POWERbreathe Medic helps patients with breathing problems AND saves NHS money and resources

Health bosses announced back in October 2014 that the NHS in England needed extra money and an overhaul to services in order for patient care not to suffer.

When it comes to respiratory care the NHS could save both money and resources if they prescribed POWERbreathe Medic Respiratory Muscle Training (RMT) for patients with medical conditions such as COPD, Heart Failure, Asthma, Thoracic Surgery, Ventilator Weaning, Cystic Fibrosis and Neuromuscular Disease.

In a 2005 study of the benefits of a 12-month programme of POWERbreathe RMT, researchers observed significant reductions in the use of healthcare resources.1

POWERbreathe RMT for COPD

Accordingly to Professor Peter Calverley (Lung Report III. British Lung Foundation), in the average PCT serving 250,000 people, there would be 14,200 GP consultations per year for chronic obstructive pulmonary disease (COPD), and 9,600 inpatient bed days. Reducing length of hospital stay is an NHS productivity indicator.

POWERbreathe reduced hospital bed days by 29% and GP consultations by 23% compared with placebo (see table above).

POWERbreathe RMT for Asthma

In another study, Weiner et al2 observed an 86% reduction in hospitalisations/emergency room visits following respiratory muscle training in moderate/severe asthmatics (from 1.4 to 0.2 per 3 months per patient).

And in three separate studies, Weiner et al. observed an average 51% reduction in β2-agonist consumption (from 3.9 to 1.6 puffs per day)2,3,4 after respiratory muscle training, and in one study3, corticosteroid use decreased ~80%.

How POWERbreathe Medic could save NHS money & resources

In 2005 when this study was conducted, the total potential annual savings derived from POWERbreathe Medic prescription per average PCT due to reduced hospital bed days and medication consumption (not including savings due to reduction in GP consultations) were substantial.

The POWERbreathe Medic offers an evidence-based, drug-free treatment for patients with medical conditions such as COPD, Heart Failure, Asthma, Thoracic Surgery, Ventilator Weaning, Cystic Fibrosis and Neuromuscular Disease. It is the only Inspiratory Muscle Training device for RMT available for prescription that has been used in research into the benefits of IMT for a variety of medical conditions and prescribed by medical professionals as either a standalone intervention or as part of a rehabilitation programme.

For respiratory care professionals there is a POWERbreathe Medic Try-Before-You-Prescribe demonstration kit; an educational tool designed to help healthcare professionals and patients understand and experience the effect POWERbreathe Medic has on the respiratory muscles.

Since the approval of the POWERbreathe Medic for prescription in 2006, POWERbreathe has introduced the revolutionary, electronic POWERbreathe KH1, intended for use by healthcare professionals for respiratory muscle training and assessment in patients with dyspnoea, including patients with asthma, COPD, bronchitis, cystic fibrosis, emphysema, heart disease, neuromuscular disease, Parkinson’s disease and spinal injury.

The POWERbreathe KH1 is also suitable for use with disposable TrySafe filters and can be used bedside, on the ward, as part of a pulmonary program, or for single patient use at home under medical supervision.

Launched after the POWERbreathe Medic, following the latest technological advances in research and design, is the next generation POWERbreathe Medic: the POWERbreathe Medic Plus for patients to use at home, straight out of the box, with improved airflow dynamics and a more comfortable user experience. And for healthcare professionals (and their patients), is the new POWERbreathe KH2 with Breathe-Link Medic Live Feedback Software.

References:

  1. Beckerman M, Magadle R, Weiner M, Weiner P. The effects of 1 year of specific inspiratory muscle training in patients with COPD. Chest. 2005 Nov;128(5):3177-82.
  2. Weiner P, Azgad Y, Ganam R, Weiner M. Inspiratory muscle training in patients with bronchial asthma. Chest. 1992;102(5):1357-61.
  3. Weiner P, Berar-Yanay N, Davidovich A, Magadle R, Weiner M. Specific inspiratory muscle training in patients with mild asthma with high consumption of inhaled beta(2)-agonists. Chest. 2000;117(3):722-7.
  4. Weiner P, Magadle R, Massarwa F, Beckerman M, Berar-Yanay N. Influence of gender and inspiratory muscle training on the perception of dyspnea in patients with asthma. Chest. 2002;122(1):197-201.

