Aortic Dissection: A Review of the Pathophysiology, Management & Prospective Advances

: Aortic dissection is an emergent medical condition, generally affecting the elderly, characterized by a separation of the aortic wall layers and subsequent creation of a pseudolumen that may compress the true aortic lumen. Predisposing factors mediate their risk by either increasing tension on the wall or by causing structural degeneration. They include hypertension, atherosclerosis, and a number of connective tissue diseases. If it goes undetected, aortic dissection carries a significant mortality risk; therefore, a high degree of clinical suspicion and a prompt diagnosis are required to maximize survival chances. Imaging methods, most commonly a CT scan, are essential for diagnosis; however, several studies have also investigated the effect of several biomarkers to aid in the detection of the condition. The choice of intervention varies depending on the type of dissection, with open surgical repair remaining of choice in those with type. A dissections; however, the role of conventional open surgery has considerably diminished in complicated type B dissections, with endovascular repair, a much less invasive technique, proving more effective. In uncomplicated type B dissections, where medical choice reigned supreme as the optimal intervention, endovascular repair is being explored as a viable option which may reduce long term mortality outcomes, although the ideal intervention in this situation is far from settled.

Is the Croatian Medical law in harmony with the International comparative standards on the right to self-determination?

Are Jehovah’s Witnesses (JW) outstanding patients? One might answer in the affirmative. Is not their refusal of blood transfusions, a treatment traditionally considered as a life-saving treatment, problematic both from the medical and legal viewpoint? However, traditions are not everlasting. Both modern medical science and legal standards have greatly improved during the last two decades. Over the last few years, JW medical choice has become standard treatment for many physicians specialized in bloodless surgeries. From the legal standpoint, laws and case-law worldwide have been moving in the same direction: a patient endowed with discernment has the absolute right to choose the treatment he/she deems the most appropriate according to his/her own personal values. In light of this evolution worldwide, JW patients have become ordinary patients. Since this is not the case in Croatia yet, this article seeks to put the Croatian legislation in harmony with the international standards by using the example of JW. It does so by answering five fundamental questions: 1) Should a JW patient be forced to undergo a blood transfusion against his or her will? 2) Should a JW patient be forced to undergo a blood transfusion in an emergency situation where life is at risk, and the patient is unconscious? 3) Can a doctor refuse to treat a JW patient because the patient refuses to accept a treatment deemed life-saving? 4) Can a doctor be held liable for respecting a JW patient’s wishes if the patient dies? 5) Can a doctor be held liable for overriding a JW patient’s wishes and administering a blood transfusion by force?

Competency of aMCI patients to consent to cholinesterase treatment

Background:In medical practice, a patient’s loss of competency is a major obstacle when choosing a treatment and a starting treatment program smoothly. A large number of studies have revealed the lack of medical competency in patients with dementia. However, there have been only a few reports focusing on the capacity of patients with mild cognitive impairment (MCI) to make a medical choice.Methods:In this study, we evaluated the competency of 40 patients with amnestic MCI (aMCI) and 33 normal subjects to make a medical choice using the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). We compared the judgement of a team conference using the recorded semi-structured interview with the clinical judgement of a chief clinician.Results:A team conference concluded that 12 aMCI patients had no competency, and the clinical judgement, without any special interview, judged that five aMCI patients had no competency. All subjects in the control groups were judged to be competent to consent to treatment by both clinicians and the team conference.Conclusions:Without supplementary tools such as explanatory documents, not a few patients with aMCI were judged by a team conference to have no competency to consent to therapy even in a relatively simple and easy case. In contrast, clinical physicians tended to evaluate the competency of aMCI patients in a generous manner.

Public Transportation Environment and Medical Choice for Chronic Disease: A Case Study of Gaoyou, China

Current research on the built environment and medical choice focuses mainly on the construction and optimization of medical service systems from the perspective of supply. There is a lack of in-depth research on medical choice from the perspective of patient demand. Based on the medical choice behaviour of patients with chronic diseases, this article identifies the spatial distribution and heterogeneity characteristics of medical choice and evaluates the balance between medical supply and demand in each block. On this basis, we explored the mechanism of patient preferences for different levels of medical facilities by considering the patient’s socioeconomic background, medical resource evaluation, and other built environment features of the neighbourhood by referring to patient questionnaires. In addition to socioeconomic characteristics, the results show that public transportation convenience, medical accessibility, and medical institution conditions also have significant influences on patient preferences, and the impact on low-income patients is more remarkable. The conclusions of the study provide a reference for the promotion and optimization of the functions of urban medical resources and the guidance of relevant public health policies.

