bluuebunny/crossref_metadata_2025 huggingface dataset:
Improving breast and lung cancer services in hospital using experience based co-design (EBCD)
Authors: Wiseman T , Tsianakas V , Maben J , Robert G , Richardson A
Published: May 2011

Background and aims

This project sought to design better experiences for patients and health care staff from the breast and lung cancer services within two large teaching hospitals in England. Experience based co-design (EBCD) was the chosen action research approach.1 EBCD is a new and innovative methodology combining (1) a user-centred orientation (by adopting a narrative storytelling approach) and (2) a participatory, collaborative change process, allowing staff to ‘see the person in the patient’ and placing patient and staff experience at the centre of service development.

Methods and results

The project involved an in-depth qualitative study of how care was delivered by staff and received by patients, focusing on patients' emotional ‘journey’. It included 36 filmed patient narratives, capturing the key emotional ‘touch points’, 60 staff interviews about their experience of providing services, and ethnographic observation of clinical areas. Patient and staff interviews were analysed to identify themes and issues for which were feedback to patients and staff at various group events. For example, a composite 30 min film of breast and lung cancer patients’ experiences, was created and used to feedback patient narratives to staff. Through a facilitated three-stage change process which will be described, patients and staff agreed on joint priorities for improvement and then worked together in co-design groups that focused on identified priority areas (for example information provision, day surgery, continuity of care, diagnosis and outpatient care).

Discussion and conclusions

The paper reflects on lessons learned for improving patient/staff experiences through the use of EBCD. It explores the value of the EBCD approach, the use of narratives, observation and film (excerpts will be shown) as a way of humanising health care and engaging staff and patients in a change process to facilitate meaningful and lasting improvements in service provision.
Introducing an electronic palliative care summary: patient, carer and professional perspectives
Authors: Hall S , Campbell C , Kiehlman P , Murchie P , Murray S A
Published: May 2011

Introduction and aims

The electronic Palliative Care Summary (ePCS) is being introduced throughout Scotland to provide out of hours (OOH) staff with up to date records of medications, decisions regarding treatment and health status of patients requiring palliative care. Automatic twice-daily updates of information from General Practitioner (GP) records to a central electronic repository are available to OOH services. We sought to identify key issues related to the introduction of ePCS from primary care and OOH staff, to identify facilitators and barriers to its use, to explore the experiences of patients and carers, and to make recommendations for improvements.

Methods

Semi-structured interviews were carried out with a purposive sample of GPs from practices using different computing software systems; out-of-hours GPs; and patients (and/or their carer) for whom an ePCS had been completed. Interviews were digitally recorded with consent, transcribed and analysed thematically.

Results

Patients and carers were reassured that OOH staff were informed about their current circumstances. OOH staff considered the ePCS allowed them to be better informed in decision–making and in carrying out home visits. GPs viewed the introduction of ePCSs to have benefits for in-hours structures of care such as advance care planning. No interviewee expressed concern about loss of confidentiality. Barriers raised related mainly to the introduction of a new technology including unfamiliarity with the process, limited time and IT skills.

Conclusions

The ePCS has the potential to improve patient care. Training in ePCS completion and updating should be available for all GPs and community nurses.
Improving care and support for people with progressive illness in primary care
Authors: Harrison N , Cavers D , Campbell C , Murray S A
Published: May 2011

Introduction and aims

The Palliative Care Directed Enhanced Service (DES) was introduced in Scotland in 2008/2009 to stimulate anticipatory care by GP practice teams. We aimed to evaluate how practices were implementing this by assessing how they were

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identifying patients for their palliative care register (PCR),

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assessing/reviewing needs,

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sharing information with out of hours (OOH) providers,

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using the Liverpool Care Pathway (LCP).

Methods

Six practices were recruited from three Scottish Health Boards. Data were collected on current palliative care patients and on patients dying in the previous 6 months; semi-structured interviews were conducted with GPs, district nurses (DN) and administrative staff (total 20) and with patients and bereaved relatives (total 11); the researcher observed multidisciplinary practice meetings.

Results

Only 29% of patients were on the PCR prior to death (range 10–38% between practices). Of these, 69% had cancer, 17% organ failure and 14% dementia or physical frailty and 25% died in hospital (cf. 44% of all deaths). 52% on the current PCR had a record of preferred place of care and 35% of resuscitation status. Practices valued better focused and structured palliative care, improved communication with OOH providers and introduction of the LCP but raised some difficulties in including non-cancer patients on the PCR. Patients and relatives appreciated pro-active care.

Conclusion

Despite this initiative few patients were identified for palliative care. However when identified, their multidisciplinary and OOH care improved and hospital admissions to die decreased. Practices must identify more patients earlier for palliative care.
Identifying patients with supportive and palliative care needs in acute cardiology
Authors: Fenning S J , Woolcock R , Haga K , Skene C , Boyd K , Murray S A , Denvir M
Published: May 2011

Introduction and aims

Due to the variable illness trajectory and uncertain prognosis, most patients with advanced heart disease fail to receive adequate end-of-life care. The Gold Standards Framework (GSF) has been used in primary care to identify such patients. We assessed its utility in patients presenting in the acute hospital setting with acute coronary syndrome (ACS).

