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Abstract Background Anxiety adversely affects quality of life and is common in adults with advanced life-limiting disease. There are no UK-wide guidelines on the assessment and management of anxiety in this specific population and there is little evidence regarding drug treatments. This study aimed to explore how palliative care physicians assess and manage anxiety in their patients, and to identify barriers encountered. Methods A cross-sectional survey was undertaken of all physicians working in specialist palliative care in the UK who were members of the Association for Palliative Medicine. This was conducted in February 2014 using an online questionnaire. Results The response rate was 23% (230/980) and 61% of respondents were consultants. Most did not use tools to screen for anxiety (87%) and almost all used the clinical interview to diagnose anxiety (99%). Only 8% used psychiatric criteria. Most physicians reported difficulties managing anxiety (93%). Only 33% thought they had adequate training in this area. Most had difficulty accessing psychological and/or psychiatric services (71%, 64% respectively). The majority used a combination of pharmacological and non-pharmacological treatments for anxiety. The most frequently prescribed first-line medications for patients with a prognosis of days to weeks were benzodiazepines (93%), usually lorazepam. The use of benzodiazepines over antidepressants was statistically significant (p

The shift in climate that occurred between the Last Glacial Maximum (LGM) and the Early Holocene (ca. 18–12 kyr BP) displayed rates of temperature increase similar to present-day warming trends. The most rapid recorded changes in temperature occurred during the abrupt climate oscillations known as the Bølling–Allerød interstadial (14.7–12.9 kyr BP) and the Younger Dryas stadial (12.9–11.7 kyr BP). Reconstructing ice sheet dynamics during these climate oscillations provides the opportunity to assess long-term ice sheet evolution in reaction to a rapidly changing climate. Here, we use glacial geomorphological inversion methods (flowsets) to reconstruct the ice flow dynamics and the marginal retreat pattern of the southwestern sector of the Laurentide Ice Sheet (SWLIS). We combine our reconstruction with a recently compiled regional deglaciation chronology to depict ice flow dynamics that encompass the time period from pre-LGM to the Early Holocene. Our reconstruction portrays three macroscale reorganizations in the orientation and dynamics of ice streaming followed by regional deglaciation associated with rapid warming during the Bølling–Allerød interstadial. Initial westward flow is documented, likely associated with an early set of ice streams that formed during the advance to the LGM. During the LGM ice streaming displays a dominant north to south orientation. Ice sheet thinning at ∼15 ka is associated with a macroscale reorganization in ice stream flow, with a complex of ice streams recording south-eastward flow. A second macroscale reorganization in ice flow is then observed at ∼14 ka, in which southwestern ice flow is restricted to the Hay, Peace, Athabasca, and Churchill river lowlands. Rates of ice sheet retreat then slowed considerably during the Younger Dryas stadial; at this time, the ice margin was situated north of the Canadian Shield boundary and ice flow continued to be sourced from the northeast. Resulting from these changes in ice sheet dynamics, we recognize a three-part pattern of deglacial landform zonation within the SWLIS characterized by active ice margin recession, stagnation and downwasting punctuated by local surging (terrestrial ice sheet collapse): the outer deglacial zone contains large recessional moraines aligned with the direction of active ice margin retreat; the intermediate deglacial zone contains large regions of hummocky and stagnation terrain, in some areas crosscut by the signature of local surges, reflecting punctuated stagnation and downwasting; and the inner deglacial zone contains inset recessional moraines demarcating progressive regional ice margin retreat. We attribute these macroscale changes in ice flow geometry and associated deglacial behaviour to external climatic controls during the Bølling–Allerød and Younger Dryas but also recognize the role of internal (glaciological, lithological and topographic) controls in SWLIS dynamics.

Conceptual ice stream land systems derived from geomorphological and sedimentological observations provide constraints on ice–meltwater–till–bedrock interactions on palaeo-ice stream beds. Within these land systems, the spatial distribution and formation processes of ribbed bedforms remain unclear. We explore the conditions under which these bedforms may develop and their spatial organization with (i) an experimental model that reproduces the dynamics of ice streams and subglacial land systems and (ii) an analysis of the distribution of ribbed bedforms on selected examples of palaeo-ice stream beds of the Laurentide Ice Sheet. We find that a specific kind of ribbed bedform can develop subglacially through soft-bed deformation, where the ice flow undergoes lateral or longitudinal velocity gradients and the ice–bed interface is unlubricated; oblique ribbed bedforms develop beneath lateral shear margins, whereas transverse ribbed bedforms develop below frontal lobes. We infer that (i) ribbed bedforms strike orthogonally to the compressing axis of the horizontal strain ellipse of the ice surface and (ii) their development reveals distinctive types of subglacial drainage patterns: linked cavities below lateral shear margins and efficient meltwater channels below frontal lobes. These ribbed bedforms may act as convenient geomorphic markers to reconstruct lateral and frontal margins, constrain ice flow dynamics, and infer meltwater drainage characteristics of palaeo-ice streams.

