A rare actinomycosis of humerus: an unusual location and a diagnostic dilemma. A case report

Background Isolated actinomycosis of the humerus is a very rare entity. Method A 30-year-old male had an erythematous plaque with a pus-(minimal) discharging sinus over left lower arm. The patient had no discharge of sulphur granules from the sinus. The patient had raised ESR with a single lytic lesion with minimal sclerosis and inconspicuous periosteal reaction on radiographs. Such atypical clinical and radiological features lead to initial wrong diagnosis of tuberculosis. A diagnosis of Actinomycosis of humerus became possible after demonstration of filamentous bacilli in culture and on histopathology from the sulphur grains obtained by open biopsy. Result The patient recovered completely after administering PenicillinG 24 million units intravenous for 7 days followed by 1.2 g of oral amoxicillin in three divided doses for 3 months and did not show any recurrence during last 2 years of follow up. Conclusion Surgeons should be aware of this rare entity and difficulty in its diagnosis due to its variable manifestations, including confusion with highly endemic tuberculous infection. Awareness of full spectrum of the diseases and careful evaluation in individual cases will expedite diagnosis and avoid unnecessary surgical interventions. No financial or any otherwise support has been received in any regard from any organization or institution for this case report titled “A rare actinomycosis of humerus: an unusual location and a diagnostic dilemma—a case report.” All authors have contributed to the study and publication of this case report and agree in congruence to the same.     

Experience of moral distress among pediatric surgery trainees

Purpose

The aim of this study was to identify and qualify the ethical dilemmas faced by pediatric surgery trainees.

Methods

An online survey was sent to pediatric surgery trainees graduating between 2005 and 2008. Consent was obtained, and study investigators were blinded to the identity of the respondents during data analysis.

Results

Of the 40 respondents, only 59% felt they had received adequate training in bioethics to handle ethical issues pertaining to the care of critically ill children. Although 83% of respondents routinely participated in palliative care discussions, 30% of respondents desired to have more opportunities to discuss end-of-life issues with their staff. Moral conflicts were resolved through direct discussions with the medical staff, family, or friends. Despite the presence and awareness of institutional policies on ethical behavior, 58% of respondents did not believe that ethical conflicts were resolved as a result of these policies, whereas 31% of respondents felt that reporting of unethical conduct would result in personal reprisals.

Conclusion

Pediatric surgery trainees face ethical and moral conflicts, but some are fearful of reprisals if these concerns are reported. A neutral forum to raise such issues may facilitate open discussions and eventual resolution of these conflicts.     

Testosterone, facial symmetry and cooperation in the prisoners' dilemma

Recent research has analyzed how individual characteristics, like the exposure to different hormones and symmetry, affect decision-making and strategic behaviour. The present article investigates the effect of symmetry, of exposure to testosterone (T) in utero and during puberty and of current T on cooperation in a Prisoners' Dilemma Game (PDG). T is a hormone with well known effect on males' behaviour, and that promotes activities that seek to increase reproductive success. Fluctuating Asymmetry (FA) reflects the ability of the organism to maintain a stable development and it is usually employed as a variable reflecting genetic quality (low FA values are thought to signal higher genetic quality). Our results show that subjects with intermediate levels of second to fourth digit ratio (a proxy of exposure to T in utero) and with high FA cooperate more often in the PDG. We also observe that the latter effect is due to the fact that FA has an impact on subjects' expectations about the behaviour of their counterpart in the game. These results reinforce the described link between markers related to genetic quality and cooperative behaviour. This possible linkage of individual condition and pro-social behaviour in humans clearly merits further attention.     

Comment droit et éthique s’enrichissent mutuellement dans la prise en charge médicale des personnes avec handicap

Whatever his or her disability, a person has the right to medical care of the same quality as any other patient. The law tries to meet the needs of vulnerable people, regardless of their situation. For example, a minor, disabled or not, may seek a treatment while preserving confidentiality regarding his/her parents. Privacy is a concept that does not begin at 18. In France, the law of 4 March 2002 already addressed this hypothesis; the law of 26 January 2016 modernizing our health system extended it. An adult, disabled or not, may need help not only for administrative and financial procedures, but also for medical or medicosocial matters. The law offers various support solutions with the family, guardian, support person, relatives, caregivers, attorneys involved with a mandate for future protection. In medical practice, a number of situations, simple in theory, can be very problematic. The ethical approach will be essential to help deal with all these questions.     

