Ärztliche Verantwortung gegenüber Palliativpatienten unter dem neuen Paradigma der Kundenorientierung

Definition of the problem

Establishing a good physician–patient relationship based on mutual trust and professional responsibility is a central element in physicians’ professionalism. Recently, however, there has been considerable debate in the field of medical ethics regarding trends toward an economic approach to medicine, which could potentially undermine healthy doctor–patient relationships. Part of this economic approach to medicine involves viewing the patient as an autonomous customer. But what does the customer role mean for vulnerable patients who are restricted in their autonomy and what effect does it have on the physician–patient relationship?

Arguments

In the following article, we pursue the question whether the physicians’ responsibility and the physician–patient relationship change when the (vulnerable) patient attributes the customer role to him-/herself. The study was conducted within the field of palliative care because terminally ill patients represent an especially vulnerable patient population. We base our argumentation in this article on the results of a qualitative interview study that investigated terminally ill patients’ attitudes regarding the topic “the patient as customer” as well as autonomy and decision-making.

Conclusion

The interview results show that autonomy must be understood in relational terms; furthermore, the analysis of the interviews indicates that the physician plays a crucial role in enabling the patient’s autonomy, regardless of whether patients view themselves as a patient or a customer. Subsequently, we deliberate whether the patients’ statements point to potential changes in the doctor–patient relationship and physicians’ responsibility towards patients. Based on these findings, practical implications for the doctor–patient relationship are considered in regard to the “Ethics of Care”, emphasizing the need for an individualized approach to working with patients, especially those with particularly vulnerable conditions.     

Zum Verbesserungspotenzial schriftlicher Aufklärungsmaterialien zu (bio)medizinischen Forschungsvorhaben – Empirische Analyse von Antragsunterlagen einer Forschungsethikkommission

Background

One of the elementary prerequisites for medical research on and with humans is the patients’ or probands’ informed consent. To ensure informed consent, study participants must be—among other things—provided with high-quality information. We developed criteria to assess and evaluate the quality of various written patient information material.

Methods

Based on a catalogue addressing 117 single criteria, we assessed the quality of 128 randomly selected documents from study proposals submitted to the ethical committee of Luebeck University in 2006. Each criterion refers to one of six quality areas (such as “readability and comprehensibility” or “potential benefit and harm”).

Results

The documents on average satisfied half of the criteria with a range from 20–76% for single items. The area with the highest quality score was “consent form” (64%), while “potential benefit and harm” (35%) was the lowest. Material from drug trials showed a significantly higher quality than that from other study types. Only 21 out of 117 criteria were met in more than 80% of all relevant documents.

Conclusion

The study provides evidence for significant deficits in the information material from basic and clinical research projects presented to one academic research ethics committee. Researchers need support in developing and writing informed consent documents. Our set of criteria could be used to make them more sensitive to the various demands involved.     

Bioluminescent Optogenetics: A Novel Experimental Therapy to Promote Axon Regeneration after Peripheral Nerve Injury

Functional recovery after peripheral nerve injury (PNI) is poor, mainly due to the slow and incomplete regeneration of injured axons. Experimental therapies that increase the excitability of the injured axons have proven remarkably successful in promoting regeneration, but their clinical applicability has been limited. Bioluminescent optogenetics (BL-OG) uses luminopsins, fusion proteins of light-generating luciferase and light-sensing ion channels that could be used to increase neuronal excitability if exposed to a suitable substrate. Excitatory luminopsins were expressed in motoneurons of transgenic mice and in wildtype mice transduced with adeno-associated viral vectors. Intraperitoneal administration of coelenterazine (CTZ), a known luciferase substrate, generated intense bioluminescence in peripheral axons. This bioluminescence increased motoneuron excitability. A single administration of CTZ immediately after sciatic nerve transection and repair markedly enhanced motor axon regeneration. Compound muscle action potentials were 3–4 times larger than controls by 4 weeks after injury. The results observed with transgenic mice were comparable to those of mice in which the luminopsin was expressed using viral vectors. Significantly more motoneurons had successfully reinnervated muscle targets four weeks after nerve injury in BL-OG treated mice than in controls. Bioluminescent optogenetics is a promising therapeutic approach to enhancing axon regeneration after PNI.     

Inorganic Protection of Polymer Nanocapsules: A Strategy to Improve the Efficiency of Encapsulated Optically Active Molecules

We demonstrate that the efficiency under ambient conditions of optically active molecules encapsulated in polymer nanocapsules can be significantly improved by depositing an inorganic layer onto the polymeric shell. A triplet-triplet annihilation upconversion (TTA-UC) system consisting of a porphyrin derivative and perylene is used as a representative case. Different inorganic materials are deposited on the surface of functionalized polymer nanocapsules synthesized by free-radical polymerization in miniemulsion. First, a silicate clay with formula [Si₈(Mg_5.45Li_0.4)O₂₀(OH)₄]Na_0.7 is deposited on the surface of positively charged polystyrene nanocapsules via layer-by-layer deposition. Second, controlled in situ mineralization of hydroxyapatite and cerium(IV) oxide are carried out on the surface of negatively charged polystyrene nanocapsules. In both cases the inorganic materials on the nanocapsule surface act as a scavenger and avoid the entry of oxygen from the external environment. By avoiding the entry of oxygen, the photo-oxidation process of perylene molecules is avoided within the system, and an increase in the TTA-UC properties occurs.     

