Conflictos morales al final de la vida: aspectos médicos, filosóficos y jurídicos

 La rutina impuesta a los médicos es reconocer y perseguir múltiples objetivos, que pueden ser complementarios o excluyentes. Curar la enfermedad, cuidar de la insuficiencia orgánica, restablecer la función, compensar la pérdida, aliviar los sufrimientos; confortar pacientes y familiares, y acompañar, activa y serenamente, los últimos momentos de la vida del paciente no es tarea fácil y libre de frustraciones, pues los obliga a considerar, caso por caso, el justo equilíbrio en la toma de decisiones, evitando la obstinación terpeútica en el final de la vida, reconociendo la finitud humana y las limitaciones de la ciencia médica sin dejar de proporcionar todos los beneficios ofrecidos por los avances del conocimiento científico. Aspecto no menos importante es la valoración de las creencias del enfermo, pues la búsqueda de un sentido trascendente de la existencia ocupa un lugar sustancial en la historia de vida de las personas. El presente artículo ofrece reflexiones para orientar la búsqueda prudente del adecuado equilibrio en el uso de las modernas tecnologías biomédicas en el tratamiento de pacientes con enfermedades crónico–degenerativas en fase terminal. Además, es imperativo que los médicos sean receptivos y respetuosos de las creencias y valores personales de sus pacientes, y que el arduo ejercicio de la profesión no sea más costoso si se adopta el peligroso camino de la medicina defensiva

Conflitos morais sobre a terminalidade da vida: aspectos médicos, filosóficos e jurídicos

 A rotina imposta aos médicos é reconhecer e perseguir múltiplos objetivos, que podem ser complementares ou excludentes. Curar a enfermidade, cuidar da insuficiência orgânica, restabelecer a função, compensar a perda, aliviar os sofrimentos; confortar pacientes e familiares e acompanhar, ativa e serenamente, os últimos momentos da vida do paciente não é tarefa fácil e isenta de frustrações, pois os obriga a considerar, caso a caso, o justo equilíbrio nas tomadas de decisões, evitando a obstinação terapêutica em circunstância de terminalidade da vida, reconhecendo a finitude humana e as limitações da ciência médica sem deixar de proporcionar todos os benefícios oferecidos pelos avanços do conhecimento científico. Aspecto não menos importante é o da valorização das crenças do enfermo, pois a busca por um sentido transcendente da existência ocupa lugar importante na história biográfica das pessoas. O presente artigo pretende oferecer reflexões para orientar a busca prudente do adequado equilíbrio no uso das hodiernas tecnologias biomédicas no tratamento de pacientes com enfermidades crônico-degenerativas em fase terminal. Outrossim, consideramos ser imperioso que os médicos sejam receptivos e respeitosos às crenças e valores pessoais de seus pacientes e que o árduo exercício da profissão não seja ainda mais custoso caso se adote o perigoso atalho da medicina defensiva

Effects of grid spacing on high-frequency precipitation variance in coupled high-resolution global ocean–atmosphere models

