Site-specific Practice Research Articles

Targeted interventions to address local challenges in HR+/HER2- and HER2+ breast cancer treatment in community-based settings.

e23213 Background: Advancements in novel targeted agents and antibody-drug conjugates (ADCs) have dramatically improved patient outcomes and survival for breast cancer patients, yet the successful utilization of these agents remains a key challenge for clinicians, particularly in the community. To improve the care of HR+/HER2- and HER2+ patients, a quality improvement (QI) initiative was conducted across 6 community-based oncology practices. Methods: Between 7/2023 and 10/2023, multidisciplinary oncology team members (N = 98) across 6 US-based community oncology practices were surveyed to identify gaps in the treatment and management of patients with HR+/HER2- and HER2+ breast cancer. Providers then participated in audit/feedback (AF) sessions where they (a) assessed site-specific practice gaps identified via the provider surveys; (b) received targeted education based on their specific gaps; and (c) developed action plans for improvement. Follow-up surveys administered 90 days after AF sessions will evaluate the impact of practice changes driven by the QI initiative. Results: Top challenges reported by providers in caring for patients with HR+/HER2- and HER2+ breast cancer were providing patient-centered supportive care measures (37%), individualizing treatment plans (18%), and managing treatment-related adverse events (14%). Reported challenges in treatment sequencing included rapidly evolving guideline recommendations (44%) and knowing which treatment to select when patients are eligible for multiple lines of therapy (34%). Additionally, oncology team members reported having the most difficulty managing treatment-related neurological effects (32%), neutropenia (16%), and GI toxicities (14%). Providers believed improved collaboration across interprofessional teams (28%) and increased patient education/referrals for supportive care (26%) would most improve care for breast cancer patients. To address the identified gaps at each location, teams participated in targeted AF sessions focused on addressing their specific gaps and developed action plans, such as developing new workflows for improving care coordination, implementing institutional protocols for identifying and managing adverse events, and improving patient supportive care, quality-of-life assessments, and distress screenings. Full findings from baseline surveys will be presented, along with follow-up surveys measuring real-world impact of the system-level practice changes. Conclusions: Through this QI initiative, teams identified gaps/barriers in their own practices, and developed and implemented action plans for improvement. These data and actionable insights support safe, effective, and evidence-based integration of novel therapies into HR+/HER2- and HER2+ breast cancer care to optimize patient outcomes.

Solo, collaborative or collective? Newly qualified teachers’ experiences of being stirred into induction practices

ABSTRACT This study investigated newly qualified primary and lower secondary school teachers with a master’s degree in Norway and how they experienced being stirred into induction practices in their school. The theory of practice architectures was the theoretical framework used in the analysis, and the term ‘stirred into’ refers to the dynamics of entering and becoming a practitioner of a specific practice. A thematic analysis of 42 interviews revealed three induction practices: 1) solo practices where the teachers plan and evaluate the teaching alone, 2) collaborative practices where the teachers plan and develop the teaching through collaboration with a few colleagues and 3) collective practices where the teachers can discuss their teaching with all their colleagues and engage in mutually beneficial and productive interactions. The study identifies how the schools’ site-specific practice architectures prefigures and shapes newly qualified teachers’ practices during the induction phase.

Retrospective Analysis of the Safety and Efficacy of Fecal Microbiota, Live-jslm (REBYOTATM) Administered Under Enforcement Discretion to Patients With Clostridioides difficile Infection.

Fecal microbiota, live-jslm (RBL; REBYOTA™), the first microbiota-based live biotherapeutic approved by the US Food and Drug Administration to prevent recurrent Clostridioides difficile infection (rCDI) in adults, has been evaluated in 5 prospective clinical trials. A retrospective analysis considered the safety and efficacy of RBL administered under US Food and Drug Administration enforcement discretion to patients with rCDI and broad eligibility criteria mimicking real-world practice. We retrospectively identified adults with rCDI treated with RBL under enforcement discretion between November 1, 2015, and September 30, 2019, across 5 study sites. CDI diagnosis was based on site-specific practice. The primary safety set (PSS) included all patients who were naïve to previous RBL treatment and had continuously comprehensive medical records for 6 months following treatment. The primary treatment cohort had 94 patients; the PSS included 64 patients with common comorbidities receiving diverse chronic therapeutics. Most treatment-emergent adverse events were mild to moderate in severity and comparable between comorbidity subgroups and the overall population. There were no serious adverse events related to RBL or the administration procedure. In the PSS, 82.8% of RBL-treated patients responded at 8 weeks, of whom 88.7% had sustained response through 6 months. The number of RBL doses administered had no marked effect on outcome. Together with prospective clinical trial outcomes, these findings support the efficacy and safety of RBL to prevent rCDI, with diagnostics and comorbidities representative of real-world clinical practice.

