What does “futility” mean? An empirical study of doctors’ perceptions

Objective(s) To describe how doctors define and use the terms “futility” and “futile treatment” in end-of-life care. Design, Setting, Participants A qualitative study using semi-structured interviews with 96 doctors across a range of specialties who treat adults at the end of life. Doctors were recruited from three large Australian teaching hospitals and were interviewed from May to July 2013. Results Doctors’ conceptions of futility focused on the quality and chance of patient benefit. Aspects of benefit included physiological effect, weighing benefits and burdens, and quantity and quality of life. Quality and length of life were linked, but many doctors discussed instances when benefit was determined by quality of life alone. Most doctors described the assessment of chance of success in achieving patient benefit as a subjective exercise. Despite a broad conceptual consensus about what futility means, doctors noted variability in how the concept was applied in clinical decision-making. Over half the doctors also identified treatment that is futile but nevertheless justified, such as short-term treatment as part of supporting the family of a dying person. Conclusions There is an overwhelming preference for a qualitative approach to assessing futility, which brings with it variation in clinical decision-making. “Patient benefit” is at the heart of doctors’ definitions of futility. Determining patient benefit requires discussions with patients and families about their values and goals as well as the burdens and benefits of further treatment.

Climate response to changes in atmospheric carbon dioxide and solar irradiance on the time scale of days to weeks

Recent studies show that fast climate response on time scales of less than a month can have important implications for long-term climate change. In this study, we investigate climate response on the time scale of days to weeks to a step-function quadrupling of atmospheric CO2 and contrast this with the response to a 4% increase in solar irradiance. Our simulations show that significant climate effects occur within days of a stepwise increase in both atmospheric CO2 content and solar irradiance. Over ocean, increased atmospheric CO2 warms the lower troposphere more than the surface, increasing atmospheric stability, moistening the boundary layer, and suppressing evaporation and precipitation. In contrast, over ocean, increased solar irradiance warms the lower troposphere to a much lesser extent, causing a much smaller change in evaporation and precipitation. Over land, both increased CO2 and increased solar irradiance cause rapid surface warming that tends to increase both evaporation and precipitation. However, the physiological effect of increased atmospheric CO2 on plant stomata reduces plant transpiration, drying the boundary layer and decreasing precipitation. This effect does not occur with increased solar irradiance. Therefore, differences in climatic effects from CO2 versus solar forcing are manifested within days after the forcing is imposed.

Plasma levels of the immunomodulatory cytokine interleukin-10 during normal human pregnancy: a longitudinal study.

Pregnancy is proposed to be a Th2 phenomenon, where Th2 cytokines inhibit Th1 responses to improve fetal survival. The importance of interleukin-10 (IL-10), an immunomodulatory cytokine produced by Th2 cells, in the maintenance of normal pregnancy is becoming increasingly apparent. In a longitudinal case-control study, the physiological effect of pregnancy on plasma IL-10 was investigated. The plasma concentration of IL-10 was determined using an ELISA technique in 99 pregnant women sampled at 12, 20 and 35 weeks of gestation, 38 non-pregnant control subjects sampled in parallel and in a subgroup of women sampled at 3 days post-partum (n, pregnant 21, non-pregnant 21). Plasma IL-10 was significantly higher in pregnant women at 12, 20 and 35 weeks of gestation (p

Isolation, pharmacology and gene organization of KPSFVRFamide: A neuropeptide from Caenorhabditis elegans

To date, 53 peptides with C-terminal RFamides have been identified by the genome sequencing project in the nematode, Caenorhabditis elegans. In this study the FMRFamide-related peptide (FaRP) KPSFVRFamide (879.90 Da [MH](+)) was structurally characterized from extracts of the nematode, Caenorhabditis elegans. Two copies of KPSFVRFamide are encoded by a gene designated flp-9. RT-PCR identified a single cDNA product which was confirmed as flp-9 by sequence determination. Flp-9 cDNA was isolated from larval stages of C. elegans but was not detected-in adult worms, indicating that its expression is may be developmentally regulated. KPSFVRFamide displays sequence homology to the nematode peptide, KPNFIRFamide (PF4). The physiological effects of KPSFVRFamide, PF4 and the chimeras, KPNFVRFamide and KPSFIRFamide, were measured on body wall muscle and the vagina vera of the parasitic nematode, Ascaris suum. KPNFVRFamide and KPNFIRFamide had Cl--dependent inhibitory activity on innervated and denervated muscle-preparations, whereas KPSFVRFamide and KPSFIRFamide did not elicit a detectable physiological effect. Although all 4 peptides had inhibitory effects on the vagina vera, KPSFVRFamide and KPSFIRFamide (threshold, greater than or equal to 0.1 mu M) were less potent than KPNFVRFamide and KPNFIRFamide (threshold, greater than or equal to 10 nM). (C) 1999 Academic Press.

