The aim of the study was to explore heterogeneity of change in state affect following the introduction of insulin therapy in patients with type 2 diabetes. State affect was assessed twice among 305 patients: just before the introduction of insulin therapy and at 1-month follow-up. Latent class growth modeling showed that negative affect increased in 78% of the sample, whereas positive affect improved in only 17% of the participants. On the basis of cross-tabulation of these changes (...) a 4-class model of emotional response to the new treatment was obtained. The largest subgroup of participants manifested “threat response”, i.e. moderate-stable PA with increase in NA. Participants in the “challenge response” subgroup showed increases in both NA and PA. The third class characterized by “no response”, had low-stable NA and moderate-stable PA. The smallest “stress response” subgroup showed increase in NA and high-stable PA. Gender, age and education level were significant covariates of group membership. Thus, the findings revealed heterogeneous emotional response to the new treatment, which may be of clinical relevance for improving diabetic patients’ adjustment through a more individual, person-centered approach. (shrink)

Aphasia is a language disorder that occurs after a stroke and impairs listening, speaking, reading, writing, and calculation skills. Patients with post-stroke aphasia in Japan are increasing due to population aging and the advancement of medical treatment. Opportunities for adequate speech therapy in chronic stroke are limited due to time constraints. Recent studies have reported that intensive speech therapy for a short period of time or continuous speech therapy using high-tech equipment, including speech applications (apps, can (...) improve aphasia even in the chronic stage. However, its underlying mechanism for improving language function and its effect on other cognitive functions remains unclear. In the present study, we investigated whether intensive speech therapy using a newly developed speech support app could improve aphasia and other cognitive functions in patients with chronic stroke. Furthermore, we examined whether it can alter the brain network related to language and other cortical areas. Thus, we conducted a prospective, single-comparison study to examine the effects of a new speech support app on language and cognitive functions and used resting state functional MRI (rs-fMRI) regions of interest (ROI) to ROI analysis to determine changes in the related brain network. Two patients with chronic stroke participated in this study. They used the independent speech therapy system to perform eight sets of 20 randomly presented words/time (taking approximately 20 min), for 8 consecutive weeks. Their language, higher cognitive functions including attention function, and rs-fMRI, were evaluated before and after the rehabilitation intervention using the speech support app. Both patients had improved pronunciation, daily conversational situations, and attention. The rs-fMRI analysis showed increased functional connectivity of brain regions associated with language and attention related areas. Our results show that intensive speech therapy using this speech support app can improve language and attention functions even in the chronic stage of stroke, and may be a useful tool for patients with aphasia. In the future, we will conduct longitudinal studies with larger numbers of patients, which we hope will continue the trends seen in the current study, and provide even stronger evidence for the usefulness of this new speech support app. (shrink)

Nicotinamide adenine dinucleotide (NAD+) biosynthetic pathway, mediated by nicotinamide phosphoribosyltransferase (NAMPT), a key NAD+ biosynthetic enzyme, plays a pivotal role in controlling many biological processes, such as metabolism, circadian rhythm, inflammation, and aging. Over the past decade, NAMPT‐mediated NAD+ biosynthesis, together with its key downstream mediator, namely the NAD+‐dependent protein deacetylase SIRT1, has been demonstrated to regulate glucose and lipid metabolism in a tissue‐dependent manner. These discoveries have provided novel mechanistic and therapeutic insights into obesity and its metabolic complications, such (...) as insulin resistance, an important risk factor for developing type 2 diabetes and cardiovascular disease. This review will focus on the importance of adipose tissue NAMPT‐mediated NAD+ biosynthesis and SIRT1 in the pathophysiology of obesity and insulin resistance. We will also critically explore translational and clinical aspects of adipose tissue NAD+ biology. (shrink)

This paper reports on a particular aspect of a larger ethnographic study of nursing culture in an intensive therapy unit (ITU), accomplished through participant observation over a 12‐month period, followed by interviews with 15 nurses. The paper suggests that the ITU environment is perceived as ‘dangerous’, its dangerousness stemming from the ambiguity of its patients’ conditions. Drawing on anthropological concepts of liminality, pollution, anomaly and breaching of boundaries, the paper identifies various ambiguities inherent in ITU patients’ conditions. It (...) then explores the ways in which these anomalies are managed through sequestration and other ritual and symbolic practices. Notwithstanding the undoubted scientific reasons for particular nursing practices, the paper argues that there are also ritual and symbolic elements serving other more complex purposes, both protecting patients and staff and symbolising the highly valued phenomenon of keeping patients safe. The paper identifies a contradiction inherent in nursing work in this locale inasmuch as rituals and symbolism coexist with technical and research‐based elements of nursing care. (shrink)

Galectin-3 and LTB4 are pro-inflammatory molecules recently shown to directly cause insulin resistance in mouse and human cells. They are highly expressed in the obese state, and can be targeted both genetically and pharmacologically to improve insulin sensitivity in vivo. This expands on previous research showing that targeting inflammatory cytokines can be insulin sensitizing in animal models. However, translating these potential therapies into the human setting remains challenging. Here we review this latest research, and discuss how balancing (...) their pleiotropic functions, the action of the microbiome, and the ability to identify relevant patient populations are vital considerations for successful anti-inflammatory insulin sensitizing therapy. Recent advances have indicated that a diverse range of inflammatory molecules, including leukotriene B4 and Galectin-3 can cause insulin resistance. Key challenges for translating these new targets into therapies include their pleiotropic effects and likely patient heterogeneity, such as is caused by the intestinal microbiome. (shrink)

ZusammenfassungAktuelle Positionspapiere wie das der Sektion Ethik der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin „Therapiezieländerung und Therapiebegrenzung in der Intensivmedizin“, die „Münchner Leitlinie zu Entscheidungen am Lebensende“ und die Erlanger „Empfehlungen zur Behandlungsbegrenzung auf Intensivstationen“ konzentrieren sich auf die Begründung und Erstellung praxistauglicher Entscheidungspfade. Dabei bleibt kaum Raum für die Darlegung der moraltheoretischen Grundlagen zur formalen Handlungsbewertung einer Indikationsstellung am Lebensende. Der Beitrag will anhand einer intensivmedizinischen Entscheidungssituation zeigen, dass im Falle einer Therapiezieländerung aus Indikationsgründen eine aristotelische Argumentation zentrale (...) Bedeutung erhält. Sie besteht in der begründeten Festlegung eines realistisch erreichbaren Ziels und des dahin führenden Therapiepfades. Klinische Ethikberatung, so das Resultat, kann demnach nicht nur die Bedeutung von inhaltlichen Prinzipien unterstreichen, sondern muss auch ihre Kenntnis der formalen Handlungsbewertung zur Geltung bringen. (shrink)

