General practitioners' reasons for removing patients from their lists: postal survey in England and Wales

The removal of patients from doctors' lists causes con­ siderable public and political concern, with speculation that patients are removed for inappropriate, including financial, reasons. In 1999 the House of Commons Select Committee on Public Administration noted that little evidence was available on either the frequency of, or the reasons for, removal of patients. National statistics do not distinguish between patients removed after moving out of a practice area and those removed for other reasons. Two postal surveys have reported why general practitioners might, in general, remove patients, and one small study has described the reasons doctors give for particular removals. We therefore determined the current scale of, and doctors' reasons for, removal of patients from their lists in Eng­ land and Wales

Inconsistent evidence: Analysis of six national guidelines for vaginal birth after cesarean section

Background: Guidelines are increasingly used to direct clinical practice, with the expectation that they improve clinical outcomes and minimize health care expenditure. Several national guidelines for vaginal birth after cesarean section (VBAC) have been released or updated recently, and their range has created dilemmas for clinicians and women. The purpose of this study was to summarize the recommendations of existing guidelines and assess their quality using a standardized and validated instrument to determine which guidelines, if any, are best able to guide clinical practice. Methods: English language guidelines on VBAC were purposively selected from national and professional organizations in the United Kingdom, United States, Canada, New Zealand, and Australia. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was applied to each guideline, and each was analyzed to determine the range and level of evidence on which it was based and the recommendations made. Results: Six guidelines published or updated between 2004 and 2007 were examined. Only two of the six guidelines scored well overall using the AGREE instrument, and the evidence used demonstrated great variety. Most guidelines cited expert opinion and consensus as evidence for some recommendations. Reported success rates for VBAC ranged from 30 to 85 percent, and reported rates of uterine rupture ranged from 0 to 2.8 percent. Conclusions: VBAC guidelines are characterized by quasi-experimental evidence and consensus-based recommendations, which lead to wide variability in recommendations and undermine their usefulness in clinical practice. © 2010, Copyright the Authors. © 2010, Wiley Periodicals, Inc

A Hydrogen-Poor Superluminous Supernova with Enhanced Iron-Group Absorption: A New Link Between SLSNe and Broad-Lined Type Ic SNe

We present optical observations of the Type I superluminous supernova (SLSN-I) SN2017dwh at $z\!\approx\!0.13$, which reached $M_{i}\!\approx\!-21$ mag at peak. Spectra taken a few days after peak show an unusual and strong absorption line centered near 3200\AA\ that we identify with Co II, suggesting a high fraction of synthesized $^{56}$Ni in the ejecta. By $\sim\!1$ month after peak, SN2017dwh became much redder than other SLSNe-I, instead strongly resembling broad-lined Type Ic supernovae (Ic-BL SNe) with clear suppression of the flux redward of $\sim\!5000$ \AA, providing further evidence for a large mass of Fe-group elements. Late-time upper limits indicate a $^{56}$Ni mass of $\lesssim 0.6$ M$_\odot$, leaving open the possibility that SN2017dwh produced a $^{56}$Ni mass comparable to SN1998bw ($\approx\!0.4$ M$_\odot$). Fitting the light curve with a combined magnetar and $^{56}$Ni model using ${\tt MOSFiT}$, we find that the light curve can easily accommodate such masses without affecting the inferred magnetar parameters. We also find that SN2017dwh occurred in the least-luminous detected host galaxy to date for a SLSN-I, with $M_{B} = -13.5$ mag and an implied metallicity of $Z\!\sim\!0.08$ $Z_\odot$. The spectral properties of SN2017dwh provide new evidence linking SLSNe-I with Type Ic-BL SNe, and in particular the high Fe-group abundance may be due to enhanced $^{56}$Ni production or mixing due to asphericity. Finally, we find that SN2017dwh represents the most extreme end of a correlation between continuum shape and Co II absorption strength in the near-peak spectra of SLSNe-I, indicating that Fe-group abundance likely accounts for some of the variation in their spectral shapes.Comment: 16 pages, 7 figures, Submitted to Ap

