Difficult Set Research Articles

Conventional Wisdom versus Actual Outcomes: Challenges in the Conduct of an Ebola Vaccine Trial in Liberia during the International Public Health Emergency.

.Clinical trials are challenging endeavors. Planning and implementing an investigational vaccine trial in Liberia, in the midst of an Ebola virus disease (EVD) epidemic that World Health Organization classified a public health emergency of international concern, presented extraordinary challenges. Normally, years of preparation and a litany of tasks lay the groundwork for a successful, randomized, blinded, placebo-controlled trial focused on safety and efficacy. Difficult research settings, unpredictable events, and other unique circumstances can add complexity. The setting in Liberia was especially problematic due to an infrastructure still badly damaged following a lengthy civil war and a very fragile health-care system that was further devastated by the EVD outbreak. The Partnership for Research on Vaccines in Liberia I EVD vaccine trial was planned and implemented in less than 3 months by a Liberian and U.S. research partnership, and its Phase II substudy was fully enrolled 3 months later. Contrasting conventional wisdom with trial outcomes offers an opportunity to compare early assumptions, barriers encountered, and adaptive strategies used, with end results. Understanding what was learned can inform future trial responses when disease outbreaks, especially in resource-poor locations with minimal infrastructure, pose a significant threat to public health.

Neutrality in foreign aid

Since the late 1990s, researchers have been predicting that the era of neutrality in aid politics is coming to an end and that foreign organizations will have to take a more engaged stance. Yet while the boundaries between humanitarianism and development are fading, in some cases the neutrality norm is actually expanding rather than giving way to an engaged paradigm. Recognizing that the principles of neutrality and independence have different meanings for different actors and that they are applied in various ways, this article examines how the humanitarian developers—small NGOs operating in Jonglei State in South Sudan—use these paradigms. The article shows that their specific variant of neutrality is not so much a pragmatic tool enabling operations in difficult settings, but instead is a structural form of identity. In this variation, neutrality is not about the absence of a political stance, but about standing apart from social structures and social immunity.

Selection of Significant Clusters of Genes based on Ensemble Clustering and Recursive Cluster Elimination (RCE)

Background: Advances in technology have facilitated the generation of gene expression data from large numbers of samples and the development of “Big Data” approaches to analysing gene expression in basic and biomedical systems. That being said, the data still includes relatively small numbers of samples and tens of thousands of variables/gene expression. A variety of different approaches have been developed for searching these gene spaces in order to select the most informative variables that can accurately distinguish one class of subjects/ samples from another. However, there is still a need for new approaches that can accurately distinguish biologically different classes of subjects with similar gene expression profiles. We describe a new and promising approach for selecting the most informative differentially expressed genes that addresses this problem. We describe a method for identifying significant differentially expressed clusters of genes using a process of Recursive Cluster Elimination (RCE) that is based on an ensemble clustering approach. We refer to this approach as SVM-RCE-EC (Ensemble Clustering). We show that SVM-RCE-EC improves gene selection, classification accuracy as compared to other methods including the traditional SVM-RCE approach, and that this is particularly evident when applied to difficult data sets that are poorly resolved by other approaches. Methods: To implement SVM-RCE-EC we first applied an ensemble-clustering method, to identify robust gene clusters. We then applied Support Vector Machines (SVMs), with cross validation to score (rank) those clusters of genes based on their contributions to classification accuracy. The clusters of genes that are least significant are progressively removed by the procedure of RCE with the most significant clusters being retained until one identifies the most robust, significantly differentially expressed genes between the two classes. We compare the classification performance of SVM-RCE-EC to a variety of published classification algorithms. Results and Conclusion: Utilization of gene clusters selected using the ensemble method enhances classification performance as compared to other methods and identifies sets of significant genes that appear to be more biologically meaningful to the system being analyzed. We show that SVM-RCE-EC outperforms several other methods on data that represent highly similar sample classes that are difficult to distinguish and is comparable to other methods when applied to data where the classes are more easily separated. The improved performance of SVM-RCE-EC on difficult data sets is likely due to the fact that the significant clusters, as determined by the ensemble approach, capture the native structure of the data while SVM-RCE leaves that determination to the user. This hypothesis is supported by the observations that the performance of the clusters generated by SVM-RCE-EC is more robust. Availability: The Matlab version of SVM-RCE-EC is available upon request to the first author and at GitHub (https://github.com/malikyousef/svm-rce-ec).

