Author(s): Rezende KF, Bergami E, Alves KVB, Corsi I, Barbieri E
Titanium Dioxide Nanoparticles (TiO2NPs) could cause alterations in exposed aquatic species, in terms of oxygen consumption, ammonia excretion and tissues functionality therefore, the aim of the present study is to evaluate the effects of acute exposure to different concentrations of TiO2NPs (0.1, 0.5, 1.0 and 2.5 mgL-1) on routine metabolism (oxygen consumption and ammonia excretion) and histological parameters (branchial and hepatic) in Oreochromis niloticus. After 24 hours, we observed an increase in oxygen consumption of 2.36 and 3.23 times in groups exposed to 1.0 and 2.5 mgL-1 of TiO2 NPs respectively, as well as an increase in ammonia excretion of 3.54, 4.0 and 4.82 times higher in groups exposed to 0.5, 1.0 and 2.5 mgL-1 of TiO2 NPs respectively, compared to the control group. Histological analysis showed, after 72 hours, moderate to severe alterations in both gills and liver of TiO2 exposed fish at concentrations 1.0 and 2.5 mgL-1, the severity and occurrence of the alteration observed was grade 3 (severe and extensive pathological alterations). We concluded that waterborne exposure of Nile tilapia to TiO2 NPs caused alteration in routine metabolism and histological parameters in a dose-dependent manner.(AU)
Referred From: https://pesquisa.bvsalud.org/portal/resource/pt/vti-731193
Author(s): Baun A, Hartmann NB, Grieger K, Kusk KO
Author(s): Zhu X, Wang J, Zhang X, Chang Y, Chen Y
Author(s): Ju-Nam Y, Lead JR
Author(s): Xia J, Zhao HZ, Lu GH
Author(s): Shaw BJ, Handy RD
Author(s): Handy RD, Shaw BJ
Author(s): Çavas T, Ergene-Gozukara S
Author(s): Filho JDS, Matsubara EY, Franchi LP, Martins IP, Rivera LMR, et al.
Author(s): Schrand AM, Rahman MF, Hussain SM, Schlager JJ, Smith DA, et al.
Author(s): Gajewicz A, Rasulev B, Dinadayalane TC, Urbaszek P, Puzyn T, et al.
Author(s): Ivask A, Juganson K, Bondarenko O, Mortimer M, Aruoja V, et al.
Author(s): Smith CJ, Shaw BJ, Handy RD
Author(s): Chen J, Dong X, Xin Y, Zhao M
Author(s): Xiong DW, Fang T, Yu L, Sima X, Zhu W
Author(s): Campos-Garcia J, Martinez DT, Rezende KF, da Silva JR, Alves OL, et al.
Author(s): Barbieri E, Campos-Garcia J, Martinez ST, da Silva JR, Alves OL, et al.
Author(s): Cimbaluk GV, Ramsdorf WA, Perussolo MC, Santos HKF, Da Silva, et al.
Author(s): Arnold MC, Badireddy AR, Wiesner MR, Di Giulio RT, Meyer JN
Author(s): Felix LC, Ortega VA, Ede JD, Goss GG


