Preliminary development and validation of a new endof-life patient-reported outcome measure assessing the ability of patients to finalise their affairs at the end of life

Introduction:The ability of patients to finalise their affairs at the end of life is an often neglected aspect of quality of life (QOL) measurement in palliative care effectiveness research despite compelling evidence of the high value patients place on this domain. Objective: This paper describes the preliminary development and evaluation of a new, single-item, end-of-life patientreported outcome measure (EOLPRO) designed to capture changes in the ability of patients to finalise their affairs at the end of life. Methods: Cognitive interviews with purposively sampled Australian palliative care patients (N = 9) were analysed thematically to explore content validity. Simultaneously, secondary analysis of data from a randomised controlled trial comparing ketamine and placebo for the management of cancer pain (N = 185) evaluated: construct validity; test-retest reliability; and responsiveness. Results:Preliminary findings suggest patients interpret the new measure consistently. The EOLPRO captures the ability to complete physical tasks and finalise practical matters although it is unclear whether emotional tasks or resolution of relationship issues are considered. Personal and financial affairs should be separated to allow for differences in ability for these two types of affairs. The significant correlation between performance status and EOLPRO scores (r = 0.41, p,<.01, n = 137) and expected relationships between EOLPRO and proximity to death and constipation demonstrated construct validity. Pre-and post-treatment EOLPRO scores moderately agreed (n = 14, k = 0.52 [95% CI 0.19, 0.84]) supporting reliability. The measure's apparent lack of sensitivity to discriminate between treatment responders and non-responders may be confounded. Conclusion:Based on the preliminary findings, the EOLPRO should be separated into 'personal' and 'financial' affairs with further testing suggested, particularly to verify coverage and responsiveness. Initial evaluation suggests that the single-item EOLPRO is a useful addition to QOL outcome measurement in palliative care effectiveness research because common palliative care specific QOL questionnaires do not include or explicitly capture this domain. © 2014 McCaffrey et al

Assimilation of stratospheric and mesospheric temperatures from MLS and SABER into a global NWP model

International audienceThe forecast model and three-dimensional variational data assimilation components of the Navy Operational Global Atmospheric Prediction System (NOGAPS) have each been extended into the upper stratosphere and mesosphere to form an Advanced Level Physics High Altitude (ALPHA) version of NOGAPS extending to ~100 km. This NOGAPS-ALPHA NWP prototype is used to assimilate stratospheric and mesospheric temperature data from the Microwave Limb Sounder (MLS) and the Sounding of the Atmosphere using Broadband Radiometry (SABER) instruments. A 60-day analysis period in January and February, 2006, was chosen that includes a well documented stratospheric sudden warming. SABER temperatures indicate that the SSW caused the polar winter stratopause at ~40 km to disappear, then reform at ~80 km altitude and slowly descend during February. The NOGAPS-ALPHA analysis reproduces this observed stratospheric and mesospheric temperature structure, as well as realistic evolution of zonal winds, residual velocities, and Eliassen-Palm fluxes that aid interpretation of the vertically deep circulation and eddy flux anomalies that developed in response to this wave-breaking event. The observation minus forecast (O-F) standard deviations for MLS and SABER are ~2 K in the mid-stratosphere and increase monotonically to about 6 K in the upper mesosphere. Increasing O-F standard deviations in the mesosphere are expected due to increasing instrument error and increasing geophysical variance at small spatial scales in the forecast model. In the mid/high latitude winter regions, 10-day forecast skill is improved throughout the upper stratosphere and mesosphere when the model is initialized using the high-altitude analysis based on assimilation of both SABER and MLS data

Large-amplitude mesospheric response to an orographic wave generated over the Southern Ocean Auckland Islands (50.7°S) during the DEEPWAVE project

The Deep Propagating Gravity Wave Experiment (DEEPWAVE) project was conducted over New Zealand and the surrounding regions during June and July 2014, to more fully understand the generation, propagation, and effects of atmospheric gravity waves. A large suite of instruments collected data from the ground to the upper atmosphere (~100 km), with several new remote-sensing instruments operating on board the NSF Gulfstream V (GV) research aircraft, which was the central measurement platform of the project. On 14 July, during one of the research flights (research flight 23), a spectacular event was observed as the GV flew in the lee of the sub-Antarctic Auckland Islands (50.7°S). An apparent ship wave pattern was imaged in the OH layer (at ~83.5 km) by the Utah State University Advanced Mesospheric Temperature Mapper and evolved significantly over four successive passes spanning more than 4 h. The waves were associated with orographic forcing generated by relatively strong (15-20 m/s) near-surface wind flowing over the rugged island topography. The mountain wave had an amplitude T_ ~ 10 K, a dominant horizontal wavelength ~40 km, achieved a momentum flux exceeding 300 m2 s-2, and eventually exhibited instability and breaking at the OH altitude. This case of deep mountain wave propagation demonstrates the potential for strong responses in the mesosphere arising from a small source under suitable propagation conditions and suggests that such cases may be more common than previously believed. © 2016. American Geophysical Union. All Rights Reserved