Practical issues in pragmatic trials: the implementation of the Diuretic Comparison Project.

The US Department of Veterans Affairs Point of Care Clinical Trial Program conducts studies that utilize informatics infrastructure to integrate clinical trial protocols into routine care delivery. The Diuretic Comparison Project compared hydrochlorothiazide to chlorthalidone in reduction of major cardiovascular events in subjects with hypertension. Here we describe the cultural, technical, regulatory, and logistical challenges and solutions that enabled successful implementation of this large pragmatic comparative effectiveness Point of Care clinical trial. Patients were recruited from 72 Veterans Affairs Healthcare Systems using centralized processes for subject identification, obtaining informed consent, data collection, safety monitoring, site communication, and endpoint identification with minimal perturbation of the local clinical care ecosystem. Patients continued to be managed exclusively by their clinical care providers without protocol specified study visits, treatment recommendations, or data collection extraneous to routine care. Centralized study processes were operationalized through the application layer of the electronic health record via a data coordinating center staffed by clinical nurses, data scientists, and statisticians without site-based research coordinators. Study data was collected from the Veterans Affairs electronic health record supplemented by Medicare and National Death Index data. The study exceeded its enrolled goal (13,523 subjects) and followed subjects for the 5-year study duration. The key determinant of program success was collaboration between researchers, regulators, clinicians, and administrative staff at the site level to customize study procedures to align with local clinical practice. This flexibility was enabled by designation of the study as minimal risk and determination that clinical care providers were not engaged in research by the Veterans Affairs Central Institutional Review Board. Cultural, regulatory, technical, and logistical problems were identified and solved through iterative collaboration between clinical and research entities. Paramount among these problems was customization of the Veterans Affairs electronic health record and data systems to accommodate study procedures. Leveraging clinical care for large-scale clinical trials is feasible but requires a rethinking of traditional clinical trial design (and regulation) to better meet requirements of clinical care ecosystems. Study designs must accommodate site-specific practice variation to reduce the impact on clinical care. A tradeoff thus exists between designing trial processes tailored to expedite local study implementation versus those to produce a more refined response to the research question. The availability of a uniform and flexible electronic health record in the Department of Veterans Affairs played a major role in the success of the trial. Conducting Point of Care research in other healthcare systems without such research-friendly infrastructure presents a more formidable challenge.

Placement Architectures in Practice: An Exploration of Student Learning during Non-Traditional Work-Integrated Learning in Rural Communities

Work-integrated learning (WIL) in rural communities provides students with important learning opportunities while also providing a service to those communities. To optimise the potential benefits of work-integrated learning for health students and rural communities it is important to explore the practices and outcomes of these experiences. This study used a qualitative research design underpinned by the theoretical framework of Theory of Practice Architectures to examine the way students learn during these placements. Purposive sampling was used to identify students for participation in the study. Seven students from the disciplines of paramedicine, physiotherapy, and speech pathology participated in semi-structured interviews. Data were analysed using inductive thematic analysis. The learning described by the students was examined, followed by a critical interrogation of the data to assess how these learnings and associated practices were made possible given the site-specific practice architectures. The findings of the research are represented by three themes: learning affordances related to placement design, learning through relationships between people and professions, and learning through rural embeddedness. Being embedded in rural communities gave the students access to several arrangements that fostered learning, particularly through the sayings, relatings and doings that the students engaged with. This research demonstrates the transformative potential of rural WIL opportunities for learning and future rural practice.