|Year : 2016 | Volume
| Issue : 1 | Page : 89-93
Efficacy of tramadol and butorphanol pretreatment in reducing pain on propofol injection: A placebo-controlled randomized study
Arvinderpal Singh1, Geeta Sharma2, Ruchi Gupta1, Anita Kumari1, Deepika Tikko2
1 Department of Anesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
2 Department of Pharmacology, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
|Date of Web Publication||4-Feb-2016|
Dr. Arvinderpal Singh
Department of Anesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab
Source of Support: None, Conflict of Interest: None
Background and Aims: Pain of propofol injection has been recalled by many patients as the most painful part of the induction of anesthesia. Tramadol and butorphanol are commonly used analgesics for perioperative analgesia in anesthesia practice. However, their potential to relieve propofol injection pain still needs to be explored.
Material and Methods: A randomized, double-blind, placebo-controlled study was conducted on 90 American Society of Anesthesiologists I and II adult patients undergoing elective surgery under general anesthesia with propofol as an induction agent. Consecutive sampling technique with random assignment was used to allocate three groups of 30 patients each. Group I patients received an injection of normal saline 3 ml intravenously (placebo) while Group II and Group III patients received injection of tramadol 50 mg and butorphanol 1 mg intravenously, respectively. Before induction of anesthesia patients were asked about the intensity of pain on propofol injection by using visual analog scale (VAS) before the loss of consciousness. Descriptive statistics and analysis of variance with Chi-square test were used to analyze the data. The value of P < 0.05 was considered as a significant and P < 0.0001 as highly significant.
Results: The incidence of pain in Group I was observed in 80% of the patients, while it was observed in 23.33% and 20% of patients in Group II and III, respectively. Mean VAS scores were 2.27 ± 1.51, 1.14 ± 1.74, and 1.03 ± 1.72 in Group I, II, and Group III patients, respectively. The incidence of pruritus was 10% and 6.7% and erythema in 13.2% and 6.7% in Group II and III, respectively.
Conclusion: Pretreatment with both butorphanol and tramadol significantly reduced pain on propofol injection; however, they exhibited comparable efficacy among each other. Thus, either of these two drugs can be considered for pretreatment to reduce propofol injection pain.
Keywords: Butorphanol, pain, propofol, tramadol
|How to cite this article:|
Singh A, Sharma G, Gupta R, Kumari A, Tikko D. Efficacy of tramadol and butorphanol pretreatment in reducing pain on propofol injection: A placebo-controlled randomized study. J Anaesthesiol Clin Pharmacol 2016;32:89-93
|How to cite this URL:|
Singh A, Sharma G, Gupta R, Kumari A, Tikko D. Efficacy of tramadol and butorphanol pretreatment in reducing pain on propofol injection: A placebo-controlled randomized study. J Anaesthesiol Clin Pharmacol [serial online] 2016 [cited 2020 Oct 26];32:89-93. Available from: https://www.joacp.org/text.asp?2016/32/1/89/175703
| Introduction|| |
Propofol is a commonly used drug for induction of anesthesia because of its rapid onset and short duration of action, easy titration, and favorable profile for side effects. , However, despite these positive attributes, about 28-92% patients experience pain on injection of propofol, with one of three patients reporting severe or excruciating pain. , The mechanism of propofol injection pain is still unclear; it has been postulated to be due to either a direct irritant effect giving rise to an immediate sensation of pain or an indirect effect via the release of mediators such as bradykinin leading to a delayed onset.  As a result, several interventions have been investigated to alleviate the pain associated with propofol injection with varying results. Numerous physiological and pharmacological methods have been described in literature so as to decrease the incidence of this pain such as selection of a larger vein,  decreasing the speed of injection,  or diluting the propofol solution, or pretreatment with lignocaine, ondansetron, metoclopramide, opioids, and thiopentone. ,,,,,,,,, Tramadol a centrally acting analgesic can also possibly reduce the pain due to propofol injection. ,, We also hypothesized that intravenous (IV) administration of butorphanol, a synthetic opioid agonist - antagonist can also reduce pain during induction with IV propofol. It is a kappa receptor agonist, as well as a mu-receptor antagonist, resulting in analgesic and sedative properties without profound respiratory depression or euphoria.  Studies comparing butorphanol with tramadol in reducing the propofol-induced pain are sparse. Hence, we conducted this randomized, double-blind, placebo-controlled study to compare the efficacy of pretreatment with butorphanol and tramadol for alleviation of pain associated with propofol injection.
| Material and Methods|| |
After obtaining approval from the Institutional Ethical Committee and written informed consent of the study subjects, this prospective study was conducted on 90 adult patients belonging to the American Society of Anesthesiologists (ASA) Grade I and II in the age group of 18-60 years scheduled for elective surgery under general anesthesia with propofol as an induction agent. Consecutive sampling technique with random assignment was used to allocate to one of the three groups of 30 patients each and respective drugs were given intravenously in the volume of 3 ml prior to injection of propofol. Patients with a history of chronic pain syndromes, thrombophlebitis, neurological disease, and allergy to the study drugs were excluded from the study. The patients having difficulty in communication were also excluded from the study. The patients were informed of the possibility of a "burning sensation" in the forearm during induction of anesthesia.
The drugs were prepared in identical syringes and in equal volume by the anesthesia technician who was unaware of the study design and were marked with different codes (I, II, III) so that even the anesthesiologists who were recording the observations remained blinded to the drug. A detailed preanesthesia checkup was conducted wherein the patients were educated on the use of visual analog scale (VAS) for assessment of pain during the perioperative period. All patients were advised to be kept nil per oral for 8 h prior to surgery and received uniform premedication in the form of tablet ranitidine 150 mg and tablet alprazolam 0.25 mg night before surgery. In the operating room, an IV line was secured in a peripheral vein on the dorsum of the hand with an 18-gauge IV cannula. The following monitoring was instituted: electrocardiogram for heart rate and rhythm, systolic blood pressure, diastolic blood pressure and mean arterial pressure, respiratory rate, and oxygen saturation. Recording of these parameters was done before induction, during induction, intraoperatively every 2 min up to first 10 min and thereafter every 5 min until the end of the surgical procedure.
Group I patients received injection normal saline 3 ml IV (placebo), while Group II and Group III patients received injection tramadol 50 mg and injection butorphanol 1 mg IV, respectively, made up to 3 ml by adding normal saline in a blinded manner.
Patients were preoxygenated with 100% oxygen for 3 min. A tourniquet was applied and inflated to 70 mm Hg in which the IV line was secured. Then the study drugs (tramadol, butorphanol, and placebo) were administered through IV cannula at the rate of 0.5 ml/s. After 2 min of injecting the study drug, tourniquet was deflated and immediately injection propofol 2.5 mg/kg at the rate of 0.5 ml/s was administered for induction of anesthesia. Patients were asked about the intensity of pain on propofol injection by using pain VAS on a range of scores from 0 to 100 before the loss of consciousness.  Side effects such as erythema, pruritus, sensation of heat, and allergic reaction were noted postoperatively immediately after the surgery and then 24 h after surgery.
Based on the distribution of pain VAS scores in postsurgical patients who described their postoperative pain intensity as none, mild, moderate, or severe the following cut points on the pain VAS have been recommended for this study: No pain (0-4 mm); mild pain (5-44 mm); moderate pain (45-74 mm); and severe pain (75-100 mm).
Based on the results of the previous study and assuming Type-I error (α) at 0.05, Type II error (β) at 0.1, and power of the study at 80% so as to detect a difference of 20% in the incidence of pain between the study and control groups the sample size was calculated as 26 patients in each group. However, we chose 30 patients in each group considering possible dropouts and for better validation of results. The decoding of drugs was done at the end of the study, and the entire data were compiled and analyzed by using analysis of variance and Chi-square test. Post-hoc significance test was done to validate the statistical results. Analysis was performed using statistical software Statistical Product for Social Sciences (SPSS version 11.0 for Windows, Chicago, SPSS Inc.). All the values were expressed as a mean ± standard deviation (SD); range; or percentage. Results were considered statistically significant when P value was <0.05.
| Results|| |
The demographic profile was comparable in all the three groups [Table 1]. The incidence of pain in Group I was observed in 80% of the patients [Table 2]. In Group II, 7 patients out of 30 felt pain accounting for an incidence of 23.33%, while in Group III, 6 patients out of 30 felt pain with an incidence of 20%. In Group I, the mean score of pain was (VAS ± SD) 2.27 ± 1.51 while it was 1.14 ± 1.74 and 1.03 ± 1.72 in Group II and Group III patients, respectively [Table 3]. On statistical analysis, VAS in Group I was statistically significant as compared to Group II and III (P < 0.001). The other side effects observed besides pain included pruritus and erythema. In Group II and Group III, pruritus was seen in three (10%) and two (6.7%) patients, respectively, while erythema was observed in four (13.2%) and two (6.7%) patients, respectively, in Group II and III. The overall incidence of pruritus and erythema was 23.2% and 13.4% in Group II and III, respectively, which were statistically insignificant [Table 4].
| Discussion|| |
The results of our study imply a significant reduction in pain on propofol administration after pretreatment with tramadol or butorphanol in comparison to the control placebo group. Intergroup comparison revealed that the incidence and severity of pain with propofol injection was less in the study Groups (II and III) when compared to the control group (I), but comparable efficacy was observed among both the study drugs.
We chose a control group in this study by administering a placebo so as to gauge the efficacy of tramadol and butorphanol for the amelioration of propofol injection pain, rather than opting for traditionally established gold standard lignocaine pretreatment. Moreover, with the focus shifting to newer drugs in a quest to find a better alternative to alleviate the pain on propofol injection, it seems reasonable to use opioids as a part of standard induction regime.
Opiates were shown to exert peripheral analgesic action in addition to their well-known central effects though a clear-cut discrimination between peripheral and central analgesics is debatable.  The analgesia produced by both peripheral and central mechanisms may be additive or even synergistic. Moreover, peripheral opioid receptors have been described and shown to mediate analgesic effect when activated by opioid agonists. , The analgesic effect observed in our study with both tramadol and can be attributed to the peripheral analgesic effect secondary to their venous retention for 2 min.
The higher incidence of patients (80%) experiencing higher mean VAS scores (2.27 ± 1.48) in Group I (placebo) are comparable with the 74-83% incidence reported by various other studies. , Tramadol has also been found to be as effective as lignocaine in reducing the incidence and severity of propofol-induced pain. Moreover, it also grants an added advantage of intraoperative analgesia.
Tramadol is a centrally acting weak μ-receptor agonist which inhibits noradrenaline re-uptake as well as promotes serotonin release, potentiates the monoaminergic system and can be used to treat moderate and severe pain.  In addition to its systemic effect, the local anesthetic effect of tramadol on peripheral nerves has been shown in both clinically and laboratory studies. ,, Desmeules et al. confirmed that the analgesic effect of tramadol is apportioned between the opioid and monoaminergic components.  Jou et al.  suggested that tramadol affects sensory and motor nerve conduction by a similar mechanism to that of lidocaine which acts on the voltage-dependent sodium channel leading to axonal blockage.
Butorphanol is 5-8 times more potent than morphine. After the IV administration, the onset of analgesia occurs within 1 min with a peak effect in about 4-5 min. The site of action of butorphanol in reducing the pain of propofol injection is not clear, but it could be either through opioid receptors (central and or peripheral), local anesthetic action, or both. The incidence of pain on propofol injection in this study after pretreatment with butorphanol was observed to be approximately 20%. This incidence is almost similar to the findings of earlier study by Aggarwal et al. who reported an incidence of merely 20% on propofol injection while using butorphanol as pretreatment.
The incidence of pain observed in the tramadol group (23.33%) in the our study was comparable to the results of Wong and Cheong  who compared lignocaine with placebo and observed an incidence of 27% and 83%, respectively (P < 0.001). Thus, it can be inferred that tramadol is as effective as lignocaine in alleviating propofol injection pain thereby granting the patient a smoother comfortable experience of propofol induction.
Fewer side effects, like pruritus and erythema, were observed with tramadol pretreatment (10% and 13.2%, respectively) while this incidence decreased further with butorphanol pretreatment (6.7%). The findings of our study are nearly similar to the results of Martin et al. who reported a similar incidence of pruritus and erythema with tramadol pretreatment.
| Conclusion|| |
Thus, we conclude that pretreatment with perioperatively used opioids tramadol 50 mg or butorphanol 1 mg effectively reduced the pain of propofol injection with fewer self-limiting mild side effects such as pruritus and erythema. Though statistical significance could not be achieved among both study drugs, we propose future studies exploring use of both tramadol and butorphanol as a pretreatment in relieving pain on propofol injection in large samples of surgical population.
Authors are grateful to the staff of Anaesthesia Department of our institute for their cooperation. We are also grateful to statistician for helping us in the statistical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Jalota L, Kalira V, George E, Shi YY, Hornuss C, Radke O, et al.
Prevention of pain on injection of propofol: Systematic review and meta-analysis. BMJ 2011;342:d1110.
Marik PE. Propofol: Therapeutic indications and side-effects. Curr Pharm Des 2004;10:3639-49.
Picard P, Tramèr MR. Prevention of pain on injection with propofol: A quantitative systematic review. Anesth Analg 2000;90:963-9.
Scott RP, Saunders DA, Norman J. Propofol: Clinical strategies for preventing the pain of injection. Anaesthesia 1988;43:492-4.
Jamuna T, Nicolas Israel Y. Prospective and comparative study of the analgesic effect of intravenous 2% xylocard versus intravenous tramadol in ameliorating propofol injection pain. J Evid Based Med Healthc 2015;2:3529-39.
Barker JP, Kamath BS. Prevention of pain on injection. Br J Anaesth 1988;60:243.
Mok MS, Pang WW, Hwang MH. The analgesic effect of tramadol, metoclopramide, meperidine and lidocaine in ameliorating propofol injection pain: A comparative study. J Anaesth Clin Pharmacol 1999;15:37-42.
Ambesh SP, Dubey PK, Sinha PK. Ondansetron pretreatment to alleviate pain on propofol injection: A randomized, controlled, double-blinded study. Anesth Analg 1999;89:197-9.
Pang WW, Mok MS, Huang S, Hwang MH. The analgesic effect of fentanyl, morphine, meperidine, and lidocaine in the peripheral veins: A comparative study. Anesth Analg 1998;86:382-6.
Lee TW, Loewenthal AE, Strachan JA, Todd BD. Pain during injection of propofol. The effect of prior administration of thiopentone. Anaesthesia 1994;49:817-8.
Wong WH, Cheong KF. Role of tramadol in reducing pain on propofol injection. Singapore Med J 2001;42:193-5.
Aggarwal A, Raza M, Dhiraaj S, Pandey R, Gupta D, Pandey CK, et al
. Pain during injection of propofol: The effect of prior administration of butorphanol. Anesth Analg 2005;100:903-6.
McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: A critical review. Psychol Med 1988;18:1007-19.
Jensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: A reanalysis of two clinical trials of postoperative pain. J Pain 2003;4:407-14.
Borazan H, Sahin O, Kececioglu A, Uluer MS, Et T, Otelcioglu S. Prevention of propofol injection pain in children: A comparison of pretreatment with tramadol and propofol-lidocaine mixture. Int J Med Sci 2012;9:492-7.
Stein C, Schafer M, Cabot PJ, Carter L, Zhang Q, Zhou L, et al
. Peripheral opioid analgesia. Pain Rev 1997;4:171-85.
Tariq M, Kamran M. Incidence of pain on propofol injection and efficacy of addition of lignocaine or selecting big vein or both combined in reducing it: A randomized control trial. JPMI 2006;20:8-11.
Altunkaya H, Ozer Y, Kargi E, Babuccu O. Comparison of local anaesthetic effects of tramadol with prilocaine for minor surgical procedures. Br J Anaesth 2003;90:320-2.
Pang WW, Huang PY, Chang DP, Huang MH. The peripheral analgesic effect of tramadol in reducing propofol injection pain: A comparison with lidocaine. Reg Anesth Pain Med 1999;24:246-9.
Desmeules JA, Piguet V, Collart L, Dayer P. Contribution of monoaminergic modulation to the analgesic effect of tramadol. Br J Clin Pharmacol 1996;41:7-12.
Jou IM, Chu KS, Chen HH, Chang PJ, Tsai YC. The effects of intrathecal tramadol on spinal somatosensory-evoked potentials and motor-evoked responses in rats. Anesth Analg 2003;96:783-8.
Martin SM, Pang WW, Hwang MH. The analgesic effect of tramadol, metoclopramide, meperidine and lidocaine in ameliorating propofol injection pain: A comparative study. J Anaesth Clin Pharmacol 1999;15:37-42.
[Table 1], [Table 2], [Table 3], [Table 4]


