Moral Features of the Therapeutic Relationship with Adults: Dignity, Trust, Autonomy, Vulnerability, and Resilience.

Using dignity as a foundational value of morality, this article defines trust, autonomy, vulnerability, and resilience in relational terms. A fictional narrative illustrates these attributes as well as solidarity and care, two core tenets of relational ethics. Medicine and rehabilitation are described as moral enterprises with respect for persons at the core of our professional obligations to patients-namely, duties of care, trustworthiness, and loyalty. Clinically, promoting autonomy, decreasing vulnerability, and fostering resilience are encouraged, with particular emphasis on avoiding words or actions (or inactions) that could cause patients to feel discouraged or depersonalized. In conclusion, the purpose of our work with persons with aphasia and other communication disorders is to help them live their lives as fully as possible, despite their life-changing losses. Viewing our therapeutic relationships with them in relational moral terms can enhance our work.

Consent, Refusal, and Waivers in Patient-Centered Dysphagia Care: Using Law, Ethics, and Evidence to Guide Clinical Practice.

Purpose: When patients refuse medical or rehabilitation procedures, waivers of liability have been used to bar future lawsuits. The purpose of this tutorial is to review the myriad issues surrounding consent, refusal, and waivers. The larger goal is to invigorate clinical practice by providing clinicians with knowledge of ethics and law. This tutorial is for educational purposes only and does not constitute legal advice. Method: The authors use a hypothetical case of a "noncompliant" individual under the care of an interdisciplinary neurorehabilitation team to illuminate the ethical and legal features of the patient-practitioner relationship; the elements of clinical decision-making capacity; the duty of disclosure and the right of informed consent or informed refusal; and the relationship among noncompliance, defensive practices, and iatrogenic harm. We explore the legal question of whether waivers of liability in the medical context are enforceable or unenforceable as a matter of public policy. Conclusions: Speech-language pathologists, among other health care providers, have fiduciary and other ethical and legal obligations to patients. Because waivers try to shift liability for substandard care from health care providers to patients, courts usually find waivers of liability in the medical context unenforceable as a matter of public policy.

Congenital rubella syndrome in child of woman without known risk factors, New Jersey, USA.

We report a case of congenital rubella syndrome in a child born to a vaccinated New Jersey woman who had not traveled internationally. Although rubella and congenital rubella syndrome have been eliminated from the United States, clinicians should remain vigilant and immediately notify public health authorities when either is suspected.

Retrospective cost-effectiveness analysis of treatments for aphasia: an approach using experimental data.

PURPOSE: Evidence supports the effectiveness of speech-language treatment for individuals with aphasia, yet less is known about the cost-effectiveness of such treatments. The purpose of this study was to examine the incremental cost and cost-effectiveness of aphasia treatment using previously published data. METHOD: The authors completed a retrospective cost-effectiveness analysis using experimental data that they extracted from 19 previously published aphasia treatment studies. Average and incremental cost-effectiveness ratios were calculated based on participants' pre- and posttreatment proficiency scores. RESULTS: The average cost-effectiveness ratio for all sessions was $9.54 for each 1% increase in the outcome of interest. Measures of incremental cost-effectiveness indicated that aphasia treatments resulted in statistically significant improvements up to and including 17 treatment sessions. Increases in proficiency occurred at a cost of approximately $7.00 per 1% increase for the first 3 sessions to more than $20.00 in the 14th session; the ratio was either not statistically significant or dominated (more costly and less effective) in later sessions. CONCLUSIONS: This cost-effectiveness analysis demonstrated that initial aphasia treatment sessions resulted in relatively larger and more cost-effective benefits than did later aphasia treatment sessions. The findings reported here are preliminary and have limitations. Prospective studies are needed to examine the cost-effectiveness of speech-language treatment for individuals with aphasia.

Evaluation of a pilot communication skills training intervention for minority cancer patients.

The aim of this study was to pilot test in a minority cancer patient population a communication workshop to improve doctor-patient communication skills. Thirty-two patients participated. Eighteen evaluated a face-to-face workshop, while 14 completed surveys only. Participants in the workshop group completed the Patient Report of Communication Behavior (PRCB) before and after the workshop and a course evaluation. Participants did not differ on baseline PRCB scores. Posttest scores were significantly higher than pretest scores (p < 0.01). All participants agreed or strongly agreed that they would use the communication skills; 93% agreed or strongly agreed that the skills would improve their health care.

A risk assessment approach to identifying constituents in oilfield produced water for treatment prior to beneficial use.