PS16dtm: A Tidal Disruption Event in a Narrow-line Seyfert 1 Galaxy

[Abridged] We present observations of PS16dtm, a luminous transient that occurred at the nucleus of a known Narrow-line Seyfert 1 galaxy hosting a 10$^6$ M$_\odot$ black hole. The transient was previously claimed to be a Type IIn SLSN due to its luminosity and hydrogen emission lines. The light curve shows that PS16dtm brightened by about two magnitudes in ~50 days relative to the archival host brightness and then exhibited a plateau phase for about 100 days followed by the onset of fading in the UV. During the plateau PS16dtm showed no color evolution, maintained a blackbody temperature of 1.7 x 10$^4$ K, and radiated at approximately $L_{Edd}$ of the SMBH. The spectra exhibit multi-component hydrogen emission lines and strong FeII emission, show little evolution with time, and closely resemble the spectra of NLS1s while being distinct from those of Type IIn SNe. Moreover, PS16dtm is undetected in the X-rays to a limit an order of magnitude below an archival X-ray detection of its host galaxy. These observations strongly link PS16dtm to activity associated with the SMBH and are difficult to reconcile with a SN origin or any known form of AGN variability, and therefore we argue that it is a TDE in which the accretion of the stellar debris powers the rise in the continuum and excitation of the pre-existing broad line region, while providing material that obscures the X-ray emitting region of the pre-existing AGN accretion disk. A detailed TDE model fit to the light curve indicates that PS16dtm will remain bright for several years; we further predict that the X-ray emission will reappear on a similar timescale as the accretion rate declines. Finally, we place PS16dtm in the context of other TDEs and find that TDEs in AGN galaxies are an order of magnitude more efficient and reach Eddington luminosities, likely due to interaction of the stellar debris with the pre-existing accretion disk.Comment: 19 pages, 17 figures, Submitted to Ap

A re-examination of the anatomy and systematics of the tomistomine crocodylians from the Miocene of Italy and Malta

Once a much more globally widespread crocodylian clade, Tomistominae is today represented by just one species, Tomistoma schlegelii (the false gharial), restricted to south-east Asia. Although tomistomine fossil occurrences are recognized from the early Eocene (∼55 Ma) onwards, their remains are often incomplete, making appropriate taxonomic classification within the group problematic. This is especially pertinent to several taxa from the Miocene of Europe, which were historically erected from fragmentary remains. Here we re-examine and describe four approximately contemporaneous taxa from Malta and Italy to determine their taxonomy and phylogenetic affinities: Melitosaurus champsoides, Tomistoma calaritanum, Tomistoma gaudense and Tomistoma lyceense. We place them into a phylogenetic analysis for the first time, comprising 70 taxa scored for 244 characters, several of which are revised or novel, and apply a number of character weighting strategies. Whereas ‘Tomistoma lyceense’ is deemed to be an indeterminate tomistomine, a unique combination of features confirms Melitosaurus champsoides, Tomistoma calaritanum and Tomistoma gaudense as three distinct species. These three taxa are recovered as derived tomistomines, with characters such as a posterior maxillary process between the lacrimal and nasal, large supratemporal fenestrae that are wider than long, and the posteromedial alignment of the last three premaxillary teeth, suggesting a close relationship with the approximately contemporaneous European taxa, Tomistoma lusitanica and Gavialosuchus eggenburgensis. It is unlikely that any of these species belong to Tomistoma, with the possibility that they can all be classified under Melitosaurus and Gavialosuchus. However, we retain them in open nomenclature pending reassessment of the remaining European Miocene tomistomines. Our taxonomic and phylogenetic revision helps to elucidate past tomistomine diversity in the Miocene of the Mediterranean region, prior to the group’s extirpation, and is an important first step in resolving the complicated history of European tomistomine systematics

An ultraviolet excess in the superluminous supernova Gaia16apd reveals a powerful central engine