Availability: Usually ships in 3-4 business days. + Available in e-book formats - see bottom of page.
Veronica's Happily Ever After
by Chantal Bellehumeur
As Veronicas relationship with her boyfriend, Scott, gets more serious, her happiness grows more than she ever thought possible. Everything she ever dreamed of, and more, is finally coming true. Instead of running away with fear, she embraces everything good that comes her way because she realises that she deserves it all. Of course, not every moment of her life is perfect. Veronicas third and final diary is filled with the obstacles she must overcome to reach her goals.About the Author
Chantal was born on June 30, 1981, and she lived in Toronto and Ottawa during her childhood. At the age of fourteen, she took acting classes to overcome her shyness, and theatre soon became her favourite hobby. Chantal performed in a few amateur stage productions, joined a youth-run theatre company, and studied theatre at Concordia University. Her acting career was put on hold once her son, Aidan, was born, but she still worked as an extra in movies, television shows, and commercials.
Chantal took up writing as a hobby because her head was always filled with ideas. She wrote Veronicas Soap Opera Life, her first novel, in 2009 and published the sequel that same year. Chantal continued her creative writing with Just.Another.Common.Killer in 2010.(2010, paperback, 98 pages)


In her beautifully written book, Ten Hills Farm: The Forgotten History of Slavery in the North, C.S. Manegold tells the story of, among others, Isaac Royall Jr., who came into possession of Ten Hills Farm (which lay along the Mystic River near Medford, Massachusetts) upon the death of his father in 1739.
In the course of her review of Isaac Jr., Ms. Manegold discusses a painting of Isaac and his family created by Robert Feke in 1741. I was so struck by the picture - and Ms. Manegold's description - that I thought I'd share it with you, particularly since the original is virtually inaccessible - "hiding in plain sight" in a room within Harvard's Law School, "a place so forbidding and obscure it seldom sees a visitor."
At the right is 22 year old Isaac, "wear[ing] an imperious expression," "undeniably the painting's hero." To his right (the viewer's left), "all in a row like bobbins - sit his women." Immediately to his right is his 19 year old wife Elizabeth, a Scottish heiress, "a solid figure, someone who might have thrived just as well carrying pails of milk and churning butter." Elizabeth holds their daughter.
Next to Elizabeth is her sister, Mary Palmer (nee McIntosh). "Sweet-faced and unfocused," smiling Mary seems both "sympathetic" and "fragile," "as though life might come and knock her down."
Finally at the far left is Isaac's sister Penelope, who "exudes detachment, as though she only deigns to sit at her brother's insistence."
Missing are the sources of the family's wealth. "Not a brushstroke creates the shadow of a slave."
If you want to get a book for Juneteenth, Ms. Manegold's work would make an excellent choice.


O come, O come, thou Lord of might, who to thy tribes, on Sinai’s height,
in ancient times didst give the law in cloud and majesty and awe.
“Now Mount Sinai was wrapped in smoke because the Lord had descended on it in fire. The smoke of it went up like the smoke of a kiln, and the whole mountain trembled greatly. And as the sound of the trumpet grew louder and louder, Moses spoke, and God answered him in thunder.”
Adonai, the lawgiver, is a mighty and awesome presence before his people on Mount Sinai. But what a contrast between that God who caused the mountain to tremble and smoke when he visited it, and his Son who willingly gave up his glory and might to be born a helpless baby to ordinary parents and in the most humble of circumstances. The truth of the gospel is full of contrasts and it is often easy for us to miss the depth those contrasts are meant to show us. There are times when it is easy for us to relate to the conquering God who brushes aside the enemies of his people with his powerful right arm–times when we feel threatened by the people and circumstances that seem about to overwhelm us. In those times, we are not so much drawn to Jesus as a baby who was completely reliant on the goodwill and care of his earthly parents, nor to him as a condemned man standing silent and humiliated before his accusers.
Advent is a time to consider Jesus as our God, willing to humble himself and lay down his vast glory. As we consider his humility, it is helpful for us to reflect on the words God inspired Paul to write in Colossians 3, “Put on then, as God’s chosen ones, holy and beloved, compassionate hearts, kindness, humility, meekness, and patience, bearing with one another…” When we demand to be given what we believe we are due, or are unwilling to continue to walk through the trials we are called to face, we are acting in direct opposition to the life Jesus modeled for us–the life he calls his people to live. If we desire to bring honor to the one whom we follow, love, and celebrate, we do well to picture the quaking, smoking mountain…and then turn our gaze and our hearts to the baby in the lowly manger.
Father, we are deeply moved when we consider the height of Christ’s glory and the shocking humility demonstrated by his coming to earth. Help us to stand in awe of your glory and greatness and to rejoice in the unfathomable love demonstrated by Christ’s lowly birth and his unspeakable suffering and death, all for our benefit. Help us to respond in humble obedience with great joy.


For quite some time, clinical researchers have known that chronic back pain can lead to major depression, as discussed previously (See Worz, 2003 for a review). Newer studies are now looking at how psychological variables such as depression and anxiety may be linked to the onset of a back pain problem. For example:
- Atkinson, Slater, Patterson, Grant, and Garfin (1991), in a systematic study of depressed male Veterans Administration chronic pain patients, found that 42% of patients experienced the onset of depression prior to the onset of pain, whereas 58% experienced depression after the pain began.
- Polatin et al. (1993) reported that 39% of the chronic low back pain patients they evaluated displayed symptoms of pre-existing depression.
- More recently, in a review of research studies in this area, Linton (2000) found that in 14 of the 16 reviewed studies, depression was found to have increased the risk for developing back pain problems.
Depression Impacts Spine Surgery Outcome
Research has clearly demonstrated that non-physical variables such as depression, anxiety, thought patterns, and personality style can impact a spine surgery outcome (See Block, Gatchel, Deardorff & Guyer, 2003 for a review). Unfortunately, it appears that in many cases, having a major depression may not bode well for the outcome of a spine surgery.
For instance, as discussed by Block et al. (2003), spine surgery patients who are clinically depressed pre-operatively may continue to display depressive symptoms post-operatively and these can negatively impact the surgery outcome. Particular symptoms that may impede post-operative recovery include such things as low motivation, sleep disturbance, slower healing time, difficulty with physical rehabilitation and inability to perceive improvements (Block et al, 2003; Deardorff and Reeves, 1997).
In This Article:
Pre-surgery Considerations for Patients with Depression
Block et al. (2003) discuss that, in looking at the issue of depression and spine surgery outcome, it is important to consider whether the individual is experiencing a "reactive depression" or shows a pre-injury history of more chronic depression. A reactive depression is defined as depressive symptoms in response to the chronic back pain and associated problems (loss of work, friends, etc). Reactive depression occurs in back pain patients who have no previous history of depression. However, many chronic back pain patients have a history of problems with depression even before the onset of the back pain. As reviewed previously, individuals with chronic depression may be at greater risk for developing a low back pain condition. It is also likely that this same group is at greater risk for a poorer outcome to spine surgery (Block et al., 2003).
If a patient is facing a spine surgery and has a chronic back pain problem with significant depression, he or she may want to consider postponing the surgery until the depression can be treated. Treatment for depression is often part of a preparation for spine surgery program (See Block et al., 2003; Deardorff and Reeves, 1997).


