Opioids for breathlessness: a narrative review.

Chronic breathlessness is a disabling and distressing condition for which there is a growing evidence base for a range of interventions. Non-pharmacological interventions are the mainstay of management and should be optimised prior to use of opioid medication. Opioids are being implemented variably in practice for chronic breathlessness. This narrative review summarises the evidence defining current opioids for breathlessness best practice and identifies remaining research gaps. There is level 1a evidence to support the use of opioids for breathlessness. The best evidence is for 10-30 mg daily de novo low-dose oral sustained-release morphine in opioid-naïve patients. This should be considered the current standard of care following independent, regulatory scrutiny by one of the world's therapeutics regulatory bodies. Optimal benefits are seen in steady state; however, there are few published data about longer term benefits or harms. Morphine-related adverse events are common but mostly mild and self-limiting on withdrawal of drug. Early and meticulous management of constipation, nausea and vomiting is needed particularly in the first week of administration. Serious adverse events are no more common than placebo in clinical studies. Observational studies in severe chronic lung disease do not show excess mortality or hospital admission in those taking opioids. We have no long-term data on immune or endocrine function. There are promising data regarding prophylaxis for exertion-related breathlessness, but given the risks associated with transmucosal fentanyl, caution is needed with regard to clinical use pending longer term, robust safety data

Fast physical models for Si LDMOS power transistor characterization

A new nonlinear, process-oriented, quasi-two-dimensional (Q2D) model is described for microwave laterally diffused MOS (LDMOS) power transistors. A set of one-dimensional energy transport equations are solved across a two-dimensional cross-section in a “current-driven” form. The model accounts for avalanche breakdown and gate conduction, and accurately predicts DC and microwave characteristics at execution speeds sufficiently fast for circuit simulation applications

Role of the street network in burglars' spatial decision-making

Explaining why crime is spatially concentrated has been a central theme of much criminological research. Although various theories focus on neighborhood social processes, environmental criminology asserts that the physical environment plays a central role by shaping people's activity patterns and the opportunities for crime. Here, we test theoretical expectations regarding the role of the road network in shaping the spatial distribution of crime and, in contrast to prior research, disentangle how it might influence offender awareness of criminal opportunities and the supply of ambient guardianship. With a mixed logit (discrete choice) model, we use data regarding (N = 459) residential burglaries (for the first time) to model offender spatial decision-making at the street segment level. Novel graph theory metrics are developed to estimate offender awareness of street segments and to estimate levels of ambient guardianship, distinguishing between local and nonlocal guardianship. As predicted by crime pattern theory, novel metrics concerning offender familiarity and effort were significant predictors of residential burglary location choices. And, in line with Newman's (1972) concept of defensible space, nonlocal (local) pedestrian traffic was found to be associated with an increase (decrease) in burglary risk. Our findings also demonstrate that "taste" preferences vary across offenders, which presents a challenge for future research to explain

Basking shark hotspots on the West Coast of Scotland: Key sites, threats and implications for conservation of the species

Copyright © Scottish Natural Heritage 2009.The Wildlife Trusts’ Basking Shark Project conducted effort-corrected line transect surveys for the basking shark (Cetorhinus maximus) along the west coast of Scotland between 2002- 2006. A total of 11,179km of linear transects consisting of 956 hours duration were covered, and a total of 593 sharks were recorded whilst on transect. The project aimed to establish whether key sites (hotspots) existed for the species within the overall region, where significant numbers of sharks could be seen at the surface on a regular basis. This information could then be used to develop practical means of protecting surface swimming sharks at such sites, such as educational maps of the hotspot sites for distribution to leisure and commercial boat users, and to inform future developments within the marine environment e.g. fisheries and renewable energy developments.The project enjoyed the support of many Organisations, both financially and in spirit. These include Natural England, The Wildlife Trusts, WWF-UK, Earthwatch Institute (Europe), The Born Free Foundation, The Shark Foundation (Hai Stiftung), The Shark Trust, the Marine Conservation Society, the Heritage Lottery Fund, the National Express Group, the Save Our Seas Foundation, Volvo Ocean Adventure, the Esmee Fairbairn Foundation, and Canon (UK). Their support was invaluable

Household occupancy and burglary: A case study using COVID-19 restrictions

INTRODUCTION: In response to COVID-19, governments imposed various restrictions on movement and activities. According to the routine activity perspective, these should alter where crime occurs. For burglary, greater household occupancy should increase guardianship against residential burglaries, particularly during the day considering factors such as working from home. Conversely, there should be less eyes on the street to protect against non-residential burglaries. METHODS: In this paper, we test these expectations using a spatio-temporal model with crime and Google Community Mobility data. RESULTS: As expected, burglary declined during the pandemic and restrictions. Different types of burglary were, however, affected differently but largely consistent with theoretical expectation. Residential and attempted residential burglaries both decreased significantly. This was particularly the case during the day for completed residential burglaries. Moreover, while changes were coincident with the timing and relaxation of restrictions, they were better explained by fluctuations in household occupancy. However, while there were significant decreases in non-residential and attempted non-residential burglary, these did not appear to be related to changes to activity patterns, but rather the lockdown phase. CONCLUSIONS: From a theoretical perspective, the results generally provide further support for routine activity perspective. From a practical perspective, they suggest considerations for anticipating future burglary trends

