Search

Objectives: In patients with COVID-19 respiratory failure, controlled mechanical ventilation (CMV) is often necessary during the acute phases of the disease. Weaning from CMV to pressure support ventilation (PSV) is a key objective when the patient's respiratory functions improve. Limited evidence exists regarding the factors predicting a successful transition to PSV and its impact on patient outcomes., Design: Retrospective observational cohort study., Setting: Twenty-four Italian ICUs from February 2020 to May 2020., Patients: Mechanically ventilated ICU patients with COVID-19-induced respiratory failure., Intervention: The transition period from CMV to PSV was evaluated. We defined it as "failure of assisted breathing" if the patient returned to CMV within the first 72 hours., Measurements and Main Results: Of 1260 ICU patients screened, 514 were included. Three hundred fifty-seven patients successfully made the transition to PSV, while 157 failed. Pao 2 /Fio 2 ratio before the transition emerged as an independent predictor of a successful shift (odds ratio 1.00; 95% CI, 0.99-1.00; p = 0.003). Patients in the success group displayed a better trend in Pao 2 /Fio 2 , Paco 2 , plateau and peak pressure, and pH level. Subjects in the failure group exhibited higher ICU mortality (hazard ratio 2.08; 95% CI, 1.42-3.06; p < 0.001), an extended ICU length of stay (successful vs. failure 21 ± 14 vs. 27 ± 17 d; p < 0.001) and a longer duration of mechanical ventilation (19 ± 18 vs. 24 ± 17 d, p = 0.04)., Conclusions: Our study emphasizes that the Pao 2 /Fio 2 ratio was the sole independent factor associated with a failed transition from CMV to PSV. The unsuccessful transition was associated with worse outcomes., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Competing Interests: The authors have disclosed no conflicts of interest.

Background: Impairment of ventilation and perfusion (V/Q) matching is a common mechanism leading to hypoxemia in patients with acute respiratory failure requiring intensive care unit (ICU) admission. While ventilation has been thoroughly investigated, little progress has been made to monitor pulmonary perfusion at the bedside and treat impaired blood distribution. The study aimed to assess real-time changes in regional pulmonary perfusion in response to a therapeutic intervention., Methods: Single-center prospective study that enrolled adult patients with ARDS caused by SARS-Cov-2 who were sedated, paralyzed, and mechanically ventilated. The distribution of pulmonary perfusion was assessed through electrical impedance tomography (EIT) after the injection of a 10-ml bolus of hypertonic saline. The therapeutic intervention consisted in the administration of inhaled nitric oxide (iNO), as rescue therapy for refractory hypoxemia. Each patient underwent two 15-min steps at 0 and 20 ppm iNO, respectively. At each step, respiratory, gas exchange, and hemodynamic parameters were recorded, and V/Q distribution was measured, with unchanged ventilatory settings., Results: Ten 65 [56-75] years old patients with moderate (40%) and severe (60%) ARDS were studied 10 [4-20] days after intubation. Gas exchange improved at 20 ppm iNO (PaO 2 /FiO 2 from 86 ± 16 to 110 ± 30 mmHg, p = 0.001; venous admixture from 51 ± 8 to 45 ± 7%, p = 0.0045; dead space from 29 ± 8 to 25 ± 6%, p = 0.008). The respiratory system's elastic properties and ventilation distribution were unaltered by iNO. Hemodynamics did not change after gas initiation (cardiac output 7.6 ± 1.9 vs. 7.7 ± 1.9 L/min, p = 0.66). The EIT pixel perfusion maps showed a variety of patterns of changes in pulmonary blood flow, whose increase positively correlated with PaO 2 /FiO 2 increase (R 2  = 0.50, p = 0.049)., Conclusions: The assessment of lung perfusion is feasible at the bedside and blood distribution can be modulated with effects that are visualized in vivo. These findings might lay the foundations for testing new therapies aimed at optimizing the regional perfusion in the lungs., Competing Interests: Declaration of competing interest CCAM and MA disclose receiving research grants by Timpel., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Changing trunk inclination affects lung function in patients with ARDS. However, its impacts on PEEP titration remain unknown. The primary aim of this study was to assess, in mechanically ventilated patients with COVID-19 ARDS, the effects of trunk inclination on PEEP titration. The secondary aim was to compare respiratory mechanics and gas exchange in the semi-recumbent (40° head-of-the-bed) and supine-flat (0°) positions following PEEP titration., Methods: Twelve patients were positioned both at 40° and 0° trunk inclination (randomized order). The PEEP associated with the best compromise between overdistension and collapse guided by Electrical Impedance Tomography (PEEP EIT ) was set. After 30 min of controlled mechanical ventilation, data regarding respiratory mechanics, gas exchange, and EIT parameters were collected. The same procedure was repeated for the other trunk inclination., Results: PEEP EIT was lower in the semi-recumbent than in the supine-flat position (8 ± 2 vs. 13 ± 2 cmH 2 O, p < 0.001). A semi-recumbent position with optimized PEEP resulted in higher PaO 2 :FiO 2 (141 ± 46 vs. 196 ± 99, p = 0.02) and a lower global inhomogeneity index (46 ± 10 vs. 53 ± 11, p = 0.008). After 30 min of observation, a loss of aeration (measured by EIT) was observed only in the supine-flat position (-153 ± 162 vs. 27 ± 203 mL, p = 0.007)., Conclusions: A semi-recumbent position is associated with lower PEEP EIT and results in better oxygenation, less derecruitment, and more homogenous ventilation compared to the supine-flat position.

