Palliative care for cirrhosis: a UK survey of health professionals' perceptions, current practice and future needs

Objective: To determine the knowledge and practice patterns of a UK cohort of relevant healthcare professionals (HCPs) about delivering palliative care in cirrhosis, and to inform priorities for future research. / Design: An on-line questionnaire survey with closed and open responses. / Setting: HCPs identified from the mailing list of special interest groups in hepatology and gastroenterology (liver), general practice and specialist palliative care (SPC) across the UK. / Results: Of the 6181 potential contacts identified, 517 HCPs responded. Most believed a role exists for SPC in caring for people with cirrhosis, but many SPC HCPs felt ill prepared to provide good care to those facing death. Further training was needed in managing liver-related symptoms, symptom control and end of life issues. All HCP groups wished to increase community provision of palliative care support, but many general practitioners felt unable to manage advanced cirrhosis in the community. There were differences in the optimal trigger for SPC referral with liver HCPs less likely to refer at symptom deterioration. Prognostication, symptom management and service configuration were key areas identified for future research. / Conclusions: All who responded acknowledged the role of SPC in caring for those dying with cirrhosis and need for further training to improve confidence and enable joint working between SPC, general practice and liver teams. Low response rates make it difficult to generalise these findings, which require further validation

Paedophiles in the community: inter-agency conflict, news leaks and the local press

This article explores the leaking of confidential information about secret Home Office plans to house convicted paedophiles within a local community (albeit inside a prison). It argues that a politics of paedophilia has emerged in which inter-agency consensus on the issue of ‘what to do’ with high-profile sex offenders has broken down. Accordingly, the article situates newspaper ‘outing’ of paedophiles in the community in relation to vigilante journalism and leaked information from official agencies. The article then presents research findings from a case study of news events set in train following a whistle-blowing reaction by Prison Officers’ Association officials to Home Office plans. Drawing from a corpus of 10 interviews with journalists and key protagonists in the story, the article discusses both the dynamics of whistle blowing about paedophiles and also what happens after the whistle has blown

Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysis.

Background: High-sensitivity assays for cardiac troponin T (hs-cTnT) are sometimes used to rapidly rule out acute myocardial infarction (AMI). Purpose: To estimate the ability of a single hs-cTnT concentration below the limit of detection (<0.005 µg/L) and a nonischemic electrocardiogram (ECG) to rule out AMI in adults presenting to the emergency department (ED) with chest pain. Data Sources: EMBASE and MEDLINE without language restrictions (1 January 2008 to 14 December 2016). Study Selection: Cohort studies involving adults presenting to the ED with possible acute coronary syndrome in whom an ECG and hs-cTnT measurements were obtained and AMI outcomes adjudicated during initial hospitalization. Data Extraction: Investigators of studies provided data on the number of low-risk patients (no new ischemia on ECG and hs-cTnT measurements <0.005 µg/L) and the number who had AMI during hospitalization (primary outcome) or a major adverse cardiac event (MACE) or death within 30 days (secondary outcomes), by risk classification (low or not low risk). Two independent epidemiologists rated risk of bias of studies. Data Synthesis: Of 9241 patients in 11 cohort studies, 2825 (30.6%) were classified as low risk. Fourteen (0.5%) low-risk patients had AMI. Sensitivity of the risk classification for AMI ranged from 87.5% to 100% in individual studies. Pooled estimated sensitivity was 98.7% (95% CI, 96.6% to 99.5%). Sensitivity for 30-day MACEs ranged from 87.9% to 100%; pooled sensitivity was 98.0% (CI, 94.7% to 99.3%). No low-risk patients died. Limitation: Few studies, variation in timing and methods of reference standard troponin tests, and heterogeneity of risk and prevalence of AMI across studies. Conclusion: A single hs-cTnT concentration below the limit of detection in combination with a nonischemic ECG may successfully rule out AMI in patients presenting to EDs with possible emergency acute coronary syndrome. Primary Funding Source: Emergency Care Foundation