Contemporary nursing graduates\u27 transition to practice: A critical review of transition models

AIM AND OBJECTIVE: To critically review contemporary transition theories to determine how they apply to the newly qualified graduate registered nurse programmes. BACKGROUND: Graduate nurse transition to employment is the time of significant change which has resulted in high attrition rates. Graduates are often challenged by their expectation of nursing practice and the reality of the role. The transition from hospital-based training to university-based training has resulted in the need for primary employment to commence with graduate/orientation/internship programmes to help support new graduates transition into clinical practice. One transition model, Duchscher\u27s stages of transition theory, utilised three former theories to develop a final model. DESIGN: A narrative critical literature review. METHOD: The theories selected for the review were Kramer\u27s reality shock theory, Benner\u27s novice to expert theory, Bridges transition theory and Duchscher\u27s stages of transition theory. CONCLUSION: Duchscher\u27s stages of transition theory reflects the experiences of registered nursing transition into the workforce directly from university. The application of the theory is effective to guide understanding of the current challenges that new graduate nurse\u27s experience today. There is a need for new graduates to complete their university degree as advanced beginners in order to decrease the experience of transition shock and keep pace with rapidly changing demands of the clinical environment. This may be achieved by increasing ward-based simulation in university education. A theoretical framework can provide a deep understanding of the various stages and processes of transition and enable development of successful programmes. RELEVANCE TO CLINICAL PRACTICE: Both universities and hospitals need to adapt their current practice to align with the needs of new graduates due to large student numbers and ongoing systematic advancements to decrease the attrition rate

Health-related quality of life in patients with inoperable malignant bowel obstruction: secondary outcome from a double-blind, parallel, placebo-controlled randomised trial of octreotide.

BACKGROUND:This analysis aims to evaluate health-related quality of life (HrQoL) (primary outcome for this analysis), nausea and vomiting, and pain in patients with inoperable malignant bowel obstruction (IMBO) due to cancer or its treatments randomised to standardised therapies plus octreotide or placebo over a maximum of 72 h in a double-blind clinical trial. METHODS:Adults with IMBO and vomiting recruited through 12 services spanning inpatient, consultative and community settings in Australia were randomised to subcutaneous octreotide infusion or saline. HrQoL was measured at baseline and treatment cessation (EORTC QLQ-C15-PAL). Mean within-group paired differences between baseline and post-treatment scores were analysed using Wilcoxon Signed Rank test and between group differences estimated using linear mixed models, adjusted for baseline score, sex, age, time, and study arm. RESULTS:One hundred six of the 112 randomised participants were included in the analysis (n = 52 octreotide, n = 54 placebo); 6 participants were excluded due to major protocol violations. Mean baseline HrQoL scores were low (octreotide 22.1, 95% CI 14.3, 29.9; placebo 31.5, 95% CI 22.3, 40.7). There was no statistically significant within-group improvement in the mean HrQoL scores in the octreotide (p = 0.21) or placebo groups (p = 0.78), although both groups reported reductions in mean nausea and vomiting (octreotide p < 0.01; placebo p = 0.02) and pain scores (octreotide p < 0.01; placebo p = 0.03). Although no statistically significant difference in changes in HrQoL scores between octreotide and placebo were seen, an adequately powered study is required to fully assess any differences in HrQoL scores. CONCLUSION:The HrQoL of patients with IMBO and vomiting is poor. Further research to formally evaluate the effects of standard therapies for IMBO is therefore warranted. TRIAL REGISTRATION:Australian New Zealand Clinical Trials Registry ACTRN12608000211369 (date registered 18/04/2008)

Amplification of the quasi-two day wave through nonlinear interaction with the migrating diurnal tide

We present a case study of the non-linear interaction between the quasi-two day wave (Q2DW) and the migrating diurnal tide based on global synoptic meridional wind fields for January 2006 and January 2008 from a high-altitude data assimilation/forecast system. We find large quasi-two day wave amplitudes, small diurnal tide amplitudes, and phase locking of the Q2DW with the diurnal cycle during January 2006. In January 2008 the amplitudes of the Q2DW were much smaller, with no evidence of phase locking, while the tidal amplitudes were larger than in the 2006 case. Space-time spectral analysis reveals an enhancement in a diurnal zonal wavenumber 6 feature in the January 2006 case, which can be attributed to a non-linear interaction between the Q2DW and migrating diurnal tide. The relatively strong summer easterly jet in the extratropical upper mesosphere during early January 2006 appears to have created conditions favoring this interaction.J. P. McCormack, S. D. Eckermann, K. W. Hoppel, and R. A. Vincen

