Continuous sedation until death: The everyday moral reasoning of physicians, nurses and family caregivers in the UK, The Netherlands and Belgium

Copyright © 2014 Raus et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.Background - Continuous sedation is increasingly used as a way to relieve symptoms at the end of life. Current research indicates that some physicians, nurses, and relatives involved in this practice experience emotional and/or moral distress. This study aims to provide insight into what may influence how professional and/or family carers cope with such distress. Methods - This study is an international qualitative interview study involving interviews with physicians, nurses, and relatives of deceased patients in the UK, The Netherlands and Belgium (the UNBIASED study) about a case of continuous sedation at the end of life they were recently involved in. All interviews were transcribed verbatim and analysed by staying close to the data using open coding. Next, codes were combined into larger themes and categories of codes resulting in a four point scheme that captured all of the data. Finally, our findings were compared with others and explored in relation to theories in ethics and sociology. Results - The participants’ responses can be captured as different dimensions of ‘closeness’, i.e. the degree to which one feels connected or ‘close’ to a certain decision or event. We distinguished four types of ‘closeness’, namely emotional, physical, decisional, and causal. Using these four dimensions of ‘closeness’ it became possible to describe how physicians, nurses, and relatives experience their involvement in cases of continuous sedation until death. More specifically, it shined a light on the everyday moral reasoning employed by care providers and relatives in the context of continuous sedation, and how this affected the emotional impact of being involved in sedation, as well as the perception of their own moral responsibility. Conclusion - Findings from this study demonstrate that various factors are reported to influence the degree of closeness to continuous sedation (and thus the extent to which carers feel morally responsible), and that some of these factors help care providers and relatives to distinguish continuous sedation from euthanasia.The Economic and Social Research Council (UK), the Research Foundation Flanders (BE), the Flemish Cancer Association (BE), the Research Council of Ghent University (BE), the Netherlands Organization for Scientific Research (NL) and the Netherlands Organization for Health Research and Development (NL)

How persistent are the impacts of logging roads on Central African forest vegetation?

Logging roads can trigger tropical forest degradation by reducing the integrity of the ecosystem and providing access for encroachment. Therefore, road management is crucial in reconciling selective logging and biodiversity conservation. Most logging roads are abandoned after timber harvesting; however, little is known about their long-term impacts on forest vegetation and accessibility, especially in Central Africa. In 11 logging concessions in the Congo Basin, we field-sampled a chronosequence of roads that, judging from satellite images, had been abandoned between 1985 and 2015. We assessed recovery of timber resources, tree diversity and above-ground biomass in three zones: the road track, the road edge (where forest had been cleared during road construction) and the adjacent logged forest. The density of commercial timber species <15 cm d.b.h. was almost three times higher in the road track (321 individuals ha−1) and edge (267) than in the logged adjacent forest (97). Over time, tree species diversity converged to a comparable level between roads and adjacent forests, along with an increase in canopy closure. The average width of forest clearing for road construction was 20 m, covering a total 0·76% of the forest area inside concessions. After 15 years following abandonment, road tracks had recovered 24 Mg ha−1 of above-ground woody biomass, which was 6% of that in the adjacent forest, while road edges had accumulated 167 Mg ha−1 (42%). Ten years after abandonment, roads were no longer penetrable by poachers on motorcycles. An exotic herb species was fully replaced by dominant Marantaceae that have even higher abundance in the adjacent forest. • Synthesis and applications. Our evidence of vegetation recovery suggests that logging roads are mostly transient elements in the forest landscapes. However, given the slow recovery of biomass on abandoned road tracks, we advocate both reducing the width of forest clearing for road construction and reopening old logging roads for future harvests, rather than building new roads in intact forests. Road edges seem suitable for post-logging silviculture which needs to be assisted by removing dominant herbs during the early years after abandonment while the road track is still accessible. (Résumé d'auteur

Constraining planet structure from stellar chemistry: the cases of CoRoT-7, Kepler-10, and Kepler-93

We explore the possibility that the stellar relative abundances of different species can be used to constrain the bulk abundances of known transiting rocky planets. We use high resolution spectra to derive stellar parameters and chemical abundances for Fe, Si, Mg, O, and C in three stars hosting low mass, rocky planets: CoRoT-7, Kepler-10, and Kepler-93. These planets follow the same line along the mass-radius diagram, pointing toward a similar composition. The derived abundance ratios are compared with the solar values. With a simple stoichiometric model, we estimate the iron mass fraction in each planet, assuming stellar composition. We show that in all cases, the iron mass fraction inferred from the mass-radius relationship seems to be in good agreement with the iron abundance derived from the host star's photospheric composition. The results suggest that stellar abundances can be used to add constraints on the composition of orbiting rocky planets.Comment: A&A Letters, in pres

Antitumour activity of pembrolizumab in advanced mucosal melanoma: a post-hoc analysis of KEYNOTE-001, 002, 006.