Prior to registering and marketing any new pharmaceutical, (agro)chemical or food ingredient product manufacturers must, by law, generate data to ensure human safety. Safety testing requirements vary depending on sector, but generally repeat-dose testing in animals form the basis for human health risk assessments. Dose level selection is an important consideration when designing such studies, to ensure that exposure levels that lead to relevant hazards are identified. Advice on dose level selection is provided in test guidelines and allied guidance documents, but it is not well harmonised, particularly for selection of the highest dose tested. This paper further builds on concepts developed in a technical report by the European Centre for Ecotoxicology and Toxicology of Chemicals (ECETOC) which recommends pragmatic approaches to dose selection considering regulatory requirements, animal welfare and state of the art scientific approaches. Industry sectors have differing degrees of freedom to operate regarding dose level selection, depending on the purpose of the studies and the regulatory requirements/legislation, and this is reflected in the overall recommended approaches. An understanding of systemic exposure should be utilised where possible (e.g., through toxicokinetic approaches) and used together with apical endpoints from existing toxicity studies to guide more appropriate dose level selection. The highest dose should be limited to a reasonable level, causing minimal but evident toxicity to the test animals without significantly compromising their well-being. As the science of predictive human exposure further develops and matures, this will provide exciting and novel opportunities for more human-relevant approaches to dose level selection., (© 2022. The Author(s).)

Background: External chest-wall compression (ECC) is sometimes used in ARDS patients despite lack of evidence. It is currently unknown whether this practice has any clinical benefit in patients with COVID-19 ARDS (C-ARDS) characterized by a respiratory system compliance (C rs ) < 35 mL/cmH 2 O., Objectives: To test if an ECC with a 5 L-bag in low-compliance C-ARDS can lead to a reduction in driving pressure (DP) and improve gas exchange, and to understand the underlying mechanisms., Methods: Eleven patients with low-compliance C-ARDS were enrolled and underwent 4 steps: baseline, ECC for 60 min, ECC discontinuation and PEEP reduction. Respiratory mechanics, gas exchange, hemodynamics and electrical impedance tomography were recorded. Four pigs with acute ARDS were studied with ECC to understand the effect of ECC on pleural pressure gradient using pleural pressure transducers in both non-dependent and dependent lung regions., Results: Five minutes of ECC reduced DP from baseline 14.2 ± 1.3 to 12.3 ± 1.3 cmH 2 O (P < 0.001), explained by an improved lung compliance. Changes in DP by ECC were strongly correlated with changes in DP obtained with PEEP reduction (R 2  = 0.82, P < 0.001). The initial benefit of ECC decreased over time (DP = 13.3 ± 1.5 cmH 2 O at 60 min, P = 0.03 vs. baseline). Gas exchange and hemodynamics were unaffected by ECC. In four pigs with lung injury, ECC led to a decrease in the pleural pressure gradient at end-inspiration [2.2 (1.1-3) vs. 3.0 (2.2-4.1) cmH 2 O, P = 0.035]., Conclusions: In C-ARDS patients with C rs  < 35 mL/cmH 2 O, ECC acutely reduces DP. ECC does not improve oxygenation but it can be used as a simple tool to detect hyperinflation as it improves C rs and reduces P pl gradient. ECC benefits seem to partially fade over time. ECC produces similar changes compared to PEEP reduction., (© 2022. The Author(s).)

Background: Background: Organ donation (OD) following circulatory determination of death (DCDD) is an increasing source of transplant organs but little is known about community opinions on treatment withdrawal, determination of death and acceptance of OD in DCDD., Aims: To determine attitudes on death determination in DCDD, the importance of patient choice in treatment withdrawal and OD agreement, and the importance of the 'Dead Donor Rule'., Methods: Scenario-based online survey of 1017 members of the Australian general public. Mean levels of agreement across respondent's responses to statements were compared by repeated measures ANOVA., Results: 54% (548) of respondents agreed that a DCDD scenario patient could be declared dead 2 minutes after circulatory standstill, however over 80% nonetheless agreed OD would be appropriate, including 77% (136/176) of those disagreeing with a 2-minute death declaration. 48% (484) supported OD even if it caused the patient's death. 75% (766) would accept relatively benign ante-mortem treatments administered to improve transplant outcomes. Over 70% supported a high quadriplegic patient's request to be allowed to die, with 61% (622) agreeing that he should be allowed to donate his organs under anaesthesia, but 60% (610) also agreed that he should first be declared dead., Conclusions: We found high levels of support for treatment withdrawal in severe brain injury and when requested by a quadriplegic patient. While there was variable agreement with the timing of death determination and with OD under anaesthesia, support for OD was high in both scenarios. For many people death determination prior to OD may not be of paramount importance., (© 2021 Royal Australasian College of Physicians.)

