Refractory cachexia and truth-telling about terminal prognosis; A qualitative study

The purpose of this paper is to examine the consequences that medical practitioners’ decisions about whether or not to be candid about terminal prognosis have for those suffering from refractory cachexia and their families. It presents the findings of a qualitative study which used focus groups and semi-structured interviews of a volunteer sample of doctors, nurses and dieticians in a cancer centre of a large teaching hospital in Northern Ireland. Respondents reported that some physicians tended to avoid discussing terminal prognosis in a direct manner with their patients. Nurses and dieticians tended to be reluctant to engage in conversations about weight loss with patients with cachexia. One of the reasons they reported for their lack of acknowledgement of weight loss concerned the close association between refractory cachexia and terminal prognosis. Because they viewed the telling of bad news as an exclusive prerogative of medical practitioners, they did not feel in a position to discuss cachexia because they were concerned that this had the potential to raise end-of-life issues that lay outside the boundaries of their professional role. This meant patients and their families were provided with little information about how to cope with the distressing consequences of cachexia.

Assessment of the impedance cardiogram recorded by an automated external defibrillator during clinical cardiac arrest

OBJECTIVE: To assess the impedance cardiogram recorded by an automated external defibrillator during cardiac arrest to facilitate emergency care by lay persons. Lay persons are poor at emergency pulse checks (sensitivity 84%, specificity 36%); guidelines recommend they should not be performed. The impedance cardiogram (dZ/dt) is used to indicate stroke volume. Can an impedance cardiogram algorithm in a defibrillator determine rapidly circulatory arrest and facilitate prompt initiation of external cardiac massage?

DESIGN: Clinical study.

SETTING: University hospital.

PATIENTS: Phase 1 patients attended for myocardial perfusion imaging. Phase 2 patients were recruited during cardiac arrest. This group included nonarrest controls.

INTERVENTIONS: The impedance cardiogram was recorded through defibrillator/electrocardiographic pads oriented in the standard cardiac arrest position.

MEASUREMENTS AND MAIN RESULTS: Phase 1: Stroke volumes from gated myocardial perfusion imaging scans were correlated with parameters from the impedance cardiogram system (dZ/dt(max) and the peak amplitude of the Fast Fourier Transform of dZ/dt between 1.5 Hz and 4.5 Hz). Multivariate analysis was performed to fit stroke volumes from gated myocardial perfusion imaging scans with linear and quadratic terms for dZ/dt(max) and the Fast Fourier Transform to identify significant parameters for incorporation into a cardiac arrest diagnostic algorithm. The square of the peak amplitude of the Fast Fourier Transform of dZ/dt was the best predictor of reduction in stroke volumes from gated myocardial perfusion imaging scans (range = 33-85 mL; p = .016). Having established that the two pad impedance cardiogram system could detect differences in stroke volumes from gated myocardial perfusion imaging scans, we assessed its performance in diagnosing cardiac arrest. Phase 2: The impedance cardiogram was recorded in 132 "cardiac arrest" patients (53 training, 79 validation) and 97 controls (47 training, 50 validation): the diagnostic algorithm indicated cardiac arrest with sensitivities and specificities (+/- exact 95% confidence intervals) of 89.1% (85.4-92.1) and 99.6% (99.4-99.7; training) and 81.1% (77.6-84.3) and 97% (96.7-97.4; validation).

CONCLUSIONS: The impedance cardiogram algorithm is a significant marker of circulatory collapse. Automated defibrillators with an integrated impedance cardiogram could improve emergency care by lay persons, enabling rapid and appropriate initiation of external cardiac massage.

Use of the impedance cardiogram in public access defibrillators as an indicator of cardiopulmonary resuscitation effectiveness

An algorithm has been developed for a Public Access Defibrillator which utilizes distinctive features from the impedance cardiogram (ICG) recorded via defibrillator pads to advise both lay users and minimally trained bystanders to ensure CPR effectiveness. Following ethical approval, data were collected and marked. CPR was administered by trained personnel. 211 cases were gathered and the training set included 106 cases. A retrospective analysis was carried out of simultaneously recorded ECG and ICG. The speed of compressions was calculated by counting the outstanding waves in the ICG during CPR. Also if the base-to-peak amplitude of the ICG is greater than a minimum threshold, the corresponding compressions were classified as being applied with adequate force. For the validation set, adequate speed was detected with 91.45% sensitivity and 96.27% specificity (79826s) and adequate force with 99.94% sensitivity and 97.91% specificity (91973s). © 2011 CCAL.

