Droit à mourir et suicide assisté : état des lieux et analyse critique

ObjectivesIn the context of the present re-examination of the French bioethical laws by the National Advisory Ethics Committee (“Comité consultatif national d’éthique”: CCNE), a recent survey indicated a request of the public opinion to obtain a medical aid in end of life and a so-called “assisted suicide”. This led psychiatrists to re-consider their role and deontological position which usually led them to consider a request for an assistance in suicide as – a priori – a pathological demand, occurring within a suicidal crisis. The present article intends to: 1) describe the laws and practices of countries which allow medically assisted end of life help procedures; 2) clarify the definitions of “assisted suicide”, “assistance to suicide” and “euthanasia”; 3) consider available epidemiological data and the roles given to doctors and, more specifically psychiatrists, in these procedures; 4) analyse the rationale behind these demands. These considerations should enable French psychiatrists to clarify their position when facing requests for a medical aid in dying.MethodsFour European countries (Switzerland, the Netherlands, Belgium, Luxemburg) and Oregon (the first US state to introduce legislation) were considered, since they accumulated and published a large amount of experiences and data about “assisted suicide” and medical help in dying. In total, 127 articles were selected, mainly from PubMed and Cairn databases, published between 1997 and 2020. These articles deal with legal considerations, epidemiological data, ethical and sociological considerations.ResultsLaws and practices differ notably according to the state/country. In Belgium, the Netherlands and Luxemburg, as in Oregon, the medical help in dying has been de-criminalized, as long as certain legal criteria are met. In Switzerland, where no specific law exists in the penal code, non-governmental associations have benefited from the legal vacuum and organized the practice of “assisted suicide” for “altruistic motives”. In the scientific and legal literature, the terms used to describe and define the medical help in dying upon request differ greatly. In France, the National Advisory Ethics Committee defines euthanasia (“euthanasie”), assisted suicide (“suicide assisté”) and suicide assistance (“assistance au suicide”). Available epidemiological data, whatever the country considered, indicate that requests for a medical aid in dying are expressed mainly by patients aged over 60 years and suffering from cancer. Psychiatric diseases account for only 1% to 3%. Most often, systematic assessment by a psychiatrist is neither requested nor made, when the demand does not occur during a primary psychiatric illness. In the case of an existing primary psychiatric pathology, a psychiatrist assesses the case against formal legal predefined criteria. This latter practice was only recently introduced, after some feedback and after legal actions had been brought to Court. When the underlying motivations of the request are considered, it appears that, even in the absence of an evolving psychiatric condition, several psychological or psychopathological reasons prevail such as spirituality, attachment style, social isolation, despair, depression… which should greatly benefit psychiatric exploration, investigation and expertise.ConclusionIn some countries, the request for medically assisted help in dying has become a legal and social reality. In France, where the public debate is still open, it should be emphasized that a psychiatric assessment and interview should be systematically provided to any person requesting medical assistance to die or commit suicide. It is the commitment of psychiatrists to understand the implicit demands and unexpressed motives underlying this request which have strong links with the unique life-events and emotional experiences of the person. The psychiatrist has a unique role in the contextualization of such a request.     

How medical students’ perceptions of instructor autonomy-support mediate their motivation and psychological well-being

Abstract

Purpose: Medical student well-being is an increasing concern in medical education. Understanding the role instructors and programs have in supporting well-being is an important puzzle piece. This study explores the relationship between medical students’ perceptions of instructor autonomy-support, motivation, and well-being. Using self-determination theory, we aim to provide a practical framework through which medical instructors can support student autonomy and well-being in the learning environment.

Materials and methods: Students from the University of Saskatchewan completed a survey measuring perceptions of the learning climate (LC) (instructor autonomy-support), satisfaction/frustration of basic motivational needs (autonomy, competence, relatedness), and psychological well-being. Multiple linear regression was used to determine whether age, gender, and year of study affected students’ well-being, before a mediation model was tested to assess the direct effect of the LC and indirect effects of students’ basic need fulfillment on their well-being.

Results: The response rate was 183/400 (46%). Higher ratings of autonomy-support significantly predicted better student well-being. This was mediated completely by students’ feelings of basic need fulfillment. Relatedness satisfaction contributed most to ratings of instructor autonomy-support.

Conclusions: Cultivating autonomy-support for medical students is critical to their well-being. Learning environments that optimize autonomy-support will also support students’ feelings of relatedness and competence.     