Background: Socio-cultural perceptions surrounding death have profoundly changed since the 1950s with development of modern intensive care and progress in solid organ transplantation. Despite broad support for organ transplantation, many fundamental concepts and practices including brain death, organ donation after circulatory death, and some antemortem interventions to prepare for transplantation continue to be challenged. Attitudes toward the ethical issues surrounding death and organ donation may influence support for and participation in organ donation but differences between and among diverse populations have not been studied., Objectives: In order to clarify attitudes toward brain death, organ donation after circulatory death and antemortem interventions in the context of organ donation, we conducted a scoping review of international English-language quantitative surveys in various populations., Study Appraisal: A search of literature up to October 2020 was performed, using multiple databases. After screening, 45 studies were found to meet pre-specified inclusion criteria., Results: 32 studies examined attitudes to brain death, predominantly in healthcare professionals. In most, around 75% of respondents accepted brain death as equivalent to death of the person. Less common perspectives included equating death with irreversible coma and willingness to undertake organ donation even if it caused death. 14 studies examined attitudes to organ donation following circulatory death. Around half of respondents in most studies accepted that death could be confidently diagnosed after only 5 min of cardiorespiratory arrest. The predominant reason was lack of confidence in doctors or diagnostic procedures. Only 6 studies examined attitudes towards antemortem interventions in prospective organ donors. Most respondents supported minimally invasive procedures and only where specific consent was obtained., Conclusions: Our review suggests a considerable proportion of people, including healthcare professionals, have doubts about the medical and ethical validity of modern determinations of death. The prognosis of brain injury was a more common concern in the context of organ donation decision-making than certainty of death., (© 2021. The Author(s).)

The United Nations estimates that the world's population will reach 8.5 billion by 2030, and the populations of most countries are expected to grow older. This is case for many developed countries, including Australia, the United Kingdom, Canada, the United States of America, and member states of the European Union. Older cohorts will comprise a larger proportion of overall populations, driven in part by our increases in life expectancy. An ageing population poses challenges for governments; notably, older people tend to have multiple, chronic health conditions which can place a burden of health budgets. At the same time, we are witnessing a shift in how we respond to the health needs of our populations, with global drug policy acknowledging that some substances are contributing to increased morbidity and mortality (e.g. opioids) while others may have beneficial therapeutic effects (e.g. psylocibin, cannabis). There is general agreement that as men age their levels of testosterone decrease, and there is some evidence to suggest that there have been population-level declines in testosterone which are not associated with age. Anecdotally, testosterone is accessed by men seeking to self-medicate in the belief that they are experiencing low testosterone levels. There has also been a rise in anti-ageing clinics in the United States, providing access to testosterone replacement therapy (TRT). The non-medical use of testosterone can result in a number of adverse health events, including complications from the use of black market or underground products. Placing testosterone under a new prescribing regime may address some of these concerns, but is society ready for this change, and if so, what would this regime look like? This paper will explore the issue of how society responds to enhancement for longevity, or how we increasingly use pharmaceuticals to address and prevent illness, with a specific focus on testosterone and testosterone deficiency., Competing Interests: Declarations of Interest The authors declare that they have no conflict of interest., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Competing Interests: Disclosure: The authors have no conflicts of interest to report.

Background: Limited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19). Aim of this study is to investigate the use and effect of prone position in this population during the first 2020 pandemic wave., Methods: Retrospective, multicentre, national cohort study conducted between February 24 and June 14, 2020, in 24 Italian Intensive Care Units (ICU) on adult patients needing invasive mechanical ventilation for respiratory failure caused by COVID-19. Clinical data were collected on the day of ICU admission. Information regarding the use of prone position was collected daily. Follow-up for patient outcomes was performed on July 15, 2020. The respiratory effects of the first prone position were studied in a subset of 78 patients. Patients were classified as Oxygen Responders if the PaO 2 /FiO 2 ratio increased ≥ 20 mmHg during prone position and as Carbon Dioxide Responders if the ventilatory ratio was reduced during prone position., Results: Of 1057 included patients, mild, moderate and severe ARDS was present in 15, 50 and 35% of patients, respectively, and had a resulting mortality of 25, 33 and 41%. Prone position was applied in 61% of the patients. Patients placed prone had a more severe disease and died significantly more (45% vs. 33%, p < 0.001). Overall, prone position induced a significant increase in PaO 2 /FiO 2 ratio, while no change in respiratory system compliance or ventilatory ratio was observed. Seventy-eight % of the subset of 78 patients were Oxygen Responders. Non-Responders had a more severe respiratory failure and died more often in the ICU (65% vs. 38%, p = 0.047). Forty-seven % of patients were defined as Carbon Dioxide Responders. These patients were older and had more comorbidities; however, no difference in terms of ICU mortality was observed (51% vs. 37%, p = 0.189 for Carbon Dioxide Responders and Non-Responders, respectively)., Conclusions: During the COVID-19 pandemic, prone position has been widely adopted to treat mechanically ventilated patients with respiratory failure. The majority of patients improved their oxygenation during prone position, most likely due to a better ventilation perfusion matching., Trial Registration: clinicaltrials.gov number: NCT04388670.

