Knowledge and Attitudes toward Advance Directives among Middle-Aged Women.

Purpose: This study investigated knowledge of and attitudes toward advance directives (ADs) among middle-aged women in South Korea, their willingness to write ADs in the future, and the factors related to knowledge of and attitudes toward ADs. Methods: Data were collected using a self-administrated questionnaire completed by 154 middle-aged women aged 50 to 64 from February to March 2020. The questionnaire asked about participants' knowledge of and attitude toward ADs, willingness to write ADs in the future, experiences with life-sustaining treatment within their families, experience making decisions about life-sustaining treatment, and demographic characteristics. Results: Scores for both knowledge of and attitude toward ADs were relatively high. About 60% of participants gave wrong answers when asked if attorneys were required for writing ADs. A higher knowledge score was significantly associated with a higher attitude score (r=0.227, P<0.01). The women were more likely to be willing to write ADs in the future when they reported a middle income level rather than a lower income level (odds ratio [OR]=5.952, P<0.01), considered themselves unhealthy (OR=5.873, P<0.01), and graduated college or higher (OR=4.096, P<0.05). Furthermore, women who thought that ADs would have an impact on treatment (OR=1.869, P<0.05) and on their families (OR=1.447, P<0.05) were more likely to be willing to write an AD. Conclusion: This study shows that wrong information about ADs persists among middle-aged women, and significant factors associated with knowledge of and attitude toward ADs were identified. Targeted education programs about ADs need to be developed for middle-aged women.

Electrostatic shock acceleration of ions in near-critical-density plasma driven by a femtosecond petawatt laser.

With the recent advances in ultrahigh intensity lasers, exotic astrophysical phenomena can be investigated in laboratory environments. Collisionless shock in a plasma, prevalent in astrophysical events, is produced when a strong electric or electromagnetic force induces a shock structure in a time scale shorter than the collision time of charged particles. A near-critical-density (NCD) plasma, generated with an intense femtosecond laser, can be utilized to excite a collisionless shock due to its efficient and rapid energy absorption. We present electrostatic shock acceleration (ESA) in experiments performed with a high-density helium gas jet, containing a small fraction of hydrogen, irradiated with a 30 fs, petawatt laser. The onset of ESA exhibited a strong dependence on plasma density, consistent with the result of particle-in-cell simulations on relativistic plasma dynamics. The mass-dependent ESA in the NCD plasma, confirmed by the preferential reflection of only protons with two times the shock velocity, opens a new possibility of selective acceleration of ions by electrostatic shock.

Spatiotemporal characteristics of high-density gas jet and absolute determination of size and density of gas clusters.

Properties of gas clusters such as the size and number density when expanding into the vacuum after passing through a conical nozzle are analyzed for argon at an average density of 1020/cm3. Temporally and spatially resolved size and density distribution were measured from all-optical methods of Rayleigh scattering measurement and Nomarski interferometry using a CW laser. At the gas backing pressure of 80 bar, Ar clusters as large as 100 nm were obtained, which differs significantly from the size estimated by the conventional Hagena scaling law. The two independent methods of cluster characterization presented here would be useful to precisely determine the initial conditions in a variety of intense laser-cluster interaction driven applications such as neutron generation, thermonuclear fusion, efficient x-ray emission, and energetic ion acceleration.

Laboratory Study on Disconnection Events in Comets.

When comets interacting with solar wind, straight and narrow plasma tails will be often formed. The most remarkable phenomenon of the plasma tails is the disconnection event, in which a plasma tail is uprooted from the comet's head and moves away from the comet. In this paper, the interaction process between a comet and solar wind is simulated by using a laser-driven plasma cloud to hit a cylinder obstacle. A disconnected plasma tail is observed behind the obstacle by optical shadowgraphy and interferometry. Our particle-in-cell simulations show that the difference in thermal velocity between ions and electrons induces an electrostatic field behind the obstacle. This field can lead to the convergence of ions to the central region, resulting in a disconnected plasma tail. This electrostatic-field-induced model may be a possible explanation for the disconnection events of cometary tails.

Differences in place of death between lung cancer and COPD patients: a 14-country study using death certificate data.

