Active euthanasia: can it be justified?
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Fourteen patients suffering from American cutaneous leishmaniasis were studied. Assays of the lymphocyte proliferative response induced in vitro by Leishmania braziliensis antigens were performed. After 5 days in culture, L. braziliensis-stimulated blast T cells were harvested for CD4+ and CD8+ phenotype analysis. When results before and at the end of therapy were compared, leishmaniasis patients showed an increase in the percentage of CD8+ blast T cells and a decline in the proportion of CD4+ blast T cells in cultures. The levels of gamma interferon in T-cell culture supernatants showed a tendency to increase when the patients were cured. These results show a pattern of higher proportions of Leishmania-reactive CD8+ T cells and lower proportions of Leishmania-reactive CD4+ T cells after cure.
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Trimethylaminuria is an autosomal recessive human disorder affecting a small part of the population as an inherited polymorphism. Individuals diagnosed with trimethylaminuria excrete relatively large amounts of trimethylamine in their urine, sweat, and breath, and this results in a fishy odor characteristic of trimethylamine. Activity of the human flavin-containing monooxygenase (FMO) has been proposed to be deficient in trimethylaminuria patients causing a decrease in the metabolism of trimethylamine that results in a fishy body odor. Cohorts of Australian, American, and British individuals suffering from trimethylaminuria have been identified. The human FMO3 cDNA was amplified from lymphocytes of affected patients. We report preliminary evidence of substitutions detected by screening of the cDNA and genomic DNA. The variant human FMO3 cDNA was constructed from wild type human FMO3 cDNA by site-directed mutagenesis as maltose-binding protein fusions. Five distinct human FMO3 mutants were expressed as fusion proteins in Escherichia coli and compared with wild type human FMO3 maltose-binding proteins (FMO3-MBP) for the N-oxygenation of 10-[(N,N-dimethylamino)pentyl]-2-(trifluoromethyl)phenothiazine, tyramine, and trimethylamine. Human Lys158 FMO3-MBP and, to a greater extent, human Glu158 FMO3-MBP efficiently N-oxygenated the three amine substrates. Human Lys158 Ile66 FMO3-MBP, Glu158 Ile66 FMO3-MBP, Lys158 Leu153 FMO3-MBP, and Glu158 Leu153 FMO3-MBP were all constructed as mutants identified as possible FMO3 variants responsible for trimethylaminuria and were found to be inactive as N-oxygenases. The results suggest that mutations at codons 66 and 153 of FMO3 can cause trimethylaminuria in humans. We observed a common polymorphism of Lys to Glu at codon 158 of FMO3 that segregated with almost equal allele frequencies in a number of control Australian and North American samples studied. The Lys158 to Glu158 human FMO3 polymorphism does not decrease trimethylamine N-oxygenation for the cDNA-expressed enzyme and thus does not appear to be causative of trimethyaminuria. The data show that the functional activity of human FMO3 can be significantly altered by amino acid changes that have been observed in individuals with clinically diagnosed trimethylaminuria.
Twenty-five patients suffering from chronic South American Trypanosomiasis (Chagas disease) were clinically compared with matched controls. Four of the chagasic patients provided histories of mild sensory neuropathies and on clinical examination were found to have impaired light touch sensation, vibration sense and two point discrimination. Other conditions which could have caused this neurological impairment were excluded. This is the first study to provide evidence of a detectable clinical neuropathy in chronic Chagas disease. Although this was only a limited study carried out during a medical school elective, it correlates well with the preliminary, and as yet unpublished, findings of a much larger study being carried out in Buenos Aires by Professor R E P Sica.