Perceção da comunidade educativa sobre os alimentos promotores de saúde e da sua inclusão no plano curricular do 3.º ciclo do ensino básico

Mestrado, Tecnologia e Segurança Alimentar, 4 de Março de 2016, Universidade dos Açores.

Modulation of electrical stimulation applied to human physiology and clinical diagnostic

The use, manipulation and application of electrical currents, as a controlled interference mechanism in the human body system, is currently a strong source of motivation to researchers in areas such as clinical, sports, neuroscience, amongst others. In electrical stimulation (ES), the current applied to tissue is traditionally controlled concerning stimulation amplitude, frequency and pulse-width. The main drawbacks of the transcutaneous ES are the rapid fatigue induction and the high discomfort induced by the non-selective activation of nervous fibers. There are, however, electrophysiological parameters whose response, like the response to different stimulation waveforms, polarity or a personalized charge control, is still unknown. The study of the following questions is of great importance: What is the physiological effect of the electric pulse parametrization concerning charge, waveform and polarity? Does the effect change with the clinical condition of the subjects? The parametrization influence on muscle recruitment can retard fatigue onset? Can parametrization enable fiber selectivity, optimizing the motor fibers recruitment rather than the nervous fibers, reducing contraction discomfort? Current hardware solutions lack flexibility at the level of stimulation control and physiological response assessment. To answer these questions, a miniaturized, portable and wireless controlled device with ES functions and full integration with a generic biosignals acquisition platform has been created. Hardware was also developed to provide complete freedom for controlling the applied current with respect to the waveform, polarity, frequency, amplitude, pulse-width and duration. The impact of the methodologies developed is successfully applied and evaluated in the contexts of fundamental electrophysiology, psycho-motor rehabilitation and neuromuscular disorders diagnosis. This PhD project was carried out in the Physics Department of Faculty of Sciences and Technology (FCT-UNL), in straight collaboration with PLUX - Wireless Biosignals S.A. company and co-funded by the Foundation for Science and Technology.

Analysis of a temperature sensitive mutation affecting aldehyde oxidase activity in Drosophila melanogaster

A strain of Drosophila melanogaster (mid america stock culture no. hl16) has been reported to be deficient in aldehyde oxidase activity (Hickey and Singh 1982). This strain was characterized during the course of this study and compared to other mutant strains known to be deficient in aldehyde oxidase activity. During the course of this investigation, the hl16 strain was found to be temperature sensitive in its viability. It was found that the two phenotypes, the enzyme deficiency, and the temperature sensitive lethality were the result of two different mutations, both mapping to the X-chromosome. These two mutations were found to be separable by recombination. The enzyme deficiency was found to map to the same locus as the cinnamon mutation, another mutation which affects aldehyde oxidase production. The developmental profile of aldehyde oxidase in the hl16 strain was compared to the developmental profile in the Canton S wild type strain. The aldehyde oxidase activity in adult hl16 individuals was also compared to that of various other strains. It was also found that the aldehyde oxidase activity was temperature sensitive in the adult flies. The temperature sensitive lethality mutation was mapped to position 1-0.1.

