The Care Dialog: the "ethics of care" approach and its importance for clinical ethics consultation.

Ethics consultation in institutions of the healthcare system has been given a standard form based on three pillars: education, the development of guidelines and concrete ethics consultation in case conferences. The spread of ethics committees, which perform these tasks on an organizational level, is a remarkable historic achievement. At the same time it cannot be denied that modern ethics consultation neglects relevant aspects of care ethics approaches. In our essay we present an "ethics of care" approach as well as an empirical pilot project-"Ethics from the bottom up"-which organizes ethics consultation based on this focus. Findings and philosophy of the project will be discussed as far as relevant for ethics consultation in the healthcare system.

[Dying and death in societal transformation]. / Sterben und Tod im gesellschaftlichen Wandel.

Dying and death in modern societies are subject to profound social, professional and cultural-religious changes. Secularization and a stronger differentiation of societies have led to a change in the way humans handle the dying process. Normatively ritualized collective behaviour has been replaced by an individual, subjectivized approach. In late modern societies there are many different views of what "successful" or "good" dying means.In the article this change is described by the following seven theses: 1. We live longer and we die longer. 2. We no longer die suddenly and unexpectedly but slowly and foreseeably. 3. Even though our biological life on earth has become longer, our life has been shortened by the loss of eternity. 4. We no longer die on the stage of ritualized relationships with our family and neighbours but behind the curtains of organizations. 5. We live and die in a society of organizations and have to get organized for the final phase of our life. 6. Living and dying are no large, state-owned enterprises but small, private enterprises. 7. The hospice movement as well as palliative medicine have created public awareness, made dying a matter of discussion and offered a new set of options.In late modernism end-of-life care requires new approaches based on individual and shared responsibility as well as cooperation between professional institutions and community-based voluntary care.A change towards community care is visible. Thus "dying" is a topic in the discussion about the future of public health and societal solidarity.

A European multicenter study on systematic ethics work in nursing homes.

BACKGROUND: There are many existing ethical challenges in nursing homes. Although different methods and approaches to discussing the ethical challenges have been established, systematic ethics work is not yet a standard in all nursing homes. The aim of the present study was to explore ethical challenges and approaches to implementing systematic ethics work in nursing homes. METHODS: Data from five institutions in Austria, Germany and Norway were collected, and a mixed-methods two-tiered study approach was chosen. Documentation of ethics discussions was combined with qualitative focus group interviews with staff members regarding the implementation of systematic ethics work in nursing homes. RESULTS: One hundred and five ethics meetings were documented. The main topics were advance care planning, ethical challenges associated with artificial nutrition, hospitalisation and end-of-life decision-making. Of the meetings, 33% focused mainly on everyday ethical challenges. In 76% of prospective case discussions, agreements about a solution were reached; however, in 29% of these no residents or relatives participated. The advantages of systematic ethics work described by the staff were enhanced openness and dialogue, overall, and a greater ethical awareness. Many voiced a need for structure and support from the administration. CONCLUSIONS: Systematic ethics work is greatly appreciated by the staff and helps to reach a consensus in the majority of case discussions. It should be implemented in all nursing homes. Attention to everyday ethical challenges is important. The participation of relatives and physicians could be improved. The participation of the residents' in ethics discussions should be encouraged to strengthen their autonomy and dignity.

Diffusivities of Ternary Mixtures of n-Alkanes with Dissolved Gases by Dynamic Light Scattering.