Background/objectives: The adverse effects of cancer and the long-term sequelae of associated treatments result in reduced quality of life and increased mortality for patients. Supporting patients with cancer to mitigate adverse outcomes is an important aspect of oncology care and the primary purpose of cancer rehabilitation. A retrospective service evaluation was conducted to evaluate the effectiveness of the core iCan patient-centred cancer rehabilitation service., Methods: At the beginning and end of a five-week programme, a series of questionnaires evaluating changes in mental health and wellbeing, and physical activity performance/attitudes, and functional capacity were administered to participants., Results: Following iCan, we found that functional capacity was improved (30 s sit-to-stand: +6.3 repetition; d = -1.00, p < 0.001) and that self-reported physical activity was increased (~1173 MET-mins/wk; d = -0.76, p < 0.001); participants also perceived greater capability, opportunity, and motivation to be active. Mental wellbeing was also improved (SWEMWBS: d = -0.69, p < 0.001), whilst fatigue was reduced (FACIT: d = -0.77, p < 0.001)., Conclusion: It appears that iCan has beneficial effects upon the physical/functional and psychological health of its participants. Where data are available, there appear to be clinically significant improvements across the range of measured functional, wellbeing, and activity/sedentariness outcomes, which suggest that participation in iCan is instrumental in adding value to the health and wellbeing of patients.

Introduction: Multidisciplinary Meetings (MDM) are recommended in routine lung cancer care, however its broader impacts demand further evaluation. We assessed the drivers and impacts of MDM presentation in the Victorian Lung Cancer Registry (VLCR)., Methods: We examined the effect of MDM presentation on receipt of treatment and survival in VLCR patients diagnosed between 2011 and 2020. We compared patient characteristics, drivers of MDM discussion and survival between the two groups., Results: Of 9,628 patients, 5,900 (61.3%) were discussed at MDM, 3,728 (38.7%) were not. In the non-MDM group, a lower proportion received surgery (22.1% vs. 31.2%), radiotherapy (34.2% vs. 44.4%) and chemotherapy (44.7% vs. 49.0%). Patients were less likely to be discussed if ≥80 years (OR 0.73, p < 0.001), of ECOG performance status (PS) 4 (OR 0.23, p < 0.001), clinical stage IV (OR 0.34, p < 0.001) or referred from regional (OR 0.52, p < 0.001) or private hospital (OR 0.18, p < 0.001). MDM-presented patients had better median survival (1.70 vs 0.75 years, p < 0.001) and lower adjusted mortality risk (HR 0.75; 0.71-0.80, p < 0.001), a protective effect consistent across all hospital types. Undocumented PS, histopathology and clinical stage were associated with lower likelihood of MDM discussion and worse mortality., Conclusions: In the VLCR, being male, ≥80 years, of poorer PS, advanced clinical stage and poor clinical characterisation significantly disadvantaged patients in relation to MDM discussion. MDM-discussed patients were more likely to undergo treatment and had a 25% lower risk of mortality. This study supports the use of MDMs in lung cancer and identifies areas of inequity to be addressed., (Copyright © 2021. Published by Elsevier B.V.)

