Transport of DNA across bacterial membranes involves complex DNA uptake systems. In Gram‐positive bacteria, the DNA uptake machinery shares fundamental similarities with type IV pili and type II secretion systems. Although dedicated pilus structures, such as type IV pili in Gram‐negative bacteria, are necessary for efficient DNA uptake, the role of similar structures in Gram‐positive bacteria is just beginning to emerge. Recently two essentially very different pilus structures composed of the same major pilin protein ComGC were proposed to be involved (...) in transformation of the Gram‐positive bacterium Streptococcus pneumoniae – one is a long, thin, type IV pilus‐like fiber with DNA binding capacity and the other one is a pilus structure that was thicker, much shorter and not able to bind DNA. Here we discuss how competence induced pili, either by pilus retraction or by a transient pilus‐related opening in the cell wall, may mediate DNA uptake in S. pneumoniae. (shrink)

BackgroundAlthough the Life-Sustaining Treatment (LST) Decision Act was enforced in 2018 in Korea, data on whether it is well established in actual clinical settings are limited. Hospital-acquired pneumonia (HAP) is a common nosocomial infection with high mortality. However, there are limited data on the end-of-life (EOL) decision of patients with HAP. Therefore, we aimed to examine clinical characteristics and outcomes according to the EOL decision for patients with HAP.MethodsThis multicenter study enrolled patients with HAP at 16 referral hospitals retrospectively from (...) January to December 2019. EOL decisions included do-not-resuscitate (DNR), withholding of LST, and withdrawal of LST. Descriptive and Kaplan–Meier curve analyses for survival were performed.ResultsOf 1,131 patients with HAP, 283 deceased patients with EOL decisions (105 cases of DNR, 108 cases of withholding of LST, and 70 cases of withdrawal of LST) were analyzed. The median age was 74 (IQR 63–81) years. The prevalence of solid malignant tumors was high (32.4% vs. 46.3% vs. 54.3%, P = 0.011), and the ICU admission rate was lower (42.9% vs. 35.2% vs. 24.3%, P = 0.042) in the withdrawal group. The prevalence of multidrug-resistant pathogens, impaired consciousness, and cough was significantly lower in the withdrawal group. Kaplan–Meier curve analysis revealed that 30-day and 60-day survival rates were higher in the withdrawal group than in the DNR and withholding groups (log-rank P = 0.021 and 0.018). The survival of the withdrawal group was markedly decreased after 40 days; thus, the withdrawal decision was made around this time. Among patients aged below 80 years, the rates of EOL decisions were not different (P = 0.430); however, mong patients aged over 80 years, the rate of withdrawal was significantly lower than that of DNR and withholding (P = 0.001).ConclusionsAfter the LST Decision Act was enforced in Korea, a DNR order was still common in EOL decisions. Baseline characteristics and outcomes were similar between the DNR and withholding groups; however, differences were observed in the withdrawal group. Withdrawal decisions seemed to be made at the late stage of dying. Therefore, advance care planning for patients with HAP is needed. (shrink)

This paper describes the application of eight statistical and machine-learning methods to derive computer models for predicting mortality of hospital patients with pneumonia from their findings at initial presentation. The eight models were each constructed based on 9847 patient cases and they were each evaluated on 4352 additional cases. The primary evaluation metric was the error in predicted survival as a function of the fraction of patients predicted to survive. This metric is useful in assessing a model’s potential to assist (...) a clinician in deciding whether to treat a given patient in the hospital or at home. We examined the error rates of the models when predicting that a given fraction of patients will survive. We examined survival fractions between 0.1 and 0.6. Over this range, each model’s predictive error rate was within 1% of the error rate of every other model. When predicting that approximately 30°K of the patients will survive, all the models have an error rate of less than 1.5%. The models are distinguished more by the number of variables and parameters that they contain than by their error rates; these differences suggest which models may be the most amenable to future implementation as paper-based guidelines. (shrink)

In this article, we investigated a deterministic model of pneumonia-meningitis coinfection. Employing the Atangana–Baleanu fractional derivative operator in the Caputo framework, we analyze a seven-component approach based on ordinary differential equations. Furthermore, the invariant domain, disease-free as well as endemic equilibria, and the validity of the model’s potential results are all investigated. According to controller design evaluation and modelling, the modulation technique devised is effective in diminishing the proportion of incidences in various compartments. A fundamental reproducing value is generated by (...) exploiting the next generation matrix to assess the properties of the equilibrium. The system’s reliability is further evaluated. Sensitivity analysis is used to classify the impact of each component on the spread or prevention of illness. Using simulation studies, the impacts of providing therapy have been determined. Additionally, modelling the appropriate configuration demonstrated that lowering the fractional order from 1 necessitates a rapid initiation of the specified control technique at the largest intensity achievable and retaining it for the bulk of the pandemic’s duration. (shrink)

Non-treatment decisions concerning demented patients are complex: in addition to issues concerning the health of patients, ethical and legal issues are involved. This paper describes a method for the development of a guideline that clarifies the steps to be taken in the decision making process whether to forgo curative treatment of pneumonia in psychogeriatric nursing home patients.The method of development consisted of seven steps. Step 1 was a literature study from which ethical, juridical and medical factors concerning the patient's health (...) and prognosis were identified. In step 2, a questionnaire was sent to 26 nursing home physicians to determine the relative importance of these factors in clinical practice. In a meeting of nine experienced physicians , the factors identified in step 2 were confirmed by most of these professionals. To prevent the final guideline being too directive, a concept guideline that included ethical and legal aspects was designed in the form of a “checklist of considerations” . Experts in the fields of nursing home medicine, ethics and law reviewed and commented on the concept guideline . The accordingly adapted “checklist of considerations” was tested in a pilot study , after which all experts endorsed the checklist .The resulting “checklist of considerations” structures the decision making process according to three primary domains: medical aspects, patient's autonomy, and patient's best interest. (shrink)

