Physicians' and nurses' perspectives on increased family reports of pain in dying hospitalized patients

Many indicators suggest that care of the dying in Oregon has been improving over the past decade. However, results from a recent study suggest that one aspect of care of the dying, pain management, may be worsening. In late 1997, family reports of moderate and severe pain in dying hospitalized patients increased from 33% to 57%. This occurred during a volatile time in the Oregon political climate associated with events surrounding a second vote on physician-assisted suicide. In order to better understand the observed increase better, a statewide sample of physicians and nurses was surveyed to obtain their opinions about factors that may have contributed to the increased family reports of moderate and severe pain in dying hospitalized patients. Seventy-nine percent of respondents endorsed two or more factors as partial explanations. These factors include an increase in family expectations about pain management (endorsed by 96%), decreased physician prescribing (endorsed by 66%), and reduced nurse administration of pain medication (endorsed by 59%). Physicians who thought reduced physician prescribing was a partial factor rated fears of the Board of Medical Examiners and the Drug Enforcement Administration as the most likely explanations for decreased prescribing. More research is needed to better understand family expectations for end-of-life care, fears of investigation, and pain medication practices

A J-band detection of the donor star in the dwarf nova OY Carinae, and an optical detection of its `iron curtain'

Purely photometric models can be used to determine the binary parameters of eclipsing cataclysmic variables with a high degree of precision. However, the photometric method relies on a number of assumptions, and to date there have been very few independent checks of this method in the literature. We present time-resolved spectroscopy of the P=90.9 min eclipsing cataclysmic variable OY Carinae obtained with X-shooter on the VLT, in which we detect the donor star from K I lines in the J-band. We measure the radial velocity amplitude of the donor star K2 = 470.0 +/- 2.7 km/s, consistent with predictions based upon the photometric method (470 +/- 7 km/s). Additionally, the spectra obtained in the UVB arm of X-shooter show a series of Fe I and Fe II lines with a phase and velocity consistent with an origin in the accretion disc. This is the first unambiguous detection at optical wavelengths of the `iron curtain' of disc material which has been previously reported to veil the white dwarf in this system. The velocities of these lines do not track the white dwarf, reflecting a distortion of the outer disc that we see also in Doppler images. This is evidence for considerable radial motion in the outer disk, at up to 90 km/s towards and away from the white dwarf.Comment: MNRAS accepted. 11 pages with 10 figures and 2 table

Trends in opioid use over time: 1997 to 1999

Substantial resources have been spent to improve pain control for dying patients, and increased opioid administration has been presumed. Oregon has been a consistent leading state in per capita use for morphine for the past 10 years, as recorded by the Automation of Reports and Consolidated Orders System (ARCOS). Health policy experts, extrapolating from World Health Organization methods, have suggested these data are indicative of the quality of end-of-life care in Oregon. To determine whether trends in opioid prescription at the state and national levels reflect increased opioid use for inpatients during the final week of life, chart reviews were conducted to record all opioid medications administered in the last week of life to 877 adult inpatients who died from natural causes between January 1, 1997 and December 31, 1999. Inpatient morphine use did not increase significantly for dying patients from 1997 to 1999. However, overall morphine use for both Oregon and the United States as measured by ARCOS data increased significantly. Comparisons revealed no significant difference between linear trends for Oregon and U.S. morphine use, but both were significantly greater than the dying inpatients. This pattern was also found for all other opioids. These findings suggest that ARCOS data do not necessarily provide information about opioid use for specific subpopulations of patients and raise questions about the meaning of observed increases in ARCOS data

Induction Heating Model of Cermet Fuel Element Environmental Test (CFEET)

Deep space missions with large payloads require high specific impulse and relatively high thrust to achieve mission goals in reasonable time frames. Nuclear Thermal Rockets (NTR) are capable of producing a high specific impulse by employing heat produced by a fission reactor to heat and therefore accelerate hydrogen through a rocket nozzle providing thrust. Fuel element temperatures are very high (up to 3000 K) and hydrogen is highly reactive with most materials at high temperatures. Data covering the effects of hightemperature hydrogen exposure on fuel elements are limited. The primary concern is the mechanical failure of fuel elements due to large thermal gradients; therefore, highmeltingpoint ceramicsmetallic matrix composites (cermets) are one of the fuels under consideration as part of the Nuclear Cryogenic Propulsion Stage (NCPS) Advance Exploration System (AES) technology project at the Marshall Space Flight Center. The purpose of testing and analytical modeling is to determine their ability to survive and maintain thermal performance in a prototypical NTR reactor environment of exposure to hydrogen at very high temperatures and obtain data to assess the properties of the nonnuclear support materials. The fission process and the resulting heating performance are well known and do not require that active fissile material to be integrated in this testing. A smallscale test bed; Compact Fuel Element Environmental Tester (CFEET), designed to heat fuel element samples via induction heating and expose samples to hydrogen is being developed at MSFC to assist in optimal material and manufacturing process selection without utilizing fissile material. This paper details the analytical approach to help design and optimize the test bed using COMSOL Multiphysics for predicting thermal gradients induced by electromagnetic heating (Induction heating) and Thermal Desktop for radiation calculations