IMT in mechanical ventilation: suitable protocols and endpoints

RESEARCH:

Inspiratory muscle training in mechanical ventilation: suitable protocols and endpoints, the key to clear results – a critical review

Silva, Paulo Eugênio

This research from Faculdade de Educação Física, Universidade de Brasília looked into whether Inspiratory Muscle Training (IMT) led to a shorter duration of mechanical ventilation, improved weaning success, or improved survival.

The purpose of this critical review was to determine:

1. What is the ideal prescription of IMT for patients on MV?
2. What is the best time to measure treatment effect?
3. Which kind of device should be used to IMT?
4. What are the best endpoints to evaluate the effects of IMT on the process of discontinuing from MV?

Which kind of device should be used to IMT? POWERbreathe K-Series.

“The biggest challenge in the training of mechanically ventilated patients is the use of conventional devices to impose loads on the respiratory muscles. When training starts, the patient must be disconnected from the ventilator and the respiratory monitoring is lost.”

“A new class of device is now available that is possible to monitor respiratory variables during the training. One example of this is the POWERbreathe K-Series (POWERbreathe-HaB UK) an electronic K-device with feedback software that helps professionals to understand what is happening with patients during their training. This device provides automatically processed information on external inspiratory work. Moreover, power and breathing patterns during loaded breathing tasks is shown, thus the onset of fatigue can be detected earlier.”

“POWERbreathe K-Series was externally evaluated by Belgian researchers and they concluded that the K-Series technology provides automatically processed and valid estimates of physical units of energy during loaded breathing tasks. Recently, de Souza et al. published a case report showing good results using the same technology to train a prolonged mechanically ventilated patient.”

“Another great advantage of this kind of technology is the capacity of load adjustment (1 cmH2O per 1 cmH2O) reaching 3 to 200 cmH2O. Beyond that, the device can adjust the load dynamically, imposing higher load at the beginning of inspirations and lower load close to vital capacity. Thus, a greater range of motion can be reached improving the effectiveness of the training.”

CONCLUSION:

“This review demonstrated the necessity of new RCTs despite of some well designed RCTs have already been published. Many evidences point out that a high intensity training with loads ≥ 50% of MIP in 5 to 6 sets, aiming to reach thirty breathes, one or twice a day, seven days per week is a suitable protocol to improve performance on mechanical ventilation. Patients must be trained at least for two weeks in order to IMT promotes clinically significant effects. It is possible, that outcomes such as the onset of weaning process, duration and success on the weaning, have higher correlation with IMT.” “In conclusion, IMT on mechanically ventilated patients seems to be a promissory treatment despite controversial results. RCTs should be carried out to verify the efficacy of the high intensity training during a suitable period of training using electronic kinetic devices in mechanically ventilated patients.”

Read Inspiratory muscle training in mechanical ventilation: suitable protocols and endpoints, the key to clear results – a critical review

IMT improves aerobic capacity & pulmonary function in patients with AS

Ankylosing Spondylitis (AS) is a chronic condition in which the spine and other areas of the body become inflamed, with symptoms usually involving back pain and stiffness that improves with exercise and isn’t relieved by rest; pain and swelling in other parts of the body, such as the hips, knees and ribs; and extreme fatigue.

The objective of this randomised controlled study was to evaluate the impact of inspiratory muscle training on aerobic capacity and pulmonary function in patients with AS.

STUDY:

Inspiratory muscle training improves aerobic capacity and pulmonary function in patients with ankylosing spondylitis: A randomized controlled study

Răzvan-Gabriel Drăgoi, Elena Amaricai, Mihai Drăgoi, Horatiu Popoviciu, Claudiu Avram

Conclusions:

Ankylosing spondylitis patients who performed eight weeks of inspiratory muscle training associated to conventional exercise training had an increased chest expansion, a better aerobic capacity, resting pulmonary function and ventilatory efficiency than those who performed conventional exercise training only.

See more Inspiratory Muscle Training Research >

Home-based Respiratory Training After Stroke

This new clinical trial, which is not yet open for participant recruitment, will test the hypothesis that home-based combined inspiratory muscular training (IMT) plus expiratory muscular training (EMT) program is effective in improving strength and endurance of the inspiratory and expiratory muscles, fatigue, exercise capacity, and quality of life (QoL) with stroke subjects.

