Kortärmat i vården - Om avvägningen mellan religiösa manifestationer och smittskyddsregler i vården

Den här uppsatsen syftar till att undersöka kollisionen som kan uppstå mellan å ena sidan människors vilja att manifestera sin religion och hälso- och sjukvårdshänsyn å andra sidan. Med anledning av två fall som nyligen aktualiserats i Sverige undersöker jag huruvida smittskyddsregler i vården kan grunda begränsning av religionsfriheten. Analysen görs utifrån ett mänskliga rättigheter- och diskrimineringsperspektiv. Min utgångspunkt är att utifrån en rättsdogmatisk metod skärskåda det fall från Jönköpings tingsrätt där en barnmorska på grund av tros- och samvetsbetänkligheter vägrade utföra aborter. Med hjälp av Jönköpings tingsrätts mål analyserar jag det fall där en muslimsk tandläkarstudent med hänvisning till sin religion inte kunnat bära kortärmad arbetsdräkt och av sitt universitet blivit nekad att bära engångsärmar. Uppsatsen kan uppdelas i fyra steg. Första steget består i att presentera de rättsliga förutsättningarna för kunna göra min analys. I steg två analyserar jag avvägningen mellan samvetsvägran och kvinnors rätt till en effektiv abortvård (barnmorskefallet). I steg tre görs motsvarande analys gällande avvägningen mellan religionsfrihet och diskrimineringsförbudet som har samband med religion kontra smittskydd (tandläkarfallet). I det sista steget jämförs de båda fallen. Gällande barnmorskefallet anser jag att tingsrättens bedömning är rimlig. Kvinnors rätt till en effektiv abortvård bedöms väga tyngre än barnmorskans religionsfrihet. Avvägningen måste dock vara kontextberoende och jag menar att utfallet kan variera beroende på om barnmorskan skulle arbetat på en liten klink som i frågan eller ett stort sjukhus där större hänsyn borde kunna tas till hennes religiösa tro. När det gäller tandläkarfallet är en viktigt skillnad mot barnmorskefallet att en alternativ lösning finns, nämligen användandet av engångsärmar. Skälet till att kravet på att arbetskläderna måste vara kortärmade är att möjliggöra en god handdesinfektion samt att långärmade kläder är stora smittobärare. Av Socialstyrelsens föreskrifter om basal hygien framgår, förutom att arbetskläderna ska vara kortärmade, att engångsärmar i undantagsfall kan användas och att dessa ärmar inte medför större smittorisk än kortärmade arbetskläder. Jag argumenterar för att det faktum att universitetet nekar studenten möjligheten att använda engångsärmar förskjuter avvägningen från religion kontra smittskydd till religion kontra kostnadseffektivitet. En viktig poäng i sammanhanget är att smittskyddshänsyn i sig förmodligen kan utgöra grund för begränsning av religionsfriheten i enlighet med Europadomstolens bedömning i fallet Eweida (Chaplin). Dock väger kostnadseffektivitetsargumentet enligt min mening inte tillräckligt tungt för att begränsa religionsfriheten eller diskrimineringsförbudet som har samband med religion. I det aktuella fallet är min slutsats därför att tandläkarstudenten blivit diskriminerad och fått sin religionsfrihet kränkt.The aim of this essay is to investigate the conflicting interests that can arise between religious people’s will to manifest their religion on one hand and healthcare related issues on the other hand. Based upon two recent cases in Sweden I’m trying to distinguish whether hygiene regulations in healthcare are enough to limit the freedom of religion. The analysis is done from a human rights and discriminatory perspective. Through traditional legal sources I examine a case where a midwife who claimed discrimination when being refused employment after neglecting to perform abortions due to her Christian belief. The midwife case is used to understand another case where a Muslim dentist student refused to wear short sleeved work clothes with regard to her religion. When the university neglected to provide disposable long sleeves for one-time use she claimed discrimination and violation of her religious freedom. This study can be divided into four steps. In the first step I present the legal conditions for my analysis. In the second step I analyse the contradiction between conscientious objection in abortion care and women’s right to an effective abortion care. In the third step the same analysis is made but with regard to the contradiction between hygiene rules and religious freedom and discrimination. In the last step the two different cases are compared. Based on my analysis in the midwife case I agree with the court. Women’s right to an effective abortion care is given priority to the midwifes’ religious conviction. This argument must however be contextualized. If, for example, the women’s clinics are small as in the cases, the religious aspect may have to give way to the argument of an effective abortion care, but if the midwife would be working in a large hospital, more regard would have to be shown to her religious conviction. An important difference in the dentist case is the alternative solution to the collision between religion and hygiene restrictions, namely the usage of disposable long sleeves for one-time use. There are two reasons for having short sleeved work clothing in healthcare. Short sleeves simplify hand-disinfection and long sleeves increase the risk of contagion. In the regulations on health care work clothes short sleeves are therefore demanded. However, an exception can be made with disposable long armed sleeves which will uphold the same hygiene standards. I argue that the fact that the university doesn’t allow this exception in the case with the Muslim student changes the conflicting interests from religion contra hygiene to religion contra cost-efficiency. It can be worth noting that hygiene related reasons probably in itself can ground limitations from the freedom of religion and the prohibition on discrimination, as was the case in Eweida (Chaplin) from the European Court of Human Rights. But when the conflicting issues are cost-efficiency and religion, the cost-efficiency argument is not weighing heavily enough. Hence, regarding the case in question, my conclusion is that the dentist student has been discriminated and that the students’ freedom of religion has been breached

