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

People with mild cognitive impairment are at increased risk of serious injury

Introduction Data-linkage studies using administrative hospital data have shown that people with dementia have double the rate of injury-related hospitalisations and poorer health outcomes than those without. No previous research has explored whether people with mild cognitive impairment are also at increased risk of serious injury requiring hospitalisation. Objectives and Approach A major barrier to the use of administrative hospital data for undertaking research focusing on people with MCI is that MCI cannot be reliably identified from ICD-10 coded administrative data. To overcome this limitation, hospitalisation and death data was linked to data from participants (community-dwelling 70-90 year olds) enrolled in the population-based longitudinal Sydney Memory and Ageing Study (MAS). MAS participants underwent comprehensive neuropsychological assessments at baseline, then 2, 4 and 6 years’ follow-up to accurately determine cognitive status at each time-period. Linkage to hospital records allowed identification of injury-related hospitalisations and outcomes for the 2-year period following each assessment. Results There were 335 injury-related hospitalisations for the 867 participants; 222 (25.6%) participants had at least one injury-related hospitalisation. After adjusting for age-and-sex, participants in a state of MCI had 1.7 (95%CI 1.2-2.4) times higher odds of an injury-related hospitalisation than participants in a state of normal cognition, whilst participants with dementia had 2.3 (95%CI 1.2-4.4) times higher odds. There was no difference in odds between participants with MCI and dementia. Of the 116 hospitalisations for people with MCI, the majority (79.3%) were due to falls. Non-fracture head injuries (25.9%), upper limb and trunk fractures (13.8% respectively) were the most common injury type. There were no differences in injury type, mean length of stay, or 30-day mortality between people with normal cognition, MCI and dementia. Conclusion/Implications Older people with objectively defined MCI are at higher risk of injury, predominantly as a result of falls, than their cognitively intact peers. Falls-risk screening and fall prevention initiatives may be indicated for people with MCI. Further research is required to determine which cognitive domains contribute to this increased risk

Equine-Assisted Interventions (EAIs) for Children with Autism Spectrum Disorders (ASD): Behavioural and Physiological Indices of Stress in Domestic Horses (Equus caballus) during Riding Sessions

Equine-assisted interventions (EAIs) are well-known complementary practices combining physical activity with emotional/cognitive stimulation. They are especially suited for children with autism spectrum disorders (ASD) who need a high degree of physical and psychological enrichment. Even though EAIs have become a common practice, stress responses in horses interacting with individuals that can manifest inappropriate behaviours, such as ASD children, have not been thoroughly investigated. Our multicentre study aimed to investigate behavioural and physiological indices of stress in horses involved in EAI standardised sessions with children with ASD compared to typically developing (TD) children. A controlled within-subject design with repeated measurements involving 19 horses and 38 children was adopted. Stress-related behaviours, heart rate, heart rate variability, and eye temperature were recorded during the riding sessions. Moreover, blood samples were collected from horses before and after each session to monitor changes in blood adrenocorticotropic hormone (ACTH), cortisol, and catecholamines. Results indicate that, in general, stress responses in horses involved in EAIs did not differ as a function of the horse being ridden by children with ASD or TD. A lower sympathetic tone in horses involved in ASD sessions was found, while in the mounting and dismounting phases, horses displayed behavioural signs of stress, independently from children’s behaviour. We conclude that professionals working in EAI should increase their awareness of animal welfare and refine riding practices, taking into account horse’s needs

Injury risk for matched front and rear seat car passengers by injury severity and crash type : an exploratory study

Background: The risk of serious injury or death has been found to be reduced for some front compared to rear seat car passengers in newer vehicles. However, differences in injury severity between car occupants by seating position has not been examined. This study examines the injury severity risk for rear compared to front seat car passengers. Method: A retrospective matched-cohort analysis was conducted of vehicle crashes involving injured rear vs front seat car passengers identified in linked police-reported, hospitalisation and emergency department (ED) presentation records during 2001-2011 in New South Wales (NSW), Australia. Odds ratios were estimated using an ordinal logistic mixed model and logistic mixed models. Results There were 5419 front and 4588 rear seat passengers in 3681 vehicles. There was a higher odds of sustaining a higher injury severity as a rear-compared to a front seat car passenger, with a higher odds of rear seat passengers sustaining serious injuries compared to minimal injuries. Where the vehicle occupant was older, travelling in a vehicle manufactured between 1990 and 1996 or after 1997, where the airbag deployed, and where the vehicle was driven where the speed limit was ≥70 km/h there was a higher odds of the rear passenger sustaining a higher injury severity then a front seated occupant. Conclusion: Rear seat car passengers are sustaining injuries of a higher severity compared to front seat passengers travelling in the same vehicle, as well as when travelling in newer vehicles and where the front seat occupant is shielded by an airbag deployed in the crash. Rear seat occupant protective mechanisms should be examined. Pre-hospital trauma management policies could influence whether an individual is transported to a hospital ED, thus it would be beneficial to have an objective measure of injury severity routinely available in ED records. Further examination of injury severity between rear and front seat passengers is warranted to examine less severe non-fatal injuries by car seating position and vehicle intrusion.9 page(s