Stuttering is one of the most well-known speech disorders, but the underlying neurological mechanisms are debated. In addition to genetic factors there are also major non-genetic contributions. It is here proposed that infection with group A beta-hemolytic streptococcus (GAS) was a major underlying cause of stuttering until the mid 1900s, when penicillin was introduced for the treatment of streptococcal infections about 1946. The main mechanism proposed is an autoimmune reaction from tonsillitis, targeting specific molecules, for example within the basal (...) ganglia. It is here also proposed that GAS infections may have continued to cause stuttering to some extent, to the present date, though more rarely. If so, early diagnosis of such cases would be of importance. Childhood cases with sudden onset of stuttering after throat infection may be particularly important to assess for possible GAS infection. The support for this hypothesis primarily comes from three lines of argument. First, medical record data from the 1930s strongly indicates that there was one type of medical event in particular that preceded the onset of childhood stuttering with unexpected frequency: diseases related to GAS throat infections. In particular, this included tonsillitis and scarlet fever, but also rheumatic fever. Rheumatic fever is a childhood autoimmune sequela of GAS infection, which was a relatively widespread medical problem until the early 1960s. Secondly, available reports of changes of the childhood prevalence of stuttering indicates striking parallels between stuttering and the incidence of rheumatic fever, with (1) decline from the early 1900s, (2) marked decline from the introduction of penicillin about 1946, and (3) reaching a more stable level in the 1960s. The correlations between the data for stuttering and for rheumatic fever after introduction of penicillin are very high, at about 0.95. Thirdly, there are established biological mechanisms linking GAS tonsillitis to immunological effects on the brain. In addition, a small number of more recent case reports have provided further support for the hypothesis linking stuttering to GAS infection. Overall, it is proposed that the available data provides strong evidence for the hypothesis that GAS infection was a major cause of stuttering until the mid 1900s. (shrink)

The Streptococcus pyogenes CRISPR‐Cas system has gained widespread application as a genome editing and gene regulation tool as simultaneous cellular delivery of the Cas9 protein and guide RNAs enables recognition of specific DNA sequences. The recent discovery that Cas9 can also bind and cleave RNA in an RNA‐programmable manner indicates the potential utility of this system as a universal nucleic acid‐recognition technology. RNA‐targeted Cas9 (RCas9) could allow identification and manipulation of RNA substrates in live cells, empowering the study of (...) cellular gene expression, and could ultimately spawn patient‐ and disease‐specific diagnostic and therapeutic tools. Here we describe the development of RCas9 and compare it to previous methods for RNA targeting, including engineered RNA‐binding proteins and other types of CRISPR‐Cas systems. We discuss potential uses ranging from live imaging of transcriptional dynamics to patient‐specific therapies and applications in synthetic biology. (shrink)

The new coronary pneumonia epidemic has had a tremendous impact on the world economic situation, causing a large number of enterprises to suffer from serious losses, but also bringing a large number of entrepreneurial opportunities. For college students, whether the opportunities brought by the epidemic can attract them to step into the entrepreneurial path becomes a question worthy of attention in the process of restoring economic vitality and guiding students’ employment and entrepreneurship. In this article, a mediation model was constructed (...) and tested through 245 questionnaire data by combining event system theory, regulatory focus theory, and emotion cognitive evaluation theory. The results showed that defensive regulatory focus and fear of failure and facilitative regulatory focus and fear of failure were all able to continuously mediate the effect of event intensity of the new coronary pneumonia epidemic on the entrepreneurial intentions of college students. (shrink)

Background: In 2019, an outbreak of COVID-19 broke out in Hubei, China. Medical workers from all over the country rushed to Hubei and participated in the treatment and care of COVID-19 patients. These nurses, dedicated to their professional practice, volunteered to provide compassion and expert clinical care during the pandemic. As with other acts of heroism, the ethical dilemmas associated with working on the front line must be considered for future practice. Purpose: To explore the ethical dilemmas of frontline nurses (...) of Jiangsu Province in China during deployment to Wuhan to fight the novel coronavirus pneumonia, and to provide a basis for developing strategies to help nursing staff address personal and practice concerns in order to work more effectively during this pandemic and other disasters in the future. Research design and method: Using the phenomenological research method and the purpose sampling method, semi-structured interviews were conducted with 10 nurses, post-deployment to Wuhan, who had worked on the front line to fight the novel coronavirus. Ethical considerations: The research proposal was approved by the Research Ethic Committee of Yangzhou University, China. Findings: From the analysis of the interviews of the 10 participants, three main themes were identified: ethical dilemmas in clinical nursing, ethical dilemmas in interpersonal relationships, and ethical dilemmas in nursing management. Conclusion: During a quick response to public health emergencies, where nurses are deployed immediately as a call to action, the issues surrounding ethical dilemmas from several perspectives must be considered. This research suggests that a team approach to proactive planning and open communication during the emergency is an efficient and productive strategy to improve the nurses’ experience and sense of well-being. (shrink)

Disease control has increasingly shifted towards large scale, disease specific, public health interventions. The emerging problems of HIV, hepatitis, malaria, typhoid, tuberculosis, childhood pneumonia, and meningitis have made community based trials of interventions a cost effective long term investment for the health of a population. The authors conducted this study to explore the complexities involved in obtaining informed consent to participation in rural north India, and how people there make decisions related to participation in clinical research.

Background The involvement of pregnant women in vaccine clinical trials presents unique challenges for the informed consent process. We explored the expectations and experiences of the pregnant women, spouses/partners, health workers and stakeholders of the consent process during a Group B Streptococcus maternal vaccine trial. Methods We interviewed 56 participants including pregnant women taking part in the trial, women not in the trial, health workers handling the trial procedures, spouses, and community stakeholders. We conducted 13 in-depth interviews and focus (...) group discussions with 23 women in the trial, in-depth interviews with 5 spouses, and 5 women not in the trial, key informant interviews with 5 health workers and 5 other stakeholders were undertaken. Results Decision-making by a pregnant woman to join a trial was done in consultation with spouse, parents, siblings, or trusted health workers. Written study information was appreciated by all but they suggested the use of audio and visual presentation to enhance understanding. Women stressed the need to ensure that their male partners received study information before their pregnant partners joined a clinical trial. Confidentiality in research was emphasised differently by individual participants; while some emphasised it for self, others were keen to protect their family members from being exposed, for allowing them to be involved in research. However, others wanted their community participation to be acknowledged. Conclusion We found that pregnant women make decisions to join a clinical trial after consulting with close family. Our findings suggest the need for an information strategy which informs not only the pregnant woman, but also her family about the research she is invited to engage in. (shrink)

