Evaluating the uncertainty of terrestrial water budget components over High Mountain Asia.

This study explores the uncertainties in terrestrial water budget estimation over High Mountain Asia (HMA) using a suite of uncoupled land surface model (LSM) simulations. The uncertainty in the water balance components of precipitation (P), evapotranspiration (ET), runoff(R), and terrestrial water storage (TWS) is significantly impacted by the uncertainty in the driving meteorology, with precipitation being the most important boundary condition. Ten gridded precipitation datasets along with a mix of model-, satellite-, and gauge-based products, are evaluated first to assess their suitability for LSM simulations over HMA. The datasets are evaluated by quantifying the systematic and random errors of these products as well as the temporal consistency of their trends. Though the broader spatial patterns of precipitation are generally well captured by the datasets, they differ significantly in their means and trends. In general, precipitation datasets that incorporate information from gauges are found to have higher accuracy with low Root Mean Square Errors and high correlation coefficient values. An ensemble of LSM simulations with selected subset of precipitation products is then used to produce the mean annual fluxes and their uncertainty over HMA in P, ET, and R to be 2.11±0.45, 1.26±0.11, and 0.85±0.36 mm per day, respectively. The mean annual estimates of the surface mass (water) balance components from this model ensemble are comparable to global estimates from prior studies. However, the uncertainty/spread of P, ET, and R is significantly larger than the corresponding estimates from global studies. A comparison of ET, snow cover fraction, and changes in TWS estimates against remote sensing-based references confirms the significant role of the input meteorology in influencing the water budget characterization over HMA and points to the need for improving meteorological inputs.

Balance Right in Multiple Sclerosis (BRiMS): a guided self-management programme to reduce falls and improve quality of life, balance and mobility in people with secondary progressive multiple sclerosis: a protocol for a feasibility randomised controlled trial.

BACKGROUND: Impaired mobility is a cardinal feature of multiple sclerosis (MS) and is rated by people with MS as their highest priority. By the secondary progressive phase, balance, mobility and physical activity levels are significantly compromised; an estimated 70% of people with secondary progressive MS fall regularly. Our ongoing research has systematically developed 'Balance Right in MS' (BRiMS), an innovative, manualised 13-week guided self-management programme tailored to the needs of people with MS, designed to improve safe mobility and minimise falls. Our eventual aim is to assess the clinical and cost effectiveness of BRiMS in people with secondary progressive MS by undertaking an appropriately statistically powered, multi-centre, assessor-blinded definitive, randomised controlled trial. This feasibility study will assess the acceptability of the intervention and test the achievability of running such a definitive trial. METHODS/DESIGN: This is a pragmatic multi-centre feasibility randomised controlled trial with blinded outcome assessment. Sixty ambulant people with secondary progressive MS who self-report two or more falls in the previous 6 months will be randomly allocated (1:1) to either the BRiMS programme plus usual care or to usual care alone. All participants will be assessed at baseline and followed up at 15 weeks and 27 weeks post-randomisation. The outcomes of this feasibility trial include:Feasibility outcomes, including trial recruitment, retention and completionAssessment of the proposed outcome measures for the anticipated definitive trial (including measures of walking, quality of life, falls, balance and activity level)Measures of adherence to the BRiMS programmeData to inform the economic evaluation in a future trialProcess evaluation (assessment of treatment fidelity and qualitative evaluation of participant and treating therapist experience). DISCUSSION: The BRiMS intervention aims to address a key concern for MS service users and providers. However, there are several uncertainties which need to be addressed prior to progressing to a full-scale trial, including acceptability of the BRiMS intervention and practicality of the trial procedures. This feasibility trial will provide important insights to resolve these uncertainties and will enable a protocol to be finalised for use in the definitive trial. TRIAL REGISTRATION: ISRCTN13587999.

The cost-effectiveness of patient-controlled analgesia vs. standard care in patients presenting to the Emergency Department in pain, who are subsequently admitted to hospital.

The clinical effectiveness of patient-controlled analgesia has been demonstrated in a variety of settings. However, patient-controlled analgesia is rarely utilised in the Emergency Department. The aim of this study was to compare the cost-effectiveness of patient-controlled analgesia vs. standard care in participants admitted to hospital from the Emergency Department with pain due to traumatic injury or non-traumatic abdominal pain. Pain scores were measured hourly for 12 h using a visual analogue scale. Cost-effectiveness was measured as the additional cost per hour in moderate to severe pain avoided by using patient-controlled analgesia rather than standard care (the incremental cost-effectiveness ratio). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis. The cost per hour in moderate or severe pain averted was estimated as £24.77 (€29.05, US$30.80) (bootstrap estimated 95%CI £8.72 to £89.17) for participants suffering pain from traumatic injuries and £15.17 (€17.79, US$18.86) (bootstrap estimate 95%CI £9.03 to £46.00) for participants with non-traumatic abdominal pain. Overall costs were higher with patient-controlled analgesia than standard care in both groups: pain from traumatic injuries incurred an additional £18.58 (€21.79 US$23.10) (95%CI £15.81 to £21.35) per 12 h; and non-traumatic abdominal pain an additional £20.18 (€23.67 US$25.09) (95%CI £19.45 to £20.84) per 12 h.

