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  • Chapter 37 - Postoperative Analgesia

  • from Section 4 - Walking the Walk (and Talking the Talk)
  • William Fawcett, Royal Surrey County Hospital, Guildford and University of Surrey, Olivia Dow, Guy's and St Thomas' NHS Foundation Trust, London, Judith Dinsmore, St George's Hospital, London
  • Book:
    Robinson and Hall's How to Survive in Anaesthesia
    Published online:
    09 June 2025
    Print publication:
    26 June 2025, pp 212-216

  • Summary

    Postoperative patients require analgesia, not only for humanitarian and psychological reasons, but also because to reduce the autonomic responses to pain, to encourage mobilization including deep breathing, as well eating and drinking. Ultimately this may contribute towards reduced incidence of deep vein thrombosis and an earlier return to normal life style/work.

    There are a number of common agents used for postoperative analgesia, that have different mechanisms of action. These major drugs include nonsteroidal anti-inflammatory drugs, paracetamol, local anaesthetics and opioid drugs. Less commonly used agents are corticosteroids, ketamine, magnesium, gabapentinoids, alpha2 agonists as well as non-pharmacological methods such as acupuncture and TENS.

    Although opioids provide excellent analgesia, they have a number of side effects and the concept of using drugs that work by different mechanisms of action that also reduce the dose of morphine required. This is referred to as ‘multimodal opioid sparing analgesia’ and is the major principle underpinning postoperative analgesia.

    There are many factors that influence how postoperative pain is perceived by patients. These include age, sex, preoperative analgesia and chronic pain conditions, as well as the surgery and intraoperative analgesia.

    Pain is managed according to the WHO pain ladder and assessed in terms of functional activity rather than a pain score. There are side effects of all analgesics, and these must be balanced against their proposed benefits.

  • Chapter 4 - Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

  • from Part II - Common Categories of Pharmacologic Medications to Treat Chronic Pain
  • Edited by Omar Viswanath, Creighton University, Omaha, Ivan Urits, Southcoast Brain & Spine Center, Wareham
  • Book:
    Cambridge Handbook of Pain Medicine
    Published online:
    01 December 2023
    Print publication:
    14 December 2023, pp 39-43

  • Summary

    Ibuprofen and naproxen are nonsteroidal anti-inflammatory drugs (NSAIDs) that work by inhibiting cyclooxygenase (COX) 1 and 2, enzymes involved in the synthesis of prostaglandins that contribute to pain, inflammation, and fever. Therefore, cyclooxygenase modulation contributes to the anti- inflammatory and analgesic qualities of ibuprofen and naproxen. While NSAIDs have been shown to be effective in the treatment of chronic low back pain, they can also have adverse effects on the gastrointestinal, renal, and coagulation systems, including gastric pain, vomiting, bleeding, gastric ulcers, acute renal failure, interstitial nephritis, and nephritic syndrome. Long-term use of NSAIDs increases the risk of such side effects. While short-term use is considered relatively safe, the evidence for the long-term efficacy of NSAIDs for chronic low back pain is limited, and the ACP recommends them as a first-line pharmacological agent with caution. The use of NSAIDs, especially over a prolonged time, is also not without risk. Long term use predisposes patients to considerable side effects.

  • Post-operative non-steroidal anti-inflammatory drug use for pain in infant and paediatric cardiac surgery patients

  • Dimitrios A. Savva, Omayma A. Kishk, Jill A. Morgan, Jessica M. Biggs, Hyunuk Seung, Caroline Bauer
  • Journal:
    Cardiology in the Young / Volume 29 / Issue 12 / December 2019
    Published online by Cambridge University Press:
    26 November 2019, pp. 1440-1444
  • Background:

    Pain control is an important element of care for patients after surgery, leading to better outcomes, quicker transitions to recovery, and improvement in quality of life. The purpose of this study was to evaluate the safety and efficacy of non-steroidal anti-inflammatory drugs in children after cardiac surgery

    Materials and Methods:

    Patients between the ages of 1 month and 18 years of age, who received intravenous or oral non-steroidal anti-inflammataory drugs after cardiac surgery, from November 2015 until September 2017 were included in this study. The primary endpoints were non-steroidal anti-inflammataory drug-associated renal dysfunction and post-operative bleeding. Secondary endpoints examined the effect of non-steroidal anti-inflammataory drug use on total daily dose of narcotics, number of intravenous PRN narcotic doses received, and pain assessment score. Data were analysed using descriptive statistics for frequencies and ranges. Multivariate analysis was performed to measure the association of all predictors and outcomes. Wilcoxon singed-rank test was performed for secondary outcomes.

