The experience of being a carer of a person with dementia at the end of life is expressed in these 12 accounts. This is a synthesis of the concerns and challenges for carers at the end of life. These ...accounts are often insightful and provide several views of carers’ and professionals’ experience. Having a close relationship as a carer gives a unique and poignant view. What emerges from this review is a range of perspectives that provide contrasting views of the heterogeneity of carers and professionals. This may be helpful for professionals and policy makers to consider when planning end-of-life care strategies for people with dementia and insights drawn from hearing directly from carers may be powerful learning tools.
BACKGROUND:Physician’s prescribing preference is increasingly used as an instrumental variable in studies of therapeutic effects. However, differences in prescribing patterns among physicians may ...reflect differences in preferences or in case-mix. Furthermore, there is debate regarding the possible assumptions for point estimation using physician’s preference as an instrument.
METHODS:A survey was sent to general practitioners (GPs) in The Netherlands, the United Kingdom, New Zealand, Ireland, Switzerland, and Germany, asking whether they would prescribe levothyroxine to eight fictitious patients with subclinical hypothyroidism. We investigated (1) whether variation in physician’s preference was observable and to what extent it was explained by characteristics of GPs and their patient populations and (2) whether the data were compatible with deterministic and stochastic monotonicity assumptions.
RESULTS:Levothyroxine prescriptions varied substantially among the 526 responding GPs. Between-GP variance in levothyroxine prescriptions (logit scale) was 9.9 (95% confidence interval8.0, 12) in the initial mixed effects logistic model, 8.3 (6.7, 10) after adding a fixed effect for country and 8.2 (6.6, 10) after adding GP characteristics. The occurring prescription patterns falsified the deterministic monotonicity assumption. All cases in all countries were more likely to receive levothyroxine if a different case of the same GP received levothyroxine, which is compatible with the stochastic monotonicity assumption. The data were incompatible with this assumption for a different definition of the instrument.
CONCLUSIONS:Our study supports the existence of physician’s preference as a determinant in treatment decisions. Deterministic monotonicity will generally not be plausible for physician’s preference as an instrument. Depending on the definition of the instrument, stochastic monotonicity may be plausible.
Dementia accounts for one in three deaths among people aged 65 and over, but end-of-life care for people with dementia is often sub-optimal. Palliative care for people with dementia poses particular ...challenges to those providing services, and current policy initiatives recommend education and training in palliative care for those working with patients with dementia. However, there are few evaluations of the effectiveness of dementia education and training. This paper presents a narrative review undertaken in 2011–2012 of evaluations of palliative care education for those working with people with dementia at the end of life. A total of eight papers were identified that described and evaluated such palliative care education; none reported benefits for people with dementia. There is a clear need to develop and evaluate educational interventions designed to improve palliative and end-of-life care for people with dementia. Some suggestions for educationally sound approaches are discussed.
Drawing from anthropological fieldwork in three jazz clubs, this dissertation explores the global scale of contemporary jazz practice through an examination of the communities that sustain them in ...Los Angeles, California; Santiago, Chile; and Novosibirsk, Siberia. These spaces, which bear striking similarities to one another both in terms of architectural aesthetics and community practices despite the vast distance between them, are investigated as instantiations of jazz space informed by logics of jazz listening, and as sites of jazz practice—a process that I call jazz anthropology. It argues that to understand why jazz practices continue to manifest anywhere, we must understand what they mean to people elsewhere—that is, beyond the music’s geographical centers of production on the U.S. East Coast. By attending to these peripheries, we can hear the music as a manifestation of jazz consciousness, as tendrils of black radical modes of thinking transposed to far-flung geographies—even ones that very few black people inhabit. To situate these practices in a longer genealogical timespan, the dissertation also includes brief historical sketches of jazz practice in each of the three locations in 1917, 1959, and 1990, demonstrating the long local histories that inform the music in each locale. Each subsequent chapter focuses on a different club, as well as a distinctive aspect of global jazz world-making. Taken together, they tell a story of how people around the world share a sense of meaning and emplacement in ideas of Jazz as a universal signifier.
To synthesize information about management of end of life care in people with dementia using review papers.
There are increasing numbers of people being diagnosed with dementia worldwide, and the ...needs of people with dementia and their carers at the end of life may be different from those with other chronic diseases. By highlighting the challenges of palliative care in persons with dementia and the ways they are best managed, practitioners in primary care may be able to improve services for this group of people at the end of life.