Background: The coronavirus disease 2019 (COVID-19) pandemic has had a profound and prolonged impact on healthcare services and healthcare workers., Aims: The Australian COVID-19 Frontline Healthcare Workers Study aimed to investigate the severity and prevalence of mental health issues, as well as the social, workplace and financial disruptions experienced by Australian healthcare workers during the COVID-19 pandemic., Methods: A nationwide, voluntary, anonymous, single timepoint, online survey was conducted between 27 August and 23 October 2020. Individuals self-identifying as frontline healthcare workers in secondary or primary care were invited to participate. Participants were recruited through health organisations, professional associations or colleges, universities, government contacts and national media. Demographics, home and work situation, health and psychological well-being data were collected., Results: A total of 9518 survey responses were received; of the 9518 participants, 7846 (82.4%) participants reported complete data. With regard to age, 4110 (52.4%) participants were younger than 40 years; 6344 (80.9%) participants were women. Participants were nurses (n=3088, 39.4%), doctors (n=2436, 31.1%), allied health staff (n=1314, 16.7%) or in other roles (n=523, 6.7%). In addition, 1250 (15.9%) participants worked in primary care. Objectively measured mental health symptoms were common: mild to severe anxiety (n=4694, 59.8%), moderate to severe burnout (n=5458, 70.9%) and mild to severe depression (n=4495, 57.3%). Participants were highly resilient (mean (SD)=3.2 (0.66)). Predictors for worse outcomes on all scales included female gender; younger age; pre-existing psychiatric condition; experiencing relationship problems; nursing, allied health or other roles; frontline area; being worried about being blamed by colleagues and working with patients with COVID-19., Conclusions: The COVID-19 pandemic is associated with significant mental health symptoms in frontline healthcare workers. Crisis preparedness together with policies and practices addressing psychological well-being are needed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The Australian COVID-19 Frontline Healthcare Workers Study investigated coping strategies and help-seeking behaviours, and their relationship to mental health symptoms experienced by Australian healthcare workers (HCWs) during the COVID-19 pandemic., Methods: Australian HCWs were invited to participate a nationwide, voluntary, anonymous, single time-point, online survey between 27th August and 23rd October 2020. Complete responses on demographics, home and work situation, and measures of health and psychological wellbeing were received from 7846 participants., Results: The most commonly reported adaptive coping strategies were maintaining exercise (44.9%) and social connections (31.7%). Over a quarter of HCWs (26.3%) reported increased alcohol use which was associated with a history of poor mental health and worse personal relationships. Few used psychological wellbeing apps or sought professional help; those who did were more likely to be suffering from moderate to severe symptoms of mental illness. People living in Victoria, in regional areas, and those with children at home were significantly less likely to report adaptive coping strategies., Conclusions: Personal, social, and workplace predictors of coping strategies and help-seeking behaviour during the pandemic were identified. Use of maladaptive coping strategies and low rates of professional help-seeking indicate an urgent need to understand the effectiveness of, and the barriers and enablers of accessing, different coping strategies., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Providing psychological support to people living with terminal illness is a fundamental part of hospice care. Recent research on delivery of psychological services in hospices in the United Kingdom (UK) on a national level, including inequalities or variation in practice, is limited. A nationwide survey will highlight any differences in provision and in doing so help focus future research and inform best practice both within the UK, and internationally. The specific objectives of this survey are to (1) chart the types of psychological support available to adult patients in hospices in the UK in line with the National Institute for Health and Care Excellence model; (2) explore how services are organised; and (3) gather service perspectives on adequacy of care, and facilitators and barriers to appropriate practice., Methods: A cross-sectional online survey emailed to adult hospices in the UK in November-December 2019. One staff member involved in the delivery and/or organisation of psychological support was invited to participate per hospice. Of 193 invited hospices, 116 took part., Results: Sixteen percent rated their hospice psychological service as wholly adequate. The majority reported that services can access specialist professionals, but many relied on external referrals. Barriers to best practice included funding and staff capacity; facilitators included clear referral structures, audit and appropriate needs and outcome assessments., Conclusions: Access to psychological professionals has improved since the last survey 15 years ago, but the majority of responders felt their overall service was not wholly adequate. Basic emotional support is largely felt to be sufficient, but our results indicate a need for improvements in access to more specialist care. Partnerships with external mental health services may be key. Our findings highlight core facilitators and barriers to providing good psychological care at the end of life that should be considered by services both within the UK and on an international level.