Theoretical approaches suggest that dynamic light scattering (DLS) signals from low-molecular-weight ternary mixtures are governed by fluctuations in temperature as well as two individual contributions from fluctuations in concentration that are related to the eigenvalues of the Fick diffusion matrix. Until now, this could not be proven experimentally in a conclusive way. In the present study, a detailed analysis of DLS signals in ternary mixtures consisting of n-dodecane (n-C12H26) and n-octacosane (n-C28H58) with dissolved hydrogen (H2), carbon monoxide (CO), or water (H2O) as well as of n-C12H26 or n-C28H58 with dissolved H2 and CO is given for temperatures up to 523 K and pressures up to 4.1 MPa. Thermal diffusivities of pure n-C12H26 and n-C28H58 as well as thermal and mutual diffusivities of their binary mixtures being the basis for the ternary mixtures with dissolved gas were studied for comparison purposes. For the investigated ternary mixtures, three individual signals could be distinguished in the time-resolved analysis of scattered light intensity by using photon correlation spectroscopy (PCS). For the first time, it could be evidenced that these signals are clearly associated with hydrodynamic modes. In most cases, the fastest mode observable for ternary mixtures is associated with the thermal diffusivity. The two further modes obviously related to the molecular mass transport are observable on different time scales and comparable to the modes associated with the concentration fluctuations in the respective binary mixtures. Comparison of the experimental data with results from molecular dynamics simulations revealed very good agreement.

Mutual and Self-Diffusivities in Binary Mixtures of [EMIM][B(CN)4] with Dissolved Gases by Using Dynamic Light Scattering and Molecular Dynamics Simulations.

Ionic liquids (ILs) are possible working fluids for the separation of carbon dioxide (CO2) from flue gases. For evaluating their performance in such processes, reliable mutual-diffusivity data are required for mixtures of ILs with relevant flue gas components. In the present study, dynamic light scattering (DLS) and molecular dynamics (MD) simulations were used for the investigation of the molecular diffusion in binary mixtures of the IL 1-ethyl-3-methylimidazolium tetracyanoborate ([EMIM][B(CN)4]) with the dissolved gases carbon dioxide, nitrogen, carbon monoxide, hydrogen, methane, oxygen, and hydrogen sulfide at temperatures from 298.15 to 363.15 K and pressures up to 63 bar. At conditions approaching infinite dilution of a gas, the Fick mutual diffusivity of the mixture measured by DLS and the self-diffusivity of the corresponding gas calculated by MD simulations match, which could be generally found within combined uncertainties. The obtained diffusivities are in agreement with literature data for the same or comparable systems as well as with the general trend of increasing diffusivities for decreasing IL viscosities. The DLS and MD results reveal distinctly larger molecular diffusivities for [EMIM][B(CN)4]-hydrogen mixtures compared to mixtures with all other gases. This behavior results in the failure of an empirical correlation with the molar volumes of the gases at their normal boiling points. The DLS experiments also showed that there is no noticeable influence of the dissolved gas and temperature on the thermal diffusivity of the studied systems.

OA52†"ethics from the bottom up": promoting networks and participation through shared stories of care.

BACKGROUND: The "basic action" in creating compassionate communities is to create settings where people effectively have the opportunity to develop concerns and compassion for each other. The project "ethics from the bottom up" (in Bad Bentheim, Lower Saxony, Germany) brings together the relatives of old and dying people, professionals from healthcare organisations and people from other living and working contexts in order to share their sorrows and care experiences. AIM: Current methods and concepts of applied and organised ethical deliberation (or ethics "consultation") are not qualified and able to fulfil the requirements of ethical questions in the field of health promotion and health promoting palliative care. The predominant model of ethical deliberation in healthcare settings, the clinical ethics consultation, is designed for the specific orientation needs of curative medicine. The analogous step from medicine to health promotion, from professional palliative care to compassionate communities has not been carried out in ethics. By promoting a compassionate community through shared narratives of care and concern, a paradigmatic shift from clinical ethics to "communal" ethics is put into action. METHOD: Participatory action research design. Ethical approach based on narrative and care ethics. RESULTS: We observe a new and simple way to bring relatives into communication with each other and with professional and (specialised) health services and to discuss the fundamental questions of human life. This is one way of initiating the democratisation of care, of finding support in the challenges of weakness and dying. CONCLUSION: In contrast to a narrowing tendency in modern ethics/ethics consultation (focus on moral dilemmas and treatment decisions) the objective of ethical deliberation is not just a singular decision but the sustainable cultivation of collective practical wisdom in a web of meaningful relationships.

