In the present paper we address the old question of respiratory planning in speech production. We recast the problem in terms of speakers’ communicative goals and propose that speakers try to minimise respiratory effort in line with H&H theory. We analyze respiratory cycles coinciding with no speech (i.e. silence), short verbal feedback expressions (SFE’s) as well as longer vocalisations in terms of parameters of the respiratory cycle and find little evidence for respiratory planning (...) in feedback production. We also investigate timing of speech and SFEs in the exhalation and contrast it with nods. We find that while speech is strongly tied to the exhalation onset, SFEs are distributed much more uniformly throughout the exhalation and are often produced on residual air. Given that nods, which do not have any respiratory constraints, tend to be more frequent towards the end of an exhalation, we propose a mechanism whereby respiratory patterns are determined by the trade-off between speakers’ communicative goals and respiratory constraints. (shrink)

It is now 10 years since the disease we now know as SARS—severe acute respiratory syndrome—caused more than 700 deaths around the world and made more than 8,000 people ill. More recently, in 2009 the global community experienced the first influenza pandemic of the 21st century—the 2009 H1N1 influenza pandemic. This paper analyses the major developments in international public health law relating to infectious diseases in the period since SARS and considers their implications for pandemic planning.

Respiratory illness continues to be a leading cause of paediatric morbidity and mortality in Indonesia. The Indonesian government is moving towards a more managed care-based approach as it reforms its health care system following the 1997 financial crisis. In order to better design contractual relationships between the payor and different providers, there needs to be a better understanding of the patterns and predictors of health services utilization for respiratory illness. This study uses the Indonesia Demographic and Health Survey (...) to study the determinants of private, public and non-formal provider utilization for respiratory illness. Multinomial logistic regression models for predicting use were constructed using the Andersen Behavioural Model as the conceptual framework. The findings indicate that age, household size, maternal education, religion, the asset index, location and illness severity play a role in determining use of private, public or non-formal providers. The results indicate that from a policy perspective, the Indonesian government needs be inclusive rather than exclusive in the choice of providers that are contracted by the managed care plans, in order to safeguard the health of the under-five population. (shrink)

Healthcare workers in Pakistan are still fighting at the frontline to control the spread of severe acute respiratory syndrome coronavirus-2 and have been identified as the earliest beneficiaries for COVID-19 vaccination by the health authorities of the country. Besides, the high vaccination rates of frontline healthcare workers are essential to overcome the ongoing pandemic and reduce the vaccines hesitancy among the general population. The current research employed the theory of planned behavior to investigate the COVID-19 vaccination behavior among FHWs (...) in Pakistan as well as the predictors of such behavior. Following the epidemic control and prevention policies, a sample of 680 FHWs were accessed to fill in the questionnaire evaluating the components of the TPB. Moreover, the potential role of anticipated regret and perceived susceptibility on COVID-19 vaccination behavior was also assessed. The partial least square structural equation modeling results revealed that the TPB components, as well as the AR, have positive associations with the COVID-19 vaccination behavior. The results further confirmed that PS positively affects the anticipated regret, attitude, and subjective norm to vaccinate against SARS-CoV-2. The perceived susceptibility also has a positive association with COVID-19 vaccination behavior through the mediation of anticipated regret, ATT, and SN. Our findings highlighted the importance of COVID-19 vaccination among healthcare workers, which can be applied to reduce vaccine hesitancy among the general public. (shrink)

Se analiza el debate actual sobre el concepto de Escuela de Salamanca. Se muestran las nuevas propuestas de los estudiosos: su carácter global (no solo Salamanca); su alcance interdisciplinar (no solo teológico, también jurídico, económico, sociopolítico, etc); la cuestión de los miembros también experimenta una ampliación, aunque siempre se señala un cierto cordón umbilical con los Maestros salmantinos; todo ello dentro de un marco temporal que se extiende durante el siglo XVI y primera mitad del XVII. Estas nuevas perspectivas no (...) excluyen los elementos tradicionales, sino que amplían y desarrollan el concepto primitivo, pero con carácter inclusivo. Por último, se aborda el tema de las condiciones de posibilidad de la Escuela, que se contextualiza en un ámbito histórico que la hace posible. Al término del estudio se ofrece un posible nuevo concepto de la Escuela, todavía _in fieri_. (shrink)

La psiquiatría nace con el siglo XIX, la fenomenología con el XX. Desde el advenimiento de la segunda ha querido la primera ver en ella una vía para la superación del positivismo que la atenazaba desde su mismo origen. Uno de sus intentos más logrados fue el del psiquiatra Ludwig Binswanger a lo largo de los años veinte del pasado siglo. Recorrió en ese tiempo las Investigaciones lógicas de Husserl y ensayó su acercamiento a la psicología estructural. Proponemos que una (...) deficiente lectura de las posibilidades de la fenomenología ―comprensible en su prematuridad, desgraciada en su ímpetu anti-(neo)kantiano― impidió que reconociera su horizonte trascendental y así pudiera entrever caminos de acceso al mundo, a la persona y a su concreto sufrimiento. Para concluir presentamos el intento que supone el proyecto La mirada filosófica como mirada médica por recuperar aquella problematicidad y ahondar en una aproximación respetuosa al padecer, tal como aparece, sin violentarlo por el concepto. (shrink)

The current study examines similarity or disparity of a frontally mediated physiological response of mental effort among multiple executive functioning tasks between children and adults. Task performance and phasic heart rate variability (HRV) were recorded in children (6 to 10 years old) and adults in an examination of age differences in executive functioning skills during periods of increased demand. Executive load levels were varied by increasing the difficulty levels of three executive functioning tasks: inhibition (IN), working memory (WM), and (...) class='Hi'>planning/problem solving (PL). Behavioral performance decreased in all tasks with increased executive demand in both children and adults. Adults’ phasic high frequency HRV was suppressed during the management of increased IN and WM load. Children’s phasic HRV was suppressed during the management of moderate WM load. HRV was not suppressed during either children’s or adults’ increasing load during the PL task. High frequency phasic HRV may be most sensitive to executive function tasks that have a time-response pressure, and simply requiring performance on a self-paced task requiring frontal lobe activation may not be enough to generate HRV responsitivity to increasing demand. (shrink)