Influence of temperature and photoperiod upon ionic regulation in rainbow trout Salmo gairdneri

Interactions of photoperiod and temperature upon waterelectrolyte balance were examined in rainbow trout acclimated to six combinations of two photoperiods {18h light: 6h dark, o 6h light: l8h dark) and three temperatures (2, 10 and 18 C). The influence of temperature and photoperiod upon plasma, skeletal muscle, cardiac muscle and liver levels of sodium, potassium, magnesi.um, calcium, chloride, water content, water distribution and cellular ion concentrations was determined by a one way analysis of variance. Significant (p < 0.05 or better) temperature effects at common photoperiods were observed in 70% of the analyses performed, showing no bias toward either photoperiod. Significant photoperiod effects occured in 57% of the analyses performed at common temperatures. The influence of photoperiod was most prevalent at reduced temperatures. Potassium and magnesium appeared to be particularly thermosensitive, while sodium and calcium were the most photosensitive of the electrolytes. The ionic composition of all tissues studied were relatively thermosensitive, with liver apparently being the most sensitive. On the other hand; the ionic composition of skeletal and cardiac muscle appear to be the mos.t photosensitive of the tissues examined. Water content and distribution in skeletal muscle and liver were significantly influenced by temperature in 50% of the analyses performed showing a very strong bias toward UwinterU animals. Photoperiod effects were significant in 56% of the water parameters measured with a strong bias toward the two lower temperatures. Body weight was of significant influence in 16% of the 174 analyses performed. These data are discussed in terms of the effect of temperature upon ionregulatory mechanisms and the possible impact of photoperiod variations on endocrine systems influencing water-electrolyte metabolism.

Ionic regulation in goldfish, Carassius auratus, acclimated to constant and diurnally-cycling temperature conditions

The effects of a diurnal sine-wave temperature cycle (250 +- 5° C) on the wa terI-e etc r o1 yt est a t us 0 f gol df1' Sh , Carassius auratus, was assessed through determination of Na+, K+, Mg2+, Ca2+, Cl- and water content in plasma, Red blood cells and muscle tissue. Animals were also acclimated to o 0 0 static temperatures (20 C, 25 c, 30 C) corresponding to the high, low and mid-ooint temperatures of the cycle. All groups were sampled at 03:00, 09:00, 15:00 and 21:00 hr. Hemoglobin content and packed cell volume, as well as electrolyte and 'water levels were determined for each animal and red cell ion concentrations and ion : hemoglobin ratios estimated. Cycled animals were distinct from those at constant temperatures in several respects. Hematological parameters were elevated above those of animals at constant temperature and were, on a diurnal basis, more stable. Red blood cell electrolyte levels varied in an adaptively appropriate fashion to cycle temperatures. This was not the case in the constant temperature groups_ Under the cycling regime, plasma ion levels were more diurnally stable than those of constant temperature fish. Although muscle parameters in cycled fish exhibited more fluctuation than was observed in plasma, these also tended to be relatively more stable than was the caseErythrocytic data are discussed in terms of their effects on hemoglobin-oxygen affinity while plasma and muscle observations were considered from the standpoint of overall water-electrolyte balance. In general, cycled fish appeared to be capable of stabilizing overall body fluid composition, while simultaneously effecting adaptively-appropriate modifications in the erythrocytic ionic microenvironment of hemoglobin. The sometimes marked diurnal variability of water-electrolyte status in animals held at constant temperature as opposed to the conservation of cycled fish suggests that this species is, in some fashion, programmed for regulation in a thermally-fluctuating environment. If this interpretation is valid and a phenomenon of general occurrence, some earlier studies involving constant acclimation of eurythermal species normally occupying habitats which vary in temperature on a daily basis may require reconsideration. at constant temperature.

The effects of static and diurnally-cycling temperature acclimations on thermal tolerances of rainbow trout, Salmo gairdneri

