research Articles

Practice Pointer: "My feelings are not on mute - ZOOM and Balint Practice Pointers".

Practice Pointer: "My feelings are not on mute - ZOOM and Balint Practice Pointers".

Assessment of the Health of Community Forests Based on Rubber (Hevea brasiliensis) in Tulang Bawang Regency

The knowledge and awareness of community forest managers about the importance of forest health are still relatively low, especially in community forests based on rubber (Hevea brasiliensis) plantations. Whereas through forest health measurement, reliable data and information will be obtained that can be used to ensure the quantity and quality of community forests as a form of management decisions for community forest managers. This study aimed to determine the health status of rubber plantation-based community forests in Ujung Gunung Village, Menggala District, Tulang Bawang Regency. The stages of implementing this research include: determining the number of clusters based on management prescriptions (planting year and spacing), making cluster plots based on the design of Forest Health Monitoring (FHM) clusters, collecting data by measuring forest health indicators (productivity, vitality and site quality) based on the FHM technique, data processing and analysis were carried out by calculating forest health values. The results showed that the health status of rubber community forests had a range of values from 3.97 to 7.03. The average value of forest health based on rubber plants in Ujung Gunung Village, Menggala District, Tulang Bawang Regency is 5.59, which is included in the medium value range. Thus, the value of community forest health status is moderate.

RF16 | PSUN204 Improving Inpatient Insulin Management amongst Internal Medicine Residents with a Multi-Media Structured Educational Program

Abstract Introduction Approximately 1 in 4 patients admitted to the hospital carry a diagnosis of diabetes mellitus1 and 1 in 10 patients are admitted due to diabetes complications.2 Although Internal Medicine residents comprise the primary care team for the vast majority of patients admitted to major academic hospitals, there is a paucity of resources and standardized training for inpatient diabetes management, specifically designed for residents. Methods We developed a structured resident education program consisting of a mobile/web application ("EndoApp") as an accessible resource combined with a series of short lectures. The EndoApp is comprised of checklists, guidelines, and calculators based on the most recent American Diabetes Association (ADA) and American Association of Family Physicians (AAFP) recommendations. The application addresses five major areas of inpatient insulin management—i) insulin pharmacokinetics, ii) admission dosage calculation, iii) inpatient insulin regimen adjustment, iv) management of diabetic emergencies, and v) equipment and prescription management at discharge. The confidence level of residents for each of the five areas were surveyed at months 0, 1, and 3, after the start of the program on a scale of 1-5. Results Our 3-month interim analysis showed that the confidence of residents in all five areas of inpatient insulin management improved over the study period. Increased confidence was seen in post-graduate year (PGY) 1, 2, and 3 residents. The Admission Insulin Dosing Calculator was the most frequently used function (45% of residents), followed by DKA/HHS helper (23% of residents), and Inpatient Dosage Adjustment Guidelines (21% of residents). Residents who used the Admission Insulin Dosing Calculator had greater increase in provider confidence compared to those who did not use the function. Subjective feedback from residents included expanding functions to include hypoglycemia and non-emergent hyperglycemia management, as well as having recordings of supplementary lectures available on the application. Conclusion Structured resident education in inpatient insulin management utilizing a mobile/web application and lectures as supplementary material is a promising approach to improve resident education and confidence in inpatient diabetes management.

Deciphering the potential role of Maca compounds prescription influencing gut microbiota in the management of exercise-induced fatigue by integrative genomic analysis.

