The use of anticholinergic agents to treat excessive oropharyngeal and tracheal secretions in palliative care

Palliative care involves a multi-professional team approach to the provision of active, holistic care for patients and their families when the patient's disease is no longer responsive to curative treatment. Patient care encompasses medical and pharmacological intervention for symptom control, together with psychological, spiritual and social support for patients and families. Care is provided by teams in hospice, hospital or community environments. Although traditionally associated with providing care for cancer patients, palliative care services are increasingly providing for patients with non-malignant disease. Symptoms commonly associated with terminal phase of disease include pain, nausea, agitation, respiratory symptoms and general fatigue. During the last few days of life, patients may become weak, resulting in difficulty taking oral medication and have periods of unconsciousness. Some patients may require drug administration via subcutaneous infusion. A proportion of patients may develop difficulty clearing respiratory secretions causing a characteristic ‘death rattle’, which although not generally considered to be distressing for the patient, is often treated with a variety of anticholinergic drugs in an attempt to reduce the ‘noisy breathing’ for the benefit of relatives and others who may be closely associated with the patient.This study examined treatment of death rattle in two Hospices focusing on objective and subjective outcome measures in order to determine the efficacy of anticholinergic regimens in current use. Qualitative methods were employed to elicit attitudes of professionals and carers working closely with the patient. The number of patients recruited and monitored were small, many confounding factors were identified which questioned firstly the clinical rationale for administering anticholinergic drugs routinely to treat death rattle and secondly, the ethics of administering drug regimens to patients to treat death rattle with the primary aim of relieving distress for others. Ethnical issues, including those of consent are discussed in relation to their impact on the methodology of end of life studies in medicines management in palliative care.

Contraception and heterosex: an intimate relationship

Whilst the importance of contraception within heterosex has long been accepted, particularly in relation to the prevention of HIV/AIDS, the way in which the use, or non-use, of contraception re/constructs heterosexual encounters themselves has had far less attention. The embodied nature of both the risk of pregnancy, and most contraceptive technologies leads women to assert a right to bodily autonomy. Yet this assertion conflicts with their expectation of equitable coupledom within heterosexuality and their routine consideration of men’s preferences. This article will argue that the use of contraception is an intricate part of heterosexual practices, and shows how normative ideas about heterosexuality leave men as appearing as an absent presence within women’s contraceptive decisions.

Tear film lipids:dynamic composition and clinical performance

Purpose: Meibomian-derived lipid secretions are well characterised but their subsequent fate in the ocular environment is less well understood. Phospholipids are thought to facilitate the interface between aqueous and lipid layers of the tear film and to be involved in ocular lubrication processes. We have extended our previous studies on phospholipid levels in the tear film to encompass the fate of polar and non-polar lipids in progressive accumulation and aging processes on both conventional and silicone-modified hydrogel lenses. This is an important aspect of the developing understanding of the role of lipids in the clinical performance of silicone hydrogels. Method: Several techniques were used to identify lipids in the tear film. Mass-spectrometric methods included Agilent 1100-based liquid chromatography coupled to mass spectrometry (LCMS) and Perkin Elmer gas chromatography mass spectrometry (GCMS). Thin layer chromatography (TLC) was used for separation of lipids on the basis of increasing solvent polarity. Routine assay of lipid extractions from patient-worn lenses was carried out using a Hewlett Packard 1090 liquid chromatograph coupled to both uv and Agilent 1100 fluorescence detection. A range of histological together with optical, and electron microscope techniques was used in deposit analysis. Results: Progressive lipid uptake was assessed in various ways, including: composition changes with wear time, differential lipid penetrate into the lens matrix and, particularly, the extent to which lipids become unextractable as a function of wear time. Solvent-based separation and HPLC gave consistent results indicating that the polarity of lipid classes decreased as follows: phospholipids/fatty acids > triglycerides > cholesterol/cholesteryl esters. Tear lipids were found to show autofluorescence—which underpinned the value of fluorescence microscopy and fluorescence detection coupled with HPLC separation. The most fluorescent lipids were found to be cholesteryl esters; histological techniques coupled with fluorescence microscopy indicated that white spots (’’jelly bumps’’) formed on silicone hydrogel lenses contain a high proportion of cholesteryl esters. Lipid profiles averaged for 30 symptomatic and 30 asymptomatic contact lens wearers were compiled. Peak classes were split into: cholesterol (C), cholesteryl esters (CE), glycerides (G), polar fatty acids/phospholipids (PL). The lipid ratio for ymptomatic/symptomatic was 0.6 ± 0.1 for all classes except one—the cholesterol ratio was 0.2 ± 0.05. Significantly the PL ratio was no different from that of any other class except cholesterol. Chromatography indicated that: lipid polarity decreased with depth of penetration and that lipid extractability decreased with wear time. Conclusions: Meibomian lipid composition differs from that in the tear film and on worn lenses. Although the same broad lipid classes were obtained by extraction from all lenses and all patients studied, quantities vary with wear and material. Lipid extractability diminishes with wear time regardless of the use of cleaning regimes. Dry eye symptoms in contact lens wear are frequently linked to lipid layer behaviour but seem to relate more to total lipid than to specific composition. Understanding the detail of lipid related processes is an important element of improving the clinical performance of materials and care solutions.

