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

Tradeoffs limit the evolution of male traits that are attractive to females

Tradeoffs occur between a variety of traits in a diversity of organisms, and these tradeoffs can have major effects on ecological and evolutionary processes. Far less is known, however, about tradeoffs between male traits that affect mate attraction than about tradeoffs between other types of traits. Previous results indicate that females of the variable field cricket, Gryllus lineaticeps, prefer male songs with higher chirp rates and longer chirp durations. In the current study, we tested the hypothesis that a tradeoff between these traits affects the evolution of male song. The two traits were negatively correlated among full-sibling families, consistent with a genetically based tradeoff, and the tradeoff was stronger when nutrients were limiting. In addition, for males from 12 populations reared in a common environment, the traits were negatively correlated within populations, the strength of the tradeoff was largely invariant across populations, and the within-population tradeoff predicted how the traits have evolved among populations. A widespread tradeoff thus affects male trait evolution. Finally, for males from four populations assayed in the field, the traits were negatively correlated within and among populations. The tradeoff is thus robust to the presence of environmental factors that might mask its effects. Together, our results indicate there is a fundamental tradeoff between male traits that: (i) limits the ability of males to produce multiple attractive traits; (ii) limits how male traits evolve; and (iii) might favor plasticity in female mating preferences. Includes Supplementary Materials

Detection of HC11N in the Cold Dust Cloud TMC-1

Two consecutive rotational transitions of the long cyanopolyyne HC11N, J=39-38, and J=38-37, have been detected in the cold dust cloud TMC-1 at the frequencies expected from recent laboratory measurements by Travers et al. (1996), and at about the expected intensities. The astronomical lines have a mean radial velocity of 5.8(1) km/s, in good agreement with the shorter cyanopolyynes HC7N and HC9N observed in this very sharp-lined source [5.82(5) and 5.83(5) km/s, respectively]. The column density of HC11N is calculated to be 2.8x10^(11) cm^(-2). The abundance of the cyanopolyynes decreases smoothly with length to HC11N, the decrement from one to the next being about 6 for the longer carbon chains.Comment: plain tex 10 pages plus 3 ps fig file

Effects of 5 Different Finger Rest Positions on Arm Muscle Activity During Scaling by Dental Hygiene Students

Purpose. This study was conducted to determine the effects of 5 different finger rest positions: opposite arch, standard intraoral, basic extraoral, cross arch, and finger on finger on the muscle activity of 4 forearm muscles (extensor carpi radialis longus, flexor carpi ulnaris, biceps brachii, and pronator teres) during a simulated periodontal scaling experience. Methods. A convenience sample of 32 consenting senior dental hygiene students who met inclusion criteria participated. Using a 4 x 5 counter-balanced research design, each participant used a Gracey 11/12 curet to scale one cc of artificial calculus from first permanent molar typodont teeth (#3,14,19,30). Five different typodonts were set up for each participant with fulcrums randomly assigned for use on each typodont. While scaling, the participant’s muscle activity was measured by surface electromyography. Two-way analysis of variance with repeated measures was used to determine if significant differences existed in the amount of muscle activity generated with each fulcrum. Results. Results revealed no statistically significant interaction effect between area of the mouth scaled, muscle activity, and fulcrum used. Similar muscle activity was produced throughout the mouth regardless of the fulcrum used. The upper right quadrant produced the most muscle activity (p= 0.0101) and the lower left quadrant produced the least (p=\u3c .0001). When comparing the overall muscle activity generated with each fulcrum, only the cross arch fulcrum when compared to the opposite fulcrum produced statistically significant results (p=0.0110). Conclusions. Based on the results, similar muscle activity is produced when using any of the 5 fulcrums in each quadrant of the mouth. Clinicians appear to experience minimal ergonomic advantage in terms of fulcrums used and area of the mouth scaled during a simulated scaling experience

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

A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physician Orders for Life-Sustaining Treatment (POLST) Program

