Evidence-based planning and costing palliative care services for children : novel multi-method epidemiological and economic exemplar

Background: Children’s palliative care is a relatively new clinical specialty. Its nature is multi-dimensional and its delivery necessarily multi-professional. Numerous diverse public and not-for-profit organisations typically provide services and support. Because services are not centrally coordinated, they are provided in a manner that is inconsistent and incoherent. Since the first children’s hospice opened in 1982, the epidemiology of life-limiting conditions has changed with more children living longer, and many requiring transfer to adult services. Very little is known about the number of children living within any given geographical locality, costs of care, or experiences of children with ongoing palliative care needs and their families. We integrated evidence, and undertook and used novel methodological epidemiological work to develop the first evidence-based and costed commissioning exemplar. Methods: Multi-method epidemiological and economic exemplar from a health and not-for-profit organisation perspective, to estimate numbers of children under 19 years with life-limiting conditions, cost current services, determine child/parent care preferences, and cost choice of end-of-life care at home. Results: The exemplar locality (North Wales) had important gaps in service provision and the clinical network. The estimated annual total cost of current children’s palliative care was about £5.5 million; average annual care cost per child was £22,771 using 2007 prevalence estimates and £2,437- £11,045 using new 2012/13 population-based prevalence estimates. Using population-based prevalence, we estimate 2271 children with a life-limiting condition in the general exemplar population and around 501 children per year with ongoing palliative care needs in contact with hospital services. Around 24 children with a wide range of life-limiting conditions require end-of-life care per year. Choice of end-of-life care at home was requested, which is not currently universally available. We estimated a minimum (based on 1 week of end-of-life care) additional cost of £336,000 per year to provide end-of-life support at home. Were end-of-life care to span 4 weeks, the total annual additional costs increases to £536,500 (2010/11 prices). Conclusions: Findings make a significant contribution to population-based needs assessment and commissioning methodology in children’s palliative care. Further work is needed to determine with greater precision which children in the total population require access to services and when. Half of children who died 2002-7 did not have conditions that met the globally used children's palliative care condition categories, which need revision in light of findings

Bioinspired Autonomous Visual Vertical Control of a Quadrotor Unmanned Aerial Vehicle

Near-ground maneuvers, such as hover, approach, and landing, are key elements of autonomy in unmanned aerial vehicles. Such maneuvers have been tackled conventionally by measuring or estimating the velocity and the height above the ground, often using ultrasonic or laser range finders. Near-ground maneuvers are naturally mastered by flying birds and insects because objects below may be of interest for food or shelter. These animals perform such maneuvers efficiently using only the available vision and vestibular sensory information. In this paper, the time-to-contact (tau) theory, which conceptualizes the visual strategy with which many species are believed to approach objects, is presented as a solution for relative ground distance control for unmanned aerial vehicles. The paper shows how such an approach can be visually guided without knowledge of height and velocity relative to the ground. A control scheme that implements the tau strategy is developed employing only visual information from a monocular camera and an inertial measurement unit. To achieve reliable visual information at a high rate, a novel filtering system is proposed to complement the control system. The proposed system is implemented onboard an experimental quadrotor unmanned aerial vehicle and is shown to not only successfully land and approach ground, but also to enable the user to choose the dynamic characteristics of the approach. The methods presented in this paper are applicable to both aerial and space autonomous vehicles

Practice Parameter: Therapies for Benign Paroxysmal Positional Vertigo (An Evidence-Based Review): Report of the Quality Standards Subcommittee of the American Academy of Neurologysymbol Symbol

American Academy of Neurology; BPPV = benign paroxysmal positional vertigo; CONSORT = Consolidated Standards of Reporting Trials; CRP = canalith repositioning procedure; NNT = number needed to treat

Fluorodeoxyglucose positron emission tomography in the evaluation of germ cell tumours at relapse

Differentiation of active disease from fibrosis/mature teratoma in patients with residual masses or identifying of sites of recurrence in patients with raised markers following treatment of their testicular cancer remains a problem.18F-fluorodeoxyglucose positron emission tomography (FDG-PET) has the potential to identify active disease and thereby influence further management in these patients. We performed a retrospective study of the use of FDG-PET in detecting residual/recurrent testicular carcinoma in 55 patients (seventy FDG-PET scans). Forty-seven scans were for the assessment of residual masses (18 had raised markers) and 23 scans were for the investigation of raised markers in the presence of normal CT scans. True positive results were based on positive histology or clinical follow-up. FDG-PET had a positive predictive value (PPV) of 96% and a negative predictive value (NPV) of 90% in patients with residual masses. This PPV was equivalent to that of markers (94%) but FDG-PET had the advantage of identifying the site of that recurrence. The NPV was higher than that of markers. In patients with raised markers alone the PPV of FDG-PET was 92% but the NPV was only 50%. However, subsequent FDG-PET imaging was frequently the first imaging modality to identify the site of disease. FDG-PET effected a management change in 57% of cases. FDG-PET scanning detected viable tumour in residual masses and identified sites of disease in suspected recurrence. © 2000 Cancer Research Campaig