Internationell förhandlingsskyldighet

Denna uppsats behandlar förhandlingsskyldigheten i internationell rätt. Syftet är att utreda under vilka förutsättningar en sådan skyldighet finns, hur den i så fall tar sig uttryck och hur den kan komma att se ut i framtiden. Förhandling har länge betraktats uteslutande som en diplomatisk tvistelösningsmetod. Uppsatsens fokus ligger på att utreda de juridiska aspekterna av förhandling. För att göra denna utredning används en rättsdogmatisk metod och genom uppsatsen anläggs ett rättsutvecklingsperspektiv. Både traktat- såväl som sedvanerättslig förhandlingsskyldighet kommer analyseras. Förhandlingskyldigheten i traktaträtten exemplifieras i FN-stadgans artikel 33 samt WTO:s tvistelösningssystem, medan förhandlingsskyldigheten i sedvanerätten exemplifieras genom två rättsfall från Internationella Domstolen (ICJ), samt ett pågående fall, där Marshallöarna stämt USA i amerikansk domstol. Vidare beskrivs principen om good faith, vilken har stor påverkan på förhandlingsskyldighen, och jämförs med EUs lojalitetsprincip. Avslutningsvis analyseras förhandlingsskyldigheten i ljuset av ovanstående. De slutsatser som dras är att både traktat- och sedvanerätten är under utveckling. Förhandlingsskyldigheten i internationell rätt tillskrivs alltmer juridisk tyngd, särskilt i den mer rörliga sedvanerätten, där ICJ tydligt uppmuntrar till förhandling. Även stater tycks i ökande utsträckning betrakta förhandling som en judiciell tvistelösningsmetod, och i takt med att samarbetet inom det internationella samfundet ökar får förhandlingsskyldigheten tillsammans med principen om good faith allt större betydelse. Ett skifte i synen på förhandlingsskyldighet håller således på att ske.The subject of this thesis discusses the issue of obligation to negotiate in international law. The aim is to examine whether such an obligation exists, how it, in that case, is expressed and how it may evolve in the future. Negotiation has a record of being viewed merely as a diplomatic method for peaceful settlement of disputes. The focus in this thesis is on the judicial aspects of negotiation. In order to make this analysis, conventional as well as customary law is analysed through a developmental perspective. The obligation to negotiate in conventional law is examplified through article 33 in the UN-charter and the dispute settlement system of the WTO, whereas the obligation to negotiate in customary law is examplified through two cases by the International Court of Justice (ICJ). In addition, an ongoing case about the breach of an obligation to negotiate between the Marshall Islands and the US is analysed. Furthermore is the principle of good faith, which has a large impact on the obligation to negotiate, is also described and compared to the duty of sincere cooperation in the EU. In conclusion, this thesis shows that both the conventional and customary law is evolving in regard to the obligation to negotiate. The drawn conclusions are that both the conventional and customary law is evolving in regard to the obligation to negotiate. This obligation is regarded as more and more important, especially in the customary law where the ICJ repeatedly promotes negotiation as a desirable method for settling disputes. States also seem to have an expanding appreciation of negotiation as a judicial settlement method, and while the collaborations within the international community are intensified, the importance of the obligation to negotiate together with the principle of good faith is increasing. Thus, a switch in the perception of the functions of negotiation is happening

