The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England [version 2; referees: 2 approved].

Background: The Liverpool Care Pathway for the Dying Patient (‘LCP’) was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care. It was discontinued in 2014 following mounting criticism and a national review. Understanding the problems encountered in the roll out of the LCP has crucial importance for future policy making in end of life care. We provide an in-depth account of LCP development and implementation with explanatory theoretical perspectives. We address three critical questions: 1) why and how did the LCP come to prominence as a vehicle of policy and practice? 2) what factors contributed to its demise? 3) what immediate implications and lessons resulted from its withdrawal? Methods: We use primary and secondary sources in the public domain to assemble a critical and historical review. We also draw on the ‘boundary object’ concept and on wider analyses of the use of ICPs. Results: The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. While the LCP had some weaknesses in its formulation and implementation, it became the bearer of responsibility for all aspects of NHS end-of-life care. It exposed fault lines in the NHS, provided a platform for debates about the ‘evidence’ required to underpin innovations in palliative care and became a conduit of discord about ‘good’ or ‘bad’ practice in care of the dying. It also fostered a previously unseen critique of assumptions within palliative care. Conclusions: In contrast to most observers of the LCP story who refer to the dangers of scaling up clinical interventions without an evidence base, we call for greater assessment of the wider risks and more careful consideration of the unintended consequences that might result from the roll out of new end-of-life interventions

Study of high altitude plume impingement

Computer program has been developed as analytical tool to predict severity of effects of exhaust of rocket engines on adjacent spacecraft surfaces. Program computes forces, moments, pressures, and heating rates on surfaces immersed in or subjected to exhaust plume environments. Predictions will be useful in design of systems where such problems are anticipated

A sample of low energy bursts from FRB 121102

We present 41 bursts from the first repeating fast radio burst discovered (FRB 121102). A deep search has allowed us to probe unprecedentedly low burst energies during two consecutive observations (separated by one day) using the Arecibo telescope at 1.4 GHz. The bursts are generally detected in less than a third of the 580-MHz observing bandwidth, demonstrating that narrow-band FRB signals may be more common than previously thought. We show that the bursts are likely faint versions of previously reported multi-component bursts. There is a striking lack of bursts detected below 1.35 GHz and simultaneous VLA observations at 3 GHz did not detect any of the 41 bursts, but did detect one that was not seen with Arecibo, suggesting preferred radio emission frequencies that vary with epoch. A power law approximation of the cumulative distribution of burst energies yields an index $-1.8\pm0.3$ that is much steeper than the previously reported value of $\sim-0.7$. The discrepancy may be evidence for a more complex energy distribution. We place constraints on the possibility that the associated persistent radio source is generated by the emission of many faint bursts ($\sim700$ ms$^{-1}$). We do not see a connection between burst fluence and wait time. The distribution of wait times follows a log-normal distribution centered around $\sim200$ s; however, some bursts have wait times below 1 s and as short as 26 ms, which is consistent with previous reports of a bimodal distribution. We caution against exclusively integrating over the full observing band during FRB searches, because this can lower signal-to-noise.Comment: Accepted version. 16 pages, 7 figures, 1 tabl

A deep Giant Metre-wave Radio Telescope 610-MHz survey of the 1^HXMM–Newton/Chandra survey field

We present the results of a deep 610-MHz survey of the 1^HXMM–Newton/Chandra survey area with the Giant Metre-wave Radio Telescope. The resulting maps have a resolution of ~7 arcsec and an rms noise limit of 60 μJy. To a 5σ detection limit of 300 μJy, we detect 223 sources within a survey area of 64 arcmin in diameter. We compute the 610-MHz source counts and compare them to those measured at other radio wavelengths. The well-known flattening of the Euclidean-normalized 1.4-GHz source counts below ~2 mJy, usually explained by a population of starburst galaxies undergoing luminosity evolution, is seen at 610 MHz. The 610-MHz source counts can be modelled by the same populations that explain the 1.4-GHz source counts, assuming a spectral index of −0.7 for the starburst galaxies and the steep spectrum active galactic nucleus (AGN) population. We find a similar dependence of luminosity evolution on redshift for the starburst galaxies at 610 MHz as is found at 1.4 GHz (i.e. 'Q'= 2.45^(+0.3)_(−0.4))

