Änderung des Therapieziels am Lebensende: Effekte einer Klinik-Leitlinie [Changing the treatment goal at the end of life: effects of a guideline at a hospital].

BACKGROUND AND OBJECTIVE: Deciding about treatment goals at the end of life is a frequent and difficult challenge to medical staff. As more health care institutions issue ethico-legal guidelines to their staff the effects of such a guideline should be investigated in a pilot project.¦PARTICIPANTS AND METHODS: Prospective evaluation study using the pre-post method. Physicians and nurses working in ten intensive care units of a university medical center in Germany answered a specially designed questionnaire before and one year after issuance of the guideline.¦RESULTS: 197 analyzable answers were obtained from the first (pre-guideline) and 251 from the second (post-guideline) survey (54 % and 58 % response rate, respectively). Initially the clinicians expressed their need for guidelines, advice on ethical problems, and continuing education. One year after introduction of the guideline one third of the clinicians was familiar with the guideline's content and another third was aware of its existence. 90% of those who knew the document welcomed it. Explanation of the legal aspects was seen as its most useful element. The pre- and post-guideline comparison demonstrated that uncertainty in decision making and fear of legal consequences were reduced, while knowledge of legal aspects and the value given to advance directives increased. The residents had derived the greatest benefit.¦CONCLUSION: By promoting the knowledge of legal aspects and ethical considerations, guidelines given to medical staff can lead to more certainty when making in end of life decision.

HIV-associated neurocognitive disorders (HAND): a changing pattern

Combination antiretroviral therapy has dramatically decreased the incidence of HIV-related mortality and serious opportunistic diseases, among which is HIV- associated dementia. However, minor forms of cognitive dysfunction have not disappeared and may even have increased in frequency. Aging of HIV+ patients, insufficient penetration of antiretroviral drugs into the brain with continuous low- grade viral production and inflammation may play a role. A putative neurotoxicity of combination antiretroviral therapy is controversial. In this article, we will discuss these aspects, as well as clinical and pathophysiological features shared by HIV-associated neurocognitive disorders and other neurodegenerative diseases, especially Alzheimer's disease. This article will briefly summarize the current clinical trials on neuroprotective agents, and the management of patients with neurocognitive disorders will be discussed

From the vendor in the hemp shop to the dealer in the alleyway? A comparison of the sources of supply of cannabis in a time of 'de-normalising' cannabis use.

Objectives: After several years of increasing 'normalisation' of cannabis use in Switzerland at the beginning of the new millennium, a reversed tendency, marked among others by a more stringent law-enforcement, set in. The presentation examines the question of where adolescents and young adults obtained cannabis, within the context of this societal change. In addition, it compares the sources of supply for cannabis with those found in studies of other European countries. Methods: Analyses are based on data from the Swiss Cannabis Monitoring Study. As part of this longitudinal, representative population survey, more than 5000 adolescents and young adults were interviewed by telephone on the topic of cannabis. Within the total sample, 593 (2004) or 554 (2007) respectively, current cannabis users replied to the questions on sources of supply. Changes in law-enforcement and societal climate concerning cannabis are assessed based on relevant literature, media reports and parliamentary discussions. Results: Whereas 22% of cannabis users stated in 2004 that they bought their cannabis from vendors in hemp shops, this proportion drastically decreased to 6% three years later. At the same time, cannabis was obtained increasingly from friends, while the proportion of users who purchased cannabis from dealers in the alleyway, more than doubled from 6% (2004) to 13% (2007). It was male cannabis users, and in particular, young adult and frequent users, who have moved into the alleyways. Generally, users who buy cannabis in the alleyway show more cannabis-related problems than those who mainly name other sources of supply, even when adjusted for sex, age and frequency of cannabis use. Discussion: Possible consequences of these changes in cannabis supply, like the risk of merging a previously cannabis-only market with other 'harder' drugs markets, are discussed.

The changing preference of T and B cells for partners as T-dependent antibody responses develop.

