Clinical Ethics Case Study 10: For the record: Should our patient’s relatives be able to record her treatment?

A referral to the CEC from the manager of the Accident and Emergency Department F, a 67-year-old woman, was brought in to the Accident and Emergency (A&E) Department by ambulance on a busy Friday night with acute chest pain. Her family (husband and adult daughter) arrived soon afterwards. F was not in good general health: she had diabetes and severe asthma, although these were well managed and F was compliant with ongoing treatment. She was also obese and involved in a weight loss programme through her local health centre. 2 Soon after her arrival in the A&E Department, F went into cardiac arrest and stopped breathing. A resuscitation trolley arrived in good time and a team began to work to try and resuscitate F. At this point, F's adult daughter H entered the treatment area. She retrieved her mobile phone from her bag and began to film the resuscitation attempt. This behaviour alarmed the multidisciplinary team treating F and H was asked to cease recording. The reasons for their request for H to stop were: that the team were becoming distracted and concerned that this intervention could disrupt the care they were providing to F; the effect H's filming may have on other patients and visitors; and how such footage might be interpreted in the future. Nevertheless, H was determined to continue filming. She claimed that: ‘It's our right to film our mother. If she dies, this will help the rest of our family to say goodbye. Plus, if we're worried she hasn't received the best possible treatment, this will help us later on’. H was, however, asked again to stop filming and reluctantly did so. F's resuscitation was successful and she was moved from A&E to the cardiac care ward, where she remains unconscious but slowly improving. Three days later, I (the manager of the A&E Department) received a written complaint from H and F's husband T, saying that they should have been allowed to continue filming the A&E staff resuscitating F. Through some background investigation, H had established that there was no Trust policy on relatives filming patients, or indeed any policy about patients themselves recording consultations and treatment. H claimed that: ‘several of my friends record their medical consultations to help them remember everything, and what we wanted to do is no different from that’. She also stated that ‘this is no different to family members taking photos of their loved ones to remember them by’. On behalf of the A&E Department, I am therefore approaching the CEC for assistance before responding to H's complaint. We are worried that while some people may seek to record or film consultations as an aide memoire in times of stress or for personal reassurance, others may do so for more litigious or unusual purposes (such as making the material available on the Internet). We are also concerned about how such material may be interpreted by an inexpert audience. Further, we worry about patient consent to this filming and the disruptive nature of the practice. On contacting the Trust's communications department, we have established that there seems to be a gap in hospital policy regarding this kind of recording activity, as the only relevant policy is one relating to requests from the press to film on site – with requests for filming or photographs needing to be approved by the Trust's director of communications. The communications department has received requests for clarification as to whether this policy would cover the use of phones or other hand-held devices for recording. From speaking to colleagues in other departments I have also heard anecdotal reports that such attempts at recording are on the increase – from both relatives and patients themselves. Some patients have also apparently attempted to take photographs of other patients with whom they have shared a ward, with claims that this has taken place with verbal consent. We are approaching the ethics committee with the following questions in mind: 1. Should H have been allowed to continue filming? 2. Is H's claim that filming resuscitation is akin to recording other more routine consultations defensible? 3 3. If a patient is unconscious, should a family member be able to record them, or should recording only be possible if a patient consents in advance? What should happen if a patient specifically requested such filming? Or, should recording not be permitted at all? (This is also interesting in relation to giving birth.) 4. Is Trust policy on this issue, to cover and protect both patients and staff, needed? If so, how might such a policy be structured? How could it be implemented in the hospital?This article was written by Dr Ainsley Newson during the time of her employment with the University of Bristol, UK (2006-2012). Self-archived in the Sydney eScholarship Repository with permission of Bristol University, Sept 2014

In vitro evaluation of defined oligosaccharide fractions in an equine model of inflammation