Methods

Consecutive patients with ACS admitted to an acute cardiology unit, over two separate 4 week periods, were included. Data were collected from patient notes and interviews with doctors. Patients were assessed using GSF and a clinical prognostic score (Global Registry of Acute Coronary Events, GRACE). All patients were followed-up for 1 year.

Results

168 patients were included. 40 (24%) patients were identified under the GSF as being in the last year of life due to their heart disease. Compared with GSF negative patients, GSF positive patients had a significantly higher GRACE score (13.9 vs 8.3, p=0.002). The GRACE score of patients who died within 6 months was significantly higher than those who survived (20.2 vs 9.27, p=0.008). GSF poorly predicted 6 month mortality (sensitivity 17%) but was strongly predictive of all-cause readmission during follow-up (p=0.000001).

Conclusion

GSF may be useful in predicting readmissions in ACS patients but is poor at predicting mortality. Combining GSF criteria with GRACE may guide secondary care clinicians in identifying ACS patients who may benefit from end of life care.
Systemic inflammation and symptom severity in patients with advanced cancer: a prospective study
Authors: Haworth G , Rush R , Fallon M , Laird B
Published: May 2011

Aim

Pain, depression, fatigue and nausea are common symptoms in cancer and can cause significant physical and psychological distress. In non-malignant conditions, systemic inflammation is implicated in the genesis of these symptoms. The relationship between inflammation and these symptoms in cancer is less clear. The aim of this study was to examine the relationship of systemic inflammation and pain, fatigue, depression and nausea/vomiting in patients with advanced cancer.

Methods

An observational, cross-sectional study conducted in a specialist palliative care unit. All cancer patients admitted over a 3 month period were assessed. Eligible patients had assessments of inflammation (C reactive protein (CRP) and albumin) and symptoms (ESAS). A bivariate statistical analysis was conducted.

Results

64 patients were assessed with 50 being eligible. Significant correlations (Spearman) were found for pain (0.343, p=0.015) and depression (0.357, p= 0.011) with CRP. No significant correlations were found for fatigue (0.020, p=0.890) and nausea/vomiting (0.276, p=0.052). No significant associations were found for any symptom and serum albumin.

Conclusion

Systemic inflammation is related to pain and depression in cancer. Such a relationship may provide a therapeutic opportunity for specific anti-inflammatory therapy that improved pain and depression. Further work examining this relationship would be of interest.
Audit of the use of a screening tool to improve recognition of delirium in a palliative care unit
Authors: Cogdell L M , Lunt C
Published: May 2011

Introduction

The British Geriatric Society recommends that all older patients admitted to hospital are screened for delirium using a tool such as the abbreviated mental test (AMT). No similar guidelines specifically for palliative patients exist. However delirium is very common in patients in specialist palliative care units (SPCU). Delirium remains under diagnosed and is associated with a poor prognosis. It is often reversible if recognised early and the cause identified and treated promptly. A previously undertaken audit showed that no screening tool for delirium was currently used in our SPCU despite high prevalence of delirium. The action plan recommended the introduction of routine screening.

Aim

To audit the use of AMT in patients admitted to SPCU.

Methods

Following previous audit junior doctors were asked to perform an AMT on every new admission. Education and labels listing the 10 AMT questions to stick in notes were provided. Case note review for 20 SPCU in-patients was performed on 1 day 4 months after the introduction of screening tool.

Results

70% of patients had an AMT performed on admission. The patients who did not have an AMT done were mainly in the terminal phase of their illness. 43% of patients who had an AMT performed scored less than 8 suggesting that they have a high chance of delirium.

Conclusion

The introduction of the screening tool has improved the number of newly admitted patient's being assessed for delirium.
COMPASS collaborative research Strand 1: assessment
Authors: Stark D , Bennett M , Johnson B , Murray S A , Rainey P , Rayner L , Gao W , Higginson I J
Published: May 2011

Introduction and aims

Strand 1 develops assessment and outcome measures for use and intervention in research and clinical practice. We set out to improve the patient assessment platform, to improve comparable measurement within and between studies.

Methods

Our process of meeting, rigorous collaborative discussion, guidance for researchers in training, grant application and dissemination has brought integration of service user involvement and collaboration among the different universities. We focused upon symptoms including psychological distress care giver burden and palliative outcomes. We evaluated measures from diagnosis to survivorship and end of life care.