Investigation for an Automated Avoidance of Ring Climbing in Radial-Axial Ring Rolling

Abstract Radial-axial ring rolling is the most important production process for seamless rings. One of the most occurring process errors is the climbing of a ring in the radial rolling gap. With the conventional sensors of a radial-axial ring rolling machine, it has not yet been possible to detect a ring’s climbing in any way. For this purpose, an image processing system was installed at the radial-axial ring rolling machine of the LPS (Chair of Production Systems) which particularly records the side of a ring in the radial rolling gap. This paper proves the basic measuring capability of this intelligent image processing system in the rather difficult setting and presents different steps and experiments chosen to give reliable information on the system’s measurement accuracy. Furthermore the used algorithm to detect the climbing height of rings is presented and the degree of repeatability gets examined and evaluated. Once it is proven that the system delivers reliable results, this work uses different parameters based on the state of the art to affect the climbing of a ring. The intensity with which these parameters affect a ring’s climbing is tested in a fractional factorial design. This knowledge is used to design rolling strategies which avoid a climbing of the ring. Based on these strategies, this work introduces first experiments with static parameters during the entire rolling process. This paper shows the necessary steps and the ways these are realized to implement an image processing system to determine a ring’s climbing height. This finally serves to implement an automated system to avoid a ring’s climbing at an early stage in radial-axial ring rolling.

Analysis of Factors Affecting Successful Clinical Trial Enrollment in the Context of Three Prospective, Randomized, Controlled Trials

Challenges can arise when attempting to maximize patient enrollment in clinical trials. There have been limited studies focusing on the barriers to enrollment and the efficacy of alternative study design to improve accrual. We analyzed barriers to clinical trial enrollment, particularly the influence of timing, in context of three prospective, randomized oncology trials where one arm was considered more aggressive than the other. From June 2011 to March 2015, patients who were enrolled on 3 prospective institutional protocols (an oligometastatic non-small cell lung cancer [NSCLC] trial and 2 proton vs intensity modulated radiation therapy trials in NSCLC and esophageal cancer) were screened for protocol eligibility. Eligible candidates were approached about trial participation, and patient characteristics (age, sex, T/N categorization) were recorded along with details surrounding trial presentation (appointment number). Fisher's exact test, Student's t tests, and multivariate analysis were performed to assess differences between enrolled and refusal patients. A total of 309 eligible patients were approached about trial enrollment. The enrollment success rate during this time span was 52% (n=160 patients). Enrolled patients were more likely to be presented trial information at an earlier appointment (oligometastatic protocol: 5 vs 3 appointments [P<.001]; NSCLC protocol: 4 vs 3 appointments [P=.0018]; esophageal protocol: 3 vs 2 appointments [P=.0086]). No other factors or patient characteristics significantly affected enrollment success rate. Improvement in enrollment rates for randomized control trials is possible, even in difficult accrual settings. Earlier presentation of trial information to patients is the most influential factor for success and may help overcome accrual barriers without compromising trial design.

Clinical research on rare diseases of children: neuroblastoma.

Early access to new treatment options should not preclude accurate research planning, especially for rare diseases and fragile populations. Taking neuroblastoma as a model case, we analyzed the rationale supporting the search for future therapeutic strategies in the light of preclinical and clinical evidence. We reviewed ongoing randomized trials of pharmacological interventions for the treatment of neuroblastoma retrieved by searching ClinicalTrials.gov and the European Union Clinical Trials Registry (last update March 2016). Our search identified four randomized clinical trial reports. We found poor evidence from preclinical and early clinical research supporting their rationale. Their methodology was questionable too. The urgency to cover unmet needs in difficult clinical settings like rare diseases, particularly those involving fragile populations, cannot justify disorderly research approaches. Under these circumstances, clinical questions should be properly identified and addressed to protect patients and avoid wasteful research.