Young cannabis users in residential treatment : as distressed as other clients

Doubt remains about the need for residential substance user treatment for young cannabis users. Using a series of validated clinical tools, this study compared 1,221 primarily cannabis-, psychostimulant-, alcohol-, or opioid-dependent young people admitted to an urban/rural Australian residential treatment program between 2001 and 2007. Multinomial logistic regression revealed that the cannabis user group had poorer mental health than the opioid group, poorer social functioning than the alcohol drinking group, and comparably poor functioning otherwise but remained in treatment longer than the psychostimulant and opioid user groups. Residential treatment for primarily cannabis-dependent young people with complex and multiple needs can be supported.11 page(s

Determinants of time to surgery for patients with hip fracture

Background: Guidelines for hip fracture care suggest that patients with hip fracture should undergo surgery on the day of or day after admission to hospital. This study examined factors affecting time to surgery for hip fracture extracted from existing administrative datasets in New South Wales (NSW), Australia. Method: A retrospective analysis of patients with hip fracture aged 65 years and over undergoing surgical intervention in NSW public hospitals between 1 July 2000 and 30 June 2011. A multinomial logistic model was used to identify factors impacting on time to surgery from 1 July 2006 to 30 June 2011. Results: A total of 49,317 hip fracture procedures were recorded during 2000-2001 to 2010-2011. Sixty-four per cent of patients received operative treatment on the day of or day after admission. Co-morbidity, type of surgical procedure and day of presentation all impacted significantly on time to surgery. Fourteen per cent required an inter-hospital transfer prior to receiving operative intervention. Transferred patients were 2.6 (95% confidence interval (CI): 2.31-2.85) times more likely to wait 2-4 days and 3.2 times more likely to wait 5 or more days (95% CI: 2.77-3.76) for surgery compared with patients presenting to an operating hospital. Conclusion: Significant variation exists between hospitals in the time to surgery that is not solely explained by measures of case mix or geography. Opportunities exist to consider other factors contributing to this variation and to ensure timely access to surgical intervention in the future.6 page(s

Mental Flexibility Influences the Association Between Poor Balance and Falls in Older People – A Secondary Analysis

Impairments of balance predispose older people to falls. Some cognitive functions, especially executive functioning have been shown to affect balance and discriminate fallers from non-fallers. Mental flexibility is a component of the executive function and comprises multiple cognitive processes that work together to adjust the course of thoughts or actions according to the changing demands of a situation without the use of explicit instructions. However, the role of mental flexibility in balance in older people remains unclear. The study aim was to examine the relationship between mental flexibility and falls in a cohort of 212 older people (80.6 ± 4.9 years; 62% female). We hypothesized that: (i) participants with impaired balance would have worse mental flexibility compared to those with good balance; and (ii) poor mental flexibility would predict falls in the sub-group with impaired balance. Balance performance was assessed by measuring postural sway while standing on a medium density foam mat with eyes open for 30 s. Mental flexibility was assessed using a computerized short-form of the Wisconsin Card Sorting Test (WCST; 64 cards) with its sub-components comprising general performance, perseveration, failure-to-maintain set and conceptual ability. Falls were measured prospectively for 12-months using monthly calendars. MANCOVA revealed that WCST performance was associated with balance [Wilks’ Lambda = 0.883, F = 2.168; p = 0.013, partial eta squared (η2p) = 0.061] due primarily to reduced concept formation ability [F(2,207) = 5.787, p = 0.004, η2p = 0.053]. Negative binomial regression analysis adjusting for age, education, contrast sensitivity, proprioception, inhibition, and inhibitory choice stepping reaction time (iCSRT) revealed that lower concept formation ability was predictive for falls [Incidence Rate Ratio 1.048 (95% confidence interval 1.016–1.081)]. Further, lower concept formation ability partly explained the association between balance and falls: i.e., fallers in the upper balance tertile had reduced concept formation performance whereas non-fallers had similar concept formation performance across the three balance tertiles. These findings suggest that poor mental flexibility affects the ability to maintain steady balance contributing to increased risk of falls in older people

Factors associated with variability and stability of cannabis use in young adulthood

Background: This study investigated the factors associated with initiating cannabis use, reverting to cannabis use and remaining a cannabis user in young adulthood. This is an important area of research as the risk for cannabis initiation is extending be