Ethical challenges in nursing homes--staff's opinions and experiences with systematic ethics meetings with participation of residents' relatives.

BACKGROUND: Many ethical problems exist in nursing homes. These include, for example, decision-making in end-of-life care, use of restraints and a lack of resources. AIMS: The aim of the present study was to investigate nursing home staffs' opinions and experiences with ethical challenges and to find out which types of ethical challenges and dilemmas occur and are being discussed in nursing homes. METHODS: The study used a two-tiered approach, using a questionnaire on ethical challenges and systematic ethics work, given to all employees of a Norwegian nursing home including nonmedical personnel, and a registration of systematic ethics discussions from an Austrian model of good clinical practice. RESULTS: Ninety-one per cent of the nursing home staff described ethical problems as a burden. Ninety per cent experienced ethical problems in their daily work. The top three ethical challenges reported by the nursing home staff were as follows: lack of resources (79%), end-of-life issues (39%) and coercion (33%). To improve systematic ethics work, most employees suggested ethics education (86%) and time for ethics discussion (82%). Of 33 documented ethics meetings from Austria during a 1-year period, 29 were prospective resident ethics meetings where decisions for a resident had to be made. Agreement about a solution was reached in all 29 cases, and this consensus was put into practice in all cases. Residents did not participate in the meetings, while relatives participated in a majority of case discussions. In many cases, the main topic was end-of-life care and life-prolonging treatment. CONCLUSIONS: Lack of resources, end-of-life issues and coercion were ethical challenges most often reported by nursing home staff. The staff would appreciate systematic ethics work to aid decision-making. Resident ethics meetings can help to reach consensus in decision-making for nursing home patients. In the future, residents' participation should be encouraged whenever possible.

Mutual and thermal diffusivity of binary mixtures of the ionic liquids [BMIM][C(CN)3] and [BMIM][B(CN)4] with dissolved CO2 by dynamic light scattering.

Ionic liquids (ILs) are promising solvents for gas separation processes such as carbon dioxide (CO2) capture from flue gases. For the design of corresponding processes and apparatus, thermophysical properties of ILs containing dissolved gases are required. In the present study, it is demonstrated that with a single optical setup, mutual and thermal diffusivities as well as refractive indices can be measured quasi-simultaneously for such mixtures. Dynamic light scattering (DLS) from bulk fluids was applied to determine mutual and thermal diffusivities for mixtures of 1-butyl-3-methylimidazolium tricyanomethanide ([BMIM][C(CN)3]) or 1-butyl-3-methylimidazolium tetracyanoborate ([BMIM][B(CN)4]) with dissolved CO2 at temperatures from 303.15 to 333.15 K and pressures between 2 and 26 bar in macroscopic thermodynamic equilibrium. Good agreement with literature data and only slight differences between the diffusivities measured for the two systems at the same temperature and comparable mole fractions of CO2 were found. Increasing mutual diffusivities with increasing mole fractions of CO2 are consistent with decreasing viscosities reported for other IL-CO2 mixtures in the literature and can be attributed to weakening of molecular interactions by the dissolved gas. For the conditions studied, no dependence of the thermal diffusivity on the temperature or the mole fraction of CO2 could be found.

Simultaneous determination of thermal and mutual diffusivity of binary mixtures of n-octacosane with carbon monoxide, hydrogen, and water by dynamic light scattering.