The chronic worldwide lack of organs for transplantation and the continuing improvement of strategies for in situ organ preservation have led to renewed interest in elective non-therapeutic ventilation of potential organ donors. Two types of situation may be eligible for elective intensive care: patients definitely evolving towards brain death and patients suitable as controlled non-heart beating organ donors after life-supporting therapies have been assessed as futile and withdrawn. Assessment of the ethical acceptability and the risks of these strategies is (...) essential. We here offer such an ethical assessment using the four principles of medical ethics of Beauchamp and Childress applying them in their broadest sense so as to include patients and their families, their caregivers, other potential recipients of intensive care, and indeed society as a whole. The main ethical problems emerging are the definition of beneficence for the potential organ donor, the dilemma between the duty to respect a dying patient's autonomy and the duty not to harm him/her, and the possible psychological and social harm for families, caregivers other potential recipients of therapeutic intensive care, and society more generally. Caution is expressed about the ethical acceptability of elective non-therapeutic ventilation, along with some proposals for precautionary measures to be taken if it is to be implemented. (shrink)

Mr. M is an eighty-five-year-old who presented to the hospital with congestive heart failure exacerbation, pneumonia, altered mental status, and sepsis. A physician determines that he lacks capacity, and the team in the intensive care unit looks to the patient's daughter, Celia, as his surrogate decision-maker because she is named as an agent in his medical power of attorney form. While in the ICU, Mr. M suffers acute respiratory distress secondary to pneumonia and thus requires intubation. Celia accepts several (...) life-sustaining interventions, but she sporadically refuses other medically indicated therapies. Although providers explain the importance of the ICU insulin regimen for glucose control, she either refuses the insulin or requests a lower dose. The health care team believes that it is providing substandard care and that Celia's medical decisions are not in the patient's best interests, so they request an ethics consultation. When the clinical ethicist attempts to talk with Celia, she refuses to speak with him, saying flatly, “I am not interested in talking with you.” The clinical ethicist meets with Celia on a couple of occasions, but she consistently refuses to have a conversation with him. He wonders if the patient's surrogate decision-maker can refuse a clinical ethics consultation and is unsure what his next steps should be. (shrink)

BackgroundThe Authors have laid out an analysis of Italian COVID-19 confirmed data and fatality rates, pointing out how a dearth of health care resources in northern regions has resulted in hard, ethically challenging decisions in terms of granting patient access to intensive care units (ICU).Main textHaving to make such decisions certainly entails substantial difficulties, and that has led many health care professional to seek ethical guidance. The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has attempted (...) to meet that growing need by a set of recommendations, applying “clinical soundness” as a beacon standard; that approach tends to prioritize patients with higher life expectancy, which could be characterized as a “moderately utilitarian” approach. Yet, such a selection has engendered daunting ethical quandaries. The authors believe it can only be warranted and acceptable if rooted in a transparent decision-making process and verifiable, reviewed criteria. Moreover, the authors have stressed how clinical experimentation in a pandemic setting is a subtext of great interest from an ethical perspective. In Italy, no drug therapy and trials were undertaken for COVID-19 patients for a rather long period of time. When the epidemic was already circulating, an intervention proved necessary on the system of administrative procedures, aimed at expediting the authorization and validation of protocols, then bogged down by bureaucracy. A new system has since been instituted by a government decree that was signed about one month after the first Covid-19 case was officially recorded in the country. Such a swift implementation, which took just a few weeks, is noteworthy and proves that clinical trials can be initiated in a timely fashion, even with a pandemic unfolding. The concerted, action of supportive care and RCTs is the only way to attain effective forms of treatments for COVID-19 and any other future outbreak.ConclusionsThe authors have arrived at the conclusion that the most effective and ethically sound response on the part of any national health care system would be to adequately reconfigure its organizational mechanisms, by making clinical trials and all related administrative procedures consistent with the current state of emergency. (shrink)

Die wachsende Nachfrage nach Anti-Aging-Medizin wirft die Frage auf, welche medizinischen Leistungen ein solidarisches Gesundheitssystem tragen sollte. Die deutsche Entscheidungspraxis beruft sich auf den Begriff der Krankheit. Im Blick auf Anti-Aging wäre demnach 1) zu klären, was der Krankheitsbegriff bedeutet, 2) zu prüfen, ob das Altern sich unter diesen Begriff subsumieren lässt, um 3) abzuleiten, inwieweit Anti-Aging-Maßnahmen zur Verfügung zu stellen sind. Dieses Prozedere führt jedoch zu keinem brauchbaren Ergebnis. Unter Berufung auf den Krankheitsbegriff allein ist der Umfang solidarischer Gesundheitsversorgung (...) nicht zu bestimmen. Allerdings lässt sich durch Reflexion auftretender Probleme ein gangbarer Entscheidungsweg aufzeigen. Er sieht eine faire Verständigung über die Frage vor, wie wir alt werden wollen. (shrink)

Die wachsende Nachfrage nach Anti-Aging-Medizin wirft die Frage auf, welche medizinischen Leistungen ein solidarisches Gesundheitssystem tragen sollte. Die deutsche Entscheidungspraxis beruft sich auf den Begriff der Krankheit. Im Blick auf Anti-Aging wäre demnach 1) zu klären, was der Krankheitsbegriff bedeutet, 2) zu prüfen, ob das Altern sich unter diesen Begriff subsumieren lässt, um 3) abzuleiten, inwieweit Anti-Aging-Maßnahmen zur Verfügung zu stellen sind. Dieses Prozedere führt jedoch zu keinem brauchbaren Ergebnis. Unter Berufung auf den Krankheitsbegriff allein ist der Umfang solidarischer Gesundheitsversorgung (...) nicht zu bestimmen. Allerdings lässt sich durch Reflexion auftretender Probleme ein gangbarer Entscheidungsweg aufzeigen. Er sieht eine faire Verständigung über die Frage vor, wie wir alt werden wollen. (shrink)