Located at the Department of Physical Therapy, Universidade Federal de Minas Gerais in Brazil, the starting date for this trial is July 2015, with an estimated study completion of December 2017.

OFFICIAL TITLE:

Effects of Home-based Respiratory Training After Stroke: A Randomized Controlled Trial

Rationale:

“Weakness of the respiratory muscles demonstrated by individuals with stroke, may generate important symptoms, such as fatigue and dyspnea. Since adequate strength of the inspiratory and expiratory muscles is required, mainly when performing physical activities, rehabilitation interventions for stroke subjects should include respiratory training.”

See more Inspiratory Muscle Training Research >

The value of breathing retraining

This interesting article, written by osteopath Leon Chaitow, reviews ‘The Value of Breathing Retraining for Better Posture, Balance & Less Pain and Dyskinesis.’

It talks about how problems arising from poor posture, such as back pain for instance, can come about as a result of faulty breathing mechanics.

Chaitow refers to the study, ‘Inspiratory Muscle Training Affects Proprioceptive Use and Low Back Pain’ which supports evidence that breathing training can be successful in rehabilitating function as well as reducing a variety of symptoms.

Participants in the study completed an Inspiratory Muscle Training (IMT) program using the POWERbreathe Medic over a period of 8 weeks, “known as an effective training duration”.

The study concluded: “After 8 wks of high IMT, individuals with LBP (low back pain) showed an increased reliance on back proprioceptive signals during postural control and improved inspiratory muscle strength and severity of LBP, not seen after low IMT. Hence, IMT may facilitate the proprioceptive involvement of the trunk in postural control in individuals with LBP and thus might be a useful rehabilitation tool for these patients.

Read more about the POWERbreathe Medic Classic (used in this study) and the second generation POWERbreathe Medic Plus.

It’s World COPD Day and POWERbreathe’s here to help!

World COPD Day is an annual event organised by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) to improve awareness and care of COPD around the world. You can stay up-to-date with World COPD Day news as well as connecting with others via their WORLD COPD Facebook page.

COPD (Chronic Obstructive Pulmonary Disease) damages the airways to the lungs and makes it harder for a person with COPD to get air in and out of their lungs, which results in difficulty breathing.

Dyspnoea (difficult, laboured breathing or shortness of breath) is a common feature of COPD and many other disorders, and those diagnosed with COPD will have weak inspiratory muscles (the muscles used to breathe in).

In the study, ‘The Effects of 1 Year of Specific Inspiratory Muscle Training in Patients with COPD‘ published online in CHEST (the official publication of the American College of Chest Physicians) POWERbreathe Inspiratory Muscle Training was shown to elicit:

  • Improvements in inspiratory muscle strength of 55% in patients with Chronic Obstructive Pulmonary Disease (COPD)
  • Improvements in endurance of 86% in patients with Chronic Obstructive Pulmonary Disease (COPD)
  • Improvements in quality of life by 21% in patients with Chronic Obstructive Pulmonary Disease (COPD)
  • Improvements in dyspnoea by 36% in patients with Chronic Obstructive Pulmonary Disease (COPD)

The POWERbreathe Medic is an inspiratory muscle training device (IMT), or respiratory muscle training device (RMT), which is available for prescription in the UK and offers an evidence-based, drug-free treatment for patients with COPD as well as for those with a variety of other medical conditions such as Heart Failure, Asthma, Thoracic Surgery, Ventilator Weaning, Cystic Fibrosis and Neuromuscular Disease.

Prescribed by medical professionals, the hand-held POWERbreathe Medic breathing muscle training device is being prescribed as a standalone intervention or as part of a rehabilitation programme and has no side-effects or drug interactions. Always speak to a medical professional about your medical issues or concerns. Please consult your health care provider before beginning any health related program.

Read more about POWERbreathe for COPD and how the POWERbreathe K-Series has been recognised as the ‘Gold Standard’ RMT (Respiratory Muscle Training) device for important research, and which concluded “that the handheld device provides automatically processed and valid estimates of physical units of energy during loaded breathing tasks. This enables health care providers to quantify the load on inspiratory muscles during these tests in daily clinical practice.”

Coping with respiratory problems in the colder weather

Well here in the UK summer seems to have come to an abrupt end, with cooler weather and colder, damp air.

