Prevalence and Determinants of Physician Bedside Rationing: Data from Europe

BACKGROUND: Bedside rationing by physicians is controversial. The debate, however, is clouded by lack of information regarding the extent and character of bedside rationing. DESIGN, SETTING, AND PARTICIPANTS: We developed a survey instrument to examine the frequency, criteria, and strategies used for bedside rationing. Content validity was assessed through expert assessment and scales were tested for internal consistency. The questionnaire was translated and administered to General Internists in Norway, Switzerland, Italy, and the United Kingdom. Logistic regression was used to identify the variables associated with reported rationing. RESULTS: Survey respondents (N =656, response rate 43%) ranged in age from 28 to 82, and averaged 25 years in practice. Most respondents (82.3%) showed some degree of agreement with rationing, and 56.3% reported that they did ration interventions. The most frequently mentioned criteria for rationing were a small expected benefit (82.3%), low chances of success (79.8%), an intervention intended to prolong life when quality of life is low (70.6%), and a patient over 85 years of age (70%). The frequency of rationing by clinicians was positively correlated with perceived scarcity of resources (odds ratio [OR]=1.11, 95% confidence interval [CI] 1.06 to 1.16), perceived pressure to ration (OR=2.14, 95% CI 1.52 to 3.01), and agreement with rationing (OR=1.13, 95% CI 1.05 to 1.23). CONCLUSION: Bedside rationing is prevalent in all surveyed European countries and varies with physician attitudes and resource availability. The prevalence of physician bedside rationing, which presents physicians with difficult moral dilemmas, highlights the importance of discussions regarding how to ration care in the most ethically justifiable manner

Using the General Lake Model (GLM) to simulate water temperatures and ice cover of a medium-sized lake: a case study of Lake Ammersee, Germany

Thermal dynamics of lakes has a key role in chemical and biological processes in lakes including nutrient distributions and phytoplankton growth. Applications of hydrodynamic models to lakes can provide insights into possible future alterations in thermal dynamics induced by climate change. In this study, we present the calibration and validation of the newest version of the open-source hydrodynamic model GLM (General Lake Model) to the dimictic Lake Ammersee, located in south-east Germany. The simulation of lake water temperatures for the calibration period revealed an overall root mean square error of 0.65 °C and a mean error of 0.08 °C. The seasonal stratification pattern and the annual thermal structure of this dimictic lake were reproduced by the model. The model simulated the presence of winter ice cover for the only year out of 8 years simulated, when ice cover was observed. Elevated lake water temperatures were also reproduced in model simulations during a period in 2003 of unusually high air temperatures. Statistical analysis of the model calibration results for Lake Ammersee indicates a fit comparable to or better than most other well-established hydrodynamic models and provides an opportunity for continuous simulations through periods of ice cover. Our results indicate a major improvement in GLM compared with earlier model versions and demonstrate the applicability of GLM for limnophysical studies, particularly for altered forcing conditions such as climate change.No Full Tex

Substituted Judgment: The Limitations of Autonomy in Surrogate Decision Making

Substituted judgment is often invoked as a guide for decision making when a patient lacks decision making capacity and has no advance directive. Using substituted judgment, doctors and family members try to make the decision that the patient would have made if he or she were able to make decisions. However, empirical evidence suggests that the moral basis for substituted judgment is unsound. In spite of this, many physicians and bioethicists continue to rely on the notion of substituted judgment. Given compelling evidence that the use of substituted judgment has insurmountable flaws, other approaches should be considered. One approach provides limits on decision making using a best interest standard based on community norms. A second approach uses narrative techniques and focuses on each patient’s dignity and individuality rather than his or her autonomy

Efficacy and safety assessment of two enterococci phages in an in vitro biofilm wound model

Chronic wounds affect thousands of people worldwide, causing pain and discomfort to patients and represent significant economical burdens to health care systems. The treatment of chronic wounds is very difficult and complex, particularly when wounds are colonized by bacterial biofilms which are highly tolerant to antibiotics. Enterococcus faecium and Enterococcus faecalis are within the most frequent bacteria present in chronic wounds. Bacteriophages (phages) have been proposed as an efficient and alternative against antibiotic-resistant infections, as those found in chronic wounds. We have isolated and characterized two novel enterococci phages, the siphovirus vB_EfaS-Zip (Zip) and the podovirus vB_EfaP-Max (Max) to be applied during wound treatment. Both phages demonstrated lytic behavior against E. faecalis and E. faecium. Genome analysis of both phages suggests the absence of genes associated with lysogeny. A phage cocktail containing both phages was tested against biofilms formed in wound simulated conditions at a multiplicity of infection of 1.0 and a 2.5log CFU.mL1 reduction in the bacterial load after at 3h of treatment was observed. Phages were also tested in epithelial cells colonized by these bacterial species and a 3log CFU.mL1 reduction was observed using both phages. The high efficacy of these new isolated phages against multi-species biofilms, their stability at different temperatures and pH ranges, short latent periods and non-cytotoxicity to epithelial cells suggest their therapeutic use to control infectious biofilms present in chronic wounds.This study was supported by the Portuguese Foundation for Science and Technology (FCT) under the scope of the strategic funding of UID/BIO/04469/2013 unit, COMPETE 2020 (POCI-01-0145-FEDER-006684) and the Project PTDC/BBB-BSS/6471/2014 (POCI-01-0145-FEDER-016678). This work was also supported by BioTecNorte operation (NORTE-01-0145-FEDER-000004) funded by the European Regional Development Fund under the scope of Norte2020 - Programa Operacional Regional do Norte. A.R.C. and H.O. acknowledge FCT for grant SFRH/BPD/94648/2013 and SFRH/BPD/111653/2015, respectively. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.info:eu-repo/semantics/publishedVersio