A growing number of nutraceuticals and cosmeceuticals have been utilized for millennia as anti-fatigue supplements in folk medicine. However, the anti-fatigue mechanism underlying is still far from being clearly explained. The aim of the study is to explore the underlying mechanism of the Maca compound preparation (MCP), a prescription for management of exercise-induced fatigue. In this study, mice weight-loaded swimming test was used to evaluate the anti-fatigue effect of MCP. MCP significantly improved the forelimb grip strength and Rota-rod test in behavioral tests via regulating energy metabolism. 16S rDNA sequencing results showed MCP can regulate the intestinal flora at the genus level by increasing several beneficial bacteria (i.e., Lactobacillus, Akkermansia and etc.), and decreasing the harmful bacteria (i.e., Candidatus_Planktophila and Candidatus_Arthromitus), where notable high relevance was observed between the fatigue-related biomarkers and fecal microbiota. The results of microbial function analysis suggested that MCP might improve exercise-induced fatigue by enhancing energy metabolism, carbohydrate and lipid metabolism and metabolism of terpenoids and polyketides and breakdown of amino acid metabolism. In addition, and H2O2-induced oxidative stress model on C2C12 cells was employed to further validate the regulation of MCP on energy metabolisms. MCP pre-treatment significantly reduced intracellular ROS accumulation, and increased glycogen content, ATP generation capacity and mitochondrial membrane potential of skeletal muscle cells, as well as conferred anti-cell necrosis ability. In conclusion, MCP plays a key role in regulating fatigue occurrence in exercising and gut microbiota balance, which may be of particular importance in the case of manual workers or sub-healthy populations.

Chinese herbal prescriptions for COVID-19 management: Special reference to Taiwan Chingguan Yihau (NRICM101).

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a strain of coronavirus that causes COVID-19 (coronavirus disease 2019), the respiratory illness responsible for the ongoing COVID-19 pandemic. As at June 2022, increasing numbers of newly diagnosed COVID-19-associated pneumonia cases worldwide have attracted close attention from the international community. The present review analyzes and summarizes the treatment of COVID-19 with traditional Chinese medicine (TCM). A systematic analysis of the efficacies and benefits of TCM for the treatment of COVID-19 was performed, and the mechanisms underlying such treatment are summarized. This analysis of the literature highlights the potential of TCM to prevent and treat COVID-19 via antiviral, anti-inflammatory and immunomodulatory activities, with evidence showing that many TCM components act upon multiple targets and pathways. Famous TCM formulas include Qing-Fei-Pai-Du-Tang (QFPDT), Lianhuaqingwen Capsule (LHC), Taiwan Chingguan Yihau (NRICM101), and Jing Si herbal drink (JSHD). In particular, the botanical preparation NRICM101 was developed in 2020 for use in viral respiratory tract infections and is recommended for treating non-severe and mild COVID-19 infections. NRICM101 has been adopted for use in Taiwan for the clinical treatment of COVID-19. The common components and active ingredients of 10 TCM preparations have been analyzed for the most promising substances. This review aims to provide reliable evidence demonstrating the therapeutic efficacy of TCM substances in support of their further development against novel coronavirus infectious diseases in Taiwan.

Influence of Ageism on Physical Activity Prescription for Prediabetes Management.

This study used a randomized online survey design to examine the potential influence of ageism on physical activity (PA) prescription for hypothetical patients with prediabetes of different chronological ages. Participants included 356 kinesiology students who were randomly assigned to one of four conditions. Each condition presented a clinical case study of a hypothetical patient with prediabetes referred to the participant as a qualified exercise professional for a PA intervention. Case studies were identical except for the reported patient's chronological age. Participants provided recommendations for PA support, frequency, duration, and intensity. Significant main effects were observed for PA duration, F(3, 352) = 8.62; p < .001, and intensity, F(3, 352) = 16.20; p < .001. The older patient was prescribed significantly lower PA duration and intensity compared to younger patients and no-age control. This study provides evidence for the presence and independent influence of ageism against older patients in PA prescription for prediabetes management.

Application Protocol of Standardized Neonatal Parenteral Nutrition Formulations

With the improvements in medical technology, more premature infants and infants with congenital intestinal malformations or other conditions who need parenteral nutrition (PN) support can survive. PN technology has become an important therapeutic strategy in neonatal intensive care units. Due to differences in the qualifications of medical staffs, hospital pharmacy management, hospital level, etc, the composition and preparation methods of PN prescription vary greatly in different regions and hospitals in China. In addition, delays in the starting time of PN, unreasonable formula of nutrition components, poor prescription review, large workload involved in the preparation of PN for nurses, and waste of drugs are prone to happen. In view of these issues, our hospital independently developed standardized formulas of neonatal PN solution, which has been approved in Australia as a patented invention. Herein, we reported the composition and application protocol of this standardized PN solution for newborns.

