Harm in the absence of care: Towards a medical ethics that cares

The aim of this article is to investigate the concept of care in contemporary medical practice and medical ethics. Although care has been hailed throughout the centuries as a crucial ideal in medical practice and as an honourable virtue to be observed in codes of medical ethics, I argue that contemporary medicine and medical ethics suffer from the lack of a theoretically sustainable concept of care and then discuss possible reasons that may help to explain this absence. I draw on the empirical studies of Carol Gilligan on care and connectedness as ontologically situated realities in human life. Based on a philosophical elaboration of her findings on the ethics of care emphasizing relationality, I try to show how the notion of 'relational ontology' originating from this stream of thought may be of help in developing a medical ethics that acknowledges care as a perspective to be observed in all interactions between physicians and patients.     

Employment outcome and predictors of competitive employment at 2-year follow-up of a vocational rehabilitation programme for individuals with schizophrenia in a high-income welfare society

Background: Employment is an important part of recovery for individuals with schizophrenia. The employment rate for this group is as low as 10% in Norway, and major system related barriers to employment are evident.

Aims: This study reports the competitive employment outcome at 2-year follow-up of a vocational rehabilitation study augmented with cognitive remediation (CR) or elements from cognitive behaviour therapy (CBT) for individuals with schizophrenia spectrum disorders. It also investigates if global functioning, self-esteem, and depression at baseline predicts employment outcome, and if change in these variables during the intervention period is associated with employment outcome.

Method: One hundred and forty-eight participants with schizophrenia spectrum disorders in six Norwegian counties received 10 months vocational rehabilitation augmented with either CBT (n?=?84) or CR (n?=?64). Both competitive and sheltered workplaces were used. Participants were assessed at baseline, at the end of the intervention period, and at 2-year follow-up.

Results: At 2-year follow-up, 21.2% had obtained competitive employment. A further 25.3% had work placements in competitive workplaces. Significant improvements were found in global functioning, self-esteem, and depression during the intervention period, but no significant differences between the two intervention groups. High baseline global functioning and self-esteem, as well as positive change in these variables during the intervention period, were significantly associated with higher competitive employment outcome at 2-year follow-up.

Conclusion: The results add to existing evidence that competitive employment is attainable for individuals with schizophrenia. High global functioning and self-esteem were strongly associated with competitive employment outcome.     

Psychiatric disorders in adolescents and adults with autism and intellectual disability: A representative study in one county in Norway

Few studies assess psychiatric disorders in representative samples of individuals with autism and ID. Symptoms of autism and psychiatric disorders have been confounded. PAC, a conceptually analysed and validated screening instrument, was used.AimsAssess prevalence of psychiatric disorders in individuals with intellectual disability only (ID-only) and with combination of autism and ID (autism). Sixty-two (autism) and 132 (ID-only) participants were screened for psychiatric disorders with the Psychopathology in Autism Checklist (PAC); included general adjustment problems (GAP), and severe adjustment problems (SGAP) in one county in Norway. Psychosis, depression, anxiety, and OCD were addressed. Both SGAP and a high psychiatric disorder score were required to screen a psychiatric disorder. “Diagnostic overlap” was defined as more than one psychiatric disorder concurrent with autism.Psychiatric disorders and SGAP were found to be high both in the autism (53.2%) and ID-only group (17.4%). More than 50% of the autism and approximately 20% of ID-only group had SGAP. The differences were significant. The autism–psychiatric disorder interaction was significant. The largest differences between the prevalence in the autism and the ID-only group were shown in individuals with anxiety. The majority of the individuals in both study groups were afflicted with more than one psychiatric disorder. About 60% were found to have more than one disorder. The individuals with more severe psychiatric symptoms had higher degrees of diagnostic overlap. Having an intellectual disability seem to imply high risk for developing adjustment problems, and it seems especially difficult for individuals with autism to master every-day challenges.     