Hospital service use in the last year of life by Indigenous Australians who died of heart failure or cardiomyopathy : a linked data study

Background: Aboriginal and Torres Strait Islander peoples experience disproportionate rates of heart failure. However, information regarding their use of hospital services in the last year of life is poorly delineated to inform culturally appropriate end-of-life health services. Objectives: To quantify hospital service use in the last year of life of Aboriginal and Torres Strait Islander peoples who died of heart failure or cardiomyopathy in Queensland, Australia. Methods: A subgroup analysis of a larger retrospective linkage study using administrative health data in Queensland, Australia. Individuals that identified as an Aboriginal and Torres Strait Islander person from their first hospital admission in the last year of life, who died of heart failure or cardiomyopathy from 2008 to 2018, were included. Results: There were 99 individuals, with emergency department presentation/s recorded for 85 individuals. Over 50% of individuals presenting to the Emergency Department were from regional areas (n = 43, 51%). The 99 individuals had a total of 472 hospital admissions, excluding same day admissions for haemodialysis, and 70% (n = 70) died in hospital. Most admissions were coded as acute care (n = 442, 94%), and fewer were coded as palliative care (n = 19, 4%). Median comorbidities or factors that led to hospital contact = 5 (interquartile range 3–9). Conclusion: Acute care hospital admissions in the last year of life by this population are common for those who died of heart failure or cardiomyopathy. Multimorbidity is prevalent in the last year of life, underscoring the importance of primary health care, provided by nurses and Indigenous health workers

Opportunistic pathology-based screening for diabetes

OBJECTIVE To determine the potential of opportunistic glycated haemoglobin (HbA1c) testing of pathology samples to detect previously unknown diabetes. DESIGN Pathology samples from participants collected for other reasons and suitable for HbA1c testing were utilised for opportunistic diabetes screening. HbA1c was measured with a Biorad Variant II turbo analyser and HbA1c levels of ≥6.5% (48 mmol/mol) were considered diagnostic for diabetes. Confirmation of previously unknown diabetes status was obtained by a review of hospital medical records and phone calls to general practitioners. SETTING Hospital pathology laboratory receiving samples from hospital-based and community-based (CB) settings. PARTICIPANTS Participants were identified based on the blood sample collection location in the CB, emergency department (ED) and inpatient (IP) groups. Exclusions pretesting were made based on the electronic patient history of: age <18 years, previous diabetes diagnosis, query for diabetes status in the past 12 months, evidence of pregnancy and sample collected postsurgery or transfusion. Only one sample per individual participant was tested. RESULTS Of the 22 396 blood samples collected, 4505 (1142 CB, 1113 ED, 2250 IP) were tested of which 327 (7.3%) had HbA1c levels ≥6.5% (48 mmol/mol). Of these 120 (2.7%) were determined to have previously unknown diabetes (11 (1%) CB, 21 (1.9%) ED, 88 (3.9%) IP). The prevalence of previously unknown diabetes was substantially higher (5.4%) in hospital-based (ED and IP) participants aged over 54 years. CONCLUSIONS Opportunistic testing of referred pathology samples can be an effective method of screening for diabetes, especially in hospital-based and older persons.This project was supported by a grant from the Canberra Hospital Private Practice Trust Fund

The Claims Culture: A Taxonomy of Industry Attitudes

This paper presents an analysis of a familiar aspect of construction industry culture that we have dubbed 'the claims culture'. This is a culture of contract administration that lays a strong emphasis on the planning and management of claims. The principal elements of the analysis are two sets of distinctions. The first comprises economic and occupational orders, referring to two kinds of control that are exercised over the construction process; predicated respectively on economic ownership and occupational competence. The second refers to contrasting attitudes towards relationships and problem solving within these orders: respectively 'distributive' and 'integrative'. The concepts of economic and occupational order entail further sub-categories. The various attitudes associated with these categories and sub-categories are described. They are assessed as to their consequences for change initiatives in the industry