Ethical questions arising from Otfrid Foerster's use of the Sherrington method to map human dermatomes.

Otfrid Foerster (1873-1941) is well known for his maps of human dermatomes. We have examined the history of the development of his protocols for mapping dermatomes by analyzing his lectures and publications from 1908 to 1939, focusing on his Schorstein Memorial Lecture in 1932 and his use of the isolation (Sherrington) method, in which a single dorsal root is spared in a sequence of resections (dorsal rhizotomies). Because of the absence of medical records for Foerster's patients, we also review eyewitness accounts of his operating technique, his occasional comments on patients, and the issue of consent. There appears to be no medical justification-at that time or currently-for Foerster's use of the Sherrington method to map dermatomes L1, L5, S1, and S2, and in our view, these results were obtained unethically. Hence, clinicians and researchers who use his maps should acknowledge those whom Foerster exploited in order to produce them.

Dementia, decision aids and general practice.

BACKGROUND: As our population ages, the prevalence of dementia is rising. Given the complex care needs that accompany dementia, general practitioners (GPs) will be increasingly called upon to address a range of challenging clinical issues. OBJECTIVE: This article offers an introduction to the use of decision aids by GPs when caring for patients with dementia (or their carers). In addition, obstacles that can arise during the development of dementia-related decision aids are explored. DISCUSSION: A person-centred approach to people with dementia is a worthy goal. Decision aids are evidence-based tools that help patients (and carers) participate in choosing among healthcare options. Several existing high-quality, dementia-related decision aids are of relevance to the primary care setting. However, there is a need for additional research to develop decision aids which address a broader range of issues pertinent to dementia.

Barriers to qualitative dementia research: the elephant in the room.

As our population is aging, the global prevalence of dementia is rising. Recent extensive reviews of the dementia literature highlight a clear need for additional qualitative research to address the experiences of people with dementia and their carers. To date, the vast majority of published dementia research is quantitative in nature and, perhaps not surprisingly, attracts the bulk of government funding. In contrast, qualitative dementia research is poorly resourced and less frequently published. Although a myriad of factors are responsible for this dichotomy, we propose that inadequate funding represents the "elephant in the room" of dementia research. In this article, we describe and emphasize the need for qualitative dementia research, highlight existing barriers, and outline potential solutions. Examples of barriers are provided and theoretical underpinnings are proposed.

Development and pilot testing of a decision aid for drivers with dementia.

BACKGROUND: An increasing number of older adults drive automobiles. Given that the prevalence of dementia is rising, it is necessary to address the issue of driving retirement. The purpose of this study is to evaluate how a self-administered decision aid contributed to decision making about driving retirement by individuals living with dementia. The primary outcome measure in this study was decisional conflict. Knowledge, decision, satisfaction with decision, booklet use and booklet acceptability were the secondary outcome measures. METHODS: A mixed methods approach was adopted. Drivers with dementia were recruited from an Aged Care clinic and a Primary Care center in NSW, Australia. Telephone surveys were conducted before and after participants read the decision aid. RESULTS: Twelve participants were recruited (mean age 75, SD 6.7). The primary outcome measure, decisional conflict, improved following use of the decision aid. Most participants felt that the decision aid: (i) was balanced; (ii) presented information well; and (iii) helped them decide about driving. In addition, mean knowledge scores improved after booklet use. CONCLUSIONS: This decision aid shows promise as an acceptable, useful and low-cost tool for drivers with dementia. A self-administered decision aid can be used to assist individuals with dementia decide about driving retirement. A randomized controlled trial is underway to evaluate the effectiveness of the tool.

Electronic discharge summary driving advice: Current practice and future directions.