Rationale: Prone positioning reduces mortality in patients with severe acute respiratory distress syndrome (ARDS). To date, no evidence supports the use of prone positioning (PP) during venovenous extracorporeal oxygenation (ECMO). Objectives: The aim of the study was to assess the feasibility, safety, and effect on oxygenation and lung mechanics of PP during ECMO. As a secondary exploratory aim, we assessed the association between PP and hospital mortality. Methods: We performed a multicenter retrospective cohort study in six Italian ECMO centers, including patients managed with PP during ECMO support (prone group; four centers) and patients managed in the supine position (control group; two centers). Physiological variables were analyzed at four time points (supine before PP, start of PP, end of PP, and supine after PP). The association between PP and hospital mortality was assessed by multivariate analysis and propensity score-matching. Results: A total of 240 patients were included, with 107 in the prone group and 133 in the supine group. The median duration of the 326 pronation cycles was 15 (12-18) hours. Minor reversible complications were reported in 6% of PP maneuvers. PP improved oxygenation and reduced intrapulmonary shunt. Unadjusted hospital mortality was lower in the prone group (34 vs. 50%; P  = 0.017). After adjusting for covariates, PP remained significantly associated with a reduction of hospital mortality (odds ratio, 0.50; 95% confidence interval, 0.29-0.87). Sixty-six propensity score-matched patients were identified in each group. In this matched sample, patients who underwent pronation had higher ECMO duration (16 vs. 10 d; P  = 0.0344) but lower hospital mortality (30% vs. 53%; P  = 0.0241). Conclusions: PP during ECMO improved oxygenation and was associated with a reduction of hospital mortality.

Optimal anticoagulation monitoring in patients with extracorporeal membrane oxygenation (ECMO) is fundamental to avoid hemorrhagic and thromboembolic complications. Besides conventional coagulation tests, there is growing interest in the use of viscoelastic hemostatic assays (VHA), in particular of tromboelastography (TEG). Evidence on the use of rotational thromboelastometry (ROTEM) is lacking in this setting. The aim of the study was to evaluate ROTEM as a tool for assessing hemostasis during ECMO, by comparing it to TEG and conventional coagulation assays. We conducted a prospective, observational, single-center study on adult patients on ECMO support anticoagulated with unfractioned heparin (UFH). Kaolin reaction time (R, min) for TEG and INTEM clotting time (CT, sec) for ROTEM were analyzed and compared with conventional coagulation tests. In the study period, we included 25 patients on ECMO support (14 V-A and 11 V-V); 84 data points were available for the analysis. Median UFH infusion rate was 15 [11-18] IU/min/kg. Median values for activated partial thromboplastin time (aPTT) ratio, Kaolin TEG R time, and INTEM CT were 1.44 [1.21-1.7], 22 [13-40] min, and 201 [183-225] sec, respectively. INTEM CT (ROTEM) showed a moderate correlation with standard coagulation tests (R2 = 0.34 and 0.3 for aPTT and activated clotting time (ACT), respectively, p < 0.001). No significant correlation was found between INTEM CT and Kaolin R time (R2 = 0.01). Further studies are needed to identify an appropriate anticoagulation target for ROTEM during ECMO., Competing Interests: Disclosures: M.P. received a consulting fee and travel accommodation from Werfen. The other authors declare no conflict of interests nor financial disclosures., (Copyright © ASAIO 2020.)

Background and Aims: Despite the many benefits of technological advancements, problematic use of emerging technologies may lead to consumers experiencing harms. Substantial problems and behavioral addictions, such as gambling and gaming disorders, are recognized to be related to Internet-based technologies, including the myriad of new devices and platforms available. This review paper seeks to explore problematic risk-taking behaviors involving emerging technologies (e.g., online gambling and gaming, online sexual behaviors, and oversharing of personal information via social networking sites) that have the potential to lead to problematic outcomes for individuals., Results and Discussion: Previous research has focused on policy frameworks for responding to specific issues (e.g., online gambling), but a broader framework is needed to address issues as they emerge, given lags in governments and regulators responding to dynamically evolving technological environments. In this paper, key terms and issues involved are identified and discussed. We propose an initial framework for the relative roles and responsibilities of key stakeholder groups involved in addressing these issues (e.g., industry operators, governments and regulators, community groups, researchers, treatment providers, and individual consumers/end users)., Conclusion: Multidisciplinary collaboration can facilitate a comprehensive, unified response from all stakeholders that balances individual civil liberties with societal responsibilities and institutional duty of care.

Competing Interests: Disclosure: The authors declare no conflict of interests nor financial disclosures.

Despite brain death (BD) being established as a definition of death for over 50 years, the concept remains controversial. Little is known about public perception of death determination in decision-making about withdrawal of organ support and organ donation (OD), and the importance of the 'Dead Donor Rule' (DDR). We examined perceptions about death in a BD patient and their relationship to decisions about withdrawal of vital organ support, OD and the DDR, using an online survey of 1017 Australian adults. A BD patient scenario was presented, followed by a series of questions. Statistically significant differences in responses were determined using repeated measures analyses of variance and t tests. Seven hundred and fourteen respondents (70.2%) agreed that a hypothetical BD patient was dead. Those disagreeing most commonly cited the presence of heartbeat and breathing. Seven hundred and seventy (75.7%) favoured removal of 'life support', including 136 (13.3%) who had not agreed the patient was dead. Support for OD was high, but most favoured organ removal only after heartbeat and breathing had ceased. Where OD was in keeping with the patient's known wishes, 464 (45.6%) agreed that organs could be removed even if this caused death. Forty-one (20%) of those who had indicated they considered the patient was not dead agreed to organ removal even if it caused death. Australian public views on BD, withdrawal of 'life support' and OD are complex. Emphasis on prognosis and the impact of significant brain injury may be more appropriate in these situations, rather than focussing on death determination and upholding the DDR., (© 2020 Royal Australasian College of Physicians.)