Multiple cutout optimization in composite plates using evolutionary structural optimization

The optimization of cutouts in composite plates was investigated by implementing a procedure known as Evolutionary Structural Optimization. Perforations were introduced into a finite element mesh of the plate from which one or more cutouts of a predetermined size were evolved. In the examples presented, plates were rejected from around each evolving cutout based on a predefined rejection criterion. The Limiting ply within each plate element around the cutout was determined based on the Tsai-Hill failure criterion. Finite element plates with values below the product of the average Tsai-Hill number and a rejection criterion were subsequently removed. This process was iterated until a steady state was reached and the rejection criterion was then incremented by an evolutionary rate and the above steps repeated until the desired cutout area was achieved. Various plates with differing lay-up and loading parameters were investigated to demonstrate the generality and robustness of this optimization procedure.

Postbuckling Behaviour of Hat Stiffened Thin Skinned Carbon Fibre Composite Panels

The results of a combined experimental and numerical study of hat-stiffened co-cured carbon-fibre composite panels loaded in uniaxial compression are presented. All panels consisted of two integrated stiffeners separated by an eight-ply thick skin bay of lay-up [*45/0190], . The effects of a 100 mm circular cutout in the skin was also investigated. The ultimate strength of all panels was governed by the load carrying capacity of the stiffeners. A change in the skin's buckling mode-shape was also observed for all panels loaded deep in the postbuckling region. The strains induced at the interior free-edge were not found to be critical. Non-linear finite element results correlated well with the prebuckling and initial postbuckling strain and displacements results obtained by experiment.

From hyperactive children to ADHD adults:Observations on the expansion of medical categories

Medicalization is by definition, about the extension of medical boundaries. Analogous to "domain expansion," extant medicalized categories can expand to become broader and more inclusive. This paper examines the emergence of Attention Deficit Hyperactivity Disorder (ADHD) in adults. ADHD, commonly known as Hyperactivity, became established in the 1970s as a diagnosis for children; it expanded first to include "adult hyperactives" and, in the 1990s, "ADHD Adults." This allowed for the inclusion of an entire population of people and their problems that were excluded by the original conception of hyperactive children. We show how lay, professional, and media claims help establish the expanded diagnostic category. We identify particular aspects of the social context that contributed to the rise of adult ADHD and outline some of the social implications of ADHD in adults, especially the medicalization of underperformance and the availability of new disability rights. Adult ADHD serves as an exemplar of several cases of diagnostic expansion, an important avenue of increasing medicalization.

Uses of expertise:Sources, quotes, and voice in the reporting of genetics in the news

Science journalists call upon experts for background and for clarification and comment on scientific findings. This paper examines how science writers choose and use experts, and it focuses on several cases of reporting about genetics and behavior. Our research included two sources of data: interviews with 15 science reporters and three print media samples of coverage of genetics and behavior - alcoholism (between 1980-1995), homosexuality (in 1993 and 1995), and mental illness (between 1970-1995). Science reporters seek relevant and specific experts for nearly every story. Good sources are knowledgeable, are connected to prestigious institutions, are direct and articulate and don't overqualify statements, and they return phone calls. The mean number of experts quoted was 2.8 per story, differing for alcoholism (3.5), homosexuality (2.8), and mental illness (2.6). Researchers and scientists predominated among experts quoted. Quotes were used to provide context, give legitimization, as explication, to provide a kind of balance, and to outline implications. For the homosexuality sample, a significantly greater percentage of activists and advocates were quoted (21 percent compared with 5 percent and 1 percent in other samples, X <0.0001). "Lay" quotes for alcoholism and mental illness were minimal. Except for homosexuality, whose advocates are organized, those "affected" do not have a voice in genetics news stories.

Assessing the need for and potential role of a day hospice:A qualitative study

We conducted a qualitative case study as part of a needs assessment for a day hospice in a small Ontario city. Data were gathered from semi-structured interviews with 28 stakeholders: nine health care administrators, 11 health care providers, and eight lay people (terminally ill adults and informal caregivers). Respondents described support, counselling, social activities, and respite as key day hospice services. They also described several barriers to accessing services, including location, transportation, admission criteria, referrals, and fees. For most respondents, the ideal staff mix includes both volunteers and paid professionals in either a free-standing organization or institutionally linked hospice. Although the vast majority of participants were reluctant to impose admission criteria or other limitations on hospice clientele, they expressed the need to ensure equitable access to this scarce resource. Opinions varied greatly across stakeholder groups, highlighting the need to collect information from ail relevant stakeholder groups when planning hospices.