A risk assessment approach incorporating exposure pathways and calculated risk quotients was applied to identifying constituents requiring treatment prior to beneficial use of oilfield produced water (OPW). In this study, risk quotients are ratios of constituent concentrations in soil or water to guideline concentrations for no adverse effects to receptors. The risk assessment approach is illustrated by an example of an oilfield water produced from non-marine geologic strata of a rift basin in sub-Saharan Africa. The OPW studied has the following characteristics: 704-1370 mg L(-1) total dissolved solids (TDS), 45-48 mg L(-1) chloride, and 103.8 mg L(-1) oil and grease. Exposure pathways of constituents in OPW used for irrigation include: ingestion of plant tissue, ingestion and direct contact of irrigated soil by livestock, inhalation of aerosols or volatilized constituents, and ingestion of OPW directly by livestock. Applying risk quotient methods for constituents in soil and water, constituents of concern (COCs) identified for irrigation and livestock watering using the OPW studied include: iron (Fe), manganese (Mn), nickel (Ni), zinc (Zn), and oil and grease. Approximately 165,000 barrels d(-1) (26,233 m(3) d(-1)) of OPW from the study site are available for use. Identification of COCs and consideration of water quantity allows for development of reliable treatment design criteria to ensure effective and consistent treatment is achieved to meet guideline levels required for irrigation, livestock watering, or other uses. This study illustrates the utility of risk assessment for identifying the COCs in OPW for treatment, the level of treatment required, and viable options for use of the treated water.

Research ethics III: Publication practices and authorship, conflicts of interest, and research misconduct.

PURPOSE: In this series of articles--Research Ethics I, Research Ethics II, and Research Ethics III--the authors provide a comprehensive review of the 9 core domains for the responsible conduct of research (RCR) as articulated by the Office of Research Integrity. METHOD: In Research Ethics III, they review the RCR domains of publication practices and authorship, conflicts of interest, and research misconduct. Whereas the legal definition of research misconduct under federal law pertains mainly to intentional falsification, fabrication, and plagiarism, they discuss a host of research practices that raise ethical concerns. CONCLUSIONS: The integrity of the scientific record--its accuracy, completeness, and value--ultimately impacts the health and well-being of society. For this reason, scientists are both entrusted and obligated to use the highest standards possible when proposing, performing, reviewing, and reporting research or when educating and mentoring new investigators.

Ethical principles associated with the publication of research in ASHA's scholarly journals: importance and adequacy of coverage.

PURPOSE: The purpose of this 2-part study was to determine the importance of specific topics relating to publication ethics and adequacy of the American Speech-Language-Hearing Association's (ASHA's) policies regarding these topics. METHOD: A 56-item Web-based survey was sent to (a) ASHA journal editors, associate editors, and members of the Publications Board (Group 1); (b) authors, reviewers, and members of ASHA's Board of Ethics (Group 2); and (c) a random sample of the ASHA membership, characterized as journal readers (Group 3). The survey contained 4 questions related to ethical principles associated with the publication of research: (a) In regard to scientific integrity in research publications in general, how important is the issue of [topic]? (b) Should ASHA publication policies address this issue? (c) Do ASHA policies address this issue? (d) If yes, how adequately do ASHA policies address this issue? A second study evaluated the contents of ASHA's publication policy documents in regard to their coverage of the survey topics. RESULTS: Results indicated many of the topics deemed most important by all groups were included in ASHA's publication policy documents; other topics, although included, were not adequately addressed. CONCLUSIONS: ASHA needs a single, unifying publication policy document, and increased education of all groups in the realm of ethics in the publication process is indicated.

Research ethics I: Responsible conduct of research (RCR)--historical and contemporary issues pertaining to human and animal experimentation.

PURPOSE: In this series of articles--Research Ethics I, Research Ethics II, and Research Ethics III--the authors provide a comprehensive review of the 9 core domains for the responsible conduct of research (RCR) as articulated by the Office of Research Integrity. In Research Ethics I, they present a historical overview of the evolution of RCR in the United States then examine the evolution of human and animal experimentation from the birth of scientific medicine through World War II to the present day. METHOD: They relied on authoritative documents, both historical and contemporary, insightful commentary, and empirical research in order to identify current issues and controversies of potential interest to both faculty and students. CONCLUSIONS: The authors have written this article from a historical perspective because they think all readers interested in RCR should appreciate how the history of science and all the good--and harm--it has produced can inform how researchers practice responsible research in the 21st century and beyond.

Research ethics II: Mentoring, collaboration, peer review, and data management and ownership.

