Patients who decide to forgo Breast Cancer Treatment: Perspectives and Experiences of Cancer Professionals.

Background: Breast cancer is highly treatable if caught early, yet there are increasing numbers of women who decline treatment entirely, or in favour of alternative therapies. Previous research has demonstrated that such decisions can be troubling for health professionals, creating an ethical dilemma in which the bioethical mandate to respect patient autonomy must be offset against duties to act in the patient’s best interest. Previous research has indicated that health professionals may find it difficult to accept and understand such decisions; however, this research has predominantly focused on the experiences of different health professionals in isolation. Method: Qualitative, semi-structured interviews were carried out with eight oncology health professionals (Three oncologists, two breast surgeons and three clinical nurse specialists) to explore how health professionals understood and responded to these decisions. A critical realist epistemology was adopted and interviews were analysed using thematic analysis. Results: Four overarching themes were identified including ‘Head-Heart Lag’, ‘Tug of War’ ‘You Can’t Win Them All’ and ‘The Power and Privilege of Unbiased Expertise’. Themes yielded insights into how professionals navigate their responsibilities towards patients who decline treatment and the values, frameworks and resources that influence this process. Conclusion: Results indicated that health professionals’ responses were grounded in a commitment to evidence based practice, and that time and experience are important factors in professionals learning to accept a decision to decline breast cancer treatment. Findings are considered in the broader social context of contemporary healthcare and in relation to professional and patient needs. Recommendations are made for a more reflexive medical practice which transcends the constraints of the evidence-based paradigm and liberates health professionals to engage with the existential, as well as the medical within the clinical encounter

The VLT-FLAMES Survey of Massive Stars: Observations centered on the Magellanic Cloud clusters NGC 330, NGC 346, NGC 2004, and the N11 region

We present new observations of 470 stars using the Fibre Large Array Multi-Element Spectrograph (FLAMES) instrument in fields centered on the clusters NGC 330 and NGC 346 in the Small Magellanic Cloud (SMC), and NGC 2004 and the N11 region in the Large Magellanic Cloud (LMC). A further 14 stars were observed in the N11 and NGC 330 fields using the Ultraviolet and Visual Echelle Spectrograph (UVES) for a separate programme. Spectral classifications and stellar radial velocities are given for each target, with careful attention to checks for binarity. In particular we have investigated previously unexplored regions around the central LH9/LH10 complex of N11, finding ~25 new O-type stars from our spectroscopy. We have observed a relatively large number of Be-type stars that display permitted Fe II emission lines. These are primarily not in the cluster cores and appear to be associated with classical Be-type stars, rather than pre main-sequence objects. The presence of the Fe II emission, as compared to the equivalent width of H$\alpha$, is not obviously dependent on metallicity. We have also explored the relative fraction of Be- to normal B-type stars in the field-regions near to NGC 330 and NGC 2004, finding no strong evidence of a trend with metallicity when compared to Galactic results. A consequence of service observations is that we have reasonable time-sampling in three of our FLAMES fields. We find lower limits to the binary fraction of O- and early B-type stars of 23 to 36%. One of our targets (NGC346-013) is especially interesting with a massive, apparently hotter, less luminous secondary component.Comment: 35 pages, 17 figures (some reduced in size). Replacement copy, includes an erratum on the final page. A copy with full res. & embedded figures is at http://www.roe.ac.uk/~cje/flamesMC.ps.g

The Effect of Treatment of Acidosis on Calcium Balance in Patients with Chronic Azotemic Renal Disease

Small but statistically significant negative calcium balances were found in each of eight studies in seven patients with chronic azotemic renal disease when stable metabolic acidosis was present. Only small quantities of calcium were excreted in the urine, but fecal calcium excretion equaled or exceeded dietary intake. Complete and continuous correction of acidosis by NaHCO3 therapy reduced both urinary and fecal calcium excretion and produced a daily calcium balance indistinguishable from zero. Apparent acid retention was found throughout the studies during acidosis, despite no further reduction of the serum bicarbonate concentration. The negative calcium balances that accompanied acid retention support the suggestion that slow titration of alkaline bone salts provides an additional buffer reservoir in chronic metabolic acidosis. The treatment of metabolic acidosis prevented further calcium losses but did not induce net calcium retention. It is suggested that the normal homeostatic responses of the body to the alterations in ionized calcium and calcium distribution produced by raising the serum bicarbonate might paradoxically retard the repair of skeletal calcium deficits

Quantum Backflow States from Eigenstates of the Regularized Current Operator

We present an exhaustive class of states with quantum backflow -- the phenomenon in which a state consisting entirely of positive momenta may have negative current and the probability flows in the opposite direction to the momentum. They are characterized by a general function of momenta subject to very weak conditions. Such a family of states is of interest in the light of a recent experimental proposal to measure backflow. We find one particularly simple state which has surprisingly large backflow -- about 41 percent of the lower bound on flux derived by Bracken and Melloy. We study the eigenstates of a regularized current operator and we show how some of these states, in a certain limit, lead to our class of backflow states. This limit also clarifies the correspondence between the spectrum of the regularized current operator, which has just two non-zero eigenvalues in our chosen regularization, and the usual current operator.Comment: 16 pages, 2 figure

Absolute linear instability in laminar and turbulent gas/liquid two-layer channel flow

We study two-phase stratified flow where the bottom layer is a thin laminar liquid and the upper layer is a fully-developed gas flow. The gas flow can be laminar or turbulent. To determine the boundary between convective and absolute instability, we use Orr--Sommerfeld stability theory, and a combination of linear modal analysis and ray analysis. For turbulent gas flow, and for the density ratio r=1000, we find large regions of parameter space that produce absolute instability. These parameter regimes involve viscosity ratios of direct relevance to oil/gas flows. If, instead, the gas layer is laminar, absolute instability persists for the density ratio r=1000, although the convective/absolute stability boundary occurs at a viscosity ratio that is an order of magnitude smaller than in the turbulent case. Two further unstable temporal modes exist in both the laminar and the turbulent cases, one of which can exclude absolute instability. We compare our results with an experimentally-determined flow-regime map, and discuss the potential application of the present method to non-linear analyses.Comment: 33 pages, 20 figure