护士社会支持对道德困境的影响研究

目的探讨护士社会支持对道德困境的影响,为帮助护士应对工作中的道德困境提供理论基础。方法采用社会支持评定量表和护士道德困境量表对387名护士进行问卷调查。结果护士社会支持总分(38.62±5.81)分,客观支持(8.63±2.62)分,主观支持(21.64±4.75)分,支持利用度(8.45±2.81)分。护士道德困境量表条目频率为(1.14±0.54)分,强度为(1.03±0.32)分,总体得分为(1.15±0.42)分,表明护士道德困境发生频率和强度均较低。职称、学历、是否独生子女、社会支持是护士道德困境的影响因素。结论社会支持会负向影响护士的道德困境,提高护士社会支持水平,扩大护士社会支持的来源,是应对护士道德困境的有效途径。     

Intuition,deliberation, and the evolution of cooperation

Humans often cooperate with strangers, despite the costs involved. A long tradition of theoretical modeling has sought ultimate evolutionary explanations for this seemingly altruistic behavior. More recently, an entirely separate body of experimental work has begun to investigate cooperation’s proximate cognitive underpinnings using a dual-process framework: Is deliberative self-control necessary to reign in selfish impulses, or does self-interested deliberation restrain an intuitive desire to cooperate? Integrating these ultimate and proximate approaches, we introduce dual-process cognition into a formal game-theoretic model of the evolution of cooperation. Agents play prisoner’s dilemma games, some of which are one-shot and others of which involve reciprocity. They can either respond by using a generalized intuition, which is not sensitive to whether the game is one-shot or reciprocal, or pay a (stochastically varying) cost to deliberate and tailor their strategy to the type of game they are facing. We find that, depending on the level of reciprocity and assortment, selection favors one of two strategies: intuitive defectors who never deliberate, or dual-process agents who intuitively cooperate but sometimes use deliberation to defect in one-shot games. Critically, selection never favors agents who use deliberation to override selfish impulses: Deliberation only serves to undermine cooperation with strangers. Thus, by introducing a formal theoretical framework for exploring cooperation through a dual-process lens, we provide a clear answer regarding the role of deliberation in cooperation based on evolutionary modeling, help to organize a growing body of sometimes-conflicting empirical results, and shed light on the nature of human cognition and social decision making.Cooperation, where people pay costs to benefit others, is a defining feature of human social interaction. However, our willingness to cooperate is puzzling because of the individual costs that cooperation entails. Explaining how the “selfish” process of evolution could have given rise to seemingly altruistic cooperation has been a major focus of research across the natural and social sciences for decades. Using the tools of evolutionary game theory, great progress has been made in identifying mechanisms by which selection can favor cooperative strategies, providing ultimate explanations for the widespread cooperation observed in human societies (1).In recent years, the proximate cognitive mechanisms underpinning human cooperation have also begun to receive widespread attention. For example, a wide range of experimental evidence suggests that emotion and intuition play a key role in motivating cooperation (2–5). The dual-process perspective on decision making (6–8) offers a powerful framework for integrating these observations. In the dual-process framework, decisions are conceptualized as arising from competition between two types of cognitive processes: (i) automatic, intuitive processes that are relatively effortless but inflexible; and (ii) controlled, deliberative processes that are relatively effortful but flexible. In many situations, intuitive and deliberative processes can favor different decisions, leading to inner conflict: Rather than being of a single mind, people are torn between competing desires.Despite the widespread attention that dual-process theories have received in the psychological and economic sciences (including incorporation into formal decision making models; refs. 9–11); the existence of related discussion in the theoretical biology literature regarding error management (12–14), tradeoffs between fixed and flexible behaviors (15–18), and cultural evolution and norm internalization (2, 19, 20); and a long interdisciplinary tradition of arguments suggesting that strategies developed in repeated interactions spill over to influence behavior in one-shot anonymous settings (21–25), the dual-process framework has been almost entirely absent from formal models of the evolution of cooperation. Traditional evolutionary game theory models of cooperation focus on behavior, rather than the cognition that underlies behavior. Therefore, these models do not shed light on when selection may favor the use of intuition versus deliberation, or which specific intuitive and deliberative responses will be favored by selection.In this paper, we build a bridge between ultimate and proximate levels of analysis to address these questions, introducing an evolutionary game-theoretic model of cooperation that allows for dual-process agents. These agents interact in a varied social environment, where interactions differ in the extent to which current actions carry future consequences. To capture the tradeoff between flexibility and effort that is central to many dual-process theories, we allow our agents to either (i) use an intuitive response that is not sensitive to the type of interaction currently faced; or (ii) pay a cost to deliberate, tailoring their action to the details of the current interaction.We then use this framework to explore the consequences of reciprocity and assortment (26, 27), two of the most widely studied mechanisms for the evolution of cooperation. We ask when (and to what extent) agents evolve to pay the cost of deliberation; when evolution favors intuitive responses that are selfish versus cooperative; and whether deliberation serves to increase or decrease social welfare. In doing so, we provide a formal theoretical framework to guide the emerging body of empirical work exploring prosociality from a dual-process perspective, and provide insight into the cognitive underpinnings of human cooperation.     

