The Limits of Proxy Decision Making: Undertreatment

With the passage by virtually every state legislature of healthcare proxy laws, the medical profession increasingly can expect to rely on the participation of surrogates in making decisions on behalf of incompetent patients. Several concerns about the legitimacy of proxy decision making have been discussed in the ethical and general medical literature: the lack of concordance between the views of patients and their surrogates have been documented on multiple occasions, and cases of abuse by proxies or potential conflict of interest have been reported. Another dilemma that deserves discussion arises when proxies demand withdrawal of treatment that physicians and nurses regard as essential to the wellbeing of the patient. The following case highlights this dilemma.

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Electronic fetal monitoring in the twenty-first century: Language, logic and Lewis Carroll

Clinical Ethics ◽

10.1177/1477750920971800 ◽

2020 ◽

pp. 147775092097180

Author(s):

Thomas P Sartwelle ◽

James C Johnston ◽

Berna Arda ◽

Mehila Zebenigus

Keyword(s):

Medical Literature ◽

Medical Profession ◽

Scientific Research ◽

Fetal Monitoring ◽

First Century ◽

Lewis Carroll ◽

Evidence Based ◽

Electronic Fetal Monitoring ◽

Complete Failure ◽

Twenty First Century

The Alice Books, full of illogical thoughts, words, and contradictions, were unrivaled entertainment until the publication of the medical literature promoting electronic fetal monitoring (EFM) for every pregnancy. The modern-day EFM advocates acknowledge EFM’s decades long failure but simultaneously recommend EFM use for lawsuit protection and because the profession has used EFM for every pregnancy for fifty years, therefore, it must be efficacious. These self-indulgent, illogical rationalizations ignore the half century of evidence-based scientific research proving that EFM is a complete failure as well as ignoring the fact that continued EFM use violates the fundamental principles of modern bioethics. This blind advocacy perpetuates four pernicious EFM harms occurring to mothers, babies, and the medical profession itself. This article sets out these four EFM harms with the goal of abolishing the misguided, illogical, contradictory, arguments used by the twenty-first century EFM Lewis Carroll mimics.

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Disclosure of Potential Conflict of Interest/Original Articles-With Comment and Response

Journal of Refractive Surgery ◽

10.3928/1081-597x-19900301-03 ◽

1990 ◽

Vol 6 (2) ◽

pp. 80-81

Author(s):

George O Waring

Keyword(s):

Conflict Of Interest ◽

Potential Conflict

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Ethical understandings of proxy decision making for research involving adults lacking capacity: A systematic review (framework synthesis) of empirical research

AJOB Empirical Bioethics ◽

10.1080/23294515.2018.1513097 ◽

2018 ◽

Vol 9 (4) ◽

pp. 267-286 ◽

Cited By ~ 3

Author(s):

Victoria Shepherd ◽

Kerenza Hood ◽

Mark Sheehan ◽

Richard Griffith ◽

Amber Jordan ◽

...

Keyword(s):

Systematic Review ◽

Decision Making ◽

Empirical Research ◽

Proxy Decision Making

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Measuring and Explaining Computed Tomography Use in the United States and Canada: A Consideration of Health Economics, Use Versus Appropriateness, and Interpreting Potential Conflict of Interest

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2013.08.026 ◽

2013 ◽

Vol 62 (5) ◽

pp. 545-546 ◽

Cited By ~ 3

Author(s):

David L. Schriger ◽

Michael L. Callaham ◽

Tyler W. Barrett

Keyword(s):

United States ◽

Computed Tomography ◽

Health Economics ◽

Conflict Of Interest ◽

The United States ◽

Potential Conflict

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Emotion Modulation of the Body-Selective Areas in the Developing Brain

10.1101/564633 ◽

2019 ◽

Author(s):

Paddy Ross ◽

Beatrice de Gelder ◽

Frances Crabbe ◽

Marie-Hélène Grosbras

Keyword(s):

Conflict Of Interest ◽

Right Hemisphere ◽

Brain Activity ◽

The Body ◽

Childhood And Adolescence ◽

Body Perception ◽

Body Area ◽

Potential Conflict ◽

First Time ◽

Posterior Superior Temporal Sulcus

AbstractEmotions are strongly conveyed by the human body and the ability to recognize emotions from body posture or movement is still developing through childhood and adolescence. To date, there are very few studies exploring how these behavioural observations are paralleled by functional brain development. Furthermore, there are currently no studies exploring the development of emotion modulation in these areas. In the current study, we used functional magnetic resonance imaging (fMRI) to compare the brain activity of 25 children (age 6-11), 18 adolescents (age 12-17) and 26 adults while they passively viewed short videos of angry, happy or neutral body movements. We observed that when viewing bodies generally, adults showed higher activity than children bilaterally in the body-selective areas; namely the extra-striate body area (EBA), fusiform body area (FBA), posterior superior temporal sulcus (pSTS) and amygdala (AMY). Adults also showed higher activity than adolescents, but only in right hemisphere body-selective areas. Crucially, however, we found that there were no age differences in the emotion modulation of activity in these areas. These results indicate, for the first time, that despite activity selective to body perception increasing across childhood and adolescence, emotion modulation of these areas in adult-like from 7 years of age.Conflict of InterestThe author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Muscles Recruited During an Isometric Knee Extension is Defined by Proprioceptive Feedback

10.1101/802736 ◽

2019 ◽

Author(s):

Gareth York ◽

Hugh Osborne ◽

Piyanee Sriya ◽

Sarah Astill ◽

Marc de Kamps ◽

...

