Kliinisen etiikan tukipalvelut ja niiden hyödyntäminen terveydenhuollon organisaatioiden päätöksenteossa:kirjallisuuskatsaus

Tiivistelmä. Tämä tutkimus pyrkii selvittämään tieteellisissä lehdissä julkaistuista artikkeleista millaisia kliinisen etiikan tukipalveluita on käytössä ja miten terveydenhuollon organisaatiot hyödyntävät niiden toimintaa päätöksenteko prosesseissa. Katsauksen tuottamaa tietoa voidaan jatkossa hyödyntää Suomessa edesauttamalla terveydenhuollon organisaatioita luomaan eettisesti kestävää toimintaa. Toisena henkilökohtaisena tavoitteena on asettaa näyttö käyttöön ja hyödyntää tietoa pilotti projektissa yliopistollisen sairaalan lastenklinikalla toimivan kliinisen etiikan työryhmän toiminnassa. Tutkimus on integratiivinen kirjallisuukatsaus. Aineisto kerättiin systemaattisesti terveydenhuollon tieteellisiä artikkeleita sisältävistä tietokannoista. Hakuja suoritettiin seuraavista tietokannoista: Cinahl, Ovid/Medline ja ProQuest-PsycINFO. Haku tuotti yhteensä 1234 artikkelia, joista 297 analysoitiin lukemalla ne kokonaisuudessaan. Kokotekstin lukemisen jälkeen jäi kaksitoista artikkelia, joista lopulliseen analyysiin valikoitui kuusi. Artikkelit taulukoitiin ja tiedot analysoitiin sisällön analyysin periaatteella yhdistelemällä samansisältöisiä asioita toisiinsa. Tutkimuksen tulokset osoittavat, että kliinisen etiikan tukipalveluita on käytössä enenevässä määrin globaalisti, kuhunkin kulttuuriin sopivaksi muovautuneina versioina. Keskeisimpiä kliinisen etiikan tukipalveluiden muotoja ovat; erilaiset kliinisen etiikan komiteat, autoritäärinen bioeetikko malli, fasilitoitu tapauskäsittely malli ja eettinen kiertomalli, jotka molemmat edustavat moniammatillista konsensus hakuista toimintaa, sekä viimeisenä organisaatioiden luomat strukturaaliset toimintamallit, missä on määritelty ohjeistus eettisen toiminnan muodostamisesta ja tavoitteista. Kliinisen etiikan tukipalveluiden hyödyntäminen on tukipalvelujen tapaan myös hyvin kulttuurisidonaista. Suurin ero on Pohjois-Amerikan autoritäärisen bioeetikko ja Euroopan moniammatillisen fasilitoidun keskustelu metodin välillä. Saman kaltaista vaihtelua on nähtävissä myös organisatooristen toimintamallien sovelluksissa. Tukipalveluja hyödynnetään terveydenhuollon organisaatioissa eniten haasteellisten potilastapausten käsittelyssä, hoitolinjausten päätöksenteossa. Lisäksi voidaan todeta johtopäätöksenä, että terveydenhuollossa on selkeä tarve tukea ammattilaisia heidän työssään haastellisten potilastapauksien hallinnassa, ilman organisaation luomaa eettistä tukea tämä voi johtaa moraalisen taakan lisääntymiseen.Clinical ethics support services and how healthcare organisations use these support services in their decision-making processes : literature review. Abstract. This study aims to find out from the articles published in the scientific journals what clinical ethics support services are in place and how healthcare organisations use these support services in their decision-making processes. The information generated by the review can be used in Finland in the future by contributing to the creation of ethically sustainable activities by healthcare organisations. Another, a personal objective, is to utilise this information as evidence based practise with a pilot project of a clinical ethics working group activities at a University Hospital Children’s Clinic. This research is an integrative literature review. The data was systematically collected from databases containing scientific articles on health care. Searches were conducted in the following databases: Cinahl, Ovid/Medline and ProQuest-PsycINFO. The search produced a total of 1,234 publications, of which 297 were analysed by reading them in full. Twelve articles that met the admission criteria were found, of which six articles were selected for the final analysis. The articles were tabulated and the data analyzed using the content analysis principles by combining things with the same content. The results of the study show that clinical ethics support services are increasingly available globally, in various culturally adapted versions. The most central forms of clinical ethics support services are; variable clinical ethics committees, an authorative bioethic model, a fasilitated case deliberation model and an ethics round model, both of which represent a multi-professional team seeking consensus through dialog, and lastly structured approaches created by organisations, with a guidance on the formation and objectives of ethical activities. Like the different forms of support services, their utilisation is also culturally modified and variable. The main difference is within the north American authoritative bioethisist and the multi-professional delibarative method in Europe. Similar variations can also be seen in the organisational application approaches. Support services are being provided in healthcare organisations to deal with the most challenging patient cases, especially in the decision-making concerning treatment options. It can also be concluded that there is a clear need for healthcare to support professionals in their work in managing challenging patient cases. Without the ethical support of the organisation, this can lead to an increase in moral burden