Since the discovery of superluminous supernovae (SLSNe) in the last decade, it has been known that these events exhibit bluer spectral energy distributions than other supernova subtypes, with significant output in the ultraviolet. However, the event Gaia16apd seems to outshine even the other SLSNe at rest-frame wavelengths below $\sim 3000$ \AA. Yan et al (2016) have recently presented HST UV spectra and attributed the UV flux to low metallicity and hence reduced line blanketing. Here we present UV and optical light curves over a longer baseline in time, revealing a rapid decline at UV wavelengths despite a typical optical evolution. Combining the published UV spectra with our own optical data, we demonstrate that Gaia16apd has a much hotter continuum than virtually any SLSN at maximum light, but it cools rapidly thereafter and is indistinguishable from the others by $\sim 10$-15 days after peak. Comparing the equivalent widths of UV absorption lines with those of other events, we show that the excess UV continuum is a result of a more powerful central power source, rather than a lack of UV absorption relative to other SLSNe or an additional component from interaction with the surrounding medium. These findings strongly support the central-engine hypothesis for hydrogen-poor SLSNe. An explosion ejecting $M_{\rm ej} = 4 (0.2/\kappa)$ M$_\odot$, where $\kappa$ is the opacity in cm$^2$g$^{-1}$, and forming a magnetar with spin period $P=2$ ms, and $B=2\times10^{14}$ G (lower than other SLSNe with comparable rise-times) can consistently explain the light curve evolution and high temperature at peak. The host metallicity, $Z=0.18$ Z$_\odot$, is comparable to other SLSNe.Comment: Updated to match accepted version (ApJL

Health utility after emergency medical admission: a cross-sectional survey

Objectives: Health utility combines health related quality of life and mortality to produce a generic outcome measure reflecting both morbidity and mortality. It has not been widely used as an outcome measure in evaluations of emergency care and little is known about the feasibility of measurement, typical values obtained or baseline factors that predict health utility. We aimed to measure health utility after emergency medical admission, to compare health utility to age, gender and regional population norms, and identify independent predictors of health utility. Methods: We selected 5760 patients across three hospitals who were admitted to hospital by ambulance as a medical emergency. The EQ-5D questionnaire was mailed to all who were still alive 30 days after admission. Health utility was estimated by applying tariff values to the EQ-5D responses or imputing a value of zero for those who had died. Multivariable analysis was used to identify independent predictors of health utility at 30 days. Results: Responses were received from 2488 (47.7%) patients, while 541 (9.4%) had died. Most respondents reported some or severe problems with each aspect of health. Mean health utility was 0.49 (standard deviation 0.35) in survivors and 0.45 (0.36) including non-survivors. Some 75% had health utility below their expected value (mean loss 0.32, 95% confidence interval 0.31 to 0.33) and 11% had health utility below zero (worse than death). On multivariable modelling, reduced health utility was associated with increased age and lower GCS, varied according to ICD10 code and was lower among females, patients with recent hospital admission, steroid therapy, or history of chronic respiratory disease, malignancy, diabetes or epilepsy. Conclusions: Health utility can be measured after emergency medical admission, although responder bias may be significant. Health utility after emergency medical admission is poor compared to population norms. We have identified independent predictors or health utility that need to be measured and taken into account in nonrandomized evaluations of emergency care

Explosion of a massive, He-rich star at z=0.16

We present spectroscopic and photometric data of the peculiar SN 2001gh, discovered by the 'Southern inTermediate Redshift ESO Supernova Search' (STRESS) at a redshift z=0.16. SN 2001gh has relatively high luminosity at maximum (M_B = -18.55 mag), while the light curve shows a broad peak. An early-time spectrum shows an almost featureless, blue continuum with a few weak and shallow P-Cygni lines that we attribute to HeI. HeI lines remain the only spectral features visible in a subsequent spectrum, obtained one month later. A remarkable property of SN 2001gh is the lack of significant spectral evolution over the temporal window of nearly one month separating the two spectra. In order to explain the properties of SN 2001gh, three powering mechanism are explored, including radioactive decays of a moderately large amount of 56Ni, magnetar spin-down, and interaction of SN ejecta with circumstellar medium. We favour the latter scenario, with a SN Ib wrapped in a dense, circumstellar shell. The fact that no models provide an excellent fit with observations, confirms the troublesome interpretation of the nature of SN 2001gh. A rate estimate for SN 2001gh-like event is also provided, confirming the intrinsic rarity of these objects.Comment: 11 pages, 8 figures, 3 tables. Accepted by MNRA