Background: Anxiety adversely affects quality of life and is common in adults with advanced life-limiting disease. There are no UK-wide guidelines on the assessment and management of anxiety in this specific population and there is little evidence regarding drug treatments. This study aimed to explore how palliative care physicians assess and manage anxiety in their patients, and to identify barriers encountered., Methods: A cross-sectional survey was undertaken of all physicians working in specialist palliative care in the UK who were members of the Association for Palliative Medicine. This was conducted in February 2014 using an online questionnaire., Results: The response rate was 23% (230/980) and 61% of respondents were consultants. Most did not use tools to screen for anxiety (87%) and almost all used the clinical interview to diagnose anxiety (99%). Only 8% used psychiatric criteria. Most physicians reported difficulties managing anxiety (93%). Only 33% thought they had adequate training in this area. Most had difficulty accessing psychological and/or psychiatric services (71%, 64% respectively). The majority used a combination of pharmacological and non-pharmacological treatments for anxiety. The most frequently prescribed first-line medications for patients with a prognosis of days to weeks were benzodiazepines (93%), usually lorazepam. The use of benzodiazepines over antidepressants was statistically significant (p < 0.001). For patients with a prognosis of months, antidepressants were most frequently prescribed first-line (60%), significantly more than benzodiazepines (p < 0.001). However, benzodiazepine use was still common in this prognostic group with 47% prescribing it first-line, sometimes in combination with an antidepressant., Conclusion: This is the first national survey on the assessment and management of anxiety in palliative care. Findings demonstrate the infrequent use of screening tools, variation in prescribing practice, potentially inappropriate use of benzodiazepines for patients with a prognosis of months, training gaps and poor access to psychological and psychiatric services in the UK. This highlights the need for formal training, further research into the pharmacological management of anxiety in this population and evidence-based national guidance to support clinical decision-making and service development.

EGFR amplification in cells having double minute chromosomes (DM) is commonly found in glioblastoma multiforme (GBM); however, how much it contributes to the current failure to treat GBM successfully is unknown. We studied two syngeneic primary cultures derived from a GBM with and without cells carrying DM, for their differential molecular and metabolic profiles, in vivo growth patterns, and responses to irradiation (IR). Each cell line has a distinct molecular profile consistent with an invasive "go" (with DM) or angiogenic "grow" phenotype (without DM) demonstrated in vitro and in intracranial xenograft models. Cells with DM were relatively radio-resistant and used higher glycolytic respiration and lower oxidative phosphorylation in comparison to cells without them. The DM-containing cell was able to restore tumor heterogeneity by mis-segregation of the DM-chromosomes, giving rise to cell subpopulations without them. As a response to IR, DM-containing cells switched their respiration from glycolic metabolism to oxidative phosphorylation and shifted molecular profiles towards that of cells without DM. Irradiated cells with DM showed the capacity to alter their extracellular microenvironment to not only promote invasiveness of the surrounding cells, regardless of DM status, but also to create a pro-angiogenic tumor microenvironment. IR of cells without DM was found primarily to increase extracellular MMP2 activity. Overall, our data suggest that the DM-containing cells of GBM are responsible for tumor recurrence due to their high invasiveness and radio-resistance and the mis-segregation of their DM chromosomes, to give rise to fast-growing cells lacking DM chromosomes., Competing Interests: CONFLICTS OF INTEREST The authors declare that they have no competing interest.

At least 10% of patients with cancer have pain that is refractory to systemic analgesics. For most of these patients, interventional techniques may be of benefit but are often not considered or are difficult to access. Of these techniques, spinal analgesia is most commonly used in Australia and the United Kingdom, and neurosurgical procedures, such as open cordotomy with sectioning of the spinothalamic tract, are rarely used. We describe a case illustrating the successful use of bilateral open thoracic cordotomy in a patient with refractory mixed nociceptive and neuropathic pain secondary to a lumbosacral tumor. We discuss the various interventional options and review the recent literature regarding the use of both percutaneous and open cordotomy for cancer pain., (Copyright 2010 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Background: Evidence and quality standards support the use of professional interpreters and discourage the use of family interpreters in medical consultations. The Northern Division of General Practice documented the use of professional and family interpreters in local general practices, together with barriers and possible facilitators in the use of professional interpreters., Methods: Two complementary surveys were conducted in September 2006: practices were surveyed through a brief phone interview; and a written questionnaire with multiple choice and Likert scale questions was distributed to general practitioners attending division training sessions during the same period., Discussion: Surveys of practices and GPs found the use of professional interpreters is uncommon. Over two-thirds of practices reported never using the free Doctors Priority Line phone interpreting service. Family members were frequently used as interpreters, with most GPs preferring to use family rather than professional interpreters. Over a third of practices were unaware of the Doctors Priority Line. Findings suggested that relevant standards are commonly not understood or implemented.