Background: Ethical challenges are common in clinical nursing practice, and an infectious environment could put nurses under ethical challenges more easily, which may cause nurses to submit to negative emotions and psychological pressure, damaging their mental health. Purpose: To examine the ethical challenges encountered by nurses caring for patients with the novel coronavirus pneumonia and to provide nurses with suggestions and support regarding promotion of their mental health. Research design and method: A qualitative study was carried out using a qualitative (...) content analysis. The participants were 18 nurses who agreed to attend an interview and describe their own experiences of providing care to COVID-19 patients in China. They were purposively sampled, and structured, in-depth interviews were performed. Data were iteratively collected and analyzed from February to March 2020. Ethical considerations: The proposal was approved by the Research Ethics Committee of the Second Hospital of Shandong University, China. Findings: The findings revealed three main themes and 10 categories. The themes were the following: ethical challenges ; coping styles ; and impacts on career. Conclusion: Nurses faced ethical challenges on multiple fronts in caring for COVID-19 patients. The results may help nurses with more safety, ethics, and humanistic care in nursing practice. (shrink)

Withholding and withdrawing artificial nutrition and hydration from terminally ill patients poses many ethical challenges. The literature provides little information about the Islamic beliefs, attitudes, and laws related to these challenges. Artificial nutrition and hydration may be futile and reduce quality of life. They can also harm the terminally ill patient because of complications such as aspiration pneumonia, dyspnea, nausea, diarrhea, and hypervolemia. From the perspective of Islam, rules governing the care of terminally ill patients are derived from the principle (...) that injury and harm should be prevented or avoided. The hastening of death by the withdrawal of food and drink is forbidden, but Islamic law permits the withdrawal of futile, death-delaying treatment, including life support. Nutritional support is considered basic care and not medical treatment, and there is an obligation to provide nutrition and hydration for the dying person unless it shortens life, causes more harm than benefit, or is contrary to an advance directive that is consistent with Islamic law. The decision about withholding or withdrawing artificial nutrition and hydration from the terminally ill Muslim patient is made with informed consent, considering the clinical context of minimizing harm to the patient, with input from the patient, family members, health care providers, and religious scholars. (shrink)

Mr. M. was a 77-year-old decisionally incapacitated long-term nursing home resident with chronic schizophrenia who was admitted to the hospital with a bacterial pneumonia. His past medical history was notable for deteriorating functional status over the past 2-3 years, urinary retention requiring chronic indwelling bladder catheterization, and two recent hospitalizations for urinary tract infections leading to sepsis. He developed respiratory failure soon after admission and was intubated and placed on mechanical ventilation. Follow-up studies suggested worsening pneumonia and acute respiratory distress (...) syndrome, as well as worsening kidney function. (shrink)

The novel coronavirus disease is regarded as one of the most imminent disease outbreaks which threaten public health on various levels worldwide. Because of the unpredictable outbreak nature and the virus’s pandemic intensity, people are experiencing depression, anxiety, and other strain reactions. The response to prevent and control the new coronavirus pneumonia has reached a crucial point. Therefore, it is essential—for safety and prevention purposes—to promptly predict and forecast the virus outbreak in the course of this troublesome time to have (...) control over its mortality. Recently, deep learning models are playing essential roles in handling time-series data in different applications. This paper presents a comparative study of two deep learning methods to forecast the confirmed cases and death cases of COVID-19. Long short-term memory and gated recurrent unit have been applied on time-series data in three countries: Egypt, Saudi Arabia, and Kuwait, from 1/5/2020 to 6/12/2020. The results show that LSTM has achieved the best performance in confirmed cases in the three countries, and GRU has achieved the best performance in death cases in Egypt and Kuwait. (shrink)

Background: With the coming of the Industrial Revolution, the levels of pollution grow significantly. This Technological development contributed to the worsening of shortness breath problems in great shape. especially in infants and children. There are many shortness breath diseases that infants and children face in their lives. Shortness of breath is one of a very serious symptom in children and infants and should never be ignored. Objectives: Along these lines, the main goal of this expert system is to help physician (...) in diagnosing and describe some common causes of shortness of breath in infants and children by diagnosing their cases through our expert system. Moreover, this system which we are presenting will give patient the appropriate diagnosis of disease and the treatment required. Methods: In this paper the strategy of the expert system for diagnosing a number of the existed shortness of breath in infants and children diseases such as (Asthma , Bronchiolitis, Viral Pneumonia, cough, Shortness of breath' dyspnea ', Epiglottitis, Croup, ABSCESS in the tonsil 'peritonsillar abscess', Bronchitis, Viral Bronchitis, Wheezing, sudden infant death syndrome 'SIDS' ) is introduced, an overview about the shortness of breath in children and infants diseases are delineated, the cause of diseases are sketched and the treatment of disease whenever conceivable is given . SL5 Object Expert System language was utilized for designing and implementing the proposed expert system. Results: The proposed shortness of breath in children and infants diseases diagnosis expert system was estimated by Medical students and they were satisfied with its result. Conclusions: The Proposed expert system is very useful for Respiratory physician, pediatrician, recently graduated physician, and for children's parents with shortness of breath problem. (shrink)