This commentary invites discussion about implicit and explicit factors that impede research about substance use from a nuanced perspective that recognises potential benefits and advantages. It is argued that explicit efforts to engage in scholarship beyond those informed by theoretical and philosophical assumptions that substance use is inherently risky and problematic can enhance genuine inquisition about substance use and transform which discourses and interpretations are legitimised. Prioritisation of scholarly funding and publication has largely been predicated on the notion that illicit substances pose an inherent risk for individual and social harm. This has implicitly and explicitly influenced what type of research has been conducted and how substance use is constructed. Researchers who engage in scholarship that suspends assumptions of risk and problems associated with substance use may become subject to judgement about their credibility, ethics, and expertise. Moving forward, we suggest that conscientiously attending to broad, nuanced experiences associated with substance use will contribute to a stronger evidence base. Equal opportunity should be given to examine the complexity of lived experiences. It may also be timely to consider what brings value to scholarly pursuit, recognising that health is but one valued social outcome. Perhaps other outcomes, such as human rights, compassion, and justice are equally commendable. To advance substance use scholarship, it is essential that decision-makers (e.g., funding bodies, editors) embrace research that does not conform to assumptions of risk or inherent problems as exclusively legitimate, advocate for scholarship that resists conforming to dominant discourses, and create spaces for critical perspectives and interpretations., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Case-finding for dementia is practised by general practitioners (GPs) in Australia but without an awareness of community preferences. We explored the values and preferences of informed community members around case-finding for dementia in Australian general practice., Design, Setting and Participants: A before and after, mixed-methods study in Gold Coast, Australia, with ten community members aged 50-70., Intervention: A 2-day citizen/community jury. Participants were informed by experts about dementia, the potential harms and benefits of case-finding, and ethical considerations., Primary and Secondary Outcomes: We asked participants, "Should the health system encourage GPs to practice 'case-finding' of dementia in people older than 50?" Case-finding was defined as a GP initiating testing for dementia when the patient is unaware of symptoms. We also assessed changes in participant comprehension/knowledge, attitudes towards dementia and participants' own intentions to undergo case-finding for dementia if it were suggested., Results: Participants voted unanimously against case-finding for dementia, citing a lack of effective treatments, potential for harm to patients and potential financial incentives. However, they recognized that case-finding was currently practised by Australian GPs and recommended specific changes to the guidelines. Participants increased their comprehension/knowledge of dementia, their attitude towards case-finding became less positive, and their intentions to be tested themselves decreased., Conclusion: Once informed, community jury participants did not agree case-finding for dementia should be conducted by GPs. Yet their personal intentions to accept case-finding varied. If case-finding for dementia is recommended in the guidelines, then shared decision making is essential., (© 2019 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Background: Some university students consume pharmaceutical stimulants without a medical prescription with the goal of improving their academic performance. The prevalence of this practice has been well documented in the US, but less so in other countries. The potential harms of using prescription stimulants require a better understanding of the prevalence of this practice within Australian universities., Methods: An internet survey of 1136 Australian students was conducted in 2015 in three large Australian universities. Students were asked about their personal use of prescription stimulants, attitudes and experiences with prescription stimulants. They were also asked about their use of caffeine, energy drinks and illicit drugs to enhance their academic performance., Results: Lifetime self-reported use of stimulant medication to improve academic performance was 6.5, and 4.4% in the past year. Students were far more likely to report using coffee and energy drinks (41.4 and 23.6% respectively, lifetime use) than prescription stimulants to help them study and complete university assessments. Non-medical use of prescription stimulants was strongly associated with a history of illicit drug use., Conclusion: The prevalence of nonmedical prescription stimulant use to improve academic performance is low among university students in Australia, especially when compared with their use of coffee and energy drinks.

As the world's population ages, governments and non-governmental organizations in developed countries are promoting healthy cognitive ageing to reduce the rate of age-related cognitive decline and sustain economic productivity in an ageing workforce. Recommendations from the Productivity Commission (Australia), Dementia Australia, Government Office for Science (UK), Presidential Commission for the Study of Bioethical Issues (USA), Institute of Medicine (USA), among others, are encouraging older adults to engage in mental, physical, and social activities. These lifestyle recommendations for healthy cognitive ageing are timely and well supported by scientific evidence but they make implicit normative judgments about the responsibility of ageing individuals to prevent cognitive decline. Ethical tensions arise when this individual responsibility collides with social and personal realities of ageing populations. First, we contextualize the priority given to healthy cognitive ageing within the current brain-based medical and social discourses. Second, we explore the individual responsibility by examining the economic considerations, medical evidence and individual interests that relate to the priority given to healthy cognitive ageing. Third, we identify three key ethical challenges for policymakers seeking to implement lifestyle recommendations as an effective population-level approach to healthy cognitive ageing. The result is a prospectus for future in-depth analysis of ethical tensions that arise from current policy discussions of healthy cognitive ageing., (© 2017 John Wiley & Sons Ltd.)

