Assessing patients' capacities to consent to treatment

The right of patients to accept or refuse recommended treatment requires careful reassessment when their decision-making capacities are called into question. Patients must be informed appropriately about treatment decisions and be given an opportunity to demonstrate their highest level of mental functioning. The legal standards for competence include the four related skills of communicating a choice, understanding relevant information, appreciating the current situation and its consequences, and manipulating information rationally. Since competence is a legal concept and can be formally determined only in court, the clinical examiner's proper role is to gather relevant information and decide whether an adjudication of incompetence is required. Treatment for impairment of mental functioning can sometimes restore patients' capacities, making it unnecessary to deprive them of their decision-making powers.     

Psycho-education to enhance couples' transition to parenthood

A substantial proportion of couples struggle to adapt to parenthood, feel stress in caring for their infant, and experience a significant decline in their couple relationship adjustment. Moreover, there is a substantial association between effective parenting of infants and sustaining a mutually satisfying couple relationship. This paper reviews randomized controlled trials of psycho-education to assist new parent couples with parenting and their couple relationship. The majority of programs target either the couple relationship or parenting, with few programs addressing both areas. The best outcomes seem to be achieved when programs are accessible by couples at home, when skill-training is provided, and possibly when programs target couples at high-risk of maladjustment to parenthood.     

Anaphylaxis due to hypersensitivity to Anisakis simplex

Anaphylactic reactions are among the most frequent causes for requests for emergency medical care. It is possible that no clear precipitating factor can be found delaying the onset of adequate treatment and increasing the risk of new episodes of anaphylaxis in the future. Hypersensitivity to Anisakis simplex, an intestinal parasite found in fish, is an unusual cause of anaphylaxis but it should always be borne in mind in countries where a great deal of fish is consumed, especially if it is eaten raw or undercooked. 3 cases of anaphylaxis due to hypersensitivity to A. simplex are described.     

如何指导研究生撰写英文论文并向英文杂志投稿

发表英文论文的关键是帮助研究生打好英文的基础,有针对性地提高学生的英文水平。尽早撰写与课题相关的文献综述,在进行理论知识储备的同时熟悉该领域内英文文献的特点。帮助学生对所取得的数据进行客观、全面、合理的解释。重视英文论文的书写习惯,帮助研究生从内容到形式反复修改论文,选择对该研究内容感兴趣的杂志进行投稿。认真思索编辑、审稿人的意见,根据他们提出的意见对论文的问题进行修改、解释或申诉。遵守版权公约、出版协议,避免法律纠纷。     

Adaptive responses of vertebrate neurons to anoxia--matching supply to demand

Oxygen depleted environments are relatively common on earth and represent both a challenge and an opportunity to organisms that survive there. A commonly observed survival strategy to this kind of stress is a lowering of metabolic rate or metabolic depression. Whether metabolic rate is at a normal or a depressed level the supply of ATP (glycolysis and oxidative phosphorylation) must match the cellular demand for ATP (protein synthesis and ion pumping), a condition that must of course be met for long-term survival in hypoxic and anoxic environments. Underlying a decrease in metabolic rate is a corresponding decrease in both ATP supply and ATP demand pathways setting a new lower level for ATP turnover. Both sides of this equation can be actively regulated by second messenger pathways but it is less clear if they are regulated differentially or even sequentially with the onset of anoxia. The vertebrate brain is extremely sensitive to low oxygen levels yet some species can survive in oxygen depleted environments for extended periods and offer a working model of brain survival without oxygen. Hypoxia tolerant vertebrate brain will be the primary focus of this review; however, we will draw upon research involving hypoxia/ischemia tolerance mechanisms in liver and heart to offer clues to how brain can tolerate anoxia. The issue of regulating ATP supply or demand pathways will also be addressed with a focus on ion channel arrest being a significant mechanism to reduce ATP demand and therefore metabolic rate. Furthermore, mitochondria are ideally situated to serve as cellular oxygen sensors and mediator of protective mechanisms such as ion channel arrest. Therefore, we will also describe a mitochondria based mechanism of ion channel arrest involving ATP-sensitive mitochondrial K(+) channels, cytosolic calcium and reaction oxygen species concentrations.     

