Ethical issues in rehabilitation: a qualitative analysis of dilemmas identified by occupational therapists

Little available research exists to address the range of ethical issues encountered by occupational therapists (OTs) in their daily clinical work. The few articles in the literature have tended to be case-based or anecdotal or have focused on professional issues rather than clinical issues. To characterize the array of clinical ethical issues in occupational therapy, we asked OTs in a free-standing academic rehabilitation hospital to describe in some detail up to three scenarios or situations from their clinical practice that raised morally troubling questions. A coding system was developed to preserve the richness of the detail but to allow for some categorization of the topics. A second section of the survey asked the therapists to rate whether various traditional ethics topics were of high, medium, or low interest to them. A third section asked that they identify the formats that would be most appealing to them for future educational interventions. Of the 56 therapists surveyed, 38 (or 68%) responded. The three self-generated topics mentioned most frequently by the therapists were (in decreasing order of frequency): reimbursement pressures, conflicts around goal setting, and patient/family refusal of team recommendations. The respondents were particularly interested in knowing more about patient-centered ethics topics, such as conflict resolution between teams and patients and the patient's role in decision making. Furthermore, they indicated a strong preference for interdisciplinary and interactive educational formats.     

Human autonomic activity and its response to acute oxygen supplement after high altitude acclimatization

It is well established that after acclimatization at high altitude, many sympathetic pathways are hyperactive yet heart rate (HR) remains unchanged. In this study, we attempted to determine if this unchanged heart rate is due to compensatory mechanisms such as changes in parasympathetic activity or levels of receptors for autonomic neurotransmitters. We also examined the role played by hypoxia in these autonomic adaptations to high altitude. Three experiments were carried out on five healthy lowlanders both at sea level (SL) and after 2 weeks of acclimatization at 3800 m (Post-Ac) with: (a) placebo (control); (b) acute beta-adrenergic receptor blockade by propranolol (PRO), or (c) acute parasympathetic receptor blockade by glycopyrrolate (GLY). Compared with SL control values, post-Ac venous norepinephrine (NE) and dopamine increased by 96% (p < 0.001) and 55% (p < 0.05), but epinephrine and HR did not change. PRO resulted in a smaller decrease in HR (bpm) Post-Ac than at SL (15 +/- 6 vs. 21 +/- 6, p < 0.05), while GLY caused a greater increase in HR Post-Ac than at SL (59 +/- 8 vs. 45 +/- 6, p < 0.05). Breathing oxygen at SL concentration while at altitude did not decrease NE, or alter the effect of PRO on HR, but reduced the chronotropic effect of GLY by 14% (p < 0.05). These results suggest that after acclimatization to altitude, increased parasympathetic neurotransmitter release and decreased beta-adenoreceptor activity account for the unchanged HR despite enhanced sympathetic activity. Acute oxygen replacement rapidly counteracted the parasympathetic, but not sympathetic hyperactivity that occurs at high altitude.     

X-ray digital subtraction angiography with 1 mol/L gadobutrol: results from a comparative porcine study With iodinated contrast agents

RATIONALE AND OBJECTIVES: To evaluate prospectively diagnostic accuracy of 1 mol/L gadobutrol as a contrast agent for intraarterial x-ray digital subtraction angiography (DSA) in comparison to iodinated, nonionic contrast media and 0.5 mol/L gadolinium-DTPA. METHODS: Flush arteriograms (ascending, descending, abdominal aorta, iliac, and femoral arteries) and selective angiograms (carotid, renal, and visceral arteries) were obtained from bilateral femoral arterial access (5 F sheaths) in 10 domestic pigs (70 kg body weight). Digital subtracted angiograms were obtained during injection of undiluted 1 mol/L gadobutrol, 300 mg I/mL iopromide, or 0.5 mol/L gadopentetate. Injection parameters (volume and velocity) were similar for all three contrast agents. In paired arteries, two different contrast media were used during the same angiographic run. Diagnostic quality and accuracy of the angiograms were evaluated on a three-step scale by three independent blinded investigators. RESULTS: Sufficient nonselective angiographic images were obtained in 90% of cases using iodinated contrast material. Gadobutrol achieved sufficient nonselective angiograms in 64%. Selective angiograms were sufficient in 98% using iodinated contrast material, 90% using 1 mol/L Gadobutrol and 48% using 0.5 mol/L Gd-DTPA. Adverse reactions to any of the used contrast agents were not noted. CONCLUSION: One mol/L Gadobutrol solution allows x-ray digital subtraction angiography with a diagnostic accuracy equivalent to 300 mg/mL iodinated contrast media, if selective injections are performed. Flush aortograms are of inferior image quality to iodinated contrast material.     