Recently, the pandemic caused by COVID-19 is severe in the entire world. The prevention and control of crimes associated with COVID-19 are critical for controlling the pandemic. Therefore, to provide efficient and convenient intelligent legal knowledge services during the pandemic, we develop an intelligent system for legal information retrieval on the WeChat platform in this paper. The data source we used for training our system is “The typical cases of national procuratorial authorities handling crimes against the prevention and control of (...) the new coronary pneumonia pandemic following the law”, which is published online by the Supreme People’s Procuratorate of the People’s Republic of China. We base our system on convolutional neural network and use the semantic matching mechanism to capture inter-sentence relationship information and make a prediction. Moreover, we introduce an auxiliary learning process to help the network better distinguish the relation between two sentences. Finally, the system uses the trained model to identify the information entered by a user and responds to the user with a reference case similar to the query case and gives the reference legal gist applicable to the query case. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Gaining a Heart But Missing MyselfLeilani R. GrahamI gathered it in my hands as it fell from my hair-brush, too saturated to hold anymore. It felt as if I were inside a movie and waiting for someone to yell “Cut!” but no call came. It continued to fall, feather-like onto the ground, individual strands glinting in the light of the bathroom window. My hair, nearly all of it, was (...) gone.Between the time of my heart transplant and the moment my hair began to fall out, I arguably had suffered enough. Transplant brought four open-heart surgeries, ten days on ECMO, an intra-aortic balloon pump, delirium, necrotizing pneumonia, and so much muscular atrophy that I had to re-learn how to walk. CPR, broken ribs, and the scar of a tricuspid clip from a botched biopsy: it was not the miracle I was hoping for.The internal trauma had certainly taken its toll. I no longer knew how I really felt, thanks to copious pain meds that altered my mind and body. Each limb was foreign as I re-acclimated to how one grabs hold of a cup, signs their name, touches their legs. Externally, I was a mess: covered in deep purple bruises across my torso from the diabetes treatments, dead skin pooling in unwashed pores, my ankles swollen and indiscernible from my legs. But lacking a good mirror (or the desire to find one), I still felt like “myself” during my forty-five day hospital stay. I could feel my cheekbones protruding from thinning skin, saw through unfocused eyes from the tempestuous blood sugars, and my hair sat in a rat’s nest atop my head; but I was still me.Arriving home, I felt like a newborn being brought into the real world for the first time. I needed help with everything—showers, sitting up, putting on shoes, even going to the bathroom. At age twenty-four, I felt I had regressed to the point of no return as I relied on others to do the simplest tasks. In addition, I was quarantined inside for three months, due to the risk of obtaining a fungal infection from the outside. Caged, and alone in my body, I a trapped and wounded tiger: angry, hurting, and scared. [End Page 109]When I had been prepared for transplant—and I use “prepared” loosely because the information packet I was handed was insulting at best—I knew to expect the scars. I had no issue with that, having been cut open at my throat and chest for previous surgeries. I knew to expect a 12-inch line from neck to navel: the most evident sign I would now carry that I was disabled.What I did not expect were the bullet holes— the sealed entrances of thick chest tubes that now dotted my lower torso. I did not anticipate the bruises on my arms and groin from arterial pokes. I felt violated as if I had walked into some kind of abduction and was rolled out, beaten, bruised, and, worst, touched.But it wasn’t the physical trauma that hurt the most. It was that no one seemed surprised.Immediately after transplant, the team’s focus is purely on survival. Survive the 30 days post-surgery. Survive the year. Metrics, uncomfortably tied to transplant center success statistics, funding, and clout have little to do with the patients themselves. What did I care to only survive a year? I wanted years. I wanted decades. It felt I wanted more than anyone was willing to pay attention to.The conversation was narrowed to high-risk issues: infection, rejection, or other life-threatening conditions. While this makes sense on a clinical level, what constitutes a major event for a clinician may not be of the same emotional value to the patient. In my case, I was less occupied by how the steroids were working and more obsessed with their side effects, such as how much weight I was rapidly gaining. I walked into the clinic one day with the beginnings of stretch marks and a week later had claw-like ripples down my sides. My mood swings were explosive... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Global Health Careers:Serving the Navajo CommunityMaricruz Merino, Jonathan Iralu, and Sonya ShinGallup Indian Medical Center (GIMC) sits on a hilltop in Gallup, New Mexico, a town of 20,000 in the four corners region of the Southwestern United States. From its third story windows one can see the red cliffs of the nearby Navajo Nation, a 27,000 square mile reservation that reaches into Arizona, northern New Mexico, and the southern (...) edges of Utah. It is a vast, rural landscape that houses more than 350,000 Navajos. For many on the reservation, healthcare is provided by Indian Health Service hospitals such as GIMC."Are you going to stay?" is a common question for new doctors at GIMC. The Navajo know that their geographic location, while beautiful and attractive to many young providers, will also be the reason they leave. It is hard for doctors to be away from their own homelands. Aging parents get sick, [End Page 86] educational opportunities arise, and children who need to be near extended family are born. But to the Navajo, the story of an individual provider is not so important or memorable. All they know is that providers come and go."Are you here to experiment on us?" is yet another question. Years of exploitation and efforts to destroy traditional ways and language have made many Navajo wary of healthcare providers, no matter how genuine their intentions. Many are so fearful of the hospital—they regard it as "the place to go die."Yet despite this initial suspicion, the Navajo are welcoming people at heart, and tend to develop relationships of trust with their providers. Parents will begin to talk about their grief over a son that has committed suicide or a daughter who died from alcoholic cirrhosis. The elderly will tell you how they care for their five orphaned grandchildren while they can barely take care of their own diabetes. A carpenter tells you he has not worked in a year and feels worthless. An HIV-positive woman will tell you she has been sleeping in a dry river bed because she has no place to go. It quickly becomes apparent that as a physician you will be treating patients with enormous social challenges in addition to complex medical conditions.The origins of the Federal Government's involvement in the healthcare of American Indians and Alaskan Natives (AI/ANs) in the 19th century arose out of both legal obligation and concern for self- preservation. Health services were promised to AI/ ANs in exchange for land, settlements, and agreements. In addition, infectious diseases endemic on reservations as a consequence of crowding and abject poverty, including smallpox and tuberculosis, were seen as a major public health concern. The responsibility of Native American health was first granted to the War Department, then to the Bureau of Indian Affairs, and finally to the Public Health Service in 1955 under the heading of the IHS, or Indian Health Service (U.S. Commission on Civil Rights, 2004; National Library of Medicine, 1994).Since then, the IHS has had many successes. Vaccination rates have gone up, and rates of pneumonia and tuberculosis have gone down significantly. Maternal and infant mortality have declined, and life expectancy has increased (Indian Health Services, 1999). Nonetheless, these improvements remain overshadowed by glaring health disparities among AI/ANs across a broad spectrum of diseases, both communicable and non-communicable, acute and chronic. Native Americans experience higher rates of obesity, diabetes, and cardiovascular disease than the general United States population. They are also more likely to die from alcohol-related causes and in accidents. Life expectancy remains more than five years less than that of the general U.S. population (U.S. Commission on Civil Rights, 2004; U.S. Department of Health and Human Services, 2000).Underlying these health indicators is the continued impoverished status of most AI/ANs. In Navajo, almost half of the population lives below the poverty line. According to the Navajo Nation, the current unemployment rate is 42% (Navajo Nation Department of Economic Development, 2011). Many Navajo on the reservation do not have running water or electricity. They heat with wood, which they chop and haul themselves—regardless... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:CompassionEdward J. VolpintestaTo the Editor: In his essay, “Can We Mandate Compassion?” (March–April 2011), Ron Paterson, a former health and disability commissioner in New Zealand, discusses the decline of physicians’ compassion—an issue that is receiving more attention in the media, and in our journals, hospitals, and medical societies, as well.He decided—and I agree—that compassion should not be mandated. How could it be? After all, it’s unquantifiable; it’s not meted (...) out in milliliters or grams. Compassion is a spontaneous emotion that arises from the individual caregiver’s spiritual reservoirs. Trying to regulate or mandate it would be absurd—the ultimate attempt at dehumanizing medicine. Giving students more exposure to the humanities, however, and teaching doctors what is not acceptable in “terms of conduct, attitudes, and behavior” may increase awareness of its importance. Putting that awareness into action is another thing.Could it be that physicians are too hard-pressed for time and too overstressed with ordering and interpreting tests that they have little time and energy left for compassion? Has the threat of malpractice suits made physicians distrust patients, seeing them more as potential lawsuits than as suffering human beings, as horrible as that may sound to some? Or has the vast amount of new medical knowledge that rapidly reaches doctors given them an information overload so great that they have room only for cognition and none for emotion? When one adds the pressure physicians feel to control costs and to follow guidelines that often clash with their judgment, it becomes clear why compassion has declined.As a primary care doctor, there are days when all I have to offer some patients is compassion. A divorce, problems with personal finances, depression, a recent death, a child in trouble with the law or with drugs, an unwanted pregnancy—these are some of the problems that are the most difficult and time-consuming for me. They do not require any new scientific knowledge. Like compassion, they are not quantifiable, and there are no board exams to test how well I help my patients cope with them. There is also no code that I can send to an insurance company that will accurately convey what I have done, or its value to my patients. Only my patient and I are aware of whether I was able to use compassion in a way that helped. How could it be otherwise?It is much easier for me to treat a patient with pneumonia or conjunctivitis. I doubt that there ever will be a foolproof way to teach compassion to physicians. Perhaps performing psychological tests on incoming medical students may be the best way to determine which are most inclined to become compassionate physicians.The Flexner Report of 1910, which contained many recommendations for improving medical education, may have overstressed the importance of science while neglecting the human dimensions of medical practice. The Carnegie Foundation, which funded the original study, has undertaken a second examining any unintended consequences of the first. Unlike the first, which was dominated by one man, the second comprises a broad team of educators, doctors, philosophers, and psychologists. Perhaps this broader approach will restore compassion to its rightful place.Letters to the editor may be sent by e-mail to [email protected], or to Managing Editor, Hastings Center Report, 21 Malcolm Gordon Road, Garrison, NY 10524; (845) 424-4931 fax. Letters appearing in the Report may be edited for length and stylistic consistency.Statement of Ownership, Management, and CirculationThe Hastings Center Report is a bimonthly journal published by The Hastings Center, 21 Malcolm Gordon Road, Garrison, NY 10524. The editor is Gregory Kaebnick, at the same address. The annual subscription price is $80; contact person is Anne Marie Schoonhoven; telephone number is 845-424-4040. The tax status of the organization has not changed during the preceding twelve months.As of the filing date of September 6, 2011, the average number of copies of each issue during the preceding twelve months was 3,342; the actual number of copies of the single issue published nearest to the filing date was 3,150. The journal has a total paid and/or requested circulation... (shrink)