Rise of the titans: a dusty, hyper-luminous “870 µm riser” galaxy at z~6

We report the detection of ADFS-27, a dusty, starbursting major merger at a redshift of z=5.655, using the Atacama Large Millimeter/submillimeter Array (ALMA). ADFS-27 was selected from Herschel/SPIRE and APEX/LABOCA data as an extremely red “870 m riser” (i.e., S250m<S350m<S500m<S870m), demonstrating the utility of this technique to identify some of the highest-redshift dusty galaxies. A scan of the 3mm atmospheric window with ALMA yields detections of CO(J=54) and CO(J=65) emission, and a tentative detection of H2O(211202) emission, which provides an unambiguous redshift measurement. The strength of the CO lines implies a large molecular gas reservoir with a mass of Mgas=2.51011 (CO=0:8) (0:39=r51)M, sufficient to maintain its 2400M yr1 starburst for at least 100 Myr. The 870 m dust continuum emission is resolved into two components, 1.8 and 2.1 kpc in diameter, separated by 9.0 kpc, with comparable dust luminosities, suggesting an ongoing major merger. The infrared luminosity of LIR'2.41013 L implies that this system represents a binary hyper-luminous infrared galaxy, the most distant of its kind presently known. This also implies star formation rate surface densities of SFR=730 and 750M yr1 kpc2, consistent with a binary “maximum starburst”. The discovery of this rare system is consistent with a significantly higher space density than previously thought for the most luminous dusty starbursts within the first billion years of cosmic time, easing tensions regarding the space densities of z6 quasars and massive quiescent galaxies at z&3

Exploring Cosmic Origins with CORE: Cluster Science

We examine the cosmological constraints that can be achieved with a galaxycluster survey with the future CORE space mission. Using realistic simulationsof the millimeter sky, produced with the latest version of the Planck SkyModel, we characterize the CORE cluster catalogues as a function of the mainmission performance parameters. We pay particular attention to telescope size,key to improved angular resolution, and discuss the comparison and thecomplementarity of CORE with ambitious future ground-based CMB experiments thatcould be deployed in the next decade. A possible CORE mission concept with a150 cm diameter primary mirror can detect of the order of 50,000 clustersthrough the thermal Sunyaev-Zeldovich effect (SZE). The total yield increases(decreases) by 25% when increasing (decreasing) the mirror diameter by 30 cm.The 150 cm telescope configuration will detect the most massive clusters($>10^{14}\, M_\odot$) at redshift $z>1.5$ over the whole sky, although theexact number above this redshift is tied to the uncertain evolution of thecluster SZE flux-mass relation; assuming self-similar evolution, CORE willdetect $\sim 500$ clusters at redshift $z>1.5$. This changes to 800 (200) whenincreasing (decreasing) the mirror size by 30 cm. CORE will be able to measureindividual cluster halo masses through lensing of the cosmic microwavebackground anisotropies with a 1-$\sigma$ sensitivity of $4\times10^{14}M_\odot$, for a 120 cm aperture telescope, and $10^{14} M_\odot$ for a 180 cmone. [abridged

Exploring cosmic origins with CORE : Inflation

We forecast the scientific capabilities to improve our understanding of cosmic inflation of CORE, a proposed CMB space satellite submitted in response to the ESA fifth call for a medium-size mission opportunity. The CORE satellite will map the CMB anisotropies in temperature and polarization in 19 frequency channels spanning the range 60-600 GHz. CORE will have an aggregate noise sensitivity of 1.7 mu K.arcmin and an angular resolution of 5' at 200 GHz. We explore the impact of telescope size and noise sensitivity on the inflation science return by making forecasts for several instrumental configurations. This study assumes that the lower and higher frequency channels suffice to remove foreground contaminations and complements other related studies of component separation and systematic effects, which will be reported in other papers of the series "Exploring Cosmic Origins with CORE." We forecast the capability to determine key inflationary parameters, to lower the detection limit for the tensor-to-scalar ratio down to the 10(-3) level, to chart the landscape of single field slow-roll inflationary models, to constrain the epoch of reheating, thus connecting inflation to the standard radiation-matter dominated Big Bang era, to reconstruct the primordial power spectrum, to constrain the contribution from isocurvature perturbations to the 10(-3) level, to improve constraints on the cosmic string tension to a level below the presumptive GUT scale, and to improve the current measurements of primordial non-Gaussianities down to the f(NL)(local) <1 level. For all the models explored, CORE alone will improve significantly on the present constraints on the physics of inflation. Its capabilities will be further enhanced by combining with complementary future cosmological observations.Peer reviewe

