124 research outputs found
Ethical frameworks for complex medical decision making in older patients: A narrative review
Background: With an ageing population physicians are more and more faced with complex medical and moral
situations. Medical professional guidelines are often of limited use in these cases. To assist the decision making
process, several ethical frameworks have been proposed. Ethical frameworks are analytical tools that are designed to assist physicians and other involved healthcare workers in complex moral decision-making situations.
Most frameworks are step-by-step plans that can be followed chronologically during moral case deliberations.
Some of these step-by-step plans provide specific moral guidance as to what would constitute a morally acceptable conclusion, while others do not.
Objective: In this narrative review we will present and discuss the ethical frameworks used for medically complex situations in older people that have been proposed in literature.
Methods: Three electronic databases (embase.com. Medline Ovid and PsychINFO Ovid) were searched from
inception to January 24, 2020, with the help of expert librarians.
Results: Twenty-three studies were included in the review, containing seventeen different frameworks. Twenty
studies described step-by-step-frameworks, with the number of steps varying from three to twelve. In four studies
suggestions were made as how to balance conflicting moral values.
Conclusions and implications of key findings: Ethical frameworks are meant to assist healthcare professionals who
are faced with morally complex decisions in older patients. In our view, these frameworks should contain a stepby-step plan, moral values and an approach to balancing moral values
Serum calcification propensity is associated with HbA1c in type 2 diabetes mellitus
Introduction Serum calcification propensity is emerging as an independent predictor for cardiovascular outcomes in high-risk populations. Calcification propensity can be monitored by the maturation time of calciprotein particles in serum (T-50 test). A low T-50 value is an independent determinant of cardiovascular morbidity and mortality in various populations. Aim was to investigate the T-50 and its relationship to type 2 diabetes mellitus. Research design and methods Using nephelometry, serum T-50 was cross-sectionally measured in 932 stable patients with type 2 diabetes mellitus (55% male) with a median age of 66 (62-75) years, diabetes duration of 6.5 (3.0-10.2) years and hemoglobin A1c (HbA1c) of 49 (44-54) mmol/mol. Results Serum T-50 was normally distributed with a mean value of 261 +/- 66 min. In linear regression, serum T-50 was lower in women and current smokers. A lower T-50 value was found in patients with a higher HbA1c or higher systolic blood pressure, insulin users and patients with a longer history of diabetes. The association with HbA1c was independent of other determinants in multivariable analysis. There was no association between T-50 and previous macrovascular events or the presence of microvascular disease. Conclusions Serum calcification propensity is independently associated with glycemic control, suggesting that a lower HbA1c may be associated with better cardiovascular outcomes. Retrospective analysis could not establish an association between a history of macrovascular events and T-50, and prospective studies will have to be performed to address this hypothesis
Implementing structured, multiprofessional medical ethical decision-making in a neonatal intensive care unit
Background In neonatal intensive care, a childās death
is often preceded by a medical decision. Nurses, social
workers and pastors, however, are often excluded from
ethical case deliberation. If multiprofessional ethical case
deliberations do take place, participants may not always
know how to perform to the fullest.
Setting A level-IIID neonatal intensive care unit of
a paediatric teaching hospital in the Netherlands.
Methods Structured multiprofessional medical ethical
decision-making (MEDM) was implemented to help
overcome problems experienced. Important features
were: all professionals who are directly involved with the
patient contribute to MEDM; a five-step procedure is
used: exploration, agreement on the ethical dilemma/
investigation of solutions, analysis of solutions,
decision-making, planning actions; meetings are chaired
by an impartial ethicist. A 15-item questionnaire to
survey staff perceptions on this intervention just before
and 8 months after implementation was developed.
Results Before and after response rates were 91/105
(87%) and 85/113 (75%). Factor analysis on the
questionnaire suggested a four-factor structure:
participantsā role; structure of MEDM; content of ethical
deliberation; and documentation of decisions/
conclusions. Effect sizes were 1.67 (p<0.001), 0.69
(p<0.001) and 0.40 (p<0.01) for the first three factors
respectively, but only 0.07 (pĀ¼0.65) for the fourth factor.
Nursesā perceptions of improvement did not significantly
exceed those of physicians.
