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

Beyond Trade Secrecy: Confidentiality Agreements that Act Like Noncompetes

There is a substantial literature on noncompete agreements and their adverse impact on employee mobility and innovation. But a far more common restraint in employment contracts has been underexplored: confidentiality agreements, sometimes called nondisclosure agreements (NDAs). A confidentiality agreement is not a blanket prohibition on competition. Rather, it is simply a promise not to use or disclose specific information. Confidentiality agreements encompass trade secrets, as defined by state and federal laws, but confidentiality agreements almost always go beyond trade secrecy, encompassing any information the employer imparted to the employee in confidence. Despite widespread use, confidentiality agreements have received little attention. Many commentators view them as innocuous compared to noncompetes. However, confidentiality agreements that go beyond trade secrecy are not harmless. Leveraging an original dataset of confidentiality agreements in employment relationships disclosed in federal trade secret litigation, this Article argues that many of these agreements have the effect of noncompetes. They protect far more information than trade secret law does—including publicly available or generally known information, and information that trade secret law would classify as unprotectable “general knowledge, skill, and experience.” They prohibit use as well as disclosure of the covered information. Most provide for injunctions in the event of breach, and nearly half provide for payment of attorney’s fees and costs. And unlike most noncompetes, they almost never have geographic or temporal limitations. The phenomenon of confidentiality agreements that “act like noncompetes” has not gone unnoticed. For example, the Federal Trade Commission (FTC) recently issued an unprecedented Notice of Proposed Rulemaking announcing its intention to effectively ban workplace noncompetes nationwide. The FTC also condemned what it calls “de facto non-compete clauses,” including overly broad confidentiality agreements. The FTC’s rulemaking has yet to move forward and is likely to be mired in legal challenges. Fortunately, this Article reveals that courts across the nation have already begun to invalidate confidentiality agreements that operate as de facto noncompetes. Regardless of whether the FTC ultimately succeeds in regulating these agreements, courts have the power and precedent to do so on their own. Drawing on case law and prior proposals, this Article gives guidance going forward. It does not advocate for a blanket ban on confidentiality agreements. Rather, it contends that courts and other decision makers should treat confidentiality agreements that go beyond trade secrecy under a default rule of unenforceability, similar to how most jurisdictions treat noncompetes. The burden should be on the employer to prove that such agreements are reasonably related to protecting legitimately secret information and that they do not function like noncompetes

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