Assembly: Investigating the Role That Artist Fieldwork Can Play in Islamic Sites of Worship

This photo essay reflects upon the impact of Assembly, a series of site-specific installations comprising 1:1-scale moving film projections of congregational prayer, with surround sound. To date, the work has been made in three mosques in London: Brick Lane Mosque (2018–19), Old Kent Road Mosque (2019–2021) and Harrow Central Mosque (2020–2021). Assembly investigates the materiality of site via the projected image understood as a “performative” rather than a “representational” tool using the methodology “site-integrity,” a mode of site-specific practice that potentiates an exchange between site, artist, device, and the users or inhabitants of the site, its community. Made with and for each faith community, Assembly enables an ethical and sensitive exploration of the dynamics of users in these site-specific contexts.

Moving Toward Land-Based Sound Archiving and Composition: Reflecting on Field Research From the Project Sonic Coordinates: Decolonizing Through Land-Based Composition

This paper examines the intersection of environmental sound recording, sound collection, and archiving by drawing on Land-based approaches, Indigenous epistemologies, and methodologies. In particular, this paper considers some of the implications for immersive sound-based fieldwork informed by site-specific listening methods, embodied learning and forms of reflexivity that are rooted in Indigenous concepts of relationality (kinship). Specifically, this paper revolves around an initial field research trip from our project Sonic Coordinates: Decolonizing through Land-based music composition (supported by the New Frontiers Research Fund) which took place in the region of Timiskaming (Northern Ontario, Canada) during the fall of 2019. Consequently, our paper examines what was learned through this process, and how critical listening and recording/collection of environmental sounds can be used to inform Indigenous sound/music composition and aural forms of storying. This paper ultimately explores the ephemeral concepts of sound materiality and how aural archiving and documentation (through digitizing and digital platforms) is used to preserve and engage historical memory, cultural knowledge and shifts toward the development of sonic art and communication that is informed by site-specific research practice.

Cultivating Ongoingness Through Site-Specific Arts Research and Public Engagement

In this article, I consider the contributions of projects in Latin America to the need “to think in the presence of ongoing facts of destruction”, and to imagine and design forms of “ongoingness” amid socioenvironmental challenges and conflicts. I focus on HAWAPI, Ensayos and EnlaceArq, three initiatives that have consolidated a decade of site-specific, practice research that departs from the arts to devise methods that bridge the arts, sciences, and communities to confront socioenvironmental pressures and enduring injustices caused by colonial legacies and continued extractivism. How does site-specific practice research seed and cultivate inter- and transdisciplinary collaborations around pressing socioenvironmental concerns affecting Latin America? How do projects establish critical relationships regarding the circulation of knowledges related to these issues and engage with diverse types of publics? And, insofar as the projects reviewed here often operate on the fringes of academia, what strengths and challenges does this generate for their sustainability over time and their impact on scholarly research, public conversations and the lives of specific communities?

Ecology of site-specific painting and drawing: Embodied and empathic mark-making in urban cites

The idea of ecology has changed drastically during the last few decades. The trend in scholarship has changed from exclusively studying nature and natural objects, to include human’s relationship to it. In this context the present article aims to look at the ecological implication of site-specific practice: concentrating on contemporary drawing and paintings realized in the context of urban India. To this aim some aspects of site-specific mark-making would be analysed seeking support from philosopher Merleau-Ponty’s (, ) idea of phenomenological embodiment and the theory of ecological perception proposed by psychologist ). Works of contemporary drawing/painting practitioners from India, practitioners such as Gagan Singh, artist collectives such as Networks and Neighborhood, St+art, Geechugalu, along with author’s own practice will illustrate how site-specific pattern-making can be a way of interacting with the environment, establishing new connections between art-materials, the environment, the viewers and the makers. These analyses will bring insights into how art practice can contribute to new ways of conceptualizing urban ecology.

Early Neurologic Recovery, Practice Pattern Variation, and the Risk of Endotracheal Intubation Following Established Status Epilepticus.

