RESUMO
In intensive care units far-reaching decisions are often made at short notice that require the consent of the informed patient. If this is not possible due to the patient's condition, physicians and legal representatives must ascertain the previously expressed or presumed will of the patient and act accordingly. The legal principles are specified in the Patient Advance Directives Act and the Patient Rights Act. Any indications for medical treatment need a clearly defined aim of the therapy, which can be questioned during the progress of the disease. To avoid conflicts between patient autonomy and medical treatment, the aims of therapy must be regularly discussed with the patient, representatives or relatives and documented in a written form. Checklists can be useful for structured consultations, to promote transparency and to avoid misunderstandings. Ethics consultations can help to deescalate critical situations.
Assuntos
Cuidados Críticos/ética , Diretivas Antecipadas , Cuidados Críticos/legislação & jurisprudência , Alemanha , Humanos , Consentimento Livre e Esclarecido , Direitos do Paciente , Autonomia PessoalRESUMO
Theoretical/computational methods have been extensively applied to screen possible nano-structures attempting to maximize catalytic and stability properties for applications in electrochemical devices. This work shows that the method used to model core@shell structures is of fundamental importance in order to truly represent the physicochemical changes arising from the formation of a core-shell structure. We demonstrate that using a slab approach for modelling nanoparticles the oxygen adsorption energies are qualitatively well represented. Although this is a good descriptor for the catalytic activity, huge differences are found for the calculated surface stability between the results of a nano-cluster and those of a slab approach. Moreover, for the slab method depending on the geometric properties of the core and their similarity to the elements of the core or shell, contradictory effects are obtained. In order to determine the changes occurring as the number of layers and nano particle size are increased, clusters of Ni@Pt from 13 to 260 atoms were constructed and analyzed in terms of geometric parameters, oxygen adsorption, and dissolution potential shift. It is shown that the results of modelling the Ni@Pt nanoparticles with a cluster approach are in good agreement with experimental geometrical parameters, catalytic activity, and stability of a carefully prepared series of Ni@Pt nanostructures where the shell thickness is systematically changed. The maximum catalytic activity and stability are found for a monolayer of Pt whereas adding a second and third layer the behavior is almost the same than that in pure Pt nanoparticles.
RESUMO
The task of physicians is to maintain life, to protect and re-establish health as well as to alleviate suffering and to accompany the dying until death, under consideration of the self-determination rights of patients. Increasingly more and differentiated options for this are becoming available in intensive care medicine. Within the framework of professional responsibility physicians must decide which of the available treatment options are indicated. This process of decision-making is determined by answering the following question: when and under which circumstances is induction or continuation of intensive care treatment justified? In addition to the indications, the advance directive of the patient is the deciding factor. Medical indications represent a scientifically based estimation that a therapeutic measure is suitable in order to achieve a defined therapy target with a given probability. The ascertainment of the patient directive is achieved in a graded process depending on the state of consciousness of the patient. The present article offers orientation assistance to physicians for these decisions which are an individual responsibility.
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Cuidados Críticos/ética , Administração de Caso/ética , Administração de Caso/normas , Cuidados Críticos/normas , Medicina de Emergência , Alemanha , Humanos , Comunicação Interdisciplinar , Papel do Médico , MédicosRESUMO
BACKGROUND AND CHALLENGE: Injuries, especially traumatic brain injury, or specific illnesses and their respective sequelae can result in the demise of the patients afflicted despite all efforts of modern intensive care medicine. If in principle organ donation is an option after a patient's death, intensive therapeutic measures are regularly required in order to maintain the homeostasis of the organs. These measures, however, cannot benefit the patient afflicted anymore-which in turn might lead to an ethical conflict between dignified palliative care for him/her and expanded intensive treatment to facilitate organ donation for others, especially if the patient has opted for the limitation of life-sustaining therapies in an advance directive. METHOD: The Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) have convened several meetings and a telephone conference and have arrived at a decision-making aid as to the extent of treatment for potential organ donors. This instrument focusses first on the assessment of five individual dimensions regarding organ donation, namely the certitude of a complete and irreversible loss of all brain function, the patient's wishes as to organ donation, his or her wishes as to limiting life-sustaining therapies, the intensity of expanded intensive treatment for organ protection and the odds of its successful attainment. Then, the combination of the individual assessments, as graphically shown in a {Netzdiagramm}, will allow for a judgement as to whether a continuation or possibly an expansion of intensive care measures is ethically justified, questionable or even inappropriate. RESULT: The aid described can help mitigate ethical conflicts as to the extent of intensive care treatment for moribund patients, when organ donation is a medically sound option. NOTE: Gerald Neitzke und Annette Rogge contributed equally to this paper and should be considered co-first authors.
