At the coalface: medical ethics in practice. A double dose of double effect

This paper presents a clinically orientated illustration of the doctrine of double effect. The case of an elderly gentleman with advanced cancer is discussed, with particular emphasis on two dilemmas encountered during the terminal phase of his illness. The author describes how the doctrine of double effect was applied to help the team make some complex management decisions.     

Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial.

OBJECTIVE: To determine the impact of a hospital-coordinated discharge care plan, involving a multidisciplinary team of primary health care providers, on hospital length of stay, quality of life, and both patient and general practitioner inclusion in, and satisfaction with, discharge procedures. DESIGN: This investigation comprised a prospective, randomized, controlled, clinical trial. SETTING: This multicentre and cross-jurisdictional study focused on areas of tertiary and primary health care as well as community allied health in Western Australia. PARTICIPANTS: Patients (n = 189) with chronic cardiorespiratory diagnoses were recruited from respiratory, cardiovascular, and general medical wards at two tertiary hospitals. INTERVENTION: Subjects were randomly assigned to one of two groups. Intervention group patients received a discharge care plan in accordance with that outlined in the Australian Enhanced Primary Care Package, completed before discharge and sent to the patient's general practitioner and other community service providers for review. Control patients were discharged under existing hospital processes. Outcome measures. Patients and general practitioners were surveyed pre-discharge and 7 days post-discharge for quality of life and opinion of discharge procedures. Hospital length of stay was also determined. RESULTS: Significant improvements in discharge planning involvement, health service access, confidence with discharge procedures, and opinion of discharge based on previous experience were seen for patients who received the discharge care plan. Further, improved perceptions of mental quality of life were observed within the first week post-discharge for intervention patients. Length of stay showed no difference between groups. Extent and speed of hospital-general practitioner communication were significantly improved via the intervention. CONCLUSIONS: Our results indicate that a multidisciplinary discharge care plan, initiated before separation, improves quality of life, involvement, and satisfaction with discharge care, and hospital-general practitioner integration. As such, it possesses benefits over current Western Australian hospital discharge procedures for the care of chronically ill populations.     

Glucose Reduces Norovirus Binding to Enterobacter cloacae and Alters Gene Expression of Bacterial Surface Structures in a Growth Phase Dependent Manner

Norovirus is the leading cause of acute viral gastroenteritis. Both human and murine noroviruses attach to commensal bacteria belonging to the mammalian gut flora, and binding levels are influenced by nutrients present in bacterial media. However, it is not known which nutrients are responsible for altering viral binding or why binding is altered. Gene expression of commensal bacteria can be changed by the external environment as well as by interaction with pathogens. For example, growth phase and incubation conditions impact expression levels of specific bacterial genes in Escherichia coli. We have previously shown that binding by both human and murine noroviruses to the commensal bacterium Enterobacter cloacae induces genome-wide changes in gene expression with a large number of differentially expressed genes associated with the surface structure of the bacterial cell. The current study evaluated norovirus binding under nutrient-limited conditions and assessed the expression of a select panel of these genes that are significantly altered by norovirus binding under these conditions. The goal of this work was to determine how norovirus attachment to Enterobacter cloacae affected the expression of these genes under varying nutrient and growth phase conditions. We found that the presence of glucose in minimal media reduced murine norovirus binding to E. cloacae and viral binding in the presence of glucose reduced gene expression for surface structures previously associated with norovirus attachment. Changes in viral binding and gene expression occurred in a growth phase-dependent manner. Collectively, these data demonstrate that both the growth phase and nutrient availability alter viral interactions with commensal bacteria and the subsequent changes in gene expression. Ultimately, this work advances our understanding of norovirus-bacterium interactions and provides a foundation for elucidating the conditions and surface structures that regulate norovirus attachment to bacteria.     

