End-of-life care pathways for improving outcomes in caring for the dying (Review)

Background This is an updated version of a Cochrane review first published in Issue 1, 2010 of The Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. There have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the UK. Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways with a systematic review. Objectives To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community). In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying; those related to the care such as families, carers and health professionals; or a combination of these. Search Methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2013), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles and reference lists of relevant articles.We conducted the original search in September 2009, and the updated search in June 2013. Selection Criteria All randomised controlled trials (RCTs), quasi-randomised trial or high-quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying. Data Collection and Analysis Two review authors assessed the results of the searches against the predetermined criteria for inclusion. Main Results The original review identified 920 titles. The updated search found 2042 potentially relevant titles (including the original 920), but no additional studies met criteria for inclusion in the review update. Authors’ Conclusions With sustained concerns about the safety of the pathway implementation and the lack of available evidence on important patient and relative outcomes, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. Since the last version of this review, no new studies met criteria for inclusion in the review update. With recently documented concerns related to the potential adverse effects associated with Liverpool Care Pathway (the most commonly used end-of-life care pathway), we do not recommend decision making based on indirect or low-quality evidence. All health services using end-of-life care pathways are encouraged to have their use of the pathway, to date, independently audited. Any subsequent use should be based on carefully documented evaluations. Large RCTs or other well-designed controlled studies are urgently required for the evaluation of the use of end-of-life care pathways in caring for dying people in various clinical settings. In future studies, outcome measures should include benefits or harms concerning the outcomes of interest in this review in relation to patients, families, carers and health professionals.

The increasing cost of the basic foods required to promote health in Queensland

Objective: To assess changes in the cost and availability of a standard basket of healthy food items (the Healthy Food Access Basket [HFAB]) in Queensland over time. Design and participants: A series of four cross-sectional surveys (in 1998, 2000, 2001 and 2004) describing the cost and availability of foods in the HFAB over time. In the latest survey, 97 Queensland food stores across the five Australian Bureau of Statistics remoteness categories were compared. Main outcome measures: Cost comparisons for HFAB items by remoteness category for the 97 stores surveyed in 2004; changes in cost and availability of foods in the 81 stores surveyed since 2000; comparisons of food prices in the 56 stores surveyed in 1998, 2000, 2001 and 2004. Results: In 2004, the Queensland mean cost of the HFAB was $395.28 a fortnight. The cost of the HFAB was 29.6%($113.89) higher in “very remote” areas than in “major cities” (P<0.001). Between 2001 and 2004, the Queensland mean cost of the HFAB increased by 14.0% ($48.45), while in very remote areas the cost increased by 18.0% ($76.93) (P<0.001). Since 2000, the annualised per cent increase in cost of the HFAB has been higher than the increase in Consumer Price Index for food in Brisbane. The cost of healthy foods has risen more than the cost of some less nutritious foods, so that the latter are now relatively more affordable. Conclusions: Consumers, particularly those in very remote locations, need to pay substantially more for basic healthy foods than they did a few years ago. Higher prices are likely to be a barrier to good health among people of low socioeconomic status and other vulnerable groups. Interventions to make basic healthy food affordable and accessible to all would help reduce the high burden of chronic disease.

Creating synergy in teacher education through robotics-based STEM activities

Robotics has created opportunities for educators to teach concepts across Science, Technology, Engineering, and Mathematics (STEM). This is one of the reasons robotics is becoming increasingly common in primary and secondary classrooms in Australia. To enable pre-service teachers to design engaging STEM activities that incorporate these technologies, robotics is part of the teaching program in the primary education degree at Queensland University of Technology (QUT). A number of pre-service teachers also choose to extend their abilities by implementing robotics activities on field studies, in schools on a voluntary basis, and in outreach activities such as the Robotics@QUT project. The Robotics@QUT project is a support network developed to build professional knowledge and capacity of classroom teachers in schools from a low SES area, engaging in robotics-based STEM activities. Professional Development (PD) workshops are provided to teachers in order to build their knowledge and confidence in implementing robotics activities in their classrooms, loan kits are provided, and pre-service teacher visits arranged to provide the teachers with on-going support. A key feature of the project is the partnerships developed between the teachers and the pre-service teachers involved in the project. The purpose of this study was to ascertain how the teachers in the project perceived the value of the PD workshops and the pre-service teachers’ involvement and what the benefits of the involvement in the project were for the pre-service teachers. Seventeen teachers completed a five-point (1-5) likert scale questionnaire regarding their involvement in the Robotics@QUT project. Teachers’ responses on the value of the project and the pre-service teacher support highlighted the benefits of the partnerships formed and provided insights into the value of the support provided by the pre-service teachers. This paper also describes one pre-service teacher’s experience with the project and the perceived benefits from being involved.