To quantify the association between early neurologic recovery, practice pattern variation, and endotracheal intubation during established status epilepticus, we performed a secondary analysis within the cohort of patients enrolled in the Established Status Epilepticus Treatment Trial (ESETT). We evaluated factors associated with the endpoint of endotracheal intubation occurring within 120 minutes of ESETT study drug initiation. We defined a blocked, stepwise multivariate regression, examining 4 phases during status epilepticus management: (1) baseline characteristics, (2) acute treatment, (3) 20-minute neurologic recovery, and (4) 60-minute recovery, including seizure cessation and improving responsiveness. Of 478 patients, 117 (24.5%) were intubated within 120 minutes. Among high-enrolling sites, intubation rates ranged from 4% to 32% at pediatric sites and 19% to 39% at adult sites. Baseline characteristics, including seizure precipitant, benzodiazepine dosing, and admission vital signs, provided limited discrimination for predicting intubation (area under the curve [AUC] 0.63). However, treatment at sites with an intubation rate in the highest (vs lowest) quartile strongly predicted endotracheal intubation independently of other treatment variables (adjusted odds ratio [aOR] 8.12, 95% confidence interval [CI] 3.08-21.4, model AUC 0.70). Site-specific variation was the factor most strongly associated with endotracheal intubation after adjustment for 20-minute (aOR 23.4, 95% CI 6.99-78.3, model AUC 0.88) and 60-minute (aOR 14.7, 95% CI 3.20-67.5, model AUC 0.98) neurologic recovery. Endotracheal intubation after established status epilepticus is strongly associated with site-specific practice pattern variation, independently of baseline characteristics, and early neurologic recovery and should not alone serve as a clinical trial endpoint in established status epilepticus. ClinicalTrials.gov Identifier: NCT01960075.

Exploring opportunities & pathways for advanced practice radiation therapy roles in the United States.

The evolution of practice of Radiation Therapy in the United States (U.S.) is inevitable. The scope of a radiation therapists role has progressed with advancing technology, implementation of special procedures and patient care requirements. Internationally, Canada, Australia and the United Kingdom have formalized this evolution through the Advanced Practice Radiation Therapist (APRT) role to provide new models of care, to meet growing demands in the practice of Radiation Oncology, to increase efficiency, decrease cost and retain skilled staff (Harnett et al., 2018; Society of Radiographers; Linden et al., 2019; Coleman et al., 2014) [1], [2], [3], [4]. Through evidence based practice, the APRT role has proven to provide benefits for multiple stakeholders including service-reconfiguration to reduce wait times, developing and retaining highly skilled radiation therapists, treatment review and most importantly improving patient care within much needed patient cohorts such as the palliative population (Duffton et al., 2019) [5]. The U.S. is no exception to requiring innovative care models and solutions to similar complex, care delivery challenges experienced internationally. The U.S. is experiencing an increase in demand for cancer services and a rapid rate of technological and treatment advancements. Under the current infrastructure, this has impacted the daily tasks of physicians; increasing workload, increasing the complexity of clinical decision making, increasing movement toward site specific subspecialty practice and pushing the scope of radiation therapists informally toward maximization, increased autonomy and a higher level of education and specialized skills (American Society of Clinical Oncology, 2016; ARRT, 2020; Vu et al., 2018) [6], [7], [8]. Objective The following reviews the current radiation therapy practice and professional landscape in the United States as it relates to advanced practice, exploring opportunities and challenges under the U.S. health care infrastructure. This broad analysis provides comparison to other countries and disciplines such as the Radiologist Assistant and Nurse Practitioner for potential pathways to establishing the role and describes current needs and value of the expanding scope of RT's practicing in the U.S.

САЙТ-СПЕЦИФИЧЕСКАЯ АРТ-ПРАКТИКА КАК АЛЬТЕРНАТИВНЫЙ ФОРМАТ ТЕАТРАЛЬНОГО ИСКУССТВА

The author of the article attempts to identify and distinguish traditional and alternative formats of theatre art established by the early 20s in the space of home theatre. The author considers the determinants of the emergence and spread of art practices in the domestic theatre art and refers them to the alternative formats of theatre art. The culture of complicity (participation), producer strategies of postdramatism and digitalization of daily occurrence are presented as fundamental grounds for the emergence of such a non-classical creative model as a site-specific art practice in the landscape of Russian theatre art of the XXIst century. The unstable dynamics of the attractiveness of the non-classical creative model in the Russian theatre space is caused by a number of reasons explicitly presented in the article. The accumulated home theatre experience is developing and being realized by the early 20s in traditional and alternative formats of theatre art, which simultaneously influence each other. The actualization of site-specific art practice is evaluated by the author as a positive phenomenon that allows to update and to expand the arsenal of producer strategies, to discover an innovative approach to creating an aesthetic event, to transform the audience participation within the framework of home theatre art and the culture of participation.

