Splitting Hairs or Parsing Concepts, Fuzzy Thinking or Fuzzy Categories: Where Does Motivational Interviewing End and Client-centered Therapy Begin?

An increasingly robust debate is emerging about the role of equanimity, equipoise and equality of concepts in defining what constitutes motivational interviewing (MI) versus client-centered therapy. At the heart of this debate is whether a MI practitioner may remain neutral about a goal and still be practicing MI. After that point of agreement, the debate becomes increasingly complex and defuse. However, MI has never included in its definition that the clinician identifies a specific behavioral goal. Nor is this articulated in any of the principles. Instead, it seems to be an ad hoc explanation of what does and does not constitute MI practice in an effort to establish the boundaries of MI. It is clear that a lack of data and only a nascent theory of how MI works contribute to this problem, but it may also be issues of fuzzy thinking and fuzzy categories. An exploration of these areas suggests it is possible that a practitioner could be practicing MI and not have a specific behavioral goal, other than assisting the client in resolving ambivalence

Äktenskapsförord - En avtalsrättslig komparation

Förevarande text handlar om skillnaderna mellan äktenskapsförord och förmögenhetsrättsliga avtal. Ett äktenskapsförord är ett familjerättsligt avtal med stark förmögenhetsrättslig prägel. Detta till trots gör sig dock en del typiska familjerättsliga särdrag gällande. Sådana särdrag är exempelvis de olika formkrav som gör sig gällande ifråga om äktenskapsförord. Äktenskapsförord skall upptecknas i en skriftlig handling och undertecknas av makarna för giltighet. Äktenskapsförordet skall sedan registreras. Äktenskapsförord är det enda sättet som makar kan avtala om egendomsordningen i sitt äktenskap och frångå det lagfästa giftorättssystemet. Enligt giftorättssystemet har makar antingen enskild egendom eller giftorättsgods, men bara den senare egendomstypen skall ingå i bodelning. Huvudregeln är att all makes egendom är giftorättsgods. Egendom kan dock vara enskild pga. föreskrift av givare, arvlåtare eller testator. Egendom kan även vara enskild pga. äktenskapsförord. Avtalsfriheten ifråga om äktenskapsförord är underkastad olika begränsningar. Det anses exempelvis inte möjligt enligt lag att avtala om villkorade äktenskapsförord. Makar kan inte heller i äktenskapsförord åsidosätta tredje mans föreskrift om att viss egendom skall vara enskild. Om makarna i sitt äktenskapsförord går utöver de i lag uppställda begränsningarna blir förordet ogiltigt. Att äktenskapsförord är en formbunden handling som kräver skriftlig form för giltighet gör att det skriftligt uttryckta får en särskild tyngd vid tolkningen av äktenskapsförord. Parternas vilja är givetvis avgörande vid tolkningen och utgångspunkt därför, men skriftlighetskravet gör att partsavsikten måste kunna knytas till förordstexten för att kunna bli utslagsgivande vid tolkningen. Ett äktenskapsförord utgör inte något moment i den allmänna omsättningens intresse. Härvidlag gör sig inte den sk. tillitsgrundsatsen lika starkt gällande inom det familjerättsliga avtalsparadigmet som inom det förmögenhetsrättsliga. Detta motiverar vissa skillnader i tillämpningen av ogiltighetsreglerna mellan de olika avtalsområdena. Sedan ÄktB:s ikraftträdande har äktenskapsrätten fått en egen jämkningsregel i ÄktB 12 kap. 3 §, vilken utformats med 36 § AvtL som förebild. Vissa omständigheter talar dock för att jämkning av äktenskapsförord oftare borde komma ifråga än jämkning av förmögenhetsrättsliga avtal. Exempel på sådana omständigheter är att avtalet regelmässigt sluts för lång tid och tillämpas först sedan många år gått från avtalstidpunkten samt att äktenskapsförord regelmässigt har benefika inslag. På det förmögenhetsrättsliga avtalsområdet är avtalsfriheten och avtalsbundenheten grundläggande utgångspunkter. Parterna är härvid i princip fria att avtala med vem som helst om vad som helst utan hänsyn till formkrav och dylikt. Frånvaron av formkrav innebär att avtal kan slutas såväl muntligt som skriftligt och konkludent. Parternas avtal bildar en privat rättskälla dem emellan som styr deras agerande. När parter avtalar med varandra finns en grundläggande tanke om att avtalet skall innebära balans, eller ekvivalens mellan parternas prestationer. Parts befogade tillit anses mer skyddsvärd inom det förmögenhetsrättsliga området vilket gör att förmögenhetsrättsliga avtal präglas mer av den sk. tillitsprincipen än den inom familjerätten härskande viljeprincipen. Trots att avtalsfriheten är en grundläggande princip är den omgärdad av kraftiga begränsningar. I vissa fall finns det exempelvis ett tvång att avtala och i andra fall kan det finnas förbud mot att vissa avtal träffas eller rentav förbud för vissa personer att träffa avtal. Formlöshet är huvudregel ifråga om förmögenhetsrättsliga avtal, men på vissa områden finns alltjämt formkrav. Konsekvenserna av ett brott mot formföreskrift varierar med avtalstypen. I vissa fall blir hela avtalet ogiltigt medan part i andra fall kan kräva att motparten medverkar till att formenligt avtal ingås. Tolkning av förmögenhetsrättsliga avtal sker som huvudregel efter den sk. tillitsteorin med den gemensamma partsviljan som överordnad tolkningsmetod. Eftersom förmögenhetsrättsliga avtal regelmässigt är längre än äktenskapsförord finns fler och mer nyanserade tolkningsmodeller för uttydningen av avtalsinnehållet. Ogiltighetsreglerna är ett exempel på en avvägning mellan tillitsteorin och viljeteorin där tillitsteorin är huvudsaklig utgångspunkt. För att ogiltighetsreglerna i AvtL skall vara tillämpliga krävs kausalitet mellan otillbörligheten och avtalets ingående. Jämkningsmöjligheterna i AvtL är exempel på undantag från den förmögenhetsrättsliga utgångspunkten att avtal skall hållas. 