    Results:

    There was no association between the incidence of renal dysfunction and the use of or duration of non-steroidal anti-inflammataory drugs; in addition no association was found with increased chest tube output. There was a statistically significant reduction of patients’ median Face, Legs, Activity, Cry, Consolability (FLACC) scores (2–0; p = 0.003), seen within first 24 hours after initiation of ketorolac, and a significant reduction of morphine requirements seen from day 1 to day 2 (0.3 mg/kg versus 0.1 mg/kg; p < 0.001) and number of as-needed doses.

    Conclusion:

    Non-steroidal anti-inflammataory drugs in paediatric cardiac surgery patients are safe and effective for post-operative pain management.

  • Effects of chronic mastitis and its treatment with ketoprofen on the milk ejection curve

  • Alfonso Zecconi, Samuele Frosi, Micaela Cipolla, Claudia Gusmara
  • Journal:
    Journal of Dairy Research / Volume 85 / Issue 1 / February 2018
    Published online by Cambridge University Press:
    22 February 2018, pp. 50-52
    Print publication:
    February 2018

  • In this Research Communication we report the results of a controlled study conducted under field conditions in which we analysed milk ejection curves in cows with chronic mastitis, and assessed the influence of antinflammatory treatment with ketoprofen. Total milking time was reduced in chronic mastitis cows, irrespective of ketoprofen treatment, and the proportion of bimodal flow curves was increased. This latter effect was partially reversed by ketoprofen. To our knowledge, this is the first study showing that chronic mastitis has a significant effect on the milk ejection curve. Antinflammatory treatment with ketoprofen was shown to be efficacious in reducing these negative effects, re-establishing a pattern close to the one observed in healthy cows.

  • Chapter 6 - Traumatic brain injury

  • Edited by Todd Crocco, West Virginia University, Michael Sayre, University of Washington
  • Book:
    Prehospital Care of Neurologic Emergencies
    Published online:
    05 August 2014
    Print publication:
    24 July 2014, pp 140-164

  • Summary

    Evaluation of the headache patient begins with the historical exam. Physical findings of concern associated with the headache include: unequal weakness; generalized malaise and inability to ambulate; fevers; neck stiffness; and unequal pupils. Primary causes for the headache include tension headache, migraine, cluster and caffeine withdrawal, and the secondary causes include infection, subarachnoid hemorrhage (SAH), eye complaints, and tumors. Secondary headache is tending to improve as underlying cause of the headache is treated. This chapter presents a review of the common treatment options for the management of headache in the EMS environment. These include inhaled oxygen, anti-emetics, opioids, nonsteroidal anti-inflammatory drugs (NSAIDS), and analgesics. EMS providers must have a heightened level of concern for the causes of headache requiring emergent treatment. The area of headache evaluation and management in the EMS environment needs further study.

  • Chapter 9 - Chronic daily headache

  • Edited by Mark W. Green, Philip R. Muskin
  • Book:
    The Neuropsychiatry of Headache
    Published online:
    05 March 2013
    Print publication:
    07 March 2013, pp 95-105

  • Summary

    Tension-type headache (TTH) is the most common form of headache in the general population. The phenotypic features of TTH are non-specific and may be seen with an assortment of secondary headache conditions, which are linked mechanistically to an identifiable structural or physiological disorder. One recent study of psychiatric comorbidity in patients with migraine, TTH, and migraine plus TTH revealed significant differences in the rate of occurrence of depression, with the combined group being of highest risk. TTH is typically managed mainly through administration of medication during acute episodes. Simple analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), and combination agents are most commonly recommended. Aspirin is more effective than placebo and comparable to the efficacy of acetaminophen in the relief of acute TTH. The prognosis is generally favorable, with limited disability during headache occurrences and age-related improvement or resolution of episodes later in life.