Chronic obstructive pulmonary disease and lung cancer are leading causes of death with comparable symptoms at the end of life. Cross-national comparisons of place of death, as an important outcome of terminal care, between people dying from chronic obstructive pulmonary disease and lung cancer have not been studied before. We collected population death certificate data from 14 countries (year: 2008), covering place of death, underlying cause of death, and demographic information. We included patients dying from lung cancer or chronic obstructive pulmonary disease and used descriptive statistics and multivariable logistic regressions to describe patterns in place of death. Of 5,568,827 deaths, 5.8% were from lung cancer and 4.4% from chronic obstructive pulmonary disease. Among lung cancer decedents, home deaths ranged from 12.5% in South Korea to 57.1% in Mexico, while hospital deaths ranged from 27.5% in New Zealand to 77.4% in France. In chronic obstructive pulmonary disease patients, the proportion dying at home ranged from 10.4% in Canada to 55.4% in Mexico, while hospital deaths ranged from 41.8% in Mexico to 78.9% in South Korea. Controlling for age, sex, and marital status, patients with chronic obstructive pulmonary disease were significantly less likely die at home rather than in hospital in nine countries. Our study found in almost all countries that those dying from chronic obstructive pulmonary disease as compared with those from lung cancer are less likely to die at home and at a palliative care institution and more likely to die in a hospital or a nursing home. This might be due to less predictable disease trajectories and prognosis of death in chronic obstructive pulmonary disease. LUNG DISEASE: IMPROVING END-OF-LIFE CARE: Structured palliative care similar to that offered to cancer sufferers should be in place for patients with chronic lung disease. Joachim Cohen at Vrije University in Brussels and co-workers examined international death certificate data collected from 14 countries to determine place of death for patients with lung cancer and chronic obstructive pulmonary disease (COPD). While patients with COPD suffer similar symptoms to lung cancer in their final days, few COPD patients receive palliative care or achieve the common wish of dying at home. This may be partly due to the inherent unpredictability of final-stage COPD compared with lung cancer. Cohen's team found that, with the exception of Italy, Spain, and Mexico, patients with COPD were significantly more likely to die in hospital than at home. They highlight the need for improved COPD palliative care provision.

Place of death in the population dying from diseases indicative of palliative care need: a cross-national population-level study in 14 countries.

BACKGROUND: Studying where people die across countries can serve as an evidence base for health policy on end-of-life care. This study describes the place of death of people who died from diseases indicative of palliative care need in 14 countries, the association of place of death with cause of death, sociodemographic and healthcare availability characteristics in each country and the extent to which these characteristics explain country differences in the place of death. METHODS: Death certificate data for all deaths in 2008 (age ≥1 year) in Belgium, Canada, the Czech Republic, England, France, Hungary, Italy, Mexico, the Netherlands, New Zealand, South Korea, Spain (Andalusia), the USA and Wales caused by cancer, heart/renal/liver failure, chronic obstructive pulmonary disease, diseases of the nervous system or HIV/AIDS were linked with national or regional healthcare statistics (N=2,220,997). RESULTS: 13% (Canada) to 53% (Mexico) of people died at home and 25% (the Netherlands) to 85% (South Korea) died in hospital. The strength and direction of associations between home death and cause of death, sociodemographic and healthcare availability factors differed between countries. Differences between countries in home versus hospital death were only partly explained by differences in these factors. CONCLUSIONS: The large differences between countries in and beyond Europe in the place of death of people in potential need of palliative care are not entirely attributable to sociodemographic characteristics, cause of death or availability of healthcare resources, which suggests that countries' palliative and end-of-life care policies may influence where people die.

International variation in place of death of older people who died from dementia in 14 European and non-European countries.

