The effect of regular exercise on sleep assessment in older adults

This study examined the effects of regular cardiovascular (CV) and weight training (WT) exercise on the subjective sleep assessment of older adults. [This is an excerpt from the abstract. For the complete abstract, please see the document.

Subsonic Ultra Green Aircraft Research: Phase II- Volume III-Truss Braced Wing Aeroelastic Test Report

This Test Report summarizes the Truss Braced Wing (TBW) Aeroelastic Test (Task 3.1) work accomplished by the Boeing Subsonic Ultra Green Aircraft Research (SUGAR) team, which includes the time period of February 2012 through June 2014. The team consisted of Boeing Research and Technology, Boeing Commercial Airplanes, Virginia Tech, and NextGen Aeronautics. The model was fabricated by NextGen Aeronautics and designed to meet dynamically scaled requirements from the sized full scale TBW FEM. The test of the dynamically scaled SUGAR TBW half model was broken up into open loop testing in December 2013 and closed loop testing from January 2014 to April 2014. Results showed the flutter mechanism to primarily be a coalescence of 2nd bending mode and 1st torsion mode around 10 Hz, as predicted by analysis. Results also showed significant change in flutter speed as angle of attack was varied. This nonlinear behavior can be explained by including preload and large displacement changes to the structural stiffness and mass matrices in the flutter analysis. Control laws derived from both test system ID and FEM19 state space models were successful in suppressing flutter. The control laws were robust and suppressed flutter for a variety of Mach, dynamic pressures, and angle of attacks investigated

Subsonic Ultra Green Aircraft Research

This report summarizes the Truss Braced Wing (TBW) work accomplished by the Boeing Subsonic Ultra Green Aircraft Research (SUGAR) team, consisting of Boeing Research and Technology, Boeing Commercial Airplanes, General Electric, Georgia Tech, Virginia Tech, NextGen Aeronautics, and Microcraft. A multi-disciplinary optimization (MDO) environment defined the geometry that was further refined for the updated SUGAR High TBW configuration. Airfoil shapes were tested in the NASA TCT facility, and an aeroelastic model was tested in the NASA TDT facility. Flutter suppression was successfully demonstrated using control laws derived from test system ID data and analysis models. Aeroelastic impacts for the TBW design are manageable and smaller than assumed in Phase I. Flutter analysis of TBW designs need to include pre-load and large displacement non-linear effects to obtain a reasonable match to test data. With the updated performance and sizing, fuel burn and energy use is reduced by 54% compared to the SUGAR Free current technology Baseline (Goal 60%). Use of the unducted fan version of the engine reduces fuel burn and energy by 56% compared to the Baseline. Technology development roadmaps were updated, and an airport compatibility analysis established feasibility of a folding wing aircraft at existing airports

Evolving Knowledge of Opioid Genetics in Cancer Pain

Abstract Inter-individual variation in response to opioids for cancer pain is a well-established phenomenon. Variation occurs in the dose of opioid required, the analgesic efficacy of the opioid and also in the side-effects experienced by the individual taking the drug. To date, no clinical factor has been identified that can reliably explain or predict such variation. In recent years there has been growing interest in the possibility that genetic factors may play a role in the variability in opioid response. The aims of this review are to present the evidence supporting pharmacogenetic research in this area, to evaluate some of the studies and results that have been published to date and to present some of the challenges for future research in this area

Evidence on the economic value of end-of-life and palliative care interventions: a narrative review of reviews.

As the demand for palliative care increases, more information is needed on how efficient different types of palliative care models are for providing care to dying patients and their caregivers. Evidence on the economic value of treatments and interventions is key to informing resource allocation and ultimately improving the quality and efficiency of healthcare delivery. We assessed the available evidence on the economic value of palliative and end-of-life care interventions across various settings. Reviews published between 2000 and 2019 were included. We included reviews that focused on cost-effectiveness, intervention costs and/or healthcare resource use. Two reviewers extracted data independently and in duplicate from the included studies. Data on the key characteristics of the studies were extracted, including the aim of the study, design, population, type of intervention and comparator, (cost-) effectiveness resource use, main findings and conclusions. A total of 43 reviews were included in the analysis. Overall, most evidence on cost-effectiveness relates to home-based interventions and suggests that they offer substantial savings to the health system, including a decrease in total healthcare costs, resource use and improvement in patient and caregivers' outcomes. The evidence of interventions delivered across other settings was generally inconsistent. Some palliative care models may contribute to dual improvement in quality of care via lower rates of aggressive medicalization in the last phase of life accompanied by a reduction in costs. Hospital-based palliative care interventions may improve patient outcomes, healthcare utilization and costs. There is a need for greater consistency in reporting outcome measures, the informal costs of caring, and costs associated with hospice