  • Assessing the ongoing threat from veterinary non-steroidal anti-inflammatory drugs to Critically Endangered Gyps vultures in India

  • Richard J. Cuthbert, Ruchi Dave, Soumya Sunder Chakraborty, Sashi Kumar, Satya Prakash, Sachin P. Ranade, Vibhu Prakash
  • Journal:
    Oryx / Volume 45 / Issue 3 / July 2011
    Published online by Cambridge University Press:
    02 August 2011, pp. 420-426
    Print publication:
    July 2011
    • Article
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  • Use of the veterinary drug diclofenac is responsible for bringing three species of Gyps vultures endemic to South Asia to the brink of extinction, and the Government of India banned veterinary use of the drug in May 2006. To evaluate the effectiveness of the ban we undertook surveys of > 250 veterinary and general pharmacies in 11 Indian states from November 2007 to June 2010. Twelve different classes of non-steroidal anti-inflammatory drugs (NSAIDs) were purchased from 176 pharmacies. Other than meloxicam (of negligible toxicity to vultures at likely concentrations in their food), diclofenac and ketoprofen (both toxic to vultures), little is known of the safety or toxicity of the remaining nine NSAIDs on sale. Meloxicam was the most commonly encountered drug, sold in 70% of pharmacies, but 50% of the meloxicam brands sold had paracetamol (acetaminophen) as a second ingredient. Diclofenac and ketoprofen were recorded in 36 and 29% of pharmacies, respectively, with states in western and central India having the highest prevalence of diclofenac (44–45%). Although the large number of manufacturers and availability of meloxicam is encouraging, the wide range of untested NSAIDs and continued availability of diclofenac is a major source of concern. Circumvention of the 2006 diclofenac ban is being achieved by illegally selling forms of diclofenac manufactured for human use for veterinary purposes. To provide a safer environment for vultures in South Asia we recommend reducing the size of vials of diclofenac meant for human use, to increase the costs of illegal veterinary use, and taking action against pharmaceutical manufacturers and pharmacies flouting the diclofenac ban.

  • Depressive psychosis associated with a cyclo oxygenase 2 inhibitor (meloxicam)

  • Daniel White, MacDara McCauley
  • Journal:
    Irish Journal of Psychological Medicine / Volume 27 / Issue 3 / September 2010
    Published online by Cambridge University Press:
    13 June 2014, pp. 157-158
    Print publication:
    September 2010

  • We describe a 60 year old man who developed a fluctuating depressive psychosis associated with meloxicam, a non-steroidal anti-inflammatory drug (NSAID). The psychological symptoms observed were temporally related to the administration of meloxicam and occurred in the presence of signs of meloxicam intolerance, such as skin rash and raised blood pressure. The depressive reaction resolved quickly following cessation of meloxicam, recurring on re-exposure. The psychiatric manifestations of NSAID intolerance are rare, however 40% of cases have a history of mental illness. Data from adverse event reporting systems suggest that the newer NSAIDs (COX-2 inhibitors) may have a higher propensity to cause psychiatric adverse effects and should be used with caution in individuals with a history of mental illness. This data may be provocative given current research in to the use of COX-2 inhibitors in augmenting neuroleptic treatment in schizophrenia.

  • Assessment of early post-operative pain following septorhinoplasty

  • P Szychta, B Antoszewski
  • Journal:
    The Journal of Laryngology & Otology / Volume 124 / Issue 11 / November 2010
    Published online by Cambridge University Press:
    06 July 2010, pp. 1194-1199
    Print publication:
    November 2010
  • Objective:

    To evaluate pain incidence and intensity in patients undergoing septorhinoplasty, and to assess analgesic treatment effectiveness, in the first 7 days after surgery.

    Design:

    Prospective outcomes analysis using visual analogue scale assessment of pain intensity in the first 7 post-operative days.

    Subjects:

    Fifty-seven patients were enrolled in the study, 29 women and 28 men, aged 18 to 51 years. All were treated for post-traumatic deformity of the external nose and/or nasal septum, with either septorhinoplasty or septoplasty.

    Results:

    In the first 3 days after septorhinoplasty, patients' mean visual analogue scale pain score exceeded the range denoting ‘analgesic success’, and showed considerable exacerbation in the evening. Patients' pain decreased to a mean score of 15.4 one hour after administration of a nonsteroidal anti-inflammatory drug (metamizole).

    Conclusion:

    Analgesia is recommended for all patients in the first 3 days after septorhinoplasty, especially in the early evening.

