The challenge of patients’ unmet palliative care needs in the final stages of chronic illness.

Background: There is consensus in the literature that the end of life care for patients with chronic illness is suboptimal, but research on the specific needs of this population is limited. Aim: This study aimed to use a mixed methodology and case study approach to explore the palliative care needs of patients with a non-cancer diagnosis from the perspectives of the patient, their significant other and the clinical team responsible for their care. Patients (n 18) had a diagnosis of either end-stage heart failure, renal failure or respiratory disease. Methods: The Short Form 36 and Hospital and Anxiety and Depression Questionnaire were completed by all patients. Unstructured interviews were (n 35) were conducted separately with each patient and then their significant other. These were followed by a focus group discussion (n 18) with the multiprofessional clinical team. Quantitative data were analysed using simple descriptive statistics and simple descriptive statistics. All qualitative data were taped, transcribed and analysed using Colaizzi’s approach to qualitative analysis. Findings: Deteriorating health status was the central theme derived from this analysis. It led to decreased independence, social isolation and family burden. These problems were mitigated by the limited resources at the individual’s disposal and the availability of support from hospital and community services. Generally resources and support were perceived as lacking. All participants in this study expressed concerns regarding the patients’ future and some patients described feelings of depression or acceptance of the inevitability of imminent death. Conclusion: Patients dying from chronic illness in this study had many concerns and unmet clinical needs. Care teams were frustrated by the lack of resources available to them and admitted they were ill-equipped to provide for the individual’s holistic needs. Some clinicians described difficulty in talking openly with the patient and family regarding the palliative nature of their treatment. An earlier and more effective implementation of the palliative care approach is necessary if the needs of patients in the final stages of chronic illness are to be adequately addressed. Pa

‘Ghosts in the Head and Ghost Towns in the Field: Ethnography and the Experience of Presence and Absence’

This article is about an anthropologist coming to terms with the field and fieldwork. In 1995, I left – was evacuated from – my fieldsite as a volcanic eruption started just as my period of fieldwork drew to a close. These eruptions dramatically and instantaneously altered life on the island of Montserrat, a British colony in the Caribbean. While Montserrat the land, and Montserratians the people, migrated and moved on with their lives, Montserrat and Montserratians were preserved in my mind and in my anthropological writings as from “back home.” Revisiting Montserrat several years into the volcano crisis, I drove through the villages and roads leading to the former capital of the island, where I had worked from. My route to this modern-day Pompeii threw up a stark contrast between absence and presence, the imagined past and the experienced present. This is understood, in part, by examining the literary work of two other travelers through Montserrat, Henry Coleridge and Pete McCarthy, both of whom have a very different experience of the place and the people.

Do environmental and task characteristics matter in the control of externalized local public services? Unveiling the relevance of party characteristics and citizens’ offstage voice

Purpose: The purpose of this paper is to investigate the mechanisms adopted by cities to control the provision of externalized public services and to explore the determinants of such control choices.

Design/methodology/approach: The paper presents the results of a multiple case study based on the experiences of three cities and three public services (transport, solid waste collection and home care services for the elderly), where control mechanisms and their possible antecedents were analyzed.

Findings: The results show that the control models found in the cases analyzed do not correspond to the "pure" patterns described in the private sector literature and that the factors identified by management control contributions do not seem to be exhaustive in explaining the configuration of control systems in the public sector. While environmental and task characteristics only partially explain the adoption of certain configurations of control, the features of the control systems seem to be rather influenced by variables that are related to party characteristics.

Originality/value: The paper shows that the combinations of control mechanisms are more multifaceted than those presented in the literature, and that the factors identified in the private sector literature do not seem to explain comprehensively the configuration of control systems in the public sector. © Emerald Group Publishing Limited.

Refractory asthma in the UK: cross-sectional findings from a UK multicentre registry

Introduction: Refractory asthma represents a significant unmet clinical need where the evidence base for the assessment and therapeutic management is limited. The British Thoracic Society (BTS) Difficult Asthma Network has established an online National Registry to standardise specialist UK difficult asthma services and to facilitate research into the assessment and clinical management of difficult asthma.
Methods: Data from 382 well characterised patients, who fulfilled the American Thoracic Society definition for refractory asthma attending four specialist UK centres—Royal Brompton Hospital, London, Glenfield Hospital, Leicester, University Hospital of South Manchester and Belfast City Hospital—were used to compare patient demographics, disease characteristics and healthcare utilisation.
Results: Many demographic variables including gender, ethnicity and smoking prevalence were similar in UK centres and consistent with other published cohorts of refractory asthma. However, multiple demographic factors such as employment, family history, atopy prevalence, lung function, rates of hospital admission/unscheduled healthcare visits and medication usage were different from published data and significantly different between UK centres. General linear modelling with unscheduled healthcare visits, rescue oral steroids and hospital admissions as dependent variables all identified a significant association with clinical centre; different associations were identified when centre was not included as a factor.
Conclusion: Whilst there are similarities in UK patients with refractory asthma consistent with other comparable published cohorts, there are also differences, which may reflect different patient populations. These differences in important population characteristics were also identified within different UK specialist centres. Pooling multicentre data on subjects with refractory asthma may miss important differences and potentially confound attempts to phenotype this population.