Background Traditional methods to communicate life-sustaining treatment preferences are largely ineffective. The Physician Orders for Life-Sustaining Treatment (POLST) Program offers an alternative approach, but comparative data are lacking. Objectives To evaluate the relationship between communication methods (POLST versus traditional practices) and documentation of life-sustaining treatment orders, symptom assessment and management, and use of life-sustaining treatments. Design Retrospective observational cohort study conducted between June 2006 and April 2007. Setting A stratified, random sample of 90 Medicaid-eligible nursing facilities in Oregon, Wisconsin, and West Virginia. Subjects 1711 living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay. Measurements Life-sustaining treatment orders; pain, shortness of breath, and related treatments over a 7-day period; and use of life-sustaining treatments over a 60-day period. Results POLST users were more likely to have orders about life-sustaining treatment preferences beyond CPR than non-POLST users (98.0% vs. 16.1%, P<.001). There were no differences between POLST users and non-users in symptom assessment or management. POLST users with orders for Comfort Measures Only were less likely to receive medical interventions (e.g., hospitalization) than residents with POLST Full Treatment orders (P=.004), residents with Traditional DNR orders (P<.001), or residents with Traditional Full Code orders (P<.001). Conclusion POLST users were more likely to have treatment preferences documented as medical orders than non-POLST users but there were no differences in symptom management or assessment. POLST orders restricting medical interventions were associated with the lower use of life-sustaining treatments. Findings suggest the POLST program offers significant advantages over traditional methods to communicate preferences about life-sustaining treatments

Three particles in a finite volume: The breakdown of spherical symmetry

Lattice simulations of light nuclei necessarily take place in finite volumes, thus affecting their infrared properties. These effects can be addressed in a model-independent manner using Effective Field Theories. We study the model case of three identical bosons (mass m) with resonant two-body interactions in a cubic box with periodic boundary conditions, which can also be generalized to the three-nucleon system in a straightforward manner. Our results allow for the removal of finite volume effects from lattice results as well as the determination of infinite volume scattering parameters from the volume dependence of the spectrum. We study the volume dependence of several states below the break-up threshold, spanning one order of magnitude in the binding energy in the infinite volume, for box side lengths L between the two-body scattering length a and L = 0.25a. For example, a state with a three-body energy of -3/(ma^2) in the infinite volume has been shifted to -10/(ma^2) at L = a. Special emphasis is put on the consequences of the breakdown of spherical symmetry and several ways to perturbatively treat the ensuing partial wave admixtures. We find their contributions to be on the sub-percent level compared to the strong volume dependence of the S-wave component. For shallow bound states, we find a transition to boson-diboson scattering behavior when decreasing the size of the finite volume.Comment: 21 pages, 4 figures, 2 table

Decreased mental time travel to the past correlates with default-mode network disintegration under lysergic acid diethylamide

This paper reports on the effects of LSD on mental time travel during spontaneous mentation. Twenty healthy volunteers participated in a placebo-controlled crossover study, incorporating intravenous administration of LSD (75 μg) and placebo (saline) prior to functional magnetic resonance imaging (fMRI). Six independent, blind judges analysed mentation reports acquired during structured interviews performed shortly after the functional magnetic resonance imaging (fMRI) scans (approximately 2.5 h post-administration). Within each report, specific linguistic references to mental spaces for the past, present and future were identified. Results revealed significantly fewer mental spaces for the past under LSD and this effect correlated with the general intensity of the drug’s subjective effects. No differences in the number of mental spaces for the present or future were observed. Consistent with the previously proposed role of the default-mode network (DMN) in autobiographical memory recollection and ruminative thought, decreased resting-state functional connectivity (RSFC) within the DMN correlated with decreased mental time travel to the past. These results are discussed in relation to potential therapeutic applications of LSD and related psychedelics, e.g. in the treatment of depression, for which excessive reflection on one’s past, likely mediated by DMN functioning, is symptomatic

The Importance of PRI Therapy for the Pastoral Counsellor

It is not always easy for pastoral counsellors to help people change. Often people have become stuck in their ways. Recent developments in the field of brain research help explain why change is difficult. This article discusses Past Reality Integration Therapy (PRI), a psychotherapeutic method that integrates recent findings of brain research and offers an important addition to the work of (pastoral) counsellors and psychotherapists. The use of this approach with Dutch students in their pastoral training is presented. Furthermore the importance of this new method for counsellors themselves, their clients and their work is discussed and some overall conclusions about the method and its practical application are presented