BACKGROUND: Driving is a complex task. Many older drivers are unaware of their obligation to inform authorities of conditions which may impact upon their driving safety. AIMS: This study sought to establish the adequacy of driving advice in electronic discharge summaries from an Australian stroke unit. METHOD: One month of in-patient electronic discharge summaries were reviewed. A predetermined list of items was used to assess each electronic discharge summary: age; gender; diagnosis; relevant co-morbidities; deficit at time of discharge; driving advice; length of stay; and discharge destination. RESULTS: Of 41 participants, the mean age was 72 years. Twenty patients had a discharge diagnosis of stroke, nine of transient ischaemic attack, four of seizure and one of encephalitis. Of these, only eight discharge summaries included driving advice. CONCLUSION: The documentation of driving advice in electronic discharge summaries is poor. This has important public health, ethical and medico-legal implications. Avenues for future research are explored.

Dementia and driving - an approach for general practice.

BACKGROUND: As our population ages, the proportion of drivers with dementia will continue to rise. Increasingly, health professionals are faced with the clinical dilemma of determining fitness to drive. Unfortunately, the management of drivers with dementia is fraught with hazards. OBJECTIVE: This article attempts to provide an overview of the complex issue of driving and dementia as it relates to general practitioners in Australia. In addition, an evidence based management strategy is proposed. DISCUSSION: When determining an individual's fitness to drive, a clinician's input may have legal, ethical, emotional and social ramifications. At present, a clear consistent national protocol detailing how one should establish fitness to drive is lacking. There is a need for research addressing how to facilitate early retirement from driving without jeopardising patient-doctor relationships.

Orbital sporadic Burkitt lymphoma in an adult diabetic African American female and a review of adult orbital cases.

A case of sporadic Burkitt lymphoma (sBL) presenting with jaw and lid involvement in a diabetic adult African American female and a review of adult orbital Burkitt lymphoma cases are presented. Lid edema, visual loss, ophthalmoparesis, proptosis, and sinusitis progressed over 4 weeks despite antibiotic and steroid treatment. Upper lid biopsy histopathological evaluation and immunophenotyping revealed a homogenous mass of atypical CD10 and CD20-negative B-cells and tingible body macrophages yielding a "starry sky" appearance. Cytogenetic analysis detected a minor variant c-MYC translocation, but no Epstein-Barr virus RNA. Detection of multiple lesions prompted a diagnosis of stage IV disease that totally regressed following radiation and chemotherapy. Review results of the six adult orbital sBL cases support a poor prognosis and a heightened suspicion of variant CD10, CD20 and BCL6 positive sBL in adults presenting with jaw pain and rapidly progressive orbital symptoms, particularly in female, African American, and diabetic patients.

Stress analgesia: the opioid analgesia of long swims suppresses the non-opioid analgesia induced by short swims in mice.

In mice, room temperature swimming for as short a period as 15 sec has been found to induce a non-opioid analgesia with a time course of 10-12 min. As the duration of the swim is increased, an opioid analgesia develops with a longer persistence (25-30 min); the development of the opioid analgesia appears to suppress the expression of the non-opioid analgesia so that none of the latter is evident after 3 min swims. The characteristics of the tail-flick nociceptive test are also described.

Paradoxical Modulation of Nociception in Mice by Barbiturate Agonism and Antagonism: Is a GABA Site Involved in Nociception?

In a battery of four acute and chronic nociceptive tests, the GABA antagonist picrotoxin produces a uniform and sustained analgesia in mice. By contrast, barbiturates which have been presumed to act at the same receptor produce mixed and paradoxical actions. At a standard time of 10 min after drug administration a convulsant barbiturate [5-ethyl-5-(3'-methyl-but-2'-enyl)-barbituric acid] produced analgesia in three tests but had no effect in the fourth; a pure hypnotic barbiturate (amylobarbitone) produced hyperalgesia in three tests but analgesia in the fourth; while the mixed hypnotic-convulsant pentobarbitone produced hyperalgesia in two of the tests and was without any effect in the other two. There was no pattern in these results with respect to acute or chronic nociceptive tests. Surprisingly, with extended observation using the tail-flick test both pentobarbitone and the pure hypnotic (amylobarbitone) gave early hyperalgesia followed by analgesia; the convulsant barbiturate gave only analgesia. The results suggest a role for GABAA receptors in the transmission of nociceptive information; they also suggest that barbiturates act at quite a different receptor.