The Book of Jasher
|LXVIII:1 And it was at that time the spirit of Elohim was upon Miriam the daughter of Amram the
sister of Aaron, and she went forth and prophecied about the house, saying, Behold a son will
be born unto us from my father and mother this time, and he will save Israel from the hands
LXVIII:2 And when Amram heard the words of his daughter, he went and took his wife back to
the house, after he had driven her away at the time of Pharaoh ordered every male child of
the house of Jacob to be thrown into the water.
LXVIII:3 So Amram took Jochebed his wife, three years after he had driven her away, and he came
to her and she conceived.
LXVIII:4 And at the end of seven months from her conception she brought forth a son, and the
whole house was filled with great light as of the light of the sun and moon at the time of
LXVIII:5 And when the woman saw the child that it was good and pleasing to the sight, she hid it
for three months in an inner room.
LXVIII:6 In those days the Egyptians conspired to destroy all the Hebrews there.
LXVIII:7 And the Egyptian women went to Goshen where the children of Israel were, and they
carried their young ones upon their shoulders, their babes who could not yet speak.
LXVIII:8 And in those days, when the women of the children of Israel brought forth, each woman
had hidden her son from before the Egyptians, that the Egyptians might not know of their
bringing forth, and might not destroy them from the land.
LXVIII:9 And the Egyptian women came to Goshen and their children who could not speak were
upon their shoulders, and when an Egyptian woman came into the house of a Hebrew woman
her babe began to cry.
LXVIII:10 And when it cried the child that was in the inner room answered it, so the Egyptian
women went and told it at the house of Pharaoh.
Commentary on Jasher LXVIII:1 (27 May 2009):
Originally Written: 27 May 2009
Latest Update: 27 May 2009
Return to Zadok Home Continue . . . Return One Page Go to Jasher Introduction


Thank goodness I'd already read the original Flashman so I knew what was coming, or else I might have given up on this early on. The first 80 pages arThank goodness I'd already read the original Flashman so I knew what was coming, or else I might have given up on this early on. The first 80 pages are all about cricket, which may be fascinating to a Brit, but to an American was like reading a foreign (and boring) language. However, I knew enough about Flashy to keep reading, and it was well worth it. What followed were two great - if disjointed - stories of Flashman in Singapore/Borneo and then a totally bizarre Madagascar that reads like a missing section of Gulliver's Travels; how had I never heard of Queen Ranavalona before??
Other than the overlong cricket section, the book also suffered from a lack of resolution in several places - main characters and story arcs like Brooke and Don Solomon (and whole continents like Asia) just disappear with no explanation. But what remained was all 4-star excellent. By description only, Flashman should be a buffoon or a cartoon character, but thanks to Fraser's excellent writing and voice he comes across as surprisingly human and sympathetic, if not necessarily someone you'd want as a travel companion....more
My good friend (and Goodreads buddy) Jim has been trying to get me to read Flashman for years, but somehow I never got around to it. However, finallyMy good friend (and Goodreads buddy) Jim has been trying to get me to read Flashman for years, but somehow I never got around to it. However, finally picked this up and was totally hooked - there's a reason he's become such an iconic figure. He's like a 19th Century Forrest Gump - if Forrest was British, way smarter, and a total (yet for some reason, still likeable) asshole.
It probably helps to have at least a basic knowledge of the British Empire and its colonial skeletons, but there are so many events from that period that I've heard of but don't really understand - the Khyber Pass, the Light Brigade, Balaclava, etc. - and these books look like a really enjoyable way to learn a little history. As I'm currently sitting in a really lame Sheraton in Borneo, I can't wait to get my hands on a copy of Flashman's Lady, which is about Flash's adventures with James Brook, the "White Rajah" of Sarawak....more
“This book is to be neither an accusation not a confession, and least of all an adventure, for death is not an adventure to those who stand face to fa“This book is to be neither an accusation not a confession, and least of all an adventure, for death is not an adventure to those who stand face to face with it. It will try simply to tell of a generation of men who, even though they may have escaped shells, were destroyed by the war.”
From these opening words to the very last page (which finally explains the title in one last heartbreaking irony), this book is a beautiful, brutal history lesson that is perhaps even more relevant today than it was in 1929.
Reading All Quiet on the Western Front was a perfect follow-up to Winston Groom’s excellent non-fiction account of the same trench warfare, A Storm in Flanders - “perfect,” that is, if you want to be intelligently and elegantly led into a totally bleak assessment of how (not) far the human race has really come. Western Front doesn’t really have much of a plot. It is more a beginning-to-end series of arresting scenes and images. The telling details simply noted in passing – the rows of fresh yellow coffins, still smelling of pine and resin; the blue faces and black tongues of the gassed corpses; the frozen clods of winter earth, which during shelling attacks become as deadly as the bomb fragments themselves; the panicked soldiers pissing into a bucket so that the water-cooled machine gun can keep firing – are painful in their precision; this is a book that was lived, not researched. And indeed, Remarque has described the book as being “simply a collection of the best stories I told, and that my friends told, as we sat over drinks and relived the War.” Understanding that, you can see how each story could have come from a different soldier – leave, killing in the crater, sex in the hospital, the Russian prisoners, guarding the supply dump – yet he weaves them into a single narrative that is both breathtaking and heartbreaking.
At times, our hero’s ruminations can get, well, too German: “In the quiet hours when the puzzling reflection of former days like a blurred mirror, projects beyond me the figure of my present existence, I often sit over against myself, as before a stranger, and wonder how the unnamable active principle that calls itself to life has adapted itself even to this form.”
But most of the time, Remarque’s prose is eloquent, spare and pointed:
“Our artillery is fired out, it has too few shells and the barrels are so worn they shoot uncertainly, and scatter so widely as even to fall on ourselves. We have too few horses. Our fresh troops are anemic boys in need of rest, who cannot carry a pack, but merely know how to die. By thousands. They understand nothing about warfare, they simply go on and let themselves be shot down. A single flyer routed two companies of them for a joke, just as they came fresh from the train – before they had ever heard of such a thing as cover.”
“Bertinick has a chest wound. After a while a fragment smashes away his chin, and the same fragment has sufficient force to tear open Leer’s hip. Leer graons as he supports himself on his arm, he bleeds quickly, no one can help him. Like an emptying tube, after a couple of minutes he collapses.
“What use is it to him now that he was such a good mathematician at school.”
“A word of command has made these silent figures our enemies. And a word of command might transform them into our friends. At some table a document is signed by some persons whom none of us knows, and then for years together that very crime on which formerly the world’s condemnation and severest penalty fall, becomes our highest aim.”
No wonder Hitler ordered this book burned.
It’s funny: I’m always surprised that so many of the “modern” weapons are war are older than I thought. I always associate napalm with Vietnam, but it was used much earlier and with devastating effect on Tokyo and Dresden. And I always think of flamethrowers in WWII, but they were introduced in the trenches of Belgium along with poison gas and that other and apparently most frightening innovation: the tank. “We do not see the guns that bombard us; the attacking lines of the infantry are men like ourselves; but these tanks are machines, their caterpillars run on as endless as the war, they are annihilation, they roll without feeling into the craters, and climb up again without stopping, a fleet of roaring, smoke-belching armor-clads, invulnerable steel beasts squashing the dead and wounded – we shrivel up in our thin skin before them, against their colossal weight our arms are sticks of straw, and our hand grenades matches.”
I was mad at the Germans after reading Flanders, and I’m mad at them still – just as I’m mad at all the people behind (so very far behind) the war. But Paul Baumer could just as well have been British or French - or Japanese and Vietnamese. He is an eloquent everyman, a good soldier who is at the same time one of the strongest anti-war voices who has ever spoken.
This is a book that truly should be read by everyone; it is a book I should have read years ago and should just be rereading now for the third or fourth time.


Main Article Content
malnutrition, diet, quality of life, elderly
Introduction: This study aims to evaluate the relationship between malnutrition, diet quality and health-related quality of life among the elderly in Famagusta, Cyprus.
Materials and Methods: This study was conducted with 279 individuals aged 65 and over who were living in Famagusta, Cyprus between February 2017 and May 2018. Data was collected via one-to-one interviews using the following evaluation forms. The Mini Nutritional Assessment (MNA) evaluated demographic characteristics, nutritional habits, 24-hour retrospective food consumption records and risk of malnutrition. The Medical Outcome Study Short Form (SF-36) evaluated quality of life. In addition, participants’ body weight, height, waist, hip, mid-upper arm and calf circumferences were measured using appropriate techniques.
Results: Of the participants, 5.4% had malnutrition, and 9.3% were at risk of malnutrition. Participants over the age of 85 had the highest risk of malnutrition (p <0.05). Males had a higher physical and mental quality of life and a lower risk of malnutrition than females (p <0.05). Those without a risk of malnutrition had a higher mental and physical quality of life than those with a risk of malnutrition (p <0.001). As diet quality increased, the physical quality of life increased. And as the quality of physical and mental life increased, the risk of malnutrition decreased (p <0.05).
Conclusion: Increased age is associated with increased risk of malnutrition. Males have a lower risk of malnutrition than females. As the quality of diet increases, the physical quality of life increases. And as the quality of physical and mental life increases, the risk of malnutrition decreases. Planning further cross-sectional, longitudinal and intervention studies with larger sample sizes to evaluate other factors that affect the relationship between malnutrition, diet and health-related quality of life in the elderly, is significant in terms of developing preventive public health policies.
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2 Corinthians 3:2-3 (NIV)
2 You yourselves are our letter, written on our hearts, known and read by everyone. 3 You show that you are a letter from Christ, the result of our ministry, written not with ink but with the Spirit of the living God, not on tablets of stone but on tablets of human hearts.
Some of these meanings from my bible: The Life Application Bible is confusing. This is what it says for this verse 3. Paul uses powerful imagery from famous Old testament passages predicting the promised day of new hearts and new beginnings for God’s people. No human minister can take credit for this process of conversion. It is the work of God’s Spirit. We do not become believers by following some manual or using some technique. Our conversion is a result of God’s implanting his Spirit in our hearts, giving us new power to live for him.
NO WE BECOME BELIEVERS BY FOLLOWING THE TEACHINGS OF BIBLE THAT WE HEAR FROM THE WORD OF GOD!