36 § AvtL har ett explicit syfte att utgöra skydd för svagare part. Jämkning är ett mer nyanserat sätt att ingripa mot obillighet i avtalsförhållanden än att förklara avtalet ogiltigt. Oskälighetsbedömningen samverkar med AvtL:s övriga ogiltighetsgrunder såtillvida att om ett avtal inte kan förklaras ogiltigt msa. t.ex. svekregeln i AvtL 30 § så kan omständigheterna som inte ansågs utgöra svek ändock påverka resultatet av en skälighetsbedömning.This text is about the various differences between prenuptial agreements and contracts dealing with property law. A prenuptial agreement is a contract between partners, with strong economical characteristics. In spite of these characteristics there are some essential differences between the two types of contracts. There are, for instance, more formal requirements to take into consideration concerning prenuptial agreements. Prenuptial agreements, according to Swedish law, are invalid unless in written form and signed by the parties thereto. The agreement shall then be subject to registration. A prenuptial agreement is the only means by which the husband and wife may deviate from the legal marital system. According to the legal marital system there are only two forms of property in any marriage; marital property and separate property. Only marital property is to be subject to partition at the event of the dissolution of the marriage in question. The main rule is that all the partners’ property is marital property. Property can also be separate due to a provision in a will or a provision stipulated by a donor. Property can also be separate due to a provision in a prenuptial agreement. The principle of freedom of contract is subject to a number of limitations when it comes to prenuptial agreements. It is prohibited to make the prenuptial agreement subject to certain conditions. Partners are also unable to revoke a third party provision stipulating that certain property is separate. If the partners exceed the legal bounds for prenuptial agreements the contract will be voided in consequence. The fact that prenuptial agreements are required to be in writing lends weight to that which is written when it comes to interpreting the contract. The will of the parties determines the interpretation of the contract, but the will of the parties must be linked to the text in the agreement. A prenuptial agreement is not part of the public circulation of goods or otherwise, which entails that the good faith of a party to a contract is less important than it would have been had the contract been of more economical characteristics. This fact is used to motivate certain differences in how the rules of invalidation of contracts are applied. The law of marriage has its own adjustment rule in ÄktB 12 kap. 3 §, which was made in the image of its predecessor the 36 § of AvtL. Certain factors indicate that adjustment might be a more frequent occurrence when dealing with prenuptial agreements than it is when dealing with contracts of property law. For instance that the prenuptial agreement is entered into long before it is supposed to be put into practice and that the agreement usually contains elements of a non-onerous nature. In the paradigm of property law the freedom of contract and the contractuality of contracts, pacta sunt servanda, are the main rules. The parties to a contract are free to enter into contracts with whomever they desire, regarding whatever they desire unconcerned with formal requirements. The absence of formal requirements makes contracts valid regardless of how they are entered into. The contract of the parties becomes a private source of law that governs the actions of the parties. There is a basic principle of equivalency in contracts. The good faith of a contractual party is considered more important in the area of property law than in the area of family law where the will of the party is paramount. Although the freedom of contracts is a basic principle of property law it is subject to a number of limitations. In certain cases there might be a requirement to enter into contracts or there might be a prohibition to enter into contracts. The absence of formal requirements is a main rule in the area of property law, but in certain cases there are different formal requirements. The consequence of a breach of a formal requirement varies. In certain cases the entire contract is voided, whereas in other cases a party to a contract can require that the other party contributes to meeting the formal requirements. Interpretation of property contracts is done from the perspective of the good faith of a party where the will of the parties is super ordinate. Due to the fact that property contracts are usually more extensive than prenuptial agreements there are more interpretation models for interpreting the contractual contents. The rules of invalidation of contracts are examples of a balance between the opposing theories of good faith and the will of a party, where the good faith of a party is the basis for considerations. For the rules of invalidation of contracts to be applicable to a certain contract, there is an absolute requirement of causality between the inappropriate act and the decision to enter into the contract. The adjustment possibilities in the law of contracts are examples of exceptions from the main rule of pacta sunt servanda. The 36 § AvtL has the explicit purpose to protect a weaker party. Adjustment is a more nuanced means by which inappropriateness in a contractual situation may be rectified than declaring the contract invalid. The assessment of whether a contract is fair or not, in the sense of 36 § AvtL, is done in unison with the rules of invalidity of contracts. If a party has been fraudulent in entering into a contract, the inappropriateness herein can influence whether or not a contract is ultimately to be considered fair