Objectives To conduct an independent evaluation of the first phase of the Health Foundation’s Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design Mixed method evaluation involving five substudies, before and after design. Setting NHS hospitals in the United Kingdom. Participants Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention The SPI1 (...) was a compound (multi-component) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration—monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items)—there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for “difference in difference” 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from 17% (63) to 13% (49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening. (shrink)

A 78 year old married woman with progressive Alzheimer's disease was admitted to a local hospital with pneumonia and other medical problems. She recognized no one and had been incontinent for about a year. Despite aggressive treatment, the pneumonia failed to resolve and it seemed increasingly likely that this admission was to be for terminal care. The patient's husband (who had been taking care of her in their home) began requesting that the doctors be less aggressive in her treatment and, (...) as the days wore on, he became more and more insistent that they scale back their aggressive care. The physicians were reluctant to do so, due to the small but real chance that the patient could survive to discharge. But her husband was her only remaining family, so he was the logical proxy decisionmaker. Multiple conferences ensued, and finally a conference with a social worker revealed that the husband had recently proposed marriage to the couple's housekeeper and she had accepted. (shrink)

Previous studies have documented the fallibility of attempts by surrogates and physicians to act in a substituted judgment capacity and predict end-of-life treatment decisions on behalf of patients. We previously reported that physicians misperceive their patients' preferences and substitute their own preferences for those of their patients with respect to four treatments: cardiopulmonary resuscitation in the event of cardiac arrest, ventilator for an indefinite period of time, medical nutrition and hydration for an indefinite period of time, and hospitalization in the (...) event of pneumonia. (shrink)

The ongoing coronavirus 2019 pandemic caused by the severe acute respiratory syndrome coronavirus 2 has resulted in a severe ramification on the global healthcare system, principally because of its easy transmission and the extended period of the virus survival on contaminated surfaces. With the advances in computer-aided diagnosis and artificial intelligence, this paper presents the application of deep learning and adversarial network for the automatic identification of COVID-19 pneumonia in computed tomography scans of the lungs. The complexity and time limitation (...) of the reverse transcription-polymerase chain reaction swab test makes it disadvantageous to depend solely on as COVID-19’s central diagnostic mechanism. Since CT imaging systems are of low cost and widely available, we demonstrate that the drawback of the RT-PCR can be alleviated with a faster, automated, and reduced contact diagnostic process via the use of a neural network model for the classification of infected and noninfected CT scans. In our proposed model, we explore the benefit of transfer learning as a means of resolving the problem of inadequate dataset and the importance of semisupervised generative adversarial network for the extraction of well-mapped features and generation of image data. Our experimental evaluation indicates that the proposed semisupervised model achieves reliable classification, taking advantage of the reflective loss distance between the real data sample space and the generated data. (shrink)

Advance directives for withholding life-saving treatment are controversial for dementia patients whose previously expressed wishes conflict with their currently expressed desires. To illustrate this ethical dilemma, McMahan conceives a hypothetical case in which an intellectually proud creative woman signs an advance directive stipulating her refusal to receive life-saving treatment if she contracts a fatal condition with dementia. However, when she develops dementia and forgets this advance directive, she contracts pneumonia and now expresses a desire to live. In response to such (...) dilemmas, scholars like Norman Cantor have defended the moral authority of advance directives by giving credence to one’s prior competent wishes over one’s current incompetent preferences. I argue that their arguments, which are rooted in the principle of respect for autonomy, operate under ableist assumptions about incompetent persons and exclude other important features of respect. I propose an ethics of care model as an alternative moral approach that reconceptualises respect as a matter of caring about people’s contemporaneous interests, even if they are not competently conceived. It fosters the virtues of care by encouraging healthcare providers to recognise dementia patients as legitimate narrative agents capable of authoring their own evolving life story. I argue that the ethics of care model not only provides an ethical defence of the creative woman’s current incompetent desire to live despite her advance directive, but also vindicates our moral intuitions about what it means to demonstrate respect to dementia patients. (shrink)