Mental disorders such as depression and anxiety are increasingly common. Yet there are too few specialists to offer help to everyone, and negative attitudes to psychological problems and their treatment discourage people from seeking it. As a result, many people never receive help for these problems. The Oxford Guide to Low Intensity CBT Interventions marks a turning point in the delivery of psychological treatments for people with depression and anxiety. Until recently, the only form of psychological intervention available for patients (...) with depression and anxiety was traditional one-to-one 60 minute session therapy - usually with private practitioners for those patients who could afford it. Now Low Intensity CBT Interventions are starting to revolutionize mental health care by providing cost effective psychological therapies which can reach the vast numbers of people with depression and anxiety who did not previously have access to effective psychological treatment. The Oxford Guide to Low Intensity CBT Interventions is the first book to provide a comprehensive guide to Low Intensity CBT interventions. It brings together researchers and clinicians from around the world who have led the way in developing evidence-based low intensity CBT treatments. It charts the plethora of new ways that evidence-based low intensity CBT can be delivered: for instance, guided self-help, groups, advice clinics, brief GP interventions, internet-based or book-based treatment and prevention programs, with supported provided by phone, email, internet, sms or face-to-face. These new treatments require new forms of service delivery, new ways of communicating, new forms of training and supervision, and the development of new workforces. They involve changing systems and routine practice, and adapting interventions to particular community contexts. The Oxford Guide to Low Intensity CBT Interventions is a state-of-the-art handbook, providing low intensity practitioners, supervisors, managers commissioners of services and politicians with a practical, easy-to-read guide - indispensible reading for those who wish to understand and anticipate future directions in health service provision and to broaden access to cost-effective evidence-based psychological therapies. (shrink)

The DNA hypomethylating agents (HMA) azacitidine (AZA) and decitabine (DAC) improve survival and transfusion independence in myelodysplastic syndrome (MDS) and enable a low intensity cytotoxic treatment for aged AML patients unsuitable for intensive chemotherapy, particularly in combination with novel agents. The proposed mechanism of AZA and DAC relies on active DNA replication and therefore patient responses are only observed after multiple cycles of treatment. Although extended dosing may provide the optimal scheduling, the reliance of injectable formulation of the drug (...) limits it to intermittent treatment. Recently, an oral formulation of AZA demonstrated significantly improved patient relapse free survival (RFS) and overall survival (OS) when used as maintenance after chemotherapy for AML. In addition, both DAC and AZA were found to be highly effective to improve survival in elderly patients with AML through combination with other drugs. These recent exciting results have changed the therapeutic paradigm for elderly patients with AML. In light of this, we review current knowledge on HMA mechanism of action, clinical trials exploring dosing and scheduling, and recent HMA combination therapies to enhance efficacy. (shrink)

Homosexual aversion therapy enjoyed two brief but intense periods of clinical experimentation: between 1950 and 1962 in Czechoslovakia, and between 1962 and 1975 in the British Commonwealth. The specific context of its emergence was the geopolitical polarization of the Cold War and a parallel polarization within psychological medicine between Pavlovian and Freudian paradigms. In 1949, the Pavlovian paradigm became the guiding doctrine in the Communist bloc, characterized by a psychophysiological or materialist understanding of mental illness. It was taken up (...) by therapists in Western countries who were critical of psychoanalysis and sought more ‘scientific’ diagnostic and therapeutic methods that focused on empirical evidence and treating actual symptoms. However, their attitude towards homosexuality often played a decisive role in how they used aversion therapy. Whereas Czechoslovakian researchers cautioned readers about low success rates and agitated for homosexual law reform in 1961, most of their anglophone counterparts selectively ignored or misrepresented the results of ‘the Prague experiment’, instead celebrating single-case ‘success’ stories in their effort to correct ‘abnormal’ sexual orientation. In histories of queer sexuality and its pathologization, the behaviourist paradigm remains almost entirely unmapped. This article provides the most detailed study to date of aversion therapy literature from both sides of the East/West border. In doing so, it contributes to the project not only of ‘decentring Western sexualities’, but of decentring Western sexological knowledge. Given its Pavlovian origins, the history of homosexual aversion therapy can be fully understood only in the context of Cold War transnational sexological knowledge exchange. (shrink)

Stem cell research has entered the public consciousness through the media. Proponents and opponents of all such research, or of human embryonic stem cell research specifically, engage in heated exchanges in the modern public forum where stakeholders negotiate, the agora. One common claim that emerges from the fray is that a particular type of stem cell research should be pursued as the most promising path toward the reduction of suffering and untimely death for all of humanity. Upon evaluation, experimental data (...) regarding the potential role of stem cells in regenerative therapies for three conditions—spinal cord injury, type 1 diabetes, and cardiovascular disease—tell distinct, complex, and inconclusive stories. Further analyses in this article incorporate realistic considerations of a broad range of relevant factors--limited funding for biomedical research, media motives, the discordance hypothesis of evolutionary medicine, the relationship between religion and science, medical care in developing nations, and culture wars over abortion. Holistic investigation inspired by the current agora conversation supports the need to drastically change interactions regarding stem cell research so that its potential to benefit humanity may be more fully realized. (shrink)

Der Artikel spürt den subtilen Veränderungen nach, die bei Patienten, die mit tiefer Hirnstimulation behandelt werden, möglicherweise beobachtet werden können. Dabei sollen im Rückgriff auf Konzeptionen zur narrativen Identität mittels einer möglichst genauen Beschreibung und Analyse der Selbstwahrnehmung der Patienten sowie der Wahrnehmung ihres Umfelds die Änderungen im praktischen Selbstverhältnis untersucht werden, u. a. am Beispiel technomorpher Metaphern, die von den Patienten in ihren Selbstbeschreibungen verwendet werden. Ziel ist es, die Neuartigkeit und das Spezifische der Neurotechnologien – über die bisherigen (...) Untersuchungen hinaus – hinsichtlich des Umgangs mit sich selbst herauszuarbeiten und greifbar zu machen. Abschließend werden auf Basis der Analyse der Patienten-Narrationen die entsprechenden normativen Implikationen für eine ethische Bewertung des Einsatzes von Neurotechnologien benannt. (shrink)

Definition of the problem: Doctor-patient-conversation is still a great challenge for doctors and patients despite intense discussion, legal normation, and multiple efforts. It seems to be particularly difficult in cases of telling the truth about diagnosis or prognosis which can be threatening to the patient.Method: It is shown by two case studies that the patient directs a specific need to the doctor which has been neglected in both the ethics discourse and in practical medicine: the need to evaluate the patient's (...) options for action at an argumentative-critical level. Derived from a general theory of language functions a model of doctor-patient-conversation is developed which allows for both ideal case typology as well as for problem analysis. Referring to a Three-Stages-Model of Doctor-Patient-Dialogue, an integrative model “Language and Relationship Between Doctor and Patient” is formulated which permits a better understanding of the processes and difficulties between doctor and patient.Conclusion: The integrative model presented may help to realize a more comprehensive doctor-patient-conversation. It may help as well to decide which of the components of this conversation may be selectively sufficient. Consequences for the conceptualization of the physician's role as well as the scope of the model in practice are discussed. (shrink)

