Somatotopic organization of the medial wall of the cerebral hemispheres: a 3 Tesla fMRI study.

Somatotopic organization of the human medial wall of the cerebral hemispheres was studied using functional MRI conducted at high field strength (3 T) with fine spatial resolution ( approximately 2 mm). Healthy subjects performed paced, repetitive movements of the fingers and toes. Within the supplementary motor area (SMA), two regions were identified: finger movements activated a region rostral and superior to that for toe movements. Two activation foci were also identified in the cingulate motor area: toe movements activated a region rostral and ventral to that activated by finger movements. All foci were located between the anterior and posterior commissures. Our results confirm previous human and non-human primate studies regarding the rostral-caudal organization of the SMA and CMA. The dorsal-ventral organization of the CMA, however, appears to be divergent from results derived from cortical stimulation studies conducted in non-human primates.

Unusual complications of warfarin therapy: skin necrosis and priapism.

Skin necrosis and priapism are unusual complications of warfarin therapy. We report a teenager with warfarin-associated skin necrosis and priapism who was subsequently found to be a compound heterozygote for protein C deficiency and a heterozygote for the factor V Leiden mutation.

A blessing in disguise? Empowering Catholic health care institutions in the current health care environment.

Health care institutions, including Roman Catholic institutions, are in a time of crisis. This crisis may provide an important opportunity to reinvigorate Roman Catholic health care. The current health care crisis offers Roman Catholic health care institutions a special opportunity to rethink their fundamental commitments and to plan for the future. The author argues that what Catholic health care institutions must first do is articulate the nature of their identity and their commitments. By a renewed commitment to the praxis of health care on their own distinctive terms, Roman Catholic health care institutions may reestablish a vision of human nature and human service in an increasingly secular society. Health care could then reclaim its place as a powerful setting for the expression of Roman Catholic faith, life and witness.

Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection.

CONTEXT: Animal model studies have demonstrated the failure of penicillin to cure Streptococcus pyogenes myositis and have suggested that clindamycin is a more effective treatment. OBJECTIVE: To determine the most effective antibiotic treatment for invasive S. pyogenes infection in humans. DESIGN AND SETTING: We conducted a retrospective review of the outcomes of all inpatients from 1983 to 1997 treated for invasive S. pyogenes infection at Children's Hospital. PATIENTS: Fifty-six children were included, 37 with initially superficial disease and 19 with deep or multiple tissue infections. MAIN OUTCOME MEASURE: Lack of progression of disease (or improvement) after at least 24 h of treatment. RESULTS: The median number of antibiotic exposures was 3 per patient (range 1 to 6) with clindamycin predominating in 39 of 45 courses of protein synthesis-inhibiting antibiotics and beta-lactams predominating amongst the cell wall-inhibiting antibiotics in 123 of 126 of the remainder. Clindamycin was often used in combination with a beta-lactam antibiotic. Overall there was a 68% failure rate of cell wall-inhibiting antibiotics when used alone. Patients with deep infection were more likely to have a favorable outcome if initial treatment included a protein synthesis-inhibiting antibiotic as compared with exclusive treatment with cell wall-inhibiting antibiotics (83% vs. 14%, P = 0.006) with a similar trend in those with superficial disease (83% vs. 48%, P = 0.07). For those children initially treated with cell wall-inhibiting antibiotics alone, surgical drainage or debridement increased the probability of favorable outcome in patients with superficial disease (100% vs. 41%, P = 0.04) with a similar trend in a smaller number of deep infections (100% vs. 0%, P = 0.14). CONCLUSIONS: This retrospective study suggests that clindamycin in combination with a beta-lactam antibiotic (with surgery if indicated) might be the most effective treatment for invasive S. pyogenes infection.

The moral appeal of assisted suicide in end-of-life decisions.

This article identifies conceptual distinctions, e.g., killing, letting die, causing, refraining from causing, and moral principles, eg, autonomy, beneficence, utility, and their implications for the debate on assisted suicide.

Changing the present legal prohibitions on assisted suicide is a bad idea.

This article argues that although there may exist morally valid reasons to justify assisted suicide in some cases, establishing state or national policies legalizing assisted suicide is morally unjustified. Five arguments are examined that support the position against legalization: consequentialist arguments, arguments about who could legitimately choose assisted suicide and when it could be chosen, the incompatability of assisted suicide policy and authentic self-determination; the probable lack of efficacy of assisted suicide in a managed care environment, and the effects of assisted suicide on the profession and practice of nursing. The article ends with a discussion of alternatives to assisted suicide legislation that might accomplish in large part what is sought by such legislation.

Why nurses must actively participate in the debate on assisted suicide: a symposium.

This article argues that nursing must undertake further careful study of assisted suicide. Nursing must determine the relationship of assisted suicide to its core values as an important condition for making beneficent, patient-centered clinical decisions as well as for participating in discussions that establish public policies and professional practice standards.

Legal decisions and public opinion informing the debate on assisted suicide.

This article examines the evolution of state and federal legislation and court opinions in the 1990s concerning treatment abatement and assisted suicide. The recent Supreme Court decision on assisted suicide is summarized, and its rejection of a recognized constitutional right to assisted suicide is explored. Additionally, surveys of the opinions of nurses, physicians, and the public regarding the permissibility of assisted suicide are evaluated. The contradictions between public opinion and some federal and state legislation are highlighted and discussed.

Abandoning informed consent: an idea whose time has not yet come.

In a recent critique of informed consent, Robert Veatch argues that the practice is in principle unable to attain the goals for which it was developed. We argue that Veatch's focus on the theoretical impossibility of determining patients' best interests is misapplied to the practical discipline of medicine, and that he wrongly assumes that the patient-physician communication fails to provide the knowledge needed to insure the patient's best interests. We further argue that Veatch's suggested alternative, value-based patient-professional pairing, is, on his own terms, impossible to implement. Finally, we reexamine the philosophical and practical justifications for informed consent and conclude that the practice should be retained.

Good life, good death, and the right to die: ethical considerations for decisions at the end of life.

This article examines a range of ethically related concerns and considerations that must be addressed by health professionals and society as they grapple with how to make decisions about the type and degree of treatment to provide to patients at the ends of their lives. These considerations include (1) medical and nursing indications; (2) patient desires; (3) patient interests, including benefit/burden analysis and quality-of-life considerations; (4) family wishes and interests; and (5) costs. The article elaborates the ethical warrants and justifications for why these concerns need to be addressed in clinical decision making and in the development of a national health care policy. A substantial bibliography of current ethics literature on these issues is included.