Later Pleistocene evolution of the Exe valley: A chronstratigraphic model of terrace formation and its implications for Palaeolithic archaeology

This paper presents the ?rst systematic chronostratigraphic study of the river terraces of the Exe catchment in South West England and a new conceptual model for terrace formation in unglaciated basins with applicability to terrace staircase sequences elsewhere. The Exe catchment lay beyond the maximum extent of Pleistocene ice sheets and the drainage pattern evolved from the Tertiary to the Middle Pleistocene, by which time the major valley systems were in place and downcutting began to create a staircase of strath terraces. The higher terraces (8-6) typically exhibit altitudinal overlap or appear to be draped over the landscape, whilst the middle terraces show greater altitudinal separation and the lowest terraces are of a cut and ?ll form. The terrace deposits investigated in this study were deposited in cold phases of the glacial-interglacial Milankovitch climatic cycles with the lowest four being deposited in the Devensian Marine Isotope Stages (MIS) 4-2. A new cascade process-response model is proposed of basin terrace evolution in the Exe valley, which emphasises the role of lateral erosion in the creation of strath terraces and the reworking of inherited resistant lithological components down through the staircase. The resultant emergent valley topography and the reworking of artefacts along with gravel clasts, have important implications for the dating of hominin presence and the local landscapes they inhabited. Whilst the terrace chronology suggested here is still not as detailed as that for the Thames or the Solent System it does indicate a Middle Palaeolithic hominin presence in the region, probably prior to the late Wolstonian Complex or MIS 6. This supports existing data from cave sites in South West England.

A pilot study of a family focused, psychosocial intervention with war-exposed youth at risk of attack and abduction in north-eastern Democratic Republic of Congo

Rural communities in the Haut-Uele Province of northern Democratic Republic of Congo live in constant danger of attack and/or abduction by units of the Lord's Resistance Army operating in the region. This pilot study sought to develop and evaluate a community-participative psychosocial intervention involving life skills and relaxation training and Mobile Cinema screenings with this war-affected population living under current threat. 159 war-affected children and young people (aged 7-18) from the villages of Kiliwa and Li-May in north-eastern DR Congo took part in this study. In total, 22% of participants had been abduction previously while 73% had a family member abducted. Symptoms of post-traumatic stress reactions, internalising problems, conduct problems and pro-social behaviour were assessed by blinded interviewers at pre- and post-intervention and at 3-month follow-up. Participants were randomised (with an accompanying caregiver) to 8 sessions of a group-based, community-participative, psychosocial intervention (n=79) carried out by supervised local, lay facilitators or a wait-list control group (n=80). Average seminar attendance rates were high: 88% for participants and 84% for caregivers. Drop-out was low: 97% of participants were assessed at post-intervention and 88% at 3 month follow-up. At post-test, participants reported significantly fewer symptoms of post-traumatic stress reactions compared to controls (Cohen's d=0.40). At 3 month follow up, large improvements in internalising symptoms and moderate improvements in pro-social scores were reported, with caregivers noting a moderate to large decline in conduct problems among the young people. Trial Registration clinicalTrials.gov, Identifier: NCT01542398.

Implementation of a non-orthogonal model for the finite element simulation of textile composite draping

In the pursuit of producing high quality, low-cost composite aircraft structures, out-of-autoclave manufacturing processes for textile reinforcements are being simulated with increasing accuracy. This paper focuses on the continuum-based, finite element modelling of textile composites as they deform during the draping process. A non-orthogonal constitutive model tracks yarn orientations within a material subroutine developed for Abaqus/Explicit, resulting in the realistic determination of fabric shearing and material draw-in. Supplementary material characterisation was experimentally performed in order to define the tensile and non-linear shear behaviour accurately. The validity of the finite element model has been studied through comparison with similar research in the field and the experimental lay-up of carbon fibre textile reinforcement over a tool with double curvature geometry, showing good agreement.

Identifying solutions to increase participation in physical activity interventions within a socio-economically disadvantaged community: a qualitative study

Background: There is an urgent need to increase population levels of physical activity, particularly amongst those who are socio-economically disadvantaged. Multiple factors influence physical activity behaviour but the generalisability of current evidence to such ‘hard-to-reach’ population subgroups is limited by difficulties in recruiting them into studies. Also, rigorous qualitative studies of lay perceptions and perceptions of community leaders about public health efforts to increase physical activity are sparse. We sought to explore, within a socio-economically disadvantaged community, residents’ and community leaders’ perceptions of physical activity (PA) interventions and issues regarding their implementation, in order to improve understanding of needs, expectations, and social/environmental factors relevant to future interventions.

