title: Complementarianism

text: According to Christians for Biblical Equality (CBE), an organization that adopts a Christian egalitarian approach, complementarianism "sidesteps the question at issue, which is not whether there are beneficial differences between men and women, but whether these differences warrant the inequitable roles, rights, and opportunities prescribed by advocates of gender hierarchy." CBE prefaces their criticism with acknowledgement of some positions they share in common with complementarians: a mutual love for and commitment to Jesus Christ, a commitment to justice as a biblical ideal, a devotion to Scripture as being God-inspired, and a desire to see the world embrace the gospel of Christ. They are divided by worldviews that CBE sees as reflecting the moral teachings of God and their purposes in this world. CBE maintains that these differing views have "enormous consequences". CBE President Mimi Haddad asserts that Christians are divided over patriarchy as they once were over slavery. She characterizes those divisions as different views of the nature, purpose, and value of humanity, all based on gender.


title: Complementarianism

text: Hierarchy in relationships was isolated as a factor that positively correlates with the acceptance of beliefs that facilitate abuse in a 2018 study by Jensen et al; gender complementarianism was used as an indicator of hierarchical relations. Critics of complementarianism have argued that it can be abused to uphold abuse and reduces women's ability to hold male abusers accountable. Some have criticized complementarianism as promoting a power imbalance that facilitates abuse. Hannah Paasch, one of the people who started the #ChurchToo hashtag, argues that complementarianism "feeds the rape culture" in aspects of American Christianity influenced by Western secular society. Supporters of complementarian ideas counter that good leadership on the part of males, as demanded by the Bible, precludes and forbids abuse. John Piper argues that complementarianism's prescription of protective male leadership helps protect women from sexual abuse.


title: Complementarianism

text: Differentiation of women's roles on the basis of religious beliefs are not unique to Christianity or Western culture.


title: Complementarianism

text: Different movements in Judaism have adopted differing views in gender relations. The Lubavitcher Rebbe stated, "In the Divine plan for creation, men and women have distinct, diverse missions. These missions complement each other, and together bring the Divine plan to harmonious fruition. The role of one is neither higher nor lower than the role of the other: they are simply different." Contrasting this, the Reform Jewish movement is entirely egalitarian, both in services and in daily life. In North America, the Conservative movement is likewise predominantly egalitarian. Although egalitarianism has been adopted in services and life by some of Orthodox Jewry, complementarianism continues to be more prevalent in Orthodox communities.


title: Complementarianism

text: The Baháʼí Faith proclaims that equality is not to deny that differences in function between women and men exist but rather to affirm the complementary roles men and women fulfill in the home and society at large. "The world of humanity is possessed of two wings: the male and the female. So long as these two wings are not equivalent in strength, the bird will not fly. Until womankind reaches the same degree as man, until she enjoys the same arena of activity, extraordinary attainment for humanity will not be realized; humanity cannot wing its way to heights of real attainment. When the two wings … become equivalent in strength, enjoying the same prerogatives, the flight of man will be exceedingly lofty and extraordinary".


title: Common basilisk

text: The common basilisk ("Basiliscus basiliscus") is a species of lizard in the family Corytophanidae. The species is endemic to Central America and South America, where it is found near rivers and streams in rainforests. It is also known as the Jesus Christ lizard, Jesus lizard, South American Jesus lizard, or legarto de Jesus Cristo for its ability to run on the surface of water.


title: Common basilisk

text: The common basilisk can be distinguished from similar species within its range by its large size and the high fin-like crest along its back. Most common basilisks are brown and cream in color. Males also have high crests on the head and tail. Both sexes are brown to olive, and have a white, cream, or yellow stripe on the upper lip and a second stripe along either side of the body; these stripes have higher contrast in juveniles and fade as the lizards age.


title: Common basilisk

text: Hatchlings weigh a mere and are long. Adults can grow to a total length (including tail) of 76 cm (2.5 feet). Females are generally , and weigh half as much as males. The tail comprises 70 to 75% of the total length: for example, a 70-cm-long (27.5-inch-long) common basilisk would have a 50-cm-long (19.5-inch-long) tail. The common basilisk has a large mouth with saw-like teeth on the inner sides of the jaw. While the common basilisk is most known for its ability to run on water, it is also an excellent climber and swimmer, and has been known to stay underwater for up to half an hour. The average lifespan is seven years in captivity; in the wild, it tends to be less because of predators.


title: Common basilisk

text: When startled, the common basilisk escapes by speeding to the nearest edge of water—and continues sprinting. The lizard runs on only its hind legs in an erect position, holding its forelegs to its sides. The common basilisk is adroit on water because its feet are large and equipped with flaps of skin along the toes that allow it to catch on tiny air bubbles. When moving quickly, the lizard can cross a surface of water before sinking. On water, it runs an average speed of 24.1 km/h (or 15 mph), which is just a little slower than its speed on land. Younger basilisks can run on water, while adults cross only a few meters before sinking. Adults do not move slowly, but they weigh more and cannot sprint for as long a time. Once a basilisk submerges, it continues swimming until it is sufficiently far from its pursuer — if the predator has followed past the bank. Although the common basilisk stays close to water to escape terrestrial predators, it swims only when necessary because some other aquatic animals would eat it given the chance.


title: Common basilisk

text: The common basilisk is found in tropical rainforests throughout Central America and in northwestern South America, usually living in low elevations, from sea level to . In Costa Rica, this basilisk can be found as high as in some places. The species ranges from southwestern Nicaragua to northwestern Colombia on the Pacific side, and from central Panama to northwestern Venezuela on the Atlantic side. In Costa Rica, it is mostly found on the Pacific side of the country. The equivalent species on the Atlantic side is the green basilisk ("Basiliscus plumifrons"), which occupies similar habitats and has similar biology. also recently being found in South Florida.


title: Common basilisk

text: "B. basiliscus" is an omnivore; its diet consists of insects, for example, beetles or dragon flies; flowers, and small vertebrates such as snakes, birds, eggs, and fish.


title: Common basilisk

text: The common basilisk has many natural predators; large reptiles, birds, and some mammals. To avoid predators, it can conceal itself under leaves on the forest floor and can remain motionless for a long time. When the common basilisk must flee, though, its skill of running on water can help it avoid many predators, and when the common basilisk can no longer run on the water, it will use its strong swimming capabilities to continue underwater.


title: Common basilisk

text: Females of "B. basiliscus" lay three to four clutches of 10–20 eggs a year. Eggs hatch after about three months and the young weigh about two grams and are up to three inches long. Their outstanding camouflage allows them to remain undetected when they remain still.


title: Common basilisk

text: The common basilisk, along with the other members of its genus, take the nickname the "Jesus Christ lizard" or "Jesus lizard" because when fleeing from predators, they gather sufficient momentum to run across the water for a brief distance while holding most of their body out of the water (similar to the biblical story of Jesus walking on water). Basilisks have large hind feet with scaly fringes on the sides of the third, fourth, and fifth toes. These are compressed against the toes when this lizard walks on land; but if it senses danger, it can jump into the water, opening up these fringes against the water's surface. This increases the surface area of the foot, thus allowing it to run on the water for short distances. This occurs in three steps. First is the slap, the downward movement of the foot that pushes water out and away from the leg. This also created pockets of air around the foot. Next is the stroke, the backwards movement of the foot, which propels it forward. Next is the recovery, when the foot comes up and out of the water and prepares to do the slap again. Smaller basilisks can run about 10–20 m without sinking. Juveniles can usually run farther than older basilisks, while holding more of their body above the water.


title: Common basilisk

text: The common basilisk is named for the creature of Greek mythology made up of parts of a rooster, snake, and lion which could turn a man to stone by its gaze: the basilisk. Its generic, specific, and common names all derive from the Greek "basilískos" (βασιλίσκος) meaning "little king". The specific epithet was given in Carl Linnaeus' 10th edition of "Systema Naturae".


title: Lytic cycle

text: The lytic cycle ( ) is one of the two cycles of viral reproduction (referring to bacterial viruses or bacteriophages), the other being the lysogenic cycle. The lytic cycle results in the destruction of the infected cell and its membrane. Bacteriophages that only use the lytic cycle are called virulent phages (in contrast to temperate phages).


title: Lytic cycle

text: In the lytic cycle, the viral DNA exists as a separate free floating molecule within the bacterial cell, and replicates separately from the host bacterial DNA, whereas in the lysogenic cycle, the viral DNA is located within the host DNA. This is the key difference between the lytic and lysogenic (bacterio)phage cycles. However, in both cases the virus/phage replicates using the host DNA machinery.


title: Lytic cycle

text: The lytic cycle, which is also commonly referred to as the "reproductive cycle" of the bacteriophage, is a six-stage cycle. The six stages are: attachment, penetration, transcription, biosynthesis, maturation, and lysis.


title: Lytic cycle

text: To infect a host cell, the virus must first inject its own nucleic acid into the cell through the plasma membrane and (if present) the cell wall. The virus does so by either attaching to a receptor on the cell's surface or by simple mechanical force. The binding is due to electrostatic interactions and is influenced by pH and the presence of ions. The virus then releases its genetic material (either single- or double-stranded RNA or DNA) into the cell. In some viruses this genetic material is circular and mimics a bacterial plasmid. At this stage the cell becomes infected and can also be targeted by the immune system. It is mostly aided by receptors in the surface of the cell.


title: Lytic cycle

text: During the transcription and biosynthesis stages, the virus hijacks the cell's replication and translation mechanisms, using them to make more viruses. The virus's nucleic acid uses the host cell's metabolic machinery to make large amounts of viral components.


title: Lytic cycle

text: In the case of DNA viruses, the DNA transcribes itself into messenger RNA (mRNA) molecules that are then used to direct the cell's ribosomes. One of the first polypeptides to be translated destroys the host's DNA. In retroviruses (which inject an RNA strand), a unique enzyme called reverse transcriptase transcribes the viral RNA into DNA, which is then transcribed again into RNA. Once the viral DNA has taken control it induces the host cell's machinery to synthesize viral DNA, protein and starts multiplying.


title: Lytic cycle

text: The biosynthesis is (e.g. T4) regulated in three phases of mRNA production followed by a phase of protein production.


