Evolution of the Kangmar Dome, southern Tibet: Structural, petrologic, and thermochronologic constraints

Structural, thermobarometric, and thermochronologic investigations of the Kangmar Dome, southern Tibet, suggest that both extensional and contractional deformational histories are preserved within the dome. The dome is cored by an orthogneiss which is mantled by staurolite + kyanite zone metasedimentary rocks; metamorphic grade dies out up section and is defined by a series of concentric kyanite-in, staurolite-in, garnet-in, and chloritoid-in isograds. Three major deformational events, two older penetrative events and a younger doming event, are preserved. The oldest event, D1, resulted in approximately E-W trending tight to isoclinal folds of bedding with an associated moderately to steeply north dipping axial planar foliation, S1. The second event, D2, resulted in a high strain mylonitic foliation, S2, which defines the domal structure, and an associated approximately N-S trending stretching and mineral alignment lineation. Shear sense during formation of S2 varied from dominantly top S shear on the south dipping flank of the dome to top N shear on the north dipping flank. The central part of the dome exhibits either opposing shear sense indicators or symmetric fabrics. Microtextural relations indicate that peak metamorphism occurred post-D1 and pre- to early D2 deformation. Quantitative thermobarometry yields peak metamorphic conditions of ∼445°C and 370 MPa in garnet zone rocks, increasing to 625°C and 860 MPa in staurolite + kyanite zone rocks. Pressures and temperatures increase with depth and northward within a single structural horizon across the dome and the apparent gradient in pressure is ∼20% of the expected gradient, suggesting that the rocks were subvertically shortened after the pressure gradient was frozen in. Mica 40Ar/39Ar thermochronology yields 15.24 ± 0.05 to 10.94 ± 0.30 Ma cooling ages that increase with depth and young northward within a single structural horizon across the dome. Diffusion modeling of potassium feldspar 40Ar/39Ar spectra yield rapid cooling rates (∼10–30°C/Myr) between ∼11.5 and 10 Ma and apatite fission track ages range from 7.9 ± 3.0 to 4.1 ± 1.9 Ma, with a mean age of ∼5.5 Ma. Both data sets show symmetric cooling across the dome between ∼11 and 5.5 Ma. The S2 mylonitic foliation, peak metamorphic isobars and isotherms, and mica 40Ar/39Ar isochrons are domed, whereas potassium feldspar 40Ar/39Ar and apatite fission track isochrons are not, suggesting that doming occurred at ∼11 Ma. Our data do not support simple, end-member metamorphic core complex-type extension, diapirism, or duplex models for gneiss dome formation. Rather, we suggest that the formation of extensional fabrics occurred within a zone of coaxial strain in the root zone of the Southern Tibetan Detachment System (STDS), implying that normal slip along the STDS and extensional fabrics within the Kangmar Dome were the result of gravitational collapse of overthickened crust. Subsequent doming during the middle Miocene is attributed to thrusting upward and southward over a north dipping ramp above cold Tethyan sediments. Middle Miocene thrust faulting in the Kangmar Dome region is synchronous with continued normal slip along the STDS and thrust motion along the Renbu Zedong thrust fault, suggesting that extension and contraction was occurring simultaneously within southern Tibet

General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multi-centre observational study

There are no current descriptions of general anaesthesia characteristics for obstetric surgery, despite recent changes to patient baseline characteristics and airway management guidelines. This analysis of data from the direct reporting of awareness in maternity patients' (DREAMY) study of accidental awareness during obstetric anaesthesia aimed to describe practice for obstetric general anaesthesia in England and compare with earlier surveys and best-practice recommendations. Consenting patients who received general anaesthesia for obstetric surgery in 72 hospitals from May 2017 to August 2018 were included. Baseline characteristics, airway management, anaesthetic techniques and major complications were collected. Descriptive analysis, binary logistic regression modelling and comparisons with earlier data were conducted. Data were collected from 3117 procedures, including 2554 (81.9%) caesarean deliveries. Thiopental was the induction drug in 1649 (52.9%) patients, compared with propofol in 1419 (45.5%). Suxamethonium was the neuromuscular blocking drug for tracheal intubation in 2631 (86.1%), compared with rocuronium in 367 (11.8%). Difficult tracheal intubation was reported in 1 in 19 (95%CI 1 in 16-22) and failed intubation in 1 in 312 (95%CI 1 in 169-667). Obese patients were over-represented compared with national baselines and associated with difficult, but not failed intubation. There was more evidence of change in practice for induction drugs (increased use of propofol) than neuromuscular blocking drugs (suxamethonium remains the most popular). There was evidence of improvement in practice, with increased monitoring and reversal of neuromuscular blockade (although this remains suboptimal). Despite a high risk of difficult intubation in this population, videolaryngoscopy was rarely used (1.9%)

Integration of oncology and palliative care : a Lancet Oncology Commission

Full integration of oncology and palliative care relies on the specific knowledge and skills of two modes of care: the tumour-directed approach, the main focus of which is on treating the disease; and the host-directed approach, which focuses on the patient with the disease. This Commission addresses how to combine these two paradigms to achieve the best outcome of patient care. Randomised clinical trials on integration of oncology and palliative care point to health gains: improved survival and symptom control, less anxiety and depression, reduced use of futile chemotherapy at the end of life, improved family satisfaction and quality of life, and improved use of health-care resources. Early delivery of patient-directed care by specialist palliative care teams alongside tumour-directed treatment promotes patient-centred care. Systematic assessment and use of patient-reported outcomes and active patient involvement in the decisions about cancer care result in better symptom control, improved physical and mental health, and better use of health-care resources. The absence of international agreements on the content and standards of the organisation, education, and research of palliative care in oncology are major barriers to successful integration. Other barriers include the common misconception that palliative care is end-of-life care only, stigmatisation of death and dying, and insufficient infrastructure and funding. The absence of established priorities might also hinder integration more widely. This Commission proposes the use of standardised care pathways and multidisciplinary teams to promote integration of oncology and palliative care, and calls for changes at the system level to coordinate the activities of professionals, and for the development and implementation of new and improved education programmes, with the overall goal of improving patient care. Integration raises new research questions, all of which contribute to improved clinical care. When and how should palliative care be delivered? What is the optimal model for integrated care? What is the biological and clinical effect of living with advanced cancer for years after diagnosis? Successful integration must challenge the dualistic perspective of either the tumour or the host, and instead focus on a merged approach that places the patient's perspective at the centre. To succeed, integration must be anchored by management and policy makers at all levels of health care, followed by adequate resource allocation, a willingness to prioritise goals and needs, and sustained enthusiasm to help generate support for better integration. This integrated model must be reflected in international and national cancer plans, and be followed by developments of new care models, education and research programmes, all of which should be adapted to the specific cultural contexts within which they are situated. Patient-centred care should be an integrated part of oncology care independent of patient prognosis and treatment intention. To achieve this goal it must be based on changes in professional cultures and priorities in health care