Listening to Silence

SUMMARY. I have examined the function of silence - its possible role and meanings - in the psychoanalytic encounter. I have argued that silence is complementary to words in general, and to analytic free-associations in particular, and that silence in the patient is often more than just the expression of his resistance.
It could be useful to consider the silent space within a session as a sort of container of words -words that, for complex, over-determined, unconscious reasons cannot be uttered. I have insisted on the significance of analytic silences and warned against responding to them either through a retaliatory silence or through a flood of premature interpretations. These inadequate reactions often stem from the analyst's own anxiety evoked in him by the patient's silence.
Anxiety and silence are closely connected. Each silence is a compromise formation, concealing the unconscious fantasy from which it originates, while expressing a conscious one, often related to the transference situation. It is the task of the analyst to listen to his patient's silences in order to help him understand their meanings.     

How to: screening for mcr-mediated resistance to colistin

BackgroundColistin belongs to the last-resort antibiotics. The discovery of plasmid-bound colistin resistance mediated by the mcr-gene(s) is of great concern because, given its biological potential, there is a risk of its rapid spread.ObjectivesTo discuss the current literature on the methods for the screening for mcr-mediated resistance to colistin.SourcesLiterature was drawn from a search of PubMed from 1 January 2016 to 26 April 2021.ContentThe selective culture-based or culture-independent approach can be used for the screening of mcr-mediated resistance to colistin in clinical samples. Rapid Polymyxin NP, Colistin Drop or Colistin Agar Spot tests are applicable for the selection of isolates with a suspected resistance to colistin that has to be confirmed by broth microdilution. The mcr-mediated resistance to colistin can be confirmed by the detection of the causal gene(s) or by phenotype using EDTA-colistin broth disc elution; production of the MCR-1 enzyme can be confirmed with lateral flow immunoassay, using matrix-assisted laser desorption/ionization time-of flight or liquid chromatography-based mass spectrometry. Whole-genome sequencing (WGS) is the ultimate typing method. When a WGS platform is not available at a healthcare facility, a WGS-outsourced service, in combination with freely available bioinformatics tools, allows for the characterization of the mcr-gene(s) carrying isolates.Implicationsmcr-mediated colistin resistance should be monitored through active targeted screening. The broth microdilution method is required for colistin susceptibility testing but as only a selected number of clinical isolates are tested, colistin resistance, including mcr-mediated, may remain undetected. In mcr-1-positive Escherichia coli isolates, the MIC to colistin can range from 2 to 8 mg/L, so it is proposed that Enterobacterales with a colistin MIC of 2 mg/L should also be included in the mcr-mediated colistin resistance screening and those with a confirmed mcr-genotype and/or MCR-phenotype should be considered to be colistin-resistant.     

Addiction to nicotine is due to high intrinsic levels of dopamine.

Smokers are less likely to develop Parkinson's disease (PD) than is true of non-smokers, and PD is the only disease inversely related to smoking. PD is associated with a reduced level of dopamine. Although nicotine can affect the receptors, including dopamine receptors, it seems unlikely that use of nicotine is protective in PD. An alternative explanation is that just as PD is associated with a lower than normal level of dopamine, addiction to smoking is linked with a higher than normal level of dopamine. This high innate level of dopamine facilitates addiction to nicotine.     

Practical guide to skin prick tests in allergy to aeroallergens

This pocket guide is the result of a consensus reached between members of the Global Allergy and Asthma European Network (GA(2) LEN) and Allergic Rhinitis and its Impact on Asthma (ARIA). The aim of the current pocket guide is to offer a comprehensive set of recommendations on the use of skin prick tests in allergic rhinitis-conjunctivitis and asthma in daily practice. This pocket guide is meant to give simple answers to the most frequent questions raised by practitioners in Europe, including 'practicing allergists', general practitioners and any other physicians with special interest in the management of allergic diseases. It is not a long or detailed scientific review of the topic. However, the recommendations in this pocket guide were compiled following an in-depth review of existing guidelines and publications, including the 1993 European Academy of Allergy and Clinical Immunology position paper, the 2001 ARIA document and the ARIA update 2008 (prepared in collaboration with GA(2) LEN). The recommendations cover skin test methodology and interpretation, allergen extracts to be used, as well as indications in a variety of settings including paediatrics and developing countries.     