Recently, a friend of one of these writers told her story of using one of a healthcare product to activate her stem cells as part of regenerative medicine. Regenerative medicine is a field of medicine that seeks to repair or replace damaged or diseased tissues and organs. This can be done through a variety of methods, including stem cell therapy, tissue engineering, and gene therapy. This is a short review article on this rapid field called regenerative medicine, in (...) particular via a new method called photobiomodulation, especially by virtue of low-intensity laser pen treatment. Hopefully it will attract more research in this interesting direction, both for laser/photobiomodulation to boost plant growth as well as in healthcare (see also: Christianto & Smarandache, 2022; Christianto, 2023). (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Breathing:Proustian Therapy1Christopher Prendergast (bio)I begin with a question I would never have imagined myself asking. Is Proust good for you? Might there even be, albeit in carefully controlled doses, a place for him in modern 'health care'? He certainly belongs in the select, if occasionally scary, company of writers whose name, or that of one of their fictional characters, has lent itself to the designation of a psycho-physical condition (...) often with medical characteristics. A short list includes: Stendhal ('Stendhal syndrome,' the condition of obsessional attachment to works of art); Musset (the 'Musset Sign,' manifested as an uncontrollable tremor of the head); Gogol's Plyushkin in Dead Souls ('compulsive hoarding syndrome'); Dickens's Miss Havisham in Great Expectations ('senile squalor syndrome'); Wilde's Lady Windermere ('Lady Windermere syndrome,' associated with pulmonary illness and breathing difficulties).There is no evidence that Proust was directly acquainted with Wilde's play, but there can be little doubt that what came to be called 'Lady Windermere Syndrome' would have spoken to him loud and clear. In an early story called L'Indifférent, Proust penned an encomium to the air we breathe: "A child who from birth has always breathed without paying any attention has no idea how much the air, which swells so sweetly his chest that he doesn't even notice it, is essential to life." A memory of this is doubtless somewhere in the background of the passing mention in Le Côté de Guermantes of "the alpine resort" that teaches him "that the act of breathing, to which we habitually pay no attention, can be a constant source of pleasure." It was almost certainly also in Proust's thoughts when, in the final volume, he penned the famous definition of Paradise Lost as the place and time of "an air we have breathed before, this purer air which the poets have tried in vain to make reign in paradise and which could not provide this profound feeling of renewal if it has not already been breathed, for the only true paradise is a paradise that we have lost."But the early story, like the novel itself, is also haunted by a subtext in which what is precious to life can also be the enemy of life, as, in an access of fever and sudden convulsion, the child feels himself to be suffocating. The story clearly has its origins in Proust's own life, the moment of his first asthma attack as a young boy on a family outing to the Bois de Boulogne. It struck out of the blue with a frightening intensity, and was to pursue [End Page 49] him throughout his life like a fury, proliferating further symptoms such as emphysema and cardiac seizures. As late as 1919, he writes in a letter of an attack that leaves him "gasping like someone half-drowned who is pulled out of water." And it was there again at the moment of Proust's exit from the world, carried off by a bout of pneumonia exacerbated by a pulmonary abscess.There were treatments and consultations galore, the former on a spectrum from inhalations to cauterizing of the nasal tubes, and the latter including a meeting with his father's colleague, Dr. Buissand, who inclined to the view– and increasingly fashionable in medical circles–that the prime cause was neurasthenic. Proust himself hesitated: in a letter he described it as "a bodily illness," but in the Recherche, "asthma crises" are linked to a "mystery" of the "unconscious" and strike out of the blue. The 'mystery' is often, and plausibly, associated with fear of separation from the protective mother. This will be one of the major themes of the novel, and the source of the "sobs that never cease" of which the narrator speaks in the opening volume. But whether physical or psychosomatic, a guaranteed trigger was proximity to tree blossoms (apple especially virulent) and certain flowers–that is, the very things that, for Proust, often something approaching quasi-sacred status, thus illustrating the law that it is what you most love that can kill you.In the novel, however, much of this is distilled into comedy, all terrifying... (shrink)

Cell therapy means treating diseases with the body's own cells. One of the cell types most in demand for therapeutic purposes is the pancreatic β‐cell. This is because diabetes is one of the major healthcare problems in the world. Diabetes can be treated by islet transplantation but the major limitation is the shortage of organ donors. To overcome the shortfall in donors, alternative sources of pancreatic β‐cells must be found. Potential sources include embryonic or adult stem cells or, from (...) existing β‐cells. There is now a startling new addition to this list of therapies: the pancreatic α‐cell. Thorel and colleagues recently showed that under circumstances of extreme pancreatic β‐cell loss, α‐cells may serve to replenish the insulin‐producing compartment. This conversion of α‐cells to β‐cells represents an example of transdifferentiation. Understanding the molecular basis for transdifferentiation may help to enhance the generation of β‐cells for the treatment of diabetes. (shrink)

Objectives Prompt Mental Health Care (PMHC) is the Norwegian version of the England’s Improving Access to Psychological Therapies (IAPT). Both programs have been associated with substantial symptom reductions from pre- to post-treatment. The present study extends these findings by investigating symptom levels at 12 months post-treatment, as well as treatment outcome in relation to low- vs. high-intensity treatment forms. Design and Outcome Measures A prospective cohort design was used. All participants ( n = 1530) were asked to complete the Patient (...) Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 questionnaire (GAD-7) at baseline, before each session during treatment, at final treatment, and at 12 months post-treatment. Cohen’s d was used as effect size measure. Sensitivity analyses were conducted to examine the impact of the high missing data rates at post-treatment (≈44%) and 12 months post-treatment (≈58%). Results A large symptom reduction was seen from baseline to 12 months post-treatment for both PHQ ( d = −0.98) and GAD ( d = −0.94). Improvements observed at post-treatment were largely maintained at 12 months post-treatment (PHQ (Δ d = 0.10) and GAD (Δ d = 0.09). Recovery rates decreased only slightly from 49.5% at post-treatment to 45.0% at follow-up. Both low- and high-intensity treatment forms were associated with substantial and lasting symptoms reductions (−1.26 ≤ d ≤ −0.73). Sensitivity analyses did not substantially alter the main results. Conclusion The findings suggest long-lasting effects of the PMHC program and encourage the use of low-intensity treatment forms in PMHC like settings. (shrink)