RD, a 32-year-old male, was admitted to the hospital with hypoxic COVID pneumonia–a potentially life-threatening condition characterized by dangerously low levels of oxygen in the body- during one of the pandemic’s surges. While RD’s age gave the clinical team hope for his prognosis, his ability to recover was complicated by his being unvaccinated and having multiple comorbidities, including diabetes and obesity. His condition worsened to the point that he required extracorporeal membrane oxygenation (ECMO), a machine that maintains the functioning of (...) a person’s heart and lungs. -/- Given its scarcity–only 264 of the over 6,000 hospitals in the United States offer ECMO, according to the Extracorporeal Life Support Organization–as well as its high cost and the inadequate supply of staff required to maintain it, ECMO primarily serves as a bridge to support critically ill patients until they can receive an organ transplant or implanted medical device. For RD, ECMO was started to support him until he could be evaluated for, and possibly receive, a bilateral lung transplant. Despite its intended use as a treatment of last resort, some patients can remain on ECMO for weeks or months. And some are awake, alert, and capable of medical decision-making. -/- RD was one such patient. However, the transplant evaluation committee ruled out RD’s candidacy for bilateral lung transplantation, based on his poor potential for recovery and a lack of family and friends to provide post-transplant support. This determination raised the prospect of continued ECMO treatment being a bridge to nowhere. But RD was comfortable on ECMO and wanted to remain in the ICU. The ICU intensivist contacted the ethics consult service with questions about whether continued ECMO support was medically and ethically inappropriate. (shrink)

Ronald Dworkin introduced the example of Margo, who was so severely demented that she could not recognise any family or friends, and could not remember anything of her life. At the same time, however, she seemed full of childish delight. Dworkin also imagines that, before her dementia, Margo signed an advance refusal of life-saving treatment. Now severely demented, she develops pneumonia, easy to treat, but lethal if untreated. Dworkin argues that the advance refusal ought to be heeded and Margo be (...) allowed to die of that pneumonia, on the basis that the prior refusal expresses her true wishes. In this paper I want to challenge Dworkin’s understanding of identity and his conclusion about advance refusals, and I develop my argument in two directions. First, I argue that the demented Margo is not some ‘lesser’ version of the ‘true’ Margo, but instead that the present Margo’s wishes should take precedence over those of the past Margo, on the grounds that all of us are entitled to change our minds. Second, I argue for a stronger role for friends and family members in sustaining the demented Margo’s identity through her years of decline. Based on this, I argue for a presumption against the advance refusal, but I allow that in extreme cases, a friend might have the authority to demand that it be heeded. (shrink)

In clinical lectures given between 1850 and 1852, William Pultney Alison, a senior Edinburgh physician, reflected on whether therapeutic bloodletting could be useful in some cases of pneumonia but harmful in others. If so, Alison reasoned, a change in the form of the disease—a change of type—could explain why therapeutic bloodletting had been nearly abandoned in treating a disease for which, only a few years earlier, it had been the standard therapy. In response, a young pathologist, John Hughes Bennett, denied (...) that anything like a change of type had occurred and insisted that bloodletting had never been an effective therapy. Over the next two decades, more than forty physicians debated the usefulness of bloodletting and the reasons for its decline. This debate, known as the Edinburgh Bloodletting Controversy, has attracted the attention of contemporary historians. Those who have discussed the debate side with Bennett and give Alison little serious attention. I argue that by examining the texts to determine what the issues really were, we can see that Alison may actually have been right. Moreover, this examination illuminates the practice of bloodletting and reveals one hitherto unrecognized factor that contributed to its decline. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Editors’ NoteJames M. DuBois, Ana S. Iltis, and Heidi A. WalshFrom childhood, David Slakter had undergone tests and invasive procedures to monitor his nephritis. It was not a surprise when in 2015, doctors told him he needed a kidney transplant. The wife of a childhood friend was a close match and gave him one of her kidneys. Before his transplant, aerobic exercise was difficult; a few months after transplant, (...) Slakter could ride his bike, hike, and work out with a personal trainer. He no longer had to weigh food or gauge his potassium consumption, a concern for people with kidney failure. For Slakter, “life post-transplant has been a significant improvement.”Individuals or family members of those who have received an organ transplant from a living or deceased donor share their stories in this issue of Narrative Inquiry in Bioethics. The symposium is titled “Receiving the Gift of Life: Stories from Organ Transplant Recipients.” Organ transplantation can extend an individual’s life by decades. It can also greatly improve an individual’s quality of life, as was Slakter’s experience. At the same time, organ transplantation is expensive and stressful. Recipients can experience complications, including organ rejection, and there are few appealing alternatives.After her heart transplant, author Leilani R. Graham required four open-heart surgeries, ECMO, and an intra-aortic balloon pump. She experienced delirium, necrotizing pneumonia, and severe muscular atrophy that required her to re-learn how to walk. She struggled with weight gain, explosive mood swings, hair loss, and was terrified that her body would reject the new heart. For Graham, “[Transplant] was not the miracle [she] was hoping for.” Graham says she felt unprepared for and inadequately informed about what to expect after her transplant, which left her “battered, beaten, and bruised” with a 12-inch line from neck to navel and “bullet holes” up and down her torso from the chest tubes. When reflecting on her experience post-transplant, Graham says, “It wasn’t the physical trauma that hurt the most. It was that no one seemed surprised [by the aftereffects of transplant].” Seemingly no one, that is except Graham, who calls on transplant providers to “prioritize empathy.”The symposium editors are Jason T. Eberl and Tristan McIntosh. Three commentary articles, written by Macey Leigh Levan, Heather Lannon, and Vidya A. Fleetwood, Roslyn B. Mannon & Krista L. Lentine, offer important insights into the authors’ stories. The editors thank Mid-America Transplant, the UCSF Lung Transplant Program, Donor Connect, William L. Freeman, MD, MPH, MJIL, CIP, Janet Monk, and the individuals who gave anonymous donations to support the publication of this issue, an open-access VOICES edition of the symposium, and accompanying teaching guides.The research article in this issue, “‘A Shell of My Former Self’: Using Figurative Language to Promote Communication about Patient Suffering,” was written by Tyler Tate, Elizabeth Stein, and Robert A. Pearlman. The relief of suffering is a primary goal of medicine. However, the authors note that clinicians often miss or ignore suffering because they focus on the causes rather than the experience of suffering, or the subjective nature of suffering makes it difficult to discuss. The authors believe that “the key to communicating about suffering lies in finding [End Page vii] the right kind of words to describe the experience” and say that figurative language offers a promising approach. In their research, the authors performed qualitative analysis on 52 works of literature and identified 254 excerpts of figurative language with themes of non-physical or psychological suffering. The authors found 13 salient themes: brokenness, diminishment, disorientation, drowning, emptiness, imprisonment, battle, darkness, isolation, invisibility, lifelessness, punishment, and torture. The authors reiterate that developing a shared language of suffering could foster a therapeutic patient-clinician relationship and improve clinicians’ ability to recognize and address a patient’s experience of suffering.María Susana Ciruzzi wrote the first of two case studies included in this issue. “The Sword of King Solomon” addresses a tragic and difficult subject—how to navigate the situation posed by conjoined twins when “any decision will produce damage and suffering.” The case involves two infant male patients born at 37 weeks gestation as omphalo-ischiopagus conjoined twins... (shrink)