Assessment of Paramedic Performance on Difficult Airway Simulation

Objective: Airway management is a common, important intervention for critically ill patients in the United States. A key element of prehospital airway management is endotracheal intubation (ETI). Prehospital ETI success rates have been shown to be as low as 77% compared to in-hospital rates of 95%. Given these rates, the use of backup airway devices is a necessary precaution for patient safety. The extent to which paramedics integrate backup airway use into their airway algorithm is unknown. The purpose of this study was to assess paramedic comprehensive airway management practices during a difficult airway simulation through which paramedics were obligated to consider alternatives to ETI. Methods: This was an observational study of airway management skills in active paramedics (N = 198). A difficult airway simulation was conducted in a mobile simulation laboratory; a Type 3 ambulance with four video cameras including an endotracheal view to capture airway management. Recordings of paramedic performance were assessed using a 110-item checklist covering four key areas: 1) placement of an endotracheal tube; 2) application of backup airway following failed ETI; 3) ventilation of the patient; and 4) achievement of airway safety and quality measures. Results: Paramedics were highly trained with 12 years (IQR: 4–20) of advanced life support experience and a median of 40 prehospital intubations over their careers (IQR: 15–100). In this difficult airway setting, first pass ETI success rate was 55.6%. However, paramedics were challenged with airway management following a failed ETI. Only 9% of providers were prepared with a clear backup plan. Sixty-three percent of the paramedics successfully placed a backup airway within 3 attempts. During the simulation, only 14% properly ventilated at a rate of 10–12 breaths/min. Ventilations were maintained without interruptions (>30 sec) in 22% of simulations. Conclusion: In a difficult airway management scenario designed for low ETI success rates, even experienced paramedics were challenged with comprehensive airway management. This was exemplified by difficulties with the use of backup airway devices. Future work needs to be directed at identifying the key determinants for airway management success and the development of interventions to improve success with the use of a comprehensive airway management plan.

Sustainability of patent-based competitive advantage in the U.S. communications services industry

Patents have long been assumed to provide firms with competitive advantage, but longitudinal results suggest that some types of patent content provide more enduring advantage than others do. The duration of advantage appeared to wane with time in the highly-dynamic U.S. communications-services industry during a period when technological changes occurred rapidly within it (1998–2012). Results suggest patents integrating technology streams that were different from the technologies of focal-patents’ grants contributed more to sustaining firms’ profit margins during this period than did focal patents that exploited extant technological knowledge. We found that firms who continually pushed their organization’s knowledge envelope outward to incorporate more unknown technologies sustained higher profit margins for a longer duration of time than did firms whose patented inventions were predominantly incremental—even within difficult settings where competition grew so intense that firms’ average operating margins were deteriorating.

Accurate Classification of RNA Structures Using Topological Fingerprints.

While RNAs are well known to possess complex structures, functionally similar RNAs often have little sequence similarity. While the exact size and spacing of base-paired regions vary, functionally similar RNAs have pronounced similarity in the arrangement, or topology, of base-paired stems. Furthermore, predicted RNA structures often lack pseudoknots (a crucial aspect of biological activity), and are only partially correct, or incomplete. A topological approach addresses all of these difficulties. In this work we describe each RNA structure as a graph that can be converted to a topological spectrum (RNA fingerprint). The set of subgraphs in an RNA structure, its RNA fingerprint, can be compared with the fingerprints of other RNA structures to identify and correctly classify functionally related RNAs. Topologically similar RNAs can be identified even when a large fraction, up to 30%, of the stems are omitted, indicating that highly accurate structures are not necessary. We investigate the performance of the RNA fingerprint approach on a set of eight highly curated RNA families, with diverse sizes and functions, containing pseudoknots, and with little sequence similarity–an especially difficult test set. In spite of the difficult test set, the RNA fingerprint approach is very successful (ROC AUC > 0.95). Due to the inclusion of pseudoknots, the RNA fingerprint approach both covers a wider range of possible structures than methods based only on secondary structure, and its tolerance for incomplete structures suggests that it can be applied even to predicted structures. Source code is freely available at https://github.rcac.purdue.edu/mgribsko/XIOS_RNA_fingerprint.

