ARTICLE 39 OF THE CISG AND ITS “NOBLE MONTH” FOR NOTICE-GIVING; A (GRACEFULLY) AGEING DOCTRINE?

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Authentic Assessment in the Library Classroom: Transforming Activities into Assessment

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Use of Opioids for Pain Management in Nursing Homes: A Dissertation

Nursing homes are an essential yet understudied provider of cancer-related care for those with complex health needs. Nine percent of nursing home residents have a cancer diagnosis at admission, and it is estimated that one-third of them experience pain on a daily basis. Although pain management is an essential component of disease treatment, few studies have evaluated analgesic medication use among adults with cancer in this setting. Use of opioids, which are the mainstay of pain management in older adults because of their effectiveness in controlling moderate to severe pain, may be significantly related to coverage by the Medicare Part D prescription drug benefit. However, little is known about Medicare Part D’s effects on opioid use in this patient population. A limited body of evidence also suggests that despite known risks of overdose and respiratory depression in opioid-naïve patients treated with long-acting opioids, use of these agents may be common in nursing homes. This dissertation examined access to appropriate and effective pain-related health care services among US nursing home residents, with a special focus on those with cancer. Objectives of this dissertation were to: 1) estimate the prevalence, and identify resident-level correlates, of pain and receipt of analgesic medications; 2) use a quasi-experimental research design to examine the relationship between implementation of Medicare Part D and changes in the use of fentanyl patches and other opioids; and 3) to estimate the prevalence, and identify resident-level correlates, of naïve initiation of long-acting opioids. Data on residents’ health status from the Resident Assessment Instrument/Minimum Data Set (versions 2.0 and 3.0) were linked with prescription drug transaction data from a nationwide long-term care pharmacy (January 2005–June 2007) and the Centers for Medicare and Medicaid Services (January–December 2011). From 2006 to 2007, more than 65% of residents of nursing homes throughout the US with cancer experienced pain (28.3% on a daily basis), among whom 13.5% reported severe pain. More than 17% of these residents who experienced daily pain received no analgesics (95% confidence interval [CI]: 16.0–19.1%), and treatment was negatively associated among those with advanced age, cognitive impairment, feeding tubes, and restraints. These findings coincided with changing patterns in opioid use among residents with cancer, including relatively abrupt 10% and 21% decreases in use of fentanyl patches and other strong opioids, respectively, after the 2006 implementation of Medicare Part D. In the years since Medicare Part D was introduced, some treatment practices in nursing homes have not been concordant with clinical guidelines for pain management among older adults. Among a contemporary population of long-stay nursing home residents with and without cancer, 10.0% (95% CI: 9.4–10.6%) of those who began receiving a long-acting opioid after nursing home admission had not previously received opioid therapy. Odds of naïve initiation of these potent opioids were increased among residents with terminal prognosis, functional impairment, feeding tubes, and cancer. This dissertation provides new evidence on pharmaceutical management of pain and on Medicare Part D’s impact on opioid use in nursing home residents. Results from this dissertation shed light on nursing home residents’ access to pain-related health care services and provide initial directions for targeted efforts to improve the quality of pain treatment in nursing homes

Neuroethical issues in cognitive enhancement: Modafinil as the example of a workplace drug?

The use of cognitive-enhancing drugs by healthy individuals has been a feature for much of recorded history. Cocaine and amphetamine are modern cases of drugs initially enthusiastically acclaimed for enhancing cognition and mood. Today, an increasing number of healthy people are reported to use cognitive-enhancing drugs, as well as other interventions, such as non-invasive brain stimulation, to maintain or improve work performance. Cognitive-enhancing drugs, such as methylphenidate and modafinil, which were developed as treatments, are increasingly being used by healthy people. Modafinil not only affects 'cold' cognition, but also improves 'hot' cognition, such as emotion recognition and task-related motivation. The lifestyle use of 'smart drugs' raises both safety concerns as well as ethical issues, including coercion and increasing disparity in society. As a society, we need to consider which forms of cognitive enhancement (e.g. pharmacological, exercise, lifelong learning) are acceptable and for which groups under what conditions and by what methods we would wish to improve and flourish

Neuroethical issues in cognitive enhancement: Modafinil as the example of a workplace drug?

The use of cognitive-enhancing drugs by healthy individuals has been a feature for much of recorded history. Cocaine and amphetamine are modern cases of drugs initially enthusiastically acclaimed for enhancing cognition and mood. Today, an increasing number of healthy people are reported to use cognitive-enhancing drugs, as well as other interventions, such as non-invasive brain stimulation, to maintain or improve work performance. Cognitive-enhancing drugs, such as methylphenidate and modafinil, which were developed as treatments, are increasingly being used by healthy people. Modafinil not only affects 'cold' cognition, but also improves 'hot' cognition, such as emotion recognition and task-related motivation. The lifestyle use of 'smart drugs' raises both safety concerns as well as ethical issues, including coercion and increasing disparity in society. As a society, we need to consider which forms of cognitive enhancement (e.g. pharmacological, exercise, lifelong learning) are acceptable and for which groups under what conditions and by what methods we would wish to improve and flourish

Reimagining, Repurposing, Reinventing: Using Libguides for Instruction and Outreach

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Physiological Responses in Reindeer to the Application of a Conducted Electrical Weapon