If you have a respiratory problem, such as COPD (Chronic Obstructive Pulmonary Disorder) or asthma, then the cold air that accompanies the change in season might affect you when you venture outdoors.

Respiratory consultant Dr Mat Jones at Nevill Hall hospital says, “Patients with airway diseases, particularly asthma often have hyper-responsive airways which are susceptible to the cold. In response to cold weather they can bronchoconstrict excessively (excessive bronchial narrowing) which can then trigger an exacerbation of their condition.”

“Patients with chronic lung disease have an increased susceptibility to infections of the lung given the structural changes in their lungs. This, accompanied by the frequency of infective organisms in the community in winter months would explain this trend of cold weather having an adverse effect on the lungs.”

The colder and drier air at this time of year, and even more so in the winter, will have sufferers of asthma and COPD feeling breathless, tight-chested and wheezing and coughing.

Although you may feel like staying in the warm and not venturing out, there are a few things you can do to make you feel more comfortable when you do have to venture outdoors.

Here are five handy tips that the British Lung Foundation suggest to help prevent your respiratory problems from worsening in the cold weather:

  1. Wash your hands regularly to avoid picking up winter bugs.
  2. Wrap up warm when heading outdoors, covering your nose and mouth with a scarf as this will help to warm up the air before you breathe it in.
  3. Keep your home well ventilated – air quality inside the home becomes more important in winter as most of us spend more time indoors. If you have a bronchodilator, use it half an hour before going outside.
  4. Make sure you carry your medication with you at all times as cold air can tighten the airways in lung disease patients making it harder to breathe.
  5. Try to breathe through your nose instead of your mouth as this will help warm the air.

You can also warm-up your breathing muscles with your POWERbreathe. In fact a POWERbreathe inspiratory warm-up is used by athletes to warm-up their breathing muscles prior to competition.

You warm up other muscles prior to exercise, so why not your breathing muscles? Physical activity at a moderate intensity is widely accepted as an acceptable and effective means of warming-up your locomotor muscles so that they’re ready to work at an intense level. But this moderate intensity activity is not enough to warm-up your breathing muscles. This was demonstrated in a study reporting that a rowing warm-up:

“that was similar to the routine adopted in preparing for a rowing race had no effect on inspiratory muscle (IM) strength despite the significant improvement in leg muscle peak torque the rowing warm-up elicited. On the other hand, they found that ventilatory activity applied to inspiratory muscle at moderate intensity could increase the force generation capacity of the muscle (Volianitis et al.2001a). Such specific inspiratory muscle activity (‘‘warm-up’’) in addition to a rowing-specific warm-up protocol was further shown to improve subsequent performance in a 6-min all-out rowing test and the improvement was partly attributed to the reduction in intensity of breathlessness sensation (Volianitis et al. 2001b).”

Your POWERbreathe warm-up is simply performed on a reduced load setting.

POWERbreathe uses the principles of resistance training to exercise your breathing muscles, making them work harder. This exercise in turn makes your breathing muscles stronger and less prone to fatigue. And because POWERbreathe is drug-free, it can be used by those with respiratory problems such as asthma and COPD. Because it has no side effects or drug interactions it can be used alongside your regular respiratory medication.

Chris Mulholland, head of British Lung Foundation Wales, said: “As respiratory conditions are often exacerbated by the cold weather, those with mild, early stage respiratory problems – that would otherwise go unnoticed at any other time of year – may notice an increase in symptoms. If you notice you’re getting more chest problems in the winter, perhaps becoming breathless, wheezy or have a persistent cough, then it could be an early warning sign. It is really worth going to see your doctor at this point because the earlier problems are diagnosed, the earlier they can be treated and managed which will have short and long-term benefits.”

Read more about how POWERbreathe could help relieve your symptoms of asthma and reduce dyspnoea in COPD, or if you’re already using POWERbreathe to help with your respiratory problem then please leave a comment here or on the POWERbreathe Forum, Facebook or Twitter as we’d love to hear from you. You can also read about how POWERbreathe has helped others with breathing problems, including asthma and COPD, in our “I have a breathing problem” blog category.

POWERbreathe Medic – approved for prescription

Inspiratory muscle weakness is inherent in various patient groups but is most common in COPD (Chronic Obstructive Pulmonary Disease), Heart Failure and Neuromuscular disease.  Weakness of the inspiratory muscles can result from a number of causes, including disease. Difficulty breathing is a sign of inspiratory weakness, and a major sign of serious disease of the airway, lungs or heart.