This monograph discusses the illness and death of René Descartes. All the hitherto available documents on his illness and death are collected in the appendix, partly also in the orginal French or Latin. These documents make it rather unlikely that Descartes died of pneumonia, the circumstances of his death suggest a poisoning by arsenic. The possible murderer and his motives are also discussed.

In lieu of an abstract, here is a brief excerpt of the content:The Eleatic BergsonDonna Jones (bio)Suzanne Guerlac. THINKING IN TIME: AN INTRODUCTION TO HENRI BERGSON. Ithaca: Cornell UP 2006. [TT]In her Thinking in Time: An Introduction to Henri Bergson Suzanne Guerlac reminds her readers that the metaphysician has indeed been the subject of many hatreds, as the Bergsonist Gilles Deleuze once noted. But from this taut philosophical study one cannot easily make out any possible grounds for enmity; nor were (...) any expressed in the special Bergson issue of Modern Literary Notes edited by Guerlac. In this short review essay I shall voice some of that historic criticism, especially in regard to the social and political implications of his thought. Guerlac’s study may also win its own opponents for its sharp criticisms of Deleuze’s interpretations of Bergson and (in her reading) comically machinic view of life [TT 176–87]. This alone makes the book worth reading; it is also exhaustively researched, and I cannot remember learning as much from the footnotes of any other book.Bergson is presented here as a great metaphysician on the nature of time and space, the philosophical father of nonlinear science, and a theorist of concrete and affective individuality. Rejecting implicitly Leszek Kolakowski’s reading of two Bergsons, Guerlac presents him as neither a cosmologist who opposes life and matter nor an existentialist who retrieves consciousness by opposing time to space. Nor does he emerge as a systematic thinker in this study. In the last chapter Guerlac offers a dizzying defense of Bergson for providing the philosophical basis for cultural studies of the qualitative irreducibility of affectual states, the metaphysics of chaos theory, the critique of artificial intelligence, and the rudiments of an aesthetic theory of digital art and virtual reality.All of this follows from the epochal significance of Bergson’s metaphysical distinction between time and space as carefully grounded in the most advanced physics of his time. Guerlac does not discuss in any detail Bergson’s vitalist critiques of Darwinian biology in Creative Evolution, the work through which the metaphysical arsonist fired the modernist imagination in diverse, contradictory, and at times violent ways.1 Nor does she explore the occult and mystical themes that run throughout Bergson’s work and informed his personal and professional associations.In fact, Guerlac writes: “An explicit appeal to the social values of mystical experience in this study [The Two Sources of Morality and Religion] appeared to vindicate those who had criticized Bergson all along for being simply a mystic. And yet the title of the work, and the basis for the notion of closed and open societies, derive from scientific, not mystical discourse. They refer us to an opposition between closed and open systems in Sadi Carnot’s theories of thermodynamics” [TT 9]. Yet Bergson bases the opposition [End Page 21] between closed and open societies not in thermodynamics but in sociobiology. Having sociobiological reasons to believe in the power of the myths of closed morality on the human mind—groups that had instilled loyalty through myth and ritual had been more successful in the course of evolutionary history; that is, humans susceptible to myth have been successful in a positivist Darwinian sense—he called for the cooptation of such susceptibility by those myths and rituals that instilled loyalty to humanity as such. Humanity could dynamically extend the scope of sociability rather than follow the roles and customs that maintained a closed society in static equilibrium. Though Bergson would later courageously risk pneumonia to stand as an old man in the cold rain to register as a Jew in Vichy France, he claimed in this last book from 1932 that the only complete inspiration for universal openness could be found in Christian mysticism and mythology [Two Sources 227]. He explicitly criticized the insularity of the Judaic religion (and caricatured Eastern forms of mysticism). In other words, Bergson put his faith in Christian mystics alone and thus invited the charge of having laid the foundation for mystical and intolerant leadership.Bergson’s universal humanism also crashed on the limits of colonial racism. In considering closed primitive societies, Bergson called attention to missionary stories full of detailed accounts of childish and monstrous deeds. He implored his... (shrink)

Intermediate filaments (IFs) formed by vimentin are less understood than their cytoskeletal partners, microtubules and F‐actin, but the unique physical properties of IFs, especially their resistance to large deformations, initially suggest a mechanical function. Indeed, vimentin IFs help regulate cell mechanics and contractility, and in crowded 3D environments they protect the nucleus during cell migration. Recently, a multitude of studies, often using genetic or proteomic screenings show that vimentin has many non‐mechanical functions within and outside of cells. These include signaling (...) roles in wound healing, lipogenesis, sterol processing, and various functions related to extracellular and cell surface vimentin. Extracellular vimentin is implicated in marking circulating tumor cells, promoting neural repair, and mediating the invasion of host cells by viruses, including SARS‐CoV, or bacteria such as Listeria and Streptococcus. These findings underscore the fundamental role of vimentin in not only cell mechanics but also a range of physiological functions. Also see the video abstract here https://youtu.be/YPfoddqvz-g. (shrink)

