Conflicts of interest in the context of end of life care for potential organ donors in Australia

End-of-life (EOL) care has become an integral part of intensive care medicine and includes the exploration of possibilities for deceased organ and tissue donation. Donation physicians are specialist doctors with expertise in EOL processes encompassing organ and tissue donation, who contribute significantly to improvements in organ and tissue donation services in many countries around the world. Donation physicians are usually also intensive care physicians, and thus they may be faced with the dual obligation of caring for dying patients and their families in the intensive care unit (ICU), whilst at the same time ensuring organ and tissue donation is considered according to best practice. This dual obligation poses specific ethical challenges that need to be carefully understood by clinicians, institutions and health care networks. These obligations are complementary and provide a unique skillset to care for dying patients and their families in the ICU.In this paper we review current controversies around EOL care in the ICU, including the use of palliative analgesia and sedation specifically with regards to withdrawal of cardiorespiratory support, the usefulness of the so-called doctrine of double effect to guide ethical decision-making, and the management of potential or perceived conflicts of interest in the context of dual professional roles.     

A case of relapsing–remitting facial palsy and ipsilateral brachial plexopathy caused by HSV-1

The etiologies of Bell’s palsy and brachial neuritis remain uncertain, and the conditions rarely co-occur or reoccur. Here we present a woman in her twenties who had several relapsing-remitting episodes with left-sided facial palsy and brachial neuropathy. The episodes always started with painful left-sided oral blisters. Repeat PCRs HSV-1 DNA from oral vesicular lesions were positive. Extensive screening did not reveal any other underlying cause. Findings on MRI T2-weighted brachial plexus STIR images, using a 3.0-Tesla scanner during an episode, were compatible with brachial plexus neuritis. Except a mannose-binding lectin deficiency, a congenital complement deficiency that is frequently found in the general Caucasian population, no other immunodeficiency was demonstrated in our patient. In vitro resistance to acyclovir was tested negative, but despite prophylactic treatment with the drug in high doses, relapses recurred. To our knowledge, this is the first ever reported documentation of relapsing-remitting facial and brachial plexus neuritis caused by HSV-1.     

Influences on Immunization Decision-Making among US Parents of Young Children

Objectives This study assessed influences on vaccination decisions among parents of young children and examined common vaccination information and advice sources. Methods Using panel samples of parents of children under 7 years, web-based surveys were conducted in 2012 (n?=?2603) and 2014 (n?=?2518). A vaccine decision-making typology (non-hesitant acceptors, hesitant acceptors, delayers, and refusers) was established and weighted population estimates of potential factors influencing parental vaccination decision (e.g., provider influence, source of information and advice) were computed by year and decision type. Results Delayers and refusers were more likely than acceptors to know someone whose child experienced a severe reaction to a vaccine or delayed/refused vaccine(s). High proportions of delayers (2012: 33.4%, 2014: 33.9%) and refusers (2012: 49.6%, 2014: 58.6%) reported selecting their healthcare provider based on whether the provider would allow them to delay/refuse vaccines. Providers were the most frequently reported trusted vaccine information source among all parents, though more often by acceptors than refusers (2012, 2014: p?<?0.01). We found differing patterns of provider advice-seeking and internet as a reliable vaccine information source by group. Among those who had considered delay/refusal, trust in their healthcare provider’s advice was the most common reason cited for their decision reversal. Conclusions for Practice Provider trust and communication along with varying degrees of personal-network influences likely contribute to immunization decisions of parents. Vaccine hesitant parents often seek providers amenable to accommodating their vaccine beliefs. Providers may benefit from vaccine communication training as their recommendations may influence hesitant parents to immunize their children.     

Antibody and cytokine-associated immune responses to S. equi antigens entrapped in PLA nanospheres

Strangles is an infectious disease caused by Streptococcus equi subspecies equi that affects the upper respiratory tract of the Equidae. The control of this disease seems to be dependent on its earlier detection and prevention, but prolonged animal protection without development of strong and severe side effects has not yet been achieved. Convalescent horses exhibit a protective immune response, mainly against SeM (58 kDa), an antiphagocytic and opsonogenic S. equi M-like protein, known as the major protective antigen against strangles. Purified recombinant SeM and S. equi protein extract-entrapped poly(lactic acid) (PLA) nanospheres were developed and their adjuvant potential was studied via the intramuscular route. The effect including molecules with adjuvant properties such as spermine, oleic acid, alginate and glycol-chitosan was also evaluated. Spherical nanometric particles <500 nm containing the protein antigen were prepared by the solvent evaporation method and protein structure was not affected throughout preparation. The humoral immune response induced by nanospheres was markedly higher than that elicited by soluble antigens, isolated or co-admixed with CpG. The IgG and IgG subtypes, along with cytokine titres, indicated that nanospheres composed by glycolchitosan developed a more balanced Th1/Th2 response for both purified SeM and S. equi enzymatic extract proteins, although those induced by the pure antigen-entrapped particles were higher than the S. equi tested vaccines composed by total antigens entrapped in polymeric nanospheres.