Assessment of depression: comparison between Beck Depression Inventory and subscales of Comprehensive Psychopathological Rating Scale

The purpose of this study was to investigate the relationship between self-rating and therapist rating in nonpsychotic patients with unipolar depressive disorders. We also wanted to find out whether the presence of personality disorders would influence the results. At admission and discharge 117 patients filled in the Beck Depression Inventory (BDI) and were rated by a therapist on the Comprehensive Psychopathological Rating Scale (CPRS). Based on the CPRS-scores, two indices of depression were calculated: CPRS-dep and Montgomery Åsberg Depression Rating Scale (MADRS). Sixty-three patients had DSM-III-R major depression, 30 had dysthymic disorder, while 24 had no depressive disorder. Eighty suffered from one or more personality disorders, mostly within cluster C. The self rating (BDI) and therapist ratings (CPRS-dep and MADRS) were strongly intercorrelated, with a nonsignificant tendency for weaker correlations in patients with personality disorders. All scales were useful to separate depressed from non-depressed, and to discriminate between major depression and dysthymic disorder, with a tendency in favour of BDI. As cut-off scores for major depression we recommend the sum score of 23 on the BDI, and mean scores of 1 on CPRS-dep and 1.1 on MADRS on a 0–3 scale. When these values are used, 70–79% of patients are correctly classified.     

Antral G cells in rats during dosing with a PPARa agonist: a morphometric and immunocytochemical study

Gastrin-producing G cells constitute one of the major populations of neuroendocrine cells in the antral mucosa of the stomach. The peroxisome proliferator-activated receptor (PPAR) alpha-agonist ciprofibrate is used as a lipid-lowering drug. Recently, ciprofibrate has been shown to induce hypergastrinemia in rats without reducing gastric acidity, which indicates a direct stimulatory effect on the G cell. Gastrin probably plays an important role in gastric tumorgenesis, and long-term dosing with ciprofibrate results in enterochromaffin-like (ECL) cell carcinoids in the oxyntic mucosa of rats. In this study, we aimed to examine changes of neuroendocrine granules in G cells following ciprofibrate dosing and relate them to changes induced by the proton pump inhibitor pantoprazole. Furthermore, we wanted to study peroxisomes in G cells. Rats received ciprofibrate 80 mg/kg/day or pantoprazole 200 mg/kg/day in 4 weeks. Antral mucosal specimens were processed for conventional staining procedures and immunocytochemistry for both the light and electron micro-scope. Specimens were immunolabeled for gastrin and peroxisome-specific proteins. Electron micrographs were analyzed planimetrically. This study shows that hypergastrinemia induced by ciprofibrate is accompanied by a decrease in granule number per cell and a relative increase in electron-dense granules. These changes were quite similar to those induced by pantoprazole, indicating signs of G-cell activation in general. However, distinctions concerning granule size and composition and both hypertrophy and hyperplasia of G cells are presented. Finally, demonstration of peroxisomes in G cells was only achieved by using the highly sensitive tyramide signal amplification technique in immunostaining for the peroxisome-specific protein PMP-70. Therefore, neither morphological nor quantitative changes of peroxisomes in G cells were detected.     

Occupational variation in the risk of female breast cancer in the Nordic countries

Objective

This study aimed to determine occupational variations in the incidence of breast cancer in the population-based cohort of Nordic Occupational Cancer Study (NOCCA).

Methods

The study included long-term follow-up data from almost 7.5 million Nordic women. Participants were assigned to one of the 54 occupational categories based on census records at the ages of 30–64 years. Sixty-two thousand cases of breast cancer were identified through record linkages between nationwide cancer registries in Finland, Sweden, Norway, Denmark, and Iceland, followed up between 1961 and 2005. Country-specific standardized incidence ratios (SIRs) with 95% confidence intervals were estimated.

Results

Overall, the highest risk elevations were seen among military personnel (SIR 1.58, 95% CI 1.03–2.32), dentists (SIR 1.43, 95% CI 1.31–1.56), and physicians (SIR 1.35, 95% CI 1.26–1.46). The lowest risks were observed among gardeners (SIR 0.76, 95% CI 0.74–0.78), farmers (SIR 0.80, 95% CI 0.78–0.82), and woodworkers (SIR 0.75, 95% CI 0.70–0.81). Welders, tobacco workers, and painters had higher SIRs for breast cancer diagnosed at age?<?50. A reduced risk was observed among forestry workers, welders, and fishery workers for breast cancers diagnosed both before and after age 50. The SIRs for breast cancer did not vary substantially by histology. A significantly increased risk of breast cancer was observed among laboratory workers in the latest calendar period (1991–2005) compared with earlier periods (1976–1990 and 1961–1975). Occupations such as farming, forestry, driving, and gardening had low SIRs during all periods.