The risk of fractures,acute myocardial infarction,atrial fibrillation and ventricular arrhythmia in geriatric patients exposed to promethazine

ABSTRACT

Objectives: This study aimed to compare the risk of fractures, acute myocardial infarction, atrial fibrillation, and ventricular arrhythmia among Danish citizens aged ≥ 65 which were new users of promethazine or domperidone, triazolam, loratadine, and betahistine. Secondly, the study aimed to perform a risk stratification to identify the most relevant predictors for the study outcomes.

Methods: The study period was 01/01/2015 to 31/12/2016. The data sources were the Danish registers. Each patient was followed for 90 days. A logistic regression model was used to compute the unadjusted and adjusted odds ratios (OR), and a conditional inference tree was used to identify the most relevant predictors for the study outcomes.

Results: Promethazine had a higher risk of hospitalization for atrial fibrillation than loratadine and betahistine (OR 1.58; 95% CI 1.07–2.63 and OR 3.22; 95% CI 1.69–7.14, respectively). For fractures, acute myocardial infarction, and ventricular arrhythmia hospitalizations, no statistically significant differences were found among drugs under investigation. The medical history of cardiac arrhythmia (OR 4.14; 95% CI 2.94–5.78, p < 0.0001) was the most relevant predictor for atrial fibrillation hospitalizations.

Conclusion: This study found an increased risk of atrial fibrillation hospitalization among promethazine users, and the risk was higher among patients with prior cardiac arrhythmia.     

人工智能在医学领域应用浅析

医疗与人工智能相结合,是医学发展的重要方向。作者综述了人工智能在诊断、治疗、预防、科研、教学等医学领域的应用情况,分析了人工智能发展面临的问题和挑战,对人工智能的应用前景进行了展望。     

Evaluation of a delineation software for cardiac atlas-based autosegmentation: An example of the use of artificial intelligence in modern radiotherapy

PurposeThe primary objective of this work was to implement and evaluate a cardiac atlas-based autosegmentation technique based on the “Workflow Box” software (Mirada Medical, Oxford UK), in order to delineate cardiac substructures according to European Society of Therapeutic Radiation Oncology (ESTRO) guidelines; review and comparison with other cardiac atlas-based autosegmentation algorithms published to date.Materials and MethodsOf an atlas of data set from 20 breast cancer patients’ CT scans with recontoured cardiac substructures creation according to the ESTRO guidelines. Performance evaluation on a validation data set consisting of 20 others CT scans acquired in the same treatment position: cardiac substructure were automatically contoured by the Mirada system, using the implemented cardiac atlas, and simultaneously manually contoured by a radiation oncologist. The Dice similarity coefficient was used to evaluate the concordance level between the manual and the automatic segmentations.ResultsDice similarity coefficient value was 0.95 for the whole heart and 0.80 for the four cardiac chambers. Average Dice similarity coefficient value for the left ventricle walls was 0.50, ranging between 0.34 for the apical wall and 0.70 for the lateral wall. Compared to manual contours, autosegmented substructure volumes were significantly smaller, with the exception of the left ventricle. Coronary artery segmentation was unsuccessful. Performances were overall similar to other published cardiac atlas-based autosegmentation algorithms.ConclusionThe evaluated cardiac atlas-based autosegmentation technique, using the Mirada software, demonstrated acceptable performance for cardiac cavities delineation. However, algorithm improvement is still needed in order to develop efficient and trusted cardiac autosegmentation working tools for daily practice.     

《东医宝鉴》对丹溪学派医著引用情况研究

丹溪学派通过其医著被《东医宝鉴》引用而对朝鲜医学产生了既深且广的影响。研究发现,《东医宝鉴》引用丹溪学派医著有14种2900多次,遍及内景、外形、杂病、汤液、针灸各篇。具体引用情况包括引文与原文内容相同,多为中医理论;引文与原文内容基本相同;剪裁编辑,调整次序;删除、补充内容,后三者多为临床诊治;佚文;间接引用朱丹溪或丹溪学派医著。朱丹溪提出的“阳常有余,阴常不足”、创用的大补阴丸、越鞠丸等核心学说和主要经验,已经被17世纪的朝鲜医学所接纳,并呈现出本土化朝向。     