About That (Про это) is a poem by Vladimir Mayakovsky written during the self-imposed two-months "exile" after a row with Lilya Brik. It was finished on 11 February 1923 and published on 29 March 1923, originally by the LEF magazine. The poem's first separate edition was illustrated by Alexander Rodchenko who in his montages used photographs made by Mayakovsky and Lilya Brik.
In summer 1922 Lilya Brik fell in love with Alexander Krasnoshchyokov, the then head of the newly formed Prombank. Mayakovsky was outraged, a quarrel ensued and the terms of the two-month separation have been agreed between the two. As a result, the poet departed to his 'boat-room' at the Lybyansky Lane, 3/6, "banned" from visiting the Briks at their Vodopyany Lane home. There, working for 16-20 hours a day, he wrote About That. On 11 February it was finished. "That was arguably my best poem in terms of the editorial work done upon it," he later wrote in a preface to the compilation This Year's Things.


Night of the Monster Men continues this week in Nightwing #6. What does Hugo Strange have up his sleeve?
Written by: Tim Seeley, Steve Orlando
Art by: Roge Antonio
U.S. Price: $2.99
“NIGHT OF THE MONSTER MEN” part five! The hunt for Hugo Strange rages onward as the Manipulator rises and uses the citizens of Gotham City to shield itself from the Bat-Family. All while the monstrous version of Nightwing looms over Gotham City.
via DC Comics


MY NIGHT AT JOHN NORTH HOUSE
Aha! So that’s the house I heard rumors about. Surely my family can’t believe it’s haunted?
After parking on a steep rise above the town center I stared at the rambling brick mansion with Georgian windows and a balcony that overlooked the front porch where pumpkins were lined up like sentries that day. When I peered through a window I saw a huge fireplace and an oak table formally laid out with candlesticks. It was easy to imagine the gracious lives of its nineteenth century owners.
But the house is a brooding presence over a narrow street and harbors unhappy memories. Someone looking out of the window during the Civil War could have witnessed skirmishes and heard cannonballs whizzing overhead. They might even have seen Col. George Crook leading a cavalry charge through the town, and bodies lying in the street.
Those thoughts quickly faded when Aimee and Paul swung the door to welcome me inside with open arms and to savory aromas from their kitchen. But after a hearty meal and chatting about old Lewisburg they gave me a book, saying, “Don’t let spooky stories keep you awake tonight!” I grinned like most scientists would. I was sure they were only tales and there was always an absence of evidence, although that does not necessarily mean evidence of absence.
Afterwards I climbed a steep staircase to my bedroom on the second floor. Apparently, it had not changed much over the years apart from a few modern paintings: a four-poster bed dominated the room with a night stand separating it from a large closet. I padded across the plank floor to pull aside a sheer curtain for cracking open the window. Looking through the darkness towards the sleeping town I remembered our earlier walk through the graveyard and the tourists standing in the unlit street below.
My family was settling down for the night, but I did not feel sleepy yet. After getting ready for bed I dove under the comforter and, pushing the book aside, turned over on my back to fix my eyes on the high ceiling and recall the evening.
Following dinner, Paul had invited me for a stroll around town with his nine-year-old son while the two younger boys were packed off to bed by Aimee. I took Alex by the hand while he carried his Magic Quest wand in the other. At our street corner we noticed a group of people huddled in the gathering dusk. One of the men who was pointing at the house and speaking stopped when they turned to stare at us.
“Who are they?” I asked.
“We are on the town ghost tour,” Paul said. “It’s popular at this time.”
“They looked at us like we are celebrities. I guess they are curious about who lives here.” I was tempted to ask them if they really believed in ghosts, but not wanting to spoil the entertainment for visitors I only waved. It was just a bit of fun, wasn’t it?
We strolled down the hill to the main street a couple of blocks away. It had shut down for the night. Stools were up-ended on tables in the coffee shop and someone was locking a restaurant door. The only signs of life were customers in an Irish pub where a trombone was being played loudly.
We turned down a side street past the glow of floodlights around the Carnegie Hall to reach the gloomier end of Church Street. Paul urged us to take a short cut past Old Stone Presbyterian Church, which is said to be the oldest west of the Alleghenies, and where the Confederate dead were laid out. Alex was reluctant to cross the graveyard at that hour, but he used his wand to zap things I never dreamt of. As we wandered among the gravestones I told him that when I was a cub scout our parents let us walk home alone and we dared each other to cross the town cemetery. We didn’t want to be called “sissy.” No one ever saw anything eerie, of course, although when I grew up I wondered if I was insensible to the occult.
Now, after propping myself up in bed with a pillow, I opened the book to the story about the John North House where I was staying. It told of a young woman who fell in love with a Union soldier garrisoned in her home town in South Carolina during the Civil War. After she tried to run off with him, her mother sent her to stay with relatives at this house until his regiment moved away. She hoped her daughter would forget him, but the lass was broken-hearted, shut herself away at the top of the house and refused to join the family or attend church. On a visit back home for Christmas her parents were so alarmed to see how thin and depressed she had become that they invited the soldier to see her under strict supervision. But when they were distracted for a moment he whispered a plan to elope after she returned to Lewisburg.
When he was free to follow her, the relatives turned him away. He stood at the street corner every day hoping to see her at the window of the bedroom where I was now curled up inside. They never met again before he rejoined his regiment, though he asked local children to deliver fresh flowers to the house every day.
As months passed without news she wondered if he had been killed in battle and sank back into despair. One day when she failed to reply to her uncle’s calling and could not possibly have left the house unnoticed, he came upstairs for her. He found her in the closet hanging by the cord of her robe. The story didn’t quite end there because a Union soldier (some say it was her lover) was shot afterwards in the street below. Passersby then began reporting the sight of a strange young woman on the second story of the house and a man’s apparition in the street, though never on the same day. The gossip continued into modern times.
Unhappy souls unable to rest during heart-rending times are usually the core of ghost stories and prone to exaggeration and invention, so it was time to put this one to rest. Closing the book, I drifted off but never sleep soundly in a strange bed and Paul’s stories kept breaking into my consciousness. Perhaps they disturbed me more because I know him well enough not to dismiss his talk lightly. The nightlight was still burning when I woke up with his stories on my mind….
He had told me that before marrying Aimee she was living in the house on her own. She sometimes heard banging at night as if doors were suddenly flying open for no reason, and a mysterious clip, clip, clip on the stairs sounded like the hard indoor soles women wore in the past. Other family members reported the same things, and a robust young man who helped them move furniture refused to enter the house because of its reputation. On one occasion she thought she heard a relative arriving late and was surprised he was gone by the morning. When she called him he denied ever being there…
As I continued to drift in and out of sleep other stories kept popping into my mind. After Aimee and Paul married, the house was flooded one day with water that seemed to come from nowhere, and a loud bang that sent their dog into a fit of barking was never explained. On another occasion when an old transom broke in the porch where he was working and an upstairs window shattered soon afterwards he thought a boy was throwing rocks at the house, but the street was empty. Paul then decided to visit the previous owner, hoping he could throw light on these strange events.
“Neighbors sometimes saw an unfamiliar woman at the window or balcony,” the man said. “And the young couple living in the house before you smelled fresh flowers when none had been brought in…”
I dozed off again, convinced there are always natural explanations if one only looks hard enough. Scientists are dismissive of the paranormal, just as I had been as a cub scout. But the next time I woke it was with a start, perhaps because the room was cold from a breeze billowing out the curtains. In the comfort of the bed I knew it was nothing, but perhaps one story that stuck in my mind had startled me in a dream.
Paul told me he had actually seen her one day while passing an open door. She was standing where I had sat in front of the fireplace. Barely five feet tall, the woman wore a full skirt of dark cotton gathered tightly around her waist and a light-colored blouse, her hair lifted up in an old-fashioned way. It all happened in the twinkling of an eye, but the shock sent him back to the previous owner.
“I’m not surprised,” he was told. “By the way, was she standing next to the mantel?”
I lay back in bed imagining the star-crossed lovers from long ago and wondered about it all. When Paul described the encounter with the woman’s ghost his expression had seemed to appeal to me: please don’t think I’m flaky! I didn’t know what to think.
My original story is published in WV South for Halloween


Featured Interview With Stephanie Williams
Tell us a little about yourself. Where were you raised? Where do you live now?
I was raised in Delaware in the United States, and I currently reside there as well. I have two pets (two pugs), but neither of them get along with each other. One is part Boston terrier, the other is part Jack Russell terrier.
At what age did you realize your fascination with books? When did you start writing?
I’ve always loved to read from the time I was little, maybe around four years old. I’ve always loved to write ever since first grade.
Who are your favorite authors to read? What is your favorite genre to read. Who Inspires you in your writings?
J.R.R. Tolkien is my favorite inspiration (stylistically). His writing is descriptive, laden with imagery, and is also very poetic at times. My favorite genres are poetry and fantasy, but sometimes I like to read classical and philosophy. I also like to read Christian literature (mainly nonfiction).
Tell us a little about your latest book?
I wrote it awhile ago (in 2015). It hasn’t received much recognition, but only because I haven’t publicized it much. It’s filled with my deepest thoughts and I loved putting it together. It was inspired largely by my faith and my spirituality.
If you enjoyed this writer’s interview, check out our Featured Authors page. We have some of the best authors to learn about. They are just waiting for you to discover them. If you enjoyed this writer’s interview feel free to share it using the buttons below. Sharing is caring!


