Non-operative Treatment of Advanced Limb Ischaemia: the Decision for Palliative Care

AbstractObjectives: to identify and describe patients with advanced limb ischaemia who were selected for palliative care, rather than surgical intervention. Design: case-note review of patients identified from a prospective register. Materials and methods: thirty patients (22 female; median age 87 years) were identified during 1993–1998, for whom a clearly documented decision was made for palliative care, rather than major amputation or possible revascularisation.Results: two-thirds of the patients had limiting cardiac problems, two-thirds were immobile, and 47% had suffered a stroke. Half had three or more important co-morbidities. Twelve (40%) had unsalvageable acute ischaemia. There were clear records of the decision about non-intervention being made by a consultant in 87%; being discussed with the patient in 43%; and with known relatives in 90%. Survival after this decision ranged from <24 hours to 42 days (median 3.5 days). Conclusion: there is a small subgroup of patients with advanced ischaemia who are best treated palliatively, and who have not been well described before. Recognising these patients, recording discussions about their management, and a high standard of terminal care are all important

Mean flow instabilities of two-dimensional convection in strong magnetic fields

The interaction of magnetic fields with convection is of great importance in astrophysics. Two well-known aspects of the interaction are the tendency of convection cells to become narrow in the perpendicular direction when the imposed field is strong, and the occurrence of streaming instabilities involving horizontal shears. Previous studies have found that the latter instability mechanism operates only when the cells are narrow, and so we investigate the occurrence of the streaming instability for large imposed fields, when the cells are naturally narrow near onset. The basic cellular solution can be treated in the asymptotic limit as a nonlinear eigenvalue problem. In the limit of large imposed field, the instability occurs for asymptotically small Prandtl number. The determination of the stability boundary turns out to be surprisingly complicated. At leading order, the linear stability problem is the linearisation of the same nonlinear eigenvalue problem, and as a result, it is necessary to go to higher order to obtain a stability criterion. We establish that the flow can only be unstable to a horizontal mean flow if the Prandtl number is smaller than order , where B0 is the imposed magnetic field, and that the mean flow is concentrated in a horizontal jet of width in the middle of the layer. The result applies to stress-free or no-slip boundary conditions at the top and bottom of the layer

Submillimeter Studies of Prestellar Cores and Protostars: Probing the Initial Conditions for Protostellar Collapse

Improving our understanding of the initial conditions and earliest stages of protostellar collapse is crucial to gain insight into the origin of stellar masses, multiple systems, and protoplanetary disks. Observationally, there are two complementary approaches to this problem: (1) studying the structure and kinematics of prestellar cores observed prior to protostar formation, and (2) studying the structure of young (e.g. Class 0) accreting protostars observed soon after point mass formation. We discuss recent advances made in this area thanks to (sub)millimeter mapping observations with large single-dish telescopes and interferometers. In particular, we argue that the beginning of protostellar collapse is much more violent in cluster-forming clouds than in regions of distributed star formation. Major breakthroughs are expected in this field from future large submillimeter instruments such as Herschel and ALMA.Comment: 12 pages, 9 figures, to appear in the proceedings of the conference "Chemistry as a Diagnostic of Star Formation" (C.L. Curry & M. Fich eds.

On opportunistic software reuse

The availability of open source assets for almost all imaginable domains has led the software industry toopportunistic design-an approach in which people develop new software systems in an ad hoc fashion by reusing and combining components that were not designed to be used together. In this paper we investigate this emerging approach. We demonstrate the approach with an industrial example in whichNode.jsmodules and various subsystems are used in an opportunistic way. Furthermore, to study opportunistic reuse as a phenomenon, we present the results of three contextual interviews and a survey with reuse practitioners to understand to what extent opportunistic reuse offers improvements over traditional systematic reuse approaches.Peer reviewe

Arterial oxygen content is precisely maintained by graded erythrocytotic responses in settings of high/normal serum iron levels, and predicts exercise capacity: an observational study of hypoxaemic patients with pulmonary arteriovenous malformations.