Cerebrospinal Fluid Alzheimer Markers in Depressed Elderly Subjects with and without Alzheimer's Disease

Depression and Alzheimer’s disease (AD) are among the most common clinical diagnosis in older people. The relation between depression and AD is complex: depression has been shown to be a risk factor, prodromal symptom and a consequence of AD. Increased understanding of the underlying mechanisms of depression in AD may lead to early detection and differential diagnosis, and is crucial for development of novel and mechanism-based treatments. The first two studies of this doctoral thesis are exploring the associations between depressive symptoms and biomarkers of amyloid deposition and neuronal injury in patients with subjective cognitive impairment (SCI), mild cognitive impairment (MCI) and AD. The aims of the third study were to describe the use of antidepressants in patients with dementia and to explore the association between mortality risk and the use of antidepressants 3 years before the dementia diagnosis. CAIDE Dementia Risk Score is taking into account midlife risk and protective factors; age, educational level, gender, systolic blood pressure, body mass index, cholesterol level and physical activity and APOE genotyping, and can predict dementia over 20 years. The last study was focused on exploring the associations between CAIDE Dementia Risk Score and biomarkers of amyloid deposition, neuronal injury and small vessel pathology in SCI and MCI patients. Additionally we explored the capacity of CAIDE Dementia Risk Score to predict dementia in a memory clinic population. Data were obtained from Memory Clinic Karolinska University Hospital Huddinge Sweden (Study I, II and IV). In study III, two large national registries were merged: the Swedish Dementia Registry (SveDem) and the Swedish Prescribed Drug Register. In study I, analysis of the three different cerebrospinal fluid biomarkers; amyloid beta (CSF Aβ), total-tau (CSF t-tau), and phosphorylated-tau did not support the hypothesis that more severe amyloid or tau pathologies are associated with more severe depressive symptoms. In contrast, SCI and AD patients with depressive symptoms tended to have lower CSF p-tau levels and, in particular, lower CSF t-tau levels than those without depression, indicating less severe neuronal injury. In study II, we used two different analysis methods of MRI to measure medial temporal lobe atrophy and hippocampus volume. Using manual tracing of the hippocampi we found smaller left hippocampus volume in SCI patients with depressive symptoms compared to those without depressive symptoms. In contrast, AD patients with depressive symptoms had less medial temporal lobe atrophy compared with those without depressive symptoms. In study III, 20,050 patients with incident dementia diagnosed in memory clinics and registered in SveDem were included. Information on the total number of medication and all antidepressants dispensed at the time of dementia diagnosis and at the first, the second and the third year prior to dementia diagnosis was obtained from the Swedish Prescribed Drug Register. During a median follow up of 2 years, 5168 (25.8%) dementia patients died. At the time of dementia diagnosis, 5,004 (25.0%) patients were on antidepressant treatment. Use of antidepressant treatment for 3 consecutive years prior to a dementia diagnosis was associated with a lower mortality risk for all dementia disorders in general and particularly in AD. In study IV, a higher CAIDE Dementia Risk Score was associated with higher CSF t-tau levels, more severe medial temporal lobe atrophy and more severe white matter changes. For the CAIDE score including APOE, a score above 9 points was associated with lower CSF Aβ, more severe medial temporal lobe atrophy and more severe white matter changes. CAIDE Dementia Risk Score (version with APOE) performed better at predicting AD compared with CAIDE Dementia Risk Score without APOE. Conclusion: We found that depressive symptoms in patients with AD and SCI are not associated with more amyloid deposition nor more neuronal injury compared with AD and SCI patients without depressive symptoms. Thus our results are consistent with the hypothesis that the mechanisms underlying depression differ between older people with and without AD. Our results have shown that use of antidepressants in prodromal AD stages is associated with a lower mortality risk. Further longitudinal studies are needed to better understand the associations between the use of antidepressants and mortality risk in dementia