Previous research has suggested that bodily signals from internal organs are associated with diverse cortical and subcortical processes involved in sensory-motor functions, beyond homeostatic reflexes. For instance, a recent study demonstrated that the preparation and execution of voluntary actions, as well as its underlying neural activity, are coupled with the breathing cycle. In the current study, we investigated whether such breathing-action coupling is limited to voluntary motor action or whether it is also present for mental actions not involving any overt (...) bodily movement. To answer this question, we recorded electroencephalography (EEG), electromyography (EMG), and respiratory signals while participants were conducting a voluntary action paradigm including self-initiated motor execution (ME), motor imagery (MI), and visual imagery (VI) tasks. We observed that the voluntary initiation of ME, MI, and VI are similarly coupled with the respiration phase. In addition, EEG analysis revealed the existence of readiness potential (RP) waveforms in all three tasks (i.e., ME, MI, VI), as well as a coupling between the RP amplitude and the respiratory phase. Our findings show that the voluntary initiation of both imagined and overt action is coupled with respiration, and further suggest that the breathing system is involved in preparatory processes of voluntary action by contributing to the temporal decision of when to initiate the action plan, regardless of whether this culminates in overt movements. -/- . (shrink)

On 24 July 2017, the long-running, deeply tragic and emotionally fraught case of Charlie Gard reached its sad conclusion. Following further medical assessment of the infant, Charlie’s parents and doctors finally reached agreement that continuing medical treatment was not in Charlie’s best interests. Life support was subsequently withdrawn and Charlie died on 28 July 2017.Box 1 ### Case summary and timeline21–23 Charlie Gard was born at full term, apparently healthy, in August 2016. At a few weeks of age his parents (...) noticed early signs of muscle weakness. At 2 months of age, he was admitted to Great Ormond Street Hospital with poor feeding, failure to thrive and respiratory failure. He was admitted to intensive care, where investigations led to the diagnosis of a rare severe mitochondrial disorder – infantile onset encephalomyopathic mitochondrial DNA depletion syndrome. The specific genetic form of MDDS in Charlie Gard had previously been reported in approximately 15 infants, with typical clinical features including early onset, rapid progression and death in infancy.24 By that point, Charlie was paralysed and unable to breathe without respiratory support. He was found to have congenital deafness, and his heart, liver and kidneys were affected by the disorder. Doctors felt that Charlie’s prognosis was extremely poor. In early 2017, Charlie’s parents identified an experimental treatment, previously used in a different form of MDDS, which they hoped might benefit Charlie. In mouse models of a myopathic form of MDDS, early supplementation with deoxypryrimidine nucleosides apparently bypasses the genetic defect and leads to a reduction in the biochemical defect and in the severity of the clinical phenotype.25 26 Doctors at GOSH initially planned to use nucleoside treatment in Charlie, but in January he developed evidence of electrical seizures, and clinicians became convinced that treatment, both continued intensive care and the requested …. (shrink)

Lockdowns, or modern quarantines, involve the use of novel restrictive non-pharmaceutical interventions (NPIs) to suppress the transmission of COVID-19. In this paper, I aim to critically analyze the emerging history and philosophy of lockdowns, with an emphasis on the communication of health evidence and risk for informing policy decisions. I draw a distinction between evidence-based and modeling-based decision-making. I argue that using the normative framework of evidence-based medicine would have recommended against the use of lockdowns. I first review the World (...) Health Organization’s evidence-based pandemic preparedness plans for respiratory viruses. I then provide a very brief history of COVID-19 modeling, which was cited as justification for the use of lockdowns in the U.K., the U.S., and much of the world. I focus on the so-called Imperial College model designed by Neil Ferguson et al. as well as the so-called Oxford model designed by José Lourenço et al. I analyze the evidence-based pandemic response known as ‘mitigation’, and I compare it with Ferguson et al.’s experimental strategy known as ‘suppression’. I summarize the strengths and weaknesses of these strategies based on their diametric aims and each model’s parametric assumptions. Based on my critical analysis of the suppression strategy, I attempt to expose what has been called the ‘logic of lockdowns’, which Sunetra Gupta of the Oxford model group has suggested is flawed. Finally, I consider Trisha Greenhalgh’s objection to evidence-based policy based on the precautionary principle, and I attempt to offer a response. I conclude with a brief narrative review of the emerging randomized evidence on restrictive NPIs, which seems to support my claim that mitigation was the strategy that would have been recommended by evidence-based medicine. If this is true, then COVID-19 modeling may serve as an important reminder of the enduring lesson of evidence-based medicine: that one should always ‘Trust the Evidence!’ for better health policy. (shrink)

The aim of this study was to evaluate terminal care among hospitalized children who died of HIV/AIDS. The design was a retrospective chart review of the terminal hospitalization. The setting was a public, secondary and tertiary children's hospital in Cape Town, South Africa (SA). The patients included a consecutive series of in‐patient deaths from HIV‐related causes. The main outcome measures included: documentation of do not resuscitate (DNR) orders and comfort care plans, intensity of diagnostic and therapeutic interventions in last 24 (...) hours of life, and presence of pain and distress in last 48 hours of life. The results are based on the review of 165 out of 167 in‐patient deaths. Of those, 79% of patients died in general wards. Median age and length of stay were 4 months and 6 days respectively. A total of 84% of patients had a DNR order. DNR orders appeared simultaneously in only 41% of medical and nursing notes. Only 44% of patients had a comfort care plan. Pain and distress in the last 48 hours was documented in 55% of patients who died in the general wards. Respiratory symptomatology and painful skin conditions accounted for most discomfort. Half (36/72) the patients with pain and distress, including 16 with a comfort care plan, received no analgesia. Conclusions drawn found that, despite clinical uncertainty, doctors made tough end of life decisions that included DNR orders and comfort care plans. The lower rate of comfort care plans suggests doctors had difficulty making the transition from curative to palliative care. Many comfort care plans were incoherent and included interventions unlikely to promote patients' comfort. In light of the HIV/AIDS pandemic in SA, reforms are needed to integrate palliative care within mainstream hospital medicine. However, without adequate human resources including trained interpreters, doctors and nurses will struggle to deliver optimal terminal care in acute hospitals. (shrink)