Women, anger, and aggression an interpretative phenomenological analysis

This study reports a qualitative phenomenological investigation of anger and anger-related aggression in the context of the lives of individual women. Semistructured interviews with five women are analyzed using interpretative phenomenological analysis. This inductive approach aims to capture the richness and complexity of the lived experience of emotional life. In particular, it draws attention to the context-dependent and relational dimension of angry feelings and aggressive behavior. Three analytic themes are presented here: the subjective experience of anger, which includes the perceptual confusion and bodily change felt by the women when angry, crying, and the presence of multiple emotions; the forms and contexts of aggression, paying particular attention to the range of aggressive strategies used; and anger as moral judgment, in particular perceptions of injustice and unfairness. The authors conclude by examining the analytic observations in light of phenomenological thinking.

Le prix de l'individualité. Maine de Brian, Samuel Taylor Coleridge et la volonté: Deux postétités distinctes

This thesis is concerned with Maine de Biran’s and Samuel Taylor Coleridge’s conceptions of will, and the way in which both thinkers’ posterities have been affected by the central role of these very conceptions in their respective bodies of thought. The research question that animates this work can therefore be divided into two main parts, one of which deals with will, while the other deals with its effects on posterity. In the first pages of the Introduction, I make the case for a comparison between two philosophers, and show how this comparison can bring one closer to truth, understood not in objective, but in subjective terms. I then justify my choice by underlining that, in spite of their many differences, Maine de Biran and Samuel Taylor Coleridge followed comparable paths, intellectually and spiritually, and came to similar conclusions concerning the essential activity of the human mind. Finally, I ask whether it is possible that this very focus on the human will may have contributed to the state of both thinkers’ works and of the reception of those works. This prologue is followed by five parts. In the first part, the similarities and differences between the two thinkers are explored further. In the second part, the connections between philosophy and singularity are examined, in order to show the ambivalence of the will as a foundation for truth. The third part is dedicated to the traditional division between subject and object in psychology, and its relevance in history and in moral philosophy. The fourth part tackles the complexity of the question of influence, with respect to both Maine de Biran’s and Coleridge’s cases, both thinkers being indebted to many philosophers of all times and places, and having to rely heavily on others for the publication, or the interpretation of their own works. The fifth part is concerned with the different aspects of the faculty of will, and primarily its relationship with interiority, as incommensurability, and actual, conditioned existence in a certain historical and spatial context. It ends with a return to the question of will and posterity and an announcement of what will be covered in the main body of the thesis. The main body is divided into three parts:‘L’émancipation’, ‘L’affirmation, and ‘La projection’. The first part is devoted to the way Maine de Biran and Samuel Taylor Coleridge extricated themselves from one epistemological paradigm to contribute to the foundation of another. It is divided in four chapters. The first chapter deals with the aforementioned change of paradigm, as corresponding to the emergence of two separate but associated movements, Romanticism and what the French philosopher refers to as ‘The Age of History’. The second chapter concerns the movement that preceded them, i.e. the Enlightenment, its main features according to both of our thinkers, and the two epistemological models that prevailed under it and influenced them heavily in their early years: Sensationism (Maine de Biran) and Associationism (Coleridge). The third chapter is about the probable influence of Immanuel Kant and his followers on Maine de Biran and Coleridge, and the various facts that allow us to claim originality for both thinkers’ works. In the fourth chapter, I contrast Maine de Biran and Coleridge with other movements and thinkers of their time, showing that, contrary to their respective thoughts, Maine de Biran and Coleridge could not but break free from the then prevailing systematic approach to truth. The second part of the thesis is concerned with the first part of its research question, namely, Maine de Biran’s and Coleridge’s