Activation of the <i>gluteus maximus</i> during performance of the back squat, split squat and barbell hip thrust and the relationship with maximal sprinting

The purpose of this research was to compare muscle activation of the gluteus maximus and ground reaction force between the barbell hip thrust, back squat, and split squat and to determine the relationship between these outcomes and vertical and horizontal forces during maximal sprinting. Twelve male team sport athletes (age 25.0 ± 4.0 years, stature 184.1 ± 6.0 cm, body mass 82.2 ± 7.9 kg) performed separate movements of the three strength exercises at a load equivalent to their individual three repetition maximum. The ground reaction force was measured using force plates and the electromyography (EMG) activity of the upper and lower gluteus maximus was recorded in each leg and expressed as percentage of the maximum voluntary isometric contraction (MVIC). Participants then completed a single sprint on a non-motorized treadmill for the assessment of maximal velocity, horizontal and vertical forces. Although ground reaction force was lower, peak EMG activity in the gluteus maximus was higher in the hip thrust than the back squat (p = 0.024; 95%CI = 4 – 56%MVIC) and split squat (p = 0.016; 95%CI = 6 – 58%MVIC). Peak sprint velocity was correlated with both anterior-posterior horizontal force (r = 0.72) and peak ground reaction force during the barbell hip thrust (r = 0.69) but no other variables. The increased activation of gluteus maximus during the barbell hip thrust and the relationship with maximal running speed suggests that this movement may be optimal for training this muscle group in comparison to the back squat and split squat

Elevated nerve growth factor and neurotrophin-3 levels in cerebrospinal fluid of children with hydrocephalus

BACKGROUND: Elevated intracranial pressure (ICP) resulting from impaired drainage of cerebrospinal fluid (CSF) causes hydrocephalus with damage to the central nervous system. Clinical symptoms of elevated intracranial pressure (ICP) in infants may be difficult to diagnose, leading to delayed treatment by shunt placement. Until now, no biochemical marker of elevated ICP has been available for clinical diagnosis and monitoring. In experimental animal models, nerve growth factor (NGF) and neurotrophin-3 (NT-3) have been shown to be produced by glial cells as an adaptive response to hypoxia. We investigated whether concentrations of NGF and NT-3 are increased in the CSF of children with hydrocephalus. METHODS: NGF was determined in CSF samples collected from 42 hydrocephalic children on 65 occasions (taps or shunt placement surgery). CSF samples obtained by lumbar puncture from 22 children with suspected, but unconfirmed bacterial infection served as controls. Analysis was performed using ELISA techniques. RESULTS: NGF concentrations in hydrocephalic children were over 50-fold increased compared to controls (median 225 vs 4 pg/mL, p < 0.0001). NT-3 was detectable (> 1 pg/mL) in 14/31 hydrocephalus samples at 2–51 pg/mL but in none of 11 control samples (p = 0.007). CONCLUSION: NGF and NT-3 concentrations are increased in children with hydrocephalus. This may represent an adaptive response of the brain to elevated ICP

Mesenchymal stromal-cell transplants induce oligodendrocyte progenitor migration and remyelination in a chronic demyelination model.