Purpose: Morbid obesity is associated with several comorbidities that often impair patients' ability to obtain and keep a job and that, eventually, could hinder their fitness to work. This study aimed at determining whether the employment status of morbidly obese patients may be positively affected by bariatric surgery., Methods: A total of 30 morbidly obese patients who underwent Roux-en-Y gastric bypass (RYGB) from March 2014 to March 2015 were prospectively evaluated. All patients underwent a pre-operative assessment including the collection of personal and occupational data and the evaluation of musculoskeletal system. All evaluations were repeated at the end of a 24-month follow up., Results: After RYGB, employment rates increased from 15/30 (50.0%) to 25/30 (83.3%, p = 0.012). Patients who were working at the end of follow-up referred lower rates of comorbidities, in particular of musculoskeletal complaints (4/25 vs. 4/5, p < 0.001), and presented significantly increased scores of energy/vitality at SF-36 assessment., Conclusions: Our study suggests that RYGB can increase employment rates, increasing tolerance to effort and reducing prevalence and severity of obesity-related symptoms and complaints.

Background: Morpho-functional modifications of the gastric remnant after Roux-en-Y gastric bypass (RYGB) have not been completely defined, due to its inaccessibility for bioptic mapping. The aim of the study is to evaluate such modifications using Gastropanel®, a non-invasive blood test cross-checking four gastric biomarkers, able to provide a snapshot of mucosa conditions., Subjects and Methods: Twenty-four women undergoing RYGB were prospectively enrolled. Gastropanel® parameters (pepsinogens, Gastrin-17 and immunoglobulins against Helicobacter pylori), biometrical/clinical data were collected preoperatively and at 6-months follow-up., Results: All parameters showed significant reduction (p < 0.05). Pepsinogen I reduction correlated with BMI percent decrease., Conclusions: The exclusion of food transit is responsible for significant drop in gastric output, hardly representing a risk factor in the remnant carcinogenesis, being unexposed to alimentary carcinogenic agents.

Purpose: To evaluate the efficacy of the modification of Adjustable Macular Buckling device in the treatment of myopic macular hole retinal detachment with posterior staphyloma., Methods: Four consecutive patients suffering from myopic macular detachment with macular hole were treated using the macular buckling procedure. An Adjustable Macular Buckling device was used in all four cases and was modified using a 29-gauge optical fiber to illuminate its macular plate., Results: Optical coherence tomography showed successful retinal reattachment and closure of the macular hole after the buckling procedure. The macular plate of the buckling device was properly positioned in all four patients. No complications were observed., Conclusion: The modification of the macular buckling device improves the accuracy of its positioning by illuminating its macular plate.

Robillard and Feng highlight incongruence between patient preferences and the procedural aspects of research ethics as they relate to protocols for dementia research. Their findings break ground for a reassessment of how research ethics, researchers, and participants (including patients and caregivers) approach participation in dementia research. However, it is unclear whether patient preferences may also herald a normative gap between how dementia research is being conducted and how it should be done. This response uses one of Robillard and Feng's findings to illustrate how descriptive empirical data might be reinterpreted into normative questions that reframe current practices in the context of dementia research.

Given advances in Alzheimer's disease (AD) research, some experts have proposed a state of "preclinical" AD to describe asymptomatic individuals displaying certain biomarkers. The diagnostic accuracy of these biomarkers remains debated; however, given economic pressures, this "diagnosis" may eventually reach consumers. Since evidence-based prevention and treatment options remain only modestly effective, patients may turn to complementary and alternative medicine (CAM). We explore ethical challenges associated with CAM use in preclinical AD. We first consider these issues through the liberal lens, which emphasizes informed choice while occasionally disregarding the complexity of decision making, at least as currently applied to CAM policies. We then broaden the liberal lens with a socio-contextual lens, which describes the impact of social context on choice. Finally, we describe an alternate lens (contextualized liberalism) and its practical health and policy implications while 1) building on the liberal commitment to autonomy and 2) recognizing contextual determinants of choice.

Objective: The authors describe the hidden ethics curriculum in two postgraduate psychiatry programs., Methods: Researchers investigated the formal, informal, and hidden ethics curricula at two demographically different postgraduate psychiatry programs in Canada. Using a case study design, they compared three sources: individual interviews with residents and with faculty and a semi-structured review of program documents. They identified the formal, informal, and hidden curricula at each program for six ethics topics and grouped the topics under two thematic areas. They tested the applicability of the themes against the specific examples under each topic. Results pertaining to one of the themes and its three topics are reported here., Results: Divergences occurred between the curricula for each topic. The nature of these divergences differed according to local program characteristics. Yet, in both programs, choices for action in ethically challenging situations were mediated by a minimum standard of ethics that led individuals to avoid trouble even if this meant their behavior fell short of the accepted ideal., Conclusions: Effective ethics education in postgraduate psychiatry training will require addressing the hidden curriculum. In addition to profession-wide efforts to articulate high-level values, program-specific action on locally relevant issues constitutes a necessary mechanism for handling the impact of the hidden curriculum.