Coronavirus disease 2019 (COVID-19) is likely to have long-term mental health effects on individuals who have recovered from COVID-19. Rightly, there is a global response for recognition and planning on how to deal with mental health problems for everyone impacted by the global pandemic. This does not just include COVID-19 patients but the general public and health care workers as well. There is also a need to understand the role of the virus itself in the pathophysiology of mental health (...) disorders and longer-term mental health sequelae. Emerging evidence suggests that COVID-19 patients develop neurological symptoms such as headache, altered consciousness, and paraesthesia. Brain tissue oedema and partial neurodegeneration have also been observed in an autopsy. In addition, there are reports that the virus has the potential to cause nervous system damage. Together, these findings point to a possible role of the virus in the development of acute psychiatric symptoms and long-term neuropsychiatric sequelae of COVID-19. The brain pathologies associated with COVID-19 infection is likely to have a long-term impact on cognitive processes. Evidence from other viral respiratory infections, such as severe acute respiratory syndrome (SARS), suggests a potential development of psychiatric disorders, long-term neuropsychiatric disorders, and cognitive problems. In this paper, we will review and evaluate the available evidence of acute and possible long-term neuropsychiatric manifestations of COVID-19. We will discuss possible pathophysiological mechanisms and the implications this will have on preparing a long-term strategy to monitor and manage such patients. (shrink)

Prematurely born children who have underdeveloped lungs may suffer a potentially fatal condition called respiratory distress syndrome. A U.S. company developed a drug, called Surfaxin, to treat such poorly functioning lungs. A placebo-controlled study was planned in four Latin American countries. At the time, in 2001, four treatments were already on the market, although not available to the research populations used in the study. This case is usually discussed as part of the standard of care debate or offered as (...) an example of exploitation. However, what concerns us in this case is rather the choice given to the parents of a prematurely born child under these circumstances: “You can give consent for your child's participation in this study. Half of the babies enrolled will receive sham air and are as likely to die as if they had not enrolled. The other half will receive an active treatment and are more likely to survive.” The parents can vastly increase their baby's chances of survival by participating in the study. Can the consent be voluntary? Do the parents have any meaningful choice? (shrink)

The modern ethical framework demands informed consent for research participation that includes disclosure of material information, as well as alternatives. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic (COVID-19) results in illness that often involves rapid deterioration. Despite the urgent need to find therapy, obtaining informed consent for COVID-19 research is needed. The current pandemic presents three types of challenges for investigators faced with obtaining informed consent for research participation: (1) uncertainty over key information to informed consent, (2) (...) time and pressure constraints, and (3) obligations regarding disclosure of new alternative therapies and re-consent. To mitigate consenting challenges, primary investigators need to work together to jointly promote urgent care and research into COVID-19. Actions they can take include (1) prior plan addressing ways to incorporate clinical research into clinical practice in emergency, (2) consider patients vulnerable with early deliberation on the consent process, (3) seek Legally Authorized Representatives (LARs), (4) create a collaborative research teams, (5) aim to consent once, despite evolving information during the pandemic, and (6) aim to match patients to a trial that will most benefit them. The COVID-19 pandemic both exacerbates existing challenges and raises unique obstacles for consent that require forethought and mindfulness to overcome. While research teams and clinician-investigators will need to be sensitive to their own contexts and adapt solutions accordingly, they can meet the challenge of obtaining genuinely informed consent during the current pandemic. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Limits of Our ObligationsRyan C. MavesDisclaimers. No funding was utilized for this manuscript. Dr. Maves is a retired U.S. Navy officer, and the opinions contained herein are his own. The opinions in this manuscript do not reflect the official opinion of the Department of the Navy, Department of Defense, nor of the U.S. Government.In 2012, I was a commander in the United States Navy, deployed to the NATO (...) Role 3 Multinational Medical Unit in Kandahar Airfield (KAF), Afghanistan. The KAF Role 3 began as a tent hospital under Canadian command, built along the flight line at Ahmad Shah Baba International Airport as [End Page 176] part of an expanding NATO base. By the time of my arrival, it was a small but capable brick-and-mortar building under U.S. Navy command, with four operating rooms, two CT scanners, and a busy intensive care unit (ICU).Not long before my deployment, the KAF Role 3 was described as one of the busiest trauma hospitals in the world. Casualties arrived every day, usually by helicopter. Blast injuries from improvised explosive devices (IEDs) were common, ranging in severity from concussions in passengers in armored vehicles, to multiple amputations from blast injuries with concomitant thoracic, abdominal, and pelvic trauma. KAF had a daytime population of over 30,000 in 2012, and our hospital was effectively the referral center for the region, so patients with non-surgical diagnoses were similarly common: myocardial infarctions, seizures, pulmonary emboli, and endemic infections, to name a few.As an infectious disease (I.D.) specialist, I functioned mainly as a hospitalist, managing patients postoperatively, but I also provided any consultative support when needed. During mass casualty events, the intensivists and I would act as backups in the trauma bay, freeing up the surgeons for the most acutely injured patients. It turned out that an I.D. doctor’s skillset lent itself well to acute trauma evaluations; we are well known for having an eye for fine details, combined with low-grade paranoia. These traits served me well during what I came to describe as “my involuntary trauma fellowship.”Our patients could be divided into five key groups: Afghan National Security Forces (ANSF, including the army and national police), non-Afghan coalition military (mostly U.S. and other NATO members), Afghan civilians, NATO civilian contract staff, and the Taliban. Our approach to each of these groups was different. For all patient groups, we would provide the same emergency care, including acute resuscitation and immediate life-saving surgery. It was after this emergency care period that our management plans diverged.For coalition forces, our next priority after acute resuscitation and stabilization was to assess whether a patient could remain in theater. Stable patients with relatively minor injuries could often undergo rehabilitation at KAF; many personnel could subsequently return to combat duty with their units. More seriously-injured patients would be transported out of Afghanistan within 24-48 hours (if not faster). Usually, this would involve stops at Bagram Airfield near Kabul and then Landstuhl Regional Medical Center in Germany before reaching a military hospital in their home countries. There were few limits on whom could be transported. Dedicated critical care air transport teams (CCATT) included intensivists, respiratory therapists, and critical care nurses, who could manage the most unstable patients on board what was effectively a flying ICU. The “lung team” in Landstuhl could fly to KAF to start patients with severe respiratory failure on extracorporeal membrane oxygenation (ECMO) and then fly them out on maximal support.NATO civilian contractors would receive comparable care, although the exact details of how they would be transported out of theater would depend on their home countries and the nature of their contract. We cared for one civilian contractor with newly-diagnosed HIV infection whom we were able to stabilize on the ventilator, get him extubated, start on initial antiretroviral therapy, and transport him home with a referral to his local HIV care program.Afghan soldiers were part of the coalition, but there was no distant home country where we could transport them. They were home. After their resuscitations and surgeries, we would arrange transfer to the Kandahar Regional... (shrink)