Decentralized voltage support in a Low Voltage feeder by droop based voltage controlled PVs

Voltage drop at network peak hours is a significant power quality problem in Low Voltage (LV) distribution feeders. Recently, voltage rise due to high penetration of Photovoltaic cells (PVs) has been creating a new power quality problem during noon periods. In this paper, a voltage control strategy is proposed for the household installed PVs to regulate the voltage along the LV feeder. For this purpose, each PV is controlled to exchange reactive power with the grid. A droop control method is utilized to coordinate the reactive power exchange of each PV. The proposed method is a decentralized local voltage support since it is based on only local measurements and does not require any communication with other PVs. The required converter and filter structure and control algorithms are proposed to ensure the dynamic performance of the system. The study focuses on 3-phase PVs. The network is studied at network peak and off-peak periods, separately. The efficacy of the proposed voltage support concept is verified through numerical and dynamic analyses with MATLAB and PSCAD/EMTDC.

On-line Demand Management of Low Voltage Residential Distribution Networks in Smart Grids

A novel intelligent online demand management system is discussed in this chapter for peak load management in low voltage residential distribution networks based on the smart grid concept. The discussed system also regulates the network voltage, balances the power in three phases and coordinates the energy storage within the network. This method uses low cost controllers, with two-way communication interfaces, installed in costumers’ premises and at distribution transformers to manage the peak load while maximizing customer satisfaction. A multi-objective decision making process is proposed to select the load(s) to be delayed or controlled. The efficacy of the proposed control system is verified by a MATLAB-based simulation which includes detailed modeling of residential loads and the network.

Reflections from early career graduates of the exceptional teachers for disadvantaged schools project

This paper aims to explore the experiences of newly qualified teachers and their supervising principals who work in schools situated in various high-poverty areas of Queensland, Australia. It is informed by data collected in the context of an Australian teacher education program, Exceptional Teachers for Disadvantaged Schools (ETDS). Now in its third year, this program was designed to prepare highly skilled pre-service teachers to work in schools that have large numbers of students from disadvantaged or low socio-economic status (SES) backgrounds. Addressing the oft-stated need to prepare high-quality teachers for low SES schools, high-achieving undergraduate education students were invited to participate in two years of specialised curriculum to prepare them for the schools that need them the most, which are also the schools that are often difficult to staff. Pre-service teachers in this program do all their teaching practicum placements in challenging or complex schools. In 2011, some of this cohort did their practicum teaching in schools with large numbers of Indigenous students and several went on to teach in remote communities after graduation. These graduates and the leaders of the schools they work in are the primary informants for this paper.

Higher uptake of long-acting reversible and permanent methods of contraception by Australian women living in rural and remote areas

Objectives: To examine factors associated with the uptake of i) long-acting reversible, ii) permanent and iii) traditional contraceptive methods among Australian women. Methods: Participants in the Australian Longitudinal Study on Women's Health born in 1973–78 reported on their contraceptive use at three surveys: 2003, 2006 and 2009. The participants were 5,849 women aged 25–30 in 2003 randomly sampled from Medicare. The main outcome measure was current contraceptive method at age 28–33 years categorised as long-acting reversible methods (implant, IUD, injection), permanent (tubal ligation, vasectomy), and traditional methods (oral contraceptive pills, condoms, withdrawal, safe period). Results: Compared to women living in major cities, women in inner regional areas were more likely to use long-acting (OR=1.26, 95%CI 1.03–1.55) or permanent methods (OR=1.43, 95%CI 1.17–1.76). Women living in outer regional/remote areas were more likely than women living in cities to use long-acting (OR=1.65, 95%CI 1.31–2.08) or permanent methods (OR=1.69, 95%CI 1.43–2.14). Conclusions: Location of residence is an important factor in women's choices about long-acting and permanent contraception in addition to the number and age of their children. Implications: Further research is needed to understand the role of geographical location in women's access to contraceptive options in Australia.