Regulation of peripheral inflammation by spinal p38 MAP kinase in rats.

BackgroundSomatic afferent input to the spinal cord from a peripheral inflammatory site can modulate the peripheral response. However, the intracellular signaling mechanisms in the spinal cord that regulate this linkage have not been defined. Previous studies suggest spinal cord p38 mitogen-activated protein (MAP) kinase and cytokines participate in nociceptive behavior. We therefore determined whether these pathways also regulate peripheral inflammation in rat adjuvant arthritis, which is a model of rheumatoid arthritis.Methods and findingsSelective blockade of spinal cord p38 MAP kinase by administering the p38 inhibitor SB203580 via intrathecal (IT) catheters in rats with adjuvant arthritis markedly suppressed paw swelling, inhibited synovial inflammation, and decreased radiographic evidence of joint destruction. The same dose of SB203580 delivered systemically had no effect, indicating that the effect was mediated by local concentrations in the neural compartment. Evaluation of articular gene expression by quantitative real-time PCR showed that spinal p38 inhibition markedly decreased synovial interleukin-1 and -6 and matrix metalloproteinase (MMP3) gene expression. Activation of p38 required tumor necrosis factor alpha (TNFalpha) in the nervous system because IT etanercept (a TNF inhibitor) given during adjuvant arthritis blocked spinal p38 phosphorylation and reduced clinical signs of adjuvant arthritis.ConclusionsThese data suggest that peripheral inflammation is sensed by the central nervous system (CNS), which subsequently activates stress-induced kinases in the spinal cord via a TNFalpha-dependent mechanism. Intracellular p38 MAP kinase signaling processes this information and profoundly modulates somatic inflammatory responses. Characterization of this mechanism could have clinical and basic research implications by supporting development of new treatments for arthritis and clarifying how the CNS regulates peripheral immune responses

Quantitative biomarker analysis of synovial gene expression by real-time PCR

Synovial biomarker analysis in rheumatoid arthritis can be used to evaluate drug effect in clinical trials of novel therapeutic agents. Previous studies of synovial gene expression for these studies have mainly relied on histological methods including immunohistochemistry and in situ hybridization. To increase the reliability of mRNA measurements on small synovial tissue samples, we developed and validated real time quantitative PCR (Q-PCR) methods on biopsy specimens. RNA was isolated from synovial tissue and cDNA was prepared. Cell-based standards were prepared from mitogen-stimulated peripheral blood mononuclear cells. Real time PCR was performed using TaqMan chemistry to quantify gene expression relative to the cell-based standard. Application of the cellular standard curve method markedly reduced intra- and inter-assay variability and corrected amplification efficiency errors compared with the C(t) method. The inter-assay coefficient of variation was less than 25% over time. Q-PCR methods were validated by demonstrating increased expression of IL-1β and IL-6 expression in rheumatoid arthritis synovial samples compared with osteoarthritis synovium. Based on determinations of sampling error and coefficient of variation, twofold differences in gene expression in serial biopsies can be detected by assaying approximately six synovial tissue biopsies from 8 to 10 patients. These data indicate that Q-PCR is a reliable method for determining relative gene expression in small synovial tissue specimens. The technique can potentially be used in serial biopsy studies to provide insights into mechanism of action and therapeutic effect of new anti-inflammatory agents

