Our Next Pandemic Ethics Challenge? Allocating “Normal” Health Care Services

The pandemic creates unprecedented challenges to society and to health care systems around the world. Like all crises, these provide a unique opportunity to rethink the fundamental limiting assumptions and institutional inertia of our established systems. These inertial assumptions have obscured deeply rooted problems in health care and deflected attempts to address them. As hospitals begin to welcome all patients back, they should resist the temptation to go back to business as usual. Instead, they should retain the more deliberative, explicit, and transparent ways of thinking that have informed the development of crisis standards of care. The key lesson to be learned from those exercises in rational deliberation is that justice must be the ethical foundation of all standards of care. Justice demands that hospitals take a safety-net approach to providing services that prioritizes the most vulnerable segments of society, continue to expand telemedicine in ways that improve access without exacerbating disparities, invest in community-based care, and fully staff hospitals and clinics on nights and weekends.     

Évaluation du risque suicidaire. Entre analyse théorique et applications en pratique clinique

Since the mid-1990s and its recognition as a “public health priority”, suicide has remained at the centre of various mental health policies. With one of the highest suicide deaths at the European level, France is particularly impacted by this issue. The predictability of a self-aggressive act remains the main concern for a patient in suicidal crisis. The Dangerous Emergency Risk Assessment, established at the consensus conference in October 2000, marked a turning point in the analysis of suicidal risk. Through a triple evaluation corresponding to each of its three items, this tool has made it possible to better clarify the proposed therapeutic management and in particular the decision or not of a hospitalization. However, the latter remaining perfectible in its analysis, a mapping of key points at the clinical level has been proposed in this article in order to have the widest possible vision of a patient in suicidal crisis. The assessment of suicidal potential remains subject, despite everything, to a part of improbability. As such, a brief hospitalization in the context of the suicidal crisis has all its interest whether in front of a suicidal person or in front of a suicidal person, this in the absence of a decompensated psychiatric pathology, in order to allow a “distance” from the anxiety-provoking environment and to create a bond of trust facilitating outpatient work.     

CT动态增强鉴别肾上腺乏脂肪腺瘤与肾上腺结节样增生的价值

目的探讨CT动态增强对鉴别肾上腺乏脂肪腺瘤与肾上腺结节样增生的价值。方法回顾性分析经手术病理证实的12例肾上腺乏脂肪腺瘤和27例肾上腺结节样增生患者的病例资料,统计两组病例各期增强CT值,利用公式灌注值P=CT静脉期-CT平扫期、廓清值C=CT静脉期-CT延迟期、绝对廓清灌注指数APC=(C/P)×100%及相对廓清灌注指数RAPC=(C/CT静脉期)×100%得到相关参数,并通过绘制受试者工作特征曲线,鉴别两者的最佳价值。结果肾上腺乏脂肪腺瘤直径较结节样增生更大;肾上腺乏脂肪腺瘤病灶各期CT值均明显高于结节样增生,且两者灌注值P、廓清值C、APC及RAPC有明显的统计学差异。年龄、性别、高血压、病灶位置、对侧肾上腺萎缩及动脉期CT值对鉴别两者无显著意义。结论CT动态增强扫描有助于鉴别肾上腺乏脂肪腺瘤和肾上腺结节样增生。     

Disorders of sex development

Disorders of sex development (DSD) occur in 1–2/10,000 live births, with a specific molecular diagnosis only possible in 20% of cases. Presentation is usually at birth, and gender assignment must be avoided before review by an expert multidisciplinary team. Initial investigations allow a working diagnosis to be made within 48 hr. In 46,XY DSD, surgery may be necessary to correct hypospadias, reposition or remove undescended testes, and remove symptomatic Müllerian remnants. In 46,XX DSD, feminizing surgery is performed less frequently than in the past, but genitoplasty may still be indicated. Psychosocial support is required to promote positive adaptation as gender dissatisfaction can occur in certain conditions. Long-term outcome data are sparse.     

Investigation and management of adrenal tumours

Disorders of the adrenal gland are rare and complex, with many potential pitfalls in management. An understanding of embryology, anatomy, physiology and biochemistry is crucial. There has been a dramatic increase in the incidental detection of adrenal lesions on cross sectional imaging in recent years. Surgical treatment may be required for syndromes of hormonal excess and/or suspicion of malignancy.     

Review/overview of pain in sickle cell disease

Sickle cell disease (SCD) is a highly complex inherited disorder of hemoglobin structure. Although the molecular lesion is a single-point mutation, the sickle gene is pleiotropic in nature causing multiple phenotypic expressions that constitute the various complications of the disease. Its manifestations could be acute, chronic, nociceptive, neuropathic that could occur singly or in various combinations. Pain continues to be the major factor of SCD phenotypic complications and the most common cause of admissions to the Emergency Department and/or the hospital. Although progress has been made in understanding the pathophysiology of SCD as well as in developing curative therapies such as hematopoietic stem cell transplantation and gene therapy, effective pain management continues to lag behind. Palliative therapies continue to be the major approach to the management of SCD and its complications. The advent of hydroxyurea made partial success in preventing the frequency of vaso-occlusive crises and l-glutamine awaits post-trial confirmation of benefits. The search for additional pharmacotherapeutic agents that could be used singly or in combination with hydroxyurea and/or l-glutamine awaits their dawn hopefully in the near future. The purpose of this review is to describe the various manifestations of SCD, their pathophysiology and their current management. Recent impressive advances in understanding the pathophysiology of pain promise the determination of agents that could replace or minimize the use of opioids.     

Psychiatric Advance Directives and their relevance to improving psychiatric care in Asian countries

People with mental illness may be unable to provide critical input about the care they wish to receive during a psychiatric crisis because of altered mental states. It is therefore imperative that clinicians seek to understand service users' wishes for care while they are well and able to provide meaningful input into the discussion. Achieving such an end may be done by discussing and completing a psychiatric advance directive. However, very few Asian countries have legislation that supports such advance directives. The present article seeks to give physicians more information about advance psychiatric directives and the potential role they could play to improve the healthcare provided in Asia to people at risk of losing capacity due to a mental illness. The degree to which mental health legislation supports psychiatric advance directives is documented for each country of South East Asia and Eastern Asia.