conceptions of the will. It is divided into four chapters. The first chapter is a reflection on the will as a paradox: on the one hand, the will cannot be caused by any other phenomenon, or it is no longer a will; but it cannot be left purely undetermined, as if it is, it is then not different from chance. It thus needs, in order to be, to be contradictorily already moral. The second chapter is a comparison between Maine de Biran’s and Coleridge’s accounts of the origin of the will, where it is found that the French philosopher only observes that he has a will, whereas the English philosopher postulates the existence of this will. The comparison between Maine de Biran’s and Coleridge’s conceptions of the will is pursued in the third chapter, which tackles the question of the coincidence between the will and the self, in both thinkers’ works. It ends with the fourth chapter, which deals with the question of the relationship between the will and what is other to it, i.e. bodily sensations, passions and desires. The third part of the thesis focuses on the second part of its research question, namely the posterity of Maine de Biran’s and Coleridge’s works. It is divided into four chapters. The first chapter constitutes a continuation of the last chapter of the preceding part, in that that it deals with Maine de Biran’s and Coleridge’s relations to the ‘other’, and particularly their potential and actual audience, and with the way these relations may have affected their writing and publishing practices. The second chapter is a survey of both thinkers’ general reception, where it is found that, while Maine de Biran has been claimed by two important movements of thoughts as their initiator, Coleridge has been neglected by the only real movement he could have, or may indeed have pioneered. The third chapter is more directly concerned with the posterities of Maine de Biran’s and Coleridge’s conceptions of will, and attempts to show that the approach to, and the meaning of the will have evolved throughout the nineteenth century, and in the French Spiritualist and the British Idealist movements, from an essentially personal one to a more impersonal one. The fourth chapter is a partial conclusion, whose aim is to give a precise idea of where Maine de Biran and Coleridge stand, in relation to their century and to the philosophical movements and matters we are concerned with. The conclusion is a recapitulation of what has been found, with a particular emphasis on the dialogue initiated between Maine de Biran and Coleridge on the will, and the relation between will and posterity. It suggests that both thinkers have to pay the price of a problematic reception for the individuality that pervades their respective works, and goes further in suggesting that s/he who chooses to found his individuality on the will is bound to feel this incompleteness in his/her own personal life more acutely than s/he who does not. It ends with a reflection on fixedness and movement, as the two antagonistic states that the theoretician of the will paradoxically aspires to.

General features of Multiple System Atrophy

Multiple system atrophy (MSA) is a rare movement disorder and a member of a group of neurodegenerative diseases referred to collectively as the ‘parkinsonian syndromes’. Characteristic of these syndromes is that the patient exhibits symptoms of ‘parkinsonism’, viz., a range of problems involving movement, most typically manifest in Parkinson’s disease (PD) itself1, but also seen in progressive supranuclear palsy (PSP), and to some extent in dementia with Lewy bodies (DLB). MSA is a relatively ‘new’ descriptive term and is derived from three previously described diseases, viz., olivopontocerebellar atrophy, striato-nigral degeneration, and Shy-Drager syndrome. The classical symptoms of MSA include parkinsonism, ataxia, and autonomic dysfunction.6 Ataxia describes a gross lack of coordination of muscle movements while autonomic dysfunction involves a variety of systems that regulate unconscious bodily functions such as heart rate, blood pressure, bladder function, and digestion. Although primarily a neurological disorder, patients with MSA may also develop visual signs and symptoms that could be useful in differential diagnosis. The most important visual signs may include oculomotor dysfunction and problems in pupil reactivity but are less likely to involve aspects of primary vision such as visual acuity, colour vision, and visual fields. In addition, the eye-care practitioner can contribute to the management of the visual problems of MSA and therefore, help to improve quality of life of the patient. Hence, this first article in a two-part series describes the general features of MSA including its prevalence, signs and symptoms, diagnosis, pathology, and possible causes.