Geologic Soil Parent Material Influence on Forest Surface Soil Chemical Characteristics in the Inland Northwest, USA

Successful fertilization treatments targeted to improve stand productivity while reducing operational complexities and cost depend on a clear understanding of soil nutrient availability under varying environmental conditions. Soil nutrient data collected from 154 forest sites throughout the Inland Northwest, USA were analyzed to examine soil nutrient characteristics on different geologic soil parent materials and to rank soil fertility. Results show that soil parent material explains significant differences in soil nutrient availability. Soils developed from volcanic rocks have the highest cation exchange capacity (CEC) and are relatively high in phosphorus (P), potassium (K), calcium (Ca), magnesium (Mg), sulfur (S), boron (B), and copper (Cu), but generally poor in mineralizable nitrogen (MinN). Forest soils developed from plutonic rocks exhibit the lowest CEC and are low in MinN, K, Ca, Mg, S, and Cu, but higher in P. Some soils located on mixed glacially derived soils are low only in K, Ca, Mg, and Cu, but many mixed glacial soils are relatively rich in other nutrients, albeit the second lowest CEC. Soils developed from metasedimentary and sedimentary rocks are among those with lowest soil nutrient availability for P and B. Sulfur was found to have the highest concentrations in metasedimentary influenced soils and the least in sedimentary derived soils. Our results should be useful in designing site-specific fertilizer and nutrient management prescriptions for forest stands growing on soils developed from these major geologies within the Inland Northwest region of the United States.

Resolution of the III International menopause expert forum

The III International Menopause Expert Forum took place on November 24, 2021. The working group of the expert council included leading experts in endocrine gynaecology from Belarus, Armenia, Georgia, Kazakhstan, Kyrgyzstan, Uzbekistan, and Ukraine.To date, menopause hormone therapy (MHT) initiated during the “therapeutic window of opportunity” has proved to have a protective effect against various age-associated diseases. Despite this, the percentage of women using MHT remains low and, for example, in Ukraine and Kazakhstan, equals nearly 2%. However, only one in four of these women have been using MHT for more than a year. The main reasons for such low percentage of women using MHT are as follows:1. Low patient adherence to MHT (due to misunderstanding of the menopause factors, menopause symptoms, treatments, hormonophobia, poor communication with healthcare professionals etc.).2. Healthcare professional’s vigilance due to the possible risks associated with MHT (breast cancer, venous thromboembolism, cardiovascular diseases etc.).3. Healthcare professionals face difficulties during the MHT prescription or subsequent patient management (unplanned haemorrhages, concomitant pathologies in a woman, i.e. fibroids, varicose veins, arterial hypertension etc.). Aiming to improve medical care for menopausal women, experts attending the Forum focused on the latest data on the risks of breast cancer and venous thromboembolism, MHT effect on the risk of coronary heart disease and arterial hypertension, the potential of prescribing MHT to patients with uterine myoma and on increasing treatment adherence.

Farmers' acceptance of results-based agri-environmental schemes: A German perspective

Results-based agri-environmental schemes (AES) seek to overcome reluctance to adopt other forms of AES in the European Union. Instead of complying with inflexible land management prescriptions, farmers receive payments after certain contracted environmental results are verified. In addition to reducing the organizational and administrative burdens, this practice allows farmers to focus on which practices can achieve the desired environmental outcomes. Farmer uptake of results-based payments may be limited by risk-adverse behavior, such as fear of not meeting environmental targets and forfeiting the contracted payment. This study investigated participation in a hypothetical results-based AES among arable farmers in the German state of North Rhine-Westphalia and the number of hectares enrolled (participation intensity). Our hypothetical scheme sought to foster biodiversity in pollinator and bird species by supporting weed-species richness in intensive arable production. Our split-treatment research design investigated how social nudging influences acceptance and intensity. Approximately 60% of the 63 farmers in our convenience sample expressed a willingness to participate in our hypothetical scheme. Using a Heckman style selection model, we could not detect any effect of the social nudge tested on the likelihood of participation or its intensity. Cognitive factors correlated positively with the likelihood of participation, whereas social and dispositional factors correlated with participation intensity. Perceived lack of control was the main obstacle found to adoption. The findings suggest that policies can mitigate barriers to acceptance by reducing the bureaucratic burden and being transparent over expected costs and ecosystem benefits. This study was the first to investigate farmers' acceptance of a hypothetical results-based AES that targets the enrichment of biodiversity in arable farming and thus may serve as a stepping stone for follow-up studies.