The deep propagating gravity wave experiment (deepwave): an airborne and ground-based exploration of gravity wave propagation and effects from their sources throughout the lower and middle atmosphere

Abstract The Deep Propagating Gravity Wave Experiment (DEEPWAVE) was designed to quantify gravity wave (GW) dynamics and effects from orographic and other sources to regions of dissipation at high altitudes. The core DEEPWAVE field phase took place from May through July 2014 using a comprehensive suite of airborne and ground-based instruments providing measurements from Earth’s surface to ∼100 km. Austral winter was chosen to observe deep GW propagation to high altitudes. DEEPWAVE was based on South Island, New Zealand, to provide access to the New Zealand and Tasmanian “hotspots” of GW activity and additional GW sources over the Southern Ocean and Tasman Sea. To observe GWs up to ∼100 km, DEEPWAVE utilized three new instruments built specifically for the National Science Foundation (NSF)/National Center for Atmospheric Research (NCAR) Gulfstream V (GV): a Rayleigh lidar, a sodium resonance lidar, and an advanced mesosphere temperature mapper. These measurements were supplemented by in situ probes, dropsondes, and a microwave temperature profiler on the GV and by in situ probes and a Doppler lidar aboard the German DLR Falcon. Extensive ground-based instrumentation and radiosondes were deployed on South Island, Tasmania, and Southern Ocean islands. Deep orographic GWs were a primary target but multiple flights also observed deep GWs arising from deep convection, jet streams, and frontal systems. Highlights include the following: 1) strong orographic GW forcing accompanying strong cross-mountain flows, 2) strong high-altitude responses even when orographic forcing was weak, 3) large-scale GWs at high altitudes arising from jet stream sources, and 4) significant flight-level energy fluxes and often very large momentum fluxes at high altitudes.David C. Fritts, Ronald B. Smith, Michael J. Taylor, James D. Doyle, Stephen D. Eckermann, Andreas Dörnbrack, Markus Rapp, Bifffford P. Williams, P.-Dominique Pautet, Katrina Bossert, Neal R. Criddddle, Carolyn A. Reynolds, P. Alex Reinecke, Michael Uddddstrom, Michael J. Revell, Richard Turner, Bernd Kaifler, Johannes S. Wagner, Tyler Mixa, Christopher G. Kruse, Alison D. Nugent, Campbell D. Watson, Sonja Gisinger, Steven M. Smith, Ruth S. Lieberman, Brian Laughman, James J. Moore, William O. Brown, Julie A. Haggerty, Alison Rockwell, Gregory J. Stossmeister, Steven F. Williams, Gonzalo Hernandez, Damian J. Murphy, Andrew R. Klekociuk, Iain M. Reid, and Jun M

The HTA risk analysis chart: visualising the need for and potential value of managed entry agreements in health technology assessment

Background Recent changes to the regulatory landscape of pharmaceuticals may sometimes require reimbursement authorities to issue guidance on technologies that have a less mature evidence base. Decision makers need to be aware of risks associated with such health technology assessment (HTA) decisions and the potential to manage this risk through managed entry agreements (MEAs). Objective This work develops methods for quantifying risk associated with specific MEAs and for clearly communicating this to decision makers. Methods We develop the ‘HTA risk analysis chart’, in which we present the payer strategy and uncertainty burden (P-SUB) as a measure of overall risk. The P-SUB consists of the payer uncertainty burden (PUB), the risk stemming from decision uncertainty as to which is the truly optimal technology from the relevant set of technologies, and the payer strategy burden (PSB), the additional risk of approving a technology that is not expected to be optimal. We demonstrate the approach using three recent technology appraisals from the UK National Institute for Health and Clinical Excellence (NICE), each of which considered a price-based MEA. Results The HTA risk analysis chart was calculated using results from standard probabilistic sensitivity analyses. In all three HTAs, the new interventions were associated with substantial risk as measured by the P-SUB. For one of these technologies, the P-SUB was reduced to zero with the proposed price reduction, making this intervention cost effective with near complete certainty. For the other two, the risk reduced substantially with a much reduced PSB and a slightly increased PUB. Conclusions The HTA risk analysis chart shows the risk that the healthcare payer incurs under unresolved decision uncertainty and when considering recommending a technology that is not expected to be optimal given current evidence. This allows the simultaneous consideration of financial and data-collection MEA schemes in an easily understood format. The use of HTA risk analysis charts will help to ensure that MEAs are considered within a standard utility-maximising health economic decision-making framework