Background: Dietary supplementation with oligosaccharides has been proven to be beneficial for health in several mammalian species. Next to prebiotic effects resulting in a modulation of gut micro biota, immunomodulatory effects of oligosaccharides have been documented in vivo. Supplementation with defined oligosaccharide fractions has been shown to attenuate allergic responses and enhance defensive immune responses. Despite the accumulating evidence for immunomodulatory effects, very limited information is available regarding the direct mechanism of action of oligosaccharides. This study aims to elucidate the effects of selected oligosaccharide fractions on the lipopolysaccharide (LPS) induced inflammatory response in equine peripheral blood mononuclear cells (PBMCs). We investigated three different products containing either galacto-oligosaccharides (GOS) alone, a combination of GOS with fructo-oligosaccharides (FOS), and a triple combination of GOS and FOS with acidic oligosaccharides (AOS), at different concentrations. These products have been used in an identical composition in various previously published in vivo experiments. As the selected oligosaccharide fractions were derived from natural products, the fractions contained defined amounts of mono- and disaccharides and minor amounts of endotoxin, which was taken into account in the design of the study and the analysis of data. Acquired data were analysed in a Bayesian hierarchical linear regression model, accounting for variation between horses.Results: Exposing cultured PBMCs to either GOS or GOS/FOS fractions resulted in a substantial dose-dependent increase of tumour necrosis factor-α (TNF-α) production in LPS challenged PBMCs. In contrast, incubation with GOS/FOS/AOS resulted in a dose-dependent reduction of both TNF-α and interleukin-10 production following LPS challenge. In addition, incubation with GOS/FOS/AOS significantly increased the apparent PBMC viability, indicating a protective or mitogenic effect. Furthermore, mono- and disaccharide control fractions significantly stimulated the inflammatory response in LPS challenged PBMCs as well, though to a lesser extent than GOS and GOS/FOS fractions.Conclusions: We found distinct immunomodulating effects of the investigated standardised oligosaccharide fractions, which either stimulated or suppressed the LPS induced inflammatory response in PBMCs. Both scenarios require additional investigation, to elucidate underlying modulatory mechanisms, and to translate this knowledge into the clinical application of oligosaccharide supplements in foals and other neonates

Титульні сторінки та зміст

Colostrum oligosaccharides are known to exhibit prebiotic and immunomodulatory properties. Oligosaccharide composition is species-specific, and equine colostrum has been reported to contain unique oligosaccharides. Therefore, equine oligosaccharides (EMOS) from colostrum from different horse breeds were analyzed by CE-LIF, CE-MSn, HILIC-MSn, and exoglycosidase degradation. Sixteen EMOS were characterized and quantified, of which half were neutral and half were acidic. EMOS showed about 63% structural overlap with human milk oligosaccharides, known for their bioactivity. Seven EMOS were not reported before in equine oligosaccharides literature: neutral Gal(beta 1-4)HexNAc, Gal(beta 1-4)Hex-Hex, beta 4'-galactosyllactose, and lactose-N- hexaose, as well as acidic 6'-Sialyl-Hex-Ac-HexNAc, sialyllacto-N-tetraose-a, and disialylacto-N-tetraose (isomer not further specified). In all colostrum samples, the average oligosaccharide concentration ranged from 2.12 to 4.63 g/L; with beta 6'and 3'- galactosyllactose, 3'-sialyllactose, and disialyllactose as the most abundant of all oligosaccharides (27-59, 16-37, 1-8, and 1-6%, respectively). Differences in presence and in abundance of specific EMOS were evident not only between the four breeds but also within the breed

Protein Tyrosine Phosphatase-Induced Hyperactivity Is a Conserved Strategy of a Subset of BaculoViruses to Manipulate Lepidopteran Host Behavior

This is the final version. Available from PLoS via the DOI in this record.Many parasites manipulate host behavior to increase the probability of transmission. To date, direct evidence for parasitic genes underlying such behavioral manipulations is scarce. Here we show that the baculovirus Autographa californica nuclear polyhedrovirus (AcMNPV) induces hyperactive behavior in Spodoptera exigua larvae at three days after infection. Furthermore, we identify the viral protein tyrosine phosphatase (ptp) gene as a key player in the induction of hyperactivity in larvae, and show that mutating the catalytic site of the encoded phosphatase enzyme prevents this induced behavior. Phylogenetic inference points at a lepidopteran origin of the ptp gene and shows that this gene is well-conserved in a group of related baculoviruses. Our study suggests that ptp-induced behavioral manipulation is an evolutionarily conserved strategy of this group of baculoviruses to enhance virus transmission, and represents an example of the extended phenotype concept. Overall, these data provide a firm base for a deeper understanding of the mechanisms behind baculovirus-induced insect behavior. © 2012 van Houte et al.Program Strategic Alliances of the Royal Dutch Academy of SciencesMEERVOUD grant from the Netherlands Organization for Scientific ResearchC.T. de Wit Graduate School for Production Ecology and Resource Conservatio