Bring me a Souvenir: performing Herstory on Ayr beach

ABSTRACT This article employs Massey’s conceptualisation of gendered space to explore the ways in which the unrepresented narratives of women in heritage sites can be promoted through site-specific performance practice. It focuses on the development and creation of Souvenir, a site-specific play performed at Ayr beach in South Ayrshire, Scotland in 2017. The project involved the development of a public performance work inspired by stories shared by local women at reminiscence workshops. Implementing a practice-as-research (PaR) methodology, this performance was created to celebrate the narratives of ‘ordinary’ women so often unrepresented in heritage spaces. The aim of this study was to extrapolate principles of feminist performance practice that can be used to respond to the lack of women’s stories, termed ‘Herstory’, in such sites. This article delineates the development process of Souvenir, noting the particular frameworks and methods employed to foreground Herstory. The performance process drew upon Smith’s mythogeography and Berger’s hydrological dramaturgy in order to explore how creative practice could highlight the feminist possibilities of the space. The combination of practice and theory serves to interrogate the performance methods used in representing marginalised narratives of women, while simultaneously exploring how personal conceptualisations of space can be altered through such work.

Expanding the Interdisciplinary Palliative Medicine Workforce: A Longitudinal Education and Mentoring Program for Practicing Clinicians

ContextThe disparity between gaps in workforce and availability of palliative care (PC) services is an increasing issue in health care. To meet the demand, team-based PC requires additional educational training for all clinicians caring for persons with serious illness. ObjectivesTo describe the educational methodology and evaluation of an existing regional interdisciplinary PC training program that was expanded to include chaplain and social worker trainees. MethodsFrom 2015 to 2017, 26 social workers, chaplains, physicians, nurses, and advanced practice providers representing 22 health systems completed a two-year training program. The curriculum comprises biannual interdisciplinary conferences, individualized mentoring and clinical shadowing, self-directed e-learning, and profession-focused seminar series for social workers and chaplains. Site-specific practice improvement projects were developed to address gaps in PC at participating sites. ResultsPC and program development skills were self-assessed before and after training. Among 12 skills common to all disciplines, trainees reported significant increases in confidence across all 12 skills and significant increases in frequency of performing 11 of 12 skills. Qualitative evaluation identified a myriad of program strengths and challenges regarding the educational format, mentoring, and networking across disciplines. ConclusionTeaching PC and program development knowledge and skills to an interdisciplinary regional cohort of practicing clinicians yielded improvements in clinical skills, implementation of practice change projects, and a sense of belonging to a supportive professional network.

The Mayo Clinic Hospital Mortality Reduction Project

Quality improvement, regulatory, and payer organizations use various definitions of hospital mortality as clinical outcome measures. In this prospective study, the authors evaluated a multicomponent intervention aimed at reducing inpatient mortality in a multistate healthcare delivery system. The project was initiated because of a statistically nonsignificant upward trend in mortality suggested by a six-quarter rise in the observed/expected mortality ratio generated by the Vizient Clinical Data Base and Resource Manager. The design of the mortality reduction plan was influenced by the known limitations of using hospital-wide mortality as a quality improvement measure. The primary objective was to reduce mortality through focused care redesign. The project leadership team attempted to implement standardized system-wide improvements while allowing individual hospitals to simultaneously pursue site-specific practice redesign opportunities. Between Q3, 2015, and Q4, 2017, system-wide mortality reduced from 1.78 to 1.53 (per 100 admissions; p = .01). The actual plan implemented in Mayo Clinic's hospitals is included as Appendix A to this article, published online as Supplemental Digital Content. The authors included it to allow comparison with similar efforts at other healthcare systems, as well as to stimulate criticism and discussion by readers.