Four independent gene phylogenies confirm the ancient relationships of Madagascar endemic species in the Papilio demoleus group (Lepidoptera, Papilionidae).

Madagascar is home to numerous endemic species and lineages, but the processes that have contributed to its endangered diversity are still poorly understood. Evidence is accumulating to demonstrate the importance of Tertiary dispersal across varying distances of oceanic barriers, supplementing vicariance relationships dating back to the Cretaceous, but these hypotheses remain tentative in the absence of well-supported phylogenies. In the Papilio demoleus group of swallowtail butterflies, three of the five recognized species are restricted to Madagascar, whereas the remaining two species range across the Afrotropical zone and southern Asia plus Australia. We reconstructed phylogenetic relationships for all species in the P. demoleus group, as well as 11 outgroup Papilio species, using 60 morphological characters and about 4 kb of nucleotide sequences from two mitochondrial (cytochrome oxidase I and II) and two nuclear (wg and EF-1a) genes. Of the three endemic Malagasy species, the two that are formally listed as endangered or at risk represented the most basal divergences in the group, while the more common third endemic was clearly related to African P. demodocus. The fifth species, P. demoleus, showed little differentiation across southern Asia, but showed divergence from its subspecies sthenelus in Australia. Dispersal-vicariance analysis using cladograms derived from morphology and three independent genes indicated a Malagasy diversification of lime swallowtails in the middle Miocene. Thus, diversification processes on the island of Madagascar may have contributed to the origin of common butterflies that now occur throughout much of the Old World tropical and subtemperate regions. An alternative hypothesis, that Madagascar is a refuge for ancient lineages resulting from successive colonizations from Africa, is less parsimonious and does not explain the relatively low continental diversity of the group.

Autopoiesis and the Home Confined Consumer: The Role of Personal Communities

Purpose – The purpose of this paper is to explore the consumption of a personal community and its role in the everyday life of the home-confined consumer. Design/methodology/approach – Using a Radical Constructivist approach, three cases of home confinement were explored in depth over a period of two years. Ongoing “conversations” captured the consumption experiences with personal communities. Findings – In relation to the home-confined context, the ability to attain individuality, empowerment and creativity are all heightened as a result of personal community construction. An underlying concern for home-confined consumers is their removal from independent living to institutionalized living, and, as a result the need to construct, manage and maintain a personal community is of major concern. Research limitations/implications – Although the study addresses a home-confined context, it is nevertheless reflective of concerns that are significant to all consumers, namely the attainment of individuality and independence irrespective of marginalization or not. Practical implications – The importance of a personal community in terms of both self-empowerment and self-identity with respect to marginalized groups and vulnerable individuals should not be underestimated. The supporting role of a personal community provides, in times of uncertainty, a framework to maintain self-identity and independence. Originality/value – This paper provides a better understanding of the role of a personal community in the consumption experiences of those consumers marginalized and vulnerable as a consequence of context. Home-confined consumers are “invisible” in the marketplace and the personal community is a means of redressing this imbalance by empowering such individuals.

Decadence in the Forest: Smyth's Der Wald in its Critical Context

Ethel Smyth’s opera, Der Wald, met with mixed reactions at its premiere in Berlin in 1902. Many factors contributed to this, not least, as Smyth herself observed, anti-British sentiment in Germany following the second Boer War. One might have expected that the reception of the opera at its British premiere on 18 July at Covent Garden might have been more positive, but even here critical opinion was divided. Even positive reviews were not free from gender discrimination, and other reviews condemned the opera for being too German or Wagnerian. What was meant by ‘Wagnerian’? This article answers the question in three ways. Firstly, I argue that ‘Wagnerian’ meant not a leitmotif-filled, through-composed work (as distinct from a number opera), but simply a lyrical drama; for British audiences the model for this was Tannhäuser or Lohengrin, not the Ring or Tristan. Secondly, taking this definition on board, I analyse the musical language of the opera, in particular the key structure. The central duet sung by the doomed lovers, Heinrich and Röschen, is in F major, almost the furthest possible distance from the home key of the opera (E major), which characterizes the forest and ‘nature’ in general; by contrast, the next scene, where the Kundry-like Iolanthe attempts to seduce Heinrich (a crucial reversal of the more conventional power relations of the love duet), sees a return to the home key. Thirdly, I set the hermeneutical implications of this reversal in the context of the decadent movement, with which late nineteenth-century Wagnerism was associated, and which, following the conviction of Oscar Wilde in 1895, was discredited. Der Wald thus failed because of its ‘guilt by association’ with an aesthetic that had fallen into disrepute.

Living arrangements, relationship to people in the household and admission to care homes for older people

Objective: to assess the separate contributions of marital status, living arrangements and the presence of children to subsequent admission to a care home.

