Clinically important differences in the intensity of chronic refractory breathlessness

Context: Clinically important differences in chronic refractory breathlessness are ill defined but important in clinical practice and trial design. Objectives: To estimate the clinical relevance of differences in breathlessness intensity using distribution and patient anchor methods. Methods: This was a retrospective data analysis from 213 datasets from four clinical trials for refractory breathlessness. Linear regression was used to explore the relationship between study effect size and change in breathlessness score (0-100 mm visual analogue scale) and to estimate the change in score equivalent to small, moderate, and large effect sizes. Pooled individual blinded patient preference data from three randomized controlled trials were analyzed. The difference between the mean change in Day 4 minus baseline scores between preferred and non-preferred arms was calculated. Results: There was a strong relationship between change in score and effect size (P = 0.001; R 2 = 0.98). Values for small, moderate, and large effects were -5.5, -11.3, and -18.2 mm. The participant preference change in score was -9 mm (95% CI, -15.8, -2.1) (P = 0.008). Conclusion: This larger dataset supports a clinically important difference of 10 mm. Studies should be powered to detect this difference

Effects of low dose morphine on perceived sleep quality in patients with refractory breathlessness : a hypothesis generating study

© 2015 Asian Pacific Society of Respirology. Background and objective The management of chronic refractory breathlessness is one of the indications for regular low-dose (≤30 mg/24 h) oral sustained release morphine. Morphine may disrupt sleep in some conditions and improve sleep quality in others. This study aimed to determine any signal of regular, low-dose morphine on perceived sleep disruption due to breathlessness and perceived sleep quality. Methods This is a secondary analysis of data from 38 participants with refractory breathlessness (30 male; 33 with COPD) aged 76 ± 0.9 years who completed a double-blind, randomized, placebo-controlled, cross-over study in which they received 20 mg oral sustained release morphine daily and placebo for 4 days each. Participant ratings of sleep disruption due to breathlessness and perceived sleep quality were obtained daily throughout the 8-day trial. Results Perceived sleep disruption due to breathlessness over the 4-day period ranged between 13% and 32% of participants for placebo and 13% and 26% for morphine, decreasing by each day of the study during the morphine arm. Most participants reported 'very good' or 'quite good' sleep throughout the trial and were less likely to perceive poor sleep quality during the morphine arm (odds ratio = 0.55, 95% confidence interval: 0.34-0.88, P = 0.01). Participants who reported decreased breathlessness during the 4 days on morphine were also likely to report improved sleep quality with morphine (P = 0.039). Conclusion Four days of low-dose morphine improved perceived sleep quality in elderly participants with refractory breathlessness. Regular low-dose morphine targeted to reduce refractory breathlessness may yield associated benefits by reducing sleep disruption and improving sleep quality

The evidence base for oxygen for chronic refractory breathlessness: issues, gaps, and a future work plan

Breathlessness or “shortness of breath”, medically termed dyspnoea, remains a devastating problem for many people and those who care for them. As a treatment intervention, administration of opioids to relieve breathlessness is an area where progress has been made with the development of an evidence base. As evidence in support of opioids has accumulated, so has our collective understanding about trial methodology, research collaboration and infrastructure that is crucial to generate reliable research results for palliative care clinical settings. Analysis of achievements to date and what it takes to accomplish these studies provides important insights into knowledge gaps needing further research as well as practical insight into design of pharmacological and non-pharmacological intervention trials in breathlessness and palliative care. This paper presents current understanding of opioids for treating breathlessness, what is still unknown as priorities for future research and highlights methodological issues for consideration in planned studies.This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors

District-University Collaborations to Support Reform-Based Mathematics Curriculum Implementation

Curriculum change is inevitable in schooling. For content areas such as mathematics that are already under the national spotlight, transitioning to new curriculum materials while concurrently enacting instructional reform creates both a challenge and an opportunity. This paper discusses how partnerships between two state universities and respective neighboring school districts resulted in the creation and implementation of graduate courses for teachers targeted at curricular and instructional reform specific to each district. Common course components between both university-district partnerships were identified in the areas of mathematics research, practice, and leadership advocacy and found to be instrumental in supporting instructional reform and fostering sustained development. Implications for collaborative partnerships, curriculum implementation and research are discussed

Blinded patient preference for morphine compared to placebo in the setting of chronic refractory breathlessness – an exploratory study

Context Patients’ preference for morphine therapy has received little attention in the setting of chronic refractory breathlessness. However, this is one important factor in considering longer term therapy. Objectives The aim of this secondary analysis is to explore blinded patient preference of morphine compared to placebo for this indication and to define any predictors of preference. Methods Data were pooled from three randomized, double-blind, crossover, placebo-controlled studies of morphine (four days each) in chronic refractory breathlessness. Blinded patient preferences were chosen at the end of each study. A multivariable regression model was used to establish patient predictors of preference. Results Sixty-five participants provided sufficient data (60 males; median age 74 years; heart failure 55%, chronic obstructive pulmonary disease 45%; median Eastern Cooperative Oncology Group performance status 2). Forty-three percent of participants preferred morphine (32% placebo and 25% no preference). Morphine preference and younger age were strongly associated: odds ratio = 0.85, 95% confidence interval 0.78, 0.93;

Inclusion and participation of children with epilepsy in schools: Views of young people, school staff and parents

