Diversitätssensitive Palliative Care

Fallvignette Frau M.S. (65 Jahre alt) stammt aus einem kleinen Dorf in der Nähe von Sivas im Osten der Türkei. Sie ging nur ein paar wenige Jahre zur Schule und verheiratete sich im Alter von 15 Jahren mit ihrem Mann, der im Alter von 30 Jahren in die Schweiz gereist ist und bis zu seiner Pensionierung im Gastgewerbe als Hilfskoch tätig war. Frau M.S. folgte ihrem Mann acht Jahre später in die Schweiz, begleitet von den drei Kindern, die damals 8, 10 und 12 Jahre alt waren. In der Schweiz war Frau M.S. für die Kinder und den Haushalt verantwortlich. Die deutsche Sprache hat sie nie erlernt. Ihre Muttersprache ist kurdisch; die türkische Sprache beherrscht sie teilweise. In ihrem Heimatdorf und auch in der weiteren Umgebung war eine ärztliche Versorgung praktisch inexistent – sie war allerdings nie auf einen Arzt angewiesen. Die drei Kinder sind im kleinen Bauernhaus der Familie zur Welt gekommen. Vor wenigen Monaten musste bei Frau M.S. die Diagnose eines fortgeschrittenen Magenkarzinoms gestellt werden. Die totale Gastrektomie führte nicht zu einer Heilung. Bei nachgewiesenen Lebermetastasen wurde eine Chemotherapie durchgeführt, die sich in den letzten Wochen nicht mehr als effektiv erwies. In einem Gespräch mit Frau M.S. und der übersetzenden Tochter soll sie von ihrer Hausärztin über die Prognose informiert werden. Die Bedürfnisse der Patientin sollen ­erfasst werden; zudem soll sie vorausverfügen, welchen lebenserhaltenden Massnahmen sie zustimmen möchte und welchen nicht. Nach dem Aufklärungsgespräch durch die Hausärztin spricht die Tochter mit ihrer Mutter eingehend in kurdischer Sprache. Auf die Frage, ob Frau M.S. Fragen habe, verneint die Tochter. Die Tochter bittet die Hausärztin, noch einige Worte mit ihr unter vier Augen wechseln zu können. Nachdem Frau M.S. das Sprechzimmer verlassen hat, teilt die Tochter der Hausärztin mit, dass sie ihrer Mutter die schlechte Prognose nicht mitgeteilt habe. Im Gegenteil habe sie ihr gesagt, dass sie ganz bald wieder gesund werde. Die Tochter bittet die Hausärztin, zukünftig nur mit ihr und niemals direkt mit der Mutter zu sprechen. Die Familie habe sich im übrigen Gedanken gemacht, weswegen die Mutter so schwer erkrankt sei. Man sei zum Schluss gekommen, dass Frau M.S. eine schreckliche Tat ihres Bruders sühnen müsse, der vor 20 Jahren im Streit seine Ehegattin getötet habe. Falls sich der Zustand der Mutter verschlechtere, möge die Hausärztin dies der Familie zeitgerecht mitteilen, damit Frau M.S. in ­Begleitung ihrer Familie in die Heimat zurückfliegen könne. Frau M.S. soll in ihrem Dorf sterben können und auch dort beerdigt werden. Ihrer Mutter würde man aber mitteilen, dass die Familie für Ferien in die Türkei fliegen würde. Daher möge man ihr auch keine zu stark sedierenden Schmerzmittel verabreichen

An S-shaped outflow from IRAS 03256+3055 in NGC 1333

The IRAS source 03256+3055 in the NGC 1333 star forming region is associated with extended sub-millimeter emission of complex morphology, showing multiple clumps. One of these is found to coincide with the driving source of a bipolar jet of S-shaped morphology seen in the emission lines of H_alpha and [SII] as well as in the H2 emission lines in the K-band. Detailed images of the driving source at the wavelengths of H_alpha and [SII] and in the I, J, H, and K bands as well as a K-band spectrum and polarimetry are discussed. The near-infrared morphology is characterized by a combination of line emission from the jet and scattered light from a source with a steep continuum spectrum. The morphology and proper motion of the jet are discussed in the context of a binary system with a precessing disk. We conclude that the molecular core associated with IRAS 03256+3055 consists of several clumps, only one of which shows evidence of recent star formation at optical and near-infrared wavelengths.We also briefly discuss a second, newly found near-infrared source associated with a compact sub-millimeter continuum source near IRAS 03256+3055, and conclude that this source may be physically unrelated the cluster of molecular clumps.Comment: 25 pages, including 5 figures. Accepted for publication in The Astronomical Journa

