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Handbook of Clinical Neurology 2023Ethical challenges in medical decision making are commonly encountered by clinicians caring for patients afflicted by neurological injury or disease at the end of life... (Review)
Review
Ethical challenges in medical decision making are commonly encountered by clinicians caring for patients afflicted by neurological injury or disease at the end of life (EOL). In many of these cases, there are conflicting opinions as to what is right and wrong originating from multiple sources. There is a particularly high prevalence of impaired patient judgment and decision-making capacity in this population that may result in a misrepresentation of their premorbid values and goals. Conflict may originate from a discordance between what is legal or from stakeholders who view and value life and existence differently from the patient, at times due to religious or cultural influences. Promotion of life, rather than preservation of existence, is the goal of many patients and the foundation on which palliative care is built. Those who provide EOL care, while being respectful of potential cultural, religious, and legal stakeholder perspectives, must at the same time recognize that these perspectives may conflict with the optimal ethical course to follow. In this chapter, we will attempt to review some of the more notable ethical challenges that may arise in the neurologically afflicted at the EOL. We will identify what we believe to be the most compelling ethical arguments both in support of and opposition to specific EOL issues. At the same time, we will consider how ethical analysis may be influenced by these legal, cultural, and religious considerations that commonly arise.
Topics: Humans; Terminal Care; Palliative Care; Death; Neurology; Suicide, Assisted; Ethics, Medical
PubMed: 36599511
DOI: 10.1016/B978-0-12-824535-4.00012-4 -
Cardiovascular Diagnosis and Therapy Jun 2023The development of the frozen elephant trunk (FET) prosthesis has revolutionised how we treat some of the most complex aortic pathology, including in the emergency... (Review)
Review
The development of the frozen elephant trunk (FET) prosthesis has revolutionised how we treat some of the most complex aortic pathology, including in the emergency setting of acute type A aortic dissection. The design of the prosthesis is fundamental to the success of the procedure in combination with the surgeon's skill in interpreting the pre-operative scan and procedural planning to juggling the technical aspects of the deployment and reimplantation of the supra-aortic vessels. Furthermore, organ protection strategies and techniques to reduce the complications of neurological and renal impairment are paramount. This article focuses on the Thoraflex Hybrid prosthesis including the evolution of the concept, design features unique to the device and surgical technique including fundamentals of sizing and implantation steps with illustrations. The Thoraflex Hybrid prosthesis provides an ergonomic and neat delivery system with a trusted gelatin coated surgical graft material making implantation and use as straightforward as possible. These features have meant that the device is a market leader in the field of FETs with outcome data and implant figures to support its efficacy globally. The success of the device is also reflected in the literature. For example, in the UK study from Mariscalco , the mortality of FET implantation in acute type A dissection, of which most were using the Thoraflex device, was only 12%. This is comparable to leading centres in Europe with the inherent advantage of improving long-term outcomes in addition. Of course, this strategy is not appropriate in all cases and precise judgement of when to deploy a FET in both the emergency and elective setting is key to achieving good outcomes.
PubMed: 37405020
DOI: 10.21037/cdt-22-506 -
Aging Brain 2022Alzheimer's disease (AD) is one of the most persistent and devastating neurodegenerative disorders of old age, and is characterized clinically by an insidious onset and... (Review)
Review
Alzheimer's disease (AD) is one of the most persistent and devastating neurodegenerative disorders of old age, and is characterized clinically by an insidious onset and a gradual, progressive deterioration of cognitive abilities, ranging from loss of memory to impairment of judgement and reasoning. Despite years of research, an effective cure is still not available. Autophagy is the cellular 'garbage' clearance system which plays fundamental roles in neurogenesis, neuronal development and activity, and brain health, including memory and learning. A selective sub-type of autophagy is mitophagy which recognizes and degrades damaged or superfluous mitochondria to maintain a healthy and necessary cellular mitochondrial pool. However, emerging evidence from animal models and human samples suggests an age-dependent reduction of autophagy and mitophagy, which are also compromised in AD. Upregulation of autophagy/mitophagy slows down memory loss and ameliorates clinical features in animal models of AD. In this review, we give an overview of autophagy and mitophagy and their link to the progression of AD. We also summarize approaches to upregulate autophagy/mitophagy. We hypothesize that age-dependent compromised autophagy/mitophagy is a cause of brain ageing and a risk factor for AD, while restoration of autophagy/mitophagy to more youthful levels could return the brain to health.