Background: Several techniques for fixation of the posterior chamber intraocular lens (IOL) have been developed. We evaluate long-term functional outcomes and safety of posterior chamber IOL implantation using Hoffman scleral haptic fixation and sutureless Sharioth technique in patients with posttraumatic and postoperative aphakia., Methods: This retrospective case-series included 42 eyes operated by one surgeon. The data including demographic data, ocular history, preoperative, early postoperative and final best corrected visual acuity (BCVA), rate of complications as well as postoperative IOL position were collected. The mean follow-up was 14.5 months. Hoffman haptic scleral fixation was performed in 31 eyes, Sharioth technique-in 11 eyes. Aphakia was due to eye trauma (19) or complicated cataract surgery (23)., Results: Overall, the final BCVA improved in 26 eyes, did not change in 5 eyes, and worsened in 11 eyes. No significant differences in BCVA were found between groups operated with Hoffman scleral fixation and Sharioth technique. Postoperatively, we noticed two dislocations of IOL fixated using Sharioth technique and none after Hoffman technique. No severe complications were observed., Conclusion: Both transscleral fixation techniques are feasible methods of secondary IOL implantation in posttraumatic and postoperative aphakia. with low incidence of complications, however visual outcomes are diverse.

Background: There are reports that some university students are using prescription stimulants for non-medical 'pharmaceutical cognitive enhancement (PCE)' to improve alertness, focus, memory, and mood in an attempt to manage the demands of study at university. Purported demand for PCEs in academic contexts have been based on incomplete understandings of student motivations, and often based on untested assumptions about the context within which stimulants are used. They may represent attempts to cope with biopsychosocial stressors in university life by offsetting students' inadequate coping responses, which in turn may affect their cognitive performance. This study aimed to identify (a) what strategies students adopted to cope with the stress of university life and, (b) to assess whether students who have used stimulants for PCE exhibit particular stress or coping patterns., Methods: We interviewed 38 university students (with and without PCE experience) about their experience of managing student life, specifically their: educational values; study habits; achievement; stress management; getting assistance; competing activities and demands; health habits; and cognitive enhancement practices. All interview transcripts were coded into themes and analyzed., Results: Our thematic analysis revealed that, generally, self-rated coping ability decreased as students' self-rated stress level increased. Students used emotion- and problem-focused coping for the most part and adjustment-focused coping to a lesser extent. Avoidance, an emotion-focused coping strategy, was the most common, followed by problem-focused coping strategies, the use of cognition on enhancing substances, and planning and monitoring of workload. PCE users predominantly used avoidant emotion-focused coping strategies until they no longer mitigated the distress of approaching deadlines resulting in the use of prescription stimulants as a substance-based problem-focused coping strategy., Conclusion: Our study suggests that students who choose coping responses that do not moderate stress where possible, may cause themselves additional distress and avoid learning more effective coping responses. Helping students to understand stress and coping, and develop realistic stress appraisal techniques, may assist students in general to maintain manageable distress levels and functioning. Furthermore, assisting students who may be inclined to use prescription stimulants for cognitive enhancement may reduce possible drug-related harms.

Ethical perspectives on the use of stimulants to enhance human cognitive performance (neuroenhancement) are polarized between conservative and liberal theories offering opposing advice on whether individuals have a right to use neuroenhancers and what the social outcomes of neuroenhancement might be. Meanwhile, empirical evidence shows modest prevalence and guarded public attitudes toward the neuroenhancement use of stimulants. In this Perspective, we argue that the dissonance between the prescriptions of ethical theories (what ought to be) and empirical evidence (what is) has impaired our understanding of neuroenhancement practices. This dissonance is a result of three common errors in research on the ethics of neuroenhancement: (1) expecting that public perspectives will conform to a prescriptive ethical framework; (2) ignoring the socio-economic infrastructures that influence individuals' decisions on whether or not to use neuroenhancement; and (3) overlooking conflicts between fundamental ethical values namely, safety of neuroenhancement and autonomy. We argue that in order to understand neuroenhancement practices it is essential to recognize which values affect individual decisions to use or refuse to use neuroenhancement. Future research on the ethics of neuroenhancement should assess the morally significant values for stakeholders. This will fill the gap between what ought to be done and what is done with an improved understanding of what can be done within a particular context. Clarifying conflicts between competing moral values is critical in conducting research on the efficacy of substances putatively used for neuroenhancement and also on neuroenhancement practices within academic, professional and social environments.

Preclinical Alzheimer's disease (AD), a newly proposed, actively researched, and hotly debated research-only diagnostic category, raises the prospect of an ethical dilemma: whether, and possibly how, to treat a disorder with no target symptoms. This proposed category rests on the detection of a number of biomarkers thought to provide evidence of AD pathophysiology years before any behavioral symptoms manifest. Faced with limited treatment options, patients and their relatives may come to consider complementary and alternative medicine (CAM) a viable option, albeit one with minimal supporting evidence. Accordingly, the hopes and needs of some preclinical patients and their relatives could further fuel market-oriented entrepreneurship for CAM. In this ethics review, we provide background and reflect on some ethical questions related to the roles of key stakeholders arising from the potential for CAM use in the context of a possible preclinical AD diagnosis.