Bursting emission from PSR B0611+22

Over the past decade it has become apparent that a class of `bursting pulsars\u27 exist with the discovery of PSR J1752+2359 and PSR J1938+2213. In these pulsars, a sharp increase in the emission is observed that then tends to systematically drop-off from pulse-to-pulse. In this paper we describe the discovery of such a relationship in high-sensitivity observations of the young (characteristic age of 90,000 yrs) 0.33 s pulsar B0611+22 at both 327 MHz and 1400 MHz with the Arecibo radio telescope. While Nowakowski previously showed that B0611+22 has mode-switching properties, the data presented here show, for the first time, that this pulsar emits bursts with characteristic time-scales of several hundred seconds. At 327 MHz, the pulsar shows steady behaviour in one emission mode which is enhanced by bursting emission slightly offset in pulse phase from this steady emission. Contrastingly at 1400 MHz, the two modes appear to behave in a competing operation while still offset in phase. Using a fluctuation spectrum analysis, we also investigate each mode independently for sub-pulse drifting. Neither emission mode (i.e. during bursts or persistent emission) shows the presence of the drifting sub-pulse phenomenon. The bursting phenomena seen here appears to be a hybrid between bursting seen in other pulsars and the bistable profile illumination behaviour reported in two other pulsars by Rankin et al. Further examples of this cross-frequency behaviour are required, as this phenomenon may be quite common among the pulsar population

Cancer patients’ experiences of living with venous thromboembolism: A systematic review and qualitative thematic synthesis

Background: Cancer-Associated thrombosis is common. Recommended treatment is daily injected low-molecular-weight heparin for 6months. Most studies focus on prophylaxis and treatment; few have explored patients’ experience. Aims To identify and synthesise the available literature concerning patients’ experience of cancer associated thrombosis. Design Systematic literature review and qualitative thematic synthesis. MethodsMEDLINE, Embase, CINAHL, PsychINFO (until 10/2016; limited to English) were searched. Eligible papers were qualitative studies of adult patients’ experience of cancer-associated thrombosis. Two researchers screened titles/abstracts/papers against inclusion criteria with recourse to a third for disagreements. Critical Appraisal Skills Programme qualitative checklist tool was used for quality appraisal. Results1397 articles were identified. Five qualitative studies (total n=92; age range 32 to 84 years) met the inclusion criteria. Participants had various cancer types. Most had advanced disease and were receiving palliative care. Four major themes emerged from the data: knowledge deficit (patients and clinicians); effects of cancer associated thrombosis (physical and psychological); effects of anticoagulation; coping strategies. ConclusionThe cancer journey is difficult in itself, but thrombosis was an additional, frightening and unexpected burden. Although the association between cancer and thromboembolism is well known, cancer patients are not educated routinely about the risk or warning symptoms/signs of thromboembolism which may otherwise be misattributed to the cancer by patient and clinician alike. This systematic review highlights the impact of cancer-associated thrombosis on the lives of cancer patients, and calls for education for patients and clinicians to be part of routine care, and further work to address this patient priority

The energetic consequence of specific dynamic action in southern bluefin tuna Thunnus maccoyii

Copyright © 2007 The Company of BiologistsThe effect of feeding on the rate of oxygen consumption (O2) of four groups of three southern bluefin tuna Thunnus maccoyii (SBT) was examined in a large static respirometer at water temperatures of 18.2-20.3°C. Six feeding events of rations between 2.1-8.5% body mass (%Mb) of Australian sardines (Sardinops neopilchardus) were recorded (two of the groups were fed twice). Before feeding, fish swam between 0.71 and 1.4 body lengths s-1 (BL s-1) and the routine metabolic rate (RMR) was 366±32.5 mg kg-1 h-1 (mean ± s.e.m.). For all trials, O2 was elevated post feeding, presumably as a result of specific dynamic action (SDA). Swimming velocity was also elevated post feeding for periods similar to that of O2 (between 20-45 h, longest for the largest rations). Post feeding swimming velocity increased to between 0.87-2.6 BL s-1 and was also dependent on ration consumed. It is suggested that the purpose of increased post-feeding swimming velocity was to increase ventilation volume as a response to the enhanced metabolic demand associated with SDA. Peak post-prandial O2 increased linearly with ration size to a maximum of 1290 mg kg-1 h-1, corresponding to 2.8 times the RMR. When converted to its energy equivalent, total magnitude of SDA was linearly correlated with ration size to a maximum of 192 kJ kg-1 h-1, and as a proportion of gross energy ingested (SDA coefficient), it averaged 35±2.2%. These results demonstrate that, although the factorial increase of SDA in SBT is similar to that of other fish species, the absolute energetic cost of SDA is much higher. These results support the contention that tuna are energy speculators, gambling high rates of energy expenditure for potentially higher rates of energy returns. The ration that southern bluefin tuna require to equal the combined metabolic costs of SDA and RMR is estimated in this study to be 3.5%Mb of Australian sardines per day.Q. P. Fitzgibbon, R. S. Seymour, D. Ellis and J. Buchana