Monomer-coated very small superparamagnetic iron oxide particles as contrast medium for magnetic resonance imaging: preclinical in vivo characterization

RATIONALE AND OBJECTIVES: Preclinical in-vivo characterization of a newly developed MR contrast medium consisting of very small superparamagnetic iron oxide particles (VSOP) coated with citrate (VSOP-C184). METHODS: VSOP-C184 (core diameter: 4 nm; total diameter: 8.6 nm; relaxivities in water at 0.94 T (T1) 20.1 and (T2) 37.1 l/[mmol*sec]) was investigated to determine its pharmacokinetics, efficacy, acute single dose toxicity, repeated dose toxicity, and genotoxicity. RESULTS: The plasma elimination half-life at 0.045 mmol Fe/kg was 21.3 +/- 5.5 minutes in rats and 36.1 +/- 4.2 minutes in pigs, resulting in a T1-relaxation time of plasma of < 100 milliseconds for 30 minutes in pigs. The particles are mainly cleared via the phagocytosing system of the liver. MR angiography at a dose of 0.045 mmol Fe/kg shows an excellent depiction of the thoracic and abdominal vasculature in rats and of the coronary arteries in pigs. The LD50 in mice is > 17.9 mmol Fe/kg. A good tolerance and safety profile was found. CONCLUSIONS: The experiments indicate, that VSOP-C184 may be a well tolerated and safe contrast medium for MR imaging that can be effectively used for MR angiography including visualization of the coronary arteries.     

Comparison of clinical types of Wilson's disease and glucose metabolism in extrapyramidal motor brain regions

In Wilson's disease a disturbed glucose metabolism especially in striatal and cerebellar areas has been reported. This is correlated with the severity of extrapyramidal motor symptoms (EPS). These findings are only based on a small number of patients. Up to now it is unknown whether EPS are caused by various patterns of disturbed basal ganglia glucose metabolism. We investigated 37 patients and 9 normal volunteers to characterize the disturbed glucose metabolism in Wilson's disease more precisely. The glucose metabolism was determined in 5 cerebellar and cerebral areas (putamen, caput nuclei caudati, cerebellum, midbrain and thalamic area) by using ¹⁸ F-Fluorodesoxyglucose-Positron-Emission-Tomography ( [ ¹⁸ F]FDG-PET). The database was evaluated by a cluster analysis. Additionally, the severity extrapyramidal motor symptoms were judged by a clinical score system. Three characteristic patterns of glucose metabolism in basal ganglia were obtained. Two of them may be assigned to patients with neurological symptoms whereas the third cluster corresponds to most patients without EPS or normal volunteers. The clusters can be identified by characteristic consumption rates in this 5 brain areas. The severity of EPS can not clearly be assigned to one of the clusters with disturbed glucose metabolism. However, the most severe cases are characterized by the lowest consumption in the striatal area. When there is marked improvement of EPS impaired glucose consumption reveals a persistent brain lesion. Finally, the neurological symptoms in Wilson's disease are caused by (at least) two different patterns of disturbed glucose metabolism in basal ganglia and cerebellum. The severity of EPS seems to be determined by a disturbed consumption in the striatal area. Received: 6 July 2001, Received in revised form: 14 November 2001, Accepted: 3 December 2001     

Fibrinogen predicts restenosis after endovascular treatment of the iliac arteries

