Reversible Cortical Blindness as a Prominent Manifestation of Cerebral Embolism due to Infective Endocarditis

Introduction. Infective endocarditis in the left heart may be complicated by stroke, due to embolisation from infectious valvular vegetations. Infarction of both occipital lobes, which are supplied by the posterior cerebral arteries, is infrequent, and is the cause of cortical blindness from lesion of the visual cortex. Cortical blindness is characterized by intact pupillary reflexes, a normal fundoscopy, and, rarely, denial of visual loss. Case Presentation. We report the case of a 58-year-old woman, recipient of a mechanical aortic valve, who presented with fever, multiple organ dysfunction, and cortical blindness. Transesophageal echocardiography and blood cultures confirmed the diagnosis of infective endocarditis caused by methicillin-sensitive Staphylococcus aureus. Computed tomography of the brain without contrast revealed the presence of infarctions in both occipital lobes. It is noteworthy that the visual loss resolved after treatment of endocarditis. Conclusions. A stroke occurring in a patient presenting with fever and a history of valvular heart disease strongly suggests the presence of infective endocarditis. Bilateral thromboembolic infarcts of the occipital lobes cause cortical blindness, that can resolve after treatment of endocarditis

Inapplicability of advance directives in a paternalistic setting: the case of a post-communist health system

<p>Abstract</p> <p>Background</p> <p>The Albanian medical system and Albanian health legislation have adopted a paternalistic position with regard to individual decision making. This reflects the practices of a not-so-remote past when state-run facilities and a totalitarian philosophy of medical care were politically imposed. Because of this history, advance directives concerning treatment refusal and do-not-resuscitate decisions are still extremely uncommon in Albania. Medical teams cannot abstain from intervening even when the patient explicitly and repeatedly solicits therapeutic abstinence. The Albanian law on health care has no provisions regarding limits or withdrawal of treatment. This restricts the individual's healthcare choices.</p> <p>Discussion</p> <p>The question of <it>'medically futile' </it>interventions and pointless life-prolonging treatment has been discussed by several authors. Dutch physicians call such interventions '<it>medisch zinloos</it>' (<it>senseless</it>), and the Netherlands, as one of the first states to legislate on end-of-life situations, actually regulates such issues through appropriate laws. In contrast, leaving an 'advance directive' is not a viable option for Albanian ailing individuals of advanced age. Verbal requests are provided during periods of mental competence, but unfortunately such instructions are rarely taken seriously, and none of them has ever been upheld in a legal or other official forum.</p> <p>Summary</p> <p>End-of-life decisions, treatment refusal and do-not-resuscitate policies are hazardous options in Albania, from the legal point of view. Complying with them involves significant risk on the part of the physician. Culturally, the application of such instructions is influenced from a mixture of religious beliefs, death coping-behaviors and an immense confusion concerning the role of proxies as decision-makers. Nevertheless, Albanian tradition is familiar with the notion of '<it>amanet</it>', a sort of living will that mainly deals the property and inheritance issues. Such living wills, verbally transmitted, may in certain cases include advance directives regarding end-of-life decisions of the patient including refusal or termination of futile medical treatments. Since these living wills are never formally and legally validated, their application is impossible and treatment refusal remains still non practicable. Tricks to avoid institutional treatment under desperate conditions are used, aiming to provide legal coverage for medical teams and relatives that in extreme situations comply with the advice of withholding senseless treatment.</p