A search of electronic databases of English language papers published in peer-reviewed journals, 2000-2011 inclusive was undertaken using broad terms related to palliative care and dementia. 6167 papers were identified. Titles and abstracts were read. Papers were included if they were literature reviews of palliative or end of life care for people with dementia/Parkinson's disease/Lewy body dementia/cognitive impairment/Alzheimer's disease or any other cognitive impairment, in any setting (hospital, care home, community) and covering people of all ages. Papers were excluded if they covered palliative care focusing on other conditions, or were about an aspect of dementia care and treatment not related to palliative care.
Our critical synthesis generated five main themes from this review of the reviews: (1) carers' (family caregivers') experiences; (2) person-centred care; (3) practice (including advance care planning, pain and comfort, nutrition, medical complications and minimizing the distress of behavioural symptoms); (4) system factors, including ethical dilemmas, decision making, information, and training; and (5) research priorities. There appears to be good evidence on the care and management of patients with dementia at the end of life which can be used to influence policy development and emerging specificity about research priorities in palliative care practice for people with dementia.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
There is limited evidence about the impact of treatment for subclinical hypothyroidism, especially among older people.
To investigate the variation in GP treatment strategies for older patients with ...subclinical hypothyroidism depending on country and patient characteristics.
Case-based survey of GPs in the Netherlands, Germany, England, Ireland, Switzerland, and New Zealand.
The treatment strategy of GPs (treatment yes/no, starting-dose thyroxine) was assessed for eight cases presenting a woman with subclinical hypothyroidism. The cases differed in the patient characteristics of age (70 versus 85 years), vitality status (vital versus vulnerable), and thyroid-stimulating hormone (TSH) concentration (6 versus 15 mU/L).
A total of 526 GPs participated (the Netherlands n = 129, Germany n = 61, England n = 22, Ireland n = 21, Switzerland n = 262, New Zealand n = 31; overall response 19%). Across countries, differences in treatment strategy were observed. GPs from the Netherlands (mean treatment percentage 34%), England (40%), and New Zealand (39%) were less inclined to start treatment than GPs in Germany (73%), Ireland (62%), and Switzerland (52%) (P = 0.05). Overall, GPs were less inclined to start treatment in 85-year-old than in 70-year-old females (pooled odds ratio OR 0.74 95% confidence interval CI = 0.63 to 0.87). Females with a TSH of 15 mU/L were more likely to get treated than those with a TSH of 6 mU/L (pooled OR 9.49 95% CI = 5.81 to 15.5).
GP treatment strategies of older people with subclinical hypothyroidism vary largely by country and patient characteristics. This variation underlines the need for a new generation of international guidelines based on the outcomes of randomised clinical trials set within primary care.
Dementia syndromes are common, increasing in prevalence and are the largest cause of disability in industrialized societies. The costs of care for people with dementia in the UK are greater than the ...annual expenditure on heart disease, stroke and cancer, combined. Delayed recognition of dementia is common in community settings, but its causes are poorly understood. Specialists tend to identify lack of diagnostic skills amongst primary care physicians as the main cause, and attempt to remedy these limitations with training and the use of brief instruments for assessing cognition. This approach appears to have had little impact over the last decade. There are fundamental misunderstandings regarding how the diagnostic characteristics of dementia syndromes diverge from the cognitive changes of normal aging, and how dementia emerges through the personality of the individual. This paper discusses the factors/processes involved in these changes in cognitive function, behavior and personality and why recognition of dementia in primary care is problematic, especially at an early stage. The important and tractable factors impeding earlier recognition of dementia in primary care include deficits in management (rather than diagnostic) skills amongst primary care practitioners and lack of adequate specialist support (including psychology and social work expertise) over the long term. Nevertheless, we believe that the diagnosis and early clinical management of dementia can be achieved in the setting of primary care. The pattern of interweaving psychological, social and economic factors relevant to the needs of individual patients and their carers can be taken into account and met in the community, providing sufficient expert resources are available and systematically organized. This paper explores the different dimensions of relevant management skills and systems and makes proposals regarding changes in primary and secondary care that will increase earlier diagnosis in the community.
This study is the first to document the history of the lesbian sadomasochist (SM) community and demonstrates its impact of the feminist Sex Wars in the United States between 1969 and 1993. Bringing ...together foundational literature and methods of inquiry from women’s studies, queer theory and the history of other excluded social groups, my dissertation highlights issues of power, resistance and collective identity formation. Drawing on newspaper articles and other published sources, archival research and oral histories, I argue that one cannot understand the history of movements for gender, sexual and sexuality equality without also understanding this issue. This project charts the evolution of feminist sexual theory from the 1960s through the 1990s, illuminates ruptures in feminist and gay/lesbian liberation theory and practice and reveals the history and the long-lasting implications of these debates. I show how lesbian SM helped to shape the pornography debates, the development of both queer theory and the field of sexuality studies and was integral to major shifts in American politics and culture in the last two decades of the twentieth century.