PubMed: 36908880
DOI: 10.1016/j.nbas.2022.100056 -
Physical Medicine and Rehabilitation... May 2024Predicting motor outcomes after stroke based on clinical judgment alone is often inaccurate and can lead to inefficient and inequitable allocation of rehabilitation... (Review)
Review
Predicting motor outcomes after stroke based on clinical judgment alone is often inaccurate and can lead to inefficient and inequitable allocation of rehabilitation resources. Prediction tools are being developed so that clinicians can make evidence-based, accurate, and reproducible prognoses for individual patients. Biomarkers of corticospinal tract structure and function can improve prediction tool performance, particularly for patients with initially moderate to severe motor impairment. Being able to make accurate predictions for individual patients supports rehabilitation planning and communication with patients and families.
Topics: Humans; Stroke; Stroke Rehabilitation; Biomarkers; Prognosis; Pyramidal Tracts; Transcranial Magnetic Stimulation; Recovery of Function
PubMed: 38514217
DOI: 10.1016/j.pmr.2023.06.003 -
Australian Journal of General Practice 2021Older people use increasingly complex medication regimens. Complex regimens are challenging to administer, particularly for those with cognitive impairment, frailty,...
BACKGROUND
Older people use increasingly complex medication regimens. Complex regimens are challenging to administer, particularly for those with cognitive impairment, frailty, poor eyesight or limited dexterity. Complex regimens have been linked to non-adherence, medication errors and hospital admissions.
OBJECTIVE
The aim of this article is to describe strategies to reduce the complexity of medication regimens in community and residential aged care settings.
DISCUSSION
Medication regimen simplification is the process of reducing medication burden through strategies such as consolidating dosing times, standardising routes of administration, using long-acting rather than shorter-acting formulations, and switching to combination products in place of single-ingredient products. Obtaining a best possible medication history, ensuring appropriateness of current therapy, and deprescribing are important steps prior to implementing regimen simplification. Implementing such strategies should be based on a discussion and consideration of patient preferences, and include clinical judgement to limit the risk of unintended consequences for patients or carers.
Topics: Aged; Clinical Protocols; Delivery of Health Care; Frailty; Humans; Medication Errors
PubMed: 33543163
DOI: 10.31128/AJGP-04-20-5322 -
Current Drug Targets 2022Alzheimer's disease (AD) is an irreversible, progressive neurodegenerative disorder that may account for approximately 60-70% of cases of dementia worldwide. AD is... (Review)
Review
Alzheimer's disease (AD) is an irreversible, progressive neurodegenerative disorder that may account for approximately 60-70% of cases of dementia worldwide. AD is characterized by impaired behavioural and cognitive functions, including memory, language, conception, attentiveness, judgment, and reasoning problems. The two important hallmarks of AD are the appearance of plaques and tangles of amyloid-beta (Aβ) and tau proteins, respectively, in the brain based on the etiology of the disease, including cholinergic impairment, metal dyshomeostasis, oxidative stress, and degradation of neurotransmitters. Currently, the used medication only provides alleviation of symptoms but is not effective in curing the disease, which creates the need to develop new molecules to treat AD. Heterocyclic compounds have proven their ability to be developed as drugs for the treatment of various diseases. The five-membered heterocyclic compound triazole has received foremost fascination for the discovery of new drugs due to the possibility of structural variation. Moreover, it has proved its significance in various drug categories. This review mainly summarizes the recent advancements in the development of novel 1,2,3-triazole and 1,2,4-triazole-based molecules in the drug discovery process for targeting various AD targets such as phosphodiesterase 1 (PDE1) inhibitors, apoptosis signal-regulating kinase 1 (ASK1) inhibitors, somatostatin receptor subtype-4 (SSTR4) agonist, several other druggable targets, molecular modelling studies, as well as various methodologies for the synthesis of triazoles containing molecules such as click reaction, Pellizzari reaction, and Einhorn- Brunner reaction.
Topics: Alzheimer Disease; Amyloid beta-Peptides; Brain; Humans; Oxidative Stress; Triazoles
PubMed: 35346005
DOI: 10.2174/1389450123666220328153741 -
Frontiers in Psychology 2022Mainstream decision research rests on two implicit working assumptions, inspired by subjective expected utility theory. The first assumes that the underlying processes...