Accuracy of clinical predictions of prognosis at the end-of-life: evidence from routinely collected data in urgent care records

BACKGROUND: The accuracy of prognostication has important implications for patients, families, and health services since it may be linked to clinical decision-making, patient experience and outcomes and resource allocation. Study aim is to evaluate the accuracy of temporal predictions of survival in patients with cancer, dementia, heart, or respiratory disease. METHODS: Accuracy of clinical prediction was evaluated using retrospective, observational cohort study of 98,187 individuals with a Coordinate My Care record, the Electronic Palliative Care Coordination System serving London, 2010-2020. The survival times of patients were summarised using median and interquartile ranges. Kaplan Meier survival curves were created to describe and compare survival across prognostic categories and disease trajectories. The extent of agreement between estimated and actual prognosis was quantified using linear weighted Kappa statistic. RESULTS: Overall, 3% were predicted to live "days"; 13% "weeks"; 28% "months"; and 56% "year/years". The agreement between estimated and actual prognosis using linear weighted Kappa statistic was highest for patients with dementia/frailty (0.75) and cancer (0.73). Clinicians' estimates were able to discriminate (log-rank p < 0.001) between groups of patients with differing survival prospects. Across all disease groups, the accuracy of survival estimates was high for patients who were likely to live for fewer than 14 days (74% accuracy) or for more than one year (83% accuracy), but less accurate at predicting survival of "weeks" or "months" (32% accuracy). CONCLUSION: Clinicians are good at identifying individuals who will die imminently and those who will live for much longer. The accuracy of prognostication for these time frames differs across major disease categories, but remains acceptable even in non-cancer patients, including patients with dementia. Advance Care Planning and timely access to palliative care based on individual patient needs may be beneficial for those where there is significant prognostic uncertainty; those who are neither imminently dying nor expected to live for "years"

Ultrasonic Sensors to Measure Internal Temperature Distribution

The in-process measurement of the internal temperature distribution is an important step toward improved processing of steels. A promising approach is the measurement of ultrasonic velocity, combined with a priori information on heat flow. Reference data on ultrasonic velocity versus temperature have been obtained for austenitic 304 stainless steel and for ferritic AISI 1018 steel. For stainless steel the longitudinal-wave velocity is nearly linear with temperature, with a proportionality constant of about -0.7 meters per second per degree Kelvin. In this paper we review the technical approach being used to ultrasonically determine internal temperature distribution. For this we (1) map the average velocity (hence average temperature) within hot steel samples (using a pulsed-laser driver and an electromagnetic acoustic transducer (EMAT) receiver) and (2) apply a reconstruction model that is based on ultrasonic tomography and utilizes the equations of heat flow

Managing uncertain recovery for patients nearing the end of life in hospital: a mixed-methods feasibility cluster randomised controlled trial of the AMBER care bundle

