Barriers to providing palliative care for older people in acute hospitals

Background: the need for access to high-quality palliative care at the end of life is becoming of increasing public health concern. The majority of deaths in the UK occur in acute hospitals, and older people are particularly likely to die in this setting. However, little is known about the barriers to palliative care provision for older people within acute hospitals. Objective: to explore the perspectives of health professionals regarding barriers to optimal palliative care for older people in acute hospitals. Methods: fifty-eight health professionals participated in eight focus groups and four semi-structured interviews. Results: participants identified various barriers to palliative care provision for older people, including attitudinal differences to the care of older people, a focus on curative treatments within hospitals and a lack of resources. Participants also reported differing understandings of whose responsibility it was to provide palliative care for older people, and uncertainly over the roles of specialist and generalist palliative care providers in acute hospitals. Conclusions: numerous barriers exist to the provision of high-quality palliative care for older people within acute hospital settings. Additional research is now required to further explore age-related issues contributing to poor access to palliative care

Genus Topology of the Cosmic Microwave Background from the WMAP 3-Year Data

We have independently measured the genus topology of the temperature fluctuations in the cosmic microwave background seen in the Wilkinson Microwave Anisotropy Probe (WMAP) 3-year data. A genus analysis of the WMAP data indicates consistency with Gaussian random-phase initial conditions, as predicted by standard inflation. We set 95% confidence limits on non-linearities of -101 < f_{nl} < 107. We also find that the observed low l (l <= 8) modes show a slight anti-correlation with the Galactic foreground, but not exceeding 95% confidence, and that the topology defined by these modes is consistent with that of a Gaussian random-phase distribution (within 95% confidence).Comment: MNRAS LaTeX style (mn2e.cls), EPS and JPEG figure

What is the cost of palliative care in the UK? A systematic review

OBJECTIVES: Little is known about the cost of a palliative care approach in the UK, and there is an absence of robust activity and unit cost data. The aim of this study was to review evidence on the costs of specialist and generalist palliative care in the UK, and to explore different approaches used for capturing activity and unit cost data. METHODS: A systematic review with narrative synthesis. Four electronic databases were searched for empirical literature on the costs of a palliative care approach in the UK, and a narrative method was used to synthesise the data. RESULTS: Ten papers met our inclusion criteria. The studies displayed significant variation in their estimates of the cost of palliative care, therefore it was not possible to present an accurate aggregate cost of palliative care in the UK. The majority of studies explored costs from a National Health Service perspective and only two studies included informal care costs. Approaches to estimating activity and costs varied. Particular challenges were noted with capturing activity and cost data for hospice and informal care. CONCLUSION: The data are limited, and the heterogeneity is such that it is not possible to provide an aggregate cost of palliative care in the UK. It is notable that the costs of hospice care and informal care are often neglected in economic studies. Further work is needed to address methodological and practical challenges in order to gain a more complete understanding of the costs of palliative care

Exploring the transition from curative care to palliative care: a systematic review of the literature.

BACKGROUND: UK policy guidance on treatment and care towards the end of life identifies a need to better recognise patients who are likely to be in the last 12 months of life. Health and social care professionals have a key role in initiating and managing a patient's transition from 'curative care' to palliative care. The aim of this paper is to provide a systematic review of evidence relating to the transition from curative care to palliative care within UK settings. METHOD: Four electronic databases were searched for studies published between 1975 and March 2010. Inclusion criteria were all UK studies relating to the transition from curative care to palliative care in adults over the age of 18. Selected studies were independently reviewed, data were extracted, quality was assessed and data were synthesised using a descriptive thematic approach. RESULTS: Of the 1464 articles initially identified, 12 papers met the criteria for inclusion. Four themes emerged from the literature: (1) patient and carer experiences of transitions; (2) recognition and identification of the transition phase; (3) optimising and improving transitions; and (4) defining and conceptualising transitions. CONCLUSIONS: The literature suggests that little is known about the potentially complex transition to palliative care. Evidence suggests that continuity of care and multidisciplinary collaboration are crucial in order to improve the experience of patients making the transition. An important role is outlined for generalist providers of palliative care. Incorporating palliative care earlier in the disease trajectory and implementing a phased transition appear key components of optimum care

Specialist palliative care nursing and the philosophy of palliative care: a critical discussion

Nursing is the largest regulated health professional workforce providing palliative care across a range of clinical settings. Historically, palliative care nursing has been informed by a strong philosophy of care which is soundly articulated in palliative care policy, research and practice. Indeed, palliative care is now considered to be an integral component of nursing practice regardless of the specialty or clinical setting. However, there has been a change in the way palliative care is provided. Upstreaming and mainstreaming of palliative care and the dominance of a biomedical model with increasing medicalisation and specialisation are key factors in the evolution of contemporary palliative care and are likely to impact on nursing practice. Using a critical reflection of the authors own experiences and supported by literature and theory from seminal texts and contemporary academic, policy and clinical literature, this discussion paper will explore the influence of philosophy on nursing knowledge and theory in the context of an evolving model of palliative care

