Obtaining a durable power of attorney for health care from nursing home residents

BACKGROUND: A durable power of attorney for health care (DPA) allows a person to appoint a surrogate decision-maker for any future period of mental incapacity. The absence of advance directives can lead to confusion and the expenditure of resources while trying to exert a substituted judgment. METHODS: The Wisconsin DPA was presented with an organized pilot program to 150 residents who had been judged by their social workers to have the capacity to make informed decisions regarding medical care. The reasons residents gave for accepting or rejecting a DPA were analyzed. RESULTS: Seventy-nine percent prepared a DPA. Reasons for signing included allowing the resident to decide who would make medical decisions and assuring that specific wishes would be carried out. Twenty-one percent did not execute a DPA. Reasons were categorized as confusion and misunderstanding regarding the legal system, mistrust, or social isolation. CONCLUSIONS: The high rate (79%) of DPA completion is probably related to individually counseling residents. However, competent residents who despite counseling do not choose to execute a DPA can have detailed advance directives ("living wills") prepared without appointing a decision-maker.     

Early assessment of diaphragmatic dysfunction in children in the ITU: chest radiology and phrenic nerve stimulation

Diaphragmatic dysfunction is a common postoperative complication of cardiac surgery in children, with important effects on respiratory morbidity. Its early diagnosis, followed by prompt surgical intervention, has been shown to reduce morbidity. However, the commonest method of diagnosis, based on hemi-diaphragmatic elevation on the chest radiograph, may be less accurate than direct techniques for assessing phrenic nerve function. We have compared electrophysiological and radiological diagnoses of diaphragmatic abnormality in 100 children (aged 3 days to 17.5 yrs) undergoing cardiac surgery, looking at respiratory morbidity as assessed by the duration of ventilation, the time spent on the cardiac intensive care unit (CICU), and the requirement for reintubation. Despite showing good reproducibility, radiological diagnosis was neither sensitive nor specific in identifying patients with electrophysiological phrenic nerve damage. Analysis of the measures of outcome supported the electrophysiological technique. Patients with electrophysiological evidence of damage had a longer duration of ventilation, spent longer on the CICU, and had a greater incidence of reintubation than either radiologically abnormal or "normal" patients. Chest X-rays are not a good method for diagnosing phrenic nerve damage in the early postoperative period in children. If early diagnosis is needed, then direct assessment of phrenic nerve function, such as the measurement of phrenic latency, may be a better technique.     

Dynamic fatigue of brittle materials containing indentation line flaws

A study is made of the dynamic fatigue response of brittle materials containing indentation-induced line flaws. The theoretical fracture mechanics of median crack evolution to failure under applied tension are first developed, with special emphasis on the role of residual contact stresses. In particular, it is shown that use of fatigue curves to evaluate the exponent in an assumed power-law crack velocity function may result in systematic error, by as much as a factor of two, if proper account is not taken of this residual contact contribution. Data from strength tests on soda-lime glass bars in water, using a tungsten carbide cutting wheel to introduce the median pre-cracks, confirm the basic predictions. The results suggest that extreme care needs to be exercised when using surfaces with a contact history, e.g. as with machining damage, in fatigue test programmes for materials analysis.     

Fatigue analysis of brittle materials using indentation flaws

The results of an experimental dynamic fatigue study on glass-ceramic specimens containing indentation flaws are analysed in terms of the theory developed in Part 1. A Vickers indenter is used to introduce the flaws, and a conventional four-point bend apparatus to break the specimens. Base-line data for testing the essential theoretical predictions and for evaluating key material/environment parameters are obtained from polished surfaces, i.e. surfaces prepared to a sufficient finish to ensure removal of any pre-existing spurious stresses. The fatigue tests are carried out in water. Inert strength tests in dry nitrogen are used to calibrate appropriate equilibrium fracture parameters, with dummy indentations on selected control specimens providing a convenient measure of the critical crack dimensions at failure. Regression analysis of the dynamic fatigue data yields values for apparent kinetic parameters, which are converted to true kinetic parameters via the transformation equations of Part I. Regeneration of the fatigue function from the theory using the parameters thus determined gives a curve which passes closely through the experimental data points, thereby providing a self-consistent check of the formalism. The implications of the results in relation to the use of macroscopic fracture parameters in the prediction of strength properties for materials with small-scale flaws is an important adjunct to this work. Finally, a recommended procedure for the general testing of dynamic fatigue properties of ceramics using indentation flaws is described.     

Hand function related to age and sex

After adapting Jebssen's Test of Hand Function to Australian conditions, this study investigated his claim of no significant difference in hand performance among participants younger than 60 years, and determined whether age might be a factor when associated with sex. The method was to test 383 subjects of both sexes in 6 age groups. A 2-factor analysis with age and sex as factors yielded significant differences (p less than 0.01) for "grip strength" "manipulating small objects," and "moving large heavy objects," and indications of significance (p less than 0.05) for "card turning" and "moving large light objects." The sex factor showed males to be significantly better "grip strength," in "moving large heavy objects," and "large light objects," except in the 66-99 age interval where females were significantly better on teh last 2 variables. Females performed better on "writing" and were generally better in "manipulating small objects." These results suggest that the one set of norms given by Jebsen for 60 years and less for each sex, should be replaced by 5 or more, even though the differences were quite small when standard deviations were considered.     