Not only can lack of activity cause inspiratory muscle weakness, but also the use of oral steroid medication to control conditions such as asthma and emphysema has been shown to cause weakness of the inspiratory muscles.

The POWERbreathe Medic 

The POWERbreathe Medic is the only Inspiratory Muscle Training device available on prescription that has been used in research into the benefits of Inspiratory Muscle Training for a variety of medical conditions.

The good news is that the inspiratory muscles can be trained using the POWERbreathe Medic to yield:

  • Improvements in inspiratory muscle strength, power and endurance (3,4)
  • Structural and biomechanical adaptations (5,6)
  • More importantly, inspiratory muscle training (IMT) reduces dyspnoea during exercise and daily activities, as well as improving exercise tolerance and quality of life, particularly in patients with COPD (4,6-12)

IMT Research >

The POWERbreathe Medic  offers an evidence-based, drug-free treatment for patients with a variety of medical conditions such as COPD, Heart Failure, Asthma, Thoracic Surgery, Ventilator Weaning, Cystic Fibrosis and Neuromuscular Disease. It is available on prescription at the prevailing charge. 

POWERbreathe Medic on the NHS

For the POWERbreathe Medic to be approved for prescription in the UK it had to undergo 20 months of rigorous assessment, after which, in 2006 the POWERbreathe Medic was made available in the UK for prescription in the National Health Serice (NHS) Drug Tariff.

Why patients are requesting the POWERbreathe Medic

You may find that when you ask your GP about the POWERbreathe Medic or IMT (Inspiratory Muscle Training), they may not yet be fully familiar with the product or concept. They can however easily refer to the NHS Drug Tariff for the details required in order to prescribe it.

POWERbreathe Medic Inspiratory Muscle Training is being prescribed by medical professionals as either a standalone intervention or as part of a rehabilitation programme. One medical professional in Brazil used the electronic POWERbreathe K5 to help a 93-year-old patient train her inspiratory muscles so that she had the strength to inhale her much-needed medication.

Patients with a breathing difficulty are more frequently asking for alternatives to traditional drug-based treatments and therapies. This may be because the side-effects of prescribed drugs may be limiting daily life, or it may be because they wish to maximise control of their condition with a complementary treatment. POWERbreathe Medic training can be tailored from low-intensity training to high-intensity training and is easy to use straight out of the box.

We have published a printable leaflet that can be printed off and taken with you to your GP’s appointment as it explains how POWERbreathe works, in case your GP isn’t familiar with it.

Download POWERbreathe Information for Healthcare Professionals >

POWERbreathe Medic – Reviewed by West Cumbria Respiratory Team

“Our patients have found it to be of great benefit. We have been using the POWERbreathe Medic for over a year as part of the pulmonary rehab programme and our patients have found it to be of great benefit and enjoy using it. We have good compliance and have found an improvement in patients’ fitness. We will continue to use the POWERbreathe Medic as an adjunct to our programme.”
Emma Hamilton, West Cumbria Respiratory Team, Workington Community Hospital.

The Medical Device Directives

Within Europe the EU passed a set of directives that introduced legal controls regulating the safety and performance of devices across the European Union. These Directives included mandatory provisions for the mandatory CE marking of products. These European Medical Devices Directives have now been implemented into UK legislation by the Medical Devices Regulations 2002.

CE Mark

The CE mark confirms that the product conforms with the relevant medical device directives and that it is fit for its intended purpose. The POWERbreathe Medic , and all POWERbreathe devices, are CE marked and are a Class 1 Medical Device.

Class 1 Medical Device

How do you know that a product is approved for prescription?

After it has been established that a product is a medical device, the next step is confirming whether the product is listed in the Drug Tariff, as only medical devices listed in Part IX of the Tariff can be prescribed on an NHS prescription.

Medical devices can only be prescribed on NHS prescriptions if the product is listed in Part IX (Appliances section) of the Drug Tariff.

The POWERbreathe Medic NHS Drug Tariff

  • NHS Drug Tariff
  • Part IXA – Appliances
  • Inspiratory Pressure Threshold Loading Device
  • NHS Supply Chain Respiratory Therapy Contract
  • PIP Code: 232-1040

Read more about the POWERbreathe Medic on prescription, or if you’re a patient already using the POWERbreathe Medic then please leave a comment here as we’d love to hear from you.