Development of a multicellular co-culture model of normal and cystic fibrosis human airways in vitro

Cystic fibrosis (CF) is the most common lethal inherited disease among Caucasians and arises due to mutations in a chloride channel, called cystic fibrosis transmembrane conductance regulator. A hallmark of this disease is the chronic bacterial infection of the airways, which is usually, associated with pathogens such as Pseudomonas aeruginosa, S. aureus and recently becoming more prominent, B. cepacia. The excessive inflammatory response, which leads to irreversible lung damage, will in the long term lead to mortality of the patient at around the age of 40 years. Understanding the pathogenesis of CF currently relies on animal models, such as those employing genetically-modified mice, and on single cell culture models, which are grown either as polarised or non-polarised epithelium in vitro. Whilst these approaches partially enable the study of disease progression in CF, both types of models have inherent limitations. The overall aim of this thesis was to establish a multicellular co-culture model of normal and CF human airways in vitro, which helps to partially overcome these limitations and permits analysis of cell-to-cell communication in the airways. These models could then be used to examine the co-ordinated response of the airways to infection with relevant pathogens in order to validate this approach over animals/single cell models. Therefore epithelial cell lines of non-CF and CF background were employed in a co-culture model together with human pulmonary fibroblasts. Co-cultures were grown on collagen-coated permeable supports at air-liquid interface to promote epithelial cell differentiation. The models were characterised and essential features for investigating CF infections and inflammatory responses were investigated and analysed. A pseudostratified like epithelial cell layer was established at air liquid interface (ALI) of mono-and co-cultures and cell layer integrity was verified by tight junction (TJ) staining and transepithelial resistance measurements (TER). Mono- and co-cultures were also found to secrete the airway mucin MUC5AC. Influence of bacterial infections was found to be most challenging when intact S. aureus, B. cepacia and P. aeruginosa were used. CF mono- and co-cultures were found to mimic the hyperinflammatory state found in CF, which was confirmed by analysing IL-8 secretions of these models. These co-culture models will help to elucidate the role fibroblasts play in the inflammatory response to bacteria and will provide a useful testing platform to further investigate the dysregulated airway responses seen in CF.

Tear analysis and lens-tear interactions:part II. Ocular lipids-nature and fate of meibomian gland phospholipids

Purpose: Published data indicate that the polar lipid content of human meibomian gland secretions (MGS) could be anything between 0.5% and 13% of the total lipid. The tear film phospholipid composition has not been studied in great detail and it has been understood that the relative proportions of lipids in MGS would be maintained in the tear film. The purpose of this work was to determine the concentration of phospholipids in the human tear film. Methods: Liquid chromatography mass spectrometry (LCMS) and thin layer chromatography (TLC) were used to determine the concentration of phospholipid in the tear film. Additionally, an Amplex Red phosphatidylcholine-specific phospholipase C (PLC) assay kit was used for determination of the activity of PLC in the tear film. Results: Phospholipids were not detected in any of the tested human tear samples with the low limit of detection being 1.3 µg/mL for TLC and 4 µg/mL for liquid chromatography mass spectrometry. TLC indicated that diacylglycerol (DAG) may be present in the tear film. PLC was in the tear film with an activity determined at approximately 15 mU/mL, equivalent to the removal of head groups from phosphatidylcholine at a rate of approximately 15 µM/min. Conclusions: This work shows that phospholipid was not detected in any of the tested human tear samples (above the lower limits of detection as described) and suggests the presence of DAG in the tear film. DAG is known to be at low concentrations in MGS. These observations indicate that PLC may play a role in modulating the tear film phospholipid concentration.