OBJECTIVE: Fibrinogen is an acute phase protein as well as a component of the coagulation cascade. Vascular inflammation and disturbed coagulation are suggested to cause restenosis after percutaneous transluminal angioplasty (PTA). We investigated the prognostic impact of fibrinogen on restenosis after endovascular treatment of iliac artery occlusive disease. METHODS: In a prospective cohort study 137 consecutive patients after iliac artery PTA (n = 74) and PTA plus selective stent implantation (n = 63) were included, 109 patients after lower limb angiography served as a control group. Patients were followed for 6 months with oscillography, ankle brachial index and duplex sonography for occurrence of restenosis. Fibrinogen and serum amyloid A (SAA), as a control parameter of inflammation, were obtained at baseline, 8, 24 and 48 h postintervention. RESULTS: PTA (adjusted OR 3.1, p = 0.05) and stenting (adjusted OR 13.3, p = 0.001) were independently associated with a higher postintervention increase of fibrinogen compared to angiography. Restenosis was found in 29 patients (21%). Patients with pre-intervention fibrinogen values in the third quartile (411-463 mg/dl) had a 6.2-fold increased adjusted risk for restenosis (p = 0.03), patients in the fourth quartile (> 463 mg/dl) had a 8.9-fold increased adjusted risk (p = 0.007). Pre-intervention SAA values were also significantly associated with restenosis (p < 0.0001). Postintervention fibrinogen and SAA levels showed no association with outcome. CONCLUSION: Balloon angioplasty and stenting of the iliac arteries cause an elevation of postintervention fibrinogen levels independently of angiographic factors. A higher pre-procedure fibrinogen level, presumably a marker of inflammatory activity, indicates a higher risk for restenosis.     

Marijuana use and the risk of Major Depressive Episode. Epidemiological evidence from the United States National Comorbidity Survey

Background This is an epidemiological study of a possible causal role of marijuana use in the development of Major Depressive Episode (MDE). Male-female differences in the suspected causal association have also been studied. Method Data are from 6,792 National Comorbidity Survey participants aged 15–45 years, assessed via the University of Michigan modified version of the Composite International Diagnostic Interview (UM-CIDI). Survival analysis methods were used to estimate cumulative risk of MDE by levels of marijuana use and to estimate suspected causal associations after adjustment for other influences. Results The risk of first MDE was moderately associated with the number of occasions of marijuana use and with more advanced stages of marijuana use. Relative to never users, non-dependent marijuana users had 1.6 times greater risk of MDE (95 % Confidence Interval: 1.1, 2.2), even with statistical adjustment for sex, birth cohorts, alcohol dependence, and history of daily tobacco smoking. Conclusions There was male-female variation in the degree of association between stage of marijuana involvement and MDE, but the strength of the association is modest at best. Accepted: 15 January 2002     

Alphavirus replicon particles expressing the two major envelope proteins of equine arteritis virus induce high level protection against challenge with virulent virus in vaccinated horses

Replicon particles derived from a vaccine strain of Venezuelan equine encephalitis (VEE) virus were used as vectors for expression in vivo of the major envelope proteins (G(L) and M) of equine arteritis virus (EAV), both individually and in heterodimer form (G(L)/M). The immunogenicity of the different replicons was evaluated in horses, as was their ability to protectively immunize horses against intranasal and intrauterine challenge with a virulent strain of EAV (EAV KY84). Horses immunized with replicons that express both the G(L) and M proteins in heterodimer form developed neutralizing antibodies to EAV, shed little or no virus, and developed only mild or inapparent signs of equine viral arteritis (EVA) after challenge with EAV KY84. In contrast, unvaccinated horses and those immunized with replicons expressing individual EAV envelope proteins (M or G(L)) shed virus for 6-10 days in their nasal secretions and developed severe signs of EVA after challenge. These data confirm that replicons that co-express the G(L) and M envelope proteins effectively, induce EAV neutralizing antibodies and protective immunity in horses.     

Efficiency of a myogenic DNA vaccine is strictly dependent upon cellular localization of HIV-1 Pr55(gag)

Most studies on DNA-based immunization have used viral promoters to drive antigen expression. Recently, the use of tissue-specific DNA vaccines has been favored regarding safety issues. In this study, we determined the impact of antigen localization and tissue-specific expression on the induction of humoral as well as cellular immune responses in a BALB/c mouse model. Thereby, we show that using the muscle-specific muscle creatine kinase (MCK) promoter/enhancer the efficiency of immune stimulation is strictly dependent on the ability of HIV-1 Pr55(gag) to be released from cells. By contrast, localization of Pr55(gag) and derivatives thereof plays only a minor role when antigen is constitutively expressed using the ubiquitous viral CMV promoter.