PURPOSE: In this series of articles--Research Ethics I, Research Ethics II, and Research Ethics III--the authors provide a comprehensive review of the 9 core domains for the responsible conduct of research (RCR) as articulated by the Office of Research Integrity. In Research Ethics II, the authors review the RCR domains of mentoring, collaboration, peer review, and data management and ownership. METHOD: They relied on authoritative documents, both historical and contemporary, insightful commentary, and empirical research in order to identify current issues and controversies of potential interest to both faculty and students. CONCLUSIONS: The authors close by urging readers to stay abreast of the manifold ethics issues facing today's community of scientists, policymakers, and research institutions, and to adhere to best practices as they evolve.

Responsible conduct of research in communication sciences and disorders: faculty and student perceptions.

PURPOSE: Two Web-based surveys (Surveys I and II) were used to assess perceptions of faculty and students in Communication Sciences and Disorders (CSD) regarding the responsible conduct of research (RCR). METHOD: Survey questions addressed 9 RCR domains thought important to the responsible conduct of research: (a) human subjects protections; (b) research involving animals; (c) publication practices and responsible authorship; (d) mentor/trainee responsibilities; (e) collaborative science; (f) peer review; (g) data acquisition, management, sharing, and ownership; (h) conflicts of interest; and (i) research misconduct. Respondents rated each of 37 topics for importance and for sufficiency of instructional coverage. RESULTS: Respondents to Survey I were 137 faculty members from 68 (26%) of the 261 graduate programs in CSD. By comparison, 237 students from 39 (15%) programs responded to Survey II. Data about the importance and sufficiency of coverage of each of the 37 items were transformed into z scores to reveal relative ratings among the 37 topics. Data presentations were grouped for topics in each of the 9 RCR domains. Ratings indicated the relatively high importance assigned among the 37 topics by CSD faculty and students. Sufficiency of coverage of those same topics received lower ratings. CONCLUSIONS: The results of these surveys support the notion that students in CSD perceive that they are receiving information about RCR. The data pertaining to sufficiency of coverage provide a basis for improving instruction in this important aspect of research education.

Averting adverse events in communication skills training: a case series.

OBJECTIVE: To document cases of adverse or near adverse events in communication skills training (CST) and to identify risk factors and strategies to reduce the likelihood of their occurrence. METHODS: Six physician CST cases meeting criteria for an adverse or near adverse collected from experienced facilitators are analyzed and discussed. RESULTS: Three types of adverse CST events are described: traumatic personal experiences or losses evoked by training; perception that feedback is not empathic; and where trainees are referred for remedial CST as a risk management strategy. CONCLUSION: Early identification of risk factors and emotional cues of trainees is a key first step that facilitates implementation of remedial strategies to avert potential adverse events. Consideration of ways that physicians' personal experiences impact communication and good feedback techniques are vital. The implications of physicians sent to CST for risk management purposes is a new scenario that deserves special consideration. PRACTICE IMPLICATIONS: To make CST safer and to optimize learning, early recognition of potential adverse events is essential. Specific feedback techniques should be mastered by all CST facilitators.

Developing an "essential functions" rubric: purposes and applications for speech-language-hearing academic programs.

This article describes the purpose and application of an essential functions rubric for prospective and current students engaged in the study of communication sciences and disorders. Adopted in 2007 by the Council on Academic Programs in Communication Sciences and Disorders (CAPCSD), the essential functions rubric identifies core skills and attributes in five areas: communication, motor, intellectual-cognitive, sensory/observational, and behavioral/social. CAPCSD does not intend the rubric to be prescriptive but rather expects that it will be adapted to reflect the unique mission or circumstances of each academic program. The value of an essential functions rubric for academic programs is the opportunity it provides to educate students about the roles and responsibilities of the disciplines. A rubric also allows academic programs an objective basis for counseling students about professional expectations. Importantly, an essential functions rubric gives both students and programs opportunities to determine what, if any, accommodations might be employed to allow students who are otherwise qualified to help them succeed both academically and clinically.

Mechanistic analysis of a dynamin effector.

Dynamin-related proteins (DRPs) can generate forces to remodel membranes. In cells, DRPs require additional proteins [DRP-associated proteins (DAPs)] to conduct their functions. To dissect the mechanistic role of a DAP, we used the yeast mitochondrial division machine as a model, which requires the DRP Dnm1, and two other proteins, Mdv1 and Fis1. Mdv1 played a postmitochondrial targeting role in division by specifically interacting and coassembling with the guanosine triphosphate-bound form of Dnm1. This regulated interaction nucleated and promoted the self-assembly of Dnm1 into helical structures, which drive membrane scission. The nucleation of DRP assembly probably represents a general regulatory strategy for this family of filament-forming proteins, similar to F-actin regulation.

Mitochondrial outer and inner membrane fusion requires a modified carrier protein.