Embodied myopia

One field study and five experiments show that seemingly irrelevant bodily actions influence consumer behavior. These studies demonstrate that arm flexion (in which the motor action is directed toward the self) versus arm extension (in which the motor action is directed away from the self) influences purchase behavior, product preferences, and economic decisions. More specifically, arm flexion increases the likelihood of purchasing vice products (Study 1a), leads to a preference for vices over virtues (Studies 1b and 2a), and leads to preference for smaller, sooner over larger, later monetary rewards (Studies 2b, 3, and 4). The authors argue that arm flexion induces present-biased preferences through activation of approach motivation. The effect of bodily actions on present-biased preferences is regulated by the behavioral approach system (Studies 3 and 4) and relies on the learned association between arm flexion and activation of this approach system (Study 4). The authors discuss implications for Intertemporal decision making, embodied cognition, and marketing practice. © 2011, American Marketing Association.

Empowering, degrading or a 'mutually exploitative' exchange For women?: Characterising the power relations of the strip club

This paper seeks to characterise the gendered and sexualised power relations of both female and male strip clubs, and to signal what this means for establishing positive definitions of female desire. It is argued that while it is not useful to present female strippers, or female patrons of male strip clubs as purely passive victims of male heterosexism within these venues, it is equally damaging to assume that these venues represent a whole-scale challenge to conventional oppressive gender and sexual relations for women. Some research has even suggested that both strippers and their patrons are engaged in a 'mutually exploitative' power relationship. Moreover, further empirical research documents key points where female dancers have perhaps wielded 'more' power over patrons at certain moments, and female dancers have highlighted feelings of empowerment and highlighted potential for gender and sexual relations which position women as passive to be subverted within stripping. However, such feelings are often temporally specific and are not applicable to all women in the strip industry. It may be particularly hard for these to manifest in women concentrated in the least economically-rewarding areas of the industry who have less 'power' to resist compromising their bodily boundaries. Furthermore, it is argued that women watching male strippers does little to reverse the 'male gaze', and nor does this male occupation carry as much negative social stigma with it as female stripping suffers. It is thus argued that the overwhelming picture, stemming largely from accounts of former dancers and from empirical studies of individual clubs, suggests these venues in fact do very little to challenge normative hetero-oppressive sexual scripts.

TEST:a tropic, embodied, and situated theory of cognition

TEST is a novel taxonomy of knowledge representations based on three distinct hierarchically organized representational features: Tropism, Embodiment, and Situatedness. Tropic representational features reflect constraints of the physical world on the agent's ability to form, reactivate, and enrich embodied (i.e., resulting from the agent's bodily constraints) conceptual representations embedded in situated contexts. The proposed hierarchy entails that representations can, in principle, have tropic features without necessarily having situated and/or embodied features. On the other hand, representations that are situated and/or embodied are likely to be simultaneously tropic. Hence, although we propose tropism as the most general term, the hierarchical relationship between embodiment and situatedness is more on a par, such that the dominance of one component over the other relies on the distinction between offline storage versus online generation as well as on representation-specific properties. © 2013 Cognitive Science Society, Inc.

Spatial perspective taking is an embodied process, but not for everyone in the same way:differences predicted by sex and social skills score

We re-analysed visuo-spatial perspective taking data from Kessler and Thomson (2010) plus a previously unpublished pilot with respect to individual- and sex differences in embodied processing (defined as body-posture congruence effects). We found that so-called 'systemisers' (males/low-social-skills) showed weaker embodiment than so-called 'embodiers' (females/high-social-skills). We conclude that 'systemisers' either have difficulties with embodied processing or, alternatively, they have a strategic advantage in selecting different mechanisms or the appropriate level of embodiment. In contrast, 'embodiers' have an advantageous strategy of "deep" embodied processing reflecting their urge to empathise or, alternatively, less flexibility in fine-tuning the involvement of bodily representations. © 2012 Copyright Taylor and Francis Group, LLC.