Abstract: Background: The AMBER (Assessment, Management, Best Practice, Engagement, Recovery Uncertain) care bundle is a complex intervention used in UK hospitals to support patients with uncertain recovery. However, it has yet to be evaluated in a randomised controlled trial (RCT) to identify potential benefits or harms. The aim of this trial was to investigate the feasibility of a cluster RCT of the AMBER care bundle. Methods: This is a prospective mixed-methods feasibility cluster RCT. Quantitative data collected from patients (or proxies if patients lack capacity) were used (i) to examine recruitment, retention and follow-up rates; (ii) to test data collection tools for the trial and determine their optimum timing; (iii) to test methods to identify the use of financial resources; and (iv) to explore the acceptability of study procedures for health professionals and patients. Descriptive statistical analyses and thematic analysis used the framework approach. Results: In total, 894 patients were screened, of whom 220 were eligible and 19 of those eligible (8.6%) declined to participate. Recruitment to the control arm was challenging. Of the 728 patients screened for that arm, 647 (88.9%) were excluded. Overall, 65 patients were recruited (81.3% of the recruitment target of 80). Overall, many were elderly (≥80 years, 46.2%, n = 30, mean = 77.8 years, standard deviation [SD] = 12.3 years). Over half (53.8%) had a non-cancer diagnosis, with a mean of 2.3 co-morbidities; 24.6% patients (n = 16) died during their hospital stay and 35.4% (n = 23) within 100 days of discharge. In both trial arms, baseline IPOS subscale scores identified moderate patient anxiety (control: mean 13.3, SD 4.8; intervention: mean 13.3, SD 5.1), and howRwe identified a good care experience (control: mean 13.1, SD 2.5; intervention: mean 11.5, SD 2.1). Collecting quantitative service use and quality of life data was feasible. No patient participants regarded study involvement negatively. Focus groups with health professionals identified concerns regarding (i) the subjectivity of the intervention’s eligibility criteria, (ii) the need to prognosticate to identify potential patients and (iii) consent procedures and the length of the questionnaire. Conclusions: A full trial of the AMBER care bundle is technically feasible but impractical due to fundamental issues in operationalising the intervention’s eligibility criteria, which prevents optimal recruitment. Since this complex intervention continues to be used in clinical care and advocated in policy, alternative research approaches must be considered and tested. Trial registration: International Standard Randomised Controlled Trial Number (ISRCTN) Register, ISRCTN36040085

Implementation of a complex intervention to improve care for patients whose situations are clinically uncertain in hospital settings: A multi-method study using normalisation process theory

Purpose: To examine the use of Normalisation Process Theory (NPT) to establish if, and in what ways, the AMBER care bundle can be successfully normalised into acute hospital practice, and to identify necessary modifications to optimise its implementation. Method: Multi-method process evaluation embedded within a mixed-method feasibility cluster randomised controlled trial in two district general hospitals in England. Data were collected using (i) focus groups with health professionals (HPs), (ii) semi-structured interviews with patients and/or carers, (iii) non-participant observations of multi-disciplinary team meetings and (iv) patient clinical note review. Thematic analysis and descriptive statistics, with interpretation guided by NPT components (coherence; cognitive participation; collective action; reflexive monitoring). Data triangulated across sources. Results: Two focus groups (26 HPs), nine non-participant observations, 12 interviews (two patients, 10 relatives), 29 clinical note reviews were conducted. While coherence was evident, with HPs recognising the value of the AMBER care bundle, cognitive participation and collective action presented challenges. Specifically: (1) HPs were unable and unwilling to operationalise the concept of ‘risk of dying’ intervention eligibility criteria (2) integration relied on a ‘champion’ to drive participation and ensure sustainability; and (3) differing skills and confidence led to variable engagement with difficult conversations with patients and families about, for example, nearness to end of life. Opportunities for reflexive monitoring were not routinely embedded within the intervention. Reflections on the use of the AMBER care bundle from HPs and patients and families, including recommended modifications became evident through this NPT-driven analysis. Conclusion: To be successfully normalised, new clinical practices, such as the AMBER care bundle, must be studied within the wider context in which they operate. NPT can be used to the aid identification of practical strategies to assist in normalisation of complex interventions where the focus of care is on clinical uncertainty in acute hospital settings

Healthcare trajectories and costs in the last year of life: a retrospective primary care and hospital analysis

Objectives To analyse healthcare utilisation and costs in the last year of life in England, and to study variation by cause of death, region of patient residence and socioeconomic status. Methods This is a retrospective cohort study. Individuals aged 60 years and over (N=108 510) who died in England between 2010 and 2017 were included in the study. Results Healthcare utilisation and costs in the last year of life increased with proximity to death, particularly in the last month of life. The mean total costs were higher among males (£8089) compared with females (£6898) and declined with age at death (£9164 at age 60–69 to £5228 at age 90+) with inpatient care accounting for over 60% of total costs. Costs decline with age at death (0.92, 95% CI 0.88 to 0.95, p<0.0001 for age group 90+ compared with to the reference category age group 60–69) and were lower among females (0.91, 95% CI 0.90 to 0.92, p<0.0001 compared with males). Costs were higher (1.09, 95% CI 1.01 to 1.14, p<0.0001) in London compared with other regions. Conclusions Healthcare utilisation and costs in the last year of life increase with proximity to death, particularly in the last month of life. Finer geographical data and information on healthcare supply would allow further investigating whether people receiving more planned care by primary care and or specialist palliative care towards the end of life require less acute care