BackgroundUse of modified texture diets—thickening of liquids and modifying the texture of foods—in the hope of preventing aspiration, pneumonia and choking, has become central to the current management of dysphagia. The effectiveness of this intervention has been questioned. We examine requirements for a valid informed consent process for this approach and whether the need for informed consent for this treatment is always understood or applied by practitioners.Main textValid informed consent requires provision of accurate and balanced information, and that agreement is (...) given freely by someone who knows they have a choice. Current evidence, including surveys of practitioners and patients in different settings, suggests that practice in this area is often inadequate. This may be due to patients’ communication difficulties but also poor communication—and no real attempt to obtain consent—by practitioners before people are ‘put on’ modified texture diets. Even where discussion occurs, recommendations may be influenced by professional misconceptions about the efficacy of this treatment, which in turn may poison the well for the informed consent process. Patients cannot make appropriate decisions for themselves if the information provided is flawed and unbalanced. The voluntariness of patients’ decisions is also questionable if they are told ‘you must’, when ‘you might consider’ is more appropriate. Where the decision-making capacity of patients is in question, inappropriate judgements and recommendations may be made by substitute decision makers and courts unless based on accurate information.ConclusionResearch is required to examine the informed consent processes in different settings, but there is ample reason to suggest that current practice in this area is suboptimal. Staff need to reflect on their current practice regarding use of modified texture diets with an awareness of the current evidence and through the ‘lens’ of informed consent. Education is required for staff to clarify the importance of, and requirements for, valid informed consent and for decision making that reflects people’s preferences and values. (shrink)

Graham Solomon, to whom this collection is dedicated, went into hospital for antibiotic treatment of pneumonia in Oc- ber, 2001. Three days later, on Nov. 1, he died of a massive stroke, at the age of 44. Solomon was well liked by those who got the chance to know him—it was a revelation to?nd out, when helping to sort out his a?airs after his death, how many “friends” he had whom he had actually never met, as his email included correspondence (...) with philosophers around the world running sometimes to hundreds of messages. He was well respected in the philosophical community more broadly. He was for several years a member of the editorial board for the Western Ontario Series in Philosophy of Science. While he was employed at Wilfrid Laurier University in Waterloo, Ontario, several of us at the University of Wat- loo always regarded our own department as a sort of second academic home for him. We therefore decided that it would be appropriate to hold a memorial conference in his honour. Thanks to the generous?nancial support of the Humphrey Conference Fund, we were able to do so in May 2003. Many of the papers in this volume were presented at that conf- ence. (shrink)

The synergies between viral and bacterial infections are well established. Most studies have been focused on the indirect mechanisms underlying this phenomenon, including immune modulation and alterations to the mucosal structures that promote pathogen outgrowth. A growing body of evidence implicates direct binding of virus to bacterial surfaces being an additional mechanism of synergy at the host–pathogen interface. These cross‐kingdom interactions enhance bacterial and viral adhesion and can alter tissue tropism. These bacterial–viral complexes play unique roles in pathogenesis and can (...) alter virulence potential. The bacterial–viral complexes may also play important roles in pathogen transmission. Additionally, the complexes are recognized by the host immune system in a distinct manner, thus presenting novel routes for vaccine development. These synergies are active for multiple species in both the respiratory and gastrointestinal tract, indicating that direct interactions between bacteria and virus to modulate host interactions are used by a diverse array of species. (shrink)

How can we provide the best care for the growing population of older adults, many of whom are either very frail or very sick? The traditional medical model of care is focused on treatment of single diseases. This can work well for pneumonia, cancer, or diabetes in younger patients. It does not, however, work as well for frail older adults who have accumulated multiple chronic conditions and disabilities. These elders often depend on family or paid caregivers to provide assistance with (...) taking medications, transportation, and other activities of daily living, such as dressing and bathing. A practitioner in the traditional medical model might prescribe medications that make sense in isolation but have harmful... (shrink)

Leonard Nelson, described by Karl Popper as an "outstanding personality," produced a great quantity of work in a tragically short life. The quantity and the tragedy may have both happened because Nelson was an insomniac who worked day and night and exhausted himself into a fatal case of pneumonia.

Previous studies have documented the fallibility of attempts by surrogates and physicians to act in a substituted judgment capacity and predict end-of-life treatment decisions on behalf of patients. We previously reported that physicians misperceive their patients' preferences and substitute their own preferences for those of their patients with respect to four treatments: cardiopulmonary resuscitation (CPR) in the event of cardiac arrest, ventilator for an indefinite period of time, medical nutrition and hydration for an indefinite period of time, and hospitalization in (...) the event of pneumonia. (shrink)

Background Evidence concerning how Japanese physicians think and behave in specific clinical situations that involve withholding or withdrawal of medical interventions for end-of-life or frail elderly patients is yet insufficient. Methods To analyze decisions and actions concerning the withholding/withdrawal of life-support care by Japanese physicians, we conducted cross-sectional web-based internet survey presenting three scenarios involving an elderly comatose patient following a severe stroke. Volunteer physicians were recruited for the survey through mailing lists and medical journals. The respondents answered questions concerning (...) attitudes and behaviors regarding decision-making for the withholding/withdrawal of life-support care, namely, the initiation/withdrawal of tube feeding and respirator attachment. Results Of the 304 responses analyzed, a majority felt that tube feeding should be initiated in these scenarios. Only 18% felt that a respirator should be attached when the patient had severe pneumonia and respiratory failure. Over half the respondents felt that tube feeding should not be withdrawn when the coma extended beyond 6 months. Only 11% responded that they actually withdrew tube feeding. Half the respondents perceived tube feeding in such a patient as a "life-sustaining treatment," whereas the other half disagreed. Physicians seeking clinical ethics consultation supported the withdrawal of tube feeding (OR, 6.4; 95% CI, 2.5–16.3; P < 0.001). Conclusion Physicians tend to harbor greater negative attitudes toward the withdrawal of life-support care than its withholding. On the other hand, they favor withholding invasive life-sustaining treatments such as the attachment of a respirator over less invasive and long-term treatments such as tube feeding. Discrepancies were demonstrated between attitudes and actual behaviors. Physicians may need systematic support for appropriate decision-making for end-of-life care. (shrink)