Mobile data collection tool for health surveillance surveys in difficult settings

Mobile data collection tool for health surveillance surveys in difficult settings

Information-seeking in an echolocating dolphin

Dolphins gain information through echolocation, a publicly accessible sensory system in which dolphins produce clicks to investigate objects. We measured information-seeking behavior by counting clicks that a blindfolded dolphin directed toward the sample object in a three-alternative matching task with object sets that varied in discriminability: Indiscriminable (performance accuracy M = 33%) vs. Easy (performance accuracy M&amp;gt;90%). The dolphin produced a similar number of clicks when first investigating each set type. Across multiple sessions, however, the dolphin emitted fewer clicks only when investigating indiscriminable (vs. easy) sets. Reduced echoic investigation with indiscriminable, but not easy, object sets was not due to overall motivation: the differential relationship between click number and object set discriminability was maintained when difficult and easy trials were interleaved and when objects from originally difficult sets were grouped with more discriminable objects. Further analyses of the dolphin’s click production towards the choice alternatives also revealed that the dolphin produced more clicks towards the chosen (vs. unchosen) alternatives when solving the task. Overall, these data suggest that dolphins calibrate the effort they invest in information seeking in accordance with the information content available in their immediate environment.

Dynamically Weighted Combination Model for Describing Inconsistent Failure Data of Software Projects

Background/Objective: The Software Reliability Engineering discipline is witnessing continued research in the field of Software Reliability Growth Models (SRGMs), in order to develop suitable models so as to match with the phenomenal developments in the software sector. The objective of this paper is to propose a combined dynamically weighed model for reliability analysis. Methods: In general, the ability of a model to describe a dataset adequately is assessed by Goodness of Fit (GoF) measures that a model achieves. We used one of the difficult data sets for evaluation of the GoF performance and the non-linear regression was carried out using Curve fitting application of the MATLABTM software tool. The coefficients of determination R-Square (R2), Sum of Squared Error (SSE), Root Mean Square Error (RMSE) are the different GoF metrics used. Findings: The major challenge for the software projects today, is to measure, analyze and control the level of quality of the delivered software. Undesirably long testing cycles adversely influence time to market and hence software development organizations are very keen on having a good control on the testing cycle. In the last few years many reliability models have been identified and recommended. However, no single model can be considered suitable for all situations. Some models assume the growth of mean value function to be exponential, while other models assume it to follow S-type growth. This poses a challenge to the reliability modeling. The dynamically weighted combination model that we propose in this paper helps to address both the phenomena. The superposition and time transformation property of Non-Homogenous Poisson Process (NHPP) model was considered to derive the proposed model. Application: Using SRGM helps to improve the reliability performance. We have derived a powerful model by combining two well-known models. The proposed model gives excellent GoF performance and provides more confidence both for the customer and for the software development organizations.

Unsupervised categorization with individuals diagnosed as having moderate traumatic brain injury: Over-selective responding

Primary objective: This study explored over-selectivity (executive dysfunction) using a standard unsupervised categorization task. Over-selectivity has been demonstrated using supervised categorization procedures (where training is given); however, little has been done in the way of unsupervised categorization (without training).Methods and procedure: A standard unsupervised categorization task was used to assess levels of over-selectivity in a traumatic brain injury (TBI) population. Individuals with TBI were selected from the Tertiary Traumatic Brain Injury Clinic at Swansea University and were asked to categorize two-dimensional items (pictures on cards), into groups that they felt were most intuitive, and without any learning (feedback from experimenter). This was compared against categories made by a control group for the same task.Outcomes and results: The findings of this study demonstrate that individuals with TBI had deficits for both easy and difficult categorization sets, as indicated by a larger amount of one-dimensional sorting compared to control participants. Deficits were significantly greater for the easy condition.Conclusions: The implications of these findings are discussed in the context of over-selectivity, and the processes that underlie this deficit. Also, the implications for using this procedure as a screening measure for over-selectivity in TBI are discussed.