Mass of Clusters in Simulations

We show that dark matter haloes, in n--body simulations, have a boundary layer (BL) with precise features. In particular, it encloses all dynamically stable mass while, outside it, dynamical stability is lost soon. Particles can pass through such BL, which however acts as a confinement barrier for dynamical properties. BL is set by evaluating kinetic and potential energies (T(r) and W(r)) and calculating R=-2T/W. Then, on BL, R has a minimum which closely approaches a maximum of w= -dlog W/dlog r. Such $Rw$ ``requirement'' is consistent with virial equilibrium, but implies further regularities. We test the presence of a BL around haloes in spatially flat CDM simulations, with or without cosmological constant. We find that the mass M_c, enclosed within the radius r_c, where the $Rw$ requirement is fulfilled, closely approaches the mass M_{dyn}, evaluated from the velocities of all particles within r_c, according to the virial theorem. Using r_c we can then determine an individual density contrast Delta_c for each virialized halo, which can be compared with the "virial" density contrast $\Delta_v ~178 \Omega_m^{0.45}$ (Omega_m: matter density parameter) obtained assuming a spherically symmetric and unperturbed fluctuation growth. The spread in Delta_c is wide, and cannot be neglected when global physical quantities related to the clusters are calculated, while the average Delta_c is ~25 % smaller than the corresponding Delta_v; moreover if $M_{dyn}$ is defined from the radius linked to Delta_v, we have a much worse fit with particle mass then starting from {\it Rw} requirement.Comment: 4 pages, 5 figures, contribution to the XXXVIIth Rencontres de Moriond, The Cosmological Model, Les Arc March 16-23 2002, to appear in the proceeding

Quantum Stability of (2+1)-Spacetimes with Non-Trivial Topology

Quantum fields are investigated in the (2+1)-open-universes with non-trivial topologies by the method of images. The universes are locally de Sitter spacetime and anti-de Sitter spacetime. In the present article we study spacetimes whose spatial topologies are a torus with a cusp and a sphere with three cusps as a step toward the more general case. A quantum energy momentum tensor is obtained by the point stripping method. Though the cusps are no singularities, the latter cusps cause the divergence of the quantum field. This suggests that only the latter cusps are quantum mechanically unstable. Of course at the singularity of the background spacetime the quantum field diverges. Also the possibility of the divergence of topological effect by a negative spatial curvature is discussed. Since the volume of the negatively curved space is larger than that of the flat space, one see so many images of a single source by the non-trivial topology. It is confirmed that this divergence does not appear in our models of topologies. The results will be applicable to the case of three dimensional multi black hole\cite{BR}.Comment: 17 pages, revtex, 3 uuencoded figures containe

Self-Gravitating Strings In 2+1 Dimensions

We present a family of classical spacetimes in 2+1 dimensions. Such a spacetime is produced by a Nambu-Goto self-gravitating string. Due to the special properties of three-dimensional gravity, the metric is completely described as a Minkowski space with two identified worldsheets. In the flat limit, the standard string is recovered. The formalism is developed for an open string with massive endpoints, but applies to other boundary conditions as well. We consider another limit, where the string tension vanishes in geometrical units but the end-masses produce finite deficit angles. In this limit, our open string reduces to the free-masses solution of Gott, which possesses closed timelike curves when the relative motion of the two masses is sufficiently rapid. We discuss the possible causal structures of our spacetimes in other regimes. It is shown that the induced worldsheet Liouville mode obeys ({\it classically}) a differential equation, similar to the Liouville equation and reducing to it in the flat limit. A quadratic action formulation of this system is presented. The possibility and significance of quantizing the self-gravitating string, is discussed.Comment: 55 page

Self-Dual Chern-Simons Solitons in (2+1)-Dimensional Einstein Gravity

We consider here a generalization of the Abelian Higgs model in curved space, by adding a Chern--Simons term. The static equations are self-dual provided we choose a suitable potential. The solutions give a self-dual Maxwell--Chern--Simons soliton that possesses a mass and a spin

Topology of structure in the Sloan Digital Sky Survey: model testing

We measure the three-dimensional topology of large-scale structure in the Sloan Digital Sky Survey (SDSS). This allows the genus statistic to be measured with unprecedented statistical accuracy. The sample size is now sufficiently large to allow the topology to be an important tool for testing galaxy formation models. For comparison, we make mock SDSS samples using several state-of-the-art N-body simulations: the Millennium run of Springel et al. (2005)(10 billion particles), Kim & Park (2006) CDM models (1.1 billion particles), and Cen & Ostriker (2006) hydrodynamic code models (8.6 billion cell hydro mesh). Each of these simulations uses a different method for modeling galaxy formation. The SDSS data show a genus curve that is broadly characteristic of that produced by Gaussian random phase initial conditions. Thus the data strongly support the standard model of inflation where Gaussian random phase initial conditions are produced by random quantum fluctuations in the early universe. But on top of this general shape there are measurable differences produced by non-linear gravitational effects (cf. Matsubara 1994), and biasing connected with galaxy formation. The N-body simulations have been tuned to reproduce the power spectrum and multiplicity function but not topology, so topology is an acid test for these models. The data show a ``meatball'' shift (only partly due to the Sloan Great Wall of Galaxies; this shift also appears in a sub-sample not containing the Wall) which differs at the 2.5\sigma level from the results of the Millennium run and the Kim & Park dark halo models, even including the effects of cosmic variance.Comment: 13 Apj pages, 7 figures High-resolution stereo graphic available at http://www.astro.princeton.edu/~dclayh/stereo50.ep