Shooting for Safety

Austin Regional Clinic announced in June that it would no longer accept new pediatric patients whose parents or guardians don't permit vaccinations. The new policy aims to protect the clinic's most vulnerable patients, such as infants who aren't fully vaccinated, seniors, those who have compromised immune systems, and pregnant women. An exception is included for patients who have adverse reactions to vaccines or severely compromised immune systems.

When the Therapist Says Goodbye

Therapist-initiated termination poses several unique problems for both the group and the therapist. This paper describes the termination process from the point of view of this therapist's experience in planning the termination of her group therapy practice. The reactions of other analysts to her decision to retire and the group processes and individual patient's reactions in this long-term psychoanalytic therapy group are described in detail. The author follows the group process and her own inner processes in the final six months of the group. The importance of the working through of the termination phase of therapy is supported by the experiences that were shared by the group and the therapist.

IPF, comorbidities and management implications: Patient case 2

PATIENT PRESENTATION AND DIAGNOSIS: The patient is a 50-year-old woman who was referred to a tertiary centre with an HRCT showing definite UIP and a 6-minute walking distance of 145 metres. She was severely ill at presentation with a diffusion capacity of just 20%.The patient had a history of peripheral arterial disease and had undergone both aortofemoral and femoro-femoral bypass due to arteriosclerosis and gluteal ischaemia. She also was suffering from renal impairment and had recently quit smoking.

Assessing equitable care for Indigenous and Afrodescendant women in Latin America

OBJECTIVE

To identify and understand the barriers to equitable care within health care settings that women of ethnic minorities encounter in Latin America and to examine possible strategies for mitigating the issues.

METHODS

This was a comprehensive review of the literature from 2000-2015 available from the online databases PubMed, Google Scholar, EBSCOhost, and SciELO in Spanish, English, and Portuguese, using a keyword search that included the Region and country names.

RESULTS

Health provider discrimination against Indigenous and Afrodescendant women is a primary barrier to quality health care access in Latin America. Discrimination is driven by biases against ethnic minority populations, women, and the poor in general. Discriminatory practices can manifest as patient-blaming, purposeful neglect, verbal or physical abuse, disregard for traditional beliefs, and the non-use of Indigenous languages for patient communication. These obstacles prevent delivery of appropriate and timely clinical care, and also produce fear of shame, abuse, or ineffective treatment, which, in addition to financial barriers, deter women from seeking care.

CONCLUSIONS

To ensure optimal health outcomes among Indigenous and Afrodescendant women in Latin America, the issue of discrimination in health care settings needs to be understood and addressed as a key driver of inequitable health outcomes. Strategies that target provider behavior alone have limited impact because they do not address women's needs and the context of socioeconomic inequality in which intra-hospital relations are built.

Is cooling still cool?

Therapeutic hypothermia (TH), where patients are cooled to between 32°C and 36°C for a period of 12-24 hours and then gradually rewarmed, may reduce the risk of ischemic injury to cerebral tissue following a period of insufficient blood flow. This strategy of TH could improve mortality and neurological function in patients who have experienced out-of-hospital cardiac arrest (OOHCA). The necessity of TH in OOHCA was challenged in late 2013 by a fascinating and potentially practice changing publication, which found that targeting a temperature of 36°C had similar outcomes to cooling patients to 33°C. This article reviews the current literature and summarizes the uncertainties and questions raised when considering cooling of patients at risk of hypoxic brain injury. Irrespective of whether TH or targeted temperature management is deployed in patients at risk of hypoxic brain injury, it would seem that avoiding hyperpyrexia is important and that a more rigorous approach to neurological evaluation is mandated.

[The refusal and on the suspension (but, perhaps, not even on the beginning) hemodialysis replacement]

The possibilities offered by scientific progress and technology are, more and more pressing questions about the limits of care:not in the perspective indicated by the policies of cost containment as a promotional support of the defense of fundamental rights of the human person. The Author explores the circumstances in which we must ask yourself some questions before or discontinuation of dialysis replacement. Discusses the scientific evidence and the recommendations contained in international documents, formulating a draft operational perspective advance care planning with 10 statements from which to draft a consensus document professional Italian.

The scene time interval and basic life support termination of resuscitation rule in adult out-of-hospital cardiac arrest

We validated the basic life support termination of resuscitation (BLS TOR) rule retrospectively using Out-of-Hospital Cardiac Arrest (OHCA) data of metropolitan emergency medical service (EMS) in Korea. We also tested it by investigating the scene time interval for supplementing the BLS TOR rule. OHCA database of Seoul (January 2011 to December 2012) was used, which is composed of ambulance data and hospital medical record review. EMS-treated OHCA and 19 yr or older victims were enrolled, after excluding cases occurred in the ambulance and with incomplete information. The primary and secondary outcomes were hospital mortality and poor neurologic outcome. After calculating the sensitivity (SS), specificity (SP), and the positive and negative predictive values (PPV and NPV), tested the rule according to the scene time interval group for sensitivity analysis. Of total 4,835 analyzed patients, 3,361 (69.5%) cases met all 3 criteria of the BLS TOR rule. Of these, 3,224 (95.9%) were dead at discharge (SS,73.5%; SP,69.6%; PPV,95.9%; NPV, 21.3%) and 3,342 (99.4%) showed poor neurologic outcome at discharge (SS, 75.2%; SP, 89.9%; PPV, 99.4%; NPV, 11.5%). The cut-off scene time intervals for 100% SS and PPV were more than 20 min for survival to discharge and more than 14 min for good neurological recovery. The BLS TOR rule showed relatively lower SS and PPV in OHCA data in Seoul, Korea.

Referrals for Movement Disorder Surgery: Under-Representation of Females and Reasons for Refusal

OBJECTIVE

Referral of movement disorder patients for deep brain stimulation surgery was examined to determine whether referred patients were representative of gender proportions in our population, and reasons why patients do not proceed to surgery.

METHODS

Demographic information on referrals to the surgical program was retrospectively reviewed from our database and from a detailed chart review.

RESULTS

Although almost equal numbers of movement disorder patients are male and female, of the 91 patients referred for surgery, only 31% were female. Sixty-one percent of referred patients did not undergo surgery. Of these, the majority were denied for medical reasons, including cognitive decline (21%), psychiatric concerns (5%) and neurological reasons (42%).

CONCLUSIONS

Almost one-third of patients referred for movement disorder surgery were denied for medical reasons. This underscores the importance of evaluation of all potential patients by a multidisiplinary team to fully assess suitablity for stereotactic surgery. Interestingly, women were under-represented in those referred. In order that all appropriate patients have the opportunity to consider surgery, education of both physicians and patients, and different strategies to approach females regarding surgery may allow more patients to benefit from this treatment.

Do motives matter in male circumcision? 'Conscientious objection' against the circumcision of a Muslim child with a blood disorder

Whilst there have been serious attempts to locate the practice of male circumcision for religious motives in the context of the (respective) religion's narrative and community, the debate, when referring to a clinical context, is often more nuanced. This article will contribute further to the debate by contextualising the Islamic practice of male circumcision within the clinical setting typical of a contemporary hospital. It specifically develops an additional complication; namely, the child has a pre-existing blood disorder. As an approach to contributing to the circumcision debate further, the ethics of a conscientious objection for secular motives towards a religiously-motivated clinical intervention will be explored. Overall, the discussion will provide relevance for such debates within the value-systems of a multi-cultural society. This article replicates several approaches to deconstructing a request for conscientious refusal of non-therapeutic circumcision by a Clinical Ethics Committee (CEC), bringing to light certain contradictions that occur in normatively categorizing motives for performing the circumcision.