In yeast, three proteins are essential for mitochondrial fusion. Fzo1 and Mgm1 are conserved guanosine triphosphatases that reside in the outer and inner membranes, respectively. At each membrane, these conserved proteins are required for the distinct steps of membrane tethering and lipid mixing. The third essential component is Ugo1, an outer membrane protein in the mitochondrial transport protein family. We show that Ugo1 is a modified member of this family, containing three transmembrane domains and existing as a dimer, a structure that is critical for the fusion function of Ugo1. Our functional analysis of Ugo1 indicates that it is required distinctly for both outer and inner membrane fusion after membrane tethering, indicating that it operates at the lipid-mixing step of fusion. This role is distinct from the fusion dynamin-related proteins and thus demonstrates that at each membrane, a single fusion protein is not sufficient to drive the lipid-mixing step, but instead, this step requires a more complex assembly of proteins.

Condom failure: examining the objective and cultural meanings expressed in interviews with African American adolescents.

The purpose of this study was to explore the meaning and context of self-reported "condom failure" among sexually active African American adolescents. Semistructured interviews regarding methods of protection from pregnancy and sexually transmitted disease (STD) with 124 youth (ages 14-19 years) were content analyzed. The findings suggested three meanings of condom failure. First, condom failure represents a legitimate and important risk related to sexual activity. Second, it can serve as an excuse repertoire for adolescents who engaged in unprotected sex and later experienced either pregnancy or a STD. Third, it may serve as an explanation for males who deceive their partners into having unprotected sex. The findings are discussed with regard to their implications for HIV or STD prevention and research.

Withdrawal (coitus interruptus) as a sexual risk reduction strategy: perspectives from African-American adolescents.

This study examined adolescents' beliefs about the benefits and risks of withdrawal (coitus interruptus) with respect to both pregnancy and sexually transmitted infections (STIs). In the course of qualitative interviews with African-American youth aged 14-19 (n = 124) about sexuality and risk, 24 adolescents spontaneously introduced the subject of withdrawal as a sexual risk reduction strategy. Eighteen percent of the sexually experienced adolescents mentioned their own use of withdrawal as a contraceptive method. From adolescents' accounts of their own and their peers' use of withdrawal, we learned that the cultural meanings of withdrawal within the context of adolescent relationships were multifaceted. Using withdrawal could signal sexual prowess in male youth, was seen as promoting trust and caring within a stable relationship, and was seen as mitigating the risk of pregnancy. However, adolescents also recognized that withdrawal did not protect against most STIs. Beliefs about withdrawal as a gendered skill and as a sign of trust may undermine some adolescents' attempts to negotiate condom use for protection against STIs.

Using culture-centered qualitative formative research to design broadcast messages for HIV prevention for African American adolescents.

The need for formative research in designing mass media health-education messages is widely accepted; however, distinct methodologies for developing such messages are less well documented. This article describes a culture-centered approach for developing messages to promote sexual risk reduction in urban African American adolescents. The method uses qualitative formative research to identify "competing narratives" that support healthy behavior despite the dominance of messages that favor risk-taking behavior. The method is illustrated using qualitative analysis of semistructured interviews with 124 adolescents. Analysis focuses on two barriers to sexual risk reduction: (a) social pressure for early initiation of sexual intercourse and (b) perceptions that condoms reduce sexual pleasure. We demonstrate how competing narratives identified in the analysis can be featured in radio and television messages advocating healthy behavior by modeling risk-reducing negotiation skills.

The requirement for perp in postnatal viability and epithelial integrity reflects an intrinsic role in stratified epithelia.

Mice lacking the desmosome protein Perp exhibit blistering in their stratified epithelia and display postnatal lethality. However, it is unclear if these phenotypes are strictly related to Perp function in stratified epithelia, as Perp expression is not restricted to these tissues during embryogenesis, and certain desmosomal blistering diseases such as pemphigus vulgaris and pemphigus foliaceus have non-cell-intrinsic bases. Furthermore, we show here that Perp is expressed in the heart, raising the possibility that defects in heart function could account for lethality in the Perp-deficient mice. To determine conclusively if Perp function in stratified epithelia is crucial for postnatal survival and epithelial adhesion, we specifically ablated Perp in stratified epithelia by breeding conditional Perp knockout mice to keratin 5 (K5)-Cre transgenic mice. We found that the majority of mice lacking Perp in stratified epithelia die within 10 days after birth, accompanied by blistering and hyperproliferation in the epithelia, similar to the constitutive Perp null mice. Together, these findings indicate that Perp's requirement for both viability and epithelial integrity reflects a role in the stratified epithelial compartment.