Assuntos
Tomada de Decisões , Medicina de Emergência , Transplante de Órgãos , Obtenção de Tecidos e Órgãos , Cuidados Críticos , Humanos , Transplante de Órgãos/ética , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/éticaRESUMO
The Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) recently published a documentation for decisions to withhold or withdraw life-sustaining therapies. The wish to donate organs was not considered explicitly. Therefore the Ethics Section and the Organ Donation and Transplantation Section of the DIVI together with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine worked out a supplementary footnote for the documentation form to address the individual case of a patient's wish to donate organs.
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A 94-year-old patient with cardiogenic shock due to myocardial infarction was admitted via the emergency room. A coronary angiography and intensive care were requested. The need for care due to dementia was known. After case discussion in the interdisciplinary and multiprofessional treatment team, the decision for a palliative care concept in the form of symptom control was made in the emergency room, taking into account the patient's medical history, the current situation, and the presumed patient consent. The integration of medical ethics aspects and palliative medicine into "geriatric emergency medicine" will present a challenge in the future.
Assuntos
Ética Médica , Geriatria , Assistência Terminal , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência , Humanos , Cuidados Paliativos , Assistência Terminal/éticaRESUMO
PCR amplification of IgH gene V-D-J junctional variability (IgH PCR) is increasingly replacing Southern analysis for the detection of clonal lymphoid populations in cases presenting diagnostic difficulties. In order to determine the most efficient strategy, we have compared three known methods, using consensus primers against the VH FR3 or FR2 (FR256) regions, or a mix of six primers against the FR1 region (FR1f), with a new approach using a consensus primer against FR1 (FR1c), never previously described for diagnostic purposes, on DNA from 89 monoclonal B-cell proliferations (16 ALL, 28 CLL/PLL, 15 myelomas, 30 NHL). We obtained a detection rate of 70% for FR3, 64% for FR1f and 77% and 78% for FR256 and FR1c, respectively. Polyclonal lymphocytes and mature T cell malignancies tested negative for all systems. Differences in the detection rate were related not only to the choice of VH primer but also the JH primer(s) used and the pathological subtype. All strategies led to adequate detection of leukaemic DNA, whereas the detection rate in myeloma varied between strategies from 47 to 80% and that of follicular lymphoma from 13 to 63%. The lowest detection rates were observed in follicular lymphoma and in mature CD5 negative proliferations, reflecting the probable correlation between somatic mutation and PCR false-negativity. The combined use of FR1c and FR256 allowed detection in at least one system of 92% of cases overall and at least 75% in all pathological subtypes, thus providing a simple, reliable and rapid non-radioactive system for the detection of B cell clonality.
Assuntos
Células Clonais , Rearranjo Gênico de Cadeia Pesada de Linfócito B , Genes de Imunoglobulinas , Cadeias Pesadas de Imunoglobulinas/genética , Leucemia de Células B/patologia , Linfoma de Células B/patologia , Mieloma Múltiplo/patologia , Reação em Cadeia da Polimerase/métodos , Alelos , Antígenos CD/análise , Antígenos de Neoplasias/análise , Sequência de Bases , Southern Blotting , Antígenos CD5 , Sequência Consenso , Primers do DNA , DNA de Neoplasias/genética , Estudos de Avaliação como Assunto , Reações Falso-Negativas , Reações Falso-Positivas , Humanos , Cadeias J de Imunoglobulina/genética , Região Variável de Imunoglobulina/genética , Leucemia de Células B/genética , Linfoma de Células B/genética , Dados de Sequência Molecular , Mieloma Múltiplo/genética , Risco , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Medical success in the last century has caused situations, in which the question arises whether therapy is right. In the same time autonomy has become more and more important. Furthermore, human beings want to decide on health, life and dying. APPROACH: Experience of limitations of life and desire of autonomy in healthcare lead to ethical questions. Different ethical services were established to deal with and to solve problems. Ethics committees with multiprofessional members and different qualifications will give guidance in critical decision making. Ethics services do not receive responsibility for the decision, but helps those who are responsible by structured reflection, estimation of values and including all concerned. DISCUSSION: Implementing ethics services also encounters obstructions and scepticism. Time, responsibility for therapy and criticism of customs and structures must be considered to perpetuate success. Instructions for implementing ethics services are presented.