Cervicovaginal vascular endothelial growth factor (VEGF) and risk of preterm birth (PTB)

Objective - During pregnancy, the human cervix undergoes angiogenic transformations. VEGF is expressed in cervical stroma and is proposed to play key roles in the process of cervical ripening and dilation. This study was conducted to evaluate whether cervical secretion of VEGF can be of clinical value in predicting impending PTB. Study Design - In an observational prospective cohort study, we analyzed cervical fluid samples from 103 pregnant women (GA: median [IQR]: 28 [25-31] wks) who presented for either a routine prenatal visit (n=61) or for evaluation of threatened preterm labor (n=42). Cervical secretions were collected under a standard protocol which was followed in all cases. Cervical length (CL) was assessed by transvaginal ultrasound using well-established criteria. Dilation was evaluated by digital exam performed only after collection of the biological samples. VEGF levels were immunoassayed by investigators unaware of the clinical outcome. Main exclusion criteria were ruptured membranes, active labor, vaginal bleeding, vaginal exam or intercourse within 24h. Results were analyzed with and without normalization for total protein. Results - 1) Clinical characteristics of the cohort are presented in Table;2) VEGF was detectable in all specimens, with no correlation between its levels, CL, twins or GA at collection; 3) There was an inverse correlation between VEGF and cervical dilation (R=-0.646, P=0.003); 4) Women with cervical dilation =1 cm had lower VEGF compared to those with a closed cervix (P=0.003); 5) Women who experienced PTB within 14 days (n=11) had lower VEGF (P=0.003); 6) A free VEGF level of =600 pg/mL had a sensitivity, specificity, +LR and -LR of 70%, 95%, 13.5 and 0.3, respectively in predicting PTB within 14 days. Conclusions - Low VEGF levels in the cervicovaginal secretions of pregnant women are associated with an increased risk of PTB within 2 weeks of collection. Active engagement of VEGF in the process of cervical ripening and dilatation and/or increased affinity of extracellular matrix components for VEGF may provide explanation for our findings.

Constructing spaces for strategic work:a multimodal perspective

In this paper we take seriously the call for strategy-as-practice research to address the material, spatial and bodily aspects of strategic work. Drawing on a video-ethnographic study of strategic episodes in a financial trading context, we develop a conceptual framework that elaborates on strategic work as socially accomplished within particular spaces that are constructed through different orchestrations of material, bodily and discursive resources. Building on the findings, our study identifies three types of strategic work - private work, collaborative work and negotiating work - that are accomplished within three distinct spaces that are constructed through multimodal constellations of semiotic resources. We show that these spaces, and the activities performed within them, are continuously shifting in ways that enable and constrain the particular outcomes of a strategic episode. Our framework contributes to the strategy-as-practice literature by identifying the importance of spaces in conducting strategic work and providing insight into the way that these spaces are constructed.

Health related quality of life and perception of stigmatisation in adolescents living with sickle cell disease in Nigeria:a cross sectional study

Background: Sickle cell disease impacts the physical, emotional and psychological aspects of life of the affected persons, often times exposing them to disease associated stigma from the society and alters the health related quality of life (HRQoL). This study compared the HRQoL of adolescents with sickle cell disease with their healthy peers, identified socio-demographic and clinical factors impacting HRQoL, and determined the extent and effects of SCD related stigma on quality of life. Procedure: We conducted a cross-sectional survey among 160 adolescents, 80 with SCD and 80 adolescents without SCD. Socio-demographic and clinical data were collected using a pre-tested questionnaire. HRQoL was investigated using the Short Form (SF-36v2) Health Survey. SCD perceived stigma was measured using an adaptation of a perceived stigma questionnaire. Results: Adolescents with SCD have significantly worse HRQoL than their peers in all of the most important dimensions of HRQoL (physical functioning, physical roles limitation, emotional roles limitation, social functioning, bodily pain, vitality and general health perception) except mental health. Recent hospital admission and SCD related complication further lowered HRQoL scores. Over seventy percent of adolescents with SCD have moderate to high level of perception of stigmatisation. Hospitalisation, SCD complication, SCD stigma were inversely, and significantly associated with HRQoL. Conclusions: Adolescents living with SCD in Nigeria have lower health related quality of life compared to their healthy peers. They also experience stigma that impacts their HRQoL. Complications of SCD and hospital admissions contribute significantly to this impairment. Pediatr Blood Cancer 2015;62:1245-1251.