BackgroundMucosal melanoma is an aggressive melanoma with poor prognosis. We assessed efficacy of pembrolizumab in patients with advanced mucosal melanoma in KEYNOTE-001 (NCT01295827), -002 (NCT01704287), and -006 (NCT01866319).MethodsPatients received pembrolizumab 2 mg/kg every 3 weeks (Q3W) or 10 mg/kg Q2W or Q3W. Response was assessed by independent central review per RECIST v1.1.Results1567 patients were treated and 84 (5%) had mucosal melanoma. Fifty-one of 84 were ipilimumab-naive. In patients with mucosal melanoma, the objective response rate (ORR) was 19% (95% CI 11-29%), with median duration of response (DOR) of 27.6 months (range 1.1 + to 27.6). Median progression-free survival (PFS) was 2.8 months (95% CI 2.7-2.8), with median overall survival (OS) of 11.3 months (7.7-16.6). ORR was 22% (95% CI 11-35%) and 15% (95% CI 5-32%) in ipilimumab-naive and ipilimumab-treated patients.ConclusionPembrolizumab provides durable antitumour activity in patients with advanced mucosal melanoma regardless of prior ipilimumab

Duplications of the critical Rubinstein-Taybi deletion region on chromosome 16p13.3 cause a novel recognisable syndrome

Background The introduction of molecular karyotyping technologies facilitated the identification of specific genetic disorders associated with imbalances of certain genomic regions. A detailed phenotypic delineation of interstitial 16p13.3 duplications is hampered by the scarcity of such patients. Objectives To delineate the phenotypic spectrum associated with interstitial 16p13.3 duplications, and perform a genotype-phenotype analysis. Results The present report describes the genotypic and phenotypic delineation of nine submicroscopic interstitial 16p13.3 duplications. The critically duplicated region encompasses a single gene, CREBBP, which is mutated or deleted in Rubinstein-Taybi syndrome. In 10 out of the 12 hitherto described probands, the duplication arose de novo. Conclusions Interstitial 16p13.3 duplications have a recognizable phenotype, characterized by normal to moderately retarded mental development, normal growth, mild arthrogryposis, frequently small and proximally implanted thumbs and characteristic facial features. Occasionally, developmental defects of the heart, genitalia, palate or the eyes are observed. The frequent de novo occurrence of 16p13.3 duplications demonstrates the reduced reproductive fitness associated with this genotype. Inheritance of the duplication from a clinically normal parent in two cases indicates that the associated phenotype is incompletely penetrant

Imaging features of retroperitoneal extra-adrenal paragangliomas in 10 dogs

Retroperitoneal paragangliomas are rare tumors of the neuroendocrine system. Only a few canine case reports are available with rare descriptions of their imaging features. The objectives of this multi-center, retrospective case series study were to describe the diagnostic imaging features of confirmed retroperitoneal paragangliomas and specify their location. Medical records and imaging studies of 10 affected dogs with cytological or histopathologic results concordant with retroperitoneal paragangliomas were evaluated. Dogs had a median age of 9 years. Four of them had clinical signs and laboratory reports compatible with excessive production of catecholamines. Six ultrasound, four CT, four radiographic, and one MRI studies were included. The paragangliomas did not have a specific location along the aorta. They were of various sizes (median 33&nbsp;mm, range: 9–85&nbsp;mm of length). Masses had heterogeneous parenchyma in six of 10 dogs, regardless of the imaging modality. Strong contrast enhancement was found in all CT studies. Encircling of at least one vessel was detected in six of 10 masses, clear invasion of a vessel was identified in one of 10 masses. In five of 10 cases, the masses were initially misconstrued as lymph nodes by the on-site radiologist. Retroperitoneal paragangliomas appear along the abdominal aorta, often presenting heterogeneous parenchyma, possibly affecting the local vasculature, and displaying strong contrast enhancement on CT. Clinical signs can be secondary to mass effects or excessive catecholamine production. Underdiagnosis and misdiagnosis of this tumor are suspected as they can be silent, of small size, or confused with other structures