Results

We have recently published about measures of psychological distress across cancer trajectories, clinical and psychometrics features of the General Health Questionnaire across the cancer trajectory, complex interventions for cancer survivors and assessment of care giver burden. In our collaborative's evolution, we continue to work on psychological distress assessment across cancers, characteristics of psychological distress, political challenges to supportive and palliative care research, cancer pain, palliative outcomes, short-form carer burden questionnaires, the selection of research assessment measures, telehealth with advanced symptoms, dignity-conserving interventions, place of death in non-cancer conditions and evaluation of services. Each of these can shape clinical research studies and services in supportive and palliative care.

Conclusions

Our commitment, complementary insights, backgrounds and methodological expertise were essential and productive. We continue to collaborate, developing high impact research, infrastructure and training and wider collaborations across Europe and beyond (PRISMA in palliative care, ENCCA in young people with cancer) across disciplines and professions in supportive and cancer survivorship care, palliative and end of life care.
‘You're sicker than you think’: continuing communication problems in end stage heart failure
Authors: Mair F S , Browne S , Morrison D , Macleod U , May C R
Published: May 2011

Heart failure is a terminal condition. Yet it has been demonstrated that compared to cancer, health professionals (HPs) lack confidence in diagnosing end stage heart failure (ESHF) and communicating a poor prognosis to patients. The present study seeks to explore patient and carer level of understanding of the diagnosis and prognosis, and how ESHF patients and carers make sense of their condition and plan for the future, and what part HPs play.

Methods

This study involves semi-structured interviews with 22 ESHF patients and their carers and explored their knowledge and understanding of the condition and its prognosis. Qualitative data analysed using thematic analysis but informed by Normalisation Process Theory. Inclusion criteria: at least Grade 3 or 4 NYHA classification HF; who have ongoing symptoms despite optimal therapy; and have a history of admissions for this condition and their carer (defined as the person most closely involved with them).

Results

Patients and carers generally understood the patient had heart problems although the term ‘heart failure’ was rarely used. Many patients had been unwell with heart problems for many years and the transition to ESHF remained unclear with few seeming to appreciate their prognosis. There was little evidence of direct communication about prognosis, with patients sometimes becoming fixated on comments by HPs such as, ‘you’re sicker than you think, you know' and wondering how to interpret such comments.

Conclusions

This study has highlighted continuing problems with regard to ESHF patient and carer knowledge and understanding of their condition.
The role of primary care in cancer care: the views and experiences of patients and family members
Authors: Adams E , Watson E K , Boulton M G , Rose P W , Richardson A , Lund S , Wilson S , Savage B , Rauf A , Belcher J
Published: May 2011

Introduction and aims

The role of primary care in the provision of cancer care is poorly defined. Practices in are offered a financial incentive to conduct a review with new patients within 6 months of diagnosis, but the extent to which these reviews occur and their scope and perceived usefulness is unknown. The purpose of this study was to explore the role of primary care in caring for and supporting cancer patients and their families.

Method

Semi-structured interviews were conducted with 38 patients, diagnosed within the last 3 years. Patients were stratified by time since diagnosis, and a maximum variation sampling strategy was employed to achieve heterogeneity in terms of cancer type and socio-demographic variables. We interviewed 19 males and 19 females, with a range of 14 different cancers. Patients were invited to ask their partner/close relative to participate – 24 family members were interviewed.

Results

Although generally satisfied with their GP practice, most patients were unaware of having had a review or any specific discussion of their cancer-related care, despite records indicating the contrary. Most patients and family members would have welcomed pro-active involvement from their GP practice and felt that a designated review appointment would provide a good opportunity to raise any concerns.

Conclusions

Although patients and family members see an important role for primary care in cancer follow-up care this is not universally being delivered at present and there is real scope for improving practice in this area.
Healthcare professionals' views on factors influencing end-of-life care in hospitals
Authors: Forbes K , Gibbins J , Burcombe M E , Bloor S J , Reid C M , McCoubrie R C
Published: May 2011

Introduction and aims

The majority of patients die in the acute setting, yet care delivered to the dying in hospitals is variable and the underlying reasons for this are not documented well. We aimed to explore healthcare professionals' views on the factors influencing good quality end-of-life care within an acute hospital Trust.

Methods

Within a feasibility study examining the impact of a simple end-of-life care tool on the dying experience we carried out qualitative interviews with healthcare professionals caring for dying patients.

Results

Five focus groups, nine face-to-face and two ‘think aloud’ interviews were analysed using the framework approach. The emerging themes were: difficulties in diagnosing dying (eg, senior doctors were required to validate the diagnosis when they might not know the patient well); role of the doctor (often task-based and directed by the nurses); changing role of nursing staff (leading end-of-life care); hospital culture (reluctance to withdraw active treatments; it was ‘brave’ to state a patient was dying); environment (appropriateness for dying patients) and the EOL tool validating care (nurses found the regular symptom scoring required by the tool helped them approach patients and families and give more appropriate care).