Elevated autoantibody content in rheumatoid arthritis synovia with lymphoid aggregates and the effect of rituximab

IntroductionThe purpose of this study was to quantitatively evaluate the contribution of synovial lymphoid aggregates to autoantibody (rheumatoid factor [RF] and anti-cyclic citrullinated peptide [anti-CCP]) and total immunoglobulin (IgG and IgM) production in rheumatoid arthritis (RA) patients and the effect thereon of the B-cell-depleting antibody, rituximab, in the ARISE (Assessment of Rituximab's Immunomodulatory Synovial Effects) trial.MethodsAutoantibodies as well as total IgM and IgG were quantified by enzyme-linked immunosorbent assay in extracts of synovial tissues and matched serum from patients with RA or osteoarthritis (OA). Synovial biopsies and serum were obtained at baseline and 8 weeks following rituximab therapy in 14 RA patients. A synovial/serum index (SSI) was calculated as the ratio of synovial to serum antibody/albumin, with values above 1 representing synovial enrichment. Lymphoid aggregates were evaluated histologically.ResultsAnti-CCP IgG, but not RF-IgM, was significantly enriched in RA synovia compared with serum. Total IgM and IgG were also enriched in RA, but not in OA. SSI correlated significantly with mRNA content for both IgM and IgG, demonstrating that it reflected synovial immunoglobulin production. RA synovia with lymphocyte aggregates contained significantly elevated RF-IgM and anti-CCP IgG compared with tissues with diffuse lymphoid infiltration. Rituximab treatment did not affect synovial autoantibody or total immunoglobulin SSI overall. However, in aggregate-containing tissues, rituximab significantly reduced total IgM and IgG SSI as well as IgM and IgG1 mRNA. Surprisingly, RF-IgM and anti-CCP IgG SSIs were unchanged by rituximab in aggregate-containing synovia.ConclusionsCombined with earlier observations that synovial lymphoid aggregates are unaltered by rituximab treatment, these data suggest that lymphoid aggregates may provide a protective niche for autoantibody-producing cells

Urinary p75(ECD): A prognostic, disease progression, and pharmacodynamic biomarker in ALS.

OBJECTIVE: To evaluate urinary neurotrophin receptor p75 extracellular domain (p75(ECD)) levels as disease progression and prognostic biomarkers in amyotrophic lateral sclerosis (ALS). METHODS: The population in this study comprised 45 healthy controls and 54 people with ALS, 31 of whom were sampled longitudinally. Urinary p75(ECD) was measured using an enzyme-linked immunoassay and validation included intra-assay and inter-assay coefficients of variation, effect of circadian rhythm, and stability over time at room temperature, 4°C, and repeated freeze-thaw cycles. Longitudinal changes in urinary p75(ECD) were examined by mixed model analysis, and the prognostic value of baseline p75(ECD) was explored by survival analysis. RESULTS: Confirming our previous findings, p75(ECD) was higher in patients with ALS (5.6 ± 2.2 ng/mg creatinine) compared to controls (3.6 ± 1.4 ng/mg creatinine, p < 0.0001). Assay reproducibility was high, with p75(ECD) showing stability across repeated freeze-thaw cycles, at room temperature and 4°C for 2 days, and no diurnal variation. Urinary p75(ECD) correlated with the revised ALS Functional Rating Scale at first evaluation (r = -0.44, p = 0.008) and across all study visits (r = -0.36, p < 0.0001). p75(ECD) also increased as disease progressed at an average rate of 0.19 ng/mg creatinine per month (p < 0.0001). In multivariate prognostic analysis, bulbar onset (hazard ratio [HR] 3.0, p = 0.0035), rate of disease progression from onset to baseline (HR 4.4, p < 0.0001), and baseline p75(ECD) (HR 1.3, p = 0.0004) were predictors of survival. CONCLUSIONS: The assay for urinary p75(ECD) is analytically robust and shows promise as an ALS biomarker with prognostic, disease progression, and potential pharmacodynamic application. Baseline urinary p75(ECD) provides prognostic information and is currently the only biological fluid-based biomarker of disease progression

Epidemiology, prehospital care and outcomes of patients arriving by ambulance with dyspnoea: An observational study

