Imagining the unthinkable, illuminating the present

During a catastrophe that disables the health system, ethically charged situations will undoubtedly emerge that will challenge patients, relatives, clinicians, and others involved in health delivery. This second of two special sections of The Journal of Clinical Ethics includes discussions of the implications of a system collapse on particularly vulnerable member of society, children, pregnant women, and those who are socio-economically, culturally, and linguistically disempowered. Additionally, it offers insights into the processes used by committees to plan for catastrophic care.     

Developmental continuity? Crawling,cruising, and walking

This research examined developmental continuity between "cruising" (moving sideways holding onto furniture for support) and walking. Because cruising and walking involve locomotion in an upright posture, researchers have assumed that cruising is functionally related to walking. Study 1 showed that most infants crawl and cruise concurrently prior to walking, amassing several weeks of experience with both skills. Study 2 showed that cruising infants perceive affordances for locomotion over an adjustable gap in a handrail used for manual support, but despite weeks of cruising experience, cruisers are largely oblivious to the dangers of gaps in the floor beneath their feet. Study 3 replicated the floor-gap findings for infants taking their first independent walking steps, and showed that new walkers also misperceive affordances for locomoting between gaps in a handrail. The findings suggest that weeks of cruising do not teach infants a basic fact about walking: the necessity of a floor to support their body. Moreover, this research demonstrated that developmental milestones that are temporally contiguous and structurally similar might have important functional discontinuities.     

Evidenzbasierte Psychotherapie der Depression

Depressive disorders are among the most frequent reasons for utilizing the health care system. Despite the availability of efficacious treatments and further advances throughout the last years, there is still a need for improving diagnostic and therapeutic procedures. A promising approach is the implementation of evidence- and consensus-based guidelines. The German “Nationale VersorgungsLeitlinie Unipolare Depression” are evidence- and consensus-based clinical practise guidelines for patients with unipolar depression. All relevant stakeholders have been involved in its development and have passed the final version at the end of 2009 to foster compliance throughout. The available evidence allows the derivation of differentiated treatment recommendations, also with regard to concomitant antidepressant medication or as alternative treatment options. In acute therapy watchful waiting over 14 days is recommended for mild depression and psychotherapy after persistence of symptoms. In cases of moderate depression, psychotherapy and pharmacotherapy are equally recommended, in cases of severe depression a combination of both is recommended.     

Bedside ethics and health system catastrophe: imagine if you will..

Preparations for large-scale disasters have tended to focus on triage schema, stockpiling of materials, and other logistical concerns. Less attention has been given to the myriad of distressing and almost unthinkable ethically charged dilemmas that will emerge at the bedside during a catastrophe, and how they may be best managed. Yet, it is these bedside issues that may limit or thwart the effectiveness of disaster planning, and, therefore, they ought to be carefully considered.     

Preservation of long-term memory and synaptic plasticity despite short-term impairments in the Tc1 mouse model of Down syndrome

Down syndrome (DS) is a genetic disorder arising from the presence of a third copy of the human chromosome 21 (Hsa21). Recently, O’Doherty and colleagues in an earlier study generated a new genetic mouse model of DS (Tc1) that carries an almost complete Hsa21. Since DS is the most common genetic cause of mental retardation, we have undertaken a detailed analysis of cognitive function and synaptic plasticity in Tc1 mice. Here we show that Tc1 mice have impaired spatial working memory (WM) but spared long-term spatial reference memory (RM) in the Morris watermaze. Similarly, Tc1 mice are selectively impaired in short-term memory (STM) but have intact long-term memory (LTM) in the novel object recognition task. The pattern of impaired STM and normal LTM is paralleled by a corresponding phenotype in long-term potentiation (LTP). Freely-moving Tc1 mice exhibit reduced LTP 1 h after induction but normal maintenance over days in the dentate gyrus of the hippocampal formation. Biochemical analysis revealed a reduction in membrane surface expression of the AMPAR (α-amino-3-hydroxy-5-methyl-4-propionic acid receptor) subunit GluR1 in the hippocampus of Tc1 mice, suggesting a potential mechanism for the impairment in early LTP. Our observations also provide further evidence that STM and LTM for hippocampus-dependent tasks are subserved by parallel processing streams.     

Clarifying the paradigm for the ethics of donation and transplantation: Was 'dead' really so clear before organ donation?

Recent commentaries by Verheijde et al, Evans and Potts suggesting that donation after cardiac death practices routinely violate the dead donor rule are based on flawed presumptions. Cell biology, cardiopulmonary resuscitation, critical care life support technologies, donation and transplantation continue to inform concepts of life and death. The impact of oxygen deprivation to cells, organs and the brain is discussed in relation to death as a biological transition. In the face of advancing organ support and replacement technologies, the reversibility of cardiac arrest is now purely related to the context in which it occurs, in association to the availability and application of support systems to maintain oxygenated circulation. The 'complete and irreversible' lexicon commonly used in death discussions and legal statutes are ambiguous, indefinable and should be replaced by accurate terms. Criticism of controlled DCD on the basis of violating the dead donor rule, where autoresuscitation has not been described beyond 2 minutes, in which life support is withdrawn and CPR is not provided, is not valid. However, any post mortem intervention that re-establishes brain blood flow should be prohibited. In comparison to traditional practice, organ donation has forced the clarification of the diagnostic criteria for death and improved the rigour of the determinations.