Recent results from studies on animals suggest that functional germ cells may be generated from human pluripotent stem cells, giving rise to three possibilities: research with these so‐called artificial gametes, including fertilization experiments in vitro; their use in vivo for therapy for the treatment of human infertility; and their use in assisted reproductive technologies in vitro. While the legal, philosophical, and ethical questions associated with these possibilities have been already discussed intensively in other countries, the debate in Germany is (...) still at its beginning. A systematic and detailed analysis of the legal framework in Germany is provided with regard to the three possibilities, including the applicable statutory laws as well as the constitutional law. The question emerges as to whether the statutory laws as well as the constitution justify a distinction to be made between embryos of artificial and natural origin. This question is subject to philosophical analysis, discussing the distinction between person and thing, dignity and price, personality and property, and nature and technique. As a result, the criterion of naturalness alone may not be sufficient to differentiate between embryos of natural and artificial origin, and other criteria need to be identified. (shrink)

End-of-life decision making frequently occurs in the intensive care unit (ICU). There is a lack of information on how a do-not-resuscitate (DNR) order affects treatments received by critically ill patients in ICUs. The objectives of this study were: (1) to compare the use of life support therapies between patients with a DNR order and those without; (2) to examine life support therapies prior to and after the issuance of a DNR order; and (3) to determine the clinical factors that (...) influence the initiation of a DNR order in ICUs in Taiwan. A prospective, descriptive, and correlational study was conducted. A total of 202 patients comprising 133 (65.8%) who had a DNR order, and 69 (34.1%) who did not, participated in this study. In the last 48 hours of their lives, patients who had a DNR order were less likely to receive life support therapies than those who did not have a DNR order. Older age, being unmarried, the presence of an adult child as a surrogate decision maker, a perceived inability to survive ultimate discharge from the ICU, and longer hospitalization in the ICU were significant predictors of issuing a DNR order for critically ill patients. This study will draw attention to how, when, and by whom, critically ill patients’ preferences about DNR are elicited and honored. (shrink)

Over the past several decades in which access to abortion has become increasingly restricted, parents' autonomy in medical decision‐making in the realms of fetal care and neonatal intensive care has expanded. Today, parents can decide against invasive medical interventions at gestational ages where abortions are forbidden, even in cases where neonates are expected to be seriously ill. Although a declared state interest in protecting the lives of fetuses and newborns contributes to justifications for restricting women's autonomy with regards to (...) abortion, it does not fully explain this discrepancy. We believe that social portrayals of women as complying with or shirking their reproductive function play a major role in explaining it. The growing divide between a woman's rights as a reproductive being and as a parent suggest that abortion restriction is rooted in a historical societal desire for women to serve as reproducers and in the corresponding fear of them abandoning this allotted role in pursuit of social equality. The Dobbs v. Jackson (2022) decision is not based in a view of abortion as a medical act occurring between a doctor and patient, as Roe v. Wade (1973) did, but decision‐making about fetal therapy or NICU care is still viewed as occurring between a doctor and patient or surrogate because in this act a woman is seen as fulfilling her role as mother. (shrink)

The purpose of the present study was to evaluate the effectiveness of a physical activity intervention program designed to enhance levels of engagement in PA. Despite robust evidence supporting the beneficial effects of PA on overall health, only about 22% of individuals engage in the recommended minimum amount of PA. Recent surveys suggested that most individuals express intentions to be physically active, though the psychological state of amotivation dismissed these struggles. In the current study, we pilot-tested a new intervention program, (...) aimed at enhancing engagement in PA among sedentary individuals. The intervention was based on two behavioral change and motivational psychological frameworks: Self-Determination Theory and Acceptance and Commitment Therapy. During a 14-week intervention program, 94 sedentary Israeli college students were randomly assigned into one of three groups: SDT and ACT-based intervention, traditional intervention, and a non-treatment group. Prior to and following the intervention, participants completed the Behavioral Regulation in Exercise Questionnaire-3 to examine motivation to exercise and the International Physical Activity Measurement IPAQ to evaluate their training frequency. Results showed that the SDT and ACT-based intervention group exhibited a significant increase in motivation to exercise between time 1 and time 2, while the other two groups showed insignificant differences in motivation to exercise. Furthermore, neither of the groups showed significant differences in their training frequency per week. However, those in the SDT and ACT-based groups reported an increase in activity intensity from time 1 to time 2 compared to the two other groups. Further, exercise psychology consultants and scholars can use the intervention protocol and utilize these findings to improve PA behaviors and promote health in the general population. Limitations, future directions, and implications are discussed in detail. (shrink)

Background: The intensive care unit environment focuses on interventions and support therapies that prolong life. The exercise by nurses of their autonomy impacts on perception of the role they assume in the multidisciplinary team and on their function in the intensive care unit context. There is much international research relating to nurses’ involvement in end-of-life situations; however, there is a paucity of research in this area in Brazil. In the Brazilian medical scenario, life support limitation generated a certain (...) reluctance of a legal nature, which has now become unjustifiable with the publication of a resolution by the Federal Medical Council. In Brazil, the lack of medical commitments to end-of-life care is evident. Objective: To understand the process by which nurses exercise autonomy in making end-of-life decisions in intensive care units. Research design: Symbolic Interactionism and Corbin and Strauss theory methodology were used for this study. Participants and research context: Data were collected through single audio-recorded qualitative interviews with 14 critical care nurses. The comparative analysis of the data has permitted the understanding of the meaning of nurse’s experience in exercising autonomy relating to end-of-life decision-making. Ethical considerations: Institutional ethics approval was obtained for data collection. Participants gave informed consent. All data were anonymized. Findings: The results revealed that nurses experience the need to exercise autonomy in intensive care units on a daily basis. Their experience expressed by the process of increase opportunities to exercise autonomy is conditioned by the pressure of the intensive care unit environment, in which nurses can grow, feel empowered, and exercise their autonomy or else can continuously depend on the decisions made by other professionals. Conclusion: Nurses exercise their autonomy through care. They work to create new spaces at the same time that they acquire new knowledge and make decisions. Because of the complexity of the end-of-life situation, nurses must adopt a proactive attitude that inserts them into the decision-making process. (shrink)