Conclusion Professionals involved in ethical case
deliberation perceived that the process of decisionmaking had improved; they we
Predictors for failure of supraglottic superimposed high-frequency jet ventilation during endoscopic upper airway surgery in pediatric patients
Airway surgery in pediatric patients is challenging with regard to balancing surgical exposure with ventilation requirements, as during the procedure the airway must be shared between laryngologist and anesthetist. For endoscopic laryngeal surgery, different methods of ventilation are used, among others jet ventilation via a specifically adapted suspension laryngoscope using a dual jet stream(Supraglottic Superimposed High Frequency Jet ventilation, SSHFJV) (1).High BMI and a history of pulmonary pathology proved to be factors contributing to failing of SSHFJV in adult patients (2). However, factors influencing the failure of SSHFJV in pediatric patients have never been described yet
Transcription-coupled and global genome repair differentially influence UV-B-induced acute skin effects and syste
Exposure to UV-B radiation impairs immune responses in mammals by
inhibiting especially Th1-mediated contact hypersensitivity and
delayed-type hypersensitivity. Immunomodulation is not restricted to the
exposed skin, but is also observed at distant sites, indicating the
existence of mediating factors such as products from exposed skin cells or
photoactivated factors present in the superficial layers. DNA damage
appears to play a key role, because enhanced nucleotide excision repair
(NER) strongly counteracts immunosuppression. To determine the effects of
the type and genomic location of UV-induced DNA damage on
immunosuppression and acute skin reactions (edema and erythema) four
congenic mouse strains carrying different defects in NER were compared:
CSB and XPC mice lacking transcription-coupled or global genome NER,
respectively, as well as XPA and TTD/XPD mice carrying complete or partial
defects in both NER subpathways, respectively. The major conclusions are
that 1) transcription-coupled DNA repair is the dominant determinant in
protection against acute skin effects; 2) systemic immunomodulation is
only affected when both NER subpathways are compromised; and 3) sunburn is
not related to UV-B-induced immunosuppression
Plasma Protein Profiling Reveals Protein Clusters Related to BMI and Insulin Levels in Middle-Aged Overweight Subjects
Biomarkers that allow detection of the onset of disease are of high interest since early detection would allow intervening with lifestyle and nutritional changes before the disease is manifested and pharmacological therapy is required. Our study aimed to improve the phenotypic characterization of overweight but apparently healthy subjects and to identify new candidate profiles for early biomarkers of obesity-related diseases such as cardiovascular disease and type 2 diabetes
Serum free thiols in type 2 diabetes mellitus:A prospective study
Aims: Oxidative stress is a driver in the development of type 2 diabetes (T2DM) complications. As thiols (R-SH) are oxidized by reactive oxygen and sulfur species, circulating concentrations may directly reflect systemic redox status. We hypothesized that high serum R-SH concentrations are a reflection of a favourable redox status and may therefore positively associate with disease status.Methods: R-SH were measured in serum of 943 T2DM outpatients (55% males, 65 years and HbA1c of 6.7% (50 mmol/mol)) with a follow-up period of 1.2 years.Results: In the highest R-SH tertile patients were younger, more often men, had less microvascular complications, lower HbA1c and were more often treated nutritionally or with oral glucose-lowering drugs. Age-and sex adjusted hazard ratios for developing micro-, macro- or any complication plus death were 0.994, 0.992 and 0.993: even after adjustment for potential confounders. The Harrell's C statistic to predict microvascular complications or any complication plus death was higher in the models with R-SH than in those without R-SH.Conclusions: Although R-SH concentrations were associated with a favourable disease status, it did not add to the predictive capacity for long-term complications. Based on the current data R-SH seems unsuitable as a prognostic marker in T2DM.</p
Coronaryāaortic interaction during ventricular isovolumic contraction