“Remember my chains…” -Paul
Is not every day, I read a book or letter and find myself moving towards change, but that is what I experience when I read Paul’s writings. Today I was reading a letter he had written to the Colossians and got to chapter 4 where he starts with a short list of instructions for how Master’s should treat their servants and how these Colossians should devout themselves to prayer.
3 And pray for us, too, that God may open a door for our message, so that we may proclaim the mystery of Christ, for which I am in chains. 4
He asks that the Christians on the outside (those who are free) would pray that they (who are in chains) may be able to proclaim the message even while they are in prison. Is no wonder those who came in contact with Paul were either moved to anger or to repentance. The man had relentless passion for Christ. He lived not for himself but so that the name of Jesus Christ be exalted and exposed to all.
“ 18 I, Paul, write this greeting in my own hand. Remember my chains. Grace be with you.
“Remember my chains…” those words kept coming back to me over an over again. Paul had knowledge, he had wisdom, and a way with words unlike any other in his time. It is no secret he had an amazing mind; he knew how to argue his message with those in positions of great power and authority, and he could be quite persuasive in his delivery. When Paul spoke people listened and their lives where changed. Why?
Besides the fact that he was chosen of God for such a time, I’d have to say, he was influential because his words had value. Because what he required of others he was willing to go through himself. It was because his faith was unshakable even when he was tortured, shipwrecked, starved, beaten, imprisoned, stoned, accused, ridiculed, rejected and left for dead. Remember my chains meant a lot to the believers reading those words. They understood exactly what Paul was saying; Jesus is enough and He alone be glorified.
I pray for a deeper passion and a strong conviction to the true gospel of the Jesus we proclaim. That our hearts will turn to prayer and compassion for those who suffer and that in doing so, we too will become living testimonies of our glorious savior and the beauty of his sacrifice.


Blood Red Road
Saba has spent her whole life in Silverlake, a dried-up wasteland ravaged by constant sandstorms. The Wrecker civilization has long been destroyed, leaving only landfills for Saba and her family to scavenge from. That's fine by her, as long as her beloved twin brother Lugh is around. But when a monster sandstorm arrives, along with four cloaked horsemen, Saba's world is shattered. Lugh is captured, and Saba embarks on an epic quest to get him back. Suddenly thrown into the lawless, ugly reality of the world outside of desolate Silverlake, Saba is lost without Lugh to guide her. So perhaps the most surprising thing of all is what Saba learns about herself: she's a fierce fighter, an unbeatable survivor, and a cunning opponent. And she has the power to take down a corrupt society from the inside. Teamed up with a handsome daredevil named Jack and a gang of girl revolutionaries called the Free Hawks, Saba stages a showdown that will change the course of her own civilization. Blood Red Road has a searing pace, a poetically minimal writing style, violent action, and an epic love story. Moira Young is one of the most promising and startling new voices in teen fiction.
- Hardback | 459 pages
- 147.32 x 210.82 x 45.72mm | 521.63g
- 07 Jun 2011
- SIMON & SCHUSTER
- New York, NY, United States
- Reprint ed.
I absolutely loved Blood Red Road.What a great read! Moira Young goes over the top with a most engaging heroine.Saba is a crusty, foul-tempered warrior woman who must be covered in scar tissue by the end of the book, but men still follow her around like starving wolves.The dialogue is fast and often humorous, the pace never lets up.No situation is so bad that it can't get worse in the next couple of pages. I especially liked the awakening of the hellwurms as they emerge to feed.Well done, Ms. Young! --Nancy Farmer, author of "The House of the Scorpion"
Our customer reviews
This is one of those books where you either hate it, or you love it. I was anticipating for this book to be alright, but what I didn't expect was to love it as much as I did. Reasons to Read: 1. Saba Saba is actually a really interesting person to read about. She's rude, callous, and incredibly strong. Usually, people like that tend to turn me off. But for Saba, it really worked. While I said that she was fairly insensitive, I could really tell just how much she loved Lugh. From page one, he is mentioned in only the highest regards. When he was taken, I felt her pain. I could tell that the amount that because she loved Lugh so much, losing him was making her go mad. Maybe it was just me, but I when I was reading some times, she really seemed to be losing her grip on her sanity. She's completely disinterested in helping anybody else but herself, but I found that I couldn't help but like her. I mean, she had every single reason to be as hard and bitter as she was. She was a completely realistic character that I thoroughly enjoyed. 2. The Post-Apocalyptic World The world that Saba and all the other characters live in I found to be thoroughly enjoyable. After the apocalypse happens, the world is basically one big wasteland. Unlike some other novels set in the future, there wasn't really any amazing technology. Some things were different, such as a sand-surfing ship, but nothing too out of the ordinary. I really liked the way that it was explained, too. The world is really, really messed up, which I found to be a cool take. You can't really trust anyone in this world, and nobody has a reason to trust you. Everyone in this world wants something, and is working purely for themselves. 3. The Adventure If you couldn't tell from the title, Blood Red Road, this novel's main focus is Saba's journey to find her brother Lugh. While there were some delays in this journey, I thought that it was thoroughly enjoyable. There are a full range of characters out, all with unique personalities. Aside from that, the action was awesome! There were tons of battles, and fights, and chase scenes that I found to be exhilerating. I was excited, scared, and just plain frustrated throughout the entire adventure. The adventure was thoroughly enjoyable. 4. The Language This is probably the most controversial part of the book. Saba has a very thick southern-style accent, and the book is written that way. While I found it disorienting at first, I got used to it by the end of the novel. I actually really liked it, and thought it fit in really well to the story. If you don't mind reading a little bit of broken English, then I don't think that you will mind to much. Although I did love this book, the one thing that I didn't like was how there were no quotation marks around the characters' dialogues. This was a bit disorienting at times, when I thought Saba would be saying something, but it would actually just be in her thoughts. Overall though, I think that this book was really well done and exceeded by expectations.show moreby Dorian
In a world decimated by .. we don't really find out in this first in series book ... where inhabitants are reduced to walking and horseback (and some to ships with wheels), and most others are addicted to chaal (an apparent drug you chew that slows you down), Saba is an 18-year-old whose adored twin brother Lugh has been taken by mounted men (the Tonton) who killed her father and left her and her 9-year-old sister Emmi orphaned and alone. Saba is determined to rescue Lugh, and even though she's never traveled to a city, she leaves Emmi with a woman named Mercy who was her mother's friend and sets off across the desert of Sandsea to find him. Told in the first-person dialect of Saba, a pretty kick-butt heroine, it may take a while to get into the flow of this novel, but once the reader's mind has adjusted itself, it does flow much more smoothly. Saba is not perfect; she has a deep resentment of her little sister that stems from her mother dying in childbirth. Despite this, the reader will find themselves cheering her on and hoping that she escapes from the predicaments she finds herself in during her quest. There's cruelty, madness, romance, and danger, but there's also a great sense of awakening and growth. The film rights for this debut novel have already been optioned (yes, pre-release), and I can picture it in my mind's eye. Hunger Games fans - I have seen reviews comparing this to Hunger Games - it's good, but definitely not Hunger Games caliber, in my opinion. The fast-flipping, heart-pounding, "oh, my gosh! I hope Katniss will be alright - I wish none of the kids had to die" feeling I got from Hunger Games was definitely not present for me here. That is not meant to take away from THIS novel; I just think the comparison is unrealistic. While I WAS interested in what happened to Saba, a deep connection didn't surface; I actually found myself invested in some of the secondary characters, however. Unlike many first-in-series, this one ends on a good note - no cliffhanger, etc. - but leaves room for more story to be told. QUOTE (from a galley; may be different in final copy): Lugh shines like the sun. That must of made it easy fer them to find him. All they had to do was follow his light. Book Rating: 3.5 out of 5 starsshow moreby Julie Smith


Jocasta (Iocaste) (shining moon) In Greek mythology, both mother and wife of Oedipus, whom she married not knowing he was her son; mother of Eteocles, Polynices, Antigone, and Ismene; daughter of Menoeceus. When Jocasta learned she was Oedipus’ mother, she killed herself by hanging. Jocasta appears in Homer’s Odyssey (book 11), where she is seen in the underworld by Odysseus. Homer calls her Epicaste. Sophocles’ Oedipus Tyrannus, often called Oedipus Rex, and Euripides’ Phoenician Women also feature Jocasta, as do modern versions of the Oedipus myth by Cocteau and Gide.
Encyclopedia of World Mythology and Legend, Third Edition – Written by Anthony S. Mercatante & James R. Dow– Copyright © 2009 by Anthony S. Mercatante


Sweets And Toxins
The twenty-first century doesn't much care for subtlety. Now is the era of the gist, the elevator pitch, the big idea boiled down. This is precisely why Christopher Woodall's fiction gives such pleasure. His meticulous stories about love, death, fidelity, friendship, and human solitude do not wave their narrative arms wildly, demanding unwarranted attention. They speak in a calm voice, inviting the reader closer--inviting him not merely to react but to feel and think. Sweets and Toxins is the first collection of short fiction to be published by this talented novelist (November) and it marks him as a writer whose sharp eye for detail and feeling for people is a rare commodity indeed. He is one of the major English authors writing today.
- Condition: New
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- Format: Paperback
- Sold by: HPB.com
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- Language: English
- Publisher: Dalkey Archive Pr
- ISBN-13: 9781628972924
- ISBN: 1628972920
- Publication Year: 2018


