Diagnosis and choice of haemostatic therapy during surgery in patients with combined coagulation factor V and VIII defi ciency

Introduction. Among the most common congenital coagulopathies are haemophilia and Von Willebrand disease. These illnesses are often mimicked by orphan hereditary coagulopathies, including combined coagulation factor V and VIII deficiency.Aim — description of a clinical presentation, hampered diagnosis and choice of haemostatic therapy in a surgical patient with combined blood coagulation factor V and VIII deficiency.Main findings. We describe a clinical case of congenital combined factor V and VIII deficiency and detail the aetiology, frequency, localisation and intensity of haemorrhages. Comorbidity and surgical indications are demonstrated to require an inter-specialty medical involvement.

The Advance of Technoscience and the Problem of Death Determination

Death determination has long been a topic of intensive technoscientific and medical involvement. Due to advances in twentieth-century medical technology, the distinction between life and death has become less evident. Ambiguities appear when we start to use life-support technologies in order to save lives, bringing about “tragic artifacts” such as brain death and persistent vegetative state. In this paper we ask how this technoscientific and medical involvement shapes our understanding of death. We provide an overview of medical literature that has appeared on (brain) death determination, highlighting thereby the role that technologies played in its establishment. Subsequently, we develop three philosophical interpretations of technological death determination: With Agamben and Marcuse as the installation of political power; with Don Ihde as an existential choice for the inevitable; and with Jacques Derrida as an encounter with the ineradicable mystery of death. To conclude, we argue that technological death determination reveals an intrinsic, paradoxical connection between human’s technicity and its ignorance of death.

‘Unfortunate creatures’: The hazards of syphilis in wet-nursing

While the selection criteria for wet-nurses had little changed across two millennia, other aspects of their occupation were far from homogenous, changing under the diverse infl uences of culture, current threats to the health of wet-nurses and the babies they fed, contemporaneous medical knowledge and healthcare. Fears of the transmission of the prevailing infectious diseases of the times led to medical involvement at all levels, from selection and inspection of applicants for wet-nurse positions to treatment of illnesses that arose in the child. The article discusses the implications of syphilis, the most serious disease transmissible through wet-nursing before the discovery of antibiotics, and the preventive measures and treatment used by the physicians across fi ve centuries, according to the knowledge of the time. The period covered extends into the early-twentieth century.

Neurointerventions and Physician Participation

This chapter takes up an issue that more narrowly relates to the question who should administer the use of neurointerventions if such treatment were to be put into practice. That such treatment would usually require at least some degree of involvement by personnel with medical skills is beyond doubt. However, this raises the question whether physicians should be involved in the treatment of offenders. The purpose of this chapter is to consider whether the combination of the fact that the treatment presupposes medical involvement, and the view that physicians should not be involved in such treatment, is sufficient to block the whole discussion of the morally legitimate use of neurointerventions in crime prevention. It is examined whether any of the arguments that have been advanced in the discussion of physician involvement in the use of lethal injection in relation to capital punishment manage to establish that physicians have a moral duty to abstain from criminal justice use of treatment by neurointerventions.

The Boundaries of Medicine

A valid concern regarding medicine in society is the medicalization of social deviance as a form of social control. Peter Conrad writes about this concern as we become more dependent on physician judgement of what is and isn’t illness. We are faced with determining what is inside and outside the realm of medicine, and what the limits of medical involvement should be. I explore two instances that reveal that medicine should be involved in cases of human suffering, though should never carry all the societal burdens of alleviating suffering. Whether or not medicine should be involved in mental illness is a view contested by Thomas Szasz in an argument that aims to establish that mental illness is outside the realm of medicine. His argument relies on the clear separation between somatic and mental illnesses, which I show are not clearly separated at all. Ultimately, I argue that as complex—and undoubtedly human—as the practice of medicine is, it is a discipline with a wide array of applications that are critically important for treating mental illness.

Patients’ perspectives on acromegaly diagnostic delay: a qualitative study

ContextAcromegaly has a substantial diagnostic delay associated with an increased risk of comorbidities and psychosocial deterioration. Qualitative methods which focus on the ways that individuals understand and relate to what they are experiencing are the best methods for exploring patients’ perspectives. To the best of our knowledge, they have not been developed in the context of acromegaly.ObjectivesThis study aimed to explore the experience of the diagnostic pathway of patients with acromegaly.DesignWe conducted a qualitative study, based on 20 face-to-face unstructured interviews in a third referral Endocrinology center. Participants, purposively selected until data saturation, were patients with acromegaly with diverse disease durations, types of treatment or associated comorbidities. The data were examined by thematic analysis.ResultsOur analysis found four themes: (i) what happened for patients before the diagnosis; (ii) what happened after; (iii) the style or type of doctor involved and (iv) patients’ suggestions for limiting diagnostic delay. Our findings underlined the direct associations between diagnostic delay and the doctor–patient encounter, and the truly catastrophic experience of this disease, both before and after the diagnosis.ConclusionsDiagnosis of acromegaly requires active medical involvement and awareness. Intervention of patient-experts in medical schools may help to be more aware of this disease. Endocrinologists caring for patients with acromegaly should also address the catastrophic dimension of the patient’s experience and initiate the narrative to help them to put it into words for preventing harmful consequences such as social isolation and QoL impairment, but also anxiety or depression.

Responses to assisted suicide requests: an interview study with Swiss palliative care physicians

ObjectivesAssisted suicide in Switzerland is mainly performed by right-to-die societies. Medical involvement is limited to the prescription of the drug and certification of eligibility. Palliative care has traditionally been perceived as generally opposed to assisted suicide, but little is known about palliative care physicians’ involvement in assisted suicide practices. This paper aims to describe their perspectives and involvement in assisted suicide practices.MethodsA qualitative interview study was conducted with 23 palliative care physicians across Switzerland. Thematic analysis was used to interpret data.ResultsSwiss palliative care physicians regularly receive assisted suicide requests while none reported having received specific training in managing these requests. Participants reported being involved in assisted suicide decision making most were not willing to prescribe the lethal drug. After advising patients of the limits on their involvement in assisted suicide, the majority explored the origins of the patient’s request and offered alternatives. Many participants struggled to reconcile their understanding of palliative care principles with patients’ wishes to exercise their autonomy. The majority of participants had no direct contact with right-to-die societies, many desired better collaboration. A desire was voiced for a more structured debate on assisted suicide availability in hospitals and clearer legal and institutional frameworks.ConclusionsThe Swiss model of assisted suicide gives palliative care physicians opportunities to develop roles which are compatible with each practitioner’s values, but may not correspond to patients’ expectations. Specific education for all palliative care professionals and more structured ways to manage communication about assisted suicide are warranted.