The decision-making environment in intensive care units (ICUs) is influenced by the transformation of intensive care medicine, the staffing situation and the increasing importance of patient autonomy. Normative implications of time in intensive care, which affect all three areas, have so far barely been considered. The study explores patterns of decision making concerning the continuation, withdrawal and withholding of therapies in intensive care. A triangulation of qualitative data collection methods was chosen. Data were collected through non-participant (...) observation on a surgical ICU at an academic medical centre followed by semi-structured interviews with nurses and physicians. The transcribed interviews and observation notes were coded and analysed using qualitative content analysis according to Mayring. Three themes related to time emerged regarding the escalation or de-escalation of therapies: influence of time on prognosis, time as a scarce resource and timing in regards to decision making. The study also reveals the ambivalence of time as a norm for decision making. The challenge of dealing with time-related efforts in ICU care results from the tension between the need to wait to optimise patient care, which must be balanced against the significant time pressure which is characteristic of the ICU setting. (shrink)

Considerable heterogeneity among pediatric chronic pain patients may at least partially explain the variability seen in the response to behavioral therapies. The current study tested whether autistic traits and attention-deficit/hyperactivity disorder symptoms in a clinical sample of children and adolescents with chronic pain are associated with socioemotional and functional impairments and response to acceptance and commitment therapy treatment, which has increased psychological flexibility as its core target for coping with pain and pain-related distress. Children and adolescents aged 8–18 years (...) were recruited. Patients and their parents completed questionnaires pre- and post-ACT of 17 sessions. Correlational analyses and mixed-effects models were used to assess the role of autistic traits and ADHD symptoms in pretreatment functioning and ACT-treatment response. Outcome variables were degree to which pain interfered with daily activities, socioemotional functioning, psychological inflexibility, and pain intensity. Autistic traits and ADHD symptoms, pain frequency, and pain duration were measured at pretreatment only. Higher autistic traits were associated with greater pain interference, higher depression, and greater psychological inflexibility. Higher ADHD symptomatology was associated with greater pretreatment pain interference, lower emotional functioning, greater depression, and longer duration of pain. Across patients, all outcome variables, except for sleep disturbances and school functioning, significantly improved from pre- to post-ACT. Higher autistic traits were associated with greater pre- to post-ACT improvements in emotional functioning and sleep disturbance and non-significant improvements in pain interference. ADHD symptomatology was not associated with treatment outcome. The current results showed that neuropsychiatric symptoms in pediatric chronic pain patients are associated with lower functioning, particularly pain interfering with daily life and lower socioemotional functioning. The results suggest that not only pediatric chronic pain patients low in neuropsychiatric symptoms may benefit from ACT, but also those high in autism traits and ADHD symptoms. With the present results in mind, pediatric chronic pain patients higher in autistic traits may actually derive extra benefit from ACT. Future research could assess whether increased psychological flexibility, the core focus of ACT, enabled those higher in autism traits to cope relatively better with pain-related distress and thus to gain more from the treatment, as compared to those lower in autism traits. Moreover, to address specific effects of ACT, inclusion of an appropriate control group is key. (shrink)

We have conducted a retrospective study of deaths on a paediatric medical intensive care unit over a two-year period and reviewed similar series from outside the UK. There were 89 deaths out of 651 admission (13.7% mortality). In almost two-thirds of the cases death occurred with a decision to limit medical treatment or withdraw mechanical ventilation, implying that additional or further therapy was considered futile. We highlight this as a crucially important issue in the practice of intensive (...) care. More comprehensive studies are needed to help clinicians derive consensus on what constitutes a futile intervention, and therefore when such an intervention should be withheld. This will help families and society better understand the limitations of intensive care. (shrink)

Jian Zhou,* Weiqiang Ju,* Xiaopeng Yuan, Xiaofeng Zhu, Dongping Wang, Xiaoshun HeOrgan Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China *These authors contributed equally to this work: Hyperosmolar nonketotic hyperglycemic coma is a serious, rare complication induced by methylprednisolone pulse therapy for acute rejection after orthotopic liver transplantation. Herein, we report an unusual case of a 58-year-old woman who experienced acute rejection at 30 months after OLT, only one case in which HNKHC resulted in (...) MP pulse therapy for acute rejection in all 913 recipients in our center. The general morbidity of HNKHC was 1.09‰ in this study. HNKHC is characterized by rapid onset, rapid progression, and a lack of specific clinical manifestations. High-dose MP management was a clear risk factor. The principle of treatment included rapid rehydration, low-dose insulin infusion, and correcting disorders of electrolytes and acidosis. In conclusion, clinicians considering MP pulse therapy after OLT should be alert to the occurrence of HNKHC. Keywords: liver transplantation, complications, hyperosmolar nonketotic hyperglycemic coma, methylprednisolone pulse therapy, principle of treatment. (shrink)

Over the last three decades, the graphic novel has developed both in sophistication and cultural importance, now being widely accepted as a unique form of literature (Versaci 2007 ). Autobiography has proved to be a successful genre within comics (the word is used in the plural to denote both the medium and the philosophy of the graphic form) and within this area a sub-genre, the memoir of the artist’s own disease or suffering, sometimes known as the graphic pathology, has arisen (...) (Green and Myers 2010 ). Storytelling and healing have been linked since ancient times, and the disclosure of ones story forms part of the psychotherapeutic treatment of trauma (Herman 1997 ). This paper will examine, in both graphic and textual form, whether, among the myriad reasons that one might embark upon the labour intensive work of making a graphic memoir, some artists might be seeking some form of healing or catharsis through their work. (shrink)

Novel cellular therapy techniques promise to cure many haematology patients refractory to other treatment modalities. These therapies are intensive and require referral to and care from specialised providers. In the USA, this pool of providers is not expanding at a rate necessary to meet expected demand; therefore, access scarcity appears forthcoming and is likely to be widespread. To maintain fair access to these scarce and curative therapies, we must prospectively create a just and practical system to distribute care. (...) In this article, we first review previously implemented medical product and personnel allocation systems, examining their applicability to cellular therapy provider shortages to demonstrate that this problem requires a novel approach. We then present an innovative system for allocating cellular therapy access, which accounts for the constraints of distribution during real-world oncology practice by using a combination of the following principles: maximising life-years per personnel time, youngest and robust first, sickest first, first come/first served and instrumental value. We conclude with justifications for the incorporation of these principles and the omission of others, discuss how access can be distributed using this combination, consider cost and review fundamental factors necessary for the practical implementation and maintenance of this system. (shrink)