I was a second-year neonatal-perinatal fellow in a meeting between other members of the neonatal intensive care team and parents who had just received devastating news about their planned-for and highly desired baby, born after what had been an uncomplicated pregnancy. At home, a little sister was waiting to meet her new brother. These conversations are never easy, but this one I found particularly disturbing. John had been born at term via emergency cesarean section after his mother, Muriel, had come (...) for a routine obstetrical visit and reported decreased fetal movement. The obstetrician had detected a very slow fetal heart rate and sent Muriel to the hospital for emergent delivery. John was born floppy, with no respiratory effort. He was resuscitated, but a heart rate was not detected until fifteen minutes after birth. Not until several months later did I discover what had troubled me so much in this family meeting. (shrink)

With a population of over 1.3 billion, China is the most populous country in the world. It is facing an acute aging population problem, with a projected 440 million residents over age 60 and 101 million over age 80 by 2050. Furthermore, rapid industrialization and urbanization in China have resulted in serious air pollution and associated public health problems, including an increase in respiratory diseases and cancers. These and other demographic trends have generated concerns about the cost of health (...) care and its impact on population health. In recent years, the Chinese government has invested heavily in the fields of translational research and biobanking with the hope that research in both fields can yield effective solutions to improve the public’s health and quality of life. The establishment of national biobanks was identified as a major initiative needed for the biomedical industry in the 12th Five-Year National Development Plan of Strategic Emerging Industries promulgated by the State Council in 2012. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“Just Because You Can—Doesn’t Mean You Should”Mindy B. StatterAs Albert R. Jonsen stated, “The technological imperative begins to rule clinical decisions: if a technology exists, it must be applied. Patients... are moved to higher and higher levels of care, finally becoming enmeshed in a tangle of tubes that extinguish their identity and needs as persons.” In this case the conflict created by the parental demand for the utilization of (...) technology, extracorporeal support in a neonate will be explored.I was consulted in the care of a newborn with a right–sided congenital diaphragmatic hernia (CDH). In this anomaly the diaphragm, the muscular partition that separates the abdomen and the thorax, forms incompletely, and the viscera migrate up into the chest compressing the developing lung, shifting the medistinum and heart and compressing the contralateral lung. The resulting lung maldevelopment is termed pulmonary hypoplasia. The maldevelopment of the lungs in CDH is variable with the most severe forms resulting in neonatal death. This congenital anomaly is associated with 55% survivability; the poor prognosis is due to the pulmonary hypoplasia. In addition to pulmonary hypoplasia, there is the association of pulmonary hypertension with CDH. Pulmonary hypertension is a condition where the vascular resistance in the lung is high with reduced blood flow within the lung. The physiologic consequence of pulmonary hypertension is hypoxemia, oxygen deficiency in the blood, and reduced oxygen delivery to all organs. Unlike severe pulmonary hypoplasia, pulmonary hypertension is reversible. When an infant with CDH is born and deteriorates due to respiratory failure it can be difficult to determine whether the respiratory failiure is due to pulmonary hypoplasia or pulmonary hypertension. Extracorporeal membrane oxygenation (ECMO) is indicated in the management of reversible respiratory and, or cardiac failure. In the case of neonates with CDH, ECMO addressess the reversible component of the respiratory failure, the pulmonary hypertension. The respiratory failure due to severe pulmonary hypoplasia is not reversible; ECMO is not indicated. There are established criteria to guide the determination of which infant is a candidate for ECMO. Depending upon the ECMO center, the stringency can vary.In this case, the baby had significant respiratory failure with impairment in both oxygenation, hypoxia, and ventilation–the elimination of carbon dioxide, hypercapnea. The neonatologist spoke with the mother who stated that she wanted “everything done” including ECMO in the management [End Page 22] of her baby. When the neonatologist consulted me to put the baby on ECMO I expressed my concern that this infant had irreversible respiratory failure due to pulmonary hypoplasia. And simply from a technical aspect, I could not guarantee that ECMO would “work”. When an infant is “cannulated” for extracorporeal support, cannulas are inserted to allow for the drainage of blood into the ECMO circuit, the blood oxygenated and the carbon dioxide is cleared, and the blood is then returned to the infant. The majority of diaphragmatic hernias are on the left and when the CDH is on the right side, the right heart may be compressed by the viscera in the chest, and venous drainage into the ECMO circuit may be impaired. When this is encountered, the next step in the management algorithm is to fix the hernia–reduce and return the viscera within the chest to the abdomen and eliminate the visceral compression of the right heart. The neonatologist shared my concern and also reiterated that this baby’s mother wanted “everything done”. I had little uncertainty as to the etiology of the respiratory failure in this baby. In meeting the mother’s demands I then suggested that the hernia be repaired first, and if there was improvement in the hypoxia and hypercapnea, then give the baby the benefit of the doubt that there is a component of reversibility to the respiratory failure and then proceed with ECMO cannulation. The neonatologist agreed with this suggested plan.I then went to talk with the baby’s mother. I explained my concerns that based on the profound hypercapnea on the arterial blood gases that the baby’s respiratory failure was due to pulmonary hypoplasia and not reversible with extracorporeal support. She insisted that her baby be put on ECMO. I then explained the operative algorithm and... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The 12–Minute JourneyHeather A. CarlsonI met Jack for the first time when he was in the intensive care unit as he was just waking up from his emergent tracheostomy surgery. As I walked into his room he opened his eyes in panic and he struggled to take in a deep breath, fighting the ventilator that was trying to deliver slow steady breaths for him. His face was flooded with (...) fear and the ventilator alarms were blaring. He was surrounded by nurses and respiratory technicians all trying to calm him down, while adjusting the settings on the machine. “Just try and breathe slowly,” they instructed him, though this seemed to be impossible for him as he continued to try and suck in as much air as possible through the new hole in his throat. As his arm flailed out I grabbed his hand and while holding it in mine I just tried to emulate tranquility for him. I thought to myself this is exactly how I would react if I woke up in this condition and could imagine the fear that he was now feeling. While nurses rushed around with suction equipment and the respiratory technicians made adjustments and monitored the results I stood there holding his hand silently praying that he become calm. With all of our support he did eventually relax and find the ability to sync his breathing with the ventilator settings.I am a palliative care nurse practitioner and had been asked to see Jack to help with symptom management and establishing his goals of care as he had recently been diagnosed with head and neck cancer. He had presented to the hospital with complaints of difficulty breathing and it didn’t take long for the emergency room physician to determine that his airway was almost completely occluded by tumor. Jack had actually been diagnosed with this cancer the month before, and had met with a radiation oncologist who planned to start radiation as soon as possible to avoid tumor growth that could impair his breathing. Unfortunately Jack was so anxious and scared about this treatment plan that he never went back to the cancer center. Instead, he stayed in his room in the boarding house that he lived in, smoking cigarettes to calm his nerves. Jack was a recovering alcoholic who had previously been homeless and out on the streets for many years before becoming sober and finding shelter at the boarding house where he now lived. He was a heavy smoker and found that it was one thing that helped to ease his anxiety. The thought of being strapped down to a table with a tight mask over his head while radiation zapped the cancer in his neck had terrified him. His anxiety and claustrophobia had prevented him from following through with his cancer treatment.My initial visits with Jack were spent trying to treat his anxiety as well as the pain he experienced in his neck and head.Because he had undergone a tracheostomy and was now on a ventilator he was unable to speak. To communicate he pointed to a picture board that had common sayings on it, like “I have pain” and “I have to go to the bathroom”. He also used a clipboard with paper and pen and could write what he wanted to say, but this was a time consuming endeavor. Despite this, he was a very animated gentleman who had a lot to say and he wasn’t going to let the loss of his voice impair him. I found myself enjoying my visits with him each day, as he would tell me more about himself. I quickly discovered that he was a very spiritual man and his faith was his inspiration. He wrote on his clipboard “this cancer is actually a gift” and went on to explain that he had been on a fast track toward self destruction, but now feels as though he has been given another chance at life. He spent his time in the hospital reflecting on his life’s journey and how he would be able to help others in similar circumstances. He wrote on his [End Page 192] clipboard multiple... (shrink)