Standing up in multiple sclerosis (SUMS): protocol for a multi-centre randomised controlled trial evaluating the clinical and cost effectiveness of a home-based self-management standing frame programme in people with progressive multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) is an incurable, unpredictable but typically progressive neurological condition. It is the most common cause of neurological disability in young adults. Within 15 years of diagnosis, approximately 50 % of affected people are unable to walk unaided, and over time an estimated 25 % depend on a wheelchair. Typically, people with such limited mobility are excluded from clinical trials. Severely impaired people with MS spend much of their day sitting, often with limited ability to change position. In response, secondary complications can occur including: muscle wasting, pain, reduced skin integrity, spasms, limb stiffness, constipation, and associated psychosocial problems such as depression and lowered self-esteem. Effective self-management strategies, which can be implemented relatively easily and cheaply within people's homes, are needed to improve or maintain mobility and reduce sedentary behaviour. However this is challenging, particularly in the latter stages of disease. Regular supported standing using standing frames is one potential option. METHODS/DESIGN: SUMS is a pragmatic multi-centre randomised controlled trial evaluating use of Oswestry standing frames with blinded outcome assessment and full economic evaluation. Participants will be randomly allocated (1:1) to either a home-based, self-management standing programme (with advice and support) along with their usual care or to usual care alone. Those in the intervention group will be asked to stand for a minimum of 30 min three times weekly over 20 weeks. Each participant will be followed-up at 20 and 36 weeks post baseline. The primary clinical outcome is motor function, assessed using the Amended Motor Club Assessment. The primary economic endpoint is quality-adjusted life years. The secondary outcomes include measures of explanatory physical impairments, key clinical outcomes, and health-related quality of life. An embedded qualitative component will explore participant's and carer's experiences of the standing programme. DISCUSSION: This is the first large scale multi-centre trial to assess the clinical and cost effectiveness of a home based standing frame programme for people who are severely impaired by MS. If demonstrated to be effective and cost-effective, we will use this evidence to develop recommendations for a health service delivery model which could be implemented across the United Kingdom. TRIAL REGISTRATION: ISRCTN69614598 DATE OF REGISTRATION: 3.2.16 (retrospectively registered).

Biomarkers and personalised medicine in rheumatoid arthritis: a proposal for interactions between academia, industry and regulatory bodies.

Rheumatoid arthritis (RA) is one of the most appropriate conditions for the application of personalised medicine as a high degree of heterogeneity has been recognised, which remains to be explained. Such heterogeneity is also reflected in the large number of treatment targets and options. A growing number of biologics as well as small molecules are already in use and there are promising new drugs in development. In order to make the best use of treatment options, both targeted and non-targeted biomarkers have to be identified and validated. To this aim, new rules are needed for the interaction between academia and industry under regulatory control. Setting up multi-centre biosample collections with clear definition of access, organising early, possibly non-committing discussions with regulatory authorities, and defining a clear route for the validation, qualification and registration of the biomarker-drug combination are some of the more critical areas where effective collaboration between the drug industry, academia and regulators is needed.

Integrated urban water management for residential areas: a reuse model.

Global concern over growing urban water demand in the face of limited water resources has focussed attention on the need for better management of available water resources. This paper takes the "fit for purpose" concept and applies it in the development of a model aimed at changing current practices with respect to residential planning by integrating reuse systems into the design layout. This residential reuse model provides an approach to the design of residential developments seeking to maximise water reuse. Water balance modelling is used to assess the extent to which local water resources can satisfy residential demands with conditions based on the city of Adelaide, Australia. Physical conditions include a relatively flat topography and a temperate climate, with annual rainfall being around 500 mm. The level of water-self-sufficiency that may be achieved within a reuse development in this environment is estimated at around 60%. A case study is also presented in which a conventional development is re-designed on the basis of the reuse model. Costing of the two developments indicates the reuse scenario is only marginally more expensive. Such costings however do not include the benefit to upstream and downstream environments resulting from reduced demand and discharges. As governments look to developers to recover system augmentation and environmental costs the economics of such approaches will increase.

Chemotherapy in the community: what do patients want?

The aim of this study was to compare the outcomes of chemotherapy delivered at a cancer centre with chemotherapy given at a community hospital. The services were compared in terms of safety, preference for location, satisfaction and resource use. Patients were randomly allocated to two groups. One group received their first two cycles of chemotherapy at a community hospital; the other group received theirs at the cancer centre. The patients then crossed over to receive their next two cycles of chemotherapy at outreach or the cancer centre and then chose where they wanted to receive the remaining two cycles of their chemotherapy. Data were collected about patient preference, anxiety and depression, satisfaction and chemotherapy-related toxicity. Forty-two patients were randomized to the study: 38, 31 and 28 patients completed cycles two, four and final chemotherapies respectively. Thirty-one patients reached the end of the crossover period, of which 30 chose the outreach location for the remainder of their chemotherapy treatments. There was strong evidence that patients were more satisfied with outreach location for ease of access and also the environment. Recommendation from this study was that a permanent outreach chemotherapy service to community hospitals be established.