改良性治疗法联合西地那非治疗勃起功能障碍维吾尔族患者2505例回顾性分析

目的:性治疗法目前尚未普及,本研究旨在评价性治疗法联合西地那非治疗勃起功能障碍(ED)的疗效。方法:根据治疗方法的不同将在本院治疗随访过的3130例维吾尔族ED患者分成2组。对照组625例,单纯口服西地那非3个月;试验组2505例,采用性治疗法联合西地那非治疗3个月。采用国际勃起功能问卷表(IIEF-5)在各组治疗前、后进行疗效评估,并随访12个月。结果:对照组治疗前、后及在6个月、12个月随访的IIEF-5评分分别为12.80±3.76、18.10±2.61、17.35±2.73和16.64±2.63;试验组治疗前、后及在6个月、12个月随访的IIEF-5评分分别为12.73±3.52、19.06±4.07、19.86±2.42和20.47±2.38。两组治疗前后IIEF-5评分自身对比差异均有显著性(P<0.05)。组间比较,试验组较对照组6个月和12个月随访IIEF-5评分均有显著性差异(P<0.05)。结论:性治疗法联合西地那非治疗ED的效果优于单纯西地那非治疗,并在12个月的随访中稳定性良好。     

Progesterone pharmacokinetics in the mouse: implications for potential stroke therapy

Objectives Progesterone has been shown to be neuroprotective in a number of preclinical central nervous system injury models including cerebral ischaemia. The aim of this study was to clarify differences in outcomes owing to different dosing regimens and the pharmacokinetic profile of progesterone, particularly in relation to brain levels. Methods Male C57 Bl/6 mice were injected intraperitoneally with progesterone (8 mg/kg in dimethylsulfoxide) or with a bolus injection followed by continuous subcutaneous infusion (1.0 µl/h of a 50 mg/ml progesterone solution) via implanted osmotic minipumps. Plasma and brain samples were collected over 24 h from bolus‐injected mice and 48 h from mice implanted with minipumps. Progesterone concentrations were measured by an enzyme‐linked immunoassay and pharmacokinetic profiles were constructed. Key findings Intraperitoneally injected progesterone had a short half‐life (fast component half‐life of 0.2 h) in both plasma and brain. Minipump delivery resulted in higher concentrations of progesterone in plasma and particularly in brain over a longer period. The volume of distribution with intraperitoneal injection was 172.78 versus 1641.84 ng/h per g via minipump in the first 24 h. Conclusions A bolus intraperitoneal loading dose of progesterone followed by continuous delivery via osmotic minipump is an effective way of delivering progesterone to the brain.     

Rethinking children’s public health: the development of an assets model

It has been suggested that asset-based strategies could provide an opportunity to rethink the approach to public health; however, this may not be a viable option unless there is clear recognition of specific individual assets. Although there has been some consideration of assets within a child health context, this is limited and previous studies have not sought to identify assets from the perspective of the child. This paper reports on a study that drew on an ethnographic approach, using a photo-elicitation method, to facilitate the mapping of children’s internal and external assets from the viewpoint of children themselves. Two primary schools in the South-East of England were used to recruit 20 year five children (aged 9–11 years of age). The participants, 10 boys and 10 girls, were given disposable cameras and asked to take photographs of the activities that they enjoyed. The children’s photographs were used as prompts during individual semi-structured interviews. A constant comparative analysis facilitated the mapping of the children’s assets as the children described them; this process revealed one overall stabilising asset (‘My Family’) as well as eight internal and three external assets. All of the assets are presented within an original model, ‘I’m good’: the children’s asset wheel [CAW], which was developed from the findings. It is suggested that the CAW could complement previous asset-based work to facilitate the rethinking of approaches to the enhancement of children’s public health.     

Adults in All Body Mass Index Categories Underestimate Daily Energy Requirements

ObjectiveTo compare the difference between self-reported and calculated daily energy requirements of adults within different body mass index (BMI) categories.MethodsAdults (n = 978) self-reported daily energy requirements, demographic information, and height, weight, age, and physical activity level (PAL) to calculate total energy expenditure.ResultsThe main effects of BMI, gender, PAL, and dieting status on the difference between self-reported and calculated energy requirements for weight maintenance were significant (P < .05); age, race/ethnicity, level of education, and being in a health-related field had no effect. Individuals across all BMI categories underestimated their energy requirements, but obese individuals underestimated to the greatest degree. Males, current dieters, and those who reported a low-active or active PAL underestimated to the greatest extent in each category.Conclusions and ImplicationsThere is a lack of basic nutrition knowledge about personal energy needs in individuals across all BMI categories regardless of age, race/ethnicity, level of education, or work/training in a health-related field.