It is demonstrated that thermal and mutual diffusivities of binary mixtures of n-octacosane (n-C28H58) with carbon monoxide (CO), hydrogen (H2), and water (H2O) are simultaneously accessible by dynamic light scattering (DLS). As the light-scattering signals originating from thermal and concentration fluctuations appear in similar time scales, different data evaluation strategies were tested to achieve minimum uncertainties in the resulting transport properties. To test the agreement of the respective theoretical model with the DLS signals in the regression, an improved multifit procedure is introduced. With the selected data evaluation strategy, uncertainties of 4 to 15% and 4 to 30% in the thermal and mutual diffusivities, respectively, could be obtained for the binary mixtures. The mutual diffusivities for the mixtures measured at temperatures ranging from 398 to 523 K and pressures of 5 to 30 bar at saturation conditions are in good agreement with molecular dynamics simulations and data from the literature.

Chronic kidney disease is associated with high abdominal incisional hernia rates and wound healing disturbances.

BACKGROUND AND OBJECTIVES: Incisional hernias are among the most frequent complications following abdominal surgery with impact on morbidity and mortality rates. Elevated uremia toxins may inhibit granulation tissue formation and impair wound healing, thereby promoting incisional hernia development. Here, we quantified the hazard ratio for incisional hernia prevalence in patients at risk undergoing abdominal reoperations with interrelationship to kidney function. In the same cohort, incidence rates for de novo wound healing disturbances within a4-month follow-up period were determined. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: Upon hospitalization for elective abdominal surgery in a university hospital (tertiary medical center), past medical histories were recorded in 251 patients and incisional hernia prevalence rates were calculated. Known modifiers for hernia formation as well as laboratory values for estimated glomerular filtration rate (eGFR) were recorded. The status of wound healing was assessed by a blinded investigator 4 months postoperatively. Chronic kidney disease(CKD) was defined as eGFR <60 ml/min/1.73 m2. To identify independent risk factors for incisional hernia or postoperative wound healing disorder, multivariate regression analyses were performed. RESULTS: The incisional hernia prevalence was 24.3 % in the overall cohort. Patients with CKD (32/251; 12.8 %)were more likely to suffer from incisional hernias with an odds ratio (OR) of 2.8 ([95 % CI 1.2-6.1]; p = 0.014) than patients with eGFR >60 ml/min (219/251; 88.2 %). In multivariate analyses, CKD proved to be an independent risk factor for incisional hernia development with an OR similar to obesity (BMI>25; OR 2.6 [95 % CI 1.3-5.1];p = 0.007). In the prospective analysis, disturbed wound healing occurred in 32 of 251 (12.8 %) patients undergoing abdominal operations. Frequency of wound healing was increased when CKD was present (8/32; 25 %; OR 2.3[95 % CI 1.1­6.7]; p = 0.026) compared to patients with eGFR>60 ml/min (24/219; 11 %). CONCLUSIONS: Chronic kidney disease is associated with impaired wound healing and constitutes an independent risk factor for incisional hernia development.

Catechol-O-methyltransferase polymorphism influences outcome after ischemic stroke: a prospective double-blind study.

BACKGROUND: To explore whether a polymorphism in dopamine metabolism influences the effectiveness of neurological rehabilitation and the outcome after ischemic stroke. METHODS: The Barthel Index (BI) and the Rivermead Motor Assessment (RMA) were assessed in 78 moderately affected stroke patients (1) after they had entered a neurological inpatient rehabilitation, (2) after 4 weeks of rehabilitation therapy, and (3) 6 months later. Polymorphisms of the gene encoding catechol-O-methyltransferase (COMT) were determined. BI and RMA results were analyzed with respect to the genetic profiles of COMT. RESULTS: Carriers of COMT Val/Val alleles showed better results in BI and RMA than COMT Met/Met carriers at all 3 time points. Val/Met carriers exhibited results in between the homozygotes, suggesting a gene-dose relationship. Altogether, BI and RMA results were highly correlated. CONCLUSION: Stroke patients with COMT Val/Val alleles had higher motor functions and abilities of activities of daily living even at the beginning of the rehabilitation period. All patient groups improved during the rehabilitation period to a similar degree, suggesting that physical therapy is comparably effective in all polymorphism subtypes.