Keyword(s):

Spinal Cord ◽

Conflict Of Interest ◽

Rectus Femoris ◽

Knee Extension ◽

Proprioceptive Feedback ◽

Muscle Synergy ◽

Knee Angle ◽

Potential Conflict ◽

Dynamic Task ◽

Isometric Knee Extension

AbstractProprioceptive feedback and its role in control of isometric tasks is often overlooked. In this study recordings were made from upper leg muscles during an isometric knee extension task. Internal knee angle was fixed and subjects were asked to voluntarily activate their rectus femoris muscle. Muscle synergy analysis of these recordings identified canonical temporal patterns in the data. These synergies were found to encode two separate features: one concerning the coordinated contraction of the recorded muscles and the other indicating agonistic/antagonistic interactions between these muscles. The second synergy changed with internal knee angle reflecting the influence of afferent activity. This is in contrast to previous studies of dynamic task experiments which have indicated that proprioception has a negligible effect on synergy expression. Using the MIIND neural simulation platform, we developed a spinal population model with an adjustable input representing proprioceptive feedback. The model is based on existing spinal population circuits used for dynamic tasks. When the same synergy analysis was performed on the output from the model, qualitatively similar muscle synergy patterns were observed. These results suggest proprioceptive feedback is integrated in the spinal cord to control isometric tasks via muscle synergies.Significance statementSensory feedback from muscles is a significant factor in normal motor control. It is often assumed that instantaneous muscle stretch does not influence experiments where limbs are held in a fixed position. Here, we identified patterns of muscle activity during such tasks showing that this assumption should be revisited. We also developed a computational model to propose a possible mechanism, based on a network of populations of neurons, that could explain this phenomenon. The model is based on well established neural circuits in the spinal cord and fits closely other models used to simulate more dynamic tasks like locomotion in vertebrates.Conflict of interest statementThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Certolizumab pegol: new opportunities for treatment of moderate to severe plaque psoriasis

Vestnik dermatologii i venerologii ◽

10.25208/0042-4609-2019-95-5-50-57 ◽

2019 ◽

Vol 95 (5) ◽

pp. 50-57

Author(s):

A. A. Kubanov ◽

A. L. Bakulev ◽

M. I. Gluzmin ◽

M. M. Kokhan ◽

L. S. Kruglova ◽

...

Keyword(s):

Psoriatic Arthritis ◽

Conflict Of Interest ◽

Plaque Psoriasis ◽

Randomized Clinical Trials ◽

Placental Transfer ◽

Certolizumab Pegol ◽

Fab Fragment ◽

Potential Conflict ◽

Severe Plaque Psoriasis ◽

Tnf Α

Tumor necrosis factor alpha (TNF-α) is one of the key inflammatory cytokines in the pathogenesis of psoriasis and psoriatic arthritis, and its inhibition with genetically engineered biological drugs ensures control of the main symptoms of these diseases. Certolizumab pegol is a PEGylated (linked to polyethylene glycol) Fab’ fragment of a monoclonal antibody that inhibits human TNF-α. It is approved for treatment of moderate to severe plaque psoriasis and psoriatic arthritis. This review summarizes the results of randomized clinical trials of efficacy and safety of certolizumab pegol in plaque psoriasis (CIMPASI 1, CIMPASI 2, and CIMPACT) and psoriatic arthritis (Rapid-PsA). The represented data demonstrate high efficacy of certolizumab pegol is bio-naïve patients and in patients previously exposed to other TNF inhibitors or IL17 inhibitors. The absence of the Fc-fragment in certolizumab pegol ensures minimal to no placental transfer of the drug and enables its usage during the entire pregnancy.Conflict of interest: the authors state that there is no potential conflict of interest requiring disclosure in this article.

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Syncope in Commercial Pilots and New Regulatory Guidance

Aerospace Medicine and Human Performance ◽

10.3357/amhp.5742.2021 ◽

2021 ◽

Vol 92 (8) ◽

pp. 642-649

Author(s):

Ryan A. Anderton ◽

Stuart J. Mitchell ◽

Sean S. ONunain

Keyword(s):

Decision Making ◽

Medical Literature ◽

Civil Aviation ◽

Positive Finding ◽

Regulatory Guidance ◽

Significant Difference ◽

Regulatory Perspective ◽

The Mean ◽

Regulatory Practice ◽

Underlying Pathology

INTRODUCTION: Syncope is both incapacitating and unpredictable, presenting a significant challenge in aircrew assessment. Previous UK Civil Aviation Authority (CAA) guidance lacked transparency and relied heavily on specialist in-house cardiology and neurology opinion. A new algorithm was developed which elaborated and formalized the decision-making process. An analysis of its impact on historic cases was undertaken to ensure it aligned with previous certificatory outcomes.METHODS: The medical literature on syncope and the approaches of other national aviation authorities were reviewed to help inform the development of a new algorithm. Using syncope cases in the CAA database, regulatory outcomes generated using the new algorithm were compared with previous decisions in terms of time off from flying (TOF) and Operational Multi-Crew Limitation (OML) duration.RESULTS: There were 40 historic syncope cases (25 existing certificate holders,15 initial applicants) which were reassessed using the new algorithm. The mean TOF for existing pilots using the new algorithm was 7.1 9.8 (mean SD) vs. 4.2 3.5 mo under the old guidance with an OML duration of 21.4 34.9 vs. 24.5 25.2 mo. One less initial applicant experienced a delay to certification. Four cases with underlying pathology were detected using old and new guidance.DISCUSSION: The reassessment of cases showed no statistically significant difference in TOF and OML duration; this is a positive finding from a regulatory perspective, enabling algorithm-led decision-making with less reliance on in-house expertise. A similar approach may be useful in future updates to other areas of regulatory practice.Anderton RA, Mitchell SJ, ONunain SS. Syncope in commercial pilots and new regulatory guidance. Aerosp Med Hum Perform. 2021; 92(8):642649.

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