title: Lytic cycle

text: About 25 minutes after initial infection, approximately 200 new virions (viral bodies) are formed. Once enough virions have matured and accumulated, specialized viral proteins are used to dissolve the cells' walls. The cell bursts (i.e. it undergoes lysis) due to high internal osmotic pressure (water pressure) that can no longer be constrained by the cell wall. This releases progeny virions into the surrounding environment, where they can go on to infect other cells and another lytic cycle begins. The phage that causes lysis of the host is called a lytic or virulent phage.


title: Lytic cycle

text: There are three classes of genes in the phage genome that regulate whether the lytic or lysogenic cycles will emerge. The first class is the immediate early genes, the second is the delayed early genes and the third is the late genes. The following refers to the well-studied temperate phage lambda of "E. coli."


title: Lytic cycle

text: Q-mediated turn-on of late transcription begins about 6–8 min after infection if the lytic pathway is chosen. More than 25 genes are expressed from the single late promoter, resulting in four parallel biosynthetic pathways. Three of the pathways are for production of the three components of the virion: the DNA-filled head, the tail, and the side tail fibers. The virions self-assemble from these components, with the first virion appearing at about 20 min after infection. The fourth pathway is for lysis. In lambda 5 proteins are involved in lysis: the holin and antiholin from gene "S", the endolysin from gene "R" and the spanin proteins from genes "Rz" and "Rz1". In wild-type lambda, lysis occurs at about 50 min, releasing approximately 100 completed virions. The timing of lysis is determined by the holin and antiholin proteins, with the latter inhibiting the former. In overview, the holin protein accumulates in the cytoplasmic membrane until suddenly forming micron-scale holes, which triggers lysis. The endolysin R is released to the periplasm, where it attacks the peptidoglycan. The spanin proteins Rz and Rz1 accumulate in the cytoplasmic and outer membranes, respectively, and form a complex spanning the periplasm through the meshwork of the peptidoglycan. When the endolysin degrades the peptidoglycan, the spanin complexes are liberated and cause disruption of the outer membrane. Destruction of the peptidoglycan by the endolysin and disruption of the outer membrane by the spanin complex are both required for lysis in lambda infections.


title: Lytic cycle

text: Lysis inhibition: T4-like phages have two genes, "rI" and "rIII", that inhibit the T4 holin, if the infected cell undergoes super-infection by another T4 (or closely related) virion. Repeated super-infection can cause the T4 infection to continue without lysis for hours, leading to accumulation of virions to levels 10-fold higher than normal.


title: Gary Janetti

text: He has written for "Family Guy", and was an executive producer on "Will and Grace". He co-created and wrote the British sitcom "Vicious", which aired on ITV from 2013 to 2016.


title: Gary Janetti

text: Janetti's Instagram page has gained international media attention primarily for a satirical characterization of Prince George and the child's imagined, and often catty, response to various photos and news stories about members of the British royal family. The page has more than 950,000 followers. Janetti produced a satire-animated sitcom version of Prince George called "The Prince" for HBO Max. He also provides the voice of Prince George.


title: Gary Janetti

text: Janetti's first solo nonfiction book, "Do You Mind If I Cancel? (Things That Still Annoy Me)", was published in October 2019, and became a "New York Times" Best Seller. His second is "Start Without Me (I'll Be There in a Minute)".


title: Gary Janetti

text: Janetti divides his time between Los Angeles and New York City. He is married to his longtime partner, fashion stylist and television personality Brad Goreski.


title: Ashley Fletcher

text: Ashley Michael Fletcher (born 2 October 1995) is an English professional footballer who plays as a forward for EFL Championship club Wigan Athletic on loan from Watford.


title: Ashley Fletcher

text: Fletcher began his professional career at Manchester United, having previously played at Bolton Wanderers during his youth. He then went on to join Barnsley on loan in 2016, where he achieved promotion and silverware, before signing for West Ham United on a free transfer. After just one season at the London Stadium, Fletcher relocated to Middlesbrough, where he broke into the first team. Furthermore, he has also briefly played for Sunderland on loan from Middlesbrough, as well as at international level for the England under-20 team.


title: Ashley Fletcher

text: Born in Keighley, West Yorkshire, Fletcher attended Canon Slade School in Bolton, where he obtained 12 GCSEs all with grades of either A or B. He played football, cricket, basketball, and athletics for the school.


title: Ashley Fletcher

text: Fletcher joined Bolton Wanderers at the age of nine, before moving to Manchester United at the age of 13. He signed his first professional contract with Manchester United in May 2014.


title: Ashley Fletcher

text: Fletcher signed for Barnsley on loan in January 2016. He scored on his professional debut on 9 January 2016, in a 1–1 draw with Fleetwood Town in the Football League Trophy Northern Area Final first leg, and scored his first league goal on 20 February 2016.


title: Ashley Fletcher

text: On 3 April 2016 he scored a goal in the 2016 Football League Trophy Final as Barnsley won the competition. On 29 May 2016, he scored the opening goal in Barnsley's 3–1 victory in the 2016 Football League One play-off Final against Millwall, helping Barnsley return to the Championship. In total Fletcher scored nine goals in 27 games for Barnsley during his spell at the club.


title: Ashley Fletcher

text: After impressing while on loan at Barnsley, Fletcher was offered a new contract at Manchester United amid interest from Championship side Leeds United. On 23 June 2016, it was reported that he had turned down the contract offer to stay at Manchester United but would continue to train at the club.


title: Ashley Fletcher

text: He made his unofficial debut for West Ham United's Development squad on 15 July 2016 in a 2–0 pre-season friendly defeat away to Chelmsford City.


title: Ashley Fletcher

text: His West Ham debut came on 18 August in the UEFA Europa League when he was introduced as a last minute substitute for Andy Carroll in a 3–0 win over NK Domžale. His Premier League debut came again from the substitutes bench on 21 August when he replaced Håvard Nordtveit after 80 minutes, in a 1–0 win over Bournemouth.


title: Ashley Fletcher

text: On 30 November 2016, Fletcher scored his first goal for West Ham, in a 4–1 defeat to Manchester United, in the EFL Cup quarter-final at Old Trafford.


title: Ashley Fletcher

text: On 28 July 2017, Fletcher signed for Middlesbrough for a fee of £6.5 million, signing a four-year contract. He made his debut on 5 August 2017 against Wolverhampton Wanderers in a 1–0 defeat. His first goal for the club came as the last of three in a 3–0 win against Scunthorpe United on 22 August 2017 in the EFL Cup, his first in the league came in a 3–2 win over Queens Park Rangers on 16 September.


title: Ashley Fletcher

text: On 31 January 2018, Fletcher made a deadline day switch to Sunderland, signing on loan for the remainder of the season. He scored his first goal for Sunderland in a 4–1 win at Derby County on 30 March 2018. Fletcher was a member of the Sunderland team that suffered relegation to League One at the end of the season, meaning that the club had suffered two consecutive relegations. Furthermore, his tenure at the club resulted in him appearing in the Netflix documentary series "Sunderland 'Til I Die", released on 14 December 2018.


title: Ashley Fletcher

text: During the off-season, Fletcher returned to Middlesbrough, with fellow Championship club Hull City expressing their interest in signing the striker. However, no move materialised, though their manager Nigel Adkins later attempted to sign him again in the winter transfer window. During his second season with Middlesbrough, Fletcher broke into Tony Pulis' team. He went on to score 5 goals in 21 league appearances, in a season where Middlesbrough narrowly failed to gain play-off qualification.


title: Ashley Fletcher

text: Fletcher claimed the number 11 shirt ahead of the 2019–20 season, the first season under new manager Jonathan Woodgate. He scored on the first day of the new season: a 3–3 draw at Luton Town on 2 August. Fletcher managed to push Britt Assombalonga out of the first-team. In January 2020, Fletcher won the Championship Goal of the Month award for December in recognition for his 30-yard volley against West Bromwich Albion, which ended in a 2–0 victory in Middlesbrough's favour. In April 2021, with his contract due to end in June, Middlesbrough manager Neil Warnock confirmed that Fletcher had turned down a new contract on reduced terms and had left the club with immediate effect.


title: Ashley Fletcher

text: On 20 May 2021, it was reported Watford had agreed to sign Fletcher on a free transfer. On 11 June 2021, Fletcher's transfer to Watford was announced, effective from 1 July. He scored his first goal for the club on his debut in an EFL Cup tie against Crystal Palace on 24 August 2021.


title: Ashley Fletcher

text: On 28 February 2022 he moved to MLS side New York Red Bulls on a six-month loan deal, with an option to purchase. His loan officially ended with New York on 11 July 2022, with Fletcher having made seven appearances for the Red Bulls, scoring no goals.


title: Ashley Fletcher

text: Born in England, Fletcher is of Jamaican descent. In November 2015, Fletcher made his debut for the England under-20 side, scoring only 10 minutes after coming on as a substitute. In March 2016, he was called up to face the Canada under-20s, playing up front with his then Manchester United teammate Marcus Rashford, and scored in a 4–1 win.


title: Die Trying (novel)

text: Die Trying is the second novel in the Jack Reacher series written by Lee Child. It was published in 1998 by Bantam Press in the UK and by Putnam in the US. It is written in the third person.


title: Die Trying (novel)

text: While in Chicago, former military police officer Jack Reacher is helping a young woman with an injured leg with her dry cleaning when they're captured at gunpoint by three men and thrown into a car, then transferred into a van and driven cross country. On the way, Reacher learns the woman is an FBI agent named Holly Johnson, though she doesn't tell him she's the daughter of the Chairman of the Joint Chiefs of Staff nor goddaughter of the President, having been accused of being the beneficiary of nepotism all her life.


title: Die Trying (novel)

text: Meanwhile, Holly's fellow agents search for her. Security footage leaves Reacher as the prime suspect, and his mentor, General Leon Garber, is brought in to help, though he insists Reacher would never do such a thing. The Chicago office where Holly worked take charge, with only agent in charge McGrath and two others, Milosevic and Brogan involved. At one point, they manage to put an APB out on the van, but get the wrong van due to a transfer of vehicles.