Background: The ideal intraocular lens in cases of aphakia without capsular support is debated. Choices include anterior chamber lenses, iris- or scleral-sutured lenses, and iris-claw lenses. Our aim was to report our long-term evaluation of the use of retropupillary implantation of the Artisan iris-claw intraocular lens (RPICIOL) in several aphakic conditions without capsular support., Methods: A retrospective analysis of consecutive 320 eyes of 320 patients (222 males and 98 females) without capsular support in which we performed RPICIOL implantation in post-traumatic aphakia (141 eyes, group 1), post-cataract surgery aphakia (122 eyes, group 2), and in cases in which penetrating keratoplasty was associated with vitrectomy (57 eyes, group 3). Either anterior or posterior vitrectomy procedures were performed with 20-, 23-, or 25-gauge techniques for different associated anterior or posterior segment indications. We reviewed the refractive outcome, anatomical outcome, long-term stability of the implants, and possible long-term complications., Results: The mean patient age was 59.7 years (range, 16-84 years) in group 1; 60.1 years (range, 14-76 years) in group 2; and 65.8 years (range, 25-71.5 years) in group 3. The mean follow-up time was 5.3 years (range, 1 month to 8 years). At the end of the follow-up period, the mean post-operative best-corrected LogMAR visual acuity was 0.6 (range, perception of light to 0.3) in group 1; 0.3 (range, 0.5-0.1) in group 2; and 0.6 (range, hand movement to 0.2) in group 3. Disenclavation of RPICIOLs occurred in three cases because of slippage of one of the iris-claw haptics and spontaneous complete posterior dislocation occurred in one case. One case presented with retinal detachment, and no cases of uveitis were observed. Eight cases complained of chronic dull pain, and severe iridodonesis was seen in five cases. One case of post-operative macular edema was observed without post-operative increase in the mean intraocular pressure. There was no statistically different change in the endothelial cell density (cells/mm(2)) at the end of the follow-up period., Conclusions: RPICIOL for secondary implantations is a valid alternative strategy to scleral-fixated or angle-supported IOL implantation.

Background: Some countries have banned the sale of electronic nicotine delivery systems (ENDS)., Aims: We analyse the ethical issues raised by this ban and various ways in which the sale of ENDS could be permitted., Method: We examine the ban and alternative policies in terms of the degree to which they respect ethical principles of autonomy, beneficence, non-maleficence and justice, as follows., Results: Respect for autonomy: prohibiting ENDS infringes on smokers' autonomy to use a less harmful nicotine product while inconsistently allowing individuals to begin and continue smoking cigarettes. Non-maleficence: prohibition is supposed to prevent ENDS recruiting new smokers and discouraging smokers from quitting, but it has not prevented uptake of ENDS. It also perpetuates harm by preventing addicted smokers from using a less harmful nicotine product. Beneficence: ENDS could benefit addicted smokers by reducing their health risks if they use them to quit and do not engage in dual use. Distributive justice: lack of access to ENDS disadvantages smokers who want to reduce their health risks. Different national policies create inequalities in the availability of products to smokers internationally., Conclusions: We do not have to choose between a ban and an unregulated free market. We can ethically allow ENDS to be sold in ways that allow smokers to reduce the harms of smoking while minimizing the risks of deterring quitting and increasing smoking among youth., (© 2015 Society for the Study of Addiction.)

In the last decade, an increasing number of studies have suggested that transcranial direct current stimulation (tDCS) may enhance brain function in healthy individuals, and ameliorate cognitive and other symptoms in patients suffering from various medical conditions. This, along with its presumed safety, simplicity, and affordability, has generated great enthusiasm amongst researchers, clinicians, patient populations, and the public (including a growing "do-it-yourself" community). However, discussion about the effectiveness and ethics of tDCS thus far has been confined to small groups of tDCS researchers and bioethicists. We conducted an international online survey targeting the opinions of researchers using tDCS who were asked to rate the technique's efficacy in different contexts. We also surveyed opinions about ethical concerns, self-enhancement and public availability. 265 complete responses were received and analyzed statistically and thematically. Our results emphasize the potential uses of tDCS in clinical and research contexts, but also highlight a number of emerging methodological and safety concerns, ethical challenges and the need for improved communication between researchers and bioethicists with regard to regulation of the device. Neither the media reputation of tDCS as a "miracle device" nor concerns expressed in recent neuroethical publications were entirely borne out in expert opinion.

Purpose. To evaluate longitudinal functional and anatomical results after combined pars plana vitrectomy (PPV) and penetrating keratoplasty (PKP) using a wide-field Landers intraoperative temporary keratoprosthesis (TKP) in patients with vitreoretinal pathology and corneal opacity due to severe ocular trauma. Material and Methods. Medical records of 12 patients who had undergone PPV/PKP/KP due to severe eye trauma were analyzed. Functional (best-corrected visual acuity) and anatomic outcomes (clarity of the corneal graft, retinal attachment, and intraocular pressure) were assessed during the follow-up (mean 16 months). Results. Final visual acuities varied from NLP to CF to 2 m. Visual acuity improved in 7 cases, was unchanged in 4 eyes, and worsened in 1 eye. The corneal graft was transparent during the follow-up in 3 cases and graft failure was observed in 9 eyes. Silicone oil was used as a tamponade in all cases and retina was reattached in 92% of cases. Conclusions. Combined PPV and PKP with the use of wide-field Landers TKP allowed for surgical intervention in patients with vitreoretinal pathology coexisting with corneal wound. Although retina was attached in most of the cases, corneal graft survived only in one-fourth of patients and final visual acuities were poor.