Analysis and Prediction of Body Test Results Based on Improved Backpropagation Neural Network Algorithm

The mining and analysis of student achievement data is of great importance to teaching management. Using the relevant data of college students’ physical fitness test and sports performance as the object of research, a BP neural network model is developed to predict performance. Based on BP neural network, an algorithm for predicting students’ endurance performance is proposed, which is applied to the sunshine long-distance intelligent sports testing system at Hangzhou Dianzi University. The nonlinear relationship between students’ performance in sunshine running and endurance performance is determined, and students’ performance in sunshine running is used to predict their endurance performance the following year. Experimental results indicate that the accuracy of the model is above 85%. At the same time, the prediction results are combined with the Internet of things technology to produce a student sports prescription management system, which sets different sunshine running parameters for students with different predicted results and provides personalized sports prescriptions for students with different physical conditions, which has extensive and far-reaching application value.

Patient demographics and clinical characteristics influence opioid and nonopioid pain management prescriptions of primary care NPs, PAs, and MDs.

Patient demographics and clinical characteristics influence opioid and nonopioid pain management prescriptions of primary care NPs, PAs, and MDs.

Patient demographics and clinical characteristics influence opioid and nonopioid pain management prescriptions of primary care NPs, PAs, and physicians.

Evidence exists on racial and gender disparities in chronic pain management among veterans. Most literature has described physicians' disparate opioid prescribing patterns, although it is unknown if prescribing disparities exist among nurse practitioners (NPs) and physician assistants (PAs) or among prescription of nonopioid analgesic strategies. To identify patient characteristics associated with opioid and nonopioid prescriptions among Veterans Affairs (VA) chronic pain patients by primary care physicians, NPs, and PAs. We used data from the VA's Survey of Health care Experience of Patients and Corporate Data Warehouse from October 2015 to September 2016. Outcomes included opioid and nonopioid analgesic prescriptions. Patient characteristics included race/ethnicity, gender, education level, age, and clinical characteristics (comorbidities, self-reported health, and self-reported mental health). Logistic regression was performed to test for associations of patient characteristics with outcomes. Patients who were White, male, age 41-64 years, and with no postsecondary education had higher odds of receiving an opioid prescription (all p -values ≤ .01), whereas patients who were Black, female, and <65 years old had higher odds of a nonopioid prescription (all p -values < .01). Having 5+ comorbidities and fair/poor self-reported health increased the odds of opioid and nonopioid prescriptions (all p -values < .01). Disparities in race, gender, and educational level significantly affect how primary care NPs, PAs, and physicians manage chronic pain. NPs and other primary care providers should pursue training opportunities to identify and mitigate potential biases that may affect their practice. Future research should take an intersectional lens in examining the source of chronic pain disparities.

Likelihood of Failure of Trees Along Electrical Utility Rights-of-Way: A Literature Review

Utility vegetation managers need tools to predict tree-related risks and knowledge of the necessary management prescriptions to reduce the risk of windthrow damage to utilities’ electrical infrastructure. This review focuses on key studies involving the likelihood of failure of trees, beginning with a description and discussion of failure in trees, followed by an examination of methodologies that have been used to assess tree failure, before concluding with a review of factors which have been found to influence tree failure. Ultimately, a better understanding of the likelihood of failure of individual trees and the relationships governing tree failure and vegetation-related outages may allow for significant advances in the risk management of utility infrastructure.