Network adaptation improves temporal representation of naturalistic stimuli in drosophila eye: II Mechanisms

Retinal networks must adapt constantly to best present the ever changing visual world to the brain. Here we test the hypothesis that adaptation is a result of different mechanisms at several synaptic connections within the network. In a companion paper (Part I), we showed that adaptation in the photoreceptors (R1-R6) and large monopolar cells (LMC) of the Drosophila eye improves sensitivity to under-represented signals in seconds by enhancing both the amplitude and frequency distribution of LMCs' voltage responses to repeated naturalistic contrast series. In this paper, we show that such adaptation needs both the light-mediated conductance and feedback-mediated synaptic conductance. A faulty feedforward pathway in histamine receptor mutant flies speeds up the LMC output, mimicking extreme light adaptation. A faulty feedback pathway from L2 LMCs to photoreceptors slows down the LMC output, mimicking dark adaptation. These results underline the importance of network adaptation for efficient coding, and as a mechanism for selectively regulating the size and speed of signals in neurons. We suggest that concert action of many different mechanisms and neural connections are responsible for adaptation to visual stimuli. Further, our results demonstrate the need for detailed circuit reconstructions like that of the Drosophila lamina, to understand how networks process information

Visual Coding in Locust Photoreceptors

Information capture by photoreceptors ultimately limits the quality of visual processing in the brain. Using conventional sharp microelectrodes, we studied how locust photoreceptors encode random (white-noise, WN) and naturalistic (1/f stimuli, NS) light patterns in vivo and how this coding changes with mean illumination and ambient temperature. We also examined the role of their plasma membrane in shaping voltage responses. We found that brightening or warming increase and accelerate voltage responses, but reduce noise, enabling photoreceptors to encode more information. For WN stimuli, this was accompanied by broadening of the linear frequency range. On the contrary, with NS the signaling took place within a constant bandwidth, possibly revealing a ‘preference’ for inputs with 1/f statistics. The faster signaling was caused by acceleration of the elementary phototransduction current - leading to bumps - and their distribution. The membrane linearly translated phototransduction currents into voltage responses without limiting the throughput of these messages. As the bumps reflected fast changes in membrane resistance, the data suggest that their shape is predominantly driven by fast changes in the light-gated conductance. On the other hand, the slower bump latency distribution is likely to represent slower enzymatic intracellular reactions. Furthermore, the Q10s of bump duration and latency distribution depended on light intensity. Altogether, this study suggests that biochemical constraints imposed upon signaling change continuously as locust photoreceptors adapt to environmental light and temperature conditions

Bumblebees socially learn behaviour too complex to innovate alone.

Culture refers to behaviours that are socially learned and persist within a population over time. Increasing evidence suggests that animal culture can, like human culture, be cumulative: characterized by sequential innovations that build on previous ones1. However, human cumulative culture involves behaviours so complex that they lie beyond the capacity of any individual to independently discover during their lifetime1-3. To our knowledge, no study has so far demonstrated this phenomenon in an invertebrate. Here we show that bumblebees can learn from trained demonstrator bees to open a novel two-step puzzle box to obtain food rewards, even though they fail to do so independently. Experimenters were unable to train demonstrator bees to perform the unrewarded first step without providing a temporary reward linked to this action, which was removed during later stages of training. However, a third of naive observer bees learned to open the two-step box from these demonstrators, without ever being rewarded after the first step. This suggests that social learning might permit the acquisition of behaviours too complex to 're-innovate' through individual learning. Furthermore, naive bees failed to open the box despite extended exposure for up to 24 days. This finding challenges a common opinion in the field: that the capacity to socially learn behaviours that cannot be innovated through individual trial and error is unique to humans

