Guidelines on artificial nutrition versus hydration in terminal cancer patients

Whether a terminally ill cancer patient should be actively fed or simply hydrated through subcutaneous or intravenous infusion of isotonic fluids is a matter of ongoing controversy among clinicians involved in the care of these patients. Under the auspices of the European Association for Palliative Care, a committee of experts developed guidelines to help clinicians make a reasonable decision on what type of nutritional support should be provided on a case-by-case basis. It was acknowledged that part of the controversy related to the definition of the terminal cancer patient, since this is a heterogeneous group of patients with different needs, expectations, and potential for a medical intervention. A major difficulty is the prediction of life expectancy and the patient's likely response to vigorous nutritional support. In an attempt to reach a decision on the type of treatment support (artificial nutrition vs. hydration) which would best meet the needs and expectations of the patient, we propose a three-step process: Step I: define the eight key elements necessary to reach a decision: Step II: make the decision; and Step III: reevaluate the patient and the proposed treatment at specified intervals. Step I involves assessing the patient concerning the following: 1) oncological/clinical condition; 2) symptoms; 3) expected length of survival; 4) hydration and nutritional status; 5) spontaneous or voluntary nutrient intake; 6) psychological profile; 7) gut function and potential route of administration; and 8) need for special services based on type of nutritional support prescribed. Step II involves the overall assessment of pros and cons, based on information determined in Step I, in order to reach an appropriate decision based on a well-defined end point (i.e. improvement of quality of life; maintaining patient survival; attaining rehydration). Step III involves the periodic reevaluation of the decision made in Step II based on the proposed goal and the attained result.

Linear inverse problems with discrete data: II. Stability and regularization

For pt.I. see ibid. vol.1, p.301 (1985). In the first part of this work a general definition of an inverse problem with discrete data has been given and an analysis in terms of singular systems has been performed. The problem of the numerical stability of the solution, which in that paper was only briefly discussed, is the main topic of this second part. When the condition number of the problem is too large, a small error on the data can produce an extremely large error on the generalised solution, which therefore has no physical meaning. The authors review most of the methods which have been developed for overcoming this difficulty, including numerical filtering, Tikhonov regularisation, iterative methods, the Backus-Gilbert method and so on. Regularisation methods for the stable approximation of generalised solutions obtained through minimisation of suitable seminorms (C-generalised solutions), such as the method of Phillips (1962), are also considered.

The temporal dynamics of metacognition: Dissociating task-related activity from later metacognitive processes

In recent years, neuroscience research spent much effort in revealing brain activity related to metacognition. Despite this endeavor, it remains unclear exactly when metacognitive experiences develop during task performance. To investigate this, the current study used EEG to temporally and spatially dissociate task-related activity from metacognitive activity. In a masked priming paradigm, metacognitive experiences of difficulty were induced by manipulating congruency between prime and target. As expected, participants more frequently rated incongruent trials as difficult and congruent trials as easy, while being completely unable to perceive the masked primes. Results showed that both the N2 and the P3 ERP components were modulated by congruency, but that only the P3 modulation interacted with metacognitive experiences. Single-trial analysis additionally showed that the magnitude of the P3 modulation by congruency accurately predicted the metacognitive response. Source localization indicated that the N2 task-related activity originated in the ACC, whereas the P3-interplay between task-related activation and metacognitive experiences originated from the precuneus. We conclude that task-related activity can be dissociated from later metacognitive processing.