title: Die Trying (novel)

text: After Reacher fails to take advantage of an opportunity to escape during the night, Holly insists that he let her handle things. However, she ends up owing him when, during another stay, one of the kidnappers, Peter Bell, tries to rape her. Reacher breaks free of his restraints, kills Bell, hides his body, and re-restrains himself before the others become suspicious. Holly finally and reluctantly accepts his help after this.


title: Die Trying (novel)

text: Reacher and Holly finally arrive at their destination; a mountain community that's home to a radical military sect wishing to secede from the US. Holly, intended by leader Beau Borken to be used as leverage to make her father agree to his demands, is placed in an upstairs room of an abandoned county courthouse, whose walls are supposedly filled with dynamite. She meets Jackson, an FBI agent working undercover, who offers to help her escape, but she refuses to leave without Reacher.


title: Die Trying (novel)

text: Meanwhile, Reacher, after witnessing Borken execute Loder, the leader of the kidnappers, for multiple failures, is shown around the camp with the intent of sending him back to the States with information on the militia's credibility. However, word soon reaches Borken of Bell's murder, and Reacher is put on trial. Learning that he'll be executed, Holly escapes her room and convinces Borken to commute his sentence after he proves his worth in a shooting match.


title: Die Trying (novel)

text: During the punishment, Reacher and Holly are forced to bury the caught Jackson's corpse, and Reacher suspects something big is about to happen. Meanwhile, the FBI figures out where the militia is. When the President, fearing political fallout from a bloodbath, refuses to authorize an attack, McGrath and his men go rogue, setting up camp near the community. That night, Reacher sneaks out of his cabin and into an abandoned mine, where he finds trucks carrying missiles.


title: Die Trying (novel)

text: The next morning, as he returns to the camp, Reacher rescues McGrath, who was caught trying to break into the camp, proving his innocence. The two realize that Brogan and Milosevic are moles working for Borken for money. They stalk the camp to save Holly, killing Brogan in the process. Borken drags Holly out on national TV and tries to force her father to give in to his demands. With a sniper rifle stolen from the ammo cabin, Reacher shoots him dead. Milosevic takes Holly hostage, but Holly manages to kill him.


title: Die Trying (novel)

text: As the FBI round up the remaining militia members and demolish the camp, Reacher discovers that Holly's cabin isn't actually filled with dynamite and realizes that Borken sent Stevie, the last kidnapper in a truck filled with it to San Francisco, where he plans to detonate in the middle of a crowd celebrating the Fourth of July. Everyone gets in a helicopter and Reacher manages to shoot and destroy the truck on time. Learning that Holly and McGrath are in a relationship, Reacher sadly says goodbye to her and is left to hitchhike down a highway.


title: Government of Spain

text: The government of Spain () is the central government which leads the executive branch and the General State Administration of the Kingdom of Spain.


title: Government of Spain

text: The Government consists of the Prime Minister and the Ministers; the prime minister has the overall direction of the Ministers and can appoint or terminate their appointments freely and all of them belong to the supreme decision-making body, known as the Council of Ministers. The Government is responsible before the Parliament (Cortes Generales), and more precisely before the Congress of the Deputies, a body which elects the Prime Minister or dismisses them through a motion of censure. This is because Spain is a parliamentary system established by the Constitution of 1978.


title: Government of Spain

text: Its fundamental regulation is placed in Title IV of the Constitution, as well as in Title V of that document, with respect to its relationship with the Cortes Generales, and in Law 50/1997, of 27 November, of the Government. According to Article 97 of the Constitution and Article 1.1 of the Government Act, ""the Government directs domestic and foreign policy, the civil and military administration and the defense of the State. It exercises the executive function and the regulatory regulation according to the Constitution and the laws"".


title: Government of Spain

text: The current prime minister is Pedro Sánchez, who took office on 2 June 2018. He is the leader of the Socialist Workers' Party.


title: Government of Spain

text: The Government is occasionally referred to by the metonymy "Moncloa", due to the fact that the residence of the Prime Minister, the Palace of Moncloa, is also the headquarters of the Government.


title: Government of Spain

text: The Kingdom of Spain is a constitutional monarchy in which executive decisions are made by the Government. More specifically, the Spanish Constitution describes Spain's form of government as "Monarquía parlamentaria," or parliamentary monarchy, in which the monarch acts as a moderator rather than a source of executory authority. Spain possesses an asymmetric bicameral parliament, called the "Cortes Generales," composed of the Congress of Deputies and the Senate. While both the Congress and Senate propose legislation, albeit by different procedural mechanisms, the Government has the right to be consulted for such proposals. The Government may also propose law directly. A Government-sponsored bill is known as a "proyecto de ley", contrasting with a "proposición de ley" which is offered by a house of parliament.


title: Government of Spain

text: Neither the prime minister nor the ministers need to be members of parliament, but the Government must account to both the Senate and Congress every week in a parliamentary meeting known as a "sesión de control" (control session) (). Questioning minor-rank ministers, such as Secretaries of State or Under Secretaries, must be done in Parliamentary Committees. While the prime minister is typically elected from the members of Congress, the current prime minister, Pedro Sánchez, was not a member of either chamber for the first year of his premiership.


title: Government of Spain

text: Under the parliamentary system, the Government is required to maintain the confidence of the Congress of Deputies. In the absence of such confidence, the Government may fall or prove unable to pass legislation. There are two procedures to ascertain the Congress's confidence in the Government: the motion of no-confidence (), by which members of parliament can ask the Congress to rescind its confidence in the prime minister and to elect another, and the question of confidence (), by which the prime minister asks the Congress if it supports the Government's political programs generally or a specific piece of legislation. A loss by the Government in either case may result in the removal of the prime minister.


title: Government of Spain

text: The Spanish monarch, currently King Felipe VI, is the head of state and the commander-in-chief of the armed forces. As a monarch of a parliamentary monarchy, the executive power does not belong to The Crown and is independent from it. The Constitution gives the monarch a symbolic role, but also a moderating role, being able to intervene if there is a conflict between the country's institutions ().


title: Government of Spain

text: As commander-in-chief of the armed forces, former King Juan Carlos I suppressed the 23-F Spanish coup d'état attempt in February 1981, showing that the monarch has more power than the constitution grants him. The heir presumptive is Leonor, Princess of Asturias.


title: Government of Spain

text: The Constitution also gives the monarch some powers known as Royal Prerogatives. These prerogatives range from the signing of international treaties, to declaring war and making peace or to dissolving the parliament. However, with the arrival of democracy, these prerogatives have been regulated and most of them must be countersigned by an official.


title: Government of Spain

text: Although the monarch is not part of the executive power, the prime minister has weekly meetings with him to inform him about the Government's activity and the King can express his opinion. In the same sense, the monarch is normally invited to the first Council of Ministers of every new government (and others if the prime ministers wants to) and to the meetings of bodies such as the National Security Council or the National Defence Council.


title: Government of Spain

text: According to Article 98 of the Spanish Constitution and Article 1.2 of the Government Law, the Government of Spain is composed of:


title: Government of Spain

text: In accordance with article 11 of the Law of the Government, ""to be a member of the Government it is required to be Spanish, adult, to enjoy the rights of active and passive suffrage, as well as not to be disabled to exercise employment or public office by sentence Judicial firm"."


title: Government of Spain

text: The members of the Government enjoy their own criminal procedure so that they will only be tried by the Criminal Chamber of the Supreme Court.


title: Government of Spain

text: The initiation of a case for treason or against the security of the State can only respond to the initiative of a quarter of the Congress of Deputies, approved by an absolute majority thereof, and can not be granted a pardon in such cases.


title: Government of Spain

text: The Caretaker Government is regulated in Section 101 of the Spanish Constitution which says that "the Government shall resign after the holding of general elections, in the event of loss of parliamentary confidence as provided in the Constitution, or on the resignation or death of the President. The outgoing Government shall continue as acting body until the new Government takes office".


title: Government of Spain

text: Between the approval of the Constitution in 1978 and the approval of the Government Act of 1997, there were no explicit limitations to the Government powers while acting as acting government except for what the doctrine and parliamentary practice said. With this constitutional precept it was intended that the succession of one Government by another does not affect the fundamental continuity of the governmental action or that paralysis or dysfunctions occur in the system as a whole. This need of not leaving a modern state without its central governing body is explained very well in a Supreme Court sentence saying that "It is easy to understand that Spain can not run out of government even for a few hours".


title: Government of Spain

text: In 1997 the Government Act was passed; the Caretaker Government is regulated in Title 4. In addition to the aforementioned constitutional provisions, Section 21 of the Government Act establishes that "the caretaker government shall facilitate the normal development of the process of formation of the new Government and the transfer of powers to it and limit its duties to the ordinary office of public affairs, abstaining from adopting, except in cases of urgency duly accredited or for reasons of general interest whose accreditation expressly justifies it, any other measures".


title: Government of Spain

text: This article also establishes explicit limitations on the Prime Minister, preventing him from "proposing to the King the dissolution of any of the Chambers or the Cortes Generales, raising the question of confidence, or proposing to the King the calling for a consultative referendum" and on the Government prohibiting it from "the approval of the State General Budget Bill or presenting bills to the Cortes Generales". The government neither may exercise the legislative delegations that the parliament has granted to it while acting as a caretaker government.


title: Government of Spain

text: On the occasion of the 2015-2016 caretaker government of Mariano Rajoy, the Government refused repeatedly to submit to the control of the Congress of Deputies alleging that there was no trust relationship between both powers for the fact of being a caretaker government and, therefore, there was no control of the legislative power over the executive. Faced with this situation, the Congress denounced the Executive Power before the Constitutional Court for refusing to submit to its control and, on 22 November 2018, the high court ruled that the Government "undermined the constitutional attribution" that the Constitution confers on Congress and that although "control of the Government's action will normally be exercised within the framework of the confidence that must exist between the Government and the Congress of Deputies", this does not mean that "exceptionally, as are the periods in which there is no relationship of trust between Congress and the Government, the aforementioned control function can not be exercised" since "the control function that corresponds to the Cortes Generales is implicit in its representative character and in the form of parliamentary government that establishes Article 1.3 of the Constitution, not being able to deny the Chambers all exercise of the control function, since this would affect to the balance of powers foreseen in our Constitution".


