RURAL WOMAN ABUSE AND SEXUALLY TRANSMITTED DISEASE: AN ETHICAL ANALYSIS OF CLINICAL DILEMMAS

Women who have experienced abuse are often offered individual and group psychotherapeutic interventions to help them overcome psychological aftereffects of abuse and avoid future abusive relationships. Clinical cases that are complicated by the existence of abuse and sexually transmitted diseases (STDs) often involve ethical issues concerning patient privacy and legitimate breaches of confidentiality that can potentially harm the individual. There is little known about the experiences of abused rural women with STDs, underscoring the need for modification of existing interventions for this patient population. This paper presents the application of an ethical framework to an actual case involving an abused rural woman with an STD that utilizes the concepts of casuistry, or case-based reasoning. A methodological tool for ethical analysis of the clinical dilemmas involving evidence-based psychotherapeutic interventions for abused rural women with STDs is used to apply the concepts of casuistry to the development of the taxonomy of cases for clinical practice.     

Towards the automatic computational assessment of enlarged perivascular spaces on brain magnetic resonance images: A systematic review

Enlarged perivascular spaces (EPVS), visible in brain MRI, are an important marker of small vessel disease and neuroinflammation. We systematically evaluated the literature up to June 2012 on possible methods for their computational assessment and analyzed confounds with lacunes and small white matter hyperintensities. We found six studies that assessed/identified EPVS computationally by seven different methods, and four studies that described techniques to automatically segment similar structures and are potentially suitable for EPVS segmentation. T2‐weighted MRI was the only sequence that identified all EPVS, but FLAIR and T1‐weighted images were useful in their differentiation. Inconsistency within the literature regarding their diameter and terminology, and overlap in shape, intensity, location, and size with lacunes, conspires against their differentiation and the accuracy and reproducibility of any computational segmentation technique. The most promising approach will need to combine various MR sequences and consider all these features for accurate EPVS determination. J. Magn. Reson. Imaging 2013;38:774–785. © 2013 Wiley Periodicals, Inc.     

Predictors of chronic breathlessness: a large population study

Background  

Breathlessness causes significant burden in our community but the underlying socio-demographic and lifestyle factors that may influence it are not well quantified. This study aims to define these predictors of chronic breathlessness at a population level.     

ECG derived Cheyne–Stokes respiration and periodic breathing are associated with cardiorespiratory arrest in intensive care unit patients

Background

Cheyne-Stokes respiration and periodic breathing (CSRPB) have not been studied sufficiently in the intensive care unit setting (ICU).

Recommendations for reporting morbid events after heart valve surgery

Major reasons for the considerable heterogeneity among published results of heart valve surgery are inconsistency in follow up techniques, reporting systems and classification of adverse events. The present recommendations are intended to harmonize the presentation of clinical material in order to improve comparison of data from different sources for the analysis of pooled data. The quality of an observational study is largely, if not entirely, due to the follow up technique, which may be graded according to six categories: Self-reporting of adverse events/well-being by the patients may be classified 'excellent'; if the information is gathered and re-checked at short-term intervals. Data obtained from in-hospital or outpatient examinations by qualified examiners at least twice a year or other personal contact through qualified examiners may be regarded as 'sufficient', if the results are re-checked by contacting the treating home physician. All other follow up techniques may be regarded as inappropriate. Consequences of complications are entirely dependent on severity and possible sequelae. It is therefore recommended to grade any reported complication according to its severity by utilizing a score system. Embolisms are best categorized by utilizing the performance status scale. Bleeding events may be categorized according to severity as fatal, major (requiring hospital transmission with transfusion, surgery or with permanently increased disability) or minor (not requiring hospital admission, surgery or transfusion). In some cases it will remain unclear whether an event was primarily embolic or hemorrhagic. These complications should be summarized as 'not categorized'. The reporting of morbid events due to thrombosis, embolism and bleeding should go along with information regarding the quality of antithrombotic management.     