Background: This study aimed to determine epidemiology and outcome for patients presenting to emergency departments (ED) with shortness of breath who were transported by ambulance. Methods: This was a planned sub-study of a prospective, interrupted time series cohort study conducted at three time points in 2014 and which included consecutive adult patients presenting to the ED with dyspnoea as a main symptom. For this sub-study, additional inclusion criteria were presentation to an ED in Australia or New Zealand and transport by ambulance. The primary outcomes of interest are the epidemiology and outcome of these patients. Analysis was by descriptive statistics and comparisons of proportions. Results: One thousand seven patients met inclusion criteria. Median age was 74 years (IQR 61-68) and 46.1 % were male. There was a high rate of co-morbidity and chronic medication use. The most common ED diagnoses were lower respiratory tract infection (including pneumonia, 22.7 %), cardiac failure (20.5%) and exacerbation of chronic obstructive pulmonary disease (19.7 %). ED disposition was hospital admission (including ICU) for 76.4 %, ICU admission for 5.6 % and death in ED in 0.9 %. Overall in-hospital mortality among admitted patients was 6.5 %. Discussion: Patients transported by ambulance with shortness of breath make up a significant proportion of ambulance caseload and have high comorbidity and high hospital admission rate. In this study, >60 % were accounted for by patients with heart failure, lower respiratory tract infection or COPD, but there were a wide range of diagnoses. This has implications for service planning, models of care and paramedic training. Conclusion: This study shows that patients transported to hospital by ambulance with shortness of breath are a complex and seriously ill group with a broad range of diagnoses. Understanding the characteristics of these patients, the range of diagnoses and their outcome can help inform training and planning of services

Immunohistochemical detection of macrophage migration inhibitory factor in fetal and adult bovine epididymis: Release by the apocrine secretion mode?

Originally defined as a lymphokine inhibiting the random migration of macrophages, the macrophage migration inhibitory factor (MIF) is an important mediator of the host response to infection. Beyond its function as a classical cytokine, MIF is currently portrayed as a multifunctional protein with growth-regulating properties present in organ systems beyond immune cells. In previous studies, we detected substantial amounts of MIF in the rat epididymis and epididymal spermatozoa, where it appears to play a role during post-testicular sperm maturation and the acquisition of fertilization ability. To explore its presence in other species not yet examined in this respect, we extended the range of studies to the bull. Using a polyclonal antibody raised against MIF purified from bovine eye lenses, we detected MIF in the epithelium of the adult bovine epididymis with the basal cells representing a prominently stained cell type. A distinct accumulation of MIF at the apical cell pole of the epithelial cells and in membranous vesicles localized in the lumen of the epididynnal duct was obvious. In the fetal bovine epididymis, we also detected MIF in the epithelium, whereas MIF accumulation was evident at the apical cell surface and in apical protrusions. By immuno-electron microscopy of the adult bovine epididymis, we localized MIF in apical protrusions of the epithelial cells and in luminal membrane-bound vesicles that were found in close proximity to sperm cells. Although the precise origin of the MIF-containing vesicles remains to be delineated, our morphological observations support the hypothesis that they become detached from the apical surface of the epididymal epithelial cells. Additionally, an association of MIF with the outer dense fibers of luminal spermatozoa was demonstrated. Data obtained in this study suggest MIF release by an apocrine secretion mode in the bovine epididymis. Furthermore, MIF localized in the basal cells of the epithelium and in the connective tissue could be responsible for regulating the migration of macrophages in order to avoid contact of immune cells with spermatozoa that carry a wide range of potent antigens. Copyright (c) 2006 S. Karger AG, Basel

An integrated analysis of Maglemose bone points reframes the Early Mesolithic of Southern Scandinavia

The extensive peat bogs of Southern Scandinavia have yielded rich Mesolithic archaeological assemblages, with one of the most iconic artefacts being the bone point. Although great in number they remain understudied. Here we present a combined investigation of the typology, protein-based species composition, and absolute chronology of Maglemosian bone points. The majority of the bone points are made from cervids and bovines. However, changes both in species composition and barb morphology can be directly linked to a paucity of finds lasting nearly 600 years in Southern Scandinavia around 10,300 cal BP. We hypothesize that this hiatus was climate-driven and forced hunter-gatherers to abandon the lakes. Furthermore, the marked change in bone points coincides with a change in lithic technology. We, therefore, propose that the Maglemose culture in Southern Scandinavia is fundamentally divided into an Early Complex and a Late Complex