With a population of over 1.3 billion, China is the most populous country in the world. It is facing an acute aging population problem, with a projected 440 million residents over age 60 and 101 million over age 80 by 2050. Furthermore, rapid industrialization and urbanization in China have resulted in serious air pollution and associated public health problems, including an increase in respiratory diseases and cancers. These and other demographic trends have generated concerns about the cost of health (...) care and its impact on population health. In recent years, the Chinese government has invested heavily in the fields of translational research and biobanking with the hope that research in both fields can yield effective solutions to improve the public’s health and quality of life. The establishment of national biobanks was identified as a major initiative needed for the biomedical industry in the 12th Five-Year National Development Plan of Strategic Emerging Industries promulgated by the State Council in 2012. (shrink)

Hello readers! Hope everyone is fine especially in this season where we often are prone to attacks of cold or flu. The holiday season is at our threshold, and we wish everyone to be in the best of health and happiness.This issue of the BJB is very interesting with topics stretching from Non Communicable Diseases to the ethical issues related to the habitation of the planet Mars, and proves how forward looking are our readers and authors.Mohammad Rashedul Islam et al (...) discuss the application of the SARA method in a district in Bangladesh. The method is based on the principle of Service Availability and Readiness Assessment of WHO. The study in a district in Bangladesh found that about 62% of all the facilities were ready to provide general services like basic amenities with basic equipment, standard precautions for infection prevention, diagnostic capacity and essential medicines. However in case of Non-Communicable Diseases (NCD), only 40% of the health facilities had chronic respiratory disease and cardiovascular diseases diagnosis/management and only 32% had availability of diabetes diagnosis/management. Therefore, service availability and readiness of the health facilities to provide NCD related health services were not satisfactory. The authors emphasize that SARA which is a tool to monitor facilities to be ready for provision of services including NCD, should be used by all clinic managers.The very scientific and forward looking article titled “SCNT Method and the Application for Patent Eligibility on Cloned Animals” by Norman K. Swazo reviews US federal court decisions regarding applications for patent in the case of live-born animal clones. A decision issued from the United States Court of Appeals for the Federal Circuit established an earlier decision of the Patent Trial and Appeal Board that live-born animals cloned by the somatic cell nuclear transfer method (SCNT) like cattle, sheep, pigs, and goats are not patentable, so a scientist using the method is not eligible for a patent claim on the animals. The author feels that this decision has ethical implications related to the moral status of cloned animals. The author argues whether the end product of a SCNT (somatic cell nuclear transfer) application is same as an invention or only a revelation of nature at the cellular level. The author quotes Article 11 of Universal Declaration on the Human Genome and Human Rights UNDHGR “Practices which are contrary to human dignity, such as reproductive cloning of human beings, shall not be permitted.” He concludes that the judicial assessments in the USA deciding on the question of patenting of animal clones provide important barriers to human reproductive cloning research, safeguarding moral and legal commitment to human dignity. The article on Ethics in Public Health Research and Clinical Research by Muhammad Waseem Khanet al discusses on the need to continue to focus on ethical values in conducting any research. Tha authors stress the importance, either in public health research or clinical research, of the need to recognize an ethical standard that respects individual’s autonomy and community’s wellbeing. This can be achieved through collective collaboration for the protection of individual’s autonomy, dignity and wellbeing. Research ethics is a fundamental criterion to be complied with throughout a research study. The very interesting article on Planetary Protection for Mars: Time for Reconsideration by Svetoslav Alexandrov looks into the ethical questions beyond mother earth but which could be affected by people from our planet. In this manuscript the author discusses the ethics of the protection of hypothetical organisms on Mars in terms of planned manned space missions and subsequent colonization. The author discusses the possible problems related to a process called terraformation where the planet is converted to make it suitable for Earth life. He argues that terraformation will change the whole condition of the planet. The author quotes Carl Sagan, of The Planetary Society: “If there is life, then I believe we should do nothing to disturb that life. Mars then, belongs to the Martians, even if they are microbes”. I think we all agree with this brilliant recommendation.The article ‘We Still Need to Improve Our Research Writing Ethics’ by Sheikh Arslan Sehgal looks into the value of maintaining professional integrity of research work. Particularly with issues like plagiarism, ethics, authorship and data fabrication. He argues that the scientific community must obey the scientific ethical norms and rules. He feels that ethical problems must be resolved for the advancement of research in countries including Pakistan. The author recommends teaching students the international, institutional and professional standards regarding research and authorship issue. Thus from the beginning researchers will know the key components of ethics in conducting research and the end product will be research work of quality and acceptability.Dear Readers, we look forward to your articles, commentaries, observations on different issues which touch our lives and will help in broadening our knowledge and understanding of Bioethics. (shrink)