In earlier work, we suggested that the start of the isovolumic contraction period could be detected in arterial pressure waveforms as the start of a temporary pre-systolic pressure perturbation (AICstart, start of the Arterially detected Isovolumic Contraction), and proposed the retrograde coronary blood volume flow in combination with a backwards traveling pressure wave as its most likely origin. In this study, we tested this hypothesis by means of a coronary artery occlusion protocol. In six YorkshireĀ ĆĀ Landrace swine, we simultaneously occluded the left anterior descending (LAD) and left circumflex (LCx) artery for 5Ā s followed by a 20-s reperfusion period and repeated this sequence at least two more times. A similar procedure was used to occlude only the right coronary artery (RCA) and finally all three main coronary arteries simultaneously. None of the occlusion protocols caused a decrease in the arterial pressure perturbation in the aorta during occlusion (PĀ >Ā 0.20) nor an increase during reactive hyperemia (PĀ >Ā 0.22), despite a higher deceleration of coronary blood volume flow (PĀ =Ā 0.03) or increased coronary conductance (PĀ =Ā 0.04) during hyperemia. These results show that the pre-systolic aortic pressure perturbation does not originate from the coronary arteries
Design and rationale of DUTCH-AF:a prospective nationwide registry programme and observational study on long-term oral antithrombotic treatment in patients with atrial fibrillation
Introduction Anticoagulation therapy is pivotal in the management of stroke prevention in atrial fibrillation (AF). Prospective registries, containing longitudinal data are lacking with detailed information on anticoagulant therapy, treatment adherence and AF-related adverse events in practice-based patient cohorts, in particular for non-vitamin K oral anticoagulants (NOAC). With the creation of DUTCH-AF, a nationwide longitudinal AF registry, we aim to provide clinical data and answer questions on the (anticoagulant) management over time and of the clinical course of patients with newly diagnosed AF in routine clinical care. Within DUTCH-AF, our current aim is to assess the effect of non-adherence and non-persistence of anticoagulation therapy on clinical adverse events (eg, bleeding and stroke), to determine predictors for such inadequate anticoagulant treatment, and to validate and refine bleeding prediction models. With DUTCH-AF, we provide the basis for a continuing nationwide AF registry, which will facilitate subsequent research, including future registry-based clinical trials. Methods and analysis The DUTCH-AF registry is a nationwide, prospective registry of patients with newly diagnosed 'non-valvular' AF. Patients will be enrolled from primary, secondary and tertiary care practices across the Netherlands. A target of 6000 patients for this initial cohort will be followed for at least 2 years. Data on thromboembolic and bleeding events, changes in antithrombotic therapy and hospital admissions will be registered. Pharmacy-dispensing data will be obtained to calculate parameters of adherence and persistence to anticoagulant treatment, which will be linked to AF-related outcomes such as ischaemic stroke and major bleeding. In a subset of patients, anticoagulation adherence and beliefs about drugs will be assessed by questionnaire. Ethics and dissemination This study protocol was approved as exempt for formal review according to Dutch law by the Medical Ethics Committee of the Leiden University Medical Centre, Leiden, the Netherlands. Results will be disseminated by publications in peer-reviewed journals and presentations at scientific congresses
Pulsed electromagnetic fields after arthroscopic treatment for osteochondral defects of the talus: double-blind randomized controlled multicenter trial
Background. Osteochondral talar defects usually affect athletic patients. The primary surgical treatment consists of arthroscopic debridement and microfracturing. Although this is mostly successful, early sport resumption is difficult to achieve, and it can take up to one year to obtain clinical improvement. Pulsed electromagnetic fields (PEMFs) may be effective for talar defects after arthroscopic treatment by promoting tissue healing, suppressing inflammation, and relieving pain. We hypothesize that PEMF-treatment compared to sham-treatment after arthroscopy will lead to earlier resumption of sports, and aim at 25% increase in patients that resume sports. Methods/Design. A prospective, double-blind, randomized, placebo-controlled trial (RCT) will be conducted in five centers throughout the Netherlands and Belgium. 68 patients will be randomized to either active PEMF-treatment or sham-treatment for 60 days, four hours daily. They will be followed-up for one year. The combined primary outcome measures are (a) the percentage of patients that resume and maintain sports, and (b) the time to resumption of sports, defined by the Ankle Activity Score. Secondary outcome measures include resumption of work, subjective and objective scoring systems (American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, Foot Ankle Outcome Score, Numeric Rating Scales of pain and satisfaction, EuroQol-5D), and computed tomography. Time to resumption of sports will be analyzed using Kaplan-Meier curves and log-rank tests. Discussion. This trial will provide level-1 evidence on the effectiveness of PEMFs in the management of osteochondral ankle lesions after arthroscopy. Trial registration. Netherlands Trial Register (NTR1636)
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