Immersive virtual environments can produce a state of behaviour referred to as ‘presence’, during which the individual responds to the virtual environment as if it were real. Presence can be arranged to scientifically evaluate and affect our consciousness within a controlled virtual environment. This phenomenon makes the use of virtual environments amenable to existing and in-development forms of therapy for various conditions. Delirium in the intensive care unit (ICU) is one such condition for which virtual reality (VR) technology (...) has not been evaluated to date. We are currently assessing the feasibility and utility of a delirium prevention and treatment system, which implements VR to improve quality of sleep, reduce pain, lower usage of sedatives, and stimulate cognition. The proposed system will consist of 3-axis wearable accelerometers, 6-DOF position trackers, a VR system and apps designed to promote sleep quality and mindfulness. Our a priori hypothesis is that our VR therapy system would lower the occurrence of delirium in patients admitted to ICUs. (shrink)

Background: Decisions of patients, families, and health care providers about medical care at the end of life depend on many factors, including the societal culture. A pan-European study was conducted to determine the frequency and types of end of life practices in European intensive care units , including those in Israel. Several results of the Israeli subsample were different to those of the overall sample.Objective: The objective of this article was to explore these differences and provide a possible explanation (...) based on the impact of culture on end of life decision making.Method: All adult patients admitted consecutively to three Israeli ICUs who died or underwent any limitation of life saving interventions between 1 January 1999 and 30 June 2000 were studied prospectively . These patients were compared with a similar sample taken from the larger study carried out in 37 European ICUs. Patients were followed until discharge, death, or 2 months from the decision to limit therapy. End of life decisions were prospectively organised into one of five mutually exclusive categories: cardiopulmonary resuscitation , brain death, withholding treatment, withdrawing treatment, and active shortening of the dying process . The data also included patient characteristics , specific therapies limited, and the method of SDP.Results: The majority of patients had treatment withheld, none underwent SDP, 62 received CPR , 31 had brain death , and 18 underwent withdrawal of treatment . The primary reason given for limiting treatment was that the patient was unresponsive to therapy . End of life discussions were held with 132 families , the vast majority of which revolved around withholding treatment and the remainder concerned withdrawing treatment .There was a statistically significant association between the type of end of life decision and region—that is, the northern region of Europe, the central region, the southern region, and Israel.Conclusions: Regional culture plays an important part in end of life decision making. Differences relating to end of life decision making exist between regions and these differences can often be attributed to cultural factors. Such cultures not only affect patients and their families but also the health care workers who make and carry out such decisions. (shrink)

Psychedelic treatments, particularly 3,4-methylenedioxymethamphetamine (MDMA)-assisted and psilocybin-assisted therapies, have recently seen renewed interest in their clinical potential to treat various mental health conditions. Clinical trials for both MDMA-assisted and psilocybin-assisted therapies have shown to be highly efficacious for post-traumatic stress disorder and major depression. Recent research trials for psychedelic-assisted therapies (PAT) have demonstrated that although they are resource-intensive, their effects are rapid-acting, durable and cost-effective. These results have generated enthusiasm among researchers seeking to investigate psychedelic therapies in active-duty service (...) members of the US military, particularly those with treatment refractory mental health conditions. At the same time, psychedelics remain in early stages of clinical investigation, have not yet achieved regulatory approval for general clinical use and may confer unique psychological and neurobiological effects that could raise novel ethical considerations when treating active-duty service members. Should psychedelics achieve regulatory approval, military relevant considerations may include issues of access to these treatments, appropriate procedures for informed consent, confidentiality standards, and possible unanticipated mental health risks and other psychological sequelae. A service member’s deployability, as well as their ability to return to full military duty following PAT, may also be of unique concern. The authors argue that MDMA-assisted therapy currently represents a promising treatment that should be more rapidly investigated as a clinical therapy for service members while still taking a measured approach that accounts for the many military-specific uncertainties that remain. (shrink)

Sharing Experiences of Illness and Effectiveness of Asthma Therapy in Children This research deals with relationships between openness and opportunities to share asthma experiences between an ill child and close family, and effectiveness of medical therapy of asthma. Subjects were 58 children, between the age of 12-14, from the allergic outpatient clinic with a diagnosed bronchial asthma and under pharmacological therapy. Each child answered questions on frequency and satisfaction with talking with parents, or other close family members, (...) on his or her experiences related to asthma. A doctor conducting the therapy was asked to evaluate results of therapy, and intensity of the asthma, for each child. The data support the hypotheses that degree of sharing own asthma-related experiences with close persons correlates positively with effectiveness of therapy. This effect appears stronger among children with more severe asthma. (shrink)

Background Little is known about the attitudes and practices of intensivists working in Lebanon regarding withholding and withdrawing life-sustaining treatments. The objectives of the study were to assess the points of view and practices of intensivists in Lebanon along with the opinions of medical, legal and religious leaders regarding withholding withdrawal of life-sustaining treatments in Lebanese intensive care units. Methods A web-based survey was conducted among intensivists working in Lebanese adult ICUs. Interviews were also done with Lebanese medical, legal (...) and religious leaders. Results Of the 229 survey recipients, 83 intensivists completed it, i.e. a response rate of. Most respondents were between 30 and 49 years old, Catholic Christians, anesthesiologists, working in Beirut. Ninety-two percent of them were familiar with the withholding and withdrawal concepts and 80% applied them. Poor prognosis of the acute and chronic disease and futile therapy were the main reasons to consider withholding and withdrawal of treatments. Ninety-five percent of intensivists agreed with the “Principle of Double Effect”. The main withheld therapies were vasopressors, respiratory assistance and CPR. Most of the respondents reported the decision was often to always multidisciplinary, involving the family, and the patient, or his advance directives or his surrogate and the nurses. The interviewees agreed there was a law governing withholding and withdrawal decisions/practices in Lebanon. Christians and Muslim Sunni leaders declared accepting those practices. Conclusion Withholding and withdrawal of LSTs in the ICU are known concepts among intensivists working in Lebanon and are being practiced. Our results could be used to inform and optimize therapeutic limitation in ICUs in the country. (shrink)

ObjectiveTo explore how clients in clinical settings experience the process of opening up and sharing their inner experiences in the initial phase of therapy.MethodsTwo psychotherapy sessions of clients were videotaped and followed by interviews. Interpersonal process recall was used to obtain in-depth descriptions of clients’ immediate experiences in session. A follow-up interview was conducted 3 months later. The interviews were analyzed using thematic analysis.ResultsThe data revealed how and why clients distanced themselves from inner experiences in the initial phase of (...) therapy. The overarching theme was “Holding back and struggling to open up,” which included four subthemes: fearing the intensity and consequences of negative emotions; experiences of being incapable and bodily stuck; being insecure about one’s worthiness and right to share inner experiences with the therapist; and struggling with feeling disloyal to loved ones.ConclusionThe participants held back because they feared different consequences of opening up. A range of concerns led participants to distance themselves from their inner experiences and/or to refrain from openly talking about them to the therapist. Concerns related to appropriate interpersonal conduct as client were especially important. This knowledge is highly relevant to clinicians when building safety for psychotherapeutic work. (shrink)