Resprouting in European beech confers resilience to high-frequency fire

AbstractEuropean beech (Fagus sylvatica L.) can regenerate successfully from seeds after mixed-severity fires with mid-to-long fire return intervals (&amp;gt;60 years). However, if fire return interval is lower than the age of sexual maturity, post-fire seeding will be limited, leaving vegetative resprouting as the only viable option for recovery. This means that the forecasted increase in fire frequency driven by climate change may erode beech forest resilience to fire. Here, we surveyed tree regeneration in a European beech forest affected by two consecutive fires, in 2003 and 2017, and applied experimental clipping of tree saplings to address the following questions: (1) What is the fire resistance and post-fire recovery via resprouting of tree saplings? (2) Which factors drive post-fire resprouting of beech saplings? (3) Does post-fire clipping of tree saplings increase the probability of survival and resprouting vigor? We monitored 2195 beech saplings and 953 saplings of other tree species during three consecutive years, from 2018 to 2020. Almost all beech saplings were top-killed by fire, and two-thirds of them died completely. However, 3 years after the second fire, 30 per cent of beech saplings survived by resprouting from the base. Post-fire resprouting was less likely in small-diameter saplings and in those more injured by fire. Overall, the second fire did not cause a major decline of beech regeneration and consequently did not alter the dominant species composition of post-fire recovery. Given the low specific resistance to fire, post-fire resprouting of saplings is therefore a key component of beech resilience to short-interval fires. The effects of clipping on post-fire survival and resprouting vigor were very limited, suggesting the unsuitability of actively clearing burned beech regeneration as a post-fire management prescription. In conclusion, basal resprouting from beech saplings after fire-induced top-kill led to a higher-than-expected resilience of beech to short-interval fires (i.e. circa 15 years).

A nonrandomized controlled trial of individualized exercise prescription combined with remote exercise management in patients who are overweight or obese

BackgroundBetween 2012 and 2020, the obesity rate increased among Chinese people aged 18 years and above, along with blood pressure, fasting blood glucose, serum total cholesterol, and triglycerides.PurposeOur objective was to compare the effects of a combined intervention, including individualized exercise prescription plus remote management versus individualized exercise prescription only, on cardiovascular risk factors in patients who are overweight or obese, with the aim of establishing a more effective remote model of health management than self-management.MethodsThis nonrandomized controlled trial (ChiCTR2100046307) studied patients who are overweight or obese at model labor health management centers from January 2019 to December 2019, including 55 people in the experimental group and 34 in the control group. The relevant indexes of all the research objects from both experimental group and control group were examined. Participants in the experimental group were given individualized exercise prescription combined with remote exercise management over a period of 3 months. The control group was prescribed exercise only at time of enrollment and taught about exercise once, followed by voluntary exercise and self-management for 3 months.ResultAfter adjusting for baseline differences, the changes in weight (−2.72 ± 4.03 kg versus 0.32 ± 2.50 kg, P < 0.0001), body mass index (−0.99 ± 1.44 kg/m2 versus 0.11 ± 0.92 kg/m2, P < 0.0001), waist circumference (−2.98 ± 6.29 cm versus 0.60 ± 5.33 cm, P < 0.0001), visceral fat area (−9.75 ± 19.68 cm2 versus −1.31 ± 12.37 cm2, P = 0.028), body fat (− 2.65 ± 3.52 kg versus 0.54 ± 2.67 kg, P < 0.0001), body fat rate (−2.50 ± 3.32% versus 0.21 ± 3.30%, P < 0.0001), uric acid (−9.75 ± 19.68 µmol/L versus −1.31 ± 12.37 µmol/L, P = 0.028), serum total cholesterol (−0.11 ± 0.40 mmol/L versus −0.11 ± 0.59 mmol/L, P = 0.004), fasting insulin (− 2.36 ± 5.20 μU/mL versus 1.22 ± 7.34 μU/mL, P = 0.009), and homeostatic model assessment of insulin resistance (−0.62 ± 1.25 versus 0.14 ± 1.83, P = 0.022) were significantly better in the experimental group than in the control group after intervention.ConclusionIndividualized exercise prescription combined with remote management in patients who are obese or overweight facilitated weight and fat loss, lowered blood pressure and serum total cholesterol, improved glucose metabolism and insulin resistance, and reduced cardiovascular risk factors. The intervention was superior to conventional education in terms of weight loss, fat reduction, total cholesterol reduction, fasting insulin reduction, and amelioration of insulin resistance.