Solutions to Penicillium taxonomy crucial to mycotoxin research and health

The stability of taxonomy within Penicillium is reviewed with respect to mycotoxin production. Identification remains difficult despite the availability of modern methods. Proficiency testing is rare and conventional identifications do not inform reliably as to whether mycotoxins were detected/produced. A solution which consists of identifying a Penicillium strain as terverticillate and then undertaking mycotoxin analysis is described.     

When to switch and what to switch to: strategic use of antiretroviral therapy

Clinical cohort studies suggest that as many as 60% of patients experience virologic failure of a first-line antiretroviral regimen. Second-line and rescue (or salvage) regimens have a poorer success record: Most studies presented to date show a short-term virologic response rate of only approximately 30% in treatment-experienced individuals. That rate will improve with better understanding of what causes initial virologic failure, continued development of new antiretroviral agents (including drugs with new mechanisms of action) and new treatment strategies (including dual-protease inhibitor regimens), and more widespread use of resistance testing. Further clinical research is needed to improve salvage options, and physicians should consider enrolling treatment-experienced patients in clinical trials.     

Leishmania infantum expresses a mitochondrial nuclease homologous to EndoG that migrates to the nucleus in response to an apoptotic stimulus

It is increasingly accepted that single-celled organisms, such as Leishmania parasites, are able to undergo a cell death process that resembles apoptosis in metazoans and is induced by a variety of stimuli. However, the molecular mechanisms that participate and regulate this death process are still very poorly described, and very few of the participating molecules have been identified. Because DNA degradation is probably the most frequently characterized event during programmed cell death in Leishmania parasites, we have focused on identifying a candidate nuclease responsible for this effect during the cell death process. The results presented herein demonstrate that Leishmania infantum promastigotes express a nuclease similar to the endonuclease G of higher eukaryotes which, according to its predicted structure, belongs to the beta beta alpha metal superfamily of nucleases. Its cation dependence resembles that of the EndoGs present in other organisms and, similarly to them, it is inhibited by moderate concentrations of K+ or Na+. L. infantum EndoG contains a signal peptide that causes its translocation to the mitochondrion where it is maintained under normal growth conditions. However, under the pressure of a death stimulus such as edelfosine treatment, L. infantum EndoG is released from the single mitochondrion and translocates to the nucleus, where it is thought to participate in the process of DNA degradation that is associated with programmed cell death. Our results also demonstrate that overexpression of the nuclease in edelfosine-treated promastigotes causes a significant increase in the percentage of TUNEL-positive parasites.     

An Integrated Approach to a Teaching File Linked to PACS

To meet the educational needs of a medical imaging department with a strong teaching commitment, a teaching file that uses digital data supplied by the institutional picture archiving and communications system (PACS) was required. This teaching file had to be easily used by the end users, have a simple submission process, be able to support multiple users, be searchable on all data fields, and implementing the teaching file must not incur any additional software or hardware costs. The teaching file developed to address this problem takes advantage of the database structure and capabilities of several components included in the commercial PACS installed at the hospital. MS Access is used to seamlessly integrate with the digital imaging and communication in medicine (DICOM) database of a normal work station that is part of the PACS. This integration allows relevant patient and study demographics to be copied from images of interest and then to be stored in a separate database as the back-end of the digital teaching file. When images for a particular teaching file case need to be reviewed, they are automatically retrieved and displayed from the main PACS database using an open application programming interface (API) connection defined on the PACS web server. Utilizing this open API connection means the teaching file contains only the relevant demographic information of each teaching file case; no image data is stored locally. The open API connection allows access to imaging data usually not encountered in a teaching file, allowing more comprehensive imaging case files to be developed by the radiologist. Other advantages of this teaching file design are that it does not duplicate image data, it is small allowing simple ongoing backup, and it can be opened with multiple users accessing the database without compromising data access or integrity.     