Mainstream decision research rests on two implicit working assumptions, inspired by subjective expected utility theory. The first assumes that the underlying processes can be separated into judgment and decision-making stages without affecting their outcomes. The second assumes that in properly run experiments, the presentation of a complete description of the incentive structure replaces the judgment stage (and eliminates the impact of past experiences that can only affect judgment). While these working assumptions seem reasonable and harmless, the current paper suggests that they impair the derivation of useful predictions. The negative effect of the separation assumption is clarified by the predicted impact of rare events. Studies that separate judgment from decision making document oversensitivity to rare events, but without the separation people exhibit the opposite bias. The negative effects of the assumed impact of description include masking the large and predictable effect of past experiences on the way people use descriptions. We propose that the cognitive processes that underlie decision making are more similar to machine learning classification algorithms than to a two-stage probability judgment and utility weighting process. Our analysis suggests that clear insights can be obtained even when the number of feasible classes is very large, and the effort to list the rules that best describe behavior in each class is of limited value.
PubMed: 36710808
DOI: 10.3389/fpsyg.2022.1041737 -
Current Alzheimer Research 2022Dementia has been characterized by atypical neurological syndromes and several cognitive deficits, such as extended memory loss, strange behavior, unusual thinking,... (Review)
Review
Dementia has been characterized by atypical neurological syndromes and several cognitive deficits, such as extended memory loss, strange behavior, unusual thinking, impaired judgment, impotence, and difficulty with daily living activities. Dementia is not a disease, but it is caused by several neurodegenerative diseases, such as Alzheimer's, Parkinson's, and Lewy's bodies. Several drugs and remedies are indicated for alleviating unusual cognitive decline, but no effective pharmacological treatment regimens are available without side effects. Herbal drugs or traditional medicines like Ayurveda have been known for facilitating and corroborating the balance between mind, brain, body, and environment. Ayurvedic therapy comprises 600 herbal formulas, 250 single plant remedies, and natural and holistic health-giving treatments that relieve dementia in patients and increase vitality. Ayurvedic Rasayana herbs [rejuvenating elements] strengthen the brain cells, enhance memory, and decrease stress. The current medicine scenario in the treatment of dementia has prompted the shift in exploring the efficacy of ayurvedic medicine, its safety, and its efficiency. This review presents the literature on several herbal treatments for improving dementia symptomatology and patients' quality of life.
Topics: Humans; Quality of Life; Phytotherapy; Medicine, Ayurvedic; Neurodegenerative Diseases; Dementia
PubMed: 35929620
DOI: 10.2174/1567205019666220805100008 -
Cureus Nov 2023This comprehensive review article explores the intricate mechanisms at work and possible remedies for the connection between sleep issues and cardiovascular health.... (Review)
Review
This comprehensive review article explores the intricate mechanisms at work and possible remedies for the connection between sleep issues and cardiovascular health. Sleep disorders, which include conditions like insomnia and sleep apnea, are drawing increasing amounts of attention due to their serious detrimental consequences on cardiovascular health. This article carefully examines the body of existing evidence to explain the intricate mechanisms that connect sleep disruptions to cardiovascular issues. Mechanisms include inflammation, disruption of the autonomic nervous system, endothelial dysfunction, and aberrant metabolic processes all have an impact on these pathways. The study also looks at a variety of existing and novel therapeutic modalities that aim to minimize the detrimental effects of sleep disruptions on cardiovascular health. This includes evaluating the effectiveness of lifestyle changes, pharmaceutical interventions, and behavioural therapy for enhancing sleep quality and hence preserving cardiovascular health. By synthesising and presenting the most recent study data, this article offers valuable insights into the complex relationships between sleep patterns, cardiovascular function, and potential therapeutics. These results provide a solid foundation for guiding future research endeavours and clinical judgements. Pharmacotherapy is a possibility for momentary relief. Cardiovascular illness has been linked to the sensorimotor problem known as restless legs syndrome (RLS), which causes a strong impulse to move the legs. Sleep disruption caused by RLS-related leg movements leads to sympathetic activation, elevated blood pressure, impaired vascular function, and potential iron deficiency. Treating the underlying iron deficiency, when present, and medications targeting dopamine receptors or regulating calcium channels are the primary interventions for RLS. In conclusion, sleep disorders significantly impact cardiovascular health through multiple mechanisms. Early detection, accurate diagnosis, and appropriate interventions are crucial for mitigating associated cardiovascular risks. Multidisciplinary approaches including lifestyle modifications, behavioral interventions, and targeted pharmacotherapy have shown promise in improving sleep quality and cardiovascular outcomes. Further research is needed to enhance our understanding of the complex interplay between sleep disorders and cardiovascular health, leading to the development of more effective interventions and improved patient outcomes.
PubMed: 38161933
DOI: 10.7759/cureus.49703