This chapter describes the process of shaping ethical guidelines for an influenza pandemicInfluenza pandemic by the North Carolina Institute of Medicine (NC IOM)/North Carolina Department of Public Health (NCDPH) Task Force. The author discusses the threat of a pandemicPandemic in the twenty-first century, comparing a potential pandemic with past flu pandemics as well as the Severe Acute Respiratory Syndrome (SARS) outbreak in Canada and parts of Asia. Also discussed are the ways in which influenza would spread, be treated, and (...) hopefully contained. Addressed are the ways in which one becomes ethically prepared for an influenza pandemic, as well as the challenges to incorporating ethical guidelines in preparations. Tong also addresses the role of a dutyDuty/obligationObligation/responsibilityResponsibility to work by health care personnelHealth/ healthcare, right topersonnel, the role of volunteers, and when health care personnel may refuse to treat someone. Also taken into consideration are such issues as the distribution of food and vaccinesFlu vaccine, quarantinesQuarantine, work stoppage, both physical and social infrastructure, the role of military and police forces, and the effect of a pandemic, isolation, and quarantine on various industries. Tong shows the complicated nature of working on a task force and the complexity of incorporating ethicsCareethics of into logistical planning. (shrink)

This essay examines the management of ventilatory failure in disaster settings where clinical needs overwhelm available resources. An ethically defensible approach in such settings will adopt a “sufficiency of care” perspective that is: (1) adaptive, (2) resource-driven, and (3) responsive to the values of populations being served. Detailed, generic, antecedently written guidelines for “ventilator triage” or other management issues typically are of limited value, and may even impede ethical disaster response if they result in rescuers’ clumsily interpreting events through the (...) lens of the guideline, rather than customizing tactics to the actual context. Especially concerning is the tendency of some expert planners to mistakenly assume that medical treatment of respiratory failure: (1) always requires full-feature mechanical ventilators, (2) will always occur in hospitals, and (3) can be planned in advance without sophisticated public consultation about likely ethical dilemmas. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Road to RedemptionAnonymous TwoI “am Dr X.* and I am a trained and board certified neonatologist with some years of experience in a high volume NICU with complex pathologies. I have been dismissed from the care of your baby by the fetal surgeon who is not trained in what he’s attempting to do,” that was how I felt when I left the operating room (OR), after performing initial (...) resuscitation on a newborn with congenital diaphragmatic hernia (CDH) with very poor prenatal prognostic indices. CDH is a diaphragm abnormality that allows abdominal organs to move into the chest and restrict lung development. The better part of me knew not to make such a statement and chose not to do so, as this was about the family and a very sick baby, not the professional wrangling of two medical teams or the expression of frustration by a neonatologist who was morally conflicted.I work in a level four Neonatal Intensive Care Unit (NICU) and a very large one by any standard. Staff turnover had been an almost nonexistent issue in previous years because of the very conducive work environment of the NICU. Every team member (physician, nurse, respiratory therapist, pharmacist, etc.) felt like a stakeholder in providing optimal outcomes for the vulnerable neonates in the NICU.As change is the only constant thing in life, the hospital management decided to explore new frontiers and open a center for fetal medicine, with the hope of being a referral center in the region. They brought in a surgeon who came highly recommended for clinical acumen, but not for interpersonal relationship skills (unbeknownst to me). This surgeon, Dr Y., was hired to oversee the fetal center and build it into a center of excellence. Since this had to be a collaborative effort, other specialties (and subspecialties) had to be involved to make this a success. A representative from each of these specialties, including bioethics, was assigned to the fetal center team.The first inkling of a major problem occurred with the very first patient. The team met for the weekly meeting, reviewed the patient’s history and made a tentative plan, which included multidisciplinary counseling. This would require either a joint meeting with the patient or individual consults with the patient at her convenience. The following week at the weekly meeting, Dr Y. informed the group that he had met with the patient and counseled her and she had agreed to an extraordinary procedure for an oral lesion. In my opinion (and that of others), this lesion was not obstructive and could be immediately dealt with at delivery by an Otolaryngologist (ENT) surgeon, without putting the mother at risk for complications arising from the procedure being offered. There was a long discussion about why this was inappropriate [End Page E1] and why further imaging, discussion between the subspecialties and counseling should have been done prior to making this delivery plan. All felt this delivery plan could be remedied prior to delivery. However the surgeon had made plans with the obstetric team (who were at his mercy for financial/ political reasons) to continue with this plan. On the day of delivery, the NICU resuscitation team was called to another operating room instead of the labor and delivery room. I was even more appalled when I realized that the oral lesion was the size of a peanut! I felt like I failed in my obligation of veracity by avoiding the mother’s questions regarding the necessity of the procedure. Every member of my team felt the same and on several occasions I had to reassure concerned nurses that this was an aberrant occurrence that would not repeat itself... so I thought.I informed my departmental chairperson, Dr Z., who had a conversation with the fetal surgeon, Dr. Y., to inform him of my concerns and the effect of Dr. Y.’s actions on my group (physician, nurse practitioner, nurses). This led to being labeled unsupportive of Dr Y.’s goals and caused a less than cordial relationship towards me and the entire NICU group. The next week a picture of Dr Y. and the parents with the baby was on the front page... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Breaking the Readmission CycleBrian HattenI want to share the story of my difficult patient Ms. L. She has twenty-seven current medical issues. Thirty-five active prescriptions. Limited mobility requiring the use of a motorized scooter. Non-medical care gaps. And over twenty hospital admissions since 2020. I met Ms. L approximately five years ago as her hospital attending and have continued to care for her during her frequent hospitalizations. I could (...) recite this 77-year-old female's litany of medical problems. But sufficed to say, her history is complex, with her admitting diagnoses running the gambit from cellulitis to gastrointestinal bleeding to altered mental status. But, her diagnosis and frequent exacerbations of congestive heart failure (CHF) are particularly frustrating for us both and will be my focus today.CHF makes her susceptible to fluid overload leading to feelings of shortness of breath, which progresses to respiratory distress. Like other individuals with CHF, she uses diuretics to prevent herself from becoming fluid overloaded. And, like many individuals who take diuretics, she hates them. She (un)affectionately calls her water pills "the bomb" because the effect is sudden, profound, and explosive when they begin working. The combination of the diuretic effect and her limited mobility causes significant emotional stress for Ms. L, a woman who values presenting herself outwardly as in control, well-dressed, and put together. Her dislike of the medical effect of her diuretics has led to her either taking them less often or outright discontinuing them. So, while discontinuation avoids those frustrating effects, it leads to fluid accumulation, subsequent respiratory distress, and readmission to the hospital.Her medical records mention she has memory issues. It is unclear how much her mild cognitive impairment affects her frequent readmissions. We have had many conversations where I would never suspect something was amiss. But sometimes, she can be forgetful and does not recall our recent discussions. That being said, she knows the names and uses of her medications. She can report to me her home weights when she checks them and knows what her "dry" weight should be. Yet, she does not act when her scales begin reading heavier or when she develops leg swelling. Instead, she presents to the emergency department in extremis. When directly questioned about why she lets her situation deteriorate to such a state that she requires hospitalization, she demurs. She comments that she can often be stubborn, that the diuretic effect of "the bomb" is burdensome, but always reminds me she is honest in admitting she wasn't taking her water pills.During several admissions, I worried for her survival after she had self-discontinued her medications and showed up at the emergency department in respiratory failure. For any patient with recurrent admissions, I discuss their overall goals of care to ensure we are working together toward achievable medical ends. But this conversation was essential to have with Ms. L. The possibility existed that she would present to the hospital too late in her disease process, and we would not be able to correct her respiratory failure. I wanted to ensure that the hospital staff and I respected her wishes regarding her care. Despite raising my concerns, she would [End Page 22] decline to discuss her wishes. Even worse, attempting to have her complete advance care planning documents like advance directives or a Physician Orders for Life-Sustaining Treatment (POLST) form was a futile endeavor. Ms. L was always vague and non-committal. She simply did not want to engage in those types of conversations. When asked why she declined to discuss these issues, Ms. L would reply that she was doing okay, the discussion was unnecessary, and she had family members to make those decisions for her.Caring for her during her hospital stays was a source of professional frustration for me. Her recurrent admissions made me feel like I was failing her. During each hospital stay, we would go over her medications. We repeatedly discussed how she should check her weights daily and monitor for lower extremity edema. We created multiple action plans for when to call her physicians so we could head off another hospital visit. We completed all the... (shrink)

This paper examines the role of bioethics in the successful control of COVID-19 in New Zealand. After the severe acute respiratory syndrome coronavirus episode in Toronto researchers developed a framework of values and principles to articulate values that were already commonly accepted “in the community of its intended users,” to be used to inform decision-making. New Zealand subsequently developed its own framework that was embedded in its Pandemic Influenza Plan. These formed the basis of the New Zealand response to (...) COVID-19. This paper illustrates the ways in which the bioethical framework was reflected in the decisions and actions made by the government. (shrink)

Respiratory rhythms sustain biological life, governing the homeostatic exchange of oxygen and carbon dioxide. Until recently, however, the influence of breathing on the brain has largely been overlooked. Yet new evidence demonstrates that the act of breathing exerts a substantive, rhythmic influence on perception, emotion, and cognition, largely through the direct modulation of neural oscillations. Here, we synthesize these findings to motivate a new predictive coding model of respiratory brain coupling, in which breathing rhythmically modulates both local and (...) global neural gain, to optimize cognitive and affective processing. Our model further explains how respiratory rhythms interact with the topology of the functional connectome, and we highlight key implications for the computational psychiatry of disordered respiratory and interoceptive inference. (shrink)

This article reports two studies investigating the relationship between emotional feelings and respiration. In the first study, participants were asked to produce an emotion of either joy, anger, fear or sadness and to describe the breathing pattern that fit best with the generated emotion. Results revealed that breathing patterns reported during voluntary production of emotion were (a) comparable to those objectively recorded in psychophysiological experiments on emotion arousal, (b) consistently similar across individuals, and (c) clearly differentiated among joy, anger, fear, (...) and sadness. A second study used breathing instructions based on Study 1's results to investigate the impact of the manipulation of respiration on emotional feeling state. A cover story was used so that participants could not guess the actual purpose of the study. This manipulation produced significant emotional feeling states that were differentiated according to the type of breathing pattern. The implications of these findings for emotion theories based on peripheral feedback and for emotion regulation are discussed. (shrink)