title: Government of Spain

text: The longest caretaker government of the Spanish politics since the restoration of democracy in 1977 has been the 2015-2016 Rajoy government with a record of 316 days.


title: Government of Spain

text: The prime minister office as well as the official headquarters of the Government are located in the Palace of Moncloa, in outside Madrid. The Council of Ministers meetings also take place here. In this palace is also the office of the deputy prime minister, the headquarters of the Ministry of the Presidency and the office of the Government's Spokesperson. Most of the government departments are located in the center of the city of Madrid, having each of them its own buildings. One of the most famous place where some ministries are located is the gubernatorial complex of New Ministries.


title: Government of Spain

text: The General State Budget is considered one of the most important legislations that a Government can pass. According to the Constitution, the Government is the only body that can make the Budget bill, although is the parliament who must to accept it, reject it or to propose modifications. If the Congress approves a full budget amend, the budget is automatically rejected.


title: Government of Spain

text: Since the approval of the Constitution of 1978, Spain was established as a decentralized unitary country which grants its regions a high degree of autonomy. The first two regions to be granted autonomy were the Basque Country and Catalonia in 1979. In 1981, four further regions achieved their autonomy: Andalusia, Asturias, Cantabria and Galicia. A year later, seven more regions were granted autonomy: Aragon, the Canary Islands, Castile-La Mancha, Navarre, Murcia and La Rioja. The last four regions to get their autonomy were the Balearic Islands, Castile and León, Extremadura and Madrid, all of them in 1983.


title: Government of Spain

text: The Constitution also grants the cities of Ceuta and Melilla autonomy, which they got in 1995. The Constitution also gives them the possibility to become fully autonomous communities, but so far these cities have not requested the activation of this clause.


title: Government of Spain

text: The Council of Ministers is structured into the Prime Minister, 4 Deputy Prime Ministers, 22 ministries, and the post of Spokesperson of the Government.


title: Government of Spain

text: Although it is not a very common position within the Administration, it has existed the position of Commissioner or High Commissioner, a senior official normally holding the position of Secretary of State or Under Secretary, being entrusted with a specific task.


title: Government of Spain

text: Currently, there are two high commissioners, three special commissioners and two commissioners, all of them with the rank of Under-Secretary:


title: Government of Spain

text: Shown here is the official flag of the Government of Spain. On the left are the EU and the Spanish flags and in the centre is the coat of arms of Spain and the words "Gobierno de España" (in English: "Government of Spain"). The ministries’ logos consist of additional yellow rectangles added to the right of the Government's logo, which read the name of the ministry in the same typographic style (Gill Sans) .


title: Sean Berdy

text: Sean Lance Berdy (born June 3, 1993) is an American actor, producer, writer and entrepreneur. He began his career as a child in the film sequel "The Sandlot 2" and starred in "Switched at Birth" for five seasons. Berdy starred in Netflix's "The Society". He is the founder of The Sign Language Agency, interpreting service company.


title: Sean Berdy

text: Berdy, a native of Boca Raton, Florida, was born deaf. He is bilingual; his first language is American Sign Language (ASL) and he speaks English. As a child, Berdy was interested in magic. He won the young magicians top award at the World Magicians Festival in Saint Petersburg. Berdy was diagnosed with bipolar disorder when he was 11 years old. His formal acting career began in 2005 with his appearance in "The Sandlot 2". He subsequently had roles in "The Bondage", "The Deaf Family", and "The Legend of the Mountain Man". Berdy was featured in several public service commercials.


title: Sean Berdy

text: Berdy relocated to California in 2011 for his role in "Switched at Birth" in which, he starred as Emmett Bledsoe, son of Melody Bledsoe, played by Marlee Matlin. He was nominated for the 2011 Teen Choice Awards under the TV category for breakout star. He completed high school remotely while filming. Berdy provided the on-camera ASL dubbing of "". In 2019, he starred as Sam Eliot, in the Netflix show "The Society".


title: Flesh-n-Bone

text: Stanley Howse, better known as Flesh-n-Bone (born June 10, 1973), is an American rapper known as a member of the hip hop group Bone Thugs-n-Harmony. He is the older brother of Layzie Bone and cousin of Wish Bone.


title: Flesh-n-Bone

text: In 1998, police reportedly caught Flesh-n-Bone with a loaded sawed-off shotgun at a relative's home and claimed he refused when asked to leave.


title: Flesh-n-Bone

text: Flesh was brought up on charges for parole violation after he pulled a rifle on a neighbor over a heated dispute about Flesh's music being played too loudly. Flesh explained that he had been involved in several altercations that week, many of them on the day, and that the rifle was pulled in his distress. The weapon was pulled out in order to protect himself, Flesh-n-Bone states, though he admits he let his frustration get the better of him and that he pulled the rifle out at a time when it wasn't needed.


title: Flesh-n-Bone

text: In December 1999, Flesh-n-Bone was involved in a dispute with one-time friend Tarrance Vickers. During the dispute, Flesh-n-Bone pulled out a loaded semiautomatic AK-47 rifle and took aim at Vickers. The presiding Van Nuys Superior Court Judge deemed Howse's life story "one of the worst cases of child abuse she had ever read, full of beatings and other physical, emotional, and mental traumas." Flesh-n-Bone apologized and took responsibility for his actions and pleaded guilty. On September 22, 2000, Howse was sent to Pleasant Valley State Prison for 12 years on charges of assault with a deadly weapon and probation violation. He was also required to undertake an anger-management course.


title: Flesh-n-Bone

text: He was released in July 2008, when he reunited with fellow group members Krayzie Bone, Layzie Bone, Bizzy Bone, and Wish Bone. They immediately went to the studio and started recording for their reunion album "", which was released on May 4, 2010.


title: Flesh-n-Bone

text: Flesh-n-Bone was picked up on gun possession charges on Thursday, April 2, 2009, in Santa Clarita, CA, according to TMZ. He was held without bail. However, the gun possession charges against him were dropped on April 20, 2009 in a Santa Clarita courthouse. "The defense turned over some information, and we investigated and realized we were unable to proceed with the charges as filed, so the judge dismissed the case," said Jane Robinson, a spokeswoman for the Los Angeles district attorneys office.


title: Flesh-n-Bone

text: On March 28, 2010, during the Bone Thugs-n-Harmony reunion tour, Flesh-n-Bone was picked up on a 10-year-old felony warrant in Cleveland, Ohio during a show at the House Of Blues. He was released from custody five days later and charges were dismissed.


title: 2019 San Francisco 49ers season

text: The 2019 season was the San Francisco 49ers' 70th in the National Football League (NFL), their 74th overall and their third under the head coach-general manager tandem of Kyle Shanahan and John Lynch. They finished their 2019 season with a 13–3 record, their best finish since 2011. Starting the season 8–0 for the first time since 1990, the 49ers surpassed their win totals from the 2016, 2017, and 2018 seasons combined. The 49ers were the second straight NFC West team to start 8–0, with the other being the 2018 Rams. With a Week 11 win over the Arizona Cardinals, the 49ers clinched their first winning season since 2013. Despite a loss to the Atlanta Falcons in Week 15, the 49ers clinched a playoff spot for the first time since 2013 with a Los Angeles Rams loss. The 49ers beat the Cardinals for the first time since 2014, won in Seattle for the first time since 2011, and beat the Panthers in the regular season for the first time since 2001.


title: 2019 San Francisco 49ers season

text: The 49ers saw significant improvements during the season on both sides of the ball, and with some analysts naming it one of the greatest single season turnarounds in NFL history. Their offense finished second in the league in scoring (479 points, most for the franchise since 1998), second in rushing yards per game (144 yards per game), first in rushing touchdowns (23), and third in point differential (+169). The defense was sixth in the league in forced turnovers (27), second in total defense (281.8 yards per game), first in passing defense (169.2 yards per game), and fourth in sacks (48). This was the first time since 2003 that the 49ers finished in the top 10 in both scoring and yards per game.


title: 2019 San Francisco 49ers season

text: The 49ers were the top seed in their conference, winning a tiebreaker with the Packers and New Orleans Saints due to head-to-head records. This was the first time the 49ers obtained home field advantage throughout the playoffs since the 1997 season. In the playoffs, the 49ers defeated the Minnesota Vikings in the Divisional Round and the Packers in the NFC Championship Game, advancing to Super Bowl LIV, their first championship appearance since the 2012 season. However, the 49ers lost Super Bowl LIV to the Kansas City Chiefs 31–20. Despite having a 20–10 lead heading into the fourth quarter, the 49ers suffered their second Super Bowl loss in franchise history. It was the first time the 49ers lost a Super Bowl when leading after the third quarter (previously 4–0). The Niners also failed to join the Pittsburgh Steelers and New England Patriots as the only franchises to win 6 Super Bowls, or win their first title in 25 years.


title: 2019 San Francisco 49ers season

text: The revamped 49ers defense put on a show on opening day. Despite an average day by the 49ers offense, the defense dominated the Buccaneers offense. The defense sacked Jameis Winston three times and forced four turnovers, including returning two interceptions for touchdowns. The 49ers three interceptions in this game surpassed all of last year, as they only had two interceptions the entire season in 2018.


title: 2019 San Francisco 49ers season

text: The 49ers were the road team for the second consecutive game, and they routed the Bengals 41–17 with their most complete performance in years. The 49ers offense racked up an astounding 571 yards of offense, including 259 yards rushing. They averaged 6.2 yards per rush and 8.4 yards per play during the game. Jimmy Garoppolo finished 17–25 passing with 296 yards and three touchdown passes, while Matt Brieda lead the team with 121 yards rushing. The 49ers defense surrendered just 25 yards rushing, along with four sacks and one turnover. The blowout win over the Bengals on the road helped the 49ers to their first 2–0 start since 2012. The 49ers were 0–8 on the road during the 2018 season, but they started the 2019 season 2–0 on the road.