  • Non-steroidal anti-inflammatory drugs prescribing in chronic kidney disease: an observational study

  • Sunil Bhopal, James Chan, Oliver Ellis, Sarah Graham, Stephen Halpin, Thomas Lawrence, Joseph Laws, Anne-Marie Howes
  • Journal:
    Primary Health Care Research & Development / Volume 11 / Issue 3 / July 2010
    Published online by Cambridge University Press:
    10 March 2010, pp. 280-284
    • Article
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  • Aim

    This study assessed the prescription of potentially nephrotoxic non-steroidal anti-inflammatory drugs (NSAIDs) to patients with chronic kidney disease (CKD) in general practice.

    Background

    CKD poses a considerable disease burden in the UK. Guidelines state that caution should be exercised when prescribing NSAIDs to CKD patients, due to increased risk of rapid kidney disease progression.

    Methods

    We reviewed the medical records of 1427 patients with CKD Stages 3–5 in seven general practices in West Yorkshire.

    Findings

    A total of 792 (55.5%) were prescribed NSAIDs; 128 (9%) of these were prescribed NSAIDs excluding low-dose aspirin. Twenty-three (20.2%) patients who were prescribed NSAIDs had no record of CKD monitoring in the preceding year.

    Conclusion

    Prescription of NSAIDs is likely to be contributing to unnecessary renal impairment.

  • Neuropathy – overview

  • from Chief complaints and diagnoses
  • Edited by Stephen H. Thomas
  • Book:
    Emergency Department Analgesia
    Published online:
    18 December 2009
    Print publication:
    25 September 2008, pp 289-300

  • Summary

    This chapter addresses perianal painful conditions encountered in the ED setting. Laxatives are the initial therapy for perianal pain from a variety of conditions. Topically applied nitroglycerin is widely recommended for pain caused by either anal fissures or thrombosed external hemorrhoids. The utility of NSAIDs in post-hemorrhoidectomy pain is demonstrated by trials of perioperative administration of agents such as ketorolac and diflunisal. For patients with chronic anal fissure or painful external hemorrhoids who fail nitroglycerin therapy, or who have intolerable side effects to the drug, calcium channel blockers have been recommended as an alternative means to reduce anal tone and relieve symptoms. Perianal pain may also be the presenting complaint for patients with Condylomata acuminatum.The systemic condition lichen sclerosus, usually treated with potent topical corticosteroids, causes perianal (and vulvar) pain that can be significantly alleviated with topical 1% pimecrolimus cream.

  • Neck and back pain – mechanical strain

  • from Chief complaints and diagnoses
  • Edited by Stephen H. Thomas
  • Book:
    Emergency Department Analgesia
    Published online:
    18 December 2009
    Print publication:
    25 September 2008, pp 263-267

  • Summary

    This chapter addresses relief of abdominal cramping and related symptoms (e.g. pelvic pain, backache) associated with the menstrual cycle. It focuses on analgesic control of dysmenorrhea symptoms, rather than hormonal regulation of the ovulatory cycle. Prostaglandin inhibition by NSAIDs is responsible for their decades of successful use as the mainstay of dysmenorrhea treatment. An RCT in patients undergoing fractional curettage demonstrated the potent analgesic effects of NSAIDs on uterine pain. Due to the need for chronic use, the COX-2 selective NSAIDs are sometimes recommended as a treatment for dysmenorrhea. Data show that valdecoxib, administered in a single dose of 40 mg PO, provides dysmenorrhea pain relief within 30 minutes that lasts for up to 24 hours. The novel analgesic flupirtine is suggested by some to have utility in dysmenorrhea, but this centrally acting agent is not recommended owing to limited evidence and frequent side effects.

  • Chronic low-back pain

  • from Chief complaints and diagnoses
  • Edited by Stephen H. Thomas
  • Book:
    Emergency Department Analgesia
    Published online:
    18 December 2009
    Print publication:
    25 September 2008, pp 175-179

  • Summary

    Opioids are the benchmark against which other biliary tract analgesics are assessed. Historically, the distinction between opioids used for biliary tract pain (BTP) has been based upon differential effects on Oddi's sphincter. NSAIDs provide good analgesic effect, lack untoward effects on biliary tract pressure, and (perhaps through anti-inflammatory activity) seem to reduce the rate of progression from uncomplicated biliary colic to acute cholecystitis. Drugs acting at the cholecystokinin receptor may also be useful in acute treatment of BTP. Spasmolytic and anticholinergic drugs have been investigated as treatment for biliary colic. Calcium channel blockers are known to relax biliary tract smooth muscle. For BTP, the most potent agent in this class appears to be nifedipine.There is currently insufficient evidence to support use of nifedipine for acute treatment of BTP, and its outpatient efficacy is hindered by suboptimal pain relief and frequent headache.