Demyelinating disorders such as leukodystrophies and multiple sclerosis are neurodegenerative diseases characterized by the progressive loss of myelin that may lead toward a chronic demyelination of the brain¿s white matter, impairing normal axonal conduction velocity and ultimately causing neurodegeneration. Current treatments modifying the pathological mechanisms are capable of ameliorating the disease; however, frequently, these therapies are not sufficient to repress the progressive demyelination into a chronic condition and permanent loss of function. To this end, we analyzed the effect that bone marrowderived mesenchymal stromal cell (BM-MSC) grafts exert in a chronically demyelinated mouse brain. As a result, oligodendrocyte progenitors were recruited surrounding the graft due to the expression of various trophic signals by the grafted MSCs. Although there was no significant reaction in the non-grafted side, in the grafted regions oligodendrocyte progenitors were detected. These progenitors were derived from the nearby tissue as well as from the neurogenic niches, including the subependymal zone and dentate gyrus. Once near the graft site, the cells matured to myelinating oligodendrocytes. Finally, electrophysiological studies demonstrated that axonal conduction velocity was significantly increased in the grafted side of the fimbria. In conclusion, we demonstrate here that in chronic demyelinated white matter, BM-MSC transplantation activates oligodendrocyte progenitors and induces remyelination in the tissue surrounding the stem cell graft

Effects of DHA- Rich n-3 Fatty Acid Supplementation on Gene Expression in Blood Mononuclear Leukocytes: The OmegAD Study

Background: Dietary fish oil, rich in n-3 fatty acids (n-3 FAs), e. g. docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), regulate inflammatory reactions by various mechanisms, e. g. gene activation. However, the effects of long-term treatment with DHA and EPA in humans, using genome wide techniques, are poorly described. Hence, our aim was to determine the effects of 6 mo of dietary supplementation with an n-3 FA preparation rich in DHA on global gene expression in peripheral blood mononuclear cells. Methods and Findings: In the present study, blood samples were obtained from a subgroup of 16 patients originating from the randomized double-blind, placebo-controlled OmegAD study, where 174 Alzheimer disease (AD) patients received daily either 1.7 g of DHA and 0.6 g EPA or placebo for 6 months. In blood samples obtained from 11 patients receiving n-3 FA and five placebo, expressions of approximately 8000 genes were assessed by gene array. Significant changes were confirmed by real-time PCR. At 6 months, the n-3 FAs group displayed significant rises of DHA and EPA plasma concentrations, as well as up-and down-regulation of nine and ten genes, respectively, was noticed. Many of these genes are involved in inflammation regulation and neurodegeneration, e. g. CD63, MAN2A1, CASP4, LOC399491, NAIP, and SORL1 and in ubiqutination processes, e. g. ANAPC5 and UBE2V1. Down-regulations of ANAPC5 and RHOB correlated to increases of plasma DHA and EPA levels. Conclusions: We suggest that 6 months of dietary n-3 FA supplementatio

Small molecule activators of the Trk receptors for neuroprotection

The neurotophin signaling network is critical to the development and survival of many neuronal populations. Especially sensitive to imbalances in the neurotrophin system, cholinergic neurons in the basal forebrain are progressively lost in Alzheimer's disease. Therapeutic use of neurotrophins to prevent this loss is hampered, however, by a number of pharmacological challenges. These include a lack of transport across the blood-brain barrier, rapid degradation in the circulation, and difficulty in production. In this review we discuss the evidence supporting the neurotrophin system's role in preventing neurodegeneration and survey some of the pharmacological strategies being pursued to develop effective therapeutics targeting neurotrophin function