End-of-life practices in the intensive care unit

Intensive care may prolong the dying process in patients who have been unresponsive to the treatment already provided. Limitation of life-sustaining therapy, either by withholding or withdrawing support, is an ethically acceptable and common worldwide practice. The purpose of the present study was to examine the frequency, types and rationale of limiting life support in Greek intensive care units (ICUs), the clinical and demographic parameters associated with it, and the participation of relatives in decision–making. This was a prospective observational study conducted in 8 Greek multidisciplinary ICUs. We studied all consecutive ICU patients who died, excluding those who stayed in the ICU less than 48 hours or were brain dead. Three hundred and six patients comprised the study population, with a mean age of 64 years and a mean APACHE II score on admission of 21. Of study patients, 41% received full support including unsuccessful cardiopulmonary resuscitation (CPR), 48% died after withholding of CPR, 8% died after withholding of other treatment modalities besides CPR, and 3% died after withdrawal of treatment. Patients in whom therapy was limited had a longer ICU (p<0.01) and hospital (p=0.01) length of stay, a lower GCS on admission (p<0.01), a higher APACHE II score 24 hours prior to death (p<0.01), and were more likely to be admitted with a neurological diagnosis (p<0.01). Patients who received full support were more likely to be admitted with either a cardiovascular (p=0.02) or trauma diagnosis (p=0.05), and to be surgical rather than medical (p=0.05). The main factors that influenced the physician’s decision were, when providing full support, reversibility of illness and prognostic uncertainty, while, when limiting therapy, unresponsiveness to treatment already offered, prognosis of underlying chronic disease, and prognosis of acute disorder. Relatives’ participation in decision-making occurred in 20% of cases. Reasons for not discussing end-of-life dilemmas with relatives included the fact that the family was thought not to understand (60%) and the family was unavailable (25%). Advance directives were rare (1%). Conclusively, limitation of life-sustaining treatment is a common phenomenon in Greek ICUs. However, in a large majority of cases, it is equivalent to the withholding of CPR alone. Withholding of other therapies besides CPR and withdrawal of support are infrequent. The main factor that motivates the decision to limit therapy is unresponsiveness to treatment already offered. Medical paternalism predominates in decision-making.Η εντατική θεραπεία δυνατόν να παρατείνει τη διαδικασία του θανάτου ασθενών που δεν ανταποκρίθηκαν στην ήδη χορηγηθείσα αγωγή. Η μη-κλιμάκωση ή απόσυρση της υποστηρικτικής της ζωής αγωγής αποτελεί μια ηθικώς αποδεκτή και παγκοσμίως διαδεδομένη πρακτική. Σκοπός της παρούσας μελέτης ήταν να εξετάσει τη συχνότητα, τις μορφές και το σκεπτικό της μη-κλιμάκωσης / διακοπής της υποστήριξης στις ελληνικές Μονάδες Εντατικής Θεραπείας (ΜΕΘ), τις κλινικές και δημογραφικές παραμέτρους που σχετίζονται με αυτήν, και τη συμμετοχή των συγγενών στη λήψη της απόφασης. Πρόκειται για μια προοπτική μελέτη παρατήρησης η οποία διενεργήθηκε σε 8 ελληνικές πολυδύναμες ΜΕΘ. Μελετήσαμε όλους τους διαδοχικούς ασθενείς που πέθαναν στη ΜΕΘ εντός συγκεκριμένων χρονικών περιόδων, αποκλείοντας αυτούς που παρέμειναν στη ΜΕΘ για λιγότερο από 48 ώρες, καθώς και τους εγκεφαλικά νεκρούς. Ο πληθυσμός της μελέτης