A Disk Shadow Around the Young Star ASR 41 in NGC 1333

We present images of the young stellar object ASR 41 in the NGC 1333 star forming region at the wavelengths of H_alpha and [SII] and in the I, J, H, and K-bands. ASR 41 has the near-infrared morphology of an edge-on disk object, but appears an order of magnitude larger than typical systems of this kind. We also present detailed models of the scattering and radiative transfer in systems consisting of a young star surrounded by a proto-planetary disk, and the whole system being embedded in either an infalling envelope or a uniform molecular cloud. The best fit to the observed morphology can be achieved with a disk of approx. 200 AU diameter, immersed in a low density cloud. The low cloud density is necessary to stay below the sub-mm flux upper limits and to preserve the shadow cast by the disk via single scattering. The results demonstrate that ASR 41 is probably not inherently different from typical edge-on disk objects, and that its large apparent size is due to the shadow of a much smaller disk being projected into the surrounding dusty molecular material

The Variable Reflection Nebula Cepheus A East

We report K'-band imaging observations of the reflection nebula associated with Cepheus A East covering the time interval from 1990 to 2004. Over this time the reflection nebula shows variations of flux distribution, which we interpret as the effect of inhomogeneous and varying extinction in the light path from the illuminating source HW2 to the reflection nebula. The obscuring material is located within typical distances of approximately 10 AU from the illuminating source.Comment: 22 pages, including 6 figures, accepted for publication in The Astronomical Journa

Situations de détresse sociale et proches aidants au cabinet médical

Soziale Notlagen sind in der hausärztlichen Sprechstunde keine Seltenheit. Viele Ärztinnen und Ärzte der Grundversorgung sind mit Themen wie sozialer Isolation, überlasteten Angehörigen, prekärer Wohnsituation, finanziellen Schwierigkeiten, Sprachbarrieren oder herausfordernden Aufenthaltsbewilligungen konfrontiert. Der folgende Beitrag zeigt, dass in diesen Situationen die Zusammenarbeit mit Sozialarbeitenden nicht nur die Behandlungsqualität, sondern auch die Arbeitszufriedenheit der Ärzteschaft erhöhen kann.Les situations de détresse sociale ne sont pas rares dans les consultations de médecine de famille. De nombreux médecins de premier recours sont confrontés à des thèmes tels que l’isolement social, des proches surmenés, des conditions de logement précaires, des difficultés financières, des barrières linguistiques ou des difficultés à obtenir un permis de séjour. Cet article montre que dans de telles situations, la collaboration avec des travailleuses et travailleurs sociaux peut non seulement améliorer la qualité des soins, mais aussi la satisfaction professionnelle des médecins

Protostellar outflows with Smoothed Particle Magnetohydrodynamics (SPMHD)

The protostellar collapse of a molecular cloud core is usually accompanied by outflow phenomena. The latter are thought to be driven by magnetorotational processes from the central parts of the protostellar disc. While several 3D AMR/nested grid studies of outflow phenomena in collapsing magnetically supercritical dense cores have been reported in the literature, so far no such simulation has been performed using the Smoothed Particle Hydrodynamics (SPH) method. This is mainly due to intrinsic numerical difficulties in handling magnetohydrodynamics within SPH, which only recently were partly resolved. In this work, we use an approach where we evolve the magnetic field via the induction equation, augmented with stability correction and divergence cleaning schemes. We consider the collapse of a rotating core of one solar mass, threaded by a weak magnetic field initially parallel to the rotation axis so that the core is magnetically supercritical. We show, that Smoothed Particle Magnetohydrodynamics (SPMHD) is able to handle the magnetorotational processes connected with outflow phenomena, and to produce meaningful results which are in good agreement with findings reported in the literature. Especially, our numerical scheme allows for a quantitative analysis of the evolution of the ratio of the toroidal to the poloidal magnetic field, which we performed in this work.Comment: 5 pages, 4 figures. Accepted to MNRAS Letter

