Ethical Issues in Genetic Testing for Inherited Cancer Predisposition Syndromes: the Potentially Conflicting Interests of Patients and Their Relatives

Purpose of Review This review uses clinical cases to highlight some of the ethical dilemmas currently faced by oncologists, geneticists and others who request genetic testing for inherited cancer disorders. Recent Findings Recent ethical guidance supports clinicians in testing patients when other family members decline similar testing, even when such testing will reveal those family members’ genetic status. And increasingly there is acknowledgement that when a patient declines to share genetic results with family members, clinicians may have an ethical duty to breach patient confidentiality in order to inform at-risk relatives to whom they may owe a duty of care, so that they can choose to access genetic testing and potentially life-saving screening and treatment. Summary Genetic testing for inherited cancer disorders raises multiple ethical issues, which cannot always be easily resolved by discussion with patients, or with their family members. Clinical ethics committees can provide valuable assistance in resolving the dilemmas presented in these cases

The Implementation of Telemedicine in the Covid-19 Era

Introduction: During the COVID-19 global pandemic in 2020, social distancing policies called for health care providers to turn to telemedicine platforms for most of their patient encounters. We aimed to better understand the experiences and perspectives of patients and providers who used telemedicine in the primary care setting. Methods: This study included semi-structured interviews with patients and providers who participated in telemedicine visits during the beginning of the COVID-19 pandemic. Patients (n = 14) were from a rural Maine practice and providers (n = 10) were from practices within 100 miles of a tertiary care center. The interviews were analyzed through inductive coding and applying the constant comparative method. Results: Both patients and providers expressed general satisfaction with their telemedicine experiences. Patients (64%) and providers (90%) felt “comfortable” with telemedicine. They praised telemedicine for its convenience and recognized the benefit of having a telemedicine option in the future. However, there was a mixed response regarding perceived efficacy of telemedicine and the ability to emotionally connect over virtual platforms. Finally, the participants in this study discussed dissatisfaction with the loss of the “ritual of medicine.” Discussion: The COVID-19 pandemic posed barriers to health care that parallel existing barriers in rural states. For much of this rural population, the rapid implementation of telemedicine enabled easier access to care. However, the implementation also saw many technological and infrastructural roadblocks. Conclusions: Understanding the benefits and challenges of telemedicine for patients and providers will be critical in assuring that telemedicine continues to improve access to health care

A Subsurface Eddy Associated With a Submarine Canyon Increases Availability and Delivery of Simulated Antarctic Krill to Penguin Foraging Regions

The distribution of marine zooplankton depends on both ocean currents and swimming behavior. Many zooplankton perform diel vertical migration (DVM) between the surface and subsurface, which can have different current regimes. If concentration mechanisms, such as fronts or eddies, are present in the subsurface, they may impact zooplankton near-surface distributions when they migrate to near-surface waters. A subsurface, retentive eddy within Palmer Deep Canyon (PDC), a submarine canyon along the West Antarctic Peninsula (WAP), retains diurnal vertically migrating zooplankton in previous model simulations. Here, we tested the hypothesis that the presence of the PDC and its associated subsurface eddy increases the availability and delivery of simulated Antarctic krill to nearby penguin foraging regions with model simulations over a single austral summer. We found that the availability and delivery rates of simulated krill to penguin foraging areas adjacent to PDC were greater when the PDC was present compared to when PDC was absent, and when DVM was deepest. These results suggest that the eddy has potential to enhance krill availability to upper trophic level predators and suggests that retention may play a significant role in resource availability for predators in other similar systems along the WAP and in other systems with sustained subsurface eddies

‘Not dead … abandoned’ – a clinical case study of childhood and combat-related trauma

This clinical case study examines inter-subjective processes with a counselling client who presented with symptoms of complex trauma including severe anxiety, low mood, dissociation and suicidality. Therapy lasted 12 months and the ending was unplanned. Psychoanalytic and phenomenological hermeneutic frameworks are drawn on in theorizing the work. From this perspective, loss associated with trauma is conceptualized as relational, as traumatic states threaten psychological organization and the continuing experience of relational ties that are needed for survival. Dissociation is understood as a defensive state that changes the way that temporality is experienced. The client’s capacity for dissociation appeared to have developed in early childhood in response to physical abuse, predisposing him to further ongoing and severe trauma as an adult soldier. There will be a focus on the way that dissociation and enactment in the therapeutic relationship limited the therapist’s capacity to provide the client with inter-subjective regulation of disavowed affect. The client’s unconscious experience of unbearable affect led to a breakdown of the therapeutic relationship and the termination of therapy. Detailed session and supervision notes, and correspondence received from the client were used to evaluate theory and practice links, as well as some methodological aspects of case study research

Subsurface Eddy Facilitates Retention of Simulated Diel Vertical Migrators In a Biological Hotspot