  • Gastritis and peptic ulcer disease

  • from Chief complaints and diagnoses
  • Edited by Stephen H. Thomas
  • Book:
    Emergency Department Analgesia
    Published online:
    18 December 2009
    Print publication:
    25 September 2008, pp 213-224

  • Summary

    Thoracic trauma constitutes 10-15% of all injuries, with rib fractures (RF) being common and painful. The intrathecal injection of morphine has been studied for patients with multiple RFs. If conditions are suitable for their use, the local anesthetics are the most efficacious mechanism for managing RF pain. Local anesthetics (sometimes co-administered with opioids) have also been used by the epidural administration route. This approach is associated with decreased pulmonary morbidity and mortality in patients older than 60 years of age with RF. For the majority of patients with RF, the controversy surrounding NSAIDs and delayed bone fracture healing is relevant. Used in patients with chest wall trauma, epidural analgesia produces pain relief that is superior to that produced by systemic opioids or other local anesthetic approaches. Local anesthetic administration via thoracic paravertebral block entails injecting an agent such as bupivacaine alongside the thoracic vertebrae.

  • Corneal abrasion

  • from Chief complaints and diagnoses
  • Edited by Stephen H. Thomas
  • Book:
    Emergency Department Analgesia
    Published online:
    18 December 2009
    Print publication:
    25 September 2008, pp 184-187

  • Summary

    Treating the pain of land-based envenomations is an acute care priority, since the discomfort may be both severe and long lasting. In some cases, administration of antivenom (or antivenin) can dramatically relieve pain and other symptoms of envenomation, even after failure of other approaches such as opioids and muscle relaxants. While neurotoxic envenomation should prompt close respiratory monitoring, opioids should be administered if clinically indicated for pain relief. The histamine pathway's contributions to terrestrial envenomation symptoms create a role for antihistamines (e.g. diphenhydramine) in treating land-based bites and stings. NSAIDs have been reported useful in small case series of bites from spiders such as brown recluses and tarantulas. Preliminary evidence from animal models and case reports suggests a role for NSAIDs for scorpion envenomation. Case studies suggest that corticosteroids are occasionally useful for some centipede bites, especially in cases in which Wells' syndrome (eosinophilic cellulitis) develops.

  • Tension-type headache

  • from Chief complaints and diagnoses
  • Edited by Stephen H. Thomas
  • Book:
    Emergency Department Analgesia
    Published online:
    18 December 2009
    Print publication:
    25 September 2008, pp 384-388

  • Summary

    Given the frequency of otitis media (OM) and otitis externa (OE), there is surprisingly little evidence on treating pain associated with these conditions. For both conditions, there can be utility in mechanical interventions. The NSAIDs are typically recommended as first-line treatment, although evidence is sparse. Topically applied local anesthetics, generally benzocaine, are widely used for otalgia. A eutectic mixture of local anesthetics (EMLA), which contains lidocaine and prilocaine, is described as effective for relieving OE pain. Naturopathic topical approaches for OM are found by one investigator to be effective than the topical local anesthetic amethocaine. Trial evidence and reviews find neither antihistamines nor corticosteroids are effective in reducing OM pain. There are no data assessing otalgia relief for systemically administered opioids. However, expert panel evidence supports use of oral agents such as oxycodone or hydrocodone (usually in combination with acetaminophen or ibuprofen) for severe otalgia from either OM or OE.