Expression of Trichoderma reesei β-Mannanase in Tobacco Chloroplasts and Its Utilization in Lignocellulosic Woody Biomass Hydrolysis

Lignocellulosic ethanol offers a promising alternative to conventional fossil fuels. One among the major limitations in the lignocellulosic biomass hydrolysis is unavailability of efficient and environmentally biomass degrading technologies. Plant-based production of these enzymes on large scale offers a cost-effective solution. Cellulases, hemicellulases including mannanases and other accessory enzymes are required for conversion of lignocellulosic biomass into fermentable sugars. β-mannanase catalyzes endo-hydrolysis of the mannan backbone, a major constituent of woody biomass. In this study, the man1 gene encoding β-mannanase was isolated from Trichoderma reesei and expressed via the chloroplast genome. PCR and Southern hybridization analysis confirmed site-specific transgene integration into the tobacco chloroplast genomes and homoplasmy. Transplastomic plants were fertile and set viable seeds. Germination of seeds in the selection medium showed inheritance of transgenes into the progeny without any Mendelian segregation. Expression of endo-β-mannanase for the first time in plants facilitated its characterization for use in enhanced lignocellulosic biomass hydrolysis. Gel diffusion assay for endo-β-mannanase showed the zone of clearance confirming functionality of chloroplast-derived mannanase. Endo-β-mannanase expression levels reached up to 25 units per gram of leaf (fresh weight). Chloroplast-derived mannanase had higher temperature stability (40°C to 70°C) and wider pH optima (pH 3.0 to 7.0) than E.coli enzyme extracts. Plant crude extracts showed 6–7 fold higher enzyme activity than E.coli extracts due to the formation of disulfide bonds in chloroplasts, thereby facilitating their direct utilization in enzyme cocktails without any purification. Chloroplast-derived mannanase when added to the enzyme cocktail containing a combination of different plant-derived enzymes yielded 20% more glucose equivalents from pinewood than the cocktail without mannanase. Our results demonstrate that chloroplast-derived mannanase is an important component of enzymatic cocktail for woody biomass hydrolysis and should provide a cost-effective solution for its diverse applications in the biofuel, paper, oil, pharmaceutical, coffee and detergent industries

Advance Care Planning for People with Dementia: The Role of General Practitioners

General practitioners (GPs) play a key role in the timely diagnosis of dementia and also in advance care planning (ACP). They often have known patients and their families for decades and are familiar with their values and treatment preferences; they are, therefore, in a position to initiate the ACP process even before the appearance of the first symptoms of dementia and certainly following disclosure of the diagnosis. To do so, they should recognise whether patients are receptive to an ACP consultation or whether they might reject it for personal, social or cultural reasons. Under no circumstances should the patient or their family be coerced into making these provisions. In most countries, the current framework does not provide enough time and money for GPs to carry out actual ACP consultations completely on their own. There is evidence that specially trained health professionals are able to more effectively discuss treatment goals and limits of life-prolonging measures than GPs who are well acquainted with their patients. Consequently, we suggest that it will be the GPs' task to seize the right moment for starting an ACP process, to raise awareness of patients and their relatives about ACP, to test the patient's decision-making capacity and, finally, to involve appropriately trained healthcare professionals in the actual ACP consultation process. Care should be taken that these professionals delivering time-intensive ACP consultations are not only able to reflect on the patient's values but are also familiar with the course of the disease, the expected complications and the decisions that can be anticipated. The GP will ensure an active exchange with the ACP professional and should have access to the documentation drawn up in the ACP consultation process (treatment plan and advance directive including instructions for medical emergencies) as soon as possible. GPs as coordinators of healthcare provision should document appropriately all specialists involved in the care and ensure that treatment decisions are implemented in accordance with the patient's preferences for future care or the presumed will of the patient