OBJECTIVE: To gain an understanding of the views of children with epilepsy, their parents and staff regarding inclusion and participation of children with epilepsy in school. METHODS: During the study period, 136 children with 'active' epilepsy (taking anti-seizure Medications (ASMs) for epilepsy), were identified in the study area and of these 68 (50% of those eligible) families agreed to participate. Children (n = 20) with 'active epilepsy' their parents (n = 68) and staff (n = 56) were interviewed or completed surveys. The quantitative data were analysed using descriptive statistics and chi-square analyses. The answers to open questions were analysed using thematic analyses. RESULTS: Staff in mainstream schools were more concerned about the child's attendance than staff in special schools (p = 0.008).Parents and school staff cited a number of negative aspects of the child's attendance difficulties including social-emotional and academic aspects. The majority of parents and staff felt that young people with epilepsy were included in school to the same extent as peers. Parents were however, significantly less likely than staff to agree that children were included in all playground activities (p = 0.045). Parents of children in special schools were more likely to agree that their child was included in school than parents of children attending mainstream schools (p = 0.041). Thematic analysis revealed that parents felt that their child could be excluded in school due to staff decisions, child's own choice and peer led exclusion. The majority of children (64%) and parents (56%) agreed that the child with epilepsy was restricted from doing things their peers could do because of their epilepsy. While more than half of children with epilepsy (63%) reported that they had been bullied, most did not attribute this bullying to having epilepsy. Parents were more likely to agree that their child was bullied because of their epilepsy (p = 0.035) and non-epilepsy reasons than staff (p<0.001). Parents of children with epilepsy attending mainstream schools were more likely to agree that their child was bullied because of their epilepsy (p = 0.017) and non-epilepsy reasons (p = 0.026), compared to parents of children with epilepsy attending special schools. CONCLUSIONS: School attendance difficulties for children with epilepsy can contribute to academic and social-emotional difficulties. Most parents and teachers feel that children with epilepsy are included in classroom activities to the same extent as peers. Children with epilepsy and their parents believe that they are more restricted in non-classroom activities compared with their peers. Difficulties with participation, friendships and bullying for children with epilepsy may be due to presence of other conditions as opposed to epilepsy per se. There is a need to increase understanding of the wide ranging impact of epilepsy on school life in order to enhance attendance and inclusion and to reduce bullying

Building a Participatory Culture: Collaborating with Student Organizations for Twenty-first Century Library Instruction

Today’s students are critical thinkers, collaborators, and creators. They expect to participate in twenty-first century learning environments not as passive information consumers (think lectures), but as active contributors (think team-based problem-solving). There are opportunities for instruction librarians to collaborate directly with student-led organizations. These partnerships have the potential to increase attendance at library events and provide platforms for students to engage in richer forms of exploratory learning that incorporate twenty-first century skills. This article will discuss the literature surrounding library instruction collaborations, identify “Librarian–Student Organization Collaborations” as an important form of partnership, and supply specific case studies of successful library instruction events based on these collaborations

Sea star inspired crawling and bouncing

The oral surface of sea stars is lined with arrays of tube feet that enable them to achieve highly controlled locomotion on various terrains. The activity of the tube feet is orchestrated by a nervous system that is distributed throughout the body without a central brain. How such a distributed nervous system produces a coordinated locomotion is yet to be understood. We develop mathematical models of the biomechanics of the tube feet and the sea star body. In the model, the feet are coupled mechanically through their structural connection to a rigid body. We formulate hierarchical control laws that capture salient features of the sea star nervous system. Namely, at the tube foot level, the power and recovery strokes follow a state-dependent feedback controller. At the system level, a directionality command is communicated through the nervous system to all tube feet. We study the locomotion gaits afforded by this hierarchical control model. We find that these minimally-coupled tube feet coordinate to generate robust forward locomotion, reminiscent of the crawling motion of sea stars, on various terrains and for heterogeneous tube feet parameters and initial conditions. Our model also predicts a transition from crawling to bouncing consistent with recent experiments. We conclude by commenting on the implications of these findings for understanding the neuromechanics of sea stars and their potential application to autonomous robotic systems

Variable Hard X-ray Emission from the Candidate Accreting Black Hole in Dwarf Galaxy Henize 2-10

We present an analysis of the X-ray spectrum and long-term variability of the nearby dwarf starburst galaxy Henize 2-10. Recent observations suggest that this galaxy hosts an actively accreting black hole with mass ~10^6 M_sun. The presence of an AGN in a low-mass starburst galaxy marks a new environment for active galactic nuclei (AGNs), with implications for the processes by which "seed" black holes may form in the early Universe. In this paper, we analyze four epochs of X-ray observations of Henize 2-10, to characterize the long-term behavior of its hard nuclear emission. We analyze observations with Chandra from 2001 and XMM-Newton from 2004 and 2011, as well as an earlier, less sensitive observation with ASCA from 1997. Based on detailed analysis of the source and background, we find that the hard (2-10 keV) flux of the putative AGN has decreased by approximately an order of magnitude between the 2001 Chandra observation and exposures with XMM-Newton in 2004 and 2011. The observed variability confirms that the emission is due to a single source. It is unlikely that the variable flux is due to a supernova or ultraluminous X-ray source, based on the observed long-term behavior of the X-ray and radio emission, while the observed X-ray variability is consistent with the behavior of well-studied AGNs.Comment: 7 pages, 4 figures, 2 tables; accepted for publication in Ap