Image-guided sampling reveals increased stroma and lower glandular complexity in mammographically dense breast tissue

Mammographic density (MD) adjusted for age and body mass index (BMI) is a strong heritable breast cancer risk factor; however, its biological basis remains elusive. Previous studies assessed MD-associated histology using random sampling approaches, despite evidence that high and low MD areas exist within a breast and are negatively correlated with respect to one another. We have used an image-guided approach to sample high and low MD tissues from within individual breasts to examine the relationship between histology and degree of MD. Image-guided sampling was performed using two different methodologies on mastectomy tissues (n = 12): (1) sampling of high and low MD regions within a slice guided by bright (high MD) and dark (low MD) areas in a slice X-ray film; (2) sampling of high and low MD regions within a whole breast using a stereotactically guided vacuum-assisted core biopsy technique. Pairwise analysis accounting for potential confounders (i.e. age, BMI, menopausal status, etc.) provides appropriate power for analysis despite the small sample size. High MD tissues had higher stromal (P = 0.002) and lower fat (P = 0.002) compositions, but no evidence of difference in glandular areas (P = 0.084) compared to low MD tissues from the same breast. High MD regions had higher relative gland counts (P = 0.023), and a preponderance of Type I lobules in high MD compared to low MD regions was observed in 58% of subjects (n = 7), but did not achieve significance. These findings clarify the histologic nature of high MD tissue and support hypotheses regarding the biophysical impact of dense connective tissue on mammary malignancy. They also provide important terms of reference for ongoing analyses of the underlying genetics of MD.

The experiences of teachers teaching children with Down syndrome in the early years of schooling

This innovative collective case study research documented teachers' experiences of teaching children with Down syndrome in the early years of schooling in Australia. Results indicated differences in teachers' conceptualisation of children with Down syndrome as learners and how these variations impacted the way the child was included within the class. Unique to this research was the utilisation of a mind-mapping technique of data collection which effectively captured the individual nature of teachers' experiences, making implicit knowledge explicit through description and interpretation of these experiences. Overall findings indicated that teachers were more likely to include children with Down syndrome into general education classrooms if they operated within a contemporary understanding of disability, had positive support from key stakeholders such as school principals and parents/caregivers, and had access to current information on Down syndrome from professional bodies.

Analysis and modelling of the hydraulic conductivity in aquitards : application to the Galilee Basin and the Great Artesian Basin, Australia

In large sedimentary basins with layers of different rocks, the groundwater flow between aquifers depends on the hydraulic conductivity (K) of the separating low-permeable rocks, or aquitards. Three methods were developed to evaluate K in aquitards for areas with limited field data: • Coherence and harmonic analysis: estimates the regional-scale K based on water-level fluctuations in adjacent aquifers. • Cokriging and Bayes' rule: infers K from downhole geophysical logs. • Fluvial process model: reproduces the lithology architecture of sediment formations which can be converted to K. These proposed methods enable good estimates of K and better planning of further drillholes.

The activation, appropriation and practices of student-equity policy in Australian higher education

Current national reforms in Australian higher education have prioritised efforts to reduce educational disadvantage within a vernacular expression of neoliberal education policy. Student-equity policy in universities is enmeshed in a set of competitive student recruitment relations. This raises practice-based tensions as universities strive to meet specific institutional targets for low-socio-economic status (SES) and Indigenous student participation, whilst broadening participation more generally within the sector. This paper seeks empirically to trace the activation and appropriation of federal policy through two sites of higher education policy practices: a state government-sponsored equity practitioner body and two differently positioned universities, Dawson and McIllwraith, as they engage with low-SES schools. Working together Dorothy Smith’s insights into the textually mediated activation of local practices, Levinson and colleagues’ concept of the local appropriation of authorised policy, and Bourdieu’s notion of the contested field, we demonstrate that the generation of state level and institutionally specific policies for student-equity practices not only articulates to federal policy, but also appropriates the ruling relations of mandated policy. Further, the scope of these creative local appropriations is organised within a hierarchical academic field through which particular institutional imperatives, as well as the needs of low-SES students, are negotiated. The analysis demonstrates the vernacularisation of policy in the national rearticulation of global discourses, in appropriation at the level of the state body and in the practices of equity workers.

Low- and high-temperature controls in carbon nanofiber growth in reactive plasmas

A numerical growth model is used to describe the catalyzed growth of carbon nanofibers in the sheath of a low-temperature plasma. Using the model, the effects of variation in the plasma sheath parameters and substrate potential on the carbon nanofiber growth characteristics, such as the growth rate, the effective carbon flux to the catalyst surface, and surface coverages, have been investigated. It is shown that variations in the parameters, which change the sheath width, mainly affect the growth parameters at the low catalyst temperatures, whereas the other parameters such as the gas pressure, ion temperature, and percentages of the hydrocarbon and etching gases, strongly affect the carbon nanofiber growth at higher temperatures. The conditions under which the carbon nanofiber growth can still proceed under low nanodevice-friendly process temperatures have been formulated and summarized. These results are consistent with the available experimental results and can also be used for catalyzed growth of other high-aspect-ratio nanostructures in low-temperature plasmas.