The Displaced Hero
Abdulrazak Gurnah has been awarded the Nobel Prize for Literature 2021 "for his uncompromising and compassionate penetration of the effects of colonialism and the fate of the refugee in the gulf between cultures and continents". His body of work constitutes 10 novels, of which his novel, Paradise (1994), was shortlisted for both the Booker and the Whitbread Prize, his novel By the Sea (2001), was longlisted for the Booker Prize and shortlisted for the Los Angeles Times Book Prize; and his book Desertion (2005), was shortlisted for the Commonwealth Prize
The Wise Owl Team analyses Gurnah’s writing which mirrors the sense of loss of a displaced character, who struggles to sever cultural ties but is unable to let lose the fragile skeins that bind him to his roots. The analysis is made with reference to Gurnah’s novel, The Last Gift.
He liked wearing the clothes he was comfortable in and liked to think that
if he saw himself approaching, he would recognize himself from the clothes he wore…the habit of mind of a stranger unreconciled to his surroundings dressing lightly so he could throw the coat off quickly when the time came
to move on… (The Last Gift, 2011)
This is how Abdulrazak Gurnah describes Abbas, the protagonist of The Last Gift. And yet, the stranger unreconciled to his surroundings, the immigrant with a dislocated psyche searching for familiarity in the clothes he wore, mirrors the author’s own sense of being a rootless, cultural outcaste. Abdulrazak Gurnah was born in Zanzibar, an archipelago in the Indian Ocean, and stayed in Zanzibar till he was 18 years of age. A violent uprising in Zanzibar in 1964, deposing the then Sultan Jamshid din Abdullah, made him flee his birthplace, never to return. His departure was sudden, final and stealthy and severed all physical connection with his homeland, a tragic severance that is reflected in the opening lines of his book, The Last Gift, where he says succinctly:
One day, long before the troubles, he slipped away without saying a word to
anyone and never went back
England, the place he sought refuge in, was different from anything he had seen before. Unhappy and homesick, he began recording scattered feelings and thoughts in his diary. He slowly became a storyteller, transferring his pain and sense of displacement on to fictional characters that were sculpted from his own flesh and blood. The trauma of colonialism, war and dislocation is the common theme that strings together all his narratives. This legacy is carried by all his protagonists like an albatross around their neck, and springs from the author’s own sense of displacement and disenchantment with his past self. Gurnah says:
The thing that motivated the whole experience of writing for me was this
idea of losing your place in the world
From being a Nursing orderly to a professor of English Literature at the University of Kent to becoming an acclaimed author, his journey was long and fraught and the sense of guilt at having left his country for foreign shores dogged him all his life. When Abbas talks about floating on a raft made from the timbers of [his] cowardice, he is very obviously echoing Gurnah’s sense of guilt at having betrayed his culture and homeland. There is also a dawning conviction that he has failed the new generation. The mistaken belief that the new generation would meld seamlessly with a new culture if they were not smothered by their cultural antecedents, was misplaced, making the children cultural orphans. Abbas, an alter ego of the author, ruminates that the children's questions about his home country were met with the response that he was a monkey from Africa. This had made them unsure and afraid. Abbas says:
She (Maryam) says our children are here, in a strange place, and all we have given them are bewildering stories about who we are. She thinks it makes them unsure and afraid about themselves
The revelation of the past comes eventually, but is too late to save the cultural orphans adrift and apart. Hannah, Abbas’s daughter, rejects it categorically saying she can't bear these shitty, vile immigrant tragedies, while his son Jamal distances himself from it by fictionalizing it like his father. He ironically says:
Another father story. Such a predictable immigrant subject.
The Last Gift, in fact, reads like an autobiographical work. Gurnah’s sense of displacement, loss and a debilitating guilt is shouldered by Abbas. This thread of cultural loss and displacement is central to all his novels. All the characters struggle in their own way with their sense of dislocation and a soul searing schism. Anders Olsson, Chairman of Academys Nobel prize committee very rightly says that the characters peopling Gurnah’s work,
"find themselves in the gulf between cultures and continents, between the life left behind and the life to come, confronting racism and prejudice, but also compelling themselves to silence the truth or reinventing biography to avoid conflict with reality."


In This Grave Hour is the thirteenth Maisie Dobb’s book, and as the title suggests, WWII has just been declared. As with any long running series, some books are better than others. In the early stages of this one, I thought we had one of the lesser Maisie’s on our hands. It felt a little clunky, like it was trying too hard to find the Maisie magic of old.
But as we went along, the pace picked up and Winspear found her groove. The regular, much-loved cast of characters add the heart and soul to this story and they all got a chance to shine in this story, especially Maisie’s dad, who I just adore.
The crime centred around the revenge-styled murders of Belgium refugees from WWI, but the emotional heart of the story involved the children evacuated from London during the early days of the wars announcement. Maisie also got to revisit an old flame in the guise of Richard Stratton, recalled to London to help with the war effort.
After feeling so fearful for Priscilla’s young adults sons in the previous book, In This Grave Hour brings the sense of tension back a few notches. This reflected the anti-climax that occurred in England after the initial announcement when nothing actually happened, leading the early stages of WWII to be called the phoney war or the bore war.
In This Grave Hour was not Maisie’s best work, but she’s such a lovely, comfort read for me, that I will forgive many sins, just to disappear into her world for a while. Her happy mix of empathy and rational thought is a combination that I find endearing and admirable. Spending time with such kind hearted, well-meaning people will always feel like a good thing to do.
Maisie Dobbs #1
Maisie Dobbs #2 Birds of a Feather
Maisie Dobbs #3 Pardonable Lies
Maisie Dobbs #4 Messenger of Truth
Maisie Dobbs #5 An Incomplete Revenge
Maisie Dobbs #6 Among the Mad
Maisie Dobbs #7 The Mapping of Love and Death
Maisie Dobbs #8 A Lesson in Secrets
Maisie Dobbs #9 Elegy for Eddie
Maisie Dobbs #10 Leaving Everything Most Loved
Maisie Dobbs #11 A Dangerous Place
Maisie Dobbs #12 Journey to Munich
Maisie Dobbs #13 In This Grave Hour
Maisie Dobbs #14 To Die But Once
One thought on “Maisie Dobbs #13 In This Grave Hour”


What is validity in research
Improving the validity of your market research can increase the effectiveness of your marketing strategies when you. Establishing validity in qualitative research the following module discusses reliability and validity in qualitative research, with an emphasis on establishing. Test reliability and validity defined reliability test reliablility refers to the degree to which a test is consistent and stable in measuring what it is intended to. Shiken: jalt testing & evaluation sig newsletter, 4 (2) oct 2000 (p 8 - 12) 10 coming back to your question, either the traditional view of construct validity or the. Because of the nature of behavioral research, sociologists frequently use surveys and various other types of written data.
Validity in grounding qualitative research,validity receives more importance than reliability validity means that the research is sound and based on solid grounds. 1 validity in qualitative research p ivi kinnunen t-1065550/6500 methods and results in computing education research 2 by validity in this context i mean. Education research and perspectives, vol38, no1 105 validity and reliability in social science research ellen a drost california state university, los angeles. Questionnaires are most widely used tools in specially social science research most questionnaire's objective in research is to obtain relevant information in most.
Conclusions drawn from analyzing survey data are only acceptable to the degree to which they are determined valid validity is used to determine whether. Depending on their philosophical perspectives, some qualitative researchers reject the framework of validity that is commonly accepted in more quantitative research. Validity: the best available approximation to the truth of a given proposition, inference, or conclusion the first thing we have to ask is: validity of what.78 thomson, s b (2011) qualitative research: validity joaag, vol 6 no 1 introduction researchers have a choice of two broad streams of research. Reliability and validity issues in research any remaining errors or omissions rest solely with the author(s) of this paper abstract instrument validity and. For the statistical consultant working with social science researchers the estimation of reliability and validity is so the first decision that the research is. The principles of validity and reliability are fundamental cornerstones of the scientific method. Construct validity in psychological tests lee j established by different types of research and validity), continuing research has tried to.
A key concept relevant to a discussion of research methodology is that of validity when an individual asks, is this study valid, they are questioning. In this essay, the definition of reliability and validity in quantitative and qualitative research will be discussed then requirements of a good. According to joppe (2000), validity denotes the extent to which a measurement does what it is supposed to do.
Reliability in research reliability, like validity, is a way of assessing the quality of the measurement procedure used to collect data in a dissertation. Free market research resources for the marketing research industry available from the market research world qualitative and quantitative research. Start studying chapter 8- research validity learn vocabulary, terms, and more with flashcards, games, and other study tools. What is information validity full text search our database of 113,700 titles for information validity to find related research papers.
Validity, qualitative patti lather validity is not just one of many issues in science but the crux of the issue: practices of validity in qualitative research. Definition of criterion validity: also called concrete validity, criterion validity refers to a test’s correlation with a concrete outcome. Full-text paper (pdf): validity and reliability in quantitative research.