The SPARC Toroidal Field Model Coil (TFMC) Program was a three-year effort between 2018 and 2021 that developed novel Rare Earth Yttrium Barium Copper Oxide (REBCO) superconductor technologies and ...then successfully utilized these technologies to design, build, and test a first-in-class, high-field (~20 T), representative-scale (~3 m) superconducting toroidal field coil. With the principal objective of demonstrating mature, large-scale, REBCO magnets, the project was executed jointly by the MIT Plasma Science and Fusion Center (PSFC) and Commonwealth Fusion Systems (CFS). The TFMC achieved its programmatic goal of experimentally demonstrating a large-scale high-field REBCO magnet, achieving 20.1 T peak field-on-conductor with 40.5 kA of terminal current, 815 kN/m of Lorentz loading on the REBCO stacks, and almost 1 GPa of mechanical stress accommodated by the structural case. Fifteen internal demountable pancake-to-pancake joints operated in the 0.5 to 2.0 nOhm range at 20 K and in magnetic fields up to 12 T. The DC and AC electromagnetic performance of the magnet, predicted by new advances in high-fidelity computational models, was confirmed in two test campaigns while the massively parallel, single-pass, pressure-vessel style coolant scheme capable of large heat removal was validated. The REBCO current lead and feeder system was experimentally qualified up to 50 kA, and the crycooler based cryogenic system provided 600 W of cooling power at 20 K with mass flow rates up to 70 g/s at a maximum design pressure of 20 bar-a for the test campaigns. Finally, the feasibility of using passive, self-protection against a quench in a fusion-scale NI TF coil was experimentally assessed with an intentional open-circuit quench at 31.5 kA terminal current.
The presented research discusses the design, analysis, and testing of a low current, LaB6 heaterless hollow cathode for space propulsion applications. A heaterless design using LaB6 is chosen to ...reduce complexity and increase electrical power efficiency and robustness. Argon propellant is used due to its more favorable breakdown voltage characteristics compared to xenon.;
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An original model for the insert region plasma is derived by combining several analyses in literature. This model allows the simultaneous calculation of many plasma and thermal parameters in the cathode using only two completely unobtrusive measurements, and requires several assumptions which are common in hollow cathode research. The design of the cathode and its subsystems are presented in detail. No diagnostics were used in the cathode except direct voltage measurements in the power circuit.;
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A discussion of emitter poisoning and ignition behavior is presented. The cathode is characterized by measuring anode and keeper voltages as a function of anode current and propellant flow rate, with the cathode discharging directly to a flat metal anode. Results are consistent with those obtained by previous investigations of argon hollow cathodes. This data is used with the derived plasma model to calculate the dependence of various parameters on current and flow rate. A discussion of the spot-plume transition behavior is presented. Finally, insights and design improvements are discussed based on the experimental results.
Master of Science
In recent years, the space industry has seen rapidly accelerating growth due to the continuing advancement of technology. A critical area of spacecraft technology is the spacecraft’s propulsion system, which allows the vehicle to achieve and maintain its desired orbit or trajectory through space. One class of propulsion systems known as “electric propulsion” uses electrical power to accelerate the fuel of the spacecraft. These types of propulsion systems are far more efficient than traditional propulsion systems, which use chemical reactions to create thrust. ;
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One of the main components of certain types of electric propulsion systems is the hollow cathode, which initiates and sustains the thruster operation. In this research, a hollow cathode with several non-conventional characteristics is developed and tested. First of all, standard hollow cathodes use a heater to bring the cathode up to operational temperature, but this design is heaterless which offers several benefits to the cathode and electrical power system designs. Secondly, the cathode uses a non-conventional choice of material for the “emitter”, which emits electrons when heated and allows the cathode to operate. Lastly, while typical electric propulsion systems use xenon for fuel, this cathode uses argon which has several benefits over xenon including cost. ;
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An overview of electric propulsion is presented, as well as a new physics-based model of this type of cathode that allows useful calculations based on simple measurements. The design and test results of the cathode are discussed in detail, with several interesting and insightful behaviors that were noted during testing. Heaterless cathodes have the potential to improve the efficiency, cost, and weight of electric propulsion systems, and this research therefore contributes to an important field for the future of space exploration.
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