Equity, need and access in health care: a mixed methods investigation of specialist palliative care use in relation to age

The equitable provision of care is a core principle of the NHS. Previous research suggests that older cancer patients may be less likely to use specialist palliative care than younger patients, but studies have failed to fully define and measure clinical need. The aim of this study was to examine use of specialist palliative care in relation to age, after controlling for need. I used a mixed methods approach, grounded in a pragmatic philosophy and drawing upon a health capability account of equitable healthcare. I undertook a focused ethnography of three specialist palliative care services, using documentary evidence, observation of meetings, and interviews to investigate conceptualisations of need for care. I derived two models of need. The first ‘aspirational’ model encompassed physical, psychological, social and spiritual care for patients and carers. However, with limited resources, a predominantly physical model of need was applied. Additionally, observations suggested that care may vary in relation to patient characteristics including age. To locate a suitable measure of need, I conducted a systematic literature review and critical and content appraisal of health-related quality of life instruments. I chose the EORTC QLQ-C30 instrument as the indicator of need in a cross-sectional survey of patients and carers, conducted to measure use of specialist palliative care in relation to age. 252 patients and 137 carers attending four outpatient lung cancer clinics participated. 39% received specialist palliative care. Age was not associated with use of specialist palliative care; metastatic disease, global quality of life (‘need’) and the clinic where treatment was provided were. These findings suggest equitable use of specialist palliative care. However, a comprehensive account of equity must consider both use and quality of care. There were some suggestions that, within a resource-limited context, the quality of care may vary. Future equity research should prospectively consider variations in use and quality of specialist palliative care for different patient groups across all care settings, and from diagnosis to death

Developing and testing a generic micro-combined heat and power model for simulations of dwellings and highly distributed power systems

This paper elaborates an approach to the modelling of domestic micro-combined heat and power (μ-CHP) using a building simulation tool that can provide a detailed picture of the environmental performance of both the μ-CHP heating system and the dwelling it serves. The approach can also provide useful data for the modelling of highly distributed power systems (HDPS). At the commencement of the work described in this paper no μ-CHP device model that was compatible with a building simulation tool was available. The development of such a model is described along with its calibration and verification. The simulation tool with the device model was then applied to the analysis of a dwelling with a Stirling engine-based heating system. Different levels of thermal insulation and occupancy types were modelled. The energy and environmental performance of the μ-CHP device was quantified for each case; additionally, the potential for its participation in the control and operation of an HDPS was assessed. Analysis of the simulation results indicated that the parasitic losses associated with the μ-CHP system balance of plant reduced the overall heating system efficiency by up to 40 per cent. Performance deteriorated with increasing levels of insulation in the dwelling, resulting in reduced thermal efficiency and increased cycling, though overall fuel use was reduced. The analysis also indicated that the device was generally available to participate in HDPS control for greater than 90 per cent of the simulation time. The potential length of the participation time ranged from 1 to 800+min and depended upon the state of the μ-CHP system thermal buffer and prevailing heat loads. Probabilities for different participation times and modes were calculated

The shape and dynamics of a heliotropic dusty ringlet in the Cassini Division

The so-called "Charming Ringlet" (R/2006 S3) is a low-optical-depth, dusty ringlet located in the Laplace gap in the Cassini Division. This ringlet is particularly interesting because its radial position varies systematically with longitude relative to the Sun in such a way that the ringlet's geometric center appears to be displaced away from Saturn's center in a direction roughly toward the Sun. In other words, the ringlet is always found at greater distances from the planet's center at longitudes near the sub-solar longitude than it is at longitudes near Saturn's shadow. This "heliotropic" behavior indicates that the dynamics of the particles in this ring are being influenced by solar radiation pressure. In order to investigate this phenomenon, which has been predicted theoretically but has never been observed this clearly, we analyze multiple image sequences of this ringlet obtained by Cassini in order to constrain its shape and orientation. These data can be fit reasonably well with a model in which both the eccentricity and the inclination of the ringlet have "forced" components (that maintain a fixed orientation relative to the Sun) as well as "free" components (that drift around the planet at steady rates determined by Saturn's oblateness). While the magnitude of the forced eccentricity is roughly consistent with theoretical expectations for radiation pressure acting on 10-to-100-micron-wide icy grains, the existence of significant free eccentricities and inclinations poses a significant challenge for models of low-optical-depth dusty rings.Comment: 31 pages, 6 figures, accepted for publication in Icarus. Slight edits made to match various proof correction

Charities and ICTs: Can IS-enabled Innovation in Business Critical Activities Be Delivered?