© The Author(s), 2022. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Light, C., Arbic, B., Martin, P., Brodeau, L., Farrar, J., Griffies, S., Kirtman, B., Laurindo, L., Menemenlis, D., Molod, A., Nelson, A., Nyadjro, E., O’Rourke, A., Shriver, J., Siqueira, L., Small, R., & Strobach, E. Effects of grid spacing on high-frequency precipitation variance in coupled high-resolution global ocean–atmosphere models. Climate Dynamics, (2022): 1–27, https://doi.org/10.1007/s00382-022-06257-6.High-frequency precipitation variance is calculated in 12 different free-running (non-data-assimilative) coupled high resolution atmosphere–ocean model simulations, an assimilative coupled atmosphere–ocean weather forecast model, and an assimilative reanalysis. The results are compared with results from satellite estimates of precipitation and rain gauge observations. An analysis of irregular sub-daily fluctuations, which was applied by Covey et al. (Geophys Res Lett 45:12514–12522, 2018. https://doi.org/10.1029/2018GL078926) to satellite products and low-resolution climate models, is applied here to rain gauges and higher-resolution models. In contrast to lower-resolution climate simulations, which Covey et al. (2018) found to be lacking with respect to variance in irregular sub-daily fluctuations, the highest-resolution simulations examined here display an irregular sub-daily fluctuation variance that lies closer to that found in satellite products. Most of the simulations used here cannot be analyzed via the Covey et al. (2018) technique, because they do not output precipitation at sub-daily intervals. Thus the remainder of the paper focuses on frequency power spectral density of precipitation and on cumulative distribution functions over time scales (2–100 days) that are still relatively “high-frequency” in the context of climate modeling. Refined atmospheric or oceanic model grid spacing is generally found to increase high-frequency precipitation variance in simulations, approaching the values derived from observations. Mesoscale-eddy-rich ocean simulations significantly increase precipitation variance only when the atmosphere grid spacing is sufficiently fine (< 0.5°). Despite the improvements noted above, all of the simulations examined here suffer from the “drizzle effect”, in which precipitation is not temporally intermittent to the extent found in observations.Support for CXL’s effort on this project was provided by a Research Experiences for Undergraduates (REU) supplement for National Science Foundation (NSF) grant OCE-1851164 to BKA, which also provided partial support for PEM. In addition, BKA acknowledges NSF grant OCE-1351837, which provided partial support for AKO, Office of Naval Research grant N00014-19-1-2712 and NASA grants NNX17AH55G, which also provided partial support for ADN, and 80NSSC20K1135. JTF’s participation, and the SPURS-II buoy data, were funded by NASA grants 80NSSC18K1494 and NNX15AG20G

Orbital-selective Mott transitions: Heavy fermions and beyond

Quantum phase transitions in metals are often accompanied by violations of Fermi liquid behavior in the quantum critical regime. Particularly fascinating are transitions beyond the Landau-Ginzburg-Wilson concept of a local order parameter. The breakdown of the Kondo effect in heavy-fermion metals constitutes a prime example of such a transition. Here, the strongly correlated f electrons become localized and disappear from the Fermi surface, implying that the transition is equivalent to an orbital-selective Mott transition, as has been discussed for multi-band transition-metal oxides. In this article, available theoretical descriptions for orbital-selective Mott transitions will be reviewed, with an emphasis on conceptual aspects like the distinction between different low-temperature phases and the structure of the global phase diagram. Selected results for quantum critical properties will be listed as well. Finally, a brief overview is given on experiments which have been interpreted in terms of orbital-selective Mott physics.Comment: 29 pages, 4 figs, mini-review prepared for a special issue of JLT

Development of standard clinical endpoints for use in dengue interventional trials: introduction and methodology

Background: As increasing numbers of dengue vaccines and therapeutics are in clinical development, standardized consensus clinical endpoint definitions are urgently needed to assess the efficacy of different interventions with respect to disease severity. We aimed to convene dengue experts representing various sectors and dengue endemic areas to review the literature and propose clinical endpoint definitions for moderate and severe disease based on the framework provided by the WHO 2009 classification. Methods: The endpoints were first proposed and discussed in a structured expert consultation. After that, the Delphi method was carried out to assess the usefulness, validity and feasibility of the standardized clinical disease endpoints for interventional dengue research. Results: Most respondents (&gt; 80%) agreed there is a need for both standardized clinical endpoints and operationalization of severe endpoints. Most respondents (67%) felt there is utility for moderate severity endpoints, but cited challenges in their development. Hospitalization as a moderate endpoint of disease severity or measure of public health impact was deemed to be useful by only 47% of respondents, but 89% felt it could bring about supplemental information if carefully contextualized according to data collection setting. Over half of the respondents favored alignment of the standard endpoints with the WHO guidelines (58%), but cautioned that the endpoints could have ramifications for public health practice. In terms of data granularity of the endpoints, there was a slight preference for a categorical vs numeric system (e.g. 1–10) (47% vs 34%), and 74% of respondents suggested validating the endpoints using large prospective data sets. Conclusion: The structured consensus-building process was successful taking into account the history of the debate around potential endpoints for severe dengue. There is clear support for the development of standardized endpoints for interventional clinical research and the need for subsequent validation with prospective data sets. Challenges include the complexity of developing moderate disease research endpoints for dengue

Convalescent plasma for COVID-19 in hospitalised patients : an open-label, randomised clinical trial