Binary diffusion coefficients for mixtures of ionic liquids [EMIM][N(CN)2], [EMIM][NTf2], and [HMIM][NTf2] with acetone and ethanol by dynamic light scattering (DLS).

Mutual diffusivities for binary mixtures of the ionic liquids (ILs) [EMIM][N(CN)2] (1-ethyl-3-methylimidazolium dicyanimide), [EMIM][NTf2] (1-ethyl-3-methylimidazolium bis(trifluoromethylsulfonyl)imide), and [HMIM][NTf2] (1-hexyl-3-methylimidazolium bis(trifluoromethylsulfonyl)imide) with acetone and ethanol were studied in dependence on composition in the temperature range from 283.15 to 323.15 K, applying dynamic light scattering (DLS). The influence of experimental parameters on the achievable uncertainties was analyzed to ensure the acquisition of accurate data in adequate measurement times. For all probed systems, increasing binary diffusion coefficients were found for increasing temperatures. The systematic variation of anion and cation of the investigated ILs as well as a comparison with the literature data demonstrates the considerable influence of different ions on the resulting binary diffusion coefficients. Mutual diffusivities were found to be lower for the mixtures with ethanol than for those with acetone, which could be related to the formation of hydrogen bonds between ethanol and the ions. Most of the investigated IL solvent mixtures show increasing binary diffusion coefficients with increasing solvent concentration. For the mixtures of [EMIM][NTf2] with ethanol, however, a minimum of the mutual diffusivities was found in the ethanol mole fraction range from 0.7 to 0.8, which may hint at the vicinity of a critical demixing point. The viscosity of the pure ILs turned out to be no reliable indicator for the mutual diffusivity in mixtures with the same solvent.

Topical use of dexpanthenol in skin disorders.

Pantothenic acid is essential to normal epithelial function. It is a component of coenzyme A, which serves as a cofactor for a variety of enzyme-catalyzed reactions that are important in the metabolism of carbohydrates, fatty acids, proteins, gluconeogenesis, sterols, steroid hormones, and porphyrins. The topical use of dexpanthenol, the stable alcoholic analog of pantothenic acid, is based on good skin penetration and high local concentrations of dexpanthenol when administered in an adequate vehicle, such as water-in-oil emulsions. Topical dexpanthenol acts like a moisturizer, improving stratum corneum hydration, reducing transepidermal water loss and maintaining skin softness and elasticity. Activation of fibroblast proliferation, which is of relevance in wound healing, has been observed both in vitro and in vivo with dexpanthenol. Accelerated re-epithelization in wound healing, monitored by means of the transepidermal water loss as an indicator of the intact epidermal barrier function, has also been seen. Dexpanthenol has been shown to have an anti-inflammatory effect on experimental ultraviolet-induced erythema. Beneficial effects of dexpanthenol have been observed in patients who have undergone skin transplantation or scar treatment, or therapy for burn injuries and different dermatoses. The stimulation of epithelization, granulation and mitigation of itching were the most prominent effects of formulations containing dexpanthenol. In double-blind placebo-controlled clinical trials, dexpanthenol was evaluated for its efficacy in improving wound healing. Epidermal wounds treated with dexpanthenol emulsion showed a reduction in erythema, and more elastic and solid tissue regeneration. Monitoring of transepidermal water loss showed a significant acceleration of epidermal regeneration as a result of dexpanthenol therapy, as compared with the vehicle. In an irritation model, pretreatment with dexpanthenol cream resulted in significantly less damage to the stratum corneum barrier, compared with no pretreatment. Adjuvant skin care with dexpanthenol considerably improved the symptoms of skin irritation, such as dryness of the skin, roughness, scaling, pruritus, erythema, erosion/fissures, over 3 to 4 weeks. Usually, the topical administration of dexpanthenol preparations is well tolerated, with minimal risk of skin irritancy or sensitization.