New approaches to the delivery of drugs to the brain

The Human Immunodeficiency Virus (HIV) is the causative agent of AIDS and this has been found to be neurotropic. For this reason the development of an effective strategy for the delivery of antiviral drugs across the blood-brain barrier is of paramount importance in the treatment of HIV infection. There are insulin receptors on the capillary endothelial cells making up the blood-brain barrier (BBB) and it is proposed that these may play a role, along with exogenously administered insulin, in enhancing the transport of drug molecules across the BBB. Evidence is presented showing that insulin may be used as a pharmacologic adjunct in the therapy of HIV infection by allowing for higher concentrations of antiviral drugs to be obtained within the CNS using lower total doses of drug. This would enhance the drug's therapeutic effectiveness while simultaneously obviating potential dose-related side-effects.     

如何引导医学生学好“抗生素”

 药理学是临床医学专业学生一门重要的基础课,涉及药物种类繁多,授课内容复杂,需掌握的知识点多,学生畏难情绪较重。在药理学抗生素教学实践中,教师可根据医学生特点和具体的授课内容,灵活运用多种授课技巧和方法,以提高学生的兴趣和教学质量,本文一一举例。     

Patients' willingness to allow residents to learn to practice medical procedures.

PURPOSE: Consent for teaching procedures has been the focus of ethical discussion recently. Patients may consent to a procedure but be unaware that the procedure is to be performed by a resident, perhaps for the first time. In such cases, patients have not specifically consented to the practice of teaching medical procedures. The authors studied patients' awareness of resident training and willingness to allow residents to perform procedures on them. METHOD: A survey was administered to a convenience sample of 202 Vanderbilt University Medical Center emergency department patients from February to April 2000. Three procedures (intubation, lumbar puncture, and sutures) were demonstrated. Patients were asked about their awareness of residents' training and willingness to allow a resident to perform the procedures for the first time versus the tenth time. RESULTS: In all, 60% of patients did not realize they could be the first person a resident performs a procedure on. Only 49% of the patients were completely comfortable being the first patient for sutures, 29% for intubation, and 15% for a lumbar puncture. Most patients felt they should be informed if it was the resident's first time performing procedures (66% for sutures, 69% for intubation, and 82% for lumbar puncture). CONCLUSION: Not only do the majority of patients not know that they might be the first patient on whom a resident performs a procedure, more than two thirds believed they should be told if they are the first patient. Particularly for intubation and lumbar puncture, patients indicated that they would be uncomfortable being the first patient on whom these procedures were performed. These data raise ethical questions regarding physicians' obligations to inform patients about resident-performed procedures.     

Adverse reactions to heparin

Heparin is a medication that has gained widespread use in clinical medicine as the therapy of choice for acute anticoagulation in the prevention and treatment of thromboembolic disease. Therapy with heparin is associated with many potential adverse side effects. Heparin-induced skin necrosis is an uncommon complication of heparin therapy that is now believed to be a thrombotic complication of heparin-induced thrombocytopenia. The pathogenesis of this disorder is unknown, but it is presumed to be immunologically mediated. The diagnosis is frequently one of exclusion. Significant morbidity and mortality may arise from failure to recognize this adverse reaction.     

Mast cell contribution to angiogenesis related to tumour progression

The current wisdom is that tumours are endowed with an angiogenic capability and that their growth, invasion and metastasis are angiogenesis dependent. It is now well documented that neoplastic cells are influenced by their microenvironment and vice versa. The specific organ microenvironment determines the extent of cancer cell proliferation, angiogenesis, invasion and survival. Tumour cells are surrounded by an infiltrate of inflammatory cells, namely lymphocytes, neutrophils, macrophages and mast cells (MCs), which communicate via a complex network of intercellular signalling pathways, mediated by surface adhesion molecules, cytokines and their receptors. This review article summarizes: (i) the MC mediators involved in angiogenesis; (ii) the experimental evidence concerning the role played by MCs in angiogenesis; (iii) the list of solid and haematological tumours in which a close relationship between angiogenesis, tumour progression and MCs has been demonstrated; (iv) the circumstances in which MCs are a critical source of angiogenic factors in vivo, and in such cases, the signals that regulate their production and secretion that need to be determined as a prelude to the elaboration of new therapeutic strategies associated with MC presence and activation.