703-P: Significant Weight Reduction and Improvement in Glycemic Control among People with T2D after Participation in Diabefly Digital Therapeutics Program

Background: Digital therapeutics platforms provide accessible and multidisciplinary care for the management of T2D. The current study explored the effectiveness of the Diabefly program for improving glycemic control in people with T2D. Methods: Diabefly program provides a combination of mobile application, remote lifestyle coaching, live video consultations by experts (psychologist, physiotherapist and nutritionist) , and digital logging of parameters. The outcome of the study was to evaluate the change in HbA1c, fasting blood sugar (FBS) , postprandial blood sugar (PPBS) , weight, and body mass index (BMI) at the beginning and end of the program. All the outcomes were evaluated using paired t-test with P&amp;lt;0.considered as significant. Results: A significant mean reduction in HbA1c levels by 1.69 ± 1.91% from a baseline of 8.66 ± 2.05% was observed (P&amp;lt;0.001) . Among all the participants, 93.02% (160/172) showed a reduction in their HbA1c, out of which 56.25% (90/160) showed a HbA1c reduction of more than 1%. Similarly, weight and BMI were also significantly reduced by 2.59 ± 3.31 kg and 0.92 ± 1.15 kg/m2 from a baseline of 75.94 ± 16.24 kg and 27.49 ± 4.71 kg/m2 respectively (P&amp;lt;0.0for both) . Among all the participants, 70.34% (121/172) reduced their weight, out of which 32.23% (39/121) showed a weight reduction of at least 5 kg. Among participants (n=42) with complete FBS and PPBS data, a significant mean reduction by 51.44 ± 58.87 mg/dL and 90.90 ± 78.96 mg/dL from a baseline of 164.87 ± 63.83 mg/dL and 227.95 ± 82.34 mg/dL was observed respectively (P&amp;lt;0.0for both) . Conclusion: Effective glycemic control and significant weight reduction was achieved at the end of the program. Thus, Diabefly program can help in providing continuous support to implement lifestyle changes between quarterly doctor visits and greater usage of a remote lifestyle coaching can be a useful adjunct to doctor’s prescription for holistic management of diabetes. Disclosure R. Verma: Employee; Fitterfly Healthtech Pvt Ltd, Wellthy Therapeutics Pvt Ltd. M.A. Khader: Employee; Fitterfly HealthTech Pvt Ltd. T. Lathia: Advisory Panel; Abbott, AstraZeneca, Biocon, Boehringer Ingelheim International GmbH, Novartis Pharmaceuticals Corporation, Novo Nordisk, Sanofi. S. Guntur: Employee; Fitterfly Health Tech Pvt. Ltd. A.K. Singal: Other Relationship; Fitterfly Healthtech Pvt Ltd.

Balancing model generality and specificity in management-focused habitat selection models for Gunnison sage-grouse

Identifying, protecting, and restoring habitats for declining wildlife populations is foundational to conservation and recovery planning for any species at risk of decline. Resource selection analysis is a key tool to assess habitat and prescribe management actions. Yet, it can be challenging to map suitable resource conditions across a wide range of ecological contexts and use the resulting models to identify effective and universal habitat improvement actions. We developed a management-centric modeling approach that sought to balance the need to evaluate the consistency of key habitat conditions and improvement actions across multiple, distinct populations, while allowing context-specific environmental variables and spatial scales to nuance selection responses that form the basis of location-specific management prescriptions. To demonstrate this approach, we developed a set of habitat selection models for Gunnison sage-grouse ( Centrocercus minimus ), a threatened species under the U.S. Endangered Species Act. Conservation, species recovery, and habitat management efforts are needed in six isolated satellite populations (San Miguel, Crawford, Piñon Mesa, Dove Creek, Cerro Summit-Cimarron-Sims, and Poncha Pass) where environmental conditions differ, and the already small number of birds are declining. We used multi-scale and seasonal resource selection analyses to quantify relationships between environmental conditions and sites used by animals. All models included key habitat variables often altered through management actions to assess their differential influences across models. We found important similarities and differences among satellites, indicating that, although some rules of thumb are generally well-grounded, the consideration of population-specific environmental differences could increase the efficiency of local habitat improvement actions. Sage-grouse also had diverse responses to resource conditions at different scales, indicating that regional spatial (e.g., landscape) and local patch scale can differentially influence expected habitat improvements associated with where such management actions are implemented. Although context variables such as topography cannot be manipulated, sage-grouse associations revealed information that could guide the siting of improvement actions. This approach to balancing management objectives associated with habitat assessment may benefit spatially-structured populations with different environmental contexts and species with complex habitat needs and associations.