Conducted Electrical Weapons (CEWs) have potential as effective alternatives to chemical restraint for short-term non-routine capture and handling as well as aversion hazing of wildlife. To assess immediate and delayed physiologic effects of exposure to a CEW, we assigned 15 captive reindeer (Rangifer tarandus tarandus) to one of three treatment groups: immobilized with carfentanil and xylazine (CX), 10 second exposure to a CEW, or exposure to the CEW while immobilized with CX (CEW+CX). Blood samples were collected pre-treatment, immediately post-intervention, 10 min, 20 min, 4 hours, and 24 hours post-intervention. Physiologic effects were evaluated by analysis of blood, clinical observation for signs of physiologic compromise, and vital signs. Parameters that changed significantly (P \u3c 0.05) post-exposure (lactate, glucose, rectal temperature, blood oxygen, cardiac troponin I, cortisol, and catecholamines) were not significantly different from baseline values within 24 hours. Cortisol, glucose, and peak rectal temperature were lower in CEW exposed individuals, while lactate, oxygen, and catecholamines were higher than for the CX exposed individuals. The catecholamine response observed in the CEW only group paralleled the response in the CEW+CX group. No long term health effects were detected from either restraint method. Use of a CEW does not appear to increase the risk of capture myopathy

Medicare Part D and Long-Term Care: A Systematic Review of Quantitative and Qualitative Evidence

BACKGROUND: In the largest overhaul to Medicare since its creation in 1965, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established Part D in 2006 to improve access to essential medication among disabled and older Americans. Despite previous evidence of a positive impact on the general Medicare population, Part D\u27s overall effects on long-term care (LTC) are unknown. OBJECTIVE: The purpose of this systematic review was to evaluate the literature regarding Part D\u27s impact on the LTC context, specifically costs to LTC residents, providers and payers; prescription drug coverage and utilization; and clinical and administrative outcomes. DATA SOURCES: Four electronic databases [PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Business Fulltext Elite and Science Citation Index Expanded], selected US government and non-profit websites, and bibliographies were searched for quantitative and qualitative studies characterizing Part D in the LTC context. Searches were limited to studies that may have been published between 1 January 2006 (date of Part D implementation) and 8 January 2013. STUDY SELECTION: Systematic searches identified 1,624 publications for a three-stage (title, abstract and full-text) review. Included publications were in English language; based in the US; assessed Part D-related outcomes; and included or were directly relevant to LTC residents or settings. News articles, reviews, opinion pieces, letters or commentaries; case reports or case series; simulation or modeling studies; and summaries that did not report original data were excluded. STUDY APPRAISAL AND SYNTHESIS METHODS: A standardized form was used to abstract study type, study design, LTC setting, sources of data, method of data collection, time periods assessed, unit of observation, outcomes and results. Methodological quality was assessed using modified criteria specific to quantitative and qualitative studies. RESULTS: Eleven quantitative and eight qualitative studies met inclusion criteria. In the seven years since its implementation, Part D decreased out-of-pocket costs among enrolled nursing home residents and potentially increased costs borne by LTC facilities. Coverage of prescription drugs frequently used by older adults was adequate, except for certain drugs and alternative formulations of importance to LTC residents. The use of medications that raise safety concerns was decreased, but overall drug utilization may have been unaffected. Although there was uncertain impact on clinical outcomes, quantitative studies demonstrated evidence of unintended health consequences. Qualitative studies consistently revealed increased administrative burden among providers. LIMITATIONS: Empirical evidence of Part D\u27s LTC impact was sparse. Due to limitations in available types of data, quantitative studies were generically lacking in methodological rigor. Qualitative studies suffered from lack of clarity of reporting. As future studies use clinical Medicare data, study quality is expected to improve. CONCLUSION: Although LTC-specific policies continue to evolve, it appears that the prescription drug benefit may require further modifications to more effectively provide for LTC residents\u27 unique medication needs and improve their health outcomes. Adjustments may be needed for Part D to be more compatible with LTC prescription drug delivery processes

Pharmaceutical Pain Management among Older Adults with Cancer in Nursing Homes

Background: In the mid-1990s, 29.4% of nursing home (NH) residents with cancer suffered from daily pain, and among them 26% failed to receive analgesic medication. Improvements in cancer pain management in NHs have not been re-evaluated since the implementation of pain management quality indicators. Methods: We performed a cross-sectional study using nationwide data on NH resident health from the Minimum Data Set (version 2.0) linked to all-payer pharmacy dispensing records (February 2006–June 2007). Prevalence of pain (daily, less than daily, horrible/excruciating, moderate) and receipt of non-opioid and opioid analgesics were calculated. We used multinomial logistic regression to evaluate resident-level correlates of pain and binomial logistic regression to identify correlates of untreated pain. Results: 8,094 newly-admitted, Medicare-eligible residents had cancer. 65.6% had any pain (28.3% daily, 37.3% less than daily), among whom 13.5% had severe and 61.3% had moderate pain. Women, residents who were bedfast and those with compromised activities of daily living, depressed mood, indwelling catheter, or terminal prognosis were more likely to report pain. More than 17% of residents in daily pain (95% confidence interval [CI], 15.8–18.9%) and 14.2% with horrible/excruciating pain (95% CI, 11.7–16.8%) received no analgesics. Analgesic treatment was negatively associated with age \u3e85 (adjusted odds ratio [aOR]=0.67, 95% CI: 0.55–0.81 versus aged 65–74), impaired cognition (aOR=0.71, 95% CI: 0.61–0.82), presence of feeding tube (aOR=0.75, 95% CI: 0.58–0.97), and use of restraints (aOR=0.50, 95% CI: 0.31–0.81). Conclusion: Untreated pain is still common among NH residents with cancer, and persists despite pain management quality indicators