Family-Centered Care in Juvenile Justice Institutions: A Mixed Methods Study Protocol.

BackgroundTreatment and rehabilitation interventions in juvenile justice institutions aim to prevent criminal reoffending by adolescents and to enhance their prospects of successful social reintegration. There is evidence that these goals are best achieved when the institution adopts a family-centered approach, involving the parents of the adolescents. The Academic Workplace Forensic Care for Youth has developed two programs for family-centered care for youth detained in groups for short-term and long-term stay, respectively.ObjectiveThe overall aim of our study is to evaluate the family-centered care program in the first two years after the first steps of its implementation in short-term stay groups of two juvenile justice institutions in the Netherlands. The current paper discusses our study design.MethodsBased on a quantitative pilot study, we opted for a study with an explanatory sequential mixed methods design. This pilot is considered the first stage of our study. The second stage of our study includes concurrent quantitative and qualitative approaches. The quantitative part of our study is a pre-post quasi-experimental comparison of family-centered care with usual care in short-term stay groups. The qualitative part of our study involves in-depth interviews with adolescents, parents, and group workers to elaborate on the preceding quantitative pilot study and to help interpret the outcomes of the quasi-experimental quantitative part of the study.ResultsWe believe that our study will result in the following findings. In the quantitative comparison of usual care with family-centered care, we assume that in the latter group, parents will be more involved with their child and with the institution, and that parents and adolescents will be more motivated to take part in therapy. In addition, we expect family-centered care to improve family interactions, to decrease parenting stress, and to reduce problem behavior among the adolescents. Finally, we assume that adolescents, parents, and the staff of the institutions will be more satisfied with family-centered care than with usual care. In the qualitative part of our study, we will identify the needs and expectations in family-centered care as well as factors influencing parental participation. Insight in these factors will help to further improve our program of family-centered care and its implementation in practice. Our study results will be published over the coming years.ConclusionsA juvenile justice institution is a difficult setting to evaluate care programs. A combination of practice-based research methods is needed to address all major implementation issues. The study described here takes on the challenge by means of practice-based research. We expect the results of our study to contribute to the improvement of care for adolescents detained in juvenile justice institutions, and for their families.

