Das medizinisch-ethische Dilemma von Reanimationsentscheidungen bei Notfallpatienten

Despite established structures for consultation regarding clinical ethics, emergency physician often faces the problem of making decisions in cases of emergencies in a very short time without knowing the patient’s preferences, because a clinical–ethic consultation, such as an ethics committee, is not possible in an emergency department. Resuscitation represents a special situation. The emergency physician in this case cannot rely on valid medical data, since on the one hand—as in the work presented here—there are currently no reliable studies (long-term studies) investigating survival after resuscitation and on the other hand, the studies for futility, that means hopelessness of life-prolonging measures, are very heterogeneous. In various works, authors therefore demand that the professional make an individual decision. In the present work, it is argued that an individual treatment decision involves moral values of the physician and therefore ethical aspects enter the decision. Today’s medical ethics, which is based on the four principles of modern bioethics (welfare, non-harm, autonomy, and justice), includes the need of valid medical “input” on the benefits or harm of the proposed treatment method and thus survival option or “futility” in the given situation. But proper evidence-based data are currently not available. Thus, the logical argumentation in this paper is a vicious circle from which there is currently no way out. This means that even ethics can offer no solutions here, because application of the four leading principles requires precisely those medical data which are currently not yet available. The task of the present work is to draw attention to this problem and to stimulate discussion on how to make treatment decisions in this context and how to judge them.     

A review of interventions in the parent-child relationship informed by attachment theory

Bowlby's attachment theory has inspired a dramatic shift in the way we understand the development of the early relationship between infant and caregiver(s). Though almost all infants develop an attachment relationship to their primary caregiver(s), not all of them are able to use their caregiver(s) as a secure base or haven of safety from which to explore the world. Mary Ainsworth was the first to describe in detail the aspects of the caregiving system that are most important for the development of the attachment relationship. During the last decade several studies have started to evaluate the possibility that insensitive and perhaps even inadequate parenting can be effectively ameliorated by interventions. The present article sketches the theory behind attachment-based interventions and reviews the evidence for the effectiveness of such interventions. Finally, the article gives examples of successful preventive as well as therapeutic interventions.     

Abnormal architecture of the ventricles in hearts with an overriding aortic valve and a perimembranous ventricular septal defect (“Eisenmenger VSD”)

Among 111 hearts with so-called “isolated” ventricular septal defect, 18 specimens were found to have a subaortic perimembranous defect with an overriding aortic valve but without pulmonary stenosis. The ventricular architecture was characterized by several abnormalities. A constant finding was the wide right ventricular outflow tract. The outlet septum had its normal continuity with the septomarginal trabecula, but its parietal extension was located relatively far anteriorly. Part of the aortic valve thus inserted to the right ventricular component of the ventriculo-infundibular fold in the gap between the outlet septum and the tricuspid valve. Left ventricular abnormalities comprised mitral valve anomalies in all cases. There was an anteroseptal twist (leftward thickening of the anterior part of the ventricular septum) in 16 cases. A bicuspid aortic valve and/or malformed cusps were observed in 4 cases. Because of the linking phenomenon of aortic override, we also examined 10 hearts with tetralogy of Fallot and, in the latter, such abnormalities were not found. Our observations indicate that this seemingly simple type of defect is part of a complex malformation involving both septation and valve formation. Awareness of the existence of the architectural abnormalities might make them accessible for echocardiographic diagnosis. It was noteworthy that 11 of the 18 patients had chromosomal abnormalities, 9 of them presenting with trisomy-18.     

消化系肿瘤的介入治疗

编者按 胃、结直肠癌、肝癌是我国常见的消化系统恶性肿瘤,约占整个消化系肿瘤的50%以上,严重影响患者的生存质量.如何进行早期诊断、治疗并提高患者的生存质量一直是临床医生研究的方向.近年来,随着内镜和放射介入技术的不断发展,介入治疗已经成为一个介入传统内科学和外科学之间的临床治疗体系,具有安全、简便、并发症小等优点.     

Hypervariable-control-region sequences reveal global population structuring in a long-distance migrant shorebird, the Dunlin (Calidris alpina).

Hypervariable segments of the control region of mtDNA as well as part of the cytochrome b gene of Dunlins were amplified with PCR and sequenced directly. The 910 base pairs (bp) obtained for each of 73 individuals complete another of the few sequencing studies that examine the global range of a vertebrate species. A total of 35 types of mtDNA were detected, 33 of which were defined by the hypervariable-control-region segments. Thirty of the latter were specific to populations of different geographic origin in the circumpolar breeding range of the species. The remaining three types indicate dispersal between populations in southern Norway and Siberia, but female-mediated flow of mtDNA apparently is too low to overcome the effects of high mutation rates of the control-region sequences, as well as population subdivision associated with historical range disjunctions. A genealogical tree relating the types grouped them into five populations: Alaska, West Coast of North America, Gulf of Mexico, western Europe, and the Taymyr Peninsula. The Dunlin is thus highly structured geographically, with measures of mutational divergence approaching 1.0 for fixation of alternative types in different populations. High diversity of types within populations as well as moderate long-term effective population sizes argue against severe population bottlenecks in promoting this differentiation. Instead, population fragmentation in Pleistocene refuges is the most plausible mechanism of mtDNA differentiation but at a much earlier time scale than suggested previously with morphometric data.