The purpose of this study was to produce a well-characterised electrospun polystyrene scaffold which could be used routinely for three-dimensional (3D) cell culture experimentation. A linear relationship (p<0.01) between three principal process variables (applied voltage, working distance and polymer concentration) and fibre diameter was reliably established enabling a mathematical model to be developed to standardise the electrospinning process. Surface chemistry and bulk architecture were manipulated to increase wetting and handling characteristics, respectively. X-ray photoelectron spectroscopy (XPS) confirmed the presence of oxygen-containing groups after argon plasma treatment, resulting in a similar surface chemistry to treated tissue culture plastic. The bulk architecture of the scaffolds was characterised by scanning electron microscopy (SEM) to assess the alignment of both random and aligned electrospun fibres, which were calculated to be 0.15 and 0.66, respectively. This compared to 0.51 for collagen fibres associated with native tissue. Tensile strength and strain of approximately of 0.15 MPa and 2.5%, respectively, allowed the scaffolds to be routinely handled for tissue culture purposes. The efficiency of attachment of smooth muscle cells to electrospun scaffolds was assessed using a modified 3-[4,5-dimethyl(thiazol-2yl)-3,5-diphery] tetrazolium bromide assay and cell morphology was assessed by phalloidin-FITC staining of F-actin. Argon plasma treatment of electrospun polystyrene scaffold resulted in significantly increased cell attachment (p<0.05). The alignment factors of the actin filaments were 0.19 and 0.74 for the random and aligned scaffold respectively, compared to 0.51 for the native tissue. The data suggests that electrospinning of polystyrene generates 3D scaffolds which complement polystyrene used in 2D cell culture systems.

Changes in gellan polymer morphology during the sol-gel transition were directly visualized by transmission electron microscopy and a model incorporating these changes and existing physical data is proposed. Our observations suggest that the most thermodynamically stable conformations of gellan polymers in solution, in the absence of added cations, are the double helix and double-helical duplexes. We have demonstrated two forms of lateral aggregation of gellan helices in the presence of Ca(2+) and K(+) ions. One type forms junction zones that lead to network formation and gelation, while the second type leads to the formation of isolated fibers of aggregated helices and inhibition of gelation. The proposed model of gellan gelation is based on these observations where thermoreversibility, gel strength, and endothermic transitions of gellan gels can be explained., (Copyright 2000 John Wiley & Sons, Inc.)

Objective: We aimed to assess whether GP input into discharge planning for high-risk aged in-patients admitted under the care of a geriatrician results in improved patient outcomes., Methods: We conducted a prospective randomized controlled trial in Sydney, Australia. The subjects were 364 patients aged 60 years and over. The main outcome measures included community service referral, accommodation changes, length of stay, readmission rate, length of time to first readmission and patient satisfaction with discharge arrangements., Results: No significant differences were found with regard to length of stay, readmission rates or time to first readmission. Test-group subjects were significantly more likely to be recommended for community services at discharge and to report that hospital personnel had discussed their discharge plan with them. Significantly more of the test group reported that their return home was well prepared., Conclusions: Although GP pre-discharge visits did not alter the likelihood of 'hard outcomes such as risk of readmission', the results suggest that quality of care is enhanced amongst patients receiving a pre-discharge visit and that GPs can perform a key role in planning post-discharge care with other services.

Objective: To compare GPs' willingness to participate in a GP pre-discharge project as measured by a survey, with actual participation rates. To identify the characteristics of GPs likely to make a pre-discharge visit to frail, aged inpatients admitted under the care of a geriatrician. METHOD PRE-IMPLEMENTATION GP SURVEY: Survey of a random sample of 100 GPs from the Central Sydney area using a standardised questionnaire. PRE-DISCHARGE VISIT PROJECT: Information on actual participation rates and GPs who declined to make a pre-discharge visit was obtained from an audit of Division of General Practice records. Information on Patient characteristics was obtained from patient interviews and medical records. The survey was conducted at the Balmain Hospital and Concord Repatriation and General Hospitals located within the Central Sydney Area Health Service. The subjects were GPs practising in central Sydney and patients admitted under the care of a geriatrician at Balmain and Concord Hospitals., Results: Twenty-nine per cent of GPs reported that they were willing to undertake visits without remuneration and 71% reported they were willing to make a pre-discharge visit if remunerated. Fifty-three per cent of GPs actually complied with a request to make a remunerated pre-discharge visit. This was 18% less than the rate determined by the survey. GPs were less likely to make a visit if they were solo practitioners and not members of the Division. Patients who were more dependent, as measured by total Barthel's score, and those from nursing homes were less likely to receive a visit., Conclusion: GP surveys may overestimate participation rates in Division projects. In reality, it appears difficult for GPs to accommodate pre-discharge visits in a general practice routine and the offered remunerations may not be adequate compensation for time lost when undertaking a pre-discharge visit. Lastly, some GPs may not see a benefit in visiting more dependent patients.