Conclusion

This qualitative study has identified factors influencing care given to dying patients in an acute hospital setting. We suggest these factors need to be taken into account when trying to improve care for dying patients and in facilitating the use of EOL care pathways.
Non-professional carers' views on the care of the dying; the impact of a simple end-of-life care tool
Authors: Forbes K , Gibbins J , Burcombe M E , Bloor S J , Reid C M , McCoubrie R C
Published: May 2011

Introduction and aims

The Department of Health's End of Life (EOL) strategy promotes integrated care pathways for the dying as a means of improving end-of-life care. We designed a pilot study to determine whether a simple EOL care tool could improve the dying experience in an acute hospital setting as perceived by carers.

Methods

40 patients received ‘usual’ end-of-life care and 30 patients had their end-of-life care directed by a simplified EOL care tool. Bereaved carers were contacted a month after the patient's death and asked to complete the validated VOICES questionnaire.

Results

20/40 questionnaires were returned by carers whose relatives received ‘usual’ care and 18/30 by carers whose relative received care directed by the tool. Although numbers are small and therefore changes are not statistically significant, improvements were seen in the responses regarding medical and nursing care (43.8% of relatives rated nursing care as excellent in the usual care group compared to 83% in the EOL tool group). Benefits were also seen for pain management (56.3% of carers perceived their relative had pain receiving usual care vs 28% in those receiving the care tool). More carers were present when their relative died following introduction of the tool (43.8% for usual care vs 67% for those receiving the care tool).

Conclusion

Non-professional carers reported improvements in some aspects of end-of-life care following the introduction of a simple EOL care tool. This needs further testing in an adequately powered trial.
Palliative care pathways for teenagers and young adults with cancer
Authors: Stirling L C , Anderson A K , Lewis J , Stoneham S
Published: May 2011

In 2009, a Palliative Care subgroup of the teenagers and young adults with cancer (TYAC) service development group was formed and asked to develop best practice guidelines for the Palliative, End of Life (EoL) and Bereavement care for teenagers and young adults (TYA) with cancer.

Methods

Relevant national guidelines from paediatric and adult palliative care, as well as clinical expertise from around the UK from both medical, nurse, social and education, were used to develop draft pathways to guide generic clinicians in the provision of care of a TYA with cancer, and his/her loved ones, from the time that it is recognised that his/her malignancy is incurable, through to care in early bereavement. The pathways were disseminated widely within the membership of TYAC for comments and suggestions as well as from parents and carers. Amendments were made in the light of the comments received.

Results

Three pathways were developed that outline the range of interventions needed to provide optimal Palliative care, End of Life care and Bereavement care for TYA with cancer.

Conclusions

These pathways will be disseminated and used as a gold standard to guide provision of service and audit care for this population.
Using the measure of patient centred communication to assess oncology consultations
Authors: Absolom K , Hector C , Campbell L , Eng S , Taylor S , Takeuchi E , Warrington L , Ziegler L , Velikova G
Published: May 2011

Numerous instruments to assess doctor-patient communication have been developed to date. The Measure of Patient Centred Communication (MPCC)1 was created for use in primary care and measures three components of communication (1) Exploring the disease (2) Understanding the whole person (3) Finding common ground. In ongoing research we are exploring the suitability of the MPCC for assessing chemotherapy review consultations. Here we present our preliminary experiences of using this coding framework.

Methods

Between October 2009 and November 2010, 496 outpatient consultations with 124 patients were audio-recorded at St James' Institute of Oncology, Leeds. All patients were receiving chemotherapy for either advanced colorectal (n=49), gynaecological (n=48) or breast cancer (n=27). A team of eight coders are analysing recordings using both the MPCC and content analyses.

Results

Preliminary findings suggest the MPCC can be applied to oncology consultations. The coding team have reached agreement on how to code key issues discussed by patients and doctors including symptoms of the cancer, side effects of treatment, questions about prognosis, treatment decision making and the doctors' explanations about cancer status throughout chemotherapy cycles.

Conclusions

The MPCC may be a useful tool for examining patient-centredness in oncology. Future work will explore the value of the MPCC in assessing the impact of routinely collecting and feeding back patient reported outcome (PRO) data to oncologists. The MPCC will be used to assess if training oncologists to interpret and use the PRO data improves patient-centred care in consultations.
COMPASS collaborative research Strand 2: The development and evaluation of complex interventions for psychological distress in cancer patients
Authors: Velikova G , Sharpe M , Brown J
Published: May 2011

Aims

To provide the basis for the development of active components of complex interventions for distress and rigorous evaluation of process measures and patient outcomes. A staged co-ordinated approach was adopted, with collaborative members completing different components of the work.

Methods

To supplement COMPASS trials evaluating screening for distress and testing complex interventions for depression in cancer patients, preparatory work for an intervention for distress was undertaken. Systematic meta-review of the use and meaning of the terms ‘psychological distress’ and ‘psychological interventions’ were completed. A prospective study of the outcomes of moderate distress over time (n=326) and a qualitative study of patient's views on potential treatments for moderate psychological distress (n=25) was undertaken in Edinburgh. The views of hospital-based oncology professionals about the assessment and management of psychological distress were explored in an interview study across the Yorkshire Cancer Network.