Oxygen, haemoglobin and cardiac output are integrated components of oxygen transport: each gram of haemoglobin transports 1.34 mls of oxygen in the blood. Low arterial partial pressure of oxygen (PaO2), and haemoglobin saturation (SaO2), are the indices used in clinical assessments, and usually result from low inspired oxygen concentrations, or alveolar/airways disease. Our objective was to examine low blood oxygen/haemoglobin relationships in chronically compensated states without concurrent hypoxic pulmonary vasoreactivity.165 consecutive unselected patients with pulmonary arteriovenous malformations were studied, in 98 cases, pre/post embolisation treatment. 159 (96%) had hereditary haemorrhagic telangiectasia. Arterial oxygen content was calculated by SaO2 x haemoglobin x 1.34/100.There was wide variation in SaO2 on air (78.5-99, median 95)% but due to secondary erythrocytosis and resultant polycythaemia, SaO2 explained only 0.1% of the variance in arterial oxygen content per unit blood volume. Secondary erythrocytosis was achievable with low iron stores, but only if serum iron was high-normal: Low serum iron levels were associated with reduced haemoglobin per erythrocyte, and overall arterial oxygen content was lower in iron deficient patients (median 16.0 [IQR 14.9, 17.4]mls/dL compared to 18.8 [IQR 17.4, 20.1]mls/dL, p<0.0001). Exercise tolerance appeared unrelated to SaO2 but was significantly worse in patients with lower oxygen content (p<0.0001). A pre-defined athletic group had higher Hb:SaO2 and serum iron:ferritin ratios than non-athletes with normal exercise capacity. PAVM embolisation increased SaO2, but arterial oxygen content was precisely restored by a subsequent fall in haemoglobin: 86 (87.8%) patients reported no change in exercise tolerance at post-embolisation follow-up.Haemoglobin and oxygen measurements in isolation do not indicate the more physiologically relevant oxygen content per unit blood volume. This can be maintained for SaO2 ≥78.5%, and resets to the same arterial oxygen content after correction of hypoxaemia. Serum iron concentrations, not ferritin, seem to predict more successful polycythaemic responses

Designing a physical activity parenting course : parental views on recruitment, content and delivery

Background Many children do not engage in sufficient levels of physical activity (PA) and spend too much time screen-viewing (SV). High levels of SV (e.g. watching TV, playing video games and surfing the internet) and low levels of PA have been associated with adverse health outcomes. Parenting courses may hold promise as an intervention medium to change children’s PA and SV. The current study was formative work conducted to design a new parenting programme to increase children’s PA and reduce their SV. Specifically, we focussed on interest in a course, desired content and delivery style, barriers and facilitators to participation and opinions on control group provision. Methods In-depth telephone interviews were conducted with thirty two parents (29 female) of 6–8 year olds. Data were analysed thematically. An anonymous online survey was also completed by 750 parents of 6–8 year old children and descriptive statistics calculated. Results Interview participants were interested in a parenting course because they wanted general parenting advice and ideas to help their children be physically active. Parents indicated that they would benefit from knowing how to quantify their child’s PA and SV levels. Parents wanted practical ideas of alternatives to SV. Most parents would be unable to attend unless childcare was provided. Schools were perceived to be a trusted source of information about parenting courses and the optimal recruitment location. In terms of delivery style, the majority of parents stated they would prefer a group-based approach that provided opportunities for peer learning and support with professional input. Survey participants reported the timing of classes and the provision of childcare were essential factors that would affect participation. In terms of designing an intervention, the most preferred control group option was the opportunity to attend the same course at a later date. Conclusions Parents are interested in PA/SV parenting courses but the provision of child care is essential for attendance. Recruitment is likely to be facilitated via trusted sources. Parents want practical advice on how to overcome barriers and suggest advice is provided in a mutually supportive group experience with expert input

cAMP-Signalling Regulates Gametocyte-Infected Erythrocyte Deformability Required for Malaria Parasite Transmission.

Blocking Plasmodium falciparum transmission to mosquitoes has been designated a strategic objective in the global agenda of malaria elimination. Transmission is ensured by gametocyte-infected erythrocytes (GIE) that sequester in the bone marrow and at maturation are released into peripheral blood from where they are taken up during a mosquito blood meal. Release into the blood circulation is accompanied by an increase in GIE deformability that allows them to pass through the spleen. Here, we used a microsphere matrix to mimic splenic filtration and investigated the role of cAMP-signalling in regulating GIE deformability. We demonstrated that mature GIE deformability is dependent on reduced cAMP-signalling and on increased phosphodiesterase expression in stage V gametocytes, and that parasite cAMP-dependent kinase activity contributes to the stiffness of immature gametocytes. Importantly, pharmacological agents that raise cAMP levels in transmissible stage V gametocytes render them less deformable and hence less likely to circulate through the spleen. Therefore, phosphodiesterase inhibitors that raise cAMP levels in P. falciparum infected erythrocytes, such as sildenafil, represent new candidate drugs to block transmission of malaria parasites