DNR and COVID-19: The Ethical Dilemma and Suggested Solutions

Ethics are considered a basic aptitude in healthcare, and the capacity to handle ethical dilemmas in tough times calls for an adequate, responsible, and blame-free environment. While do-not-resuscitate (DNR) decisions are made in advance in certain medical situations, in particular in the setting of poor prognosis like in advanced oncology, the discussion of DNR in relation to acute medical conditions, the COVID-19 pandemic in this example, might impose ethical dilemmas to the patient and family, healthcare providers (HCPs) including physicians and nurses, and to the institution. The literature on DNR decisions in the more recent pandemics and outbreaks is scarce. DNR was only discussed amid the H1N1 influenza pandemic in 2009, with clear global recommendations. The unprecedented condition of the COVID-19 pandemic leaves healthcare systems worldwide confronting tough decisions. DNR has been implemented in some countries where the healthcare system is limited in capacity to admit, and thus intubating and resuscitating patients when needed is jeopardized. Some countries were forced to adopt a unilateral DNR policy for certain patient groups. Younger age was used as a discriminator in some, while general medical condition with anticipated good outcome was used in others. The ethical challenge of how to balance patient autonomy vs. beneficence, equality vs. equity, is a pressing concern. In the current difficult situation, when cases top 100 million globally and the death toll surges past 2.7 million, difficult decisions are to be made. Societal rather than individual benefits might prevail. Pre-hospital triaging of cases, engagement of other sectors including mental health specialists and religious scholars to support patients, families, and HCPs in the frontline might help in addressing the psychological stress these groups might encounter in addressing DNR in the current situation.

A case of multiple trauma and lighter gas inhalation

The rate of volatile substance abuse is increasing among young people around the world. A 10-year-old boy was brought to the emergency room by the 112-emergency ambulance service due to fall from the roof of a four-storey building. His general medical condition was moderate-poor; his GCS (Glasgow Coma Scale) was nine, blood pressure: 118/90 mmHg, heart rate: 98/min, O2 saturation was: 100%. Skin abrasions were present on his jaw and the occipital region of the scalp. The patient was accepted as a multiple trauma patient. When the patient's confusion did not resolve, the patient's father informed us that the child may have inhaled lighter gas. The patient was hospitalized at the pediatric ward and was discharged on the 14th day of admission as his symptoms completely improved. Clinicians should be alert with regard to acute and/or chronic end-organ damages in the cases of gas inhalation without any antidote.

Case Report: Use of Subcutaneous Midazolam During an Episode of Catatonia

Midazolam is a benzodiazepine (BZD) mainly used in anesthetic induction due to its pharmacokinetic features. Its place in the therapeutic management of catatonia remains to be determined. Here we present the case of a 65-year-old man who presented with a first episode of catatonia with opposition to any form of oral treatment, where a single dose of 1 mg of subcutaneous (SC) Midazolam permitted clinical improvement allowing oral treatment to be given. The patient's history notably included a renal transplant linked to Polycystic Kidney Disease (PKD) and no history of psychiatric illness nor of any use of psychotropic drugs. As the patient refused to drink or eat and ceased answering basic questions, a psychiatric assessment was required. A diagnosis of Catatonic disorder due to a general medical condition [DSM 5–293.89/ ICD10 [F06.1]] was made. A Bush-Francis Catatonia Rating Scale (BFCRS) analysis returned a score of 15 out of 62, with stupor, mutism, negativism, staring, withdrawal, rigidity, and stereotypy. As the negativism prevented the patient from taking any form of oral treatment, after a brief discussion with the unit's physician, it was decided to administer 1 mg of SC Midazolam. One hour later, the patient was more responsive and compliant, and agreed to drink, eat, and take medication. Thus, the catatonic signs of mutism, negativism, staring, and withdrawal were resolved, but waxy flexibility and catalepsy appeared, leading to a new BFCRS score of 10 out of 62. Oral treatment with 2.5 mg Lorazepam, 4 times a day, was then initiated. Midazolam could be a safer choice compared with the other options available, such as other SC BZD, considering the complex safety profile of this patient with renal insufficiency. This situation represents the first report of using SC Midazolam as an injectable treatment for catatonia. More studies are needed to assess the clinical pertinence of SC Midazolam in the treatment of catatonia.