Does growth of nonperforming loan ratio have a temporal impact on private credit growth in Bangladesh economy?

PurposeThis paper addresses the question “Does the growth of nonperforming loan ratio (GNPL) have a temporal impact on private credit growth (PCG)?” for the Bangladesh banking industry during and after the global financial crisis of 2008.Design/methodology/approachIt employs the autoregressive distributed lag (ARDL) model to examine the temporal equilibrium relationship and causality between PCG and GNPL.FindingsThe results of ARDL bound tests confirm the existence of a single cointegrating vector and temporal equilibrium relationship between variables of interest. According to the error correction mechanism (ECM), there is unidirectional causality from GNPL to PCG in the long run and short run. In the long run, higher GNPL curtails PCG since bankers use the nonperforming loan ratio as a signal and indicator of credit risk in their loan decision-making. In the short run, GNPL positively impacts PCG. It may be because banks go through a rigorous process before declaring a loan as nonperforming that takes time. At the same time, bankers' loan decisions may also be guided by the banks myopic concern of reputation in the short run.Practical implicationsThe paper recommends policy prescriptions for the bank risk management, regulatory bodies and the legal authorities. The lending policy of banks should consider the legacy of bad assets. The efficiency of the legal system can also aid in effectively implementing the regulatory guidelines.Originality/valueThe paper inaugurates a bivariate cointegration analysis between PCG and GNPL in the literature. It has utilized quarterly aggregate data in the context of a developing economy like Bangladesh.

Comparison of the Analgesic Efficacy of Opioid-Sparing Multimodal Analgesia and Morphine-Based Patient-Controlled Analgesia in Minimally Invasive Surgery for Colorectal Cancer.

A multimodal analgesia (MMA) protocol has shown the effect of postoperative pain control and reduced the postoperative opioid consumption. However, it was questionable whether MMA could replace opioid-based patient-controlled analgesia (PCA) for postoperative pain control. Therefore, this study aimed to investigate whether an MMA protocol is non-inferior to opioid-based PCA for pain management after a minimally invasive colorectal cancer surgery. A randomized, open-label, non-inferiority clinical trial was conducted on patients undergoing laparoscopic or robotic resection of colorectal cancer. The patients were randomly assigned to either the PCA or MMA group. The MMA protocol included pregabalin, tramadol, wound infiltration, and transversus abdominis plane block. The primary outcome was the numeric rating scale (NRS) score for pain at rest 24h postoperatively. Ninety-seven patients were included in the intention-to-treat analysis. The mean difference in NRS score at rest at 24h was 0.25 (95% confidence interval, - 0.61 to 1.11). This result demonstrated the non-inferiority of MMA to PCA in our non-inferiority margin (- 1). Compared with the PCA group, the median remifentanil dose (996 vs. 654μg; p < 0.001) and time in the post-anesthesia care unit (35 vs. 25min; p < 0.001) were significantly less in the MMA group. Our MMA protocol successfully controlled postoperative pain and was non-inferior to morphine-based PCA based on patient-reported pain intensity, with no significant increase in adverse events. These results will help construct a strategy to reduce conventional opioid prescriptions for pain management after a minimally invasive colorectal cancer surgery. Trial Registration Number Trial Registration Clinical Research Information Service Identifier: KCT0002593.