Re-examining ethical obligations in the intensive care unit: HIV disclosure to surrogates

Physicians treating newly incapacitated patients often must help navigate surrogate decision-makers through a difficult course of treatment decisions, while safeguarding the patient's autonomy. We offer guidance for intensive care physicians who must frequently address the difficult questions concerning disclosure of confidential information to surrogates. Three clinical vignettes will highlight the ethical challenges to physician disclosure of a critically ill patient's HIV status. Two key distinctions are offered that influence the propriety of disclosure: first, whether HIV infection represents a 'primary cause' for the patient's critical illness; and second, whether the surrogate may be harmed by failure to disclose HIV status. This balanced consideration of the direct duties of physicians to patients, and their indirect duties to surrogates and third-party contacts, may be used as a framework for considering other ethical obligations in the intensive care unit. We also provide a tabulation of individual US state laws relevant to disclosure of HIV status

Putative role of circulating human papillomavirus DNA in the development of primary squamous cell carcinoma of the middle rectum: A case report

Here we present the case of a patient affected by rectal squamous cell carcinoma in which we demonstrated the presence of Human Papillomavirus (HPV) by a variety of techniques. Collectively, the virus was detected not only in the tumor but also in some regional lymph nodes and in non-neoplastic mucosa of the upper tract of large bowel. By contrast, it was not identifiable in its common sites of entry, namely oral and ano-genital region. We also found HPV DNA in the plasma-derived exosome. Next, by in vitro studies, we confirmed the capability of HPV DNA-positive exosomes, isolated from the supernatant of a HPV DNA positive cell line (CaSki), to transfer its DNA to human colon cancer and normal cell lines. In the stroma nearby the tumor mass we were able to demonstrate the presence of virus DNA in the stromal compartment, supporting its potential to be transferred from epithelial cells to the stromal ones. Thus, this case report favors the notion that human papillomavirus DNA can be vehiculated by exosomes in the blood of neoplastic patients and that it can be transferred, at least in vitro, to normal and neoplastic cells. Furthermore, we showed the presence of viral DNA and RNA in pluripotent stem cells of non-tumor tissue, suggesting that after viral integration (as demonstrated by p16 and RNA in situ hybridization positivity), stem cells might have been activated into cancer stem cells inducing neoplastic transformation of normal tissue through the inactivation of p53, p21, and Rb. It is conceivable that the virus has elicited its oncogenic effect in this specific site and not elsewhere, despite its wide anatomical distribution in the patient, for a local condition of immune suppression, as demonstrated by the increase of T-regulatory (CD4/CD25/FOXP3 positive) and T-exhausted (CD8/PD-1positive) lymphocytes and the M2 polarization (high CD163/CD68 ratio) of macrophages in the neoplastic microenvironment. It is noteworthy that our findings depicted a static picture of a long-lasting dynamic process that might evolve in the development of tumors in other anatomical sites

Gokyo Khumbu/Ama Dablam Trek 2012

In the expedition Gokyo Khumbu/Ama Dablam Trek 2012, we studied the effects of two 12-day training periods performed both at sea level and at high altitude. The main results on adult women have been published in six original articles. In women, high altitude trekking induced CD69 T cell activation and promoted anti-stress effects of the immune responses and the oxidative balance (1). Low-to-moderate exercise training at s.l. improves the regenerative capacity of skeletal muscle and depicted the epigenetic signature of satellite cells. The cell differentiation was favored by increased [Ca2+]i and fusion index (2). On the contrary, the training in hypobaric-hypoxia induced oxidative stress and impaired the regenerative capacity of satellite cells (6). Although training did not significantly modify muscle phenotype , it induced beneficial adaptations of the oxygen transport-utilization systems witnessed by faster VO2 kinetics at exercise onset (3). The two training periods did not influence the postural stability (4). In young adult women, micturition physiological parameters were affected during adaptation to hypoxia; the correlation with SpO2 strongly suggests a role of hypoxia in these changes (5

An analysis of pacing profiles of world-class racewalkers

PURPOSE: The aim of this study was to describe the pacing profiles used by racewalkers competing in IAAF World Championships. METHODS: The times for each 5-km segment were obtained for 225 men competing over 20 km, 214 women competing over 20 km, and 232 men competing over 50 km, of whom 49 did not finish. Athletes were grouped based on finishing position (for medalists) or finishing time. RESULTS: Different pacing profiles were used by athletes grouped by finishing time, with 20-km medalists using negative pacing and those finishing within 5% of the winning time matching the medalists' early pace but failing to maintain it. Lower-placed 20-km athletes tended to start more quickly relative to personal-best pace and experienced significant decreases in pace later. Across all competitions, the fastest finishers started the slowest relative to previous best performance. All 50-km athletes slowed toward the finish, but lower-placed finishers tended to decrease pace earlier (with up to 60% of the race remaining). After halfway in the 50-km, 8 of the 15 athletes who had a 5-km split more than 15% slower than the previous split dropped out. CONCLUSIONS: The negative pacing profile used by 20-km medalists required the ability to start fast and maintain this pace, and similarly paced training may be beneficial in race preparation. Over 50 km, the tactic of starting slower than personal-best pace was generally less risky; nonetheless, any chosen pacing strategy should be based on individual strengths