απαρτίσθηκε από 306 ασθενείς, με μέση ηλικία 64 έτη και μέσο APACHE II score εισόδου στη ΜΕΘ 21. Από τους ασθενείς αυτούς, 41% έλαβαν πλήρη υποστήριξη μέχρι τέλους, συμπεριλαμβανομένης της ανεπιτυχούς προσπάθειας καρδιοπνευμονικής αναζωογόνησης (ΚΑΡΠΑ), ενώ 48% πέθαναν χωρίς να επιχειρηθεί ΚΑΡΠΑ (αλλά εξαντλήθηκαν όλα τα υπόλοιπα διαθέσιμα υποστηρικτικά μέσα). Σε 8%, έλαβε χώρα μη-κλιμάκωση της αγωγής (που αφορούσε και σε άλλες θεραπείες πέραν της ΚΑΡΠΑ), και σε 3% έγινε διακοπή αγωγής. Οι ασθενείς στους οποίους η αγωγή περιορίσθηκε καθ’ οιονδήποτε τρόπο, συγκρινόμενοι με τους ασθενείς που υποστηρίχθηκαν πλήρως μέχρι τέλους και με εφαρμογή ΚΑΡΠΑ, είχαν μεγαλύτερο χρόνο νοσηλείας στη ΜΕΘ (p<0.01), μεγαλύτερο ολικό χρόνο παραμονής στο νοσοκομείο (p=0.01), χαμηλότερο GCS score εισαγωγής στη ΜΕΘ (p<0.01), υψηλότερο APACHE II score 24 ώρες προ του θανάτου (p<0.01), και ήταν πιθανότερο να φέρουν ως διάγνωση εισόδου στη ΜΕΘ νευρολογική νόσο (p<0.01). Οι ασθενείς που υποστηρίχθηκαν πλήρως ήταν πιθανότερο να έχουν εισαχθεί λόγω καρδιοαγγειακής νόσου (p=0.02) ή τραύματος (p=0.05), και να είναι χειρουργικοί μάλλον παρά παθολογικοί (p=0.05). Οι κύριοι παράγοντες που επηρέασαν την απόφαση του ιατρού ήταν, όσον αφορά μεν στην παροχή ενεργού υποστήριξης, η αναστρεψιμότητα της ασθένειας και η προγνωστική αβεβαιότητα, όσον αφορά δε στη μη-κλιμάκωση / απόσυρση της αγωγής, η απουσία ανταπόκρισης στην ήδη χορηγουμένη θεραπεία, η πρόγνωση της υποκειμένης χρονίας νόσου και η πρόγνωση της οξείας διαταραχής. Συμμετοχή των συγγενών στη λήψη της απόφασης υπήρξε στο 20% των περιπτώσεων. Οι λόγοι της μη-συζητήσεως των προτελευτίων διλημμάτων με τους συγγενείς ήταν η αντίληψη ότι η οικογένεια δεν θα κατανοούσε το προς επίλυση πρόβλημα (60%) και η μη-διαθεσιμότητά της (25%). Οι εκ των προτέρων δοθείσες οδηγίες ήσαν σπάνιες (1%). Συμπερασματικά, ο περιορισμός της υποστηρικτικής της ζωής αγωγής αποτελεί συχνό φαινόμενο στις ελληνικές ΜΕΘ. Ωστόσο, στη συντριπτική πλειονότητα των περιπτώσεων, ισοδυναμεί με αναστολή μόνον της ΚΑΡΠΑ. Η μη-κλιμάκωση της αγωγής, όσον αφορά άλλες θεραπείες πέραν της ΚΑΡΠΑ, και η απόσυρση αγωγής είναι ασυνήθεις. Ο κύριος παράγοντας που ωθεί στην απόφαση περιορισμού της αγωγής είναι η απουσία ανταπόκρισης στη ήδη χορηγουμένη θεραπεία. Ο ιατρικός πατερναλισμός κυριαρχεί στη διαδικασία λήψης της απόφασης

The correlates of crime and deviance: Additional evidence

Comparable survey data collected simultaneously in major cities in Greece, Russia, and Ukraine indicate that the usual correlates of self-reported criminal/deviant behavior derived from research in well-studied, mostly Western societies, do not necessarily hold cross-nationally. The data confirm only two of six potential correlates of self-reported criminal/deviant behavior-age and deviant peer association. Two widely assumed correlates of criminal propensity-gender and marital status-prove to be somewhat unreliable and sensitive to these cultural contexts. Religiosity is generally negatively linked to crime/deviance in bivariate but not multivariate analyses. In bivariate analysis socioeconomic status (SES) proves to be highly sensitive to the investigated cultural contexts whereas in multivariate analysis SES is not significantly related in any consistent fashion to criminality in any of the three countries. These results show the value of cross-cultural research and suggest that effective explanation of criminal and deviant behavior may require more attention to cultural variations. © 2010 The Author(s)