Chronic pain is of significant global concern. There is growing evidence that body–mind therapies and psychological approaches can contribute toward changing chronic pain perceptions. This is the first model described in the literature that combines a mindfulness-based approach with dance movement therapy and explores the potential psychological and pain-related changes for this client population. In this paper, the results from the pilot study are presented involving patients with chronic headache recruited in an outpatient rehabilitation setting.Methods: In this pilot study, (...) 29 patients with chronic headache were randomized to either the Mindful-Based Dance Movement Therapy group or the waiting list control group. The MBDMT group was offered 10 sessions in a clinical outpatient rehabilitation setting for 5 weeks. Data were collected pre- and post-intervention and 16 weeks after the intervention was finished. The Hospital Anxiety and Depression Scale, Patient Health Questionnaire−9, Five Facet Mindfulness Questionnaire, and Numeric Rating Scale were used as outcome measures.Results: The working model of MBDMT identifies nine therapeutic mechanisms. Per-protocol analysis reveals statistically significant reduction of pain intensity and depression scores in favor of the MBDMT group, and these improvements were maintained in the follow-up assessment.Conclusions: The results suggest that MBDMT is a feasible and promising therapy approach for chronic pain patients. The pilot study offered sufficient information and preliminary results in the desirable direction to enable the researchers to move to a randomized controlled trial stage in order to establish the efficacy of the intervention.Clinical Trial Registration: The study was registered in the www.researchregistry.com, registry. (shrink)

Using a longitudinal case study design, we have tracked the recovery of motor function following severe traumatic brain injury (TBI) through a multimodal neuroimaging approach. In 2006, Canadian Soldier Captain (retired) Trevor Greene (TG) was attacked with an axe to the head while on tour in Afghanistan. TG continues intensive daily rehabilitation, which recently included the integration of physical therapy (PT) with neuromodulation using translingual neurostimulation (TLNS) to facilitate neuroplasticity. Recent findings with PT+TLNS demonstrated that recovery of motor (...) function occurred beyond conventional time limits, currently extending past 14-years post-injury. To investigate whether PT+TLNS similarly resulted in associated cognitive function improvements, we examined event-related potentials (ERPs) with the brain vital signs framework. In parallel with motor function improvements, brain vital signs detected significant increases in basic attention (as measured by P300 response amplitude) and cognitive processing (as measured by contextual N400 response amplitude). These objective cognitive improvements corresponded with TG’s self-reported improvements, including a noteworthy and consistent reduction in ongoing symptoms of post-traumatic stress disorder (PTSD). The findings provide valuable insight into the potential importance of non-invasive neuromodulation in cognitive rehabilitation, in addition to initial indications for physical rehabilitation. (shrink)

Conversion therapy refers to a range of unscientific, discredited and harmful heterosexist practices that attempt to re-align an individual’s sexual orientation, usually from non-heterosexual to heterosexual. In Australia, the state of Victoria recently joined Queensland and the Australian Capital Territory in criminalising conversion therapy. Although many other jurisdictions have also introduced legislation banning conversion therapy, it persists in over 60 countries. Children are particularly vulnerable to the harmful effects of conversion therapy, which can include coercion, rejection, (...) isolation and blame. However, if new biotechnologies create safe and effective conversion therapies, the question posed here is whether it would ever be morally permissible to use them. In addressing this question, we need to closely examine the individual’s circumstances and the prevailing social context in which conversion therapy is employed. I argue that, even in a sexually unjust world, conversion therapy may be morally permissible if it were the only safe and effective means of relieving intense anguish and dysphoria for the individual. The person providing the conversion therapy must be qualified, sufficiently independent from any religious organisation and must provide conversion therapy in a way that is positively affirming of the individual and their existing sexuality. (shrink)

Critical care is in an emerging crisis of conflict between what individuals expect and the economic burden society and government are prepared to provide. The goal of critical care support is to prevent suffering and premature death by intensive therapy of reversible illnesses within a reasonable timeframe. Recently, it has become apparent that early support in an intensive care environment can improve patient outcomes. However, life support technology has advanced, allowing physicians to prolong life (and postpone death) (...) in circumstances that were not possible in the recent past. This has been recognized by not only the medical community, but also by society at large. One corollary may be that expectations for recovery from critical illness have also become extremely high. In addition, greater numbers of patients are dying in intensive care units after having receiving prolonged durations of life-sustaining therapy. Herein lies the emerging crisis – critical care therapy must be available in a timely fashion for those who require it urgently, yet its provision is largely dependent on a finite availability of both capital and human resources. Physicians are often placed in a troubling conflict of interest by pressures to use health resources prudently while also promoting the equitable and timely access to critical care therapy. In this commentary, these issues are broadly discussed from the perspective of the individual clinician as well as that of society as a whole. The intent is to generate dialogue on the dynamic between individual clinicians navigating the complexities of how and when to use critical care support in the context of end-of-life issues, the increasing demands placed on finite critical care capacity, and the reasonable expectations of society. (shrink)

ObjectiveDropout rates are a prominent problem in youth psychotherapy. An important determinant of dropouts is the quality of the therapeutic relationship. This study aimed to evaluate the association between the therapeutic relationship and dropouts in an intensive mentalization-based treatment for adolescents with personality disorders.MethodsPatients included were either dropouts or completers of an intensive MBT. The therapeutic relationship was measured with the child version of the Session Rating Scale, which was completed by the patient after each group therapy (...) session. For each patient, the treatment termination status was indicated by the treatment staff. The reliable change index was calculated for the C-SRS to determine significant changes in the therapeutic relationship.ResultsWhile both groups started with similar scores on the C-SRS, the scores between dropouts and completers differed significantly at the end of the treatment period. On average, during therapy, an increase was seen in the scores of completers, and a decrease was seen in the scores of dropouts. While dropouts could not be predicted based on the C-SRS scores, a significant decrease in C-SRS scores during the last two sessions occurred more often for dropouts than for completers.ConclusionOur findings show that to prevent dropouts, the patient’s judgment of the quality of the therapeutic relationship should be monitored continuously, and decreases discussed with the patient and the group. (shrink)