人工智能在内镜诊断上消化道早癌领域的研究进展

随着深度学习算法的不断开发,人工智能在内镜辅助诊断中的应用也备受关注。上消化道肿瘤因其早期不易被发现的特点成为内镜医师镜下诊断的难题,而计算机辅助诊断等新技术有望实现对上消化道早期恶性病变及其相关危险因素的识别及诊断。本文阐述了目前人工智能在内镜诊断上消化道早癌领域的应用情况和发展前景。     

Undergraduate medical students. Simulation-based activity to conduct the informed consent process for health research studies

IntroductionTraining through medical simulation allows for continuous learning under controlled conditions. Simulation-based training activities can be used simultaneously with other educational strategies to strengthen the attitudinal skills needed to develop an informed consent process in the context of health research.ObjectiveTo facilitate learning in undergraduate medicine students, and to evaluate their competences to carry out an informed consent process in a scenario that resembles reality.Materials and methodsIn this semi-longitudinal study, a simulation-based activity was conducted with 136 medical students of the fourth (Group A) and fifth year (Group B) of the Marist University of Mérida, in southern Mexico.ResultsThe mean score for both groups was 72.48 ± 1.05 (95% CI = 70.4–74.5); 86.2 ± 0.96 (95% CI = 84.2–88.0); and 77.7 ± 0.72 (95% CI = 76.3–79.1), in the pre-test, the simulation and the post-test, respectively. The students of group A self-evaluated their performance with 3.93/5.00, and those of Group B, 4.04/5.00.DiscussionThis study showed that Group A students did not score lower on simulation-based activity when compared to students in Group B, suggesting that before the fifth year of undergraduate medical education, students could properly develop an informed consent-process for health research if they receive early education about medical ethics and research bioethics. Issues related to bioethics in human health research can be included as soon as medical students initiate research methodology courses.     

Family History for Cardio-Metabolic Diseases: A Predictor of Major Adverse Cardiovascular Events in Men With Erectile Dysfunction

BackgroundFamily history (FH) of cardiovascular (CV) disease is a known CV risk factor. However, it is rarely considered for CV risk stratification. Furthermore, FH for metabolic diseases is generally overlooked.AimTo evaluate, in a population of men with erectile dysfunction (ED), whether FH for cardio-metabolic diseases could provide insights into metabolic and sexual features and predict the occurrence of forthcoming major adverse CV events (MACE).MethodsA consecutive series of 4,693 individuals (aged 51.3 ± 13.3 years) attending an Andrology outpatient clinic for ED was studied. A subset of these (n = 1,595) was evaluated retrospectively for MACE occurrence.OutcomesSeveral metabolic and sexual function–related parameters were studied. For the retrospective study, information on an incident MACE was collected over a mean follow-up of 4.2 ± 2.5 years.ResultsA greater number of cardio-metabolic FH factors were associated with a worse metabolic profile, including higher waist circumference, triglycerides, glucose, glycosylated hemoglobin, and diastolic blood pressure, as well as lower high-density lipoprotein cholesterol. An increased number of FH factors were associated with worse erectile function (odds ratio = 1.14[1.07;1.23], P < .0001), impaired penile dynamic peak systolic velocity, and lower testosterone levels. In the retrospective study, a positive cardiometabolic FH was associated with a significantly higher incidence of MACEs, even after adjusting for age and comorbidities (hazard ratio = 1.51[1.06-2.16], P = .023). Interestingly, when dividing the sample into high- and low-risk categories according to several CV risk factors (age, previous MACEs, high-density lipoprotein cholesterol, and comorbidities), FH was confirmed as a predictor of incident MACE only among the low-risk individuals.Clinical ImplicationsInvestigating FH for cardio-metabolic diseases is a quick and easy task that could help clinicians in identifying, among individuals with ED, those who deserve careful evaluation of CV and metabolic risk factors. Moreover, considering FH for CV risk stratification could predict MACEs in individuals who, according to conventional CV risk factors, would be erroneously considered at low risk.Strengths & LimitationsThe large sample size and the systematic collection of MACEs through an administrative database, with no risk of loss at follow-up, represent strengths. The use of administrative database for MACE collection may lead to some misclassifications. The specific population of the study limits the generalizability of the results.ConclusionFH is simple and inexpensive information that should be part of the CV risk assessment in all men with ED because it helps in the identification of those who need lifestyle and risk factor modifications and whose risk would otherwise be overlooked.Rastrelli G, Yannas D, Mucci B, et al. Family History for Cardio-Metabolic Diseases: A Predictor of Major Adverse Cardiovascular Events in Men With Erectile Dysfunction. J Sex Med 2020;17:2370–2381.