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Government regulators and researchers in Taiwan (Republic of China) express optimism about their country's economic success in its transition from a traditional society to a first world, industrialized nation. But this economic success, as measured by the standards and ideology of globalization, also has a dark side for many ordinary workers, especially Taiwan's 300,000 foreign workers. The promise of growth and future prosperity is conditional upon global economic practices and an adherence to a science-technology ideological perspective that shapes political content. Multiple centers of opposition and critical thinking have no public presence in Taiwan; nor do organizational defiance and resistance by trade unions. Instead, individuals and small human rights groups seek to reveal areas of human degradation and suffering in a response to poverty and the American dream. Meanwhile, the dominant ideological perspective as articulated by globalism seeps into and directs all public policy on the work environment so that it is coherent with the neoliberal political agenda of multinational corporations. This direction is being questioned by students of the work environment and by labor activists in North America, who report the deterioration of working conditions and worsening of government regulatory instruments for protecting workers from physical, mental, and social risk and harm in the workplace.
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We describe two cases of serologically confirmed human T-lymphotropic virus type I (HTLV-I)-associated myelopathy involving North American men coinfected by the human immunodeficiency virus type 1. Our first patient suffered from a gradually progressive spastic paraparesis for 10 years prior to presenting with Kaposi's sarcoma, while our second patient developed subacutely progressive spastic paraparesis in the setting of full-blown acquired immunodeficiency syndrome. Autopsy examination of the spinal cords from these two cases revealed widespread axonal loss and demyelination principally involving the lateral columns of case no. 1 and the lateral and anterior columns of case no. 2. Vascular sclerosis and hyalinization were prominent in both cases, but in neither was there a conspicuous inflammatory component. In case no. 2, HTLV-I mRNA was not detected by in situ hybridization, but HTLV-I proviral DNA sequences were detected in this case by polymerase chain reaction. Neither case exhibited multinucleated cell (human immunodeficiency virus type 1) myelitis, vacuolar myelopathy, or evidence of HTLV-II infection by polymerase chain reaction assay.
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American society is failing to provide humane care for people who are dying. Unnecessary physical suffering continues even in our most prestigious institutions, and the enormous burden on family caregivers remains unrecognized. The cost of health services and burdensome regulations remain major barriers to improving the quality of care. Healthcare planners and policy makers are gradually awakening to the realities of an increasingly older population and a looming labor shortage of qualified paid caregivers. Several features of palliative care render it attractive within managed care. Evidence is emerging that palliative care, focused on meticulous prospective care planning and coordination, delivers high quality and cost-effective end-of-life care. Innovative demonstration projects around the country are exploring models for integrating palliative care within the routine operational processes and protocols of health systems and are providing examples of feasible "best practices" crucial for raising public expectations and framing possible solutions for policymakers and planners. Ultimately, it will be a marketing asset for a managed care organization to be known as a center of excellence in palliative care, and in some markets it will be a necessity. The goals of managed care and palliative care are already well aligned, joint efforts among clinicians, provider institutions, insurers, and employee health benefit managers can address the needs and preferences of dying patients and families, while increasing public trust in managed care.
Intolerable human suffering and the role of the ancestor: literary criticism as a means of analysis This essay explores the experience of intolerable human suffering in Toni Cade Bambara's novel, The Salt Eaters. The method of analysis is literary criticism, a technique that shares many of the same goals as other types of inquiry. It employs close reading to illuminate the novel's meaning(s), thereby revealing information about the nature of intolerable human suffering. Morrison's characteristics of black art is the literary and cultural framework that guides the analysis of Bambara's novel. The paradigm has broad application for nursing. The purpose of this analysis was to describe the role of the ancestral system as a predictor of the trajectory of suffering. The results extend Morrison's paradigm and her notion of ancestor to include traditions and other non-corporeal factors that are essential for well-being and survival. The protagonist in Bambara's novel, Velma Henry, is the patient and exemplar who does not succumb to intolerable suffering because of its cumulative weight, but because she has lost touch with the traditions of her people, an essential component of her ancestral system. The ancestral system is a rich and complex network of individuals, groups, customs and beliefs that are instructive, protective and benevolent. Ancestors are also timeless and provide wisdom, but when the ancestral system is weak or absent, the trajectory of suffering is not favourable. Nurses must learn to recognize intolerable human suffering, to identify the patient's ancestral system, and to work within that system to keep suffering patients from harm.
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