Results

Moderate distress is common in cancer patients and persistent in a substantial minority at 7 months (36%). Distressed patients prefer information and guidance provided by those who understand the effect of cancer but are reluctant to see mental health professionals. 23 cancer professionals were interviewed (8 oncologists, 4 surgeons, 6 clinical nurse specialists (CNS) and 5 nurses). The CNS was pivotal to the detection and management of distress and overall, effective management was not optimal due to a lack of referral guidance and limited access to specialist psychological care. These studies supplement ongoing work evaluating screening for distress and depression and the evaluation of intensive treatments for depression in cancer patients.

Future research

Future research generated from the COMPASS collaboration includes development of a training programme to enable clinicians to use output from screening measures and self-help interventions for psychological distress incorporating e-health technology.
Co-ordination of generalist care for patients towards the end of life: a literature review
Authors: Mason B L , Barclay S , Dale J , Daveson B , Donaldson A , Epiphaniou E , Harding R , Higginson I J , Munday D , Nanton V , Shipman C , Murray S A
Published: May 2011

Introduction and aim

Increased coordination and collaboration have been highlighted as improving the provision of health and social care for people at the end of life. We aimed to review the literature concerning coordination or collaboration of care to determine whether coordination and collaboration improves the quality of care delivered by generalists towards the end of life.

Methods

Searches in PUBMED and ISI Web of Knowledge for the stems ‘coordinat-‘ or ‘collaborat-‘ in the context of the stem ‘palliat-‘ or the phrase ‘terminal care.’ Search of Web of Knowledge for the categories ‘generalist health care’ and ‘palliative.’ Search of PUBMED MeSH terms ‘palliative care admin and organisation’, ‘terminal care admin and organisation’ and ‘Cooperative Behavior.’ Electronic searches were supplemented by hand searches of leading palliative care journals (2008–2010).

Results

1672 articles initially identified as requiring further screening, and 55 eligible studies identified. Different approaches/terminology to enabling coordination and collaboration were identified including networks, integrated care pathways, partnerships, frameworks, programmes and ‘collaboratives’. Lack of coordination and/or collaboration was routinely identified as a barrier to good palliative care.

Conclusion

Approaches to enabling coordination and collaboration are evident in the literature but no metrics to measure coordination or collaboration were uncovered so it is impossible to determine whether a particular intervention increased coordination or collaboration. Therefore more research to determine whether collaboration and coordination improves quality of care is needed. Management or organisational theory as well as robust evaluation of models of co-ordination is indicated to guide current policy developments. This will require increased conceptual clarity regarding the terms collaboration and coordination in this context.
Development of guidelines for the management of cancer related fatigue
Authors: Eng S , Velikova G
Published: May 2011

Introduction

Cancer related fatigue (CRF) is a common symptom that is neither formally assessed not actively addressed. Despite a plethora of tools available for measuring fatigue, there is a lack of a clear pathway for its management.

Aims

To develop guidelines for management of fatigue to be used together with a computerised touch screen system for patients to report fatigue.

Method

A literature review was conducted on management of CRF. This was followed by a series of individual meetings with physiotherapists (3), dieticians (2) sleep physicians (2), sleep nurse (1), providers of complementary therapists (4) to ascertain referral criteria and types of local services available for cancer patients with fatigue. Informal meetings with SHOs (2), consultant oncologists (2) and nurses (11) helped ascertain current management strategies.

Results

There is a paucity of knowledge surrounding the management of CRF, and a lack of awareness of available services. A local guideline was developed as anaide memoirefor medical oncologists and nurses. Information is presented in sections with assessment questions to determine the level of fatigue, prompts for biologic assessments and its corresponding management. A traffic light system is used to represent severity of fatigue, matching it with available services and information, contact details, referral criteria and structured advice on diet, exercise and sleep.

Conclusion

The guidelines will be used as part of a resource package for training doctors and will be available in outpatient clinics.
Factors influencing exercise capacity in people with thoracic cancer
Authors: Maddocks M , England R , Manderson C , Wilcock A
Published: May 2011

Introduction and aims

Patients with thoracic cancer often complain of a reduced exercise capacity which can impede levels of independence and quality of life. Several factors may be responsible but there is little formal study in this group. We have explored how various physiological and psychological factors relate to performance in a test of exercise capacity.

Methods

Inspiratory muscle strength, peripheral muscle power, lung function and mastery over breathlessness were assessed using sniff nasal inspiratory pressure, leg extensor power, simple spirometry and the mastery domain of the Chronic Respiratory Disease Questionnaire respectively. Exercise capacity was assessed using the Incremental Shuttle walk Test (ISWT) during which patients wore a K4 b2 system allowing continuous measurement of heart rate, minute ventilation (VE) and oxygen uptake (VO2). Relationships between ISWT distance and independent factors were determined using Pearson's correlation coefficient and β regressions coefficients.