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Consultoria Ética/organização & administração , Ética Médica , Alemanha , Implementação de Plano de Saúde/organização & administração , Humanos , Comunicação Interdisciplinar , Colaboração IntersetorialRESUMO
The recent development of atomic resolution, low dose-rate electron microscopy allows investigating 2D materials as well as catalytic nano particles without compromising their structural integrity. For graphene and a variety of nanoparticle compositions, it is shown that a critical dose rate exists of <100 e(-)/Å(2) s at 80 keV of electron acceleration that allows maintaining the genuine object structures including their surfaces and edges even if particles are only 3 nm large or smaller. Moreover, it is demonstrated that electron beam-induced phonon excitation from outside the field of view contributes to a contrast degradation in recorded images. These degradation effects can be eliminated by delivering electrons onto the imaged area, only, by using a Nilsonian illumination scheme in combination with a suitable aperture at the electron gun/monochromator assembly.
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The long term effects of GH replacement in adult GH-deficient (GHD) patients have not yet been clarified. We studied 21 GHD adults who originally took part in a randomized, double blind, placebo-controlled trial of GH treatment in 1987. After completion of that trial, 10 patients received continuous GH replacement for the subsequent 10 yr, whereas 11 did not. A group of 11 age- and sex-matched normal controls were also studied in 1987 and 1997. Lean body mass, as assessed by total body potassium measurement and computed tomography scanning of the dominant thigh, increased in the GH-treated group (P < 0.01 for both) only (P < 0.05 between groups for total body potassium). Low density lipoprotein cholesterol decreased in the GH-treated group (P < 0.05) only. Carotid intima media thickness was significantly greater (P < 0.05) in the untreated group than in the GH-treated group. Assessment of psychological well-being using the Nottingham Health Profile revealed improvement in overall score, energy levels, and emotional reaction in the GH-treated group compared with those in the untreated group (P < 0.02). In conclusion, GH treatment for 10 yr in GHD adults resulted in increased lean body and muscle mass, a less atherogenic lipid profile, reduced carotid intima media thickness, and improved psychological well-being.
Assuntos
Hormônio do Crescimento/uso terapêutico , Hormônio do Crescimento Humano/deficiência , Adulto , Pressão Sanguínea/efeitos dos fármacos , Composição Corporal , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de TempoRESUMO
Exercise-induced anaphylaxis (EIA) is a rare form of physical allergy. Although histamine release is a feature of EIA, and histamine provocation of coronary spasm has been described, serious cardiac arrhythmias in EIA have not been reported. Exercise-induced anaphylaxis was diagnosed in a survivor of out-of-hospital cardiac arrest due to ventricular fibrillation after ECG signs of coronary spasm. Coronary artery disease was excluded. Ergonovine provocation induced coronary spasm in this patient. This is, to the authors' knowledge, the first description of ventricular fibrillation in EIA, possibly due to coronary spasm.
Assuntos
Anafilaxia/etiologia , Vasoespasmo Coronário/etiologia , Esforço Físico , Fibrilação Ventricular/etiologia , Anafilaxia/sangue , Vasos Coronários/patologia , Ergonovina , Teste de Esforço/efeitos adversos , Histamina/sangue , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/etiologia , Peptídeo Hidrolases/sangue , Esforço Físico/fisiologiaRESUMO
A 25 year old woman suffering from recurrent attacks of hypoglycaemia underwent a laparotomy for suspected insulinoma. No tumour was found, but histology showed islet cell hyperplasia and nesidioblastosis. Although these changes have been reported as a cause of hypoglycaemia in infants, they are only rarely the cause of hypoglycaemia in adults; in the present case they were found to be the result of covert sulphonylurea administration. The fact that sulphonylureas can cause nesidioblastosis is not well recognised by either physicians or pathologists and it should be considered before "cryptogenic nesidioblastosis" is deemed the cause of hypoglycaemia in adults.