Offline: A prescription for prosperity

Health is bad for you. That's what many economists believe. A man called William Baumol may be largely to blame. In the 1960s, he invented the notion of a “cost disease” in modern societies. It was a powerful metaphor, one that has shaped the prejudices of many a Minister of Finance ever since. His central idea sounds convincing. Some industries are good at increasing their productivity. As a result, they earn more money to invest in the wages of their employees. These sectors of the economy deserve our praise. There are other sectors where increasing productivity is harder. An orchestra, for example (playing faster isn't going to help much). Or ballet (dancing frenetically may subvert the aesthetics of the choreography). Or among health professionals. In areas that depend on human beings interacting with one another, as medicine does, productivity gains are hard to achieve. But the salaries of those working in these productivity-poor sectors rise anyway. Why? Because, thanks to increases in salaries in productivity-enriching sectors, salaries also increase in productivity-poor sectors to keep pace with the rising expectations of employees. If wages stayed low in productivity-poor sectors, musicians, ballet dancers, and doctors might well abandon their calling and become traders in Goldman Sachs. The result of the Baumol effect is a disaster for society. The costs of a concert, ballet, or health service increase even though productivity stays stubbornly the same. What else could this be but a malignant “cost disease” on our collective welfare. But what if Professor Baumol got his sums wrong? In an as yet unpublished World Bank paper led by Jean-Louis Arcand (Director of the Centre for Finance and Development at the Graduate Institute in Geneva), Baumol's hypothesis is challenged. Contrary to a half-century of consensus among economists, investing in health—and specifically health employment—is good, not only for health but also for the economy. Arcand took a more global view than Baumol, who studied only nations in the Organisation for Economic Cooperation and Development. Including low-income and middle-income countries in Arcand's calculations makes a profound difference. Investing in the health workforce is not a “cost disease” at all. On the contrary, investing in health workers improves the growth rate of economies. The effects of higher health employment are significantly greater than even the financial sector can achieve. This result is a discovery of Nobelesque proportions. What is the point of this excursion into the minutiae of economic theory? Last week, Presidents François Hollande and Jacob Zuma launched the final report of their High-Level Commission on Health Employment and Economic Growth at the UN General Assembly in New York. The purpose of the Commission was to examine the economic case for investing in the health workforce. The result was an affirmation of the value of the health sector to wider society. Expanding the number of health workers, and transforming their education at the same time, has the potential to accelerate health equity and inclusive economic growth. Employing these additional health workers in national programmes to deliver universal health coverage can be a trigger for economic revival. It sounds easy, but of course it is not. Many countries are facing, in whole or in part, extreme fragility—humanitarian catastrophe, conflict, post-conflict, or natural disasters. In these settings the economy is likely to be devastated. Investing in more doctors, nurses, midwives, or community-based health workers will be no magic solution. Added to which, health workers don't stay still. They often migrate. How does one encourage a doctor to stay and work in a difficult setting when moving country might be a far more attractive prospect? Gender equality, social protection, technology, financing, and better governance will also be critical determinants of success. The Expert Group to the Commission (which I chaired) recommended a “5-year action plan (2016–21) for an expanded, transformed, interdependent, and sustainable health workforce to accelerate inclusive economic growth and to ensure healthy lives, wellbeing, equity, and economic security for all”. Hollande and Zuma went further, demanding an even faster response. Despite challenges, the Commission on Health Employment and Economic Growth might be one of the most compelling opportunities in a generation to encourage Presidents and Prime Ministers, and perhaps most importantly their Ministers of Finance, to take health a great deal more seriously. The High-Level Commission on Health Employment and Economic Growth was co-convened by the World Health Organization, the International Labour Organization, and the OECD The High-Level Commission on Health Employment and Economic Growth was co-convened by the World Health Organization, the International Labour Organization, and the OECD

Communist Legacies and Democratic Survival in a Comparative Perspective

The literature on the legacies of communism for democratization has focused almost exclusively on explaining variation in the democratic experiences within the postcommunist space. While this is useful in many ways, it says little about a communist legacy in comparison to other types of antecedent regimes. We take a different approach, looking at the question by comparing postcommunist legacies to those of other states through the prism of democratic survival. One key implication of this shift in perspective is that the literature on democratic survival highlights a range of social and economic factors that are likely to help postcommunist democracies survive, which stands in stark contrast to the postcommunist democratic performance literature that emphasizes potential disadvantages. We assess these competing and contradictory implications by analyzing the relative likelihood of democratic survival using a sample of all third-wave democracies from 1970 to 2010. We find that postcommunist democracies are neither systematically more nor less likely to fail than other democracies. Further, we find no evidence that the prospects of failure are significantly affected by past membership in the Soviet Union or the Eastern Bloc, the type of communist regime, or the number of years under communist rule. These findings provide little evidence that the problems of postcommunist democratization pose a more difficult set of conditions for democratic survival.

Mechanisms and Development of Ceria-Based, Fast Oxide Slurries

Recent developments in vertical integration schemes including 3D-NAND flash memory have introduced a significant need for fast oxide slurries (1). Specifically, the new staircase CMP process requires exceptionally large step heights to be polished in a timely manner. Balancing low defectivity and high planarization efficiency with extremely fast bulk oxide removal rates is a difficult but crucial set of requirements. Ceria-based slurries with fine-tuned chemistries are well suited to meet these challenges. Mechanisms for ceria-based slurries polishing behavior on oxide surfaces have been the subject of investigation for a number of years now. A careful examination of these proposed mechanisms can drive the design and development of next generation fast oxide slurries.