Buccal alterations in diabetes mellitus

Long standing hyperglycaemia besides damaging the kidneys, eyes, nerves, blood vessels, heart, can also impair the function of the salivary glands leading to a reduction in the salivary flow. When salivary flow decreases, as a consequence of an acute hyperglycaemia, many buccal or oral alterations can occur such as: a) increased concentration of mucin and glucose; b) impaired production and/or action of many antimicrobial factors; c) absence of a metalloprotein called gustin, that contains zinc and is responsible for the constant maturation of taste papillae; d) bad taste; e) oral candidiasis f) increased cells exfoliation after contact, because of poor lubrication; g) increased proliferation of pathogenic microorganisms; h) coated tongue; i) halitosis; and many others may occur as a consequence of chronic hyperglycaemia: a) tongue alterations, generally a burning mouth; b) periodontal disease; c) white spots due to demineralization in the teeth; d) caries; e) delayed healing of wounds; f) greater tendency to infections; g) lichen planus; h) mucosa ulcerations. Buccal alterations found in diabetic patients, although not specific of this disease, have its incidence and progression increased when an inadequate glycaemic control is present

Beetroot supplementation improves the physiological responses to incline walking

The final publication is available at Springer via http://dx.doi.org/10.1007/s00421-018-3843-xPurpose: We investigated the effects of an acute 24-h nitrate-rich beetroot juice supplement (BR) on the energy cost, exercise efficiency and blood pressure responses to intermittent walking at different gradients. Methods: In a double-blind, cross-over design, eight participants were provided with a total of 350 ml of nitrate-rich (~20.5 mmol nitrate) BR or placebo (PLA) across 24-h before completing intermittent walking at 3 km/h on treadmill at gradients of 1%, 5%, 10%, 15% and 20%. Results: Resting mean arterial pressure (MAP) was ~4.1% lower after BR (93 vs. 89 mmHg; P = 0.001), as well as during exercise (102 vs. 99 mmHg; P = 0.011) and recovery (97 vs. 94 mmHg; P = 0.001). Exercising (1227 vs. 1129 ml/min P < 0.001) and end-stage (1404 vs. 1249 ml/min; P = 0.002) oxygen uptake (O2) was lower in BR compared to PLA, which was accompanied by an average reduction in phase II ̇O2 amplitude (1067 vs. 940 ml/min; P = 0.025). Similarly, recovery O2 (509 vs. 458 ml/min; P = 0.001) was lower in BR. Whole-blood potassium concentration increased from pre-post exercise in PLA (4.1 ± 0.3 vs. 4.5 ± 0.3 mmol/L; P = 0.013) but not BR (4.1 ± 0.31 vs. 4.3 ± 0.2 mmol/L; P = 0.188). Conclusions: Energy cost of exercise, recovery of O2, MAP and blood markers were ameliorated after BR. Previously reported mechanisms explain these findings, which are more noticeable during less efficient walking at steep gradients (15-20%). These findings have practical implications for hill-walkers

Serum ferritin in colorectal cancer patients and its prognostic evaluation

The aim of this study was to investigate the relationship between preoperative serum ferritin levels, clinico-pathological parameters and survival analysis of patients with colorectal cancer. Ninety-four patients (57 males) with a mean age of 65 years (39-87 years) underwent 63 curative and 31 palliative operations. Follow-up was at least 5 years. Patients were categorized with normal (30-215 ng/mL in men and 11-148 ng/mL in women), low, or high serum ferritin levels. Prognostic evaluation was undertaken with stratified survival analysis and Cox's regression model. Twenty-nine of the patients (30.9%) had raised ferritin levels and 14 (14.9%) had low values. Comparisons of the survival curves showed significant differences in stage C disease; specifically, patients with either low or high ferritin levels had a shorter survival than patients with normal levels. Patients who underwent palliative surgery and had high ferritin serum values also had a shorter survival. In multivariate analysis, the variables with a negative effect on survival were stage, serum ferritin levels and age. Our data suggest that patients with advanced colorectal cancer having normal preoperative serum ferritin levels may have a better prognosis, although the prognostic value related to this association requires further investigation