Statistical study of auroral omega bands

The presence of very few statistical studies on auroral omega bands motivated us to test-use a semi-automatic method for identifying large-scale undulations of the diffuse aurora boundary and to investigate their occurrence. Five identical all-sky cameras with overlapping fields of view provided data for 438 auroral omega-like structures over Fennoscandian Lapland from 1996 to 2007. The results from this set of omega band events agree remarkably well with previous observations of omega band occurrence in magnetic local time (MLT), lifetime, location between the region 1 and 2 field-aligned currents, as well as current density estimates. The average peak emission height of omega forms corresponds to the estimated precipitation energies of a few keV, which experienced no significant change during the events. Analysis of both local and global magnetic indices demonstrates that omega bands are observed during substorm expansion and recovery phases that are more intense than average substorm expansion and recovery phases in the same region. The omega occurrence with respect to the substorm expansion and recovery phases is in a very good agreement with an earlier observed distribution of fast earthward flows in the plasma sheet during expansion and recovery phases. These findings support the theory that omegas are produced by fast earthward flows and auroral streamers, despite the rarity of good conjugate observations

Mutations in DDX3X Are a Common Cause of Unexplained Intellectual Disability with Gender-Specific Effects on Wnt Signaling

Intellectual disability (ID) affects approximately 1%-3% of humans with a gender bias toward males. Previous studies have identified mutations in more than 100 genes on the X chromosome in males with ID, but there is less evidence for de novo mutations on the X chromosome causing ID in females. In this study we present 35 unique deleterious de novo mutations in DDX3X identified by whole exome sequencing in 38 females with ID and various other features including hypotonia, movement disorders, behavior problems, corpus callosum hypoplasia, and epilepsy. Based on our findings, mutations in DDX3X are one of the more common causes of ID, accounting for 1%-3% of unexplained ID in females. Although no de novo DDX3X mutations were identified in males, we present three families with segregating missense mutations in DDX3X, suggestive of an X-linked recessive inheritance pattern. In these families, all males with the DDX3X variant had ID, whereas carrier females were unaffected. To explore the pathogenic mechanisms accounting for the differences in disease transmission and phenotype between affected females and affected males with DDX3X missense variants, we used canonical Wnt defects in zebrafish as a surrogate measure of DDX3X function in vivo. We demonstrate a consistent loss-of-function effect of all tested de novo mutations on the Wnt pathway, and we further show a differential effect by gender. The differential activity possibly reflects a dose-dependent effect of DDX3X expression in the context of functional mosaic females versus one-copy males, which reflects the complex biological nature of DDX3X mutations

Intrinsic activity in the fly brain gates visual information during behavioral choices

The small insect brain is often described as an input/output system that executes reflex-like behaviors. It can also initiate neural activity and behaviors intrinsically, seen as spontaneous behaviors, different arousal states and sleep. However, less is known about how intrinsic activity in neural circuits affects sensory information processing in the insect brain and variability in behavior. Here, by simultaneously monitoring Drosophila's behavioral choices and brain activity in a flight simulator system, we identify intrinsic activity that is associated with the act of selecting between visual stimuli. We recorded neural output (multiunit action potentials and local field potentials) in the left and right optic lobes of a tethered flying Drosophila, while its attempts to follow visual motion (yaw torque) were measured by a torque meter. We show that when facing competing motion stimuli on its left and right, Drosophila typically generate large torque responses that flip from side to side. The delayed onset (0.1-1 s) and spontaneous switch-like dynamics of these responses, and the fact that the flies sometimes oppose the stimuli by flying straight, make this behavior different from the classic steering reflexes. Drosophila, thus, seem to choose one stimulus at a time and attempt to rotate toward its direction. With this behavior, the neural output of the optic lobes alternates; being augmented on the side chosen for body rotation and suppressed on the opposite side, even though the visual input to the fly eyes stays the same. Thus, the flow of information from the fly eyes is gated intrinsically. Such modulation can be noise-induced or intentional; with one possibility being that the fly brain highlights chosen information while ignoring the irrelevant, similar to what we know to occur in higher animals