title: 2019 San Francisco 49ers season

text: The 49ers faced adversity for the first time during the 2019 season. Despite outgaining the Steelers in yardage 436–239, the game was close due to the 49ers committing an unprecedented five turnovers, including three fumbles inside the Steelers 25-yard line. The worst of the bunch came with 6:49 left in the game; with the 49ers at third-and-goal from the Pittsburgh 7-yard line, an errant snap hit 49ers running back Jeff Wilson Jr (who was in motion), and was recovered by T. J. Watt of the Steelers. The 49ers defense responded by forcing Steelers James Conner to fumble, giving San Francisco the ball back. From there, Garoppolo hit Dante Pettis for a 5-yard touchdown pass, giving the 49ers the lead with just 1:15 left to play. The 49ers defense then held to give them the 24–20 win. Points off turnovers ended up being the difference; despite the five turnovers given up, the 49ers held Pittsburgh to just six points off them, both coming on Chris Boswell field goals in the first quarter. The close win over the Steelers at home helped the 49ers to their first 3–0 start since 1998 as they went into their bye week.


title: 2019 San Francisco 49ers season

text: The blowout win over the Browns at home helped the 49ers to their first 4–0 start since 1990, during the Joe Montana era. Notably, 49ers DE Nick Bosa celebrated a sack of Browns QB Baker Mayfield with a faux flag planting motion, echoing Mayfield's own celebration some years earlier when the two faced off at the NCAA level.


title: 2019 San Francisco 49ers season

text: This game was the biggest test of the year so far for the 49ers, as they played the defending NFC champion Rams. Multiple sports analysts predicted the Rams to win. The result was the 49ers' best defensive effort in years. They held the high-powered Rams offense to just 157 total yards and seven points, which the Rams scored on their first possession of the game (a Robert Woods 8-yard touchdown run). The Rams were shut out for the remainder of the game. A goal line stand by the 49ers defense in the second quarter, in which Malcolm Brown was stuffed on fourth-and-goal from the 1-yard line and 49ers defensive coordinator Robert Saleh garnered fame for his ebullient reaction to the play, flipped the script in the 49ers' favor. Rams quarterback Jared Goff threw for just 78 yards during the game and was sacked four times. The 49ers had 331 yards of offense and 22 first downs compared to the Rams, who had 157 yards and just 10 first downs.


title: 2019 San Francisco 49ers season

text: In a game that was affected by heavy rain and a slippery field, three field goals by 49ers Robbie Gould were the only scores in the game. The 49ers defense again dominated, holding the Redskins to just 154 yards of offense. This was the first shutout win for the 49ers since their 2016 season opener, ironically also against Case Keenum. With the road win over the Redskins, the 49ers started 6–0 for the first time since 1990. Their 9 points scored was the fewest by a winning team all season.


title: 2019 San Francisco 49ers season

text: Coming into the game, the 49ers were on an eight-game winless streak against the Cardinals, having not beaten them since Week 17 of the 2014 season. The usually stout 49ers defense gave up an opening drive touchdown for the first time all year, giving up a 4-yard rushing touchdown to Kenyan Drake. The 49ers tied it just before the close of the first quarter with a 30-yard touchdown pass from Jimmy Garoppolo to George Kittle. The 49ers went into halftime with a 21–7 lead, aided by a blunder by Cardinals coach Kliff Kingsbury; he called a timeout when the 49ers had been stuffed at the goal line on fourth-and-goal. The timeout gave the 49ers another chance, and they converted with an Emmanuel Sanders 1-yard touchdown catch. The 49ers built a 28–14 lead in the third quarter with a 21-yard touchdown catch by Dante Pettis. A furious comeback by the Cardinals made it a three-point game, but the 49ers ended the game with an 11 play drive, including three third down conversions. The last was an 11-yard pass by Garoppolo to Ross Dwelley on third-and-9 to seal the game. Jimmy Garoppolo had his finest game as a 49er, throwing for 317 yards and four touchdown passes, a career high. With the close win over the Cardinals on the road, the 49ers started 8–0 for the first time since 1990, and had their first win against Arizona in five seasons.


title: 2019 San Francisco 49ers season

text: The 49ers welcomed the archrival Seattle Seahawks in a Monday Night Football showdown in a highly anticipated game. The 49ers had a great start, taking a 10–0 lead after a 10-yard touchdown catch by receiver Kendrick Bourne. But after Emmanuel Sanders went out of the game with an injury (the 49ers were also without top tight end George Kittle and kicker Robbie Gould due to injuries), the 49ers offense sputtered for over two quarters, allowing the Seahawks to take control. After falling behind 21–10 in the third quarter, the game changed in the 49ers' favor after a strip sack of Russell Wilson led to a 12-yard fumble recovery touchdown by DeForest Buckner. The 49ers sent it into overtime with a field goal by kicker Chase McLauglin as time expired. In overtime, the Seahawks were able to get to the 49ers' 14-yard line, but Dre Greenlaw intercepted the ball and returned it to the Seattle 49-yard line. With the game on the line, replacement kicker McLaughlin shanked the game-winning field goal, giving Seattle another try. Kicker Jason Myers of Seattle won it as time expired. The two teams combined for seven turnovers (four by Seattle; three by San Francisco). With their first loss of the season, the 49ers fell to 8–1. It also dropped the 49ers' record to 1–11 in the last 12 games against the Seahawks.


title: 2019 San Francisco 49ers season

text: A week after their first loss of the season, the 49ers responded by coming out sluggish and uninspired, falling behind 16–0 to the Cardinals. The 49ers rallied to take the lead in the third quarter, only to give up a go-ahead touchdown to fall behind 26–23 with 5:44 left. On the next drive, quarterback Jimmy Garoppolo tossed an interception, all but dooming the 49ers. But the 49ers defense forced a quick three-and-out and got the ball back with 2:02 left in the game. Garoppolo led the 49ers down the field in crunch time and threw a game-winning 25-yard touchdown pass to Jeff Wilson with just 31 seconds left to lead the 49ers to victory. It was Garoppolo's second game-winning touchdown pass this season, the first being in Week 3 against the Steelers. The 49ers tacked on another six points due to a fumble on lateral tries by the Cardinals, which was returned for a touchdown. With the win over the Cardinals, the 49ers improved to 9–1. They clinched their first winning season and swept the season series with the Cardinals for the first time since 2013.


title: 2019 San Francisco 49ers season

text: The 49ers started a tough three-game span with a Sunday Night game against the NFC North Division Leader Packers. The 49ers hammered Green Bay, holding Aaron Rodgers to just 104 yards passing and the entire Green Bay offense to 198 yards. The Packers were also held to just 1.7 yards per pass play, a career low for Aaron Rodgers. On the first possession of the game, the 49ers defense forced a fumble and recovered on the Packers 2-yard line. The next play, Tevin Coleman ran for a 2-yard touchdown, giving the 49ers a 7–0 lead and setting the tone for the rest of the game. Touchdown catches of 42 yards (Deebo Samuel) and 61 yards (George Kittle) were more than enough as the 49ers built a 23–0 halftime lead and never looked back. With the blowout win over the Packers, the 49ers improved to 10–1 and reached 10 wins for the first time since 2013.


title: 2019 San Francisco 49ers season

text: The 49ers traveled to Baltimore seeking their eleventh win of the season against a red-hot Baltimore Ravens team. San Francisco opened the game with a seven-play possession culminating in a 33-yard touchdown pass from quarterback Jimmy Garoppolo to Deebo Samuel for a 7–0 lead. In doing so, the 49ers became the first team of the season to score an opening-drive touchdown against the Ravens. Following a Ravens punt, Garoppolo was sacked and fumbled the ball at his own 23, which was recovered by Baltimore. Two plays later the Ravens capitalized on the turnover, tying the game at 7 on a 20-yard Lamar Jackson touchdown pass to Mark Andrews. The 49ers punted on their next possession, after which Jackson orchestrated a 13-play drive culminating with him running the ball in from the 1-yard line for a touchdown and a 14–7 lead. The 49ers leveled the score on the ensuing drive with a 40-yard touchdown run by Raheem Mostert, but the Ravens regained the lead with a 30-yard Justin Tucker field goal, and led 17–14 at halftime. In the opening drive of the second half, the Ravens drove to the San Francisco 20-yard line before 49ers safety Marcell Harris stripped Jackson of the ball. The 49ers then went on a 14-play drive consuming 8:26 of clock time, but the drive stalled at the Baltimore 14 and they had to settle for a 32-yard Robbie Gould field goal, tying the game at 17. The score remained the same until, with 6:28 remaining in the game, Jackson and the Ravens drove the ball down to the San Francisco 31-yard line, where Tucker kicked a 49-yard field as time ran out. The 49ers dropped to 10–2 on the season with their second loss; both of them were decided by last-second field goals.


title: 2019 San Francisco 49ers season

text: In a game that had huge playoff seeding implications, including deciding the #1 seed, the 49ers prevailed in a back and forth affair in a 48–46 win in which both teams combined for 981 yards of offense. The 49ers fell behind 20–7 and 27–14 in the first half, surrendering touchdowns on the first four Saints possessions. But the 49ers rallied, with a trick play touchdown pass by Emmanuel Sanders to Raheem Mostert for 35 yards to cut the lead to 27–21. After forcing a punt, the 49ers went nine plays for 80 yards, with a Mostert 10-yard touchdown run to give the 49ers a 28–27 lead at halftime. The third quarter saw the 49ers outscore the Saints 7–6 to take a 35–33 lead into the final quarter. In the fourth quarter, the Saints scored a touchdown with 53 seconds left in the game to take a 46–45 lead. The following possession, with the 49ers facing a fourth-and-2 from their own 33-yard line with :39 left, Jimmy Garoppolo connected with George Kittle on a 39-yard pass to the New Orleans 28-yard line. A 15-yard face mask penalty by Saints safety Marcus Williams tacked on more yards during the play. Kicker Robbie Gould then connected on a 30-yard field goal as time expired, giving the 49ers the win. This was the second time this season the 49ers rallied from an early double-digit deficit and won. With the close win over the Saints, the 49ers improved to 11–2 on the season and they reached 11 wins for the first time since 2013.