Diel vertical migration (DVM) is common in zooplankton populations worldwide. Every day, zooplankton leave the productive surface ocean and migrate to deepwater to avoid visual predators and return to the surface at night to feed. This behavior may also help retain migrating zooplankton in biological hotspots. Compared to fast and variable surface currents, deep ocean currents are sluggish, and can be more consistent. The time spent in the subsurface layer is driven by day length and the depth of the surface mixed layer. A subsurface, recirculating eddy has recently been described in Palmer Deep Canyon (PDC), a submarine canyon in a biological hotspot located adjacent to the West Antarctic Peninsula. Circulation model simulations have shown that residence times of neutrally buoyant particles increase with depth within this feature. We hypothesize that DVM into the subsurface eddy increases local retention of migrating zooplankton in this feature and that shallow mixed layers and longer days increase residence times. We demonstrate that simulated vertically migrating zooplankton can have residence times on the order of 30 days over the canyon, which is five times greater than residence times of near-surface, nonmigrating zooplankton within PDC and other adjacent coastal regions. The potential interaction of zooplankton with this subsurface feature may be important to the establishment of the biological hotspot around PDC by retaining food resources in the region. Acoustic field observations confirm the presence of vertical migrators in this region, suggesting that zooplankton retention due to the subsurface eddy is feasible

Probability and consequences of a rapid boron dilution sequence in a PWR

The reactor restart scenario is one of several beyond-design-basis events in a pressurized water reactor (PWR) which can lead to rapid boron dilution in the core. This in turn can lead to a power excursion and the potential for fuel damage. A probabilistic analysis had been done for this event for a European PWR. The estimated core damage frequency was found to be high partially because of a high frequency for a LOOP and assumptions regarding operator actions. As a result, a program of analysis and experiment was initiated and corrective actions were taken. A system was installed so that the suction of the charging pumps would switch to the highly borated refueling water storage tank (RWST) when there was a trip of the RCPs. This was felt to reduce the estimated core damage frequency to an acceptable level. In the US, this original study prompted the Nuclear Regulatory Commission to issue an information notice to follow work being done in this area and to initiate studies such as the work at BNL reported herein. In order to see if the core damage frequency might be as high in US plants, a probabilistic assessment of this scenario was done for three plants. Two important conservative assumptions in this analysis were that (1) the mixing of the injectant was insignificant and (2) fuel damage occurs when the slug passes through the core. In order to study the first assumption, analysis was carried out for two of the plants using a mixing model. The second assumption was studied by calculating the neutronic response of the core to a slug of deborated water for one of the plants. All three types of analyses are summarized below. More information is available in the original report

Digital innovation for cancer risk assessment allows large-scale service redevelopment of regional cancer genetics service delivery.

Family-history assessment can identify individuals above population-risk for cancer to enable targeted Screening, Prevention and Early Detection (SPED). The online patient-facing cancer Family History Questionnaire Service (cFHQS) is a digitalised, resource efficient tool for family history data capture to facilitate this. The capturing of digital data from cFHQS allows for data interrogation of patients referred to Clinical Genetics for the purposes of service improvement. Digital data from 4,044 cFHQS respondents over a three-year period was collected and interrogated with respect to the number and type of familial tumour diagnoses to enable service improvement and streamlining of referral pathways. 81% of colorectal and 71% of breast screening assessments were population- or moderate-risk. Most patients who completed cFHQS reported more than one diagnosis of cancer/tumour/polyps in their family. 2.5% of family history assessment patients had a second indication that required assessment that would have been missed if single tumour type assessment was undertaken. Implementation of an innovative, digital family history data collection pathway has allowed large scale interrogation of referral patterns and assessment outcomes to enable service development. The high volume of inappropriate referrals to Clinical Genetics for population and moderate risk patients highlighted the need for dedicated secondary care pathway provision for these patients. The use of cFHQS streamlined family history assessment allows for redistribution of resources to improve equity and access to genetic cancer risk assessment

Contingent self-importance among pathological narcissists: Evidence from an implicit task

Pathological narcissists are thought to hold unstable, contingent views of their self-importance. They harbor grandiose fantasies about the self, but are vulnerable and hypersensitive as well. The present study (N = 84) sought to provide evidence for this important set of clinical ideas. Following a manipulation priming dominant versus submissive self-views, a task developed to assess implicit self-importance of an interpersonal type was administered. As hypothesized, the manipulation and levels of pathological narcissism interacted to predict implicit self-importance. Implicit self-importance scores were unaffected by the priming manipulation at low levels of pathological narcissism, but were strongly affected at high levels of pathological narcissism. These results support clinical intuitions concerning pathological narcissism

The role of empathy in psychoanalytic psychotherapy: A historical exploration

Empathy is one of the most consistent outcome predictors in contemporary psychotherapy research. The function of empathy is particularly important for the development of a positive therapeutic relationship: patients report positive therapeutic experiences when they feel understood, safe, and able to disclose personal information to their therapists. Despite its clear significance in the consulting room and psychotherapy research, there is no single, consensual definition of empathy. This can be accounted by the complex and multi-faceted nature of empathy, as well as the ambiguous and conflicting literature surrounding it. This paper provides a historical exploration of empathy and its impact on the therapeutic relationship across the most influential psychoanalytic psychotherapies: classic psychoanalysis, person-centered therapy and self-psychology. By comparing the three clinical schools of thought, the paper identifies significant differences in the function of transference and therapist’s role. Then, drawing on the different clinical uses of empathy, the paper argues that the earlier uses of empathy (most notably through Jaspers’ and Freud’s writings) are limited to its epistemological (intellectual or cognitive) features, whilst person-centered and self-psychology therapies capitalise on its affective qualities. Finally, the paper provides a rationale for further study of the overarching features of empathy in contemporary psychotherapy research