Das Problem der verantworteten Therapieentscheidung in der Neonatologie

Definition of the problem: Physicians and nurses who work in neonatology—as in intensive care at all—are often forced to decide whether to stop or to continue with the treatment of a severely ill patient. The literature provides several decision making instruments, which are meant to help and to rationalize such decisions. Method and conclusion: Two of these instruments (“Schema zur ethischen Urteilsbildung nach dem Muster der aristotelischen Ethik”, Honnefelder 1994; “Nimwegener Methode für ethische Fallbesprechung”, Gordijn 1998) were tested by retrospectively examining two cases of our NICU. Results of our study show that the use of a decision making instrument is basically helpful. But the above mentioned instruments showed also shortcomings when used in the framework of neonatology. Therefore we developed the “Kölner Arbeitsbogen zur ethischen Entscheidungsfindung in der Neonatologie”, which is adapted to the specific needs of neonatology.     

Moral und Abhängigkeit

Definition of the problem:

Being satisfied with one’s work depends on professional autonomy, which is attributed to the medical profession to a high degree, combined with specialized knowledge and moral authority for vital questions. That is why physicians enjoy a high reputation. At the beginning of a person's medical career, moral competence is developed nearly completely, but specialized knowledge must be learned. Hospitals, in which further medical education regularly takes place, are still traditionally hierarchically organized today. Unfortunately, feudalistic or military structures hinder autonomous moral decisions and cause structural irresponsibility.

Arguments:

Obstructions and pressure by superiors, financial restrictions, arrogance and trying to make one's mark are shown in typical conflict situations. Stress, discontent, moral conflicts and illness, even including burn out are possible. Commitment and creativity by employees are prevented and mistakes cannot be constructively managed. Thus, patients may suffer unreasonably or be hurt.

Conclusion:

There is a risk to subordinate moral principles under other interests, not only with subordinates but also with superiors. Ways to create a culture that promotes autonomy among physicians and between different professions are discussed. Therefore it is necessary to institutionalize communication based on a reciprocal high regard in a team with people treated as equal partners, who are then able to discuss moral questions in a discourse.     

“Ärztliche Freiheit und Berufsethos“ — Hängen ärztliche Berufsfreiheit und ärztliches Berufsethos zusammen?

Ohne Zusammenfassung     

Influence of motion correction on the visual analysis of cardiac magnetic resonance stress perfusion imaging

Objective

Image post-processing corrects for cardiac and respiratory motion (MoCo) during cardiovascular magnetic resonance (CMR) stress perfusion. The study analyzed its influence on visual image evaluation.

Materials and methods

Sixty-two patients with (suspected) coronary artery disease underwent a standard CMR stress perfusion exam during free-breathing. Image post-processing was performed without (non-MoCo) and with MoCo (image intensity normalization; motion extraction with iterative non-rigid registration; motion warping with the combined displacement field). Images were evaluated regarding the perfusion pattern (perfusion deficit, dark rim artifact, uncertain signal loss, and normal perfusion), the general image quality (non-diagnostic, imperfect, good, and excellent), and the reader’s subjective confidence to assess the images (not confident, confident, very confident).

Results

Fifty-three (non-MoCo) and 52 (MoCo) myocardial segments were rated as ‘perfusion deficit’, 113 vs. 109 as ‘dark rim artifacts’, 9 vs. 7 as ‘uncertain signal loss’, and 817 vs. 824 as ‘normal’. Agreement between non-MoCo and MoCo was high with no diagnostic difference per-patient. The image quality of MoCo was rated more often as ‘good’ or ‘excellent’ (92 vs. 63%), and the diagnostic confidence more often as “very confident” (71 vs. 45%) compared to non-MoCo.

Conclusions

The comparison of perfusion images acquired during free-breathing and post-processed with and without motion correction demonstrated that both methods led to a consistent evaluation of the perfusion pattern, while the image quality and the reader’s subjective confidence to assess the images were rated more favorably for MoCo.

     

Multi-spin-echo J-resolved spectroscopic imaging without water suppression: application to a rat glioma at 7 T

Two-dimensional J-resolved spectroscopy may be used to separate resonances which overlap in 1D NMR spectra. Coupled with spectroscopic imaging (SI), it would give unequivocal information on the distribution of such resonances. Multi-echo acquisition decreases the minimum experimental time of such 4D experiments. The water peak may be used for phase and chemical-shift reference. This study aimed to demonstrate the feasibility of J-resolved SI based on a multi-echo sequence and without water suppression, and its ability to separate the peaks for lactate and mobile lipid in a rat glioma. Experiments were performed on rat brain, without water suppression, at 7 T. The water signal was used for correcting the phase of the echoes. A FOCSY-like acquisition was used to collect the first part of the echoes at short echo times. Two different data processing methods were tested to overcome the problem of contaminations of metabolite signals by the intense water signal. Maps of N-acetylaspartate, choline, creatine, lactate and mobile lipids were obtained in vivo on a rat glioma in 70 min. The in-plane resolution was 2 mm². The 2D spatially resolved, 2D J-resolved spectra enabled the separate mapping of lactate and mobile lipids.     

Anticipation of digital patterns

A memristive device is a novel passive device, which is essentially a resistor with memory. This device can be used for novel technical applications like neuromorphic computation. In this paper, we focus on anticipation—a capability of a system to decide how to react in an environment by predicting future states. Especially, we have designed an elementary memristive circuit for the anticipation of digital patterns, where this circuit is based on the capability of an amoeba to anticipate periodically occurring unipolar pulses. The resulting circuit has been verified by digital simulations and has been realized in hardware as well. For the practical realization, we have used an Ag‐doped TiO_2?x‐based memristive device, which has been fabricated in planar capacitor structures on a silicon wafer. The functionality of the circuit is shown by simulations and measurements. Finally, the anticipation of information is demonstrated by using images, where the robustness of this anticipatory circuit against noise and faulty intermediate information is visualized.     

Interface reactions between rutile coatings and molten aluminium or AlSi7Mg0.6 alloy

Rutile coatings deposited on corundum substrates are considered as promising functional elements improving the efficiency of the filtration of oxide inclusions out of aluminium melts. This contribution describes the reactions between rutile and two kinds of the aluminium melts and discusses the consequences of these reactions for the filtration process. It was found that the contact of rutile coatings with molten aluminium leads to the formation of a corundum layer at the solid/liquid interface. The exposure of the rutile coatings to molten AlSi7Mg0.6 alloy produces an interface layer of MgTiO₃. The interface layers possess defined orientation relationship to rutile which is characteristic for locally heteroepitaxial growth. The density functional theory calculations revealed that the TiO₂/α-Al₂O₃ and TiO₂/MgTiO₃ interfaces with the orientation relationships observed experimentally have low interface energies. The mechanisms of the interface layer formation and the impact of these layers on the degradation of the rutile coatings are discussed.