Results

41 patients (21 male, mean (SD) age 64 (8) years) took part. They walked a median (IQR) 320 (250–430) m and reached 76 (10)%, 48 (14)% and 77 (25)% of their predicted maximal heart rate, VE and VO2 respectively. Exercise capacity was significantly associated only with inspiratory muscle strength (r=0.42, p<0.01) and peripheral muscle power (r=0.39, p=0.01). These factors were also significant determinants of exercise capacity (β coefficients (95% CI) 1.77 (0.53 to 3.01) and 1.22 (0.31 to 2.14)).

Conclusions

Both inspiratory and peripheral muscle performance appear to influence exercise capacity in people with thoracic cancer. Interventions aimed at maintaining or slowing down the decline in exercise capacity should include components targeting muscular performance.
Resolving tensions: optimising the role of primary care in lung cancer follow-up care
Authors: Highet G , Murray S A , Campbell C , Kendall M , Rainey P , Neal R , Rose P , Anandan C , Amoakwa E , Weller D
Published: May 2011

Introduction

There is a little consensus on how to manage the supportive and palliative care needs of people with lung cancer once they have completed initial treatment. We aimed to gain insights into the perspectives of clinicians and service users as to how primary care could provide better care in collaboration with lung cancer specialists.

Methods

We conducted a qualitative study encompassing (a) telephone interviews (84) with healthcare professionals from four UK healthcare authorities, recruited through primary care research networks and other professional contacts and working in primary, secondary and palliative care, and (b) focus groups (4) with lung cancer patients and carers recruited through the Roy Castle Foundation. Interviews and focus groups were digitally recorded, transcribed and entered into NVivo for thematic analysis, initially from different perspectives and then synthesised across the whole data set.

Results

Lung cancer care is currently ‘shared’ rather than ‘integrated’ across heath care sectors. Debates about follow-up care tend to make a distinction between clinical care (provided in hospital by specialists) and supportive care (provided in the community by generalists) and there are contested ideas about where best to follow-up lung cancer patients who are relatively ‘stable’. Psycho-social support, support for carers and communication between primary and secondary care were identified as potential areas for development.

Conclusion

Lung cancer follow-up care is characterised by a range of tensions which must be resolved if primary care is to play an optimum role in providing follow-up care and support for lung cancer patients and their carers.
Distal protection for treatment of complete cervical internal carotid occlusion
Authors: Hungerford John P , Chaudry Imran , Turner Raymond , Turk Aquilla S
Published: May 2011

Distal protection devices (DPD) have been advocated for carotid artery stenting to reduce the risk of distal embolization. These devices were designed for deployment in the straight cervical segment of the internal carotid artery. We present a case of total cervical carotid occlusion recanalized with the aid of a distal protection device deployed ‘distally’ in the intracranial internal carotid artery.
A tale of both sides of Iapetus – upper Darriwilian (Ordovician) graptolite faunal dynamics on the edges of two continents
Authors: Maletz Jörg , Egenhoff Sven , Böhme Martina , Asch Robert , Borowski Katarina , Höntzsch Stefan , Kirsch Moritz , Werner Mirko
Published: May 2011

Ordovician graptolite faunal compositions between the Laurentia and Baltica margins of the Iapetus Ocean differ considerably in the upper Darriwilian (Da 3 – Da 4; upper Middle Ordovician). Detailed investigation of a number of sections in the Table Head and Goose Tickle groups in western Newfoundland and the Elnes Formation of Norway provides important new faunal data for the interval from the Holmograptus lentus Biozone to the Dicellograptus vagus Biozone. The Nicholsonograptus fasciculatus and Pterograptus elegans biozones are introduced for the Table Head and Goose Tickle groups and can be recognized widely in North America. The characteristic, but poorly correlatable, shallow-water endemic faunas of the platform regions (Atlantic and Pacific faunal realms) grade into the cosmopolitan oceanic graptolite faunas (isograptid biofacies) and provide a means to precisely correlate cold-water and warm-water endemic graptolite faunas through transitional zones. The faunal differences between western Newfoundland and Scandinavia are less pronounced than hitherto assumed, and many faunal elements can now be recognized in both regions, allowing for a more precise biostratigraphic correlation. The paleobiogeographic differentiation of both regions has been based on few, but usually extremely common faunal elements, masking the presence of important biostratigraphic marker species.
ARC-FRACTAL AND THE DYNAMICS OF COASTAL MORPHOLOGY
Authors: HUYNH HOAI NGUYEN , CHEW LOCK YUE
Published: May 2011

In this paper, we present an idea of creating fractals by using the geometric arc as the basic element. This approach of generating fractals, through the tuning of just three parameters, gives a universal way to obtain many novel fractals including the classic ones. Although this arc-fractal system shares similar features with the well-known Lindenmayer system, such as the same set of invariant points and the ability to tile the space, they do have different properties. One of which is the generation of pseudo-random number, which is not available in the Lindenmayer system. Furthermore, by assuming that coastline formation is based purely on the processes of erosion and deposition, the arc-fractal system can also serve as a dynamical model of coastal morphology, with each level of its construction corresponds to the time evolution of the shape of the coastal features. Remarkably, our results indicate that the arc-fractal system can provide an explanation on the origin of fractality in real coastline.
FRACTAL STRUCTURE ON k-SAT
Authors: WANG QIN , XI LIFENG
Published: May 2011