Clinical Management of Hyperkalemia

© 2020 Mayo Foundation for Medical Education and Research Hyperkalemia is an electrolyte abnormality with potentially life-threatening consequences. Despite various guidelines, no universally accepted consensus exists on best practices for hyperkalemia monitoring, with variations in precise potassium (K+) concentration thresholds or for the management of acute or chronic hyperkalemia. Based on the available evidence, this review identifies several critical issues and unmet needs with regard to the management of hyperkalemia. Real-world studies are needed for a better understanding of the prevalence of hyperkalemia outside the clinical trial setting. There is a need to improve effective management of hyperkalemia, including classification and K+ monitoring, when to reinitiate previously discontinued renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, and when to use oral K+-binding agents. Monitoring serum K+ should be individualized; however, increased frequency of monitoring should be considered for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia and for those receiving RAASi therapy. Recent clinical studies suggest that the newer K+ binders (patiromer sorbitex calcium and sodium zirconium cyclosilicate) may facilitate optimization of RAASi therapy. Enhancing the knowledge of primary care physicians and internists with respect to the safety profiles of these newer K+ binders may increase confidence in managing patients with hyperkalemia. Lastly, the availability of newer K+-binding agents requires further study to establish whether stringent dietary K+ restrictions are needed in patients receiving K+-binder therapy. Individualized monitoring of serum K+ among patients with an increased risk of hyperkalemia and the use of newer K+-binding agents may allow for optimization of RAASi therapy and more effective management of hyperkalemia

Kanamycin resistance during in vitro development of pollen from transgenic tomato plants

Effects of kanamycin on pollen germination and tube growth of pollen from non-transformed plants and from transgenic tomato plants containing a chimaeric kanamycin resistance gene were determined. Germination of pollen was not affected by the addition of kanamycin to the medium in both genotypes. Kanamycin, however, severely affected tube growth of pollen from non-transformed plants, while pollen from plants containing the chimaeric gene were less sensitive and produced significantly longer tubes at kanamycin concentrations between 200-400 mg l-1. Apparently, this resistance for kanamycin correlates with the expression of the chimaeric gene during male gametophytic development.

Superpotentials for M-theory on a G_2 holonomy manifold and Triality symmetry

For $M$-theory on the $G_2$ holonomy manifold given by the cone on {\bf S^3}\x {\bf S^3} we consider the superpotential generated by membrane instantons and study its transformations properties, especially under monodromy transformations and triality symmetry. We find that the latter symmetry is, essentially, even a symmetry of the superpotential. As in Seiberg/Witten theory, where a flat bundle given by the periods of an universal elliptic curve over the $u$-plane occurs, here a flat bundle related to the Heisenberg group appears and the relevant universal object over the moduli space is related to hyperbolic geometry.Comment: 58 pages, latex; references adde

Exploring seasonal and regional relationships between the Evaporative Stress Index and surface weather and soil moisture anomalies across the United States

This study uses correlation analyses to explore relationships between the satellite-derived Evaporative Stress Index (ESI) – which depicts standardized anomalies in an actual to reference evapotranspiration (ET) fraction – and various land and atmospheric variables that impact ET. Correlations between the ESI and forcing variable anomalies calculated over sub-seasonal timescales were computed at weekly and monthly intervals during the growing season. Overall, the results revealed that the ESI is most strongly correlated to anomalies in soil moisture and 2&thinsp;m dew point depression. Correlations between the ESI and precipitation were also large across most of the US; however, they were typically smaller than those associated with soil moisture and vapor pressure deficit. In contrast, correlations were much weaker for air temperature, wind speed, and radiation across most of the US, with the exception of the south-central US where correlations were large for all variables at some point during the growing season. Together, these results indicate that changes in soil moisture and near-surface atmospheric vapor pressure deficit are better predictors of the ESI than precipitation and air temperature anomalies are by themselves. Large regional and seasonal dependencies were also observed for each forcing variable. Each of the regional and seasonal correlation patterns were similar for ESI anomalies computed over 2-, 4-, and 8-week time periods; however, the maximum correlations increased as the ESI anomalies were computed over longer time periods and also shifted toward longer averaging periods for the forcing variables.</p