Recent findings regarding the cellular biology and immunology of BST‐2 (also known as tetherin) indicate that its function could be exploited as a universal replication inhibitor of enveloped respiratory viruses (e.g., influenza, respiratory syncytial virus, etc.). BST‐2 inhibits viral replication by preventing virus budding from the plasma membrane and by inducing an antiviral state in cells adjacent to infection via unique inflammatory signaling mechanisms. This review presents the first comprehensive summary of what is currently known about BST‐2 anti‐viral (...) function against respiratory viruses, how these viruses construct countermeasures to antagonize BST‐2, and how BST‐2 function might be targeted to develop therapies to treat respiratory virus infections. The authors address the current gaps in knowledge, including the need for mechanistic understanding of BST‐2 antagonism by respiratory viruses, that should be bridged to achieve that goal. (shrink)

Contemplative practices, such as meditation and yoga, are increasingly popular among the general public and as topics of research. Beneficial effects associated with these practices have been found on physical health, mental health, and cognitive performance. However, studies and theories that clarify the underlying mechanisms are lacking or scarce. This theoretical review aims to address and compensate this scarcity. We will show that various contemplative activities have in common that breathing is regulated or attentively guided. This respiratory discipline in (...) turn could parsimoniously explain the physical and mental benefits of contemplative activities through changes in autonomic balance. We propose a neurophysiological model that explains how these specific respiration styles could operate, by phasically and tonically stimulating the vagal nerve: respiratory vagal nerve stimulation. The vagal nerve, as a proponent of the parasympathetic nervous system, is the prime candidate in explaining the effects of contemplative practices on health, mental health, and cognition. We will discuss implications and limitations of our model. (shrink)

There is a growing consensus that math anxiety highly correlates with trait anxiety and that the emotional component elicited by math anxiety affects math performance. Yet few studies have examined the impact of “specific math anxiety” on math performance and the underlying physiological and affective mechanism. The present study examines the mediation effect of heart rate variability—an affective measurement indexed by respiratory sinus arrhythmia —in the relationship between specific math anxiety and arithmetic speed. A total of 386 junior high (...) school students completed a self-reported questionnaire to measure their anxiety level. Among this sample, 29 individuals with specific math anxiety, 29 with specific reading anxiety, 24 with specific trait anxiety, and 22 controls were selected to participate in an arithmetic task and a reading task while RSA was recorded when they performed the tasks. Results revealed that individuals with specific math anxiety showed lower RSA and longer reaction time than the other three groups in the arithmetic task. Regression and mediation analyses further revealed that RSA mediated the relation between specific math anxiety and arithmetic speed. The present study provides the first account of evidence for the affective hypothesis of specific math anxiety and suggests that affective responses may be an important mechanism underlying the detrimental effect of specific math anxiety on math performance. (shrink)

Eyal et al have recently argued that researchers should consider conducting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) human challenge studies to hasten vaccine development. We have conducted (J. L.) and overseen (L. D.) human challenge studies and agree that they can be useful in developing anti-infective agents. We also agree that adults can autonomously choose to undergo risks with no prospect of direct benefit to themselves. However, we disagree that SARS-CoV-2 challenge studies are ethically appropriate at this time, (...) for 3 reasons: (1) current scientific knowledge of SARS-CoV-2 infection is insufficient to manage risks; (2) autonomous decision making, while necessary, does not override concerns about risk; and (3) undertaking challenge studies now would imperil confidence in the research enterprise, potentially undermining the global response to the coronavirus disease 2019 (COVID-19) pandemic. (shrink)

Our capacity for planning agency is central to our human lives. These essays aim both to deepen our understanding of basic norms that guide our plan-infused thinking and to defend their status as norms of practical rationality. This defense appeals both to forms of pragmatic support and to the ways in which these norms track conditions of a planning agent's self-governance, both at a time and over time.

In the following I discuss the debate between epistemological internalists and externalists from an unfamiliar meta-epistemological perspective. In doing so, I focus on the question of whether rationality is best captured in externalist or internalist terms. Using a conception of epistemic judgments as “doxastic plans,” I characterize one important subspecies of judgments about epistemic rationality—focusing on the distinctive rational/functional role these judgments play in regulating how we form beliefs. Then I show why any judgment that plays this role should be (...) expected to behave the manner internalists predict. In this way, I argue, we can explain why our basic toolbox for epistemic evaluation includes an internalist conception of rationality. (shrink)

We are purposive agents; but we—adult humans in a broadly modern world—are more than that. We are reflective about our motivation. We form prior plans and policies that organize our activity over time. And we see ourselves as agents who persist over time and who begin, develop, and then complete temporally extended activities and projects. Any reasonably complete theory of human action will need in some way to advert to this trio of features—to our reflectiveness, our planfulness, and our conception (...) of our agency as temporally extended. These are, further, features that have great significance for the kinds of lives we can live. For these two reasons I will say that these are among the core features of human agency. A theory of human action needs to say what these core features consist in and how they are related to each other. And such a theory needs also to clarify the relation between these core features of our agency and the possibility that we are fully embedded in an event causal order. (shrink)

Graphical AbstractTesting for respiratory viruses and SARS-CoV-2 in clinical and epidemiological settings has contrasting purposes and utility. Symptomatic patients are best tested with respiratory virus panels to establish the pathogen and guide personalized treatment. Asymptomatic patients are tested for a single infectious pathogen to establish carrier status and guide containment.

We sometimes strive to achieve difficult goals when our evidence suggests that success is unlikely – not just because it will require strength of will, but because we are targets of prejudice and discrimination or because success will require unusual ability. Optimism about one’s prospects can be useful for persevering in these cases. That said, excessive optimism can be dangerous; when our evidence is unfavourable, we should be at most agnostic about whether we will succeed. This paper explores the nature (...) and rational significance of agnostic practical commitments. Most importantly, the rationality of striving against the odds can depend on investing in a plan for failure: a plan B. I aim to make headway on an account of what backup plans are, how they are related to primary plans, and whether the standard norms of plan rationality apply to our agnostic commitments. (shrink)