title: 2019 San Francisco 49ers season

text: As a result of this game, the 49ers finished the hardest three game stretch (by opponents' win percentage) in the Super Bowl era with a 2–1 record. No team has ever played three straight teams with an .800 or better winning percentage this late in the season.


title: 2019 San Francisco 49ers season

text: After a tough three-game stretch during which the 49ers became the first team in NFL history to play three straight teams with an .800 or better winning percentage, fears of a trap game loomed ahead of a matchup against an inferior Atlanta squad. Those fears were vindicated as the 49ers were sluggish on both sides of the ball for most of the game. The 49ers were missing multiple starters on defense due to injury and struggled to get off the field, allowing Atlanta to go 7-for-13 on third downs. The Falcons scored a touchdown with :02 left in the game when Julio Jones caught a pass from Matt Ryan and was tackled at the goal line by Jimmie Ward just as the football crossed the plane, to take a 23–22 lead. A fumble on the ensuing kick off due to multiple laterals gave the Falcons another 6 points as time expired. The 49ers lost all three of their games by a combined 13 points, narrowest in the NFL. With the loss, the 49ers dropped to 11–3 on the year and fell to the #5 seed in the NFC with the Seattle Seahawks victory over the Carolina Panthers. Despite the loss, they backed into a playoff berth by virtue of the Los Angeles Rams losing to the Dallas Cowboys, which also allowed the Seattle Seahawks and Green Bay Packers to clinch spots in the playoffs.


title: 2019 San Francisco 49ers season

text: Unlike Week 6 in which there were only 27 combined points between these teams, this game was a shootout. The Rams started out fast, with touchdowns by Brandin Cooks and Todd Gurley to give the Rams a 14–3 lead. Another touchdown by Rams running back Todd Gurley gave the Rams a 21–10 lead in the second quarter. After the 49ers cut the lead to 21–17, 49ers linebacker Fred Warner intercepted a Jared Goff pass and returned it for 46 yards for a touchdown to give the 49ers a 24–21 lead at halftime. In the second half, the 49ers offensive line struggled to protect quarterback Jimmy Garoppolo, giving up six sacks after halftime. This allowed the Rams to control the game and take a 28–24 lead. With 8:41 left in the game, Garoppolo led the 49ers on a 6 play, 91-yard drive that ended with a George Kittle seven-yard touchdown catch to give the 49ers a 31–28 lead. The defense surrendered a field goal to allow the Rams to tie the game at 31 with 2:30 left in regulation. On the following possession, in one of the most clutch performances of the season, Garoppolo led the 49ers down the field in crunch time. This included converting a third-and-16 with an 18-yard pass to receiver Kendrick Bourne, and then another third-and-16 conversion, this time a 46-yard pass to receiver Emmanuel Sanders, who was wide open due to a blown coverage to put the 49ers in field goal range. Kicker Robbie Gould won it as time expired with a 33-yard field goal, giving the 49ers the 34–31 win. This was the third time this season the 49ers trailed by double digits and came back to win the game. This was the fifth game-winning drive of the year for Garoppolo. With the close win over the Rams, the 49ers won 12 games for the first time since 2013. The 49ers swept the season series with the Rams for the first time since 2016 and regained possession of the #1 seed and the NFC West after the Cardinals upset the Seahawks.


title: 2019 San Francisco 49ers season

text: In the 49ers' biggest game since the 2013 NFC Championship Game, they traveled to Seattle to decide not only who would win the division, but also if the 49ers could capture home-field advantage throughout the NFC playoffs. Prior to this game, the last time the 49ers had won at CenturyLink Field was on December 24, 2011. During that span, the 49ers failed to score twenty points in any of those games (going 0–7 from 2012 to 2018). In the first half, the 49ers dominated every aspect, taking a 13–0 halftime lead, aided by a Deebo Samuel 30-yard touchdown run on a pitch and catch. The 49ers also held Seattle to just 79 yards of total offense, including stuffing running back Marshawn Lynch on a fourth-and-inches attempt from the 49ers 31-yard line, causing a turnover on downs. In the second half, the Seahawks proved resilient, scoring multiple times. The Seahawks never led in this game, however, as the 49ers countered every Seahawks score with one of their own, including a Raheem Mostert 13-yard touchdown run to make it 26–14 with 5:51 left. After Seattle cut the lead to five, a questionable personal foul call against Ben Garland forced a punt, giving them the ball back with 2:27 left. They marched all the way down to the 49ers 1-yard line, but a delay of game penalty pushed them back to the 6-yard line. After three incomplete passes, the Seahawks faced fourth-and-goal. Russell Wilson hit receiver Jacob Hollister with a pass to the 49ers 1-yard line, but Hollister was stopped inches short of the goal line by linebacker Dre Greenlaw, causing a turnover on downs with nine seconds left that sealed the victory.


title: 2019 San Francisco 49ers season

text: With the close win over the Seahawks, the 49ers snapped their seven-game losing streak at CenturyLink Field, while obtaining home-field advantage throughout the playoffs. This game also snapped the team's 22-year number one seed drought.


title: 2019 San Francisco 49ers season

text: In the first playoff game at Levi's Stadium for the 49ers, they hosted the Minnesota Vikings for the first time since 1997. After winning the coin toss and deferring, they had a great start, forcing a three-and-out on the Vikings offense. They then proceeded to march 61 yards on just eight plays, culminating in a 3-yard touchdown pass from Jimmy Garoppolo to Kendrick Bourne to take a 7–0 lead. Garoppolo went 5-for-6 passing for 49 yards on that drive, silencing criticisms that he might be rattled in his first playoff game. The Vikings tied the game on a 41-yard touchdown pass from Kirk Cousins to Stefon Diggs on their ensuing possession. Later in the game, another three-and-out by the Vikings set the 49ers up with good field position, finished off by a Tevin Coleman 1-yard touchdown run to retake the lead, 14–7. Before halftime, Garoppolo threw an interception to Eric Kendricks to put the Vikings deep in 49ers territory, but the 49ers defense stood tall, forcing the Vikings to kick a field goal, sending the game into halftime with the 49ers leading 14–10.


title: 2019 San Francisco 49ers season

text: From there, the 49ers completely dominated the second half, taking a 17–10 lead after a 35-yard Robbie Gould field goal on their opening possession after halftime. Partway through the third quarter, 49ers cornerback Richard Sherman intercepted a pass from Cousins, giving the 49ers great field position at the Vikings 44-yard line. The 49ers went 44 yards on eight successive run plays, and finishing the drive with a 2-yard touchdown run from Coleman to give the 49ers a 24–10 lead. For the rest of the game, the 49ers defense controlled the line of scrimmage and kept the Vikings off the board to give the 49ers their first playoff win since 2013.


title: 2019 San Francisco 49ers season

text: The 49ers defense finished the game with six sacks and two forced turnovers, and surrendered just 147 total yards of offense. The Vikings earned just seven first downs on the day and had only 21 rushing yards, the fewest the 49ers had ever given up in a playoff game. On offense, the 49ers rushed for 186 yards on the day, more than the entire Vikings offense managed in the game.


title: Pain management

text: Pain management is an aspect of medicine and health care involving relief of pain (pain relief, analgesia, pain control) in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals provide some pain control in the normal course of their practice, and for the more complex instances of pain, they also call on additional help from a specific medical specialty devoted to pain, which is called pain medicine.


title: Pain management

text: Pain management often uses a multidisciplinary approach for easing the suffering and improving the quality of life of anyone experiencing pain, whether acute pain or chronic pain. Relief of pain in general (analgesia) is often an acute affair, whereas managing chronic pain requires additional dimensions. The typical pain management team includes medical practitioners, pharmacists, clinical psychologists, physiotherapists, occupational therapists, recreational therapists, physician assistants, nurses, and dentists. The team may also include other mental health specialists and massage therapists. Pain sometimes resolves quickly once the underlying trauma or pathology has healed, and is treated by one practitioner, with drugs such as pain relievers (analgesics) and occasionally also anxiolytics. Effective management of chronic (long-term) pain, however, frequently requires the coordinated efforts of the pain management team. Effective pain management does not always mean total eradication of all pain. Rather, it often means achieving adequate quality of life in the presence of pain, through any combination of lessening the pain and/or better understanding it and being able to live happily despite it.


title: Pain management

text: Medicine treats injuries and diseases to support and speed healing. It treats distressing symptoms such as pain to relieve suffering during treatment, healing, and dying. The task of medicine is to relieve suffering under three circumstances. The first is when a painful injury or pathology is resistant to treatment and persists. The second is when pain persists after the injury or pathology has healed. Finally, the third circumstance is when medical science cannot identify the cause of pain. Treatment approaches to chronic pain include pharmacological measures, such as analgesics (pain killer drugs), antidepressants, and anticonvulsants; interventional procedures, physical therapy, physical exercise, application of ice or heat; and psychological measures, such as biofeedback and cognitive behavioral therapy.


title: Pain management

text: In the nursing profession, one common definition of pain is any problem that is "whatever the experiencing person says it is, existing whenever the experiencing person says it does".


title: Pain management

text: Pain management includes patient and communication about the pain problem. To define the pain problem, a health care provider will likely ask questions such as:


title: Pain management

text: After asking such questions, the health care provider will have a description of the pain. Pain management will then be used to address that pain.


title: Pain management

text: A common challenge in pain management is communication between the health care provider and the person experiencing pain. People experiencing pain may have difficulty recognizing or describing what they feel and how intense it is. Health care providers and patients may have difficulty communicating with each other about how pain responds to treatments. There is a risk in many types of pain management for the patient to take treatment that is less effective than needed or which causes other difficulties and side effects. Some treatments for pain can be harmful if overused. A goal of pain management for the patient and their health care provider is to identify the amount of treatment needed to address the pain without going beyond that limit.


title: Pain management

text: Another problem with pain management is that pain is the body's natural way of communicating a problem. Pain is supposed to resolve as the body heals itself with time and pain management. Sometimes pain management covers a problem, and the patient might be less aware that they need treatment for a deeper problem.