  • Undifferentiated abdominal pain

  • from Chief complaints and diagnoses
  • Edited by Stephen H. Thomas
  • Book:
    Emergency Department Analgesia
    Published online:
    18 December 2009
    Print publication:
    25 September 2008, pp 392-397

  • Summary

    This chapter focuses on sore throat caused by viral or bacterial infection. It assumes that clinicians exercise appropriate precautions about airway management and possible complicating diagnoses. The NSAIDs, most commonly ibuprofen, are usually recommended for pain treatment of mild-to-moderate viral or bacterial pharyngitis (PG) in both adults and children. Aspirin, commonly dosed at 400-800 mg orally, is an effective PG pain reliever and is associated with symptomatic improvement. Acetaminophen is an effective reliever of mild pain, providing better PG relief than placebo within as little as 15 minutes. Corticosteroids, administered IM or PO in single or multiple doses, hasten the onset of both partial and complete pain relief in adults. In children, the utility of dexamethasone probably mirrors that of use of corticosteroids in adults with PG. Benzocaine (delivered by lozenges or spray) is commonly used for PG pain, but there are little applicable data for this indication.

  • Neck and back pain – radicular syndromes

  • from Chief complaints and diagnoses
  • Edited by Stephen H. Thomas
  • Book:
    Emergency Department Analgesia
    Published online:
    18 December 2009
    Print publication:
    25 September 2008, pp 268-272

  • Summary

    NSAIDs are widely considered as the first-line therapy for the pain associated with endometriosis. Combined oral contraceptive pills (COCPs) are generally recommended as the second-line therapy for endometriosis pain. A 2007 Cochrane review concluded that COCPs are at least as effective as gonadotropin-releasing hormone (GnRH) agonists. Medroxyprogesterone acetate is comparable to the androgen danazol, with both agents reducing pain scores by 50-74% compared with placebo. An SC form of depot medroxyprogesterone appears to relieve endometriosis as effectively as the proven approach of the GnRH agonist leuprolide acetate. Cochrane review has shown that there is generally equivalent pain relief achieved with multiple endocrine therapies for endometriosis. The myriad menopausal, androgenic, and hepatic side effects from some of the endocrine agents (e.g. danazol) used to treat endometriosis should serve to underline the importance of ED physician communication and follow-up arrangements with longitudinal care providers.

  • Sickle cell crisis

  • from Chief complaints and diagnoses
  • Edited by Stephen H. Thomas
  • Book:
    Emergency Department Analgesia
    Published online:
    18 December 2009
    Print publication:
    25 September 2008, pp 365-379

  • Summary

    While mechanical approaches (e.g. splinting) are important in managing sprain, strain, and fracture (SSF) pain, pharmacotherapy retains an important position for orthopedic analgesia. Systemic analgesics used for SSF include acetaminophen (paracetamol), NSAIDs, and opioids. This chapter focuses on systemically active analgesics. Pain relief for SSF can often be facilitated with local or regional injection of local anesthetics. Opioids have long been effectively used for severe SSF pain. Intravenous opioids (e.g. morphine) remain the most effective means for achieving both rapid analgesia and sustained relief (e.g. using patient-controlled analgesia) in most SSF conditions when combined with acetaminophen, the mixed-mechanism opioid tramadol is found to be equally efficacious to hydrocodone for relieving SSF pain. Many combination products are available and often include an opioid and a weaker analgesic such as acetaminophen or aspirin. However, few studies have rigorously evaluated their performance against alternative approaches such as opioid monotherapy.

  • Orthopedic extremity trauma – sprains, strains, and fractures

  • from Chief complaints and diagnoses
  • Edited by Stephen H. Thomas
  • Book:
    Emergency Department Analgesia
    Published online:
    18 December 2009
    Print publication:
    25 September 2008, pp 323-330

  • Summary

    The etiologic differences between radiating spine pain (RSP) and other causes of neck and back pain translate into differences in therapeutic approach. This chapter focuses on pharmacologic treatment modalities for RSP. Patients with refractory RSP often require opioid therapy, but available evidence does not support specific recommendations. Studies suggest no incremental benefit, compared with NSAIDs, for PO low-potency opioids (e.g. codeine) or agonist-antagonist agents (e.g. meptazinol, ethoheptazine). The authors believe that the main role for low-potency opioids in RSP is for use in patients who fail, or do not tolerate, other therapies such as NSAIDs. Corticosteroids have been used for the treatment of acute RSP since 1960s. The injection of corticosteroids into the epidural space is a commonly used approach. A single dose of methylprednisolone significantly reduces pain scores in RSP, but the effect is small in magnitude and limited in duration.

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