Methods: Within an ongoing regeneration project (Connswater Community Greenway), in a socio-economically disadvantaged community in Belfast, we collaborated with a Community Development Agency to purposively sample leaders from public- and voluntary-sector community groups and residents. Individual semi-structured interviews were conducted with 12 leaders. Residents (n=113), of both genders and a range of ages (14 to 86 years) participated in focus groups (n=14) in local facilities. Interviews and focus groups were recorded, transcribed verbatim and analysed using a thematic framework.

Results: Three main themes were identified: awareness of PA interventions; factors contributing to intervention effectiveness; and barriers to participation in PA interventions. Participants reported awareness only of interventions in which they were involved directly, highlighting a need for better communications, both inter- and intra-sectoral, and with residents. Meaningful engagement of residents in planning/organisation, tailoring to local context, supporting volunteers, providing relevant resources and an ‘exit strategy’ were perceived as important factors related to intervention effectiveness. Negative attitudes such as apathy, disappointing experiences, information with no perceived personal relevance and limited access to facilities were barriers to people participating in interventions.

Conclusions: These findings illustrate the complexity of influences on a community’s participation in PA interventions and support a social-ecological approach to promoting PA. They highlight the need for cross-sector working, effective information exchange, involving residents in bottom-up planning and providing adequate financial and social support. An in-depth understanding of a target population’s perspectives is of key importance in translating PA behaviour change theories into practice.

Multilayered glass fibre-reinforced composites in rotational moulding

The potential of multiple layer fibre-reinforced mouldings is of growing interest to the rotational moulding industry because of their cost/performance ratio. The particular problem that arises when using reinforcements in this process relate to the fact that the process is low shear and good mixing of resin and reinforcement is not optimum under those conditions. There is also a problem of the larger/heavier reinforcing agents segregating out of the powder to lay up on the inner part surface. In this study, short glass fibres were incorporated and distributed into a polymer matrix to produce fibre-reinforced polymer composites using the rotational moulding process and characterised in terms of morphology and mechanical properties. © 2011 American Institute of Physics.

Detection of cardiac arrest using a simplified frequency analysis of the impedance cardiogram recorded from defibrillator pads

An algorithm based only on the impedance cardiogram (ICG) recorded through two defibrillation pads, using the strongest frequency component and amplitude, incorporated into a defibrillator could determine circulatory arrest and reduce delays in starting cardiopulmonary resuscitation (CPR). Frequency analysis of the ICG signal is carried out by integer filters on a sample by sample basis. They are simpler, lighter and more versatile when compared to the FFT. This alternative approach, although less accurate, is preferred due to the limited processing capacity of devices that could compromise real time usability of the FFT. These two techniques were compared across a data set comprising 13 cases of cardiac arrest and 6 normal controls. The best filters were refined on this training set and an algorithm for the detection of cardiac arrest was trained on a wider data set. The algorithm was finally tested on a validation set. The ICG was recorded in 132 cardiac arrest patients (53 training, 79 validation) and 97 controls (47 training, 50 validation): the diagnostic algorithm indicated cardiac arrest with a sensitivity of 81.1% (77.6-84.3) and specificity of 97.1% (96.7-97.4) for the validation set (95% confidence intervals). Automated defibrillators with integrated ICG analysis have the potential to improve emergency care by lay persons enabling more rapid and appropriate initiation of CPR and when combined with ECG analysis they could improve on the detection of cardiac arrest.

Supplementary feeding increases Common Buzzard Buteo buteo productivity but only in poor-quality habitat

Temporal heterogeneity in the effects of food supply during the breeding season on the productivity of the Common Buzzard Buteo buteo was investigated in a supplementary feeding experiment. Pairs were fed artificially (1) before egg-laying, (2) after chicks hatched and (3) continuously throughout the season, and compared with (4) unfed controls. Pairs fed before egg-laying had marginally larger clutches than those not fed, but lay date, egg volume and weight, brood size and hatching success were unaffected. Territorial quality had far greater effects, with pairs nesting in low-quality habitats (bog, scrub and semi-natural grassland) laying later and having lower hatching success, smaller broods and fewer fledglings than those in more productive agricultural landscapes. Supplementary feeding after egg hatching neutralized the negative effect of poor habitat, resulting in fed birds having significantly more fledglings. This study emphasizes the importance of food availability when provisioning chicks in suboptimal habitats and has implications for the success of diversionary feeding in reducing game losses to Buzzards.