Professional Counseling\u27s Alignment with the Core Competencies for Interprofessional Collaborative Practice

Previous findings show that there is a misconception of the counseling profession and a lack of awareness of their role in interprofessional collaboration; which may lead to underutilization of counselors for team based care. As an example, in 2009 six professional health related associations developed core competencies for interprofessional collaborative practice and counseling associations were not involved in the development. This manuscript introduces the profession of counseling to others in medical health professions in hopes that similarities will bridge the gap between knowledge and future collaborative practice. The manuscript shows how the profession aligns with the core competencies for interprofessional collaborative practice (CCIPC), ethical codes, accreditation bodies, and existing counseling literature. It concludes with implications for practice, system level support, and policy

Outcome measurement of refractory breathlessness: Endpoints and important differences

© 2015 Wolters Kluwer Health, Inc. All rights reserved. Purpose of review Standardized measurement of self-rated breathlessness using appropriate tools is essential for research and clinical care. The purpose was to review recent advances in the measurement of breathlessness and the minimal clinically important differences (MCIDs) in intensity of chronic breathlessness. Recent findings Two tools have been validated in people with chronic obstructive pulmonary disease (COPD) to measure daily symptoms and breathlessness related to daily activities. Two multidimensional tools have been developed for different settings and aetiologies, which measure both the perceived intensity, unpleasantness, quality of breathlessness, and the person's emotional response to it. MCIDs have been reported for the intensity of chronic refractory breathlessness, the daily symptom diary, and breathlessness related to daily activities in COPD. Summary There have been substantial developments in instruments able to provide reliable and valid unidimensional and multidimensional measurement of self-reported breathlessness and in the understanding of the MCID for chronic breathlessness. Routine use of agreed outcome measures in clinical practice and research are crucial steps to improve our understanding of the science of breathlessness and its impact on patients' outcomes

Predictors and trajectory of performance status in patients with advanced cancer: A secondary data analysis of the international European Palliative Care Cancer Symptom study.

Background: Performance status, a predictor of cancer survival, and ability to maintain independent living deteriorate in advanced disease. Understanding predictors of performance status trajectory could help identify those at risk of functional deterioration, target support for independent living and reduce service costs. The relationship between symptoms, analgesics and performance status is poorly delineated. Aim: The aim of this study is to determine whether demographics, analgesics, disease characteristics, quality-of-life domains and C-reactive protein predict the trajectory of Karnofsky Performance Status (KPS) in patients with advanced cancer. Design: The study design is the secondary data analysis of the international prospective, longitudinal European Palliative Care Cancer Symptom study (ClinicalTrials.gov: NCT01362816). A multivariable regression model was built for KPS area under the curve per day (AUC). Setting and participants: This included adults with advanced, incurable cancer receiving palliative care, without severe cognitive impairment and who were not imminently dying (n = 1739). Results: The mean daily KPS AUC (n = 1052) was 41.1 (standard deviation = 14.1). Opioids (p < 0.001), co-analgesics (p = 0.023), poorer physical functioning (p < 0.001) and appetite loss (p = 0.009) at baseline were explanatory factors for lower KPS AUC. A subgroup analysis of participants with C-reactive protein data (n = 240) showed that only C-reactive protein (p = 0.040) and physical function (p < 0.001) were associated with lower KPS AUC. Conclusion: This study is novel in determining explanatory factors for subsequent functional trajectories in an international dataset and identifying systemic inflammation as a candidate therapeutic target to improve functional performance. The effect of interventions targeting physical function, appetite and inflammation, such as those used for cachexia management, on maintaining functional status in patients with advanced cancer needs to be investigated

Modelled effects of rising CO2 concentration and climate change on native perennial grass and sown grass-legume pastures

Native perennial grass and sown grass-legume pastures are an important agricultural and environmental resource. We investigated the impact of rising carbon dioxide concentration ([CO2]) and projected climate changes on these pasture ecosystems in southeastern Tasmania, Australia, using a biophysical simulation model, EcoMod. The model consists of interdependent modules that describe soil physicochemical and hydrological characteristics, and pasture growth and senescence, with fluxes described by empirical and mechanistic equations. Our simulations showed that in native pastures, projected climate change increased the biomass of C-4 grasses, with limited impact upon C-3 grasses, a trend reversed by rising [CO2]. In sown pastures, projected climate change decreased the biomass of perennial rye grass Lolium perenne and total biomass markedly by 2070, whilst subterranean clover Trifolium subterraneum biomass increased. Subterranean clover biomass changed little with increased [CO2] alone, whereas perennial rye grass biomass increased. Responses across pastures reflected species' tolerances to environmental factors, with projected climate change generally having more of an impact on biomass than rising [CO2]. Changes in both [CO2] and climate led to a reduction in protein content and digestibility. Soil inorganic nutrient concentrations decreased with increasing [CO2] and increased with projected climate change. Further simulations should investigate whether these patterns are robust for different sites and alternative environmental futures. Our results reinforce the need to pursue adaptation strategies in response to environmental change in order to maintain productive pasture ecosystems