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BACKGROUND AND OBJECTIVES: Advance directives (AD) are based on state-specific statutes that vary in structure, terminology, and options. This variability leads to inconsistent end-of-life (EOL) care for patients who have executed an AD in one state but fall ill in another state. This study revisits a 2002 article that identified considerable differences in ADs to determine whether ADs have become more uniform. RESEARCH DESIGN AND METHODS: ADs from all 50 states and the District of Columbia were examined to determine the frequency of document types and seven key issues. The results were = compared to the 2002 study using non-parametric approaches. Mean numbers of key issues were compared using t-tests and one-way ANOVA. RESULTS: Consistent with 2002, three states in 2023 provide statutes for Health Care Power of Attorney (HCPOA). However, states offering a combined HCPOA, and living will (LW), deemed an advance directive for health care (ADHC), increased from 13 to 30. Between both studies, Long Term Care increased significantly in LW and ADHC, while Artificial Sustenance significantly increased in LW. Despite the rising prevalence of Alzheimer's in the United States, only 10% of states included this issue in 2023. DISCUSSION AND IMPLICATIONS: Despite evolving healthcare trends, minimal revisions have been made to ADs since 2002. This lack of uniformity can cause confusion regarding proper understanding of EOL wishes. The authors recommend that the Uniform Act for Advance Directives be revisited to promote greater uniformity in ADs and ensure that individuals' preferences are understood and respected across different states.
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Introduction In the United States, persons who inject drugs (PWID) represent an increasingly vulnerable population, with a high risk of HIV transmission related to needle sharing. This paper aims to investigate the availability of HIV-related services within substance abuse treatment facilities while emphasizing the need for implementing comprehensive harm-reduction strategies in such facilities. Methods This study explores the prevalence and trends regarding HIV-related services within substance abuse treatment facilities in the United States including testing, counseling, early intervention, and medication provision. Data from the National Survey of Substance Abuse Treatment Services (N-SSATS) were analyzed in order to assess trends in HIV-related services from 2013 to 2020. Results Facility response rates revealed an increase in the availability of HIV testing and specialized programs for individuals with HIV. However, there was a contrasting trend with the decline in early intervention and counseling services, only with a slight increase in 2020. Additionally, government-owned facilities demonstrated superior performance in delivering HIV services compared to private facilities. Conclusion This study highlights the dire need for implementing routine opt-out HIV testing within substance abuse treatment facilities in order to identify new cases. Additionally emphasized is the importance of early intervention for this at-risk population. To effectively address these challenges, we suggest considering the adoption of the "Seek, Test, Treat, Retain" model as a potential solution. Increasing access to HIV-related services within substance abuse facilities requires enhanced resource allocation as well as integrated programs. Identifying deficiencies in HIV service integration is crucial to enhancing care and reducing HIV transmission among PWID.
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ABSTRACT: Decades of efforts in elucidating pain mechanisms, including pharmacological, neuroanatomical, and physiological studies have provided insights into how nociceptive information transmits from the periphery to the brain and the locations receiving nociceptive signals. However, little is known about which specific stimulus-dependent activated neurons, amongst heterogeneous neural environments, discriminatively evoke the cognate pain behavior. We here shed light on the population of neurons in the spinal cord activated by a painful stimulus to identify chronic pain-dependent activated neuronal subsets using Fos2A-iCreER (TRAP2) mice. We have found a large number of neurons activated by a normally nonpainful stimulus in the spinal cord of spinal nerve-ligated mice, compared with sham. Neuronal activation was observed in laminae I and II outer under heat hyperalgesia. A large number of neurons in laminae II inner were activated in both mechanical allodynia and heat hyperalgesia conditions, while mechanical allodynia tends to be the only stimulus that activates cells at lamina II inner dorsal region. Neuroanatomical analyses using spinal cell markers identified a large number of spinal inhibitory neurons that are recruited by both mechanical allodynia and heat hyperalgesia. Of interest, spinal neurons expressing calretinin, calbindin, and parvalbumin were activated differently with distinct pain modalities (ie, mechanical allodynia vs heat hyperalgesia). Chemogenetic inhibition of those activated neurons significantly and specifically reduced the response to the pain stimulus associated with the stimulus modality originally given to the animals. These findings support the idea that spinal neuronal ensembles underlying nociceptive transmission undergo dynamic changes to regulate selective pain responses.
Assuntos
Dor Crônica , Hiperalgesia , Camundongos , Animais , Corno Dorsal da Medula Espinal/fisiologia , Medula Espinal , Neurônios/fisiologia , Nervos EspinhaisRESUMO
BACKGROUND: Patients, caregivers, and healthcare professionals often describe a "good death" as a pain-free process. However, many patients experience pain during their last weeks of life. Advance directives (ADs) are legally binding documents that allow individuals to express their wishes for end-of-life care which should include management of their pain. METHODS: An interprofessional team conducted a comprehensive analysis of ADs from all 50 states and the District of Columbia to assess the inclusion of language that reflects patients' wishes for pain relief at the end of life. RESULTS: Thirty-seven (73%) of the 51 entities examined reflected the prototypical directive, containing explicit instructions for withholding or withdrawing interventions that may prolong suffering rather than options for treating pain. Of these, 12 (24%) did not include the word "pain". Only 14 states (27%) provided clear guidance for managing pain. Unexpectantly, researchers found that 13 (25%) addressed the common fears of patients, caregivers, and healthcare teams when using opioids to relieve suffering, such as addiction, sedation, appetite, or respiratory suppression, and hastening death. CONCLUSION: The majority of ADs reviewed lacked clear and comprehensive measures for addressing pain relief. This deficiency may contribute to the undertreatment of pain and amplify the anxiety felt by patients, families, and healthcare providers when making end-of-life decisions. The results highlight the need for improvements in ADs to help ensure that patients' wishes regarding pain management are adequately addressed, documented and respected.