Clinical and economic outcomes of infants receiving breast milk in the NICU.

ISSUES AND PURPOSE: This study compared clinical and economic outcomes for infants who were exclusively fed breast milk and infants who were fed commercial formula. DESIGN AND METHODS: A retrospective medical record review from a regional neonatal intensive care unit (N = 80) using consultation logs from the lactation coordinator and a matched sample of formula-fed infants. RESULTS: Neither clinical (weight gain, length of stay, days of parenteral nutrition) nor economic outcomes (direct variable costs, net revenue) differed significantly between the groups. PRACTICE IMPLICATIONS: While it may not be possible to demonstrate sufficient cost savings while the infant resides within the NICU to justify a lactation coordinator, long-term clinical and economic outcomes may be sensitive to this specialized nursing service.

High food wastage and low nutritional intakes in hospital patients.

BACKGROUND AND AIMS: The aim of this study was to investigate the cause of continuing weight-loss in hospitalized patients. We determined 1. whether the hospital menu was able to meet the patients' minimum nutritional requirements, 2. the proportion of food being wasted and 3. the mean nutritional intakes of patients. METHODS: This study was carried out in a University hospital (1200 beds). All the food supplied and wasted was measured over a 28 day period on one ward in each of 4 different specialties. Average food intake per patient was calculated and checked against individual food intake measurements. RESULTS: The hospital menu provided over 2000 kcal/day and could meet patients' nutritional requirements. However, high wastage rates of greater than 40% resulted in energy and protein intakes within all specialties being less than 80% of that recommended. The cost of this waste was 139,655 pounds sterling in these four specialties. CONCLUSIONS: More than 40% of hospital food was wasted. Energy and protein intakes were low and patients did not, therefore, meet their recommended intakes. This helps to explain continuing weight-loss in hospital patients and represents a large waste of resources. Hospital feeding policies therefore need reviewing and made more appropriate to the needs of the sick.

Men's health: a cause for concern.

The state of men's health is a cause for concern; men are less likely to seek medical help than women even though they are more likely to die at a younger age. Andrew Barton looks at the issues surrounding men's health by focusing on prostate and testicular cancer.

Improving patient outcomes through CQI: vascular access planning.

This article reports the use of the continuous quality improvement (CQI) process to improve patient outcomes. The FADE method (focus, analyze, develop, and execute) was used to focus on vascular access planning, analyze data concerning intravenous (i.v.) therapy, develop a vascular access planning algorithm, and execute implementation of the algorithm. An evaluation study revealed that patients whose vascular access planning was consistent with the algorithm reported fewer i.v.s, less difficulty starting i.v.s, and less stress; waited significantly less time until central venous line (CVL) placement (for those who received CVLs); and had significantly shorter lengths of stay.

Re-engineering intensive care: the role of informatics.

Managed care and quality improvement are two driving forces in the current health care environment. The pressure of capitation and the recent focus on outcomes of care have generated new incentives to restructure care delivery to control costs. Intensive care units, once revenue centers, are becoming cost centers. Re-engineering, or redesigning, the process of care entails examining premises for ability to provide services as well as considering how to do things more efficiently. The assumption is that all aspects of a process are legitimately subject to examination and restructuring. Information systems provide a powerful tool to support re-engineering. Nursing informatics, which pertains to nursing data, information, and knowledge has major implications for hospital information systems. This article explores possible changes in intensive care and the role of informatics in a changing health care environment.

Strategies for a smooth hospital closure.

When a hospital closes it becomes the nurse executive's and human resource director's responsibility to ensure the quality of patient care through the transition as well as manage the staff during a stressful time. How do you keep enough staff to care for the patients during the closing period? This author, who has previous experience managing a hospital closure, describes strategies to keep staff and promote patient continuity during the closure process. She emphasizes the need to focus on both patients and staff.

Decomposing area of residence differences in multiple regression studies: the relative contributions of independent variables and model coefficients.

When rural/urban differences are found in health status or health care use, it is often desirable to identify those factors (such as age, social structure, income, etc.) that influence such differences. To this end, researchers often test rural/urban differences in age, social structure, income, etc., for statistical significance. Also, researchers commonly perform multivariate analyses (such as multiple regressions) to examine rural-urban differences in the influence of various independent variables on the dependent variable of interest. Frequently, researchers discover: (1) statistically significant rural/urban differences in the independent variables (such as age, social structure, income, etc.) and (2) statistically significant rural/urban differences in the effects of these independent variables (i.e., statistically significant rural/urban differences in regression coefficients). The analysis typically stops here, without addressing the relative contributions of (1) and (2) to the rural/urban differences in the dependent variable. This paper argues that the relative contributions of (1) and (2) have important implications for the way policy-makers address rural health problems. This paper presents a method for assessing the relative contributions of differences in the independent variables and differences in regression coefficients to observed differences in the dependent variable, and illustrates the application of the method by analyzing rural/urban differences in the risk of institutionalization.