by Kristen B.
Empire of Sand opens with a young woman painting a window sill with her blood, looking to ward against the daiva spirits of the wild sands. In some ways, the rest of Tasha Suri’s duology revolves around these older spirits that have been subjugated by the Ambhan Empire – and by those who consider them monsters and those who count them as family. Suri’s books are set in a lush, vibrant world based on the Mughal Empire – complete with vast deserts and verdant oases. Here, the Emperor governs but the Maha rules. Here, the upper class consists solely of Ambhan people and the Amrithi are outcast because of their magic.
Mehr is the privileged child of the regional governor, acknowledged but nonetheless the daughter of an Amrithi courtesan. She possesses the full inheritance of her mother’s people, but is protected by her father’s influence. Mehr lives in an uneasy truce with her step-mother, who has adopted Mehr’s younger sister as her own daughter to be raised as an Ambhan noblewoman. Mehr has no ambition for a noble marriage, but when she is discovered practicing Amrithi magic, she is given little choice.
The Maha rules the Empire through the prayers of his mystics. When Mehr accidentally divulges her abilities, she is forcibly married to the powerful mystic Amun and taken away to live a sequestered life in a distant oasis. At the Maha’s Temple, Mehr learns that she and her husband are expected to perform the Rite of the Bound. This magical rite, a choreographed dance with particular poses and gestures, allows the magic of the desert daiva and older gods to flow through the Maha and into the Empire, extending its territory and influence. Through their practice and discipline, Mehr and Amun learn about each other and the tragedies that brought each to the Maha’s temple.
It is this romance of desperation and rebellion that powers the second half of the book. I read this novel in large gulps, needing to know what happened next. As much as I enjoyed the world building, I truly came to love both Mehr and Amun, rooting for them to find a way to be together and free of the Empire. The underlying themes of colonization and prejudice give Empire of Sand an unexpected sense of gravity. There is no doubt but that individual lives were used and abused for the supposed greater good. The consequences of generations of such cruelty cannot easily be constrained or controlled.
The second book, Realm of Ash, deals with the unfolding repercussions from Mehr and Amun’s story, but from another perspective entirely. We encounter Mehr’s younger sister, Arwa, again as she makes her way to a distant convent for widowed noblewomen. Arwa was, indeed, raised as an Ambhan noblewoman and married a military officer with a bright future. When the garrison is massacred by daiva, Arwa is one of the few survivors and chooses to absent herself from high society. Not entirely surprisingly, the convent is a hotbed of Imperial politics and Arwa soon finds herself on the way to the capital city to serve in the retinue of a princess.
Where her sister has the magic of the Amrithi rites, Arwa discovers that she has a different ability that allows her to access the memories in her blood, remembrances of her ancestors, in the Realm of Ash. The princess’ illegitimate brother lives in nocturnal solitude, researching and experimenting for a way to restore the Ambhan Empire to its former safety and prestige. Arwa must learn to embrace her Amrithi heritage to help the prince and to accept her own worth. Again, a forbidden romance (Ambhan noblewomen may not remarry) lies at the heart of a rebellion against a court built on deception and corruption. And again, I found myself rooting for these two against all odds.
In some ways I preferred Realm of Ash because it shows more of the interconnected elements of the Ambhan Empire, the military and the regular people of Jah Ambha (the capital city), servants and spies. As Arwa and her prince flee into the desert and join a pilgrimage, the wide variety of life outside of palaces and temples make for a wonderful sense of place and history. The bigger picture at play in the second book is, perhaps, only made possible by the laser focus of the first novel.
The fantasy genre is chock-full of strong heroines, women who can outfight anyone and snark about it after … the term kick-ass is usually employed. Mehr and Arwa gave me a much more grounded reality, finding their courage in the face of terrifying odds. Neither young woman wants to be an agent of change or is a rebel at heart. Both have learned to keep their heads down and mouths shut so as not to attract attention or draw criticism. They do have, however, an unerring sense of fairness and a desire to be allowed to live their own lives, loving whom they choose. These sisters indelibly alter their entire world by being brave enough to take the chances presented to them, sometimes fearlessly and sometimes with only a hope and a prayer.
Kristen B. is a devoted bookworm lucky enough to work as the graphic designer for HCLS. She likes to read, stitch, and take walks in the park.


As I got older, I began to understand that things will get weirder and weirder before your period stops—something every woman should know before the stopping starts.
Then something else will happen. You will begin to notice a large chunk of the world, nearly invisible until now: an army of cool, older women, the ones who have emerged on the other side and flourished. In their eyes you will catch a glimpse of the person you want to become. You will do away with pretense then, giving up whatever is keeping you from beginning to live the rest of your life. And this is where the flamenco dancing might come in.


Thursday, December 28, 2017
Chicken in Mittens
First sentence: Zoey stepped out of the barn. So did her best pig, Sam. Fresh snow covered the farm. "We can be explorers!" said Zoey. "It's cold," said Sam. "Arctic explorers!" said Zoey.
Premise/plot: Zoey LOVES adventures. Sam, well, he's a great friend, a sidekick, to Zoey. Even if he doesn't always show the same passion or zeal for adventure as his friend does. In this one, the two set off to discover the pole. Will they find it? Well, they'll find something that's for sure!
My thoughts: This I Can Read early reader stars the characters from Chicken in Space and Chicken in School. If you loved those picture books, you should definitely seek out Chicken in Mittens.
It's an amusing book. Not all early readers can be described as amusing or delightful.
© 2017 Becky Laney of Young Readers


Mark gave a start. ‘Welcome back,’ said Mr Cruickshank. ‘Now if you’ve finished daydreaming, perhaps you could answer my question.’
This book started off as a telemovie I wrote for the Australian Children’s Television Foundation. Their series Winners gave a rare opportunity to screenwriters – the chance to write one-off films without the need to spin them out into a TV series. We could write about anything we liked as long as the story had a young person as the main character.
I got to write two of the films, Second Childhood and The Other Facts Of Life, and they were both very important stages in my transition from a screenwriter into a writer of books. For a start they were security blankets. Turning a couple of completed and filmed screenplays into books was far less scary and intimidating for me than starting a book from scratch. I’ve often wondered if I’d ever have been game to have a crack at a book the traditional way – an idea, a blank page and lots of fingers crossed.
Second Childhood is the sort of story you write when you’re given complete freedom. I went straight for one of my favourite topics. I love writing stories about the time in a young person’s life when they’re starting to think for themselves and discovering the world in new ways.
Mark and Annie, two of the main characters in Second Childhood, are just at that stage. Everything is ahead of them, new and exciting, but challenging too. One of their biggest challenges is that they’re not satisfying the expectations of some of the adults in their lives, who keep warning them about the danger of ending up as nobodies.
I thought it would be interesting for them to discover the concept of reincarnation, and come to believe that they and some of their friends had lived before as famous and important people. (And in Annie’s case a famous and important horse.) In other words, as somebodies.
That way, I hoped, they could discover an idea that has helped me a lot in my own life. That sometimes it’s the past that helps us with our future.
Second Childhood is available in bookshops and libraries in Australia and New Zealand, and online:


With the zeal of a diligent seeker, I researched love and interviewed the experts in order to deliver the goods on intimacy, passion and commitment. The fairy tale was real, but it was more than a happy ending. When we see Cinderella being swept away by the prince, we forget how many years she spent in self-therapy while cleaning her stepmother’s house and waiting on her stepsisters.
The relationship you want can only be had through hard work on yourself … and that’s the work we do our best to avoid. It’s much easier to shell out money. Americans spend 35 billion dollars a year on unproven diet products because they find it too difficult to eat less.
And eating less is easy compared to getting naked. We’re scared to death to strip away the family, the house, the degree, the job, the kids. We’ve defined ourselves by appearance, grades, athletic ability, good behavior or rebellion as far back as we can remember. You’re not alone if you’re thinking, “Who would I be without all that?” Most of us don’t know.
Strip away what can be quantified, seen or touched, and you have your authentic self. You have that for which you want to be known and loved.
Yes, you want somebody to love every little toe and sweet spot, but you also want them to love what you’re afraid to show and talk about. You want them to know that you were the last one picked for softball, that you had a speech impediment until you were 9 and that kids used to call you chubby knees. You want them to know that you’ve been dumped six times, fired once and that you’re now broke!
You want them to know the emotional struggles behind all that and still love you — not in spite of who you are, but because of who you are.
And if you weren’t so incredibly beautiful and precious stark-naked and vulnerable, that would be a tall order. My job, then, has been to help readers find the courage to peek beneath the gold watch or muscle or perfect-parent image or whatever security blanket they were clenching. As I’ve faced the fear of not being good enough that drove me to weave my own security blanket, I’ve tried to help others face theirs in order to find their authentic self.
There’s a spark of divinity in you. It’s what makes you perfect just the way you are. Perfect!
It’s also what makes you deliciously attractive to the partner of your dreams, irresistible to your kids, and priceless to an employer.
When I say naked is the only way to be in love, I don’t just mean it’s the only way to fall in love, so that somebody can know and love all of you. Naked is also the only way to be honest, the only way to keep the faith, the only way to be compassionate … the only way to love life, yourself and others.
You can’t love somebody else any better than you love yourself. You are destined to love your neighbor as you love yourself. And you can’t really love yourself without getting to know who you are … naked.
Trust what’s sacred.