title: Pain management

text: Physical medicine and rehabilitation uses a range of physical techniques such as heat and electrotherapy, as well as therapeutic exercises and behavioral therapy. These techniques are usually part of an interdisciplinary or multidisciplinary program that might also include pharmaceutical medicines. Spa therapy has showed positive effects in reducing pain among patients with chronic low back pain. However, there are limited studies looking at this approach. Studies have shown that kinesiotape could be used on individuals with chronic low back pain to reduce pain. The Center for Disease Control recommends that physical therapy and exercise can be prescribed as a positive alternative to opioids for decreasing one's pain in multiple injuries, illnesses, or diseases. This can include chronic low back pain, osteoarthritis of the hip and knee, or fibromyalgia. Exercise alone or with other rehabilitation disciplines (such as psychologically based approaches) can have a positive effect on reducing pain. In addition to improving pain, exercise also can improve one's well-being and general health.


title: Pain management

text: Manipulative and mobilization therapy are safe interventions that likely reduce pain for patients with chronic low back pain. However, manipulation produces a larger effect than mobilization.


title: Pain management

text: Specifically in chronic low back pain, education about the way the brain processes pain in conjunction with routine physiotherapy interventions may provide short term relief of disability and pain.


title: Pain management

text: Physical activity interventions, such as tai chi, yoga and Pilates, promote harmony of the mind and body through total body awareness. These practices incorporate breathing techniques, meditation and a wide variety of movements, while training the body to perform functionally by increasing strength, flexibility, and range of motion. Physical activity and exercise may improve chronic pain (pain lasting more than 12 weeks), and overall quality of life, while minimizing the need for pain medications. More specifically, walking has been effective in improving pain management in chronic low back pain.


title: Pain management

text: Transcutaneous electrical nerve stimulation (TENS) is a self-operated portable device intended to help regulate and create chronic pain via electrical impulses. Limited research has explored the effectiveness of TENS in relation to pain management of Multiple Sclerosis (MS). MS is a chronic autoimmune neurological disorder, which consists of the demyelination of the nerve axons and disruption of nerve conduction velocity and efficiency. In one study, electrodes were placed over the lumbar spine and participants received treatment twice a day and at any time when they experienced a painful episode. This study found that TENS would be beneficial to MS patients who reported localized or limited symptoms to one limb. The research is mixed with whether or not TENS helps manage pain in MS patients.


title: Pain management

text: Transcutaneous electrical nerve stimulation has been found to be ineffective for lower back pain. However, it might help with diabetic neuropathy as well as other illnesses.


title: Pain management

text: Transcranial direct current stimulation (tDCS) is a non-invasive technique of brain stimulation that can modulate activity in specific brain cortex regions, and it involves the application of low-intensity (up to 2 mA) constant direct current to the scalp through electrodes in order to modulate excitability of large cortical areas. tDCS may have a role in pain assessment by contributing to efforts in distinguishing between somatic and affective aspects of pain experience. Zaghi and colleagues (2011) found that the motor cortex, when stimulated with tDCS, increases the threshold for both the perception of non-painful and painful stimuli. Although there is a greater need for research examining the mechanism of electrical stimulation in relation to pain treatment, one theory suggests that the changes in thalamic activity may be due the influence of motor cortex stimulation on the decrease in pain sensations.


title: Pain management

text: In relation to MS, a study found that after daily tDCS sessions resulted in an individual's subjective report of pain to decrease when compared to a sham condition. In addition, the study found a similar improvement at 1 to 3 days before and after each tDCS session.


title: Pain management

text: Fibromyalgia is a disorder in which an individual experiences dysfunctional brain activity, musculoskeletal pain, fatigue, and tenderness in localized areas. Research examining tDCS for pain treatment in Fibromyalgia has found initial evidence for pain decreases. Specifically, the stimulation of the primary motor cortex resulted in significantly greater pain improvement in comparison to the control group (e.g., sham stimulation, stimulation of the DLPFC). However, this effect decreased after treatment ended, but remained significant for three weeks following the extinction of treatment.


title: Pain management

text: Acupuncture involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the "British Medical Journal", was unable to quantify the difference in the effect on pain of real, sham and no acupuncture. A systematic review in 2019 reported that acupuncture injection therapy was an effective treatment for patients with nonspecific chronic low back pain, and is widely used in Southeast Asian countries.


title: Pain management

text: Research has not found evidence that light therapy such as low level laser therapy is an effective therapy for relieving low back pain.


title: Pain management

text: Audioanalgesia and music therapy are both examples of using auditory stimuli to manage pain or other distress. They are generally viewed as (1) not sufficient when used alone, but also (2) helpful adjuncts to other forms of therapy.


title: Pain management

text: Interventional radiology procedures for pain control, typically used for chronic back pain, include epidural steroid injections, facet joint injections, neurolytic blocks, spinal cord stimulators and intrathecal drug delivery system implants.


title: Pain management

text: Pulsed radiofrequency, neuromodulation, direct introduction of medication and nerve ablation may be used to target either the tissue structures and organ/systems responsible for persistent nociception or the nociceptors from the structures implicated as the source of chronic pain. Radiofrequency treatment has been seen to improve pain in patients for facet joint low back pain. However, continuous radiofrequency is more effective in managing pain than pulsed radiofrequency.


title: Pain management

text: An intrathecal pump used to deliver very small quantities of medications directly to the spinal fluid. This is similar to epidural infusions used in labour and postoperatively. The major differences are that it is much more common for the drug to be delivered into the spinal fluid (intrathecal) rather than epidurally, and the pump can be fully implanted under the skin.


title: Pain management

text: A spinal cord stimulator is an implantable medical device that creates electric impulses and applies them near the dorsal surface of the spinal cord provides a paresthesia ("tingling") sensation that alters the perception of pain by the patient.


title: Pain management

text: Intra-articular ozone therapy has been seen to efficiently alleviate chronic pain in patients with knee osteoarthritis.


title: Pain management

text: Acceptance and Commitment Therapy (ACT) is a form of cognitive behavioral therapy that focuses on behavior change rather than symptom change, includes methods designed to alter the context around psychological experiences rather than to alter the makeup of the experiences, and emphasizes the use of experiential behavior change methods. The central process in ACT revolves around psychological flexibility, which in turn includes processes of acceptance, awareness, a present-oriented quality in interacting with experiences, an ability to persist or change behavior, and an ability to be guided by one's values. ACT has an increased evidence base for range of health and behavior problems, including chronic pain. ACT influences patients to adopt a tandem process to acceptance and change, which allows for a greater flexibility in the focus of treatment.


title: Pain management

text: Recent research has applied ACT successfully to chronic pain in older adults due to in part of its direction from individual values and being highly customizable to any stage of life. In line with the therapeutic model of ACT, significant increases in process variables, pain acceptance, and mindfulness were also observed in a study applying ACT to chronic pain in older adults. In addition, these primary results suggested that an ACT based treatment may significantly improve levels of physical disability, psychosocial disability, and depression post-treatment and at a three-month follow-up for older adults with chronic pain.


title: Pain management

text: Cognitive behavioral therapy (CBT) helps patients with pain to understand the relationship between their pain, thoughts, emotions, and behaviors. A main goal in treatment is cognitive (thinking, reasoning or remembering) restructuring to encourage helpful thought patterns. This will target healthy activities such as regular exercise and pacing. Lifestyle changes are also trained to improve sleep patterns and to develop better coping skills for pain and other stressors using various techniques (e.g., relaxation, diaphragmatic breathing, and even biofeedback).


title: Pain management

text: Studies have demonstrated the usefulness of cognitive behavioral therapy in the management of chronic low back pain, producing significant decreases in physical and psychosocial disability. CBT is significantly more effective than standard care in treatment of people with body-wide pain, like fibromyalgia. Evidence for the usefulness of CBT in the management of adult chronic pain is generally poorly understood, due partly to the proliferation of techniques of doubtful quality, and the poor quality of reporting in clinical trials. The crucial content of individual interventions has not been isolated and the important contextual elements, such as therapist training and development of treatment manuals, have not been determined. The widely varying nature of the resulting data makes useful systematic review and meta-analysis within the field very difficult.


title: Pain management

text: In 2020, a systematic review of randomized controlled trials (RCTs) evaluated the clinical effectiveness of psychological therapies for the management of adult chronic pain (excluding headaches). There is no evidence that behaviour therapy (BT) is effective for reducing this type of pain, however BT may be useful for improving a persons mood immediately after treatment. This improvement appears to be small, and is short term in duration. CBT may have a small positive short-term effect on pain immediately following treatment. CBT may also have a small effect on reducing disability and potential catastrophizing that may be associated with adult chronic pain. These benefits do not appear to last very long following the therapy. CBT may contribute towards improving the mood of an adult who experiences chronic pain, which could possibility be maintained for longer periods of time.


title: Pain management

text: For children and adolescents, a review of RCTs evaluating the effectiveness of psychological therapy for the management of chronic and recurrent pain found that psychological treatments are effective in reducing pain when people under 18 years old have headaches. This beneficial effect may be maintained for at least three months following the therapy. Psychological treatments may also improve pain control for children or adolescents who experience pain not related to headaches. It is not known if psychological therapy improves a child or adolescents mood and the potential for disability related to their chronic pain.


title: Pain management

text: A 2007 review of 13 studies found evidence for the efficacy of hypnosis in the reduction of pain in some conditions. However the studies had some limitations like small study sizes, bringing up issues of power to detect group differences, and lacking credible controls for placebo or expectation. The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions."


title: Pain management

text: Hypnosis has reduced the pain of some harmful medical procedures in children and adolescents. In clinical trials addressing other patient groups, it has significantly reduced pain compared to no treatment or some other non-hypnotic interventions. The effects of self hypnosis on chronic pain are roughly comparable to those of progressive muscle relaxation.


title: Pain management

text: Hypnosis with analgesic (painkiller) has been seen to relieve chronic pain for most people and may be a safe and effective alternative to medications. However, high quality clinical data is needed to generalize to the whole chronic pain population.


title: Pain management

text: A 2013 meta-analysis of studies that used techniques centered around the concept of mindfulness, concluded, "that MBIs [mindfulness-based interventions] decrease the intensity of pain for chronic pain patients." A 2019 review of studies of brief mindfulness-based interventions (BMBI) concluded that BMBI are not recommended as a first-line treatment and could not confirm their efficacy in managing chronic or acute pain.