:ofiedian lethal temperatures ( LT50' s ) were determined for rainbow trout, Salmo gairdnerii, acclimated for a minimum of 21 days at 5 c onstant temperatures between 4 and 20 0 C. and 2 diel temperature fluctuations ( sinewave curves of amplitudes ± 4 and ± 7 0 C. about a mean temperature of 12 0 C. ) . Twenty-four-, 48-, and 96-hour LT50 estimates were c alculated f ollowing standard flow-through aquatic bioassay techniques and probi t transformation of mortality data. The phenomenon of delayed thermal mortality was also investigated. Shifts in upper incipient lethal temperature occurred as a result of previous thermal conditioning. It was shown that increases in constant acclimation temperature result in proportional l inear increases in thermal tolerances. The increase i n estimated 96-hour LT50's was approximately 0.13 0 c. X 1 0 C:1 between 8 and 20 0 C. The effect of acclimation to both cyclic temperature regimes was an increase in LT50 to values between the mean and maximum constant equivalent daily temperatures of the cycles. Twenty-four-, 48-, and 96-hour LT50 estimates of both cycles corresponded approximately to the LT50 values of the 16 0 C. c onstant temperature equivalent . This increase i n thermal tolerance was further demonstrated by the delayed thermal mortality experiments . Cycle amplitudes appeared to i nfluence thermal resistance through alterations in initi al mortality since mortality patterns characteristic of base temperature acclimations re-appeared after approximately 68 hours exposure to test temperatures for the 12 + 4 0 C. group, whereas mortality patterns stabilized and remained constant for a period greater than 192 hours with the larger therma l cycle ( 12 + 7 0 C. ). NO s ignificant corre lations between s pecimen weight and time-to-death was apparent. Data are discussed in relation to the establishment of thermal criteria for important commercial and sport fishes , such as the salmonids , as is the question whether previously reported values on lethal temperature s may have been under estimated.

Thermoacclimatory variations in the activities of enzymes implicated in ion transport in the rainbow trout, salmo gairdneri

Two groups of rainbow trout were acclimated to 20 , 100 , and 18 o C. Plasma sodium, potassium, and chloride levels were determined for both. One group was employed in the estimation of branchial and renal (Na+-K+)-stimulated, (HC0 3-)-stimulated, and CMg++)-dependent ATPase activities, while the other was used in the measurement of carbonic anhydrase activity in the blood, gill and kidney. Assays were conducted using two incubation temperature schemes. One provided for incubation of all preparations at a common temperature of 2S oC, a value equivalent to the upper incipient lethal level for this species. In the other procedure the preparations were incubated at the appropriate acclimation temperature of the sampled fish. Trout were able to maintain plasma sodium and chloride levels essentially constant over the temperature range employed. The different incubation temperature protocols produced different levels of activity, and, in some cases, contrary trends with respect to acclimation temperature. This information was discussed in relation to previous work on gill and kidney. The standing-gradient flow hypothesis was discussed with reference to the structure of the chloride cell, known thermallyinduced changes in ion uptake, and the enzyme activities obtained in this study. Modifications of the model of gill lon uptake suggested by Maetz (1971) were proposed; high and low temperature models resulting. In short, ion transport at the gill at low temperatures appears to involve sodium and chloride 2 uptake by heteroionic exchange mechanisms working in association w.lth ca.rbonlc anhydrase. G.l ll ( Na + -K + ) -ATPase and erythrocyte carbonic anhydrase seem to provide the supplemental uptake required at higher temperatures. It appears that the kidney is prominent in ion transport at low temperatures while the gill is more important at high temperatures. 3 Linear regression analyses involving weight, plasma ion levels, and enzyme activities indicated several trends, the most significant being the interrelationship observed between plasma sodium and chloride. This, and other data obtained in the study was considered in light of the theory that a link exists between plasma sodium and chloride regulatory mechanisms.

Thermoaclimatory variations in the microenvironment of hemoglobin in the rainbow trout, Salmo gairdneri and the carp, Cyprinus carpio