In whose ‘best interests’? Ethical issues involved in the moral dilemmas surrounding the removal of sexually abused adolescents from a community-based residential treatment unit to a locked,forensic adult psychiatric unit

This study scrutinizes the ethical and moral dilemmas surrounding the removal of sexually abused adolescents from a community-based residential treatment unit to a locked, forensic adult psychiatric unit. Adolescent victims of sexual abuse exhibit a plethora of psychopathological symptomatology which can lead in many cases to the adolescent resorting to self-injurious behaviours in an attempt to relieve feelings of tension, anxiety and guilt. Because the unit in which the writer is involved is an open, community-based treatment centre with limited staffing levels, a completely secure environment may be compromised. Consequently self-injurious adolescents may become so disturbed that a more secure environment must be sought. The limited resources for disturbed adolescents in Northern Ireland means that occasionally the only option available to health care professionals who find themselves in this situation is to utilize the services of the psychiatric adult, forensic unit in Belfast which is contained within a large psychiatric hospital. Many would agree that such a placement for a disturbed adolescent seems inappropriate but is at the same time unavoidable. This study will examine the ethical and moral minefield that only recently has become a dilemma for health care professionals and particularly for nurses endeavouring to adhere to the code of professional conduct.     

美沙酮维持治疗的法律困境与选择

美沙酮维持治疗具有预防艾滋病病毒感染和戒毒的双重功能,在我国获得明显绩效。在实际运用中,美沙酮维持治疗管理涉及多部门和多部法律法规,在机构性质、行政许可、药品包装、内部管理等方面面临法律困境,因此需要在方案、责任体系、纠纷解决、监管程序等方面完善。     

困境儿童的福利需求、救助不足与保护机制研究 —— 基于困境儿童的类型化分析

  目的  了解困境家庭学龄儿童心理困难和亲社会行为状况并与普通儿童比较,评估困境家庭儿童心理健康需求,为开展适度普惠型儿童福利制度提供实证依据。  方法  2018年8 — 9月,针对困境家庭儿童进行的全国抽样调查数据,应用独立样本t检验和单项有序秩和检验（Matel-Haenszel χ²检验）等统计分析方法,比较2 099名困境家庭儿童和666名对照普通儿童长处和困难量表各因子得分及异常率并分性别分析。  结果  6～9岁困境家庭儿童情绪因子[（2.107 ± 1.977）分]（异常检出率15.5 %）和同伴交往因子[（3.449 ± 1.497）分]（异常检出率8.5 %）得分及异常检出率均明显高于对照儿童（P < 0.05）;10～15岁困境家庭儿童多动[（3.459 ± 1.691）分]（异常检出率3.7 %）、情绪[（2.121 ± 1.987）分]（异常检出率7.4 %）、品行[（2.214 ± 1.563）分]（异常检出率8.7 %）、同伴交往因子[（3.352 ± 1.445）分]（异常检出率8.1 %）得分及异常检出率均明显高于对照儿童（P < 0.01）,亲社会行为因子[（5.570 ± 2.337）分]得分明显低于对照儿童（P < 0.001）,异常检出率（28.3 %）明显高于对照儿童（P < 0.001）。6～9岁困境家庭女童亲社会行为因子[（5.229 ± 2.366）]明显低于对照女童。10～14岁困难家庭男童[（5.630 ± 2.372）分]和女童[（5.500 ± 2.295）分]亲社会行为因子得分明显低于对照男、女童（P < 0.01）。  结论  困境家庭儿童各项心理困难发生风险高、亲社会行为表现较差;年龄较大、女性困境家庭儿童应是心理健康干预措施的重中之重。