Tagging Glycoproteins with Fluorescently Labeled GDP‐Fucoses by Using α1,3‐Fucosyltransferases

Fucose‐containing glycans mediate a variety of biological processes, but there is little information on reaction processes and mechanisms mediated by fucosyltransferases. We recently reported on fluorescently labeled GDP‐β‐L ‐fucose‐ATTO 550, which enabled monitoring of α1,3‐fucosyltransferase activity. Here we present an extension to the previously described results, based on the synthesis of a fluorescein‐isothiocyanate (FITC)‐labeled and two carboxyfluorescein‐labeled (FAM‐labeled) NDP‐β‐L ‐fucose derivatives, and applied all four compounds in labeling of different glycoproteins with the aid of four different fucosyltransferases. The labeling processes were analyzed by in‐gel fluorescence and fluorescence polarization measurements. Comparison with the ATTO‐labeled sugar revealed that the FITC‐labeled fucose was the best of these substrates, and that the bacterial enzyme HP‐FucT tolerated the fluorescent substrates better than human fucosyltransferases.     

From Isonitriles to Unsaturated NHC Complexes of Gold,Palladium and Platinum

In a modular template synthesis, unsaturated NHC complexes of gold, palladium and platinum were synthesized from simple metal salts, isonitriles and amines with acetal or ketal groups. Upon the addition of amines with tethered acetal or ketal moieties to the metal‐activated isonitrile, first nitrogen acyclic carbene (NAC) complexes are formed. These undergo ring closure and elimination to the unsaturated NHC complexes upon addition of acid. This simple strategy opens an attractive and fast approach to NHC complexes of gold, palladium and platinum. The modular approach allows a fast modification and is well‐suited for the synthesis of unsymetrically and symmetrically substituted unsaturated NHC complexes.

     

Phase separation of a hafnium alkoxide-modified polysilazane upon polymer-to-ceramic transformation—A case study

The polymer-to-ceramic transformation of a hafnium alkoxide-modified polysilazane was investigated via thermogravimetric analysis coupled with in situ mass spectrometry (TG/MS), nuclear magnetic resonance (MAS NMR) and transmission electron microscopy (TEM). The results indicate that the structural evolution of the polysilazane upon ceramization is strongly affected by the modification with hafnium alkoxide. Thus, the content of carbon in the ceramic backbone was relatively low, whereas a large amount of SiN₄ sites and a segregated carbon phase was present in the sample. Furthermore, this study revealed the formation of a SiHfCNO amorphous single phase ceramic via pyrolysis of the polymer at 700 °C, whereas at higher pyrolysis temperatures precipitation of hafnia was observed, leading to an amorphous hafnia/silicon carbonitride ceramic nanocomposite. The precipitation of hafnia was shown to not rely on decomposition processes, but to be a result of rearrangement reactions occurring within the ceramic material.     

Recycling of multilayer packaging using a reversible cross-linking adhesive

Plastic-based multilayer packaging has an important function on the packaging market, but is currently not recyclable as the polymer layers used are usually thermodynamically immiscible. This work therefore follows the approach to prepare separable multilayer packaging using a packaging adhesive modified with thermally unstable adducts, and proposes a corresponding recycling process. For this purpose, typical multilayer structures (polyethylene (PE)// polyethylene terephtalate (PET), PET//aluminum, and PE//aluminum) were prepared by curing furan-/maleimide-functionalized polyurethane (PU)-prepolymers with a three-functional cross-linking agent. Adhesions of up to over 3N per 15 mm test specimen were measured or substrate failures of PET films were observed. However, heating in dimethylsulfoxide, the retro-Diels–Alder reaction takes place and the cross-linked adhesive turns thermoplastic and dissolves in the solvent. Thus, the laminate separates and the pure PE, PET, and aluminum foils can be recovered without any PU residue.     

Switching azonaphthols containing a side chain with limited flexibility. Part 1. Synthesis and tautomeric properties

A series of azo dyes, possessing amide fragments with restricted flexibility tethered to 4-(phenyldiazenyl)naphthalen-1-ol, was obtained from 1-hydroxy-2-naphthoic acid by subsequent conversion to amides and diazo coupling. It was shown that the position of the tautomeric equilibrium in solution strongly depends on the solvent in both UV and NMR concentration scale. The compounds exist as pure enol forms in chloroform and hydrocarbons, while in polar solvents (acetone, acetonitrile, alcohols) a tautomeric mixture is observed. According to the quantum-chemical calculations the aggregation of the keto tautomer is the possible reason for this shift in the position of the tautomeric equilibrium. To support the theoretical predictions, it was found that from acetone the keto form crystallizes as a dimer with hydrogen bonding between N₁-H in the one molecule and amide CO in the other forming a three-dimensional structure. The importance of the side-chain nitrogen atom on the dimer formation was confirmed by solution and solid state study of 4-(phenyldiazenyl)-2-acetylnaphthalen-1-ol. The results indicate that the new azo-dyes obtained could be suitable candidates for switching and sensing applications in non-polar solvents.