Nanoparticle manipulation in plasma-assisted nanofabrication of electron field emitters based on single crystalline carbon nanotip patterns

Nanoparticle manipulation by various plasma forces in near-substrate areas of the Integrated Plasma-Aided Nanofabrication Facility (IPANF) is investigated. In the IPANF, high-density plasmas of low-temperature rf glow discharges are sustained. The model near-substrate area includes a variable-length pre-sheath, where a negatively charged nanoparticle is accelerated, and a self-consistent collisionless sheath with a repulsive electrostatic potential. Conditions enabling the nanoparticle to overcome the repulsive barrier and deposit onto the substrate are investigated numerically and experimentally. Under certain conditions the momentum gained by the nanoparticle in the pre-sheath area appears to be sufficient for the driving ion drag force to outbalance the repulsive electrostatic and thermophoretic forces. Numerical results are applied for the explanation of size-selective nanoparticle deposition in the Ar+H2+CH4 plasma-assisted chemical vapor deposition of various carbon nanostructure patterns for electron field emitters and are cross-referenced by the field emission scanning electron microscopy. It is shown that the nanoparticles can be efficiently manipulated by the temperature gradient-controlled thermophoretic force. Experimentally, the temperature gradients in the near-substrate areas are measured in situ by means of the temperature gradient probe and related to the nanofilm fabrication conditions. The results are relevant to plasma-assisted synthesis of numerous nanofilms employing structural incorporation of the plasma-grown nanoparticles, including but not limited to nanofabrication of ordered single-crystalline carbon nanotip arrays for electron field emission applications.

Low-frequency, high-density, inductively coupled plasma sources : operation and applications

Operation regimes, plasma parameters, and applications of the low-frequency (∼500 kHz) inductively coupled plasma (ICP) sources with a planar external coil are investigated. It is shown that highly uniform, high-density (ne∼9×1012 cm-3) plasmas can be produced in low-pressure argon discharges with moderate rf powers. The low-frequency ICP sources operate in either electrostatic (E) or electromagnetic (H) regimes in a wide pressure range without any Faraday shield or an external multipolar magnetic confinement, and exhibit high power transfer efficiency, and low circuit loss. In the H mode, the ICP features high level of uniformity over large processing areas and volumes, low electron temperatures, and plasma potentials. The low-density, highly uniform over the cross-section, plasmas with high electron temperatures and plasma and sheath potentials are characteristic to the electrostatic regime. Both operation regimes offer great potential for various plasma processing applications. As examples, the efficiency of the low-frequency ICP for steel nitriding and plasma-enhanced chemical vapor deposition of hydrogenated diamond-like carbon (DLC) films, is demonstrated. It appears possible to achieve very high nitriding rates and dramatically increase micro-hardness and wear resistance of the AISI 304 stainless steel. It is also shown that the deposition rates and mechanical properties of the DLC films can be efficiently controlled by selecting the discharge operating regime.

Self-organization and dynamics of nanoparticles in chemically active plasmas for low-temperature deposition of silicon and carbon-based nanostructured films

Self-organization and dynamic processes of nano/micron-sized solid particles grown in low-temperature chemically active plasmas as well as the associated physico-chemical processes are reviewed. Three specific reactive plasma chemistries, namely, of silane (SiH4), acetylene (C 2H2), and octafluorocyclobutane (c-C4F 8) RF plasma discharges for plasma enhanced chemical vapor deposition of amorphous hydrogenated silicon, hydrogenated and fluorinated carbon films, are considered. It is shown that the particle growth mechanisms and specific self-organization processes in the complex reactive plasma systems are related to the chemical organization and size of the nanoparticles. Correlation between the nanoparticle origin and self-organization in the ionized gas phase and improved thin film properties is reported. Self-organization and dynamic phenomena in relevant reactive plasma environments are studied for equivalent model systems comprising inert buffer gas and mono-dispersed organic particulate powders. Growth kinetics and dynamic properties of the plasma-assembled nanoparticles can be critical for the process quality in microelectronics as well as a number of other industrial applications including production of fine metal or ceramic powders, nanoparticle-unit thin film deposition, nanostructuring of substrates, nucleating agents in polymer and plastics synthesis, drug delivery systems, inorganic additives for sunscreens and UV-absorbers, and several others. Several unique properties of the chemically active plasma-nanoparticle systems are discussed as well.