OBJECTIVES: The objective of this study was to examine variation in place of death of older people dying from dementia in countries across 4 continents. DESIGN: Study of death certificate data. METHODS: We included deaths of older (65 + years) people whose underlying cause of death was a dementia-related disease (ICD-10: F01, F02, F03, G30) in Belgium, the Netherlands, England, Wales, France, Italy, Spain, Czech Republic, Hungary, New Zealand, United States, Canada, Mexico and South Korea. We examined associations between place of death and sociodemographic factors, social support, and residential and health care system factors. RESULTS: Overall, 4.8% of all deaths were from a dementia-related disease, ranging from 0.4% in Mexico to 6.9% in Canada. Of those deaths, the proportion occurring in hospital varied from 1.6% in the Netherlands to 73.6% in South Korea. When controlling for potential confounders, hospital death was more likely for men, those younger than 80, and those married or living in a region with a higher availability of long-term care beds, although this could not be concluded for each country. Hospital death was least likely in the Netherlands compared with other countries. CONCLUSIONS: Place of death of older people who died from a dementia-related disease differs substantially between countries, which might point to organizational differences in end-of-life care provision. Increasing the availability of long-term care beds might be important to reduce the number of hospital deaths, while focusing specialized end-of-life care services on married people or those aged 65 to 79 might be crucial for achieving home death. However, proper end-of-life care needs to be ensured in hospitals, should this be the most appropriate end-of-life care setting.

A broadband gamma-ray spectrometry using novel unfolding algorithms for characterization of laser wakefield-generated betatron radiation.

We present a high-flux, broadband gamma-ray spectrometry capable of characterizing the betatron radiation spectrum over the photon energy range from 10 keV to 20 MeV with respect to the peak photon energy, spectral bandwidth, and unique discrimination from background radiations, using a differential filtering spectrometer and the unfolding procedure based on the Monte Carlo code GEANT4. These properties are experimentally verified by measuring betatron radiation from a cm-scale laser wakefield accelerator (LWFA) driven by a 1-PW laser, using a differential filtering spectrometer consisting of a 15-filter and image plate stack. The gamma-ray spectra were derived by unfolding the photostimulated luminescence (PSL) values recorded on the image plates, using the spectrometer response matrix modeled with the Monte Carlo code GEANT4. The accuracy of unfolded betatron radiation spectra was assessed by unfolding the test PSL data simulated with GEANT4, showing an ambiguity of less than 20% and clear discrimination from the background radiation with less than 10%. The spectral analysis of betatron radiation from laser wakefield-accelerated electron beams with energies up to 3 GeV revealed radiation spectra characterized by synchrotron radiation with the critical photon energy up to 7 MeV. The gamma-ray spectrometer and unfolding method presented here facilitate an in-depth understanding of betatron radiation from LWFA process and a novel radiation source of high-quality photon beams in the MeV regime.

Simple method for the temporal characterization of amplified spontaneous emission in femtosecond terawatt Ti:sapphire lasers.

We have analyzed the temporal characteristics of amplified spontaneous emission (ASE) in femtosecond terawatt Ti:sapphire lasers by using a simple method based on fast photodiodes. Instead of measuring ASE directly with fast photodiodes, we created a narrow gap in the spectrum of seed pulses and, after amplification, detected the pure ASE signal through the gap by using a fast photodiode covered with a bandpass filter with high transmission at the gap. Because the detected ASE signal was completely separated from amplified main pulses, preceding and even trailing ASEs could be characterized quantitatively in a single-shot measurement. We believe that our method is a good alternative or a complement to conventional methods for ASE measurements.

Organizational change and quality improvement in nursing homes: approaching success.

Nursing home residents' quality of life (QoL) is directly related to the quality improvement (QI) processes mandated by federal law. This article describes a 3-year longitudinal study of QI process innovations in two nursing homes and highlights details of a successful 6-month initiative. The initial QI initiatives were based on the principles of staff empowerment, enhanced ability through training, and financial incentives. After 18 months without measurable success, the QI process was modified to include real-time feedback. Two not-for-profit nursing homes participated in this study to explore the effect of organizational change in nursing homes on residents' quality of care and QoL and staff members' job satisfaction. At 6-month intervals, residents and staff participated in structured assessments of residents' QoL and quality of care and staff members' job satisfaction. When the QI process was modified to include real-time feedback, there was a significant reduction in the rate of new pressure ulcers, stage 2 or greater (p < .05), in one of the facilities that had struggled with this problem for more than 18 months. By examining QI processes in nursing homes, the researchers were able to identify some of the obstacles to improving quality of care and QoL. Only when the element of real-time feedback was introduced, in combination with enhanced staff abilities and financial incentives, were substantial improvements seen in key clinical outcomes.