Changes in serum thyrotropin (TSH) in man during halofenate administration

Halofenate, a serum lipid-lowering agent which inhibits binding of thyroid hormone to thyroxine-binding globulin (TBG), was administered daily for 14 days to 8 hypothyroid subjects with elevated TSH concentrations as a result of incomplete thyroxine (T4) therapy. Drug administration resulted in mean increases in serum dialyzable fraction T4 (DFT4) of 52% over pretreatment levels (P less than 0.01) and in dialyzable fraction triiodothyronine (DFT3) of 26% in 7 subjects, (P less than 0.01). During halofenate treatment in these 7 subjects, serum TSH concentrations decreased significantly (mean = 39%, P less than 0.01) when DFT4 and DFT3 were increased by halofenate. In only two subjects was there a convincing temporal relationship between increased serum absolute free T4 (AFT4) and decreased serum TSH concentrations. Contrary to what would be predicted from the "free hormone hypothesis", changes in serum TSH concentration in these hypothyroid patients appeared to relate primarily to changes in the free fraction of circulating T4 and T3 (DFT4, DFT3), rather than to alterations in AFT4 or AFT3. Halofenate did not alter serum TBG binding capacity. An eighth subject did not show increased DFT4 and DFT3 during halofenate treatment despite achievement of therapeutic serum levels of the agent; in this patient, serum TSH levels rose progressively throughout the period of inadequate T4 replacement and halofenate administration. In hypothyroid patients, short-term halofenate use suggests that the pituitary-thyroid hormone feedback circuit can respond to increases in serum DFT4 and DFT3 in the absence of detactable increases in absolute free hormone concentrations.     

Sustainable Disposal of Domestic Sanitary Waste

The study presented is an example of the assessment of the relative sustainability of either option for disposal of domestic sanitary waste, either via the toilet or via the solid waste route. This required an evaluation of the total (social, economic, environmental, and technical) benefit/cost of implementing and adopting the alternative routes and an assessment of public responsiveness to encouragement to change sanitary waste disposal practices. It illustrates how, even for an apparently straightforward either/or question, the assessment of relative sustainability is complex and the amount of data needed to quantify sustainability indicators is prodigious. The study also provides an appraisal of the effectiveness of public campaigns to reduce waterborne disposal. Important information regarding public attitude and behavior in relation to wastewater systems has been acquired and lessons for ways of encouraging behavioral change to more sustainable ways of living have been gleaned.     

Using cognitive artifacts to understand distributed cognition

Studies of patient safety have identified gaps in current work including the need for research about communication and information sharing among healthcare providers. They have also encouraged the use of decision support tools to improve human performance. Distributed cognition is the shared awareness of goals, plans, and details that no single individual grasps. Cognitive artifacts are objects such as: schedules, display boards, lists, and worksheets that form part of a distributed cognition. Cognitive artifacts that are related to operating room (OR) scheduling include: the availabilities sheet, master schedule, OR graph, and OR board. All provide a "way in" to understand how teams in the acute care setting dynamically plan and manage the balance between demand for care and the resources available to provide it. This work has import for the way that information technology supports the organization, management, and use of healthcare resources. Better computer-supported cognitive artifacts will benefit patient safety by making teamwork processes, planning, communications, and resource management more resilient.     

A Note on Testing for Homogeneity Among Effect Sizes Sharing a Common Control Group.

L. V. Hedges and I. Olkin (1985) presented a statistic to test for homogeneity among correlated effect sizes and L. J. Gleser and I. Olkin (1994) presented a large-sample approximation to the covariance matrix of the correlated effect sizes. This article presents a more exact expression for this covariance matrix, assuming normally distributed data but not large samples, for the situation where effect sizes are correlated because a single control group was compared with more than one treatment group. After the correlation between effect sizes has been estimated, the standard Q statistic for correlated effect sizes can be used to test for homogeneity. This method is illustrated using results from schizophrenia research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Discriminative Stimulus, Reinforcing, Physical Dependence, and Antinociceptive Effects of Oxycodone in Mice, Rats, and Rhesus Monkeys.

Despite oxycodone's (4,5-epoxy-14-hydroxy-3-methoxy-17-methylmorphinan-6-one) history of clinical use and the attention it has received as a drug of abuse, few reports have documented its pharmacology's relevance to its abuse or its mechanism of action. The purposes of the present study were to further characterize the analgesic effects of oxycodone, its mechanism of action, and its effects in terms of its relevance to its abuse liability. The results indicate that oxycodone had potent antinociceptive effects in the mouse paraphenylquinone writhing, hot-plate, and tail-flick assays, in which it appeared to be acting as a μ-opioid receptor agonist. It generalized to the heroin discriminative stimulus and served as a positive reinforcer in rats and completely suppressed withdrawal signs in morphinedependent rhesus monkeys. These results suggest that the analgesic and abuse liability effects of oxycodone are likely mediated through μ-opioid receptors and provide the first laboratory report of its discriminative stimulus, reinforcing, and morphine cross-dependency effects. (PsycINFO Database Record (c) 2010 APA, all rights reserved)