Total synthesis of homo- and heterodimeric bispyrrolidinoindoline dioxopiperazine natural products

Total synthesis and structural confirmation of homo- and heterodimeric bispyrrolidinoindoline dioxopiperazine alkaloids isolated from fungi and bacteria, namely, ditryptoleucine A, ditryptoleucine B (11), the N,N′-bis-demethylated analogue (+)-12, (−)-dibrevianamide F (13), (−)-SF-5280-451 (14), tetratryptomycin A (15), (−)-tryprophenaline (17), and (−)-SF-5280-415 (18), has been carried out starting from the corresponding bispyrrolidinoindolines derived from tryptophan. Our efforts to synthesize all possible diastereomers of the natural ditryptoleucine isolates uncovered structural factors that determine the rate and efficiency of dioxopiperazine ring formation, leading in some cases to mixtures of diastereomers by concomitant epimerization, to the formation of their putative monomeric dioxopiperazine dipeptide biogenetic precursors, and to the alternative formation of a dimer with a fused 1,3,5-triazepan-6-one heterocycle.Financiado para publicación en acceso aberto: Universidade de Vigo/CISUGMinisterio de Economía y Competitividad | Ref. SAF2016-77620-RXunta de Galicia | Ref. ED-431G/02 INBIOMED-FEDERXunta de Galicia | Ref. ED431C 2017/6

Functional interaction between the epidermal growth factor receptor and c-Src kinase activity

AbstractTo study the relationship between the tyrosine kinase c-Src and the epidermal growth factor receptor (EGF-R), we used the breast cancer cell line ZR75-1, which was transfected with the EGF-R. The EGF-R transfected cell line expressed 60 times more EGF-R than a control cell line transfected with the empty vector. In the presence of EGF, the EGF-R over-expressing cell line grew much faster than the control cell line. Both cell lines expressed approximately equal amounts of c-Src. However, the cell line over-expressing the EGF-R showed a twofold enhancement of c-Src kinase activity after EGF stimulation. The activation of c-Src kinase by EGF was confirmed in other EGF-R expressing cell types

Health effects of holistic housing renovation in a disadvantaged neighbourhood in the Netherlands:a qualitative exploration among residents and professionals

Background: Holistic housing renovations combine physical housing improvements with social and socioeconomic interventions (e.g. referral to social services, debt counselling, involvement in decision-making, promoting social cohesion). In a deprived neighbourhood in Utrecht, the Netherlands, this paper examined residents’ and professionals’ experiences, ideas, and perceptions regarding holistic housing renovation, its health effects, and underlying mechanisms explaining those effects. Methods: Semi-structured in-depth interviews were conducted with 21 social housing residents exposed to holistic housing renovation, and 12 professionals involved in either the physical renovation or social interventions implemented. Residents were interviewed in various renovation stages (before, during, after renovation). Transcripts were deductively and inductively coded using qualitative software. Results: Residents experienced and professionals acknowledged renovation stress caused by nuisance from construction work (noise, dust), having to move stuff around, and temporary moving; lack of information and control; and perceived violation of privacy. Involvement in design choices was appreciated, and mental health improvement was expected on the long term due to improved housing quality and visual amenity benefits. Social contact between residents increased as the renovation became topic for small talk. Few comments were made regarding physical health effects. The interviews revealed a certain amount of distrust in and dissatisfaction with the housing corporation, construction company, and other authorities. Conclusions: Renovation stress, aggravated by lack of information and poor accessibility of housing corporation and construction company, negatively affects mental health and sense of control. Potential stress relievers are practical help with packing and moving furniture, and increased predictability by good and targeted communication. Social interventions can best be offered after renovation, when residents live in their renovated apartment and the nuisance and stress from the renovation is behind them. Social partners can use the period leading up to the renovation to show their faces, offer practical help to reduce renovation stress, and increase residents’ trust in their organization and authorities in general. This might also contribute to residents’ willingness to accept help with problems in the social domain after renovation.</p