Assuntos
Clorpropamida/intoxicação , Hipoglicemia/etiologia , Insulina/sangue , Pancreatopatias/induzido quimicamente , Adulto , Feminino , Humanos , Hiperplasia , Ilhotas Pancreáticas/patologia , Pancreatopatias/complicaçõesRESUMO
The effects of 6 months' treatment with recombinant human growth hormone (rhGH) on serum lipids and lipoproteins were assessed in 24 adult patients with GH deficiency in a double-blind, placebo-controlled trial. Compared with age-, weight-, and sex-matched controls, the patients had significantly higher serum concentrations of total cholesterol (P = .002), low-density lipoprotein (LDL) cholesterol (P < .001), apolipoprotein B ([apoB] P = .011), and triglyceride (P = .017), and lower concentrations of high-density lipoprotein (HDL) cholesterol (P < .001). The prevalence of elevated serum cholesterol, triglyceride, LDL cholesterol, and apo B levels was 39%, 26%, 39%, and 25%, respectively; 75% of patients had decreased concentrations of HDL cholesterol. Treatment with rhGH (0.07 U/kg daily) resulted in decreases in total cholesterol level (5.8 +/- 0.3 to 5.1 +/- 0.3 mmol.L-1 over 6 months; P = .01 compared with placebo), LDL cholesterol level (4.22 +/- 0.25 to 3.19 +/- 0.23 mmol.L-1; P = .0003), LDL:HDL cholesterol ratio (5.57 +/- 0.47 to 3.29 +/- 0.33; P = .03), apo B level (1.07 +/- 0.06 to 0.84 +/- 0.07 g.L-1; P = .003), and apo B: A-1 ratio (0.73 +/- 0.05 to 0.69 +/- 0.05; P = .01). HDL cholesterol and apo A-1 levels did not change following rhGH treatment. The changes in lipid and lipoprotein levels were not significantly related to changes in insulin, thyroid hormones, insulin-like growth factor-1 (IGF-1), or indices of adiposity.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Hormônio do Crescimento/deficiência , Hormônio do Crescimento/uso terapêutico , Lipídeos/sangue , Lipoproteínas/sangue , Adulto , Apolipoproteína A-I/metabolismo , Apolipoproteínas B/análise , Colesterol/sangue , HDL-Colesterol/sangue , LDL-Colesterol/sangue , Método Duplo-Cego , Feminino , Humanos , Masculino , Proteínas Recombinantes/uso terapêutico , Triglicerídeos/sangueRESUMO
The effect of recombinant DNA human growth hormone (rhGH) treatment in adults with growth hormone (GH) deficiency was studied in 24 patients in a double-blind placebo-controlled trial. The dose was 0.07 U/kg body wt daily. After 6 mo of treatment, significant increases were noted in the rhGH group for total cross-sectional area of thigh muscle (+11.2 +/- 3.1 vs. -0.5 +/- 3.0 cm2; P = 0.015 vs. placebo) and quadriceps muscle (+4.1 +/- 0.8 vs. +0.4 +/- 1.2 cm2; P = 0.031) measured by computerized tomography. Strong correlations were noted between lean body mass (measured as total body potassium) and total thigh muscle area in normal and GH-deficient adults both before and after rhGH treatment. Strength of hip flexors (+1.25 +/- 0.27 vs. +0.25 +/- 0.12 z-scores; P = 0.004) and limb girdle muscles increased (P = 0.02) in the rhGH group. We conclude that 1) rhGH increases lean tissue and skeletal muscle mass in adults with human GH deficiency, 2) this suggests a role for GH in the regulation of body composition of adult humans, 3) the increase in strength of limb girdle muscles after rhGH treatment suggests that adults with GH deficiency may have a proximal myopathy, and 4) the failure to demonstrate an increase in strength in other muscle groups may require the study of larger numbers of patients.