Platinum-refractory germ cell tumors: an update on current treatment options and developments.

In general, 50% up to 80% of metastasized germ cell tumor patients can be cured by platinum-based chemotherapy. However, 3-5% of patients will still die of platinum-refractory disease and new systemic treatment options are needed to improve treatment success in this difficult setting. This review aims to give an overview on treatment options and current developments in the field of platinum-refractory male germ cell tumors. A comprehensive literature search was conducted searching PubMed, Medline, Cochrane and Embase to identify clinical trials regarding the treatment of platinum-refractory disease. ASCO, EAU and ESMO conference proceedings were searched to identify unpublished results of relevant trials. Comprehensive review papers were hand searched for additional references. Clinicaltrials.gov was checked for ongoing clinical trials in the field of platinum-refractory germ cell tumors. Outcome of platinum-refractory disease remains poor. Single-agents with reasonable activity are gemcitabine, oxaliplatin and paclitaxel, but complete remissions resulting in long-term survival could not be achieved. The triple-combination of gemcitabine, oxaliplatin and paclitaxel followed by resection of residual masses provides the best outcomes with objective responses in 51% of patients and long-term survival in approximately 10-15%. To date, no molecularly targeted agent has shown reasonable activity. Treatment options for platinum-refractory disease are limited, but a small subset of patients may achieve long-term disease-free survival by multimodal treatment. The potential of novel targeted agents, i.e. by immune-checkpoint-inhibition remains to be defined.

Teacher empowerment through engagement in a learning community in Ireland: working across disadvantaged schools

This ongoing longitudinal study examined the professional development of physical education teachers in an Irish physical education learning community where all teachers worked in inner-city disadvantaged schools. This research is framed within teacher empowerment. Four years of data collection included in-service seminar/workshop evaluations, small group discussions and focus group and individual interviews. Data were analysed to allow us to answer three research questions that focused on support in setting and achieving group goals, shared experiences of planning and teaching students and the informed development of learning communities towards a community of practice model. Results highlight the support these teachers provide one another, the empowerment these teachers developed to address issues posed by their challenging work situations (e.g. limited facilities, low economic conditions, students with challenging behaviour) and the motivation that being a member of a community afforded them to persevere in teaching in difficult settings. This research is ongoing as we explore and examine how the same group of teachers are able to maintain the work of their community, reinvent themselves and move from concluding one phase to begin new projects and impact student learning.

Therapeutic Touch® in a geriatric Palliative Care Unit – A retrospective review

Complementary therapies are increasingly used in palliative care as an adjunct to the standard management of symptoms to achieve an overall well-being for patients with malignant and non-malignant terminal illnesses. A Therapeutic Touch Program was introduced to a geriatric Palliative Care Unit (PCU) in October 2010 with two volunteer Therapeutic Touch Practitioners providing treatment. ObjectiveTo conduct a retrospective review of Therapeutic Touch services provided to patients in an in-patient geriatric palliative care unit in order to understand their responses to Therapeutic Touch. MethodsA retrospective medical chart review was conducted on both patients who received Therapeutic Touch as well as a random selection of patients who did not receive Therapeutic Touch from October 2010–June 2013. Client characteristics and the Therapeutic Touch Practitioners' observations of the patients' response to treatment were collected and analyzed. ResultsPatients who did not receive Therapeutic Touch tended to have lower admitting Palliative Performance Scale scores, shorter length of stay and were older. Based on a sample of responses provided by patients and observed by the Therapeutic Touch practitioner, the majority of patients receiving treatment achieved a state of relaxation or sleep. ConclusionsThis retrospective chart review suggests that implementation of a TT program for an inpatient geriatric Palliative Care Unit is feasible, and appears to be safe, and well-tolerated. Moreover, patient responses, as recorded in the Therapeutic Touch practitioners' session notes, suggest beneficial effects of Therapeutic Touch for a significant number of participants with no evidence of negative sequelae. Therefore, the use of TT in this difficult setting appears to have potential value as an adjunct or complementary therapy to help patients relax.