This article looks at the ways in which a number of charities are leading the United Kingdom’s ‘Third Sector’ in their use of ICT/IS capabilities to deliver innovations in a range of business critical activities. It shows that new ICT/IS capabilities afforded opportunities within different types of charities to deliver change. In the older charities established in the ‘pre-Internet’ era, these shifts tend to work with and reflect the existing ‘enterprise logic’ or established ‘ways of doing’. In the younger ‘Net generation’ organisations, the shifts tend to be more fluid in nature, enabling the delivery of new ways of doing and denoting the more flexible model of organisation upon which they were founded. Our research also shows that, in all of the charities, information and data capture and interrogation are intensifying

Social Cohesion, Structural Holes, and a Tale of Two Measures

EMBARGOED - author can archive pre-print or post-print on any open access repository after 12 months from publication. Publication date is May 2013 so embargoed until May 2014.This is an author’s accepted manuscript (deposited at arXiv arXiv:1211.0719v2 [physics.soc-ph] ), which was subsequently published in Journal of Statistical Physics May 2013, Volume 151, Issue 3-4, pp 745-764. The final publication is available at link.springer.com http://link.springer.com/article/10.1007/s10955-013-0722-

Geology of the Llanidloes district : British Geological Survey Sheet 164

This Sheet Explanation provides a summary of the geology of the district covered by Geological 1:50 000 Series Map Sheet 164 (Llanidloes), published in 2010 as a Bedrock and Superficial Deposits edition. The district mostly lies within the county of Powys, but includes small parts of Ceredigion in the extreme west and south-west. Much of the western part of the district is occupied by the deeply dissected uplands of the Cambrian Mountains, a designated Area of Outstanding Natural Beauty. In this area the land rises to 740 m on the flanks of Plynlimon (Pumlumon Fawr), the highest summit in the range. It falls away towards the eastern part of the district into rolling countryside that includes the important catchment of the River Severn (Afon Hafren) and its tributaries, the largest of which are the rivers Carno, Trannon, Cerist, Clywedog and Dulas. A major reservoir (Llyn Clywedog) occupies the upper reaches of the Clywedog valley, its purpose being to regulate river discharge and groundwater levels within the catchment. The south-western part of the district is drained by the River Wye (Afon Gwy) and its tributaries, that flow south-eastwards via Llangurig. The sources of both the Severn and Wye are situated on the eastern flanks of Plynlimon within the western part of the district. The town of Llanidloes is the main centre of population, with smaller settlements at Llangurig, Carno, Trefeglwys, Caersws and Staylittle; the Newtown conurbation impinges on the eastern part of the district. Much of the district is given over to beef and dairy farming, although sheep are reared in the remote upland areas in the west and extensive forestry plantations have been developed in places. The Ordovician and Silurian rocks of the district have been exploited locally, in the past, as a source of building material and, recently, commercial quantities of sandstone aggregate have been excavated at Penstrowed Quarry [SO 0680 9100]. The district includes part of the Central Wales Mining Field from which substantial volumes of lead and zinc ore were extracted during the 19th and early 20th centuries. A number of former mine sites are still visible, notably along the Van, Nant-y-ricket, Dylife, Dyfngwm and Llanerchyraur lodes (Jones, 1922[1]; IGS, 1974), and the historic Bryntail Mine, below the Clywedog Dam has been restored as a site of industrial archaeological interest. The district is underlain by a succession of Late Ordovician (Ashgill) to Silurian sedimentary rocks, over 5 km thick, deposited between 450 and 420 million years ago in the Early Palaeozoic Welsh Basin (Figure P930911). The basin developed on a fragment of the ancient supercontinent of Gondwana, known as Eastern Avalonia (e.g. Pickering et al., 1988[2]), that drifted northwards to collide with the continents of Baltica and Laurentia during the Late Ordovician and Silurian (Soper and Hutton, 1984[3]; Soper and Woodcock, 1990[4]; Woodcock and Strachan, 2000[5]). To the east and the south of the basin lay the Midland Platform, a relatively stable shallow marine shelf that was subject to periodic emergence. The basinal sediments are predominantly deep marine turbiditic facies that were introduced into the district by density currents from southerly, south-easterly and north-westerly quadrants. Coeval shallower-water ‘shelfal’ sediments were deposited north and east of the district, and locally impinge on its northern margins. Thickness variations within the major sedimentary units suggest that, at times, syndepositional fault movements were an important control on their distribution. During late Silurian (Ludlow) times, shallowing of the basin occurred, and sandstones, variably interpreted as a turbiditic (Cave and Hains, 2001[6]) or storm-generated facies (Tyler and Woodcock, 1987[7]), were laid down over the eastern part of the district and adjacent areas. The shallowing was a result of tectonic reconfiguration of the basin, a precursor to the late Caledonian (Acadian) Orogeny that affected the region during the late Early Devonian, around 400 million years ag

The Dynamics of Small Instanton Phase Transitions

The small instanton transition of a five-brane colliding with one end of the S1/Z2 interval in heterotic M-theory is discussed, with emphasis on the transition moduli, their potential function and the associated non-perturbative superpotential. Using numerical methods, the equations of motion of these moduli coupled to an expanding Friedmann-Robertson-Walker spacetime are solved including non-perturbative interactions. It is shown that the five-brane collides with the end of the interval at a small instanton. However, the moduli then continue to evolve to an isolated minimum of the potential, where they are trapped by gravitational damping. The torsion free sheaf at the small instanton is ``smoothed out'' into a vector bundle at the isolated minimum, thus dynamically completing the small instanton phase transition. Radiative damping at the origin of moduli space is discussed and shown to be insufficient to trap the moduli at the small instanton point.Comment: LaTeX, 23 pages, 7 figures; minor corrections, references adde