Exploring cosmic origins with CORE : Effects of observer peculiar motion

We discuss the effects on the cosmic microwave background (CMB), cosmic infrared background (CIB), and thermal Sunyaev-Zeldovich effect due to the peculiar motion of an observer with respect to the CMB rest frame, which induces boosting effects. After a brief review of the current observational and theoretical status, we investigate the scientific perspectives opened by future CMB space missions, focussing on the Cosmic Origins Explorer (CORE) proposal. The improvements in sensitivity offered by a mission like CORE, together with its high resolution over a wide frequency range, will provide a more accurate estimate of the CMB dipole. The extension of boosting effects to polarization and cross-correlations will enable a more robust determination of purely velocity-driven effects that are not degenerate with the intrinsic CMB dipole, allowing us to achieve an overall signal-to-noise ratio of 13; this improves on the Planck detection and essentially equals that of an ideal cosmic variance-limited experiment up to a multipole l similar or equal to 2000. Precise inter-frequency calibration will offer the opportunity to constrain or even detect CMB spectral distortions, particularly from the cosmological reionization epoch, because of the frequency dependence of the dipole spectrum, without resorting to precise absolute calibration. The expected improvement with respect to COBE-FIRAS in the recovery of distortion parameters (which could in principle be a factor of several hundred for an ideal experiment with the CORE configuration) ranges from a factor of several up to about 50, depending on the quality of foreground removal and relative calibration. Even in the case of similar or equal to 1% accuracy in both foreground removal and relative calibration at an angular scale of 1 degrees, we find that dipole analyses for a mission like CORE will be able to improve the recovery of the CIB spectrum amplitude by a factor similar or equal to 17 in comparison with current results based on COBE-FIRAS. In addition to the scientific potential of a mission like CORE for these analyses, synergies with other planned and ongoing projects are also discussed.Peer reviewe

Exploring Cosmic Origins with CORE: The Instrument

We describe a space-borne, multi-band, multi-beam polarimeter aiming at aprecise and accurate measurement of the polarization of the Cosmic MicrowaveBackground. The instrument is optimized to be compatible with the strict budgetrequirements of a medium-size space mission within the Cosmic Vision Programmeof the European Space Agency. The instrument has no moving parts, and usesarrays of diffraction-limited Kinetic Inductance Detectors to cover thefrequency range from 60 GHz to 600 GHz in 19 wide bands, in the focal plane ofa 1.2 m aperture telescope cooled at 40 K, allowing for an accurate extractionof the CMB signal from polarized foreground emission. The projected CMBpolarization survey sensitivity of this instrument, after foregrounds removal,is 1.7 {\mu}K$\cdot$arcmin. The design is robust enough to allow, if needed, adownscoped version of the instrument covering the 100 GHz to 600 GHz range witha 0.8 m aperture telescope cooled at 85 K, with a projected CMB polarizationsurvey sensitivity of 3.2 {\mu}K$\cdot$arcmin

Exploring cosmic origins with CORE: Gravitational lensing of the CMB

Lensing of the CMB is now a well-developed probe of large-scale clustering over a broad range of redshifts. By exploiting the non-Gaussian imprints of lensing in the polarization of the CMB, the CORE mission can produce a clean map of the lensing deflections over nearly the full-sky. The number of high-S/N modes in this map will exceed current CMB lensing maps by a factor of 40, and the measurement will be sample-variance limited on all scales where linear theory is valid. Here, we summarise this mission product and discuss the science that it will enable. For example, the summed mass of neutrinos will be determined to an accuracy of 17 meV combining CORE lensing and CMB two-point information with contemporaneous BAO measurements, three times smaller than the minimum total mass allowed by neutrino oscillations. In the search for B-mode polarization from primordial gravitational waves with CORE, lens-induced B-modes will dominate over instrument noise, limiting constraints on the gravitational wave power spectrum amplitude. With lensing reconstructed by CORE, one can "delens" the observed polarization internally, reducing the lensing B-mode power by 60%. This improves to 70% by combining lensing and CIB measurements from CORE, reducing the error on the gravitational wave amplitude by 2.5 compared to no delensing (in the null hypothesis). Lensing measurements from CORE will allow calibration of the halo masses of the 40000 galaxy clusters that it will find, with constraints dominated by the clean polarization-based estimators. CORE can accurately remove Galactic emission from CMB maps with its 19 frequency channels. We present initial findings that show that residual Galactic foreground contamination will not be a significant source of bias for lensing power spectrum measurements with CORE. [abridged

Exploring Cosmic Origins with CORE: Survey requirements and mission design

Future observations of cosmic microwave background (CMB) polarisation havethe potential to answer some of the most fundamental questions of modernphysics and cosmology. In this paper, we list the requirements for a future CMBpolarisation survey addressing these scientific objectives, and discuss thedesign drivers of the CORE space mission proposed to ESA in answer to the "M5"call for a medium-sized mission. The rationale and options, and themethodologies used to assess the mission's performance, are of interest toother future CMB mission design studies. CORE is designed as a near-ultimateCMB polarisation mission which, for optimal complementarity with ground-basedobservations, will perform the observations that are known to be essential toCMB polarisation scienceand cannot be obtained by any other means than adedicated space mission