Conclusions

The study suggests that the risk of breast cancer varies by occupation. Heterogeneity is also observed in some occupational categories according to age (before or after 50), histology, and calendar period.

     

Antitumor activity of P-4055 (elaidic acid-cytarabine) compared to cytarabine in metastatic and s.c. human tumor xenograft models.

The antineoplastic efficacy of P-4055, a 5'-elaidic acid (C18:1, unsaturated fatty acid) ester of cytarabine, a nucleoside antimetabolite frequently used in the treatment of hematological malignancies, was examined in several in vivo models for human cancer. In initial dose-finding studies in nude mice, the efficacy of P-4055 was highest when using schedules with repeated daily doses. In a Raji Burkitt's lymphoma leptomeningeal carcinomatosis model in nude rats, the control cytarabine- and saline-treated animals (five in each group) had a mean survival time of 13.2 days, whereas treatment with P-4055 resulted in three of five long-time survivors (>70 days). In a systemic Raji leukemia model in nude mice, 8 of 10 of the P-4055-treated animals survived (>80 days), compared with none of the cytarabine-treated animals (mean survival time, 34.2 days). In s.c. xenograft models, the effects of maximum tolerated doses of P-4055 and cytarabine, given in four weekly cycles of daily bolus i.v. injections for 5 subsequent days, against seven tumors (three melanomas, one lung adenocarcinoma, one breast cancer, and two osteogenic sarcomas) were investigated. P-4055 induced partial or complete tumor regression of the lung carcinoma, as well as of all three malignant melanomas. In two of the melanomas the activity was highly superior to that of cytarabine, and both P-4055 and cytarabine were, in general, more effective than several clinically established drugs previously tested in the same tumor models. In in vitro studies, inhibitors of nucleoside carrier-dependent transport, nitrobenzylmercaptopurine riboside and dipyridamol, reduced strongly the cellular sensitivity to cytarabine, but not to P-4055, indicating that P-4055 uses an alternative/additional mechanism of internalization into the cell compared with cytarabine. The results explain, at least in part, the observed differences between the two compounds in in vivo efficacy, and together the data strongly support the evaluation of P-4055 in clinical studies.     

Occupational exposure to wood dust and risk of nasal and nasopharyngeal cancer: A case‐control study among men in four nordic countries—With an emphasis on nasal adenocarcinoma

The current study aims to provide stronger evidence to aid in our understanding of the role of cumulative occupational exposure to (softwood‐dominated) mixed wood dust in aetiology of nasal cancer. We included broad exposure occurred in a range of wood‐processing occupation across varied industries in four Nordic countries. A population‐based case‐control study was conducted on all male cases with nasal adenocarcinoma (393 cases), other types of nasal cancer (2,446) and nasopharyngeal cancer (1,747) diagnosed in Finland, Sweden, Norway and Iceland between 1961 and 2005. For each case, five male controls, who were alive at the time of diagnosis of the case (index date), were randomly selected, matched by birth‐year and country. Cumulative exposures (CE)s to wood dust and formaldehyde before the index date were quantified based on a job‐exposure matrix linked to occupational titles derived from population censuses. Hazard ratios (HRs) for the CE of wood dust were estimated by conditional logistic regression, adjusted for CE to formaldehyde and 95% confidence intervals (CIs) were calculated. There was an increasing risk of nasal adenocarcinoma related to wood dust exposure. The HR in the highest CE category of wood dust (≥ 28.82 mg/m³‐years) was 16.5 (95% CI 5.05–54.1). Neither nonadenocarcinoma of the nose nor nasopharyngeal cancer could be linked to wood dust exposure. CE to softwood‐dominated mixed wood dusts is strongly linked with elevated risk in nasal adenocarcinoma but not with other types of nasal or nasopharyngeal cancer.