title: Pain management

text: Mindfulness-based pain management (MBPM) is a mindfulness-based intervention (MBI) providing specific applications for people living with chronic pain and illness. Adapting the core concepts and practices of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), MBPM includes a distinctive emphasis on the practice of 'loving-kindness', and has been seen as sensitive to concerns about removing mindfulness teaching from its original ethical framework within Buddhism. It was developed by Vidyamala Burch and is delivered through the programs of Breathworks. It has been subject to a range of clinical studies demonstrating its effectiveness.


title: Pain management

text: The World Health Organization (WHO) recommends a "pain ladder" for managing pain relief with pharmaceutical medicine. It was first described for use in cancer pain. However it can be used by medical professionals as a general principle when managing any type of pain. In the treatment of chronic pain, the three-step WHO Analgesic Ladder provides guidelines for selecting the appropriate medicine. The exact medications recommended will vary by country and the individual treatment center, but the following gives an example of the WHO approach to treating chronic pain with medications. If, at any point, treatment fails to provide adequate pain relief, then the doctor and patient move onto the next step.


title: Pain management

text: Paracetamol (acetaminophen), or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen will relieve mild pain.


title: Pain management

text: Paracetamol, an NSAID or paracetamol in a combination product with a weak opioid such as tramadol, may provide greater relief than their separate use. A combination of opioid with acetaminophen can be frequently used such as Percocet, Vicodin, or Norco.


title: Pain management

text: When treating moderate to severe pain, the type of the pain, acute or chronic, needs to be considered. The type of pain can result in different medications being prescribed. Certain medications may work better for acute pain, others for chronic pain, and some may work equally well on both. Acute pain medication is for rapid onset of pain such as from an inflicted trauma or to treat post-operative pain. Chronic pain medication is for alleviating long-lasting, ongoing pain.


title: Pain management

text: Morphine is the gold standard to which all narcotics are compared. Semi-synthetic derivatives of morphine such as hydromorphone (Dilaudid), oxymorphone (Numorphan, Opana), nicomorphine (Vilan), hydromorphinol and others vary in such ways as duration of action, side effect profile and milligramme potency. Fentanyl has the benefit of less histamine release and thus fewer side effects. It can also be administered via transdermal patch which is convenient for chronic pain management. In addition to the intrathecal patch and injectable fentanyl formulations, the FDA (Food and Drug Administration) has approved various immediate release fentanyl products for breakthrough cancer pain (Actiq/OTFC/Fentora/Onsolis/Subsys/Lazanda/Abstral). Oxycodone is used across the Americas and Europe for relief of serious chronic pain. Its main slow-release formula is known as OxyContin. Short-acting tablets, capsules, syrups and ampules which contain OxyContin are available making it suitable for acute intractable pain or breakthrough pain. Diamorphine, and methadone are used less frequently. Clinical studies have shown that transdermal Buprenorphine is effective at reducing chronic pain. Pethidine, known in North America as meperidine, is not recommended for pain management due to its low potency, short duration of action, and toxicity associated with repeated use. Pentazocine, dextromoramide and dipipanone are also not recommended in new patients except for acute pain where other analgesics are not tolerated or are inappropriate, for pharmacological and misuse-related reasons. In some countries potent synthetics such as piritramide and ketobemidone are used for severe pain. Tapentadol is a newer agent introduced in the last decade.


title: Pain management

text: For moderate pain, tramadol, codeine, dihydrocodeine, and hydrocodone are used, with nicocodeine, ethylmorphine and propoxyphene or dextropropoxyphene (less commonly).


title: Pain management

text: Drugs of other types can be used to help opioids combat certain types of pain. Amitriptyline is prescribed for chronic muscular pain in the arms, legs, neck and lower back with an opiate, or sometimes without it or with an NSAID.


title: Pain management

text: While opiates are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose.


title: Pain management

text: In 2009, the Food and Drug Administration stated: "According to the National Institutes of Health, studies have shown that properly managed medical use of opioid analgesic compounds (taken exactly as prescribed) is safe, can manage pain effectively, and rarely causes addiction." In 2013, the FDA stated that "abuse and misuse of these products have created a serious and growing public health problem".


title: Pain management

text: Opioid medications can provide short, intermediate or long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectally, transdermally, intravenously, epidurally and intrathecally. In chronic pain conditions that are opioid responsive, a combination of a long-acting (OxyContin, MS Contin, Opana ER, Exalgo and Methadone) or extended release medication is often prescribed along with a shorter-acting medication (oxycodone, morphine or hydromorphone) for breakthrough pain, or exacerbations.


title: Pain management

text: Most opioid treatment used by patients outside of healthcare settings is oral (tablet, capsule or liquid), but suppositories and skin patches can be prescribed. An opioid injection is rarely needed for patients with chronic pain.


title: Pain management

text: Although opioids are strong analgesics, they do not provide complete analgesia regardless of whether the pain is acute or chronic in origin. Opioids are effective analgesics in chronic malignant pain and modestly effective in nonmalignant pain management. However, there are associated adverse effects, especially during the commencement or change in dose. When opioids are used for prolonged periods drug tolerance, chemical dependency, diversion and addiction may occur.


title: Pain management

text: Clinical guidelines for prescribing opioids for chronic pain have been issued by the American Pain Society and the American Academy of Pain Medicine. Included in these guidelines is the importance of assessing the patient for the risk of substance abuse, misuse, or addiction. Factors correlated with an elevated risk of opioid misuse include a history of substance use disorder, younger age, major depression, and the use of psychotropic medications. Physicians who prescribe opioids should integrate this treatment with any psychotherapeutic intervention the patient may be receiving. The guidelines also recommend monitoring not only the pain but also the level of functioning and the achievement of therapeutic goals. The prescribing physician should be suspicious of abuse when a patient reports a reduction in pain but has no accompanying improvement in function or progress in achieving identified goals.


title: Pain management

text: The list below consists of commonly used opioid analgesics which have long-acting formulations. Common brand names for the extended release formulation are in parentheses.


title: Pain management

text: <nowiki>*</nowiki>Methadone and buprenorphine are each used both for the treatment of opioid addiction and as analgesics


title: Pain management

text: The other major group of analgesics are nonsteroidal anti-inflammatory drugs (NSAID). They work by inhibiting the release of prostaglandins, which cause inflammatory pain. Acetaminophen/paracetamol is not always included in this class of medications. However, acetaminophen may be administered as a single medication or in combination with other analgesics (both NSAIDs and opioids). The alternatively prescribed NSAIDs such as ketoprofen and piroxicam have limited benefit in chronic pain disorders and with long-term use are associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization. Common NSAIDs include aspirin, ibuprofen, and naproxen. There are many NSAIDs such as parecoxib (selective COX-2 inhibitor) with proven effectiveness after different surgical procedures. Wide use of non-opioid analgesics can reduce opioid-induced side-effects.


title: Pain management

text: Some antidepressant and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. They are generally used to treat nerve brain that results from injury to the nervous system. Neuropathy can be due to chronic high blood sugar levels (diabetic neuropathy). These drugs also reduce pain from viruses such as shingles, phantom limb pain and post-stroke pain. These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome. A common anti-epileptic drug is gabapentin, and an example of an antidepressant would be amitriptyline.


title: Pain management

text: Evidence of medical marijuana's effect on reducing pain is generally conclusive. Detailed in a 1999 report by the Institute of Medicine, "the available evidence from animal and human studies indicates that cannabinoids can have a substantial analgesic effect". In a 2013 review study published in "Fundamental & Clinical Pharmacology", various studies were cited in demonstrating that cannabinoids exhibit comparable effectiveness to opioids in models of acute pain and even greater effectiveness in models of chronic pain. It is mainly the THC strain of medical marijuana that provide analgesic benefits, as opposed to the CBD strain.


title: Pain management

text: Ketamine is a safe, effective alternative to opioids in the treatment of acute pain in the ED. Ketamine probably reduces pain more than opioids and with less nausea and vomiting.


title: Pain management

text: Other drugs which can potentiate conventional analgesics or have analgesic properties in certain circumstances are called analgesic adjuvant medications. Gabapentin, an anticonvulsant, can reduce neuropathic pain itself and can also potentiate opiates. Drugs with anticholinergic activity, such as orphenadrine, cyclobenzaprine, and trazodone, are given in conjunction with opioids for neuropathic pain. Orphenadrine and cyclobenzaprine are also muscle relaxants, and are useful in painful musculoskeletal conditions. Clonidine, an alpha-2 receptor agonist, is another drug that has found use as an analgesic adjuvant. In 2021, researchers described a novel type of pain therapy – a CRISPR-dCas9 epigenome editing method for repressing Na1.7 gene expression which showed therapeutic potential in three mouse models of chronic pain.


title: Pain management

text: Self-management of chronic pain has been described as the individual's ability to manage various aspects of their chronic pain. Self-management can include building self-efficacy, monitoring one's own symptoms, goal setting and action planning. It also includes patient-physician shared decision-making, among others. The benefits of self-management vary depending on self-management techniques used. They only have marginal benefits in management of chronic musculoskeletal pain. Some research has shown that self-management of pain can use different approaches. Those approaches can range from different therapies such as yoga, acupuncture,exercise and other relaxation techniques. Patients could also take a more natural approach by taking different minerals, vitamins or herbs. However, research has shown there is a difference between rural patients and non-rural patients having more access to different self-management approaches. Physicians in these areas may be readily prescribing more pain medication in these rural cities due to being less experienced with pain management. Simply put, it is sometimes easier for rural patients to get a prescription that insurance pays for instead of natural approaches that cost more money than they can afford to spend on their pain management. Self-management may be a more expensive alternative.


title: Pain management

text: The medical treatment of pain as practiced in Greece and Turkey is called algology (from the Greek άλγος, algos, "pain"). The Hellenic Society of Algology and the Turkish Algology-Pain Society are the relevant local bodies affiliated to the International Association for the Study of Pain (IASP).


title: Pain management

text: Undertreatment of pain is the absence of pain management therapy for a person in pain when treatment is indicated.