Consequences of marine barriers for genetic diversity of the coral-specialist yellowbar angelfish from the Northwestern Indian Ocean

Ocean circulation, geological history, geographic distance, and seascape heterogeneity play an important role in phylogeography of coral‐dependent fishes. Here, we investigate potential genetic population structure within the yellowbar angelfish (Pomacanthus maculosus) across the Northwestern Indian Ocean (NIO). We then discuss our results with respect to the above abiotic features in order to understand the contemporary distribution of genetic diversity of the species. To do so, restriction site‐associated DNA sequencing (RAD‐seq) was utilized to carry out population genetic analyses on P. maculosus sampled throughout the species’ distributional range. First, genetic data were correlated to geographic and environmental distances, and tested for isolation‐by‐distance and isolation‐by‐environment, respectively, by applying the Mantel test. Secondly, we used distance‐based and model‐based methods for clustering genetic data. Our results suggest the presence of two putative barriers to dispersal; one off the southern coast of the Arabian Peninsula and the other off northern Somalia, which together create three genetic subdivisions of P. maculosus within the NIO. Around the Arabian Peninsula, one genetic cluster was associated with the Red Sea and the adjacent Gulf of Aden in the west, and another cluster was associated with the Arabian Gulf and the Sea of Oman in the east. Individuals sampled in Kenya represented a third genetic cluster. The geographic locations of genetic discontinuities observed between genetic subdivisions coincide with the presence of substantial upwelling systems, as well as habitat discontinuity. Our findings shed light on the origin and maintenance of genetic patterns in a common coral reef fish inhabiting the NIO, and reinforce the hypothesis that the evolution of marine fish species in this region has likely been shaped by multiple vicariance events.This work was conducted within the framework of the NPRP project ‘Connectivity, diversity and genetic between offshore natural coral reefs and oil platforms – NPRP No. 7‐1129‐1‐201’, funded by the Qatar National Research Fund (a member of The Qatar Foundation). The statements made herein are solely the responsibility of the authors. F.T. is supported by a CNPq/Brazil fellowship through the program Science without Borders (Proc. 232875/2014‐6). We are also grateful to Filipe Vieira (University of Copenhagen) for his advice on population genetic analyses

The cost effectiveness of immunoglobulin vs. hematopoietic stem cell transplantation for CIDP

Background: Intravenous immunoglobulin (IVIG) is effective as standard first line therapy for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), but some patients remain dependent on its long-term use. Recently, we have reported that autologous non-myeloablative hematopoietic stem cell transplantation (HSCT) is an effective second line therapy for CIDP. Objectives: To compare the cost of chronic IVIG vs. autologous HSCT (a one-time therapy), we collected data on patients with CIDP undergoing HSCT between 2017 and 2019. This was compared with published literature on the costs and efficacy defined by the Inflammatory Neuropathy Cause And Treatment (INCAT) disability score, Medical Research Council (MRC) sum score, hand grip strength, and SF-36 quality of life (QOL) for CIDP. Methods: Between 2017 and 2019, nineteen patients with chronic CIDP (mean disease treatment duration prior to HSCT of 6 years) underwent autologous HSCT with mean cost of $108,577 per patient (range$56,327–277,119, standard deviation $53,092). After HSCT, 80$136,000 per year. Despite remaining treatment free, HSCT demonstrated greater improvement in efficacy compared to immunoglobulins. Recommendations: Given the long-term treatment-free remission and better outcome measurements, autologous HSCT is more cost effective than long-term IVIG treatment in patients with chronic CIDP. However, costs will depend on patient selection, the HSCT regimen, and regional variations. Further analysis of the health economics, i.e., cost/outcome ratio, of HSCT as therapy for chronically IVIG dependent CIDP is warranted

Vector Bundle Moduli and Small Instanton Transitions

We give the general presciption for calculating the moduli of irreducible, stable SU(n) holomorphic vector bundles with positive spectral covers over elliptically fibered Calabi-Yau threefolds. Explicit results are presented for Hirzebruch base surfaces B=F_r. The transition moduli that are produced by chirality changing small instanton phase transitions are defined and specifically enumerated. The origin of these moduli, as the deformations of the spectral cover restricted to the ``lift'' of the horizontal curve of the M5-brane, is discussed. We present an alternative description of the transition moduli as the sections of rank n holomorphic vector bundles over the M5-brane curve and give explicit examples. Vector bundle moduli appear as gauge singlet scalar fields in the effective low-energy actions of heterotic superstrings and heterotic M-theory.Comment: 52 pages, LATEX, corrected typo