The use of the Internet by patients with chronic diseases in Samara: an empirical analysis

Today's patients and/or their relatives periodically appeal to the Internet, its various resources in the disease situation. The information and communication capabilities of the Internet modify the traditional "role of the patient" and the patient community, significantly affect the medical choices, that patients make at different stages of the disease. In 2018, research focusing on the medical choice of patients with chronic diseases in Samara was conducted at Samara University. This paper describes the results regarding the use of the Internet by Samara patients with chronic diseases. First of all, we are talking about the distribution of the use of the "medical Internet" by gender, age and level of education, the goals of accessing the Internet in a situation of disease, and which Internet resources are used.

Logic of care versus logic of choice in modern concepts of medical practice

The article compares two fundamental and conflicting principles in the ethical interpretation of clinical experience — the patient's right to medical choice and care as an immanent ethics of healing. Conceptual attempts to theoretically and empirically justify an unconditional priority of care in modern social and humanitarian research of medicine, as well as the desire to include the logic of choice in the logic of care are made from different methodological perspectives and on the basis of different intellectual traditions. Thus it is more important to compare the key concepts of care on this issue in order to reveal the global trend in understanding the essence of medical experience. The article offers a comparative analysis of the following: firstly, the arguments of an American researcher Joan C. Tronto, formulated in the context of universal political theory and ethics, but relevant to the field of medicine, secondly, the theory of care of the German doctor and philosopher of medicine Klaus Dörner and his opposition to the principle of autonomy, carried out in the practice of informed consent, thirdly, “involved ethnography” of the logic of care, carried out by the Dutch philosopher and anthropologist Annemarie Mol. The comparative analysis of the main texts of these authors on this problem revealed many general statements expressed by them, mainly, the general idea that in the case of chronic disease, which is a typical case of pathology in modern society, the most important is the logic of good care, the logic of interdependence of all subjects of care as a process, and that it is not the political opposition of power and equality here that comes to the centre, but the opposition of care and neglect in everyday medical practices.

Medical choice of chronic patients in a large Russian сity: Situations, practices, factors

This article is devoted to the main results of a quantitative empirical study of patients’ choice in a large Russian city. The object of this study was the chronic patients of Samara city, selected using a two-step sample method according to the following criteria: disease type, gender, age (N = 510 p). Research was conducted using the semi-formal interview method. Methodologically the study goes back to an approach which was developed within the framework of cognitive medical anthropology in the theoretical and empirical works of American anthropologists Lynda Garro and James Young, which formulated the principles of the Study of Medical Choice, and the Decision-Making Approach. For this research the problem matter of “remission society”, developed by sociologists and anthropologists Anselm Strauss, Arthur Kleinman and Arthur Frank, is very much relevant. In the article, the results of the choices that chronic patients make out of the alternatives available (appeal to state and non-state biomedicine, to different forms of unconventional medicine, medical and non-medical self-treatment) are structured according to three main situations in an ill patient’s life. These are the following: the situation of first encountering the disease (“the debut of the disease”); the situation of diagnosis and prescription of treatment; the situation of the illness transitioning to a chronic state (exacerbation or control over the disease). It is shown that these situations of choice differ from each other not only by the range of available alternatives for making medical decisions by chronic patients (this conclusion was obtained at the first qualitative stage of the study, brief results of which are also presented in the article), but also by quantitative representation of identical alternatives . Thus, we can observe a significant increase in self-treatment in the third situation, caused by a number of subjective and objective reasons, as well as a significant increase in the proportion of respondents who turned to practitioners of unconventional medicine in a situation after a diagnosis was made. The principles of Study of Medical Choice are adapted in the study to the institutional conditions of the Russian healthcare system, with its inherent range of choices and factors that influence the patient’s medical decision-making. Knowledge of these decisions is necessary in order to understand the direction for reforming the Russian healthcare system and in order to organize medical care which satisfies the needs of patients. This article also presents the results of analyzing certain factors that have seriously affected, based on the respondents’ opinions, a specific solution in the situations studied. A hierarchy of representation of these factors is described for each disease situation. A quantitative representation of solutions inherent to noncompliance was revealed, such as refusing drugs, searching for another doctor, double-checking the diagnosis.

On Pediatric Vaccines and Catholic Social Teaching

Determining whether, and when, to get one's children vaccinated has become an increasingly controversial decision, often leaving parents fearful of making the “wrong” choice. Part of the challenge stems from the fact that what is rationally optimal for an individual is inherently at odds with the best outcome for the community, meaning that if everyone acted out of self-interest with respect to pediatric vaccines, communal health would suffer significantly. Given these tensions, the issue of pediatric vaccines benefits greatly from the nuanced assessment of Catholic social teaching. Specifically, the Pontifical Council for Justice and Peace's “four permanent principles” of human dignity, the common good, subsidiarity, and solidarity highlight the issues involved and help parents navigate this significant medical choice with a more informed conscience and a greater sense of their moral responsibilities. The end result is a fruitful alignment between Catholic social teaching and ethics in ordinary life.