In Silico and In Vivo Assessment of L-17, a Thiadiazine Derivative with Putative Serotonin Reuptake Properties

L-17 is a thiadiazine derivative with putative anti-inflammatory, neuroprotective, and antidepressant-like properties. In this study, we applied combined in silico and in vivo electrophysiology techniques to reveal the potential mechanism of action of L-17. PASS 10.4 Professional Extended software suggested that L-17 might have pro-cognitive, antidepressant, and antipsychotic effects. Docking energy assessment with AutoDockVina predicted that the binding affinities of L-17 to the serotonin transporter (SERT) and serotonin receptors 3 and 1A (5-HT3 and 5-HT1A) are compatible to the selective serotonin reuptake inhibitor (SSRI) fluoxetine and selective antagonists of 5-HT3 and 5-HT1A receptors, granisetron and WAY100135, respectively. However, while the binding mechanisms of L-17 to the SERT and 5-HT1A receptor were similar to fluoxetine and WAY100135, its interacting with 5-HT3 receptor might be substantially different from this of granisetron. Acute administration of L-17 led to dose-dependent inhibition of firing activity of 5-HT neurons of the dorsal raphe nucleus. This inhibition was partially reversed by subsequent administration of WAY100135. Based on both in silico and in vivo electrophysiology assessments, we suggest that L-17 is a potent 5-HT reuptake inhibitor and a putative partial agonist of 5-HT1A receptors. As such, L-17 in particular and thiadiazine derivatives, in general, might be a representative of a new class of antidepressant drugs. Since L-17 also possesses neuro- and cardioprotective properties, it can be useful in affective illness developing due to the general medical condition, such as post-stroke and post-myocardial infarction (MI) depression.

TO STUDY CLINICAL PROFILE OF ACUTE CONFUSIONAL STATE IN A TERTIARY CARE HOSPITAL IN A HILLY AREA.

Acute confusional state/Delirium is a condition that develops quickly (usually over hours or days) and involves changes in consciousness, attention, cognition (thinking and reasoning), and perception. . Delirium is usually temporary and reversible and does not reflect a persistent psychiatric disorder.1 Delirium may result from a general medical condition, from use of drugs or similar substances, or from withdrawal from these substances. Some researchers suggest that there are two forms of delirium: hyperactive (agitated) and hypoactive (lethargic). If individuals with delirium experience the hyperactive form, they may be more prone to hallucinations, delusions, agitation, and disorientation. The rate is higher in elderly persons, those with cancer, and those with acquired immunodeficiency syndrome (AIDS). Patients who have had an operation (especially heart surgery, hip surgery, and organ transplants), as well as patients with burns, dialysis, or central nervous system lesions, are at increased risk for delirium. It is very common in individuals with terminal illnesses, often occurring just before death.4 we conducted this study to see the aetiological profile of Acute Confusional State in patients admitted in medical wards in IGMC Shimla and to study the behavior pattern of such patients.

Regresso ao Trabalho após Acidente Laboral

Introduction / background / objectives Most Occupational Health teams do not have concrete experience in developing an action plan that aims to enhance the return of injured employees, especially when the work limitations are reasonable. The purpose of this review was to summarize the most recent and pertinent published data on the subject. Methodology This is a Scoping Review, initiated through a survey conducted in December 2019, in the databases “CINALH plus with full text, Medline with full text, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Nursing and Allied Health Collection: comprehensive, MedicLatina, SCOPUS and RCAAP”. Content The articles that addressed this subject were scarce and not exhaustive. In the selected documents, some circumstances/ conditions were highlighted that can modulate the return to work; sometimes the authors did not specify the meaning of that influence, but in other cases they made it clear whether it enhanced or impaired the issue. Work accidents cause significant morbidity and costs worldwide, considering both direct and indirect expenses (such as lost productivity, changes in the insurer’s wages, employee turnover and training, investigation of the event and possible compensation, depending on the legislation of each country). Conclusions It seems that the return to work is facilitated with a fair and quick injury management, a team with experience to guide these process, good communication between the different parties involved, less serious injuries, less physically burdensome tasks, absence of economic/ social interests to delay return, good copping skills and healthier self-perception of the general medical condition. It would be very pertinent for some Occupational Health teams, that work with large clients and/ or with a reasonable number of occupational accidents that have resulted in considerable absences and/ or limitations, to investigate which are the best postures/ conditions that facilitate the return to work, subsequently publishing its conclusions.