Several inorganic substances (e.g., C£ , Mg , Ca , H ) are potent negative modulators of hemoglobin-oxygen affinity. To evaluate the possibility that potentially adaptive changes in the red cell ionic environment of hemoglobin may take place during acclimation of fishes to increased environmental temperature, hematological status (hemoglobin, hematocrit, red cell numbers, mean erythrocytic volume and hemoglobin content), plasma + + 2+ 2+ and packed red cell electrolyte levels (Na , K , Ca , Mg , C£ ) were evaluated in summer and winter populations of the stenothermal rainbow trout, Salmo gairdneri, following acclimation to 2°, 10°, 18°C, and in a spring population of eurythermal carp, Cyprinus carpio, held at 2°, 16° and 30°C. From these data cell ion concentrations and ion:hemoglobin ratios were estimated. In view of the role of red cell carbonic anhydrase in the reductions of blood C02 tensions and the recruitment of Na and C£~ lost by fishes, a preliminary investigation of thermoacclimatory changes in the activity of this system in rainbow trout erythrocytes was conducted. Few changes in hematological status were encountered following acclimation. There was, however, some evidence of weight-specific differential hematological response in carp. This lead to markedly greater increases in hemoglobin, hematocrit and red cell numbers in smaller rather than in larger specimens at higher temperatures; variations which were 2+ well correlated with changes in plasma Ca . Plasma composition in summer trout was not altered by acclimation. In winter trout plasma Na and K increased at higher temperatures. Carp were characterized by increases in plasma calcium, and reductions in sodium and magnesium under these conditions. Several significant seasonal differences in plasma ion levels were observed in the trout. (n) In trout, only erythrocytic K and K :Hb were altered by acclimation, rising at higher temperatures. In carp Na , Na :Hb, C£~ and C£~:Hb in- 2+ 2+ creased with temperature, while Mg and Mg :Hb declined. Changes in overall ionic composition in carp red cells were consistent with increases in H content. In both species significant reciprocal variations in C£~ 2+ - + and Mg were found. In mammalian systems increases in C£ and H reduce hemoglobin-oxygen affinity by interaction with hemoglobin. Reduction in 2+ 2+ Mg maximizes organophosphate modulator availability by decreasing ATP»Mg complex formation. Thus, the changes observed may be of adaptive value in reducing hemoglobin-oxygen affinity, and facilitating oxygen release to cells at higher temperatures. Trout appear to maintain a high chloridelow magnesium state over the entire thermal tolerance zone. Carp, however, achieved this state only at higher temperatures. In both species mean erythrocytic volume was decreased at higher temperatures and this may facilitate branchial oxygen loading. Since mean erythrocytic volume was inversely related to red cell ion content, it is hypothesized that reductions in cell volume are achieved by export of some unidentified solute or solutes. Variations in the carbonic anhydrase activity that could be attributed to the thermoacclimatory process were quite modest. On the other hand, assays performed at the temperature of acclimation showed a large temperature effect where under in vivo conditions of temperature fish acclimated to higher temperatures might be expected to have higher activities. Furthermore, since hematocrit increased with temperature in these fish, while carbonic anhydrase is present only in the erythrocyte, the whole blood levels of this enzyme are expected to increase and further augment the temperature effect. This, in turn, could aid in the reduction of C02 (111) tension and increase the production of H and HC0~~ used in the active uptake of Na and C£ at higher temperatures.

Water and electrolyte content and distribution in tissues of thermally-acclimated rainbow trout, Salmo gairdneri

The primary objective of this investigation was that of providing a comprehensive tissue-by-tissue assessment of water-electrolyte status in thermally-acclimated rainbow trout, Salmo gairdneri. To this end levels of water and the major ions, sodium, chloride and potassium were evaluated in the plasma, at three skeletal muscle sites, and in cardiac muscle, liver, spleen, gut and brain of animals acclimated to 2°, 10° and 18°C. The occurrence of possible seasonal variations in water-electrolyte balance was evaluated by sampling sununer and late fall-early winter populations of trout. On the basis of values for water and electrolyte content, estimates of extracellular and cellular phase volumes, cellular electrolyte concentrations and Nernst equilibrium potentials were made. Since accurate assessment of the extracellular phase volume is critical in the estimation of cellular electrolyte concentrations and parameters based on assumed cellular ion levels, [14 C]-polyethylene glycol-4000, which is assumed to be confined to the extracellular space, was employed to provide comparisons with various ion-defined spaces (H20~~s, H20~~/K and H20~~s). Subsequently, the ion-defined space yielding the most realistic estimate of extracellular phase volume for each tissue was used in cellular electrolyte calculations. Water and electrolyte content and distribution varied with temperature. Tissues, such as liver, spleen and brain appeared to be the most thermosensitive, whereas skeletal and cardiac muscle and gut tissue were less influenced. 'Summer' series trout appeared to be more capable of maintaining their water- electrolyte balance than the ~fall-winter' series animals. i The data are discussed in terms of their possible effect on maintenance of appropriate cellular metabolic and electrophysiological functions.