Home-based respiratory muscle training used to improve quality of life in patients with Chronic Heart Failure

The Journal of Cardiopulmonary Rehabilitation & Prevention published the following clinical trial to evaluate the effect of inspiratory muscle training (IMT) on cardiac autonomic modulation and on peripheral nerve sympathetic activity in patients with chronic heart failure (CHF).

The Clinical Trial:

Inspiratory Muscle Training Reduces Sympathetic Nervous Activity and Improves Inspiratory Muscle Weakness and Quality of Life in Patients With Chronic Heart Failure: A CLINICAL TRIAL

METHODS:

Functional capacity, low-frequency (LF) and high-frequency (HF) components of heart rate variability, muscle sympathetic nerve activity inferred by microneurography, and quality of life were determined in 27 patients with CHF who had been sequentially allocated to 1 of 2 groups: (1) control group (with no intervention) and (2) IMT group. Inspiratory muscle training consisted of respiratory exercises, with inspiratory threshold loading of seven 30-minute sessions per week for a period of 12 weeks, with a monthly increase of 30% in maximal inspiratory pressure (PImax) at rest. Multivariate analysis was applied to detect differences between baseline and follow up period.

RESULTS:

Inspiratory muscle training significantly increased PImax (59.2 +/- 4.9 vs 87.5 +/- 6.5 cmH2O, P = .001) and peak oxygen uptake (14.4 +/- 0.7 vs 18.9 +/- 0.8 mL[middle dot]kg-1[middle dot]min-1, P = .002); decreased the peak ventilation (VE)/carbon dioxide production (VCO2) ratio (35.8 +/- 0.8 vs 32.5 +/- 0.4, P = .001) and the VE VCO2 slope (37.3 +/- 1.1 vs 31.3 +/- 1.1, P = .004); increased the HF component (49.3 +/- 4.1 vs 58.4 +/- 4.2 normalized units, P = .004) and decreased the LF component (50.7 +/- 4.1 vs 41.6 +/- 4.2 normalized units, P = .001) of heart rate variability; decreased muscle sympathetic nerve activity (37.1 +/- 3 vs 29.5 +/- 2.3 bursts per minute, P = .001); and improved quality of life. No significant changes were observed in the control group.

CONCLUSION:

Home-based IMT represents an important strategy to improve cardiac and peripheral autonomic controls, functional capacity, and quality of life in patients with CHF.

(C) 2012 Lippincott Williams & Wilkins, Inc.

You can read the Abstract here on the Journal of Cardiopulmonary Rehabilitation and Prevention website.

In patients with chronic heart failure, inspiratory muscle training, such as with the POWERbreathe Medic, has been shown to:

  • Improve exercise tolerance by 19%
  • Improve quality of life by 16%

Read more about POWERbreathe inspiratory muscle training for patients with chronic heart failure (CHF).

 

Penny Harris – 3 weeks of using my POWERbreathe Medic

Penny Harris in Turkey 2011I have now been using my Powerbreathe Medic for 3 weeks.  The day I started using it I also reduced my inhaler dosage. This was done with the full approval of the nurse at the asthmas clinic!

I have been tracking my peak flows twice a day to give me an objective picture of what is happening.

The first couple of days my peak flow stayed the same, then on day 3 it dropped slightly, only by 15-20 points.  After two days it popped back up again, and has been trundling along since then.  The only time I have had any symptoms was after a tough track session, but I always have coughed after those!

Getting into a routine with the twice daily use of the Powerbreathe has been a case of trial and error.  In the morning I try and use it before I use my inhaler, in the evening the same.

It did take a few days to get the tension right, but I got there! I am now increasing the resistance quite quickly, especially when I realise that I have done 30 breaths and not noticed! I am intrigued to see how I go over the next few weeks, as I increase the resistance higher.

I am going to see the asthma nurse again and go through the Powerbreathe with her. We are going to discuss my asthma medication again as well as I am on such a low dose of my current inhaler it is not technically therapeutic!

Penny

If you too use POWERbreathe breathing exercises for asthma, we’d love to hear from you. Please sign up to the Blog or leave a comment here.