Background: The effects of convalescent plasma (CP) therapy in hospitalised patients with coronavirus disease 2019 (COVID-19) remain uncertain. This study investigates the effect of CP on clinical improvement in these patients. Methods: This is an investigator-initiated, randomised, parallel arm, open-label, superiority clinical trial. Patients were randomly (1:1) assigned to two infusions of CP plus standard of care (SOC) or SOC alone. The primary outcome was the proportion of patients with clinical improvement 28 days after enrolment. Results: A total of 160 (80 in each arm) patients (66.3% critically ill, 33.7% severely ill) completed the trial. The median (interquartile range (IQR)) age was 60.5 (48–68) years; 58.1% were male and the median (IQR) time from symptom onset to randomisation was 10 (8–12) days. Neutralising antibody titres >1:80 were present in 133 (83.1%) patients at baseline. The proportion of patients with clinical improvement on day 28 was 61.3% in the CP+SOC group and 65.0% in the SOC group (difference −3.7%, 95% CI −18.8–11.3%). The results were similar in the severe and critically ill subgroups. There was no significant difference between CP+SOC and SOC groups in pre-specified secondary outcomes, including 28-day mortality, days alive and free of respiratory support and duration of invasive ventilatory support. Inflammatory and other laboratory marker values on days 3, 7 and 14 were similar between groups. Conclusions: CP+SOC did not result in a higher proportion of clinical improvement on day 28 in hospitalised patients with COVID-19 compared to SOC alone

Impact of neuraminidase inhibitors on influenza A(H1N1)pdm09‐related pneumonia: an individual participant data meta‐analysis

BACKGROUND: The impact of neuraminidase inhibitors (NAIs) on influenza‐related pneumonia (IRP) is not established. Our objective was to investigate the association between NAI treatment and IRP incidence and outcomes in patients hospitalised with A(H1N1)pdm09 virus infection. METHODS: A worldwide meta‐analysis of individual participant data from 20 634 hospitalised patients with laboratory‐confirmed A(H1N1)pdm09 (n = 20 021) or clinically diagnosed (n = 613) ‘pandemic influenza’. The primary outcome was radiologically confirmed IRP. Odds ratios (OR) were estimated using generalised linear mixed modelling, adjusting for NAI treatment propensity, antibiotics and corticosteroids. RESULTS: Of 20 634 included participants, 5978 (29·0%) had IRP; conversely, 3349 (16·2%) had confirmed the absence of radiographic pneumonia (the comparator). Early NAI treatment (within 2 days of symptom onset) versus no NAI was not significantly associated with IRP [adj. OR 0·83 (95% CI 0·64–1·06; P = 0·136)]. Among the 5978 patients with IRP, early NAI treatment versus none did not impact on mortality [adj. OR = 0·72 (0·44–1·17; P = 0·180)] or likelihood of requiring ventilatory support [adj. OR = 1·17 (0·71–1·92; P = 0·537)], but early treatment versus later significantly reduced mortality [adj. OR = 0·70 (0·55–0·88; P = 0·003)] and likelihood of requiring ventilatory support [adj. OR = 0·68 (0·54–0·85; P = 0·001)]. CONCLUSIONS: Early NAI treatment of patients hospitalised with A(H1N1)pdm09 virus infection versus no treatment did not reduce the likelihood of IRP. However, in patients who developed IRP, early NAI treatment versus later reduced the likelihood of mortality and needing ventilatory support

Equatorial Atlantic Ocean dynamics in a coupled ocean–atmosphere model simulation

The ocean temperatures and zonal currents at the equatorial Atlantic simulated by an improved version of the Brazilian earth system model (BESM), with changes in the cloud cover scheme and optical properties of the atmospheric component, are analyzed and compared to those obtained from a previous version of BESM and also from other seven selected CMIP5 models. It is shown that this updated version of BESM, despite some persistent biases, more accurately represents the surface temperature variation at the Equator and the equatorial thermocline east–west slope. These improvements are associated to a more realistic seasonal cycle achieved for the Atlantic equatorial undercurrent, as well as sea surface temperatures and zonal wind stress. The better simulation of the equatorial undercurrent is, in its turn, credited to a more realistic representation of the surface wind position and strength at the tropical Atlantic by the coupled model. With many of the systematic errors noticed in the previous version of the model alleviated, this version of BESM can be considered as a useful tool for modelers involved in Atlantic variability studies