Assuntos
Hormônio do Crescimento/uso terapêutico , Músculos/efeitos dos fármacos , Adolescente , Adulto , Índice de Massa Corporal , Método Duplo-Cego , Feminino , Hormônio do Crescimento/deficiência , Humanos , Fator de Crescimento Insulin-Like I/metabolismo , Masculino , Pessoa de Meia-Idade , Contração Muscular/efeitos dos fármacos , Músculos/anatomia & histologia , Músculos/fisiologiaRESUMO
Growth hormone (GH) treatment in adults with GH deficiency increases lean body mass and thigh muscle cross-sectional area. The functional significance of this was examined by incremental cycle ergometry in 24 GH-deficient adults treated in a double-blind placebo-controlled trial with recombinant DNA human GH (rhGH) for 6 mo (0.07 U/kg body wt daily). Compared with placebo, the rhGH group increased mean maximal O2 uptake (VO2max) (+406 +/- 71 vs. +133 +/- 84 ml/min; P = 0.016) and maximal power output (+24.6 +/- 4.3 vs. +9.7 +/- 4.8 W; P = 0.047), without differences in maximal heart rate or ventilation. Forced expiratory volume in 1 s, vital capacity, and corrected CO gas transfer were within normal limits and did not change with treatment. Mean predicted VO2max, based on height and age, increased from 78.9 to 96.0% in the rhGH group (compared with 78.5 and 85.0% for placebo; P = 0.036). The anaerobic ventilatory threshold increased in the rhGH group (+159 +/- 39 vs. +1 +/- 51 ml/min; P = 0.02). The improvement in VO2max was noted when expressed per kilogram body weight but not lean body mass or thigh muscle area. We conclude that rhGH treatment in adults with GH deficiency improves and normalizes maximal exercise performance and improves submaximal exercise performance and that these changes are related to increases in lean body mass and muscle mass. Improved cardiac output may also contribute to the effect of rhGH on exercise performance.
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Exercício Físico/fisiologia , Hormônio do Crescimento/uso terapêutico , Adolescente , Adulto , Anaerobiose/efeitos dos fármacos , Índice de Massa Corporal , Método Duplo-Cego , Teste de Esforço , Feminino , Hormônio do Crescimento/deficiência , Humanos , Masculino , Pessoa de Meia-Idade , Músculos/anatomia & histologia , Músculos/efeitos dos fármacos , Músculos/fisiologia , Consumo de Oxigênio/efeitos dos fármacos , Respiração/efeitos dos fármacosRESUMO
Bacteremia during infection with Shigella is relatively rare and usually self-limited. Bacteremia during shigellosis bearing a high fatality rate has been reported in young infants and in persons with malnutrition or with the acquired immunodeficiency syndrome. We report a case of Shigella sonnei septicemia in a severely neutropenic patient who had fever, abdominal pain, diarrhea, malnutrition, and dehydration. She died after five days despite intensive care. We emphasize that Shigella should be considered among the possible pathogens causing sepsis in neutropenic patients.
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Disenteria Bacilar/complicações , Neutropenia/complicações , Shigella sonnei , Adulto , Neoplasias da Mama/complicações , Carcinoma de Células Escamosas/complicações , Evolução Fatal , Feminino , HumanosRESUMO
Thirteen infants malnourished from birth have been recorded with polygraphic techniques continuously for 24 h. The developmental trend of Quiet Sleep was found to be altered; infants older than 4 months had a diminution of Quiet Sleep with shorter phases. Ambiguous Sleep was increased. These findings reflect the effects of malnutrition on central nervous system development and could have implications for growth and for anabolic processes. Nutritional rehabilitation performed through an intracave catheter led to an increase of Quiet Sleep and to a decrease of Ambiguous Sleep.
Assuntos
Transtornos da Nutrição do Lactente/complicações , Transtornos do Sono-Vigília/etiologia , Desenvolvimento Infantil , Feminino , Humanos , Lactente , Transtornos da Nutrição do Lactente/dietoterapia , Masculino , Fases do SonoRESUMO
We have studied the relationship between weight changes and polygraphically recorded sleep, during a 24 hour period, of 26 infants aged between 2 and 11 months. Weight changes (in percentage within a period of 24 h) have been found to be correlated with the following sleep parameters: total amount of ambiguous sleep, percentage of time spent in cycle of the total sleep time, mean length of the cycles. We speculate that this relationship could be important when weight variations do not proceed as expected only on the basis of the clinical conditions and the caloric intake.
Assuntos
Peso Corporal , Sono/fisiologia , Doenças do Sistema Digestório/fisiopatologia , Humanos , Lactente , Fases do SonoRESUMO
A patient with chronic monoarthritis erroneously diagnosed as osteoarthritis, in whom a high index of suspicion for tuberculosis, assisted by CT scan and closed needle synovial biopsy led to the relatively early and correct diagnosis and treatment of tuberculous arthritis is presently reported.