Foreign Maids and Beauty Queens

Every Sunday is ‘maids’ day off’ in Hong Kong, when Filipina domestic workers gather en masse in the city’s Central District. These public gatherings have become a well-known phenomenon in Hong Kong, with thousands of migrant women occupying the financial district from morning till sundown, sprawling out in front of high-end boutiques and building makeshift temporary houses from cardboard boxes. The weekly event is at the centre of social life for migrant workers and has given rise to a wide range of amateur performance practice, including choreographed dances, street catwalks and beauty pageants. For Hong Kong residents, however, such leisure activities contradict the rationale for tolerating the presence of foreign maids, whose labour is needed but needed out of sight. The excess of Filipinas performing out in the open is a highly visible transgression for a Hong Kong public that would prefer these undesirable bodies to remain invisible.In the context of Hong Kong’s exclusionary politics of labour migration, the amateur performances of Filipina domestic workers are a cultural and a site-specific practice of diasporic identity that create a public presence for an otherwise invisible migrant workforce. As amateur performers, every Sunday Filipinas counter their common experiences of servitude and contest racialized conceptions of Filipina identity as naturally inclined towards domestic work. The amateur labour that such performances entail offers a different experience of work and time for Filipinas, producing distinct embodied ways of doing politics that claim a place outside the domestic realm. These cultural practices invite us to consider the stakes of amateur performance under conditions of duress and prompt us to examine the link between amateur performance and domestic work as particular forms of labour affected by relations of value production.

Site-integrity: a dynamic exchange between site, artist, device and audience

Site-integrity is a proposal for a working methodology - a particular but original mode of site-specific practice that potentiates a dynamic exchange between site, artist, device and audience. Non-haptic, non-temporal ways of representing place have come to dominate contemporary practice. When site is reduced to representation, the experiential qualities are lost. Site-integrity repositions the act of representation from its retrospective or projective dimensions towards that which is performed and is experiential. This exposition presents three specific projects; Assembly, Moving site/sight and Screen space that explore temporal relations with space and place via motorised recording/display devices. These projects are examples of artistic devices that contributes (not exclusively) to a specific practice - site-integrity.

Boots on the Ground: Site-Based Regionality and Creative Practice in the Tasmanian Midlands

Regional identity is a constant construction, in which landscape, human activity and cultural imaginary build a narrative of place. For the Tasmanian Midlands, the interactions between history, ecology and agriculture both define place and present problems in how to recognise, communicate and balance these interactions. In this sense, regionality is defined not so much as a relation of margin to centre, but as a specific accretion of environmental and cultural histories. According weight to more-than-human perspectives, a region can be seen as a constellation of plant, animal and human interactions and demands, where creative art and design can make space and give voice to the dynamics of exchange between the landscape and its inhabitants. Consideration of three recent art and design projects based in the Midlands reveal the potential for cross-disciplinary research, embedded in both environment and community, to create distinctive and specific forms of connectivity that articulate a regional identify.

A Study on Water Use Efficiency and Pollution Control by Hydroponic Technology

At present day we are facing the pollution problems in major cities like Delhi, Hyderabad, Punjab, Haryana and some districts of U.P. These areas are having air pollution, water pollution and soil problems. The hydroponic technology like rain tower, vertical farming and aquaponics can help to control the pollution. As we have water resources of 400 million hectare meter and in 1190mm of annual rainfall 70 million hectare meter is lost to atmosphere through evaporation and transpiration, about 115 million hectare meter flows as surface run-off and remaining 215 million hectare meter soaks or infiltrates into the soil profile. Where in this technology the we reuse the water and reduces the loses of the water. This also helps in increases the yield and doubling the income of farmers in a sustainable ways. Precision agriculture means site specific management practice, its delivery the ideas of doing thing at right time and at right place. This helps the farmer avoid wasting resources and prevent run-off, ensuring that the soil has just the right amount of additives for optimum health, while also reducing costs and controlling the farm's environmental impact.

Canções de Luto

Esse projeto toma processos de luto como fundamento para sua expressão empírica: Nosso artigo é estruturado sobre dois planos entremeados. O primeiro, um lugar de intimidade expresso por meio da prática espacial da instalação-performance, delineia métodos de ‘escrita-local’ (Jane Rendell) em relação ao luto pessoal. O segundo mergulha em um plano urbano-coletivo de materialismo histórico (Walter Benjamin), trabalhando com lugares específicos que essa prática ‘ocupou’ ou operou uma ‘escrita local’. A tese questiona como histórias pessoais/particulares de luto oferecem uma contribuição significativa a espaços urbanos, planejamento e história da arquitetura. Procura minar discursos urbanos através da prática localizada entre o design urbano e a performance-instalação. Isto convida alteridades urbanas que extendem as fronteiras percebidas da cidade, desdobrando de seus limites geológicos para limiares telúricos. O presente artigo aborda uma pesquisa original de PhD a respeito da contribuição da pesquisa conduzida pela prática, em definir sua discussão através de cenas de luto pessoal e memória urbana.