Design and methods: a longitudinal study derived from the health card registration system and linked to the 2001 Census, comprising 28% of the Northern Ireland population was analysed using Cox regression to assess the likelihood of admission for 51,619 older people in the 6 years following the census. Cohort members’ age, sex, marital and health status and relationship to other household members were analysed.

Results: there were 2,138 care home admissions; a rate of 7.4 admissions per thousand person years. Those living alone had the highest likelihood of admission [hazard ratio (HR) compared with living with partner 1.66 (95% CI 1.48, 1.87)] but there was little difference between the never-married and the previously married. Living with children offered similar protection as living with a partner (HR 0.97; 95% CI 0.81, 1.16). The presence of children reduced admissions especially for married couples (HR 0.67 95% CI 0.54, 0.83; models adjusting for age, gender and health). Women were more likely to be admitted, though there were no gender differences for people living alone or those co-habiting with siblings.

Implications: presence of potential caregivers within the home, rather than those living elsewhere, is a major factor determining admission to care home. Further research should concentrate on the health and needs of these co-residents.

Nostalgically Man dwells on this Earth: Objects and domestic space in The Royal Tenenbaums and The Darjeeling Ltd

The films of Wes Anderson feature a peculiar attention to the representation of dwellings in relation to narrative development, filmic style and characters' identities. As is true of clothing, in Anderson's cinema homes with their architecture, furniture and objects strongly contribute to a nostalgic dislocation of the characters from contemporary time. Considering the house as the prime locus of identity and the core of the patriarchal family, the family home is often depicted by Anderson as the last physical trace left by the absent father; a utopian place that the characters aim to rebuild or to recall through its objectification. This paper aims to analyse the (re)construction of the family home in The Royal Tenenbaums, and will investigate its absence and surrogates in The Darjeeling Ltd.

Relative metabolomic flux: Predicting changes in the environmental metabolome from the metagenome

Background: The world's oceans are home to a diverse array of microbial life whose metabolic activity helps to drive the earth's biogeochemical cycles. Metagenomic analysis has revolutionized our access to these communities, providing a system-scale perspective of microbial community interactions. However, while metagenome sequencing can provide useful estimates of the relative change in abundance of specific genes and taxa between environments or over time, this does not investigate the relative changes in the production or consumption of different metabolites.
Results: We propose a methodology, Predicted Relative Metabolic Turnover (PRMT) that defines and enables exploration of metabolite-space inferred from the metagenome. Our analysis of metagenomic data from a time-series study in the Western English Channel demonstrated considerable correlations between predicted relative metabolic turnover and seasonal changes in abundance of measured environmental parameters as well as with observed seasonal changes in bacterial population structure.
Conclusions: The PRMT method was successfully applied to metagenomic data to explore the Western English Channel microbial metabalome to generate specific, biologically testable hypotheses. Generated hypotheses linked organic phosphate utilization to Gammaproteobactaria, Plantcomycetes, and Betaproteobacteria, chitin degradation to Actinomycetes, and potential small molecule biosynthesis pathways for Lentisphaerae, Chlamydiae, and Crenarchaeota. The PRMT method can be applied as a general tool for the analysis of additional metagenomic or transcriptomic datasets.

Responsive homes of old Cairo:Learning from the past, feeding in the future

This is a working paper published in On-line E-book

Accuracy of LightCycler® SeptiFast for the detection and identification of pathogens in the blood of patients with suspected sepsis: a systematic review protocol

Background: There is growing interest in the potential utility of molecular diagnostics in improving the detection of life-threatening infection (sepsis). LightCycler® SeptiFast is a multipathogen probebased real-time PCR system targeting DNA sequences of bacteria and fungi present in blood samples within a few hours. We report here the protocol of the first systematic review of published clinical diagnostic accuracy studies of this technology when compared with blood culture in the setting of suspected sepsis. Methods/design: Data sources: the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment Database (HTA), the NHS Economic Evaluation Database (NHSEED), The Cochrane Library, MEDLINE, EMBASE, ISI Web of Science, BIOSIS Previews, MEDION and the Aggressive Research Intelligence Facility Database (ARIF). Study selection: diagnostic accuracy studies that compare the real-time PCR technology with standard culture results performed on a patient's blood sample during the management of sepsis. Data extraction: three reviewers, working independently, will determine the level of evidence, methodological quality and a standard data set relating to demographics and diagnostic accuracy metrics for each study. Statistical analysis/data synthesis: heterogeneity of studies will be investigated using a coupled forest plot of sensitivity and specificity and a scatter plot in Receiver Operator Characteristic (ROC) space. Bivariate model method will be used to estimate summary sensitivity and specificity. The authors will investigate reporting biases using funnel plots based on effective sample size and regression tests of asymmetry. Subgroup analyses are planned for adults, children and infection setting (hospital vs community) if sufficient data are uncovered. Dissemination: Recommendations will be made to the Department of Health (as part of an open-access HTA report) as to whether the real-time PCR technology has sufficient clinical diagnostic accuracy potential to move forward to efficacy testing during the provision of routine clinical care.