Major life event stress and dyspepsia of unknown cause: a case control study

Stress is purported to be a major cause of non-ulcer dyspepsia, defined here as dyspepsia where peptic ulcer, oesophagitis, and cancer are excluded by endoscopy. There is a subgroup of non-ulcer dyspepsia patients who have no definite cause for their dyspepsia, provisionally termed essential dyspepsia. The aim of the present study was to determine if stress, as measured by major life events, was associated with essential dyspepsia. The frequency of life events during the year before the diagnosis of essential dyspepsia in 68 consecutive patients was compared with the frequency of these events over the same time period in 68 randomly selected age and sex-matched community controls. The mean number of events and the associated life change and distress scores were similar for both groups. Concerning individual events, patients reported more minor personal illness (p = 0.008). When events were broadly categorised, only one difference was found - more controls reported bereavements (p = 0.008). Age, sex, social class, and the duration of dyspepsia did not influence the number and nature of events. Although the study suggests that stress, as measured by major life events, is not associated with dyspepsia of unknown cause, it does not exclude the fact that other forms of stress, especially that associated with chronic difficulties, may be relevant.     

Factors influencing mortality from bleeding peptic ulcers

The mortality, causes of death, and the factors that are influencing deaths from bleeding acute and chronic peptic ulcers were evaluated retrospectively. During a 2-year period (1986-87) 272 patients were endoscoped for acute gastrointestinal hemorrhage and were found to have bled from a peptic ulcer (chronic gastric ulcers, 90; chronic duodenal ulcers, 114; acute gastroduodenal ulcers, 66; stomal ulcers, 2). The overall mortality was 9.6% (n = 26) (gastric ulcers, 6.7%; duodenal ulcers, 11.4%; acute ulcers, 10.6%). Statistically significant factors adversely affecting prognosis for gastric ulcer were re-bleeding, need for operation and serious intercurrent illness; for duodenal ulcer were units of transfused blood, re-bleeding, signs of recent hemorrhage at endoscopy, need for operation, and serious intercurrent illness; and for acute ulcer were increasing age, shock, units of transfused blood, re-bleeding, and serious intercurrent illness. Multivariate analysis was only attempted for duodenal ulcers because of sample sizes; it suggested that active bleeding or visible vessel at endoscopy, re-bleeding, and serious intercurrent illness were independent factors for mortality. From this study it is apparent that the major determinants of a fatal outcome in bleeding peptic ulcer diseases were serious intercurrent illness and rebleeding. As it must be anticipated that patients with these particular problems are at high risk of a poor outcome, it follows that it is important they have access to skilled treatment as provided by a specialist team in an intensive care ward. It also follows that every effort should be made to keep ulcers in remission to free the ulcer patient of potentially lethal complications.     

Primary tumor cells of myeloma patients induce interleukin-6 secretion in long-term bone marrow cultures

Long-term bone marrow cultures (LTBMC) from patients with multiple myeloma (MM) and normal donors were analyzed for immunophenotype and cytokine production. Both LTBMC adherent cells from myeloma and normal donor origin expressed CD10, CD13, the adhesion molecules CD44, CD54, vascular cell adhesion molecule 1, very late antigen 2 (VLA-2), and VLA- 5, and were positive for extracellular matrix components fibronectin, laminin, and collagen types 3 and 4. LTBMC from myeloma patients and normal donors spontaneously secreted interleukin-6 (IL-6). However, levels of IL-6 correlated with the stage of disease; highest levels of IL-6 were found in LTBMC from patients with active myeloma. To identify the origin of IL-6 production, LTBMC from MM patients and normal donors were cocultured with BM-derived myeloma cells and cells from myeloma cell lines. IL-6 was induced by plasma cell lines that adhered to LTBMC such as ARH-77 and RPMI-8226, but not by nonadhering cell lines U266 and FRAVEL. Myeloma cells strongly stimulated IL-6 secretion in cocultures with LTBMC adherent cells from normal donors and myeloma patients. When direct cellular contact between LTBMC and plasma cells was prevented by tissue-culture inserts, no IL-6 production was induced. This implies that intimate cell-cell contact is a prerequisite for IL-6 induction. Binding of purified myeloma cells to LTBMC adherent cells was partly inhibited by monoclonal antibodies against adhesion molecules VLA-4, CD44, and lymphocyte function-associated antigen 1 (LFA-1) present on the plasma cell. Antibodies against VLA-4, CD29, and LFA-1 also inhibited the induced IL-6 secretion in plasma cell-LTBMC cocultures. In situ hybridization studies performed before and after coculture with plasma cells indicated that LTBMC adherent cells produce the IL-6. These results suggest that the high levels of IL-6 found in LTBMC of MM patients with active disease are a reflection of their previous contact with tumor cells in vivo. These results provide a new perspective on tumor growth in MM and emphasize the importance of plasma cell-LTBMC interaction in the pathophysiology of MM.