The k-SAT (k ≥ 3) is a typical NP-complete problem in computer science. To visualize k-SAT, we embed the Boolean expressions in k-CNF, with variables in an infinite list, into cube [0, 1]k of Euclidean space. In this paper, we find fractal structure of the visualized image of satisfiable expressions, we also prove that the image has full Hausdorff dimension k under some reasonable condition, by constructing some Moran subset. The results show this image is quite different from that with respect to a finite list of Boolean variables as in Refs. 1 and 2.
NONLINEAR FRACTURE SIGNAL ANALYSIS USING MULTIFRACTAL APPROACH COMBINED WITH WAVELETS
Authors: AOUIT D. AIT , OUAHABI A.
Published: May 2011

Based on the continuous Wavelet Transform Modulus Maxima method (WTMM), a multifractal analysis was introduced to discriminate the irregular fracture signals of materials. This method provides an efficient numerical technique to characterize statistically the local regularity of fractures.

The results obtained by this nonlinear analysis suggest that multifractal parameters such as the capacity dimension D0, the average singularity strength α0, the aperture of the left side (α0 - α min ) and the total width (α max - α min ) of the D(α) spectra allow a better fit for the characterization of the different fracture stages.

Discriminating the three principal stages of the fracture namely the fracture initiation, the fracture propagation and the final rupture, provides a powerful diagnostic tool to identify the crack initiation site, and thus delineates the causes of the cracking of the material.
EFFECT OF OUTLIERS ON THE FRACTAL DIMENSION ESTIMATION
Authors: MOHAMMADI SHAPOUR
Published: May 2011

The effect of outliers on estimation of the fractal dimension of experimental chaotic and stock market stochastic data series is investigated. The results indicate that influential observations of a magnitude of mean ±5 standard deviations can lead to a distortion of fractal dimension estimations by as much as 40% for short (e.g. 500 observations) time series data. Moreover, the box dimension estimation method is more sensitive to outliers than information and correlation dimension estimation methods and the effect of outliers decreases as the number of observations increases. Application of outlier adjustment to the stock prices of 60 companies of the Dow Jones Industrial Index reveals that the effect of outliers is critical in estimating the fractal dimension. The fractal dimension has applications in risk analysis for financial markets that can be affected by outliers.
THERMOMECHANICAL STABILITY ANALYSIS OF FUNCTIONALLY GRADED THIN-WALLED CANTILEVER PIPE WITH FLOWING FLUID SUBJECTED TO AXIAL LOAD
Authors: HOSSEINI M. , FAZELZADEH S. A.
Published: May 2011

In this study, the thermomechanical stability of functionally graded thin-walled cantilever pipes conveying flow and loading by compressive axial force is investigated. The governing equations of motion and boundary conditions are derived via the Hamilton's variational principle. The thin-walled structure is formulated based on Rayleigh's theory. Moreover, quasi-steady flow pressure loadings and steady surface temperature are considered and the temperature gradient through the wall thickness of the pipe is included. The partial differential equations of the pipe are transformed into a set of ordinary differential equations using the extended Galerkin method. Finally, having solved the resulting thermal-structural-fluid eigenvalue system of equations, the effects of the compressive axial force, fluid speed, fluid mass ratio, volume fraction index of functionally graded materials (FGMs), and temperature change through the thickness of the pipe on the stability boundary are investigated. Numerical comparisons are also performed with the available data in the literature and good agreement is observed.
THE GENERAL THEORY OF ELASTIC STABILITY AT THE END OF THE 19th CENTURY
Authors: GODOY LUIS A.
Published: May 2011

This paper reviews the research on the theory of elastic stability published at the end of the 19th century, with emphasis on the work by G. H. Bryan in Cambridge. The state of the studies on structural stability previous to Bryan is reviewed, and two lines of work are identified: one is a general stability of rigid bodies and the other is a collection of case studies of elastic stability. Bryan's theory is discussed next, presenting his arguments based on first energy principles, which led him to strong conclusions. The importance of the word "general" and the idea of having solved the problem in each case are explained. The impact of the contributions made by Bryan, together with the critiques that this generated, is also discussed.
BUCKLING OF AN AXIALLY RESTRAINED STEEL COLUMN UNDER FIRE LOADING
Authors: HOZJAN TOMAŽ , PLANINC IGOR , SAJE MIRAN , SRPČIČ STANISLAV
Published: May 2011