Recirculating virgin CD4+ T cells spend their life migrating between the T zones of secondary lymphoid tissues where they screen the surface of interdigitating dendritic cells. T-cell priming starts when processed peptides or superantigen associated with class II MHC molecules are recognised. Those primed T cells that remain within the lymphoid tissue move to the outer T zone, where they interact with B cells that have taken up and processed antigen. Cognate interaction between these cells initiates immunoglobulin (Ig) class switch-recombination and proliferation of both B and T cells; much of this growth occurs outside the T zones B cells migrate to follicles, where they form germinal centres, and to extrafollicular sites of B-cell growth, where they differentiate into mainly short-lived plasma cells. T cells do not move to the extrafollicular foci, but to the follicles; there they proliferate and are subsequently involved in the selection of B cells that have mutated their Ig variable-region genes. During primary antibody responses T-cell proliferation in follicles produces many times the peak number of T cells found in that site: a substantial proportion of the CD4+ memory T-cell pool may originate from growth in follicles.

Effects of exaggerated amino acid and protein supply in man.

A general update review of the dynamic aspect of protein metabolism is presented. The effect of excess protein level on protein metabolism has been the object of a limited number of studies in man. From the information available, it appears that the primary regulatory pathway for body protein homeostasis is the process of amino acid (protein) oxidation.

Supply-side risk adjustment and outlier payment policy

In most health care systems where a prospective payment system is implemented, an outlier payment is used to cover the hospitals' unusually high costs. When the hospital chooses its cost reduction effort before observing a patient's severity, we show that the best outlier payment is based on the realized cost when the hospital exerts the first best level of effort, for any level of severity. [Authors]

Paid employment and the changing system of gender relations: a cross-national comparison

Equality with men in the world of paid work has been a major feminist objective. Given that work in the `public' sphere has historically been shaped on the assumption that the `worker' will be male, then national employment systems which facilitate masculine employment patterns (i.e. full-time work and unbroken employment careers) might be expected to be more likely to generate gender equality. This paper compares women's employment in France (where `masculine' careers for women are common) and Britain (where part-time work and broken employment careers are more likely) at the macro, meso (occupational), and micro (individual) levels. The two occupations studied are finance and pharmacy. The evidence presented suggests that there are considerable similarities between women in the two countries at the occupational and individual level, despite national variations. In the light of this evidence, structural and individual explanations of women's employment behaviour are examined, and the continuing significance of structural constraint on the patterning of gender relations is emphasised.

Changing paradigms--an update on the multidisciplinary management of malignant glioma.

Treatment of malignant glioma requires a multidisciplinary team. Treatment includes surgery, radiotherapy, and chemotherapy. Recently developed agents have demonstrated activity against recurrent malignant glioma and efficacy if given concurrently with radiotherapy in the upfront setting. Oligodendroglioma with 1p/19q deletions has been recognized as a distinct pathologic entity with particular sensitivity to radiotherapy and chemotherapy. Randomized trials have shown that early neoadjuvant or adjuvant administration of procarbazine, lomustine, and vincristine chemotherapy prolongs disease-free survival; however, it has no impact on overall survival. Temozolomide, a novel alkylating agent, has shown modest activity against recurrent glioma. In combination with radiotherapy in newly diagnosed patients with glioblastoma, temozolomide significantly prolongs survival. Molecular studies have demonstrated that the benefit is mainly observed in patients whose tumors have a methylated methylguanine methyltransferase gene promoter and are thus unable to repair some of the chemotherapy-induced DNA damage. For lower-grade glioma, the use of chemotherapy remains limited to recurrent disease, and first-line administration is the subject of ongoing clinical trials. Irinotecan and agents like gefitinib, erlotinib, and imatinib targeting the epidermal growth factor receptor and platelet-derived growth factor receptor have shown some promise in recurrent malignant glioma. This review summarizes recent developments, focusing on the clinical management of patients in daily neuro-oncology practice.