Analytical procedure, based on the linearized stability analysis, is presented for the determination of the buckling load and the buckling temperature of a straight, geometrically perfect, axially loaded steel column subjected to an increasing temperature simulating fire conditions. The nonlinear kinematical equations and the nonlinearity of material are considered. The stress–strain relation for steel at the elevated temperature and the rules for reduction of material parameters due to increased temperature are taken from European standard EC 3. Theoretical findings are applied in the parametric analysis of a series of Euler's columns subjected to two parametric fires. It is found how the slenderness of the column, the material nonlinearity, the temperature dependence of material parameters, and the stiffness of restraints at supports effect the critical temperature. While these parameters have major influence on the critical temperature, they have no effect on the shape of the buckling mode.
GALOIS AND UNIVERSAL COVERINGS OF LINEAR CATEGORIES AND FIBER PRODUCTS
Authors: CIBILS CLAUDE , REDONDO MARÍA JULIA , SOLOTAR ANDREA
Published: May 2011

Let k be a commutative ring. We study the behavior of coverings of k-categories through fiber products and find a criterion for a covering to be Galois or universal.
Metformin improves cardiac function in a nondiabetic rat model of post-MI heart failure
Authors: Yin Meimei , van der Horst Iwan C. C. , van Melle Joost P. , Qian Cheng , van Gilst Wiek H. , Silljé Herman H. W. , de Boer Rudolf A.
Published: May 2011

Metformin is the first choice drug for the treatment of patients with diabetes, but its use is debated in patients with advanced cardiorenal disease. Epidemiological data suggest that metformin may reduce cardiac events, in patients both with and without heart failure. Experimental evidence suggests that metformin reduces cardiac ischemia-reperfusion injury. It is unknown whether metformin improves cardiac function (remodeling) in a long-term post-MI remodeling model. We therefore studied male, nondiabetic, Sprague-Dawley rats that were subjected to either myocardial infarction (MI) or sham operation. Animals were randomly allocated to treatment with normal water or metformin-containing water (250 mg·kg−1·day−1). At baseline, 6 wk, and 12 wk, metabolic parameters were analyzed and oral glucose tolerance tests (OGTT) were performed. Echocardiography and hemodynamic parameters were assessed 12 wk after MI. In the MI model, infarct size was significantly smaller after 12-wk metformin treatment (29.6 ± 3.2 vs. 38.0 ± 2.2%, P < 0.05). Moreover, metformin resulted in less left ventricular dilatation (6.0 ± 0.4 vs. 7.6 ± 0.6 mm, P < 0.05) and preservation of left ventricular ejection fraction (65.8 ± 3.7% vs. 48.6 ± 5.6%, P < 0.05) compared with MI control. The improved cardiac function was associated with decreased atrial natriuretic peptide mRNA levels in the metformin-treated group (50% reduction compared with MI, P < 0.05). Insulin resistance did not occur during cardiac remodeling (as indicated by normal OGTT) and fasting glucose levels and the pattern of the OGTT were not affected by metformin. Molecular analyses suggested that altered AMP kinase phosphorylation status and low insulin levels mediate the salutary effects of metformin. Altogether our results indicate that metformin may have potential to attenuate heart failure development after myocardial infarction, in the absence of diabetes and independent of systemic glucose levels.
Postmaximal contraction blood volume responses are blunted in obese and type 2 diabetic subjects in a muscle-specific manner
Authors: Sanchez Otto A. , Copenhaver Elizabeth A. , Chance Marti A. , Fowler Michael J. , Towse Theodore F. , Kent-Braun Jane A. , Damon Bruce M.
Published: May 2011

The purpose of this study was to determine whether there are differences in postisometric contraction blood volume and oxygenation responses among groups of type 2 diabetes mellitus (T2DM), obese, and lean individuals detectable using MRI. Eight T2DM patients were individually matched by age, sex, and race to non-T2DM individuals with similar body mass index (obese) and lean subjects. Functional MRI was performed using a dual-gradient-recalled echo, echo-planar imaging sequence with a repetition time of 1 s and at two echo times (TE = 6 and 46 ms). Data were acquired before, during, and after 10-s isometric dorsiflexion contractions performed at 50 and 100% of maximal voluntary contraction (MVC) force. MRI signal intensity (SI) changes from the tibialis anterior and extensor digitorum longus muscles were plotted as functions of time for each TE. From each time course, the difference between the minimum and the maximum postcontraction SI (ΔSI) were determined for TE = 6 ms (ΔSI6) and TE = 46 ms (ΔSI46), reflecting variations in blood volume and oxyhemoglobin saturation, respectively. Following 50% MVC contractions, the mean postcontraction ΔSI6 values were similar in the three groups. Following MVC only, and in the EDL muscle only, T2DM and obese participants had ∼56% lower ΔSI6 than the lean individuals. Also following MVC only, the ΔSI46 response in the EDL was lower in T2DM subjects than in lean individuals. These data suggest that skeletal muscle small vessel impairment occurs in T2DM and body mass index-matched subjects, in muscle-specific and contraction intensity-dependent manners.