Clinical and functional determinants of appropriate rehabilitation referrals after stroke: a single-center retrospective cohort study.

BACKGROUND: Rehabilitation is currently the best available treatment for post-stroke disability. There is, however, great variability in the proportion of patients accessing rehabilitation across high-income countries suggesting that factors not explained by facilities availability or guidelines diversity may intervene in decision-making. OBJECTIVES: To evaluate which factors are associated with appropriate post-stroke rehabilitation referrals in a tertiary stroke unit setting. METHODS: Retrospective single-center cohort study including patients admitted to the Stroke Unit of the "Santa Maria della Misericordia" University Hospital, Udine (IT) from January 1st to December 31st, 2019. Information regarding stroke severity (National Institute of Health Stroke Scale), functional assessment (modified Rankin scale [mRS] and Barthel index [BI]), length of hospital stay, and rehabilitation pathway was collected. Outcome was defined as referral to the appropriate rehabilitation pathway. Appropriateness was assessed comparing patient clinical information at discharge against local criteria for intensive vs. extensive rehabilitation. A mixed-linear effect model was built to explore NIHSS, mRS, and BI variation over time. Multivariable logistic regression was used to estimate the adjusted-odds ratio (OR) and 95% confidence interval (CI 95%) of appropriate assignment to rehabilitation pathways. RESULTS: 288 patients were included in the study (age 73.1 years, males 57.9%) and in 75.7%, the rehabilitation pathway assignment was appropriate. NIHSS at discharge was lower compared to admission but no effect of rehabilitation assignment was evident, while mRS scores at discharge and at three months were 2.6 (CI 95% 2.2; 3.0) and 2.1 (CI 95% 1.8; 2.5) higher compared to admission (p < 0.0001). Rehabilitation assignment effect on mRS was time dependent, resulting in an additional - 0.6 (CI 95% - 1.0; - 0.2) lowering at discharge for those appropriately assigned (p = 0.003), with a trend for significance at three months (p = 0.08). BI score was higher at discharge (p < 0.0001), and appropriate assignment was associated with higher scores (p = 0.01). Multivariate analysis showed that the OR of appropriate rehabilitation pathway assignment were reduced by higher mRS (0.60 [CI 95% 0.48; 0.76], p < 0.0001) and increased by higher NIHSS (1.11 [CI 95% 1.04; 1.19], p = 0.001) scores at discharge. The latter finding might be explained by the rehabilitation assessment focus on post-stroke motor symptoms captured by NIHSS. CONCLUSIONS: Higher mRS and lower NIHSS levels at discharge were independent predictors for inappropriate rehabilitation assignment after stroke in our cohort. These findings may reflect a therapeutic bias toward patients with higher post-stroke disability in a rehabilitation framework heavily tilted on post-stroke motor symptoms.

Clinical Implications of Countertransference in the Treatment of Addictions.

The author provides a historical overview of the psychodynamics of addiction with particular emphasis on countertransference awareness and its relationship with treatment outcomes and prognosis. Countertransferences that frequently occur in the treatment of substance use disorders include shared helplessness, hopelessness, sadness, anxiety, fear, anger, rage, shame, and guilt. These emotional states in clinicians may lead to fatigue, avoidance, and acting out unless therapists are able to ground themselves and disidentify with the projected affective states. Positive emotions may lead to excessive enthusiasm in clinicians and deflect from the therapeutic process, resulting in deviation from established practice guidelines. Coexisting negative and positive affective states may lead to rescue fantasies and transgressions of boundaries. Contemporary psychodynamic clinicians appreciate the quantitative aspect of emotional reactions, where countertransferences accumulate exponentially over time, causing allostatic overload and compassion fatigue. Unanalyzed negative countertransferences are linked to either clinical avoidance or aggression, resulting in withdrawing care, failure of empathy, and dissolution or fragmentation of the therapeutic alliance. The negativism associated with the treatment of addictions may be rooted in unanalyzed countertransferences and psychosocial factors such as internalized negative societal attitudes and stigma. Degrading and dehumanizing attitudes toward people with substance use disorders could stem from internalized negative societal constructs against disenfranchised, minoritized, and stigmatized persons. This editorial introduces the work of Bernardine Han, an addiction psychiatrist who utilizes psychodynamic concepts to guide interventions with people with substance use disorders.

Cotard's Delusion and Its Relation With Different Psychiatric Diagnoses in a Tertiary Care Hospital.

Background Cotard's delusion/Cotard's syndrome is a series of delusions ranging from a false, fixed, unshakeable belief that one has lost their soul, blood, organs, and body parts to the belief that one is dead. The syndrome was initially thought to be associated with only mood disorders but later was found in other psychiatric illnesses as well. Aim The study aimed to find an association between Cotard's delusion and the psychopathology of different psychiatric diagnoses. Method The clinical study comprised seven patients presenting with symptoms of Cotard syndrome with different presentations, diagnoses, and onset and meeting inclusion criteria. The study was carried out in the Department of Psychiatry, Assam Medical College and Hospital. The patients were hospitalized and, after a detailed history, mental status examination, and laboratory investigations, were treated with pharmacological and non-pharmacological methods. A descriptive statistical analysis was done. Results Denial of the existence of body organs was the most similar complaint encountered in the cases. The duration of illness onset ranged from weeks to months. The symptoms were found to be present in different psychiatric illnesses like schizophrenia, delusional disorder, depression, and intellectual disability. The patient had responded well to pharmacological agents with the exception of three patients who were treated with electroconvulsive therapy. Conclusion The study highlights the different subtypes of Cotard's syndrome and its associated symptoms, which provides a better understanding of the condition. The case series presents a finding of a higher proportion of male patients and adolescent cases than in previous reports. The study also provides valuable insights into its heterogeneity in the diagnosis and treatment of Cotard's syndrome, which may help in the early recognition and management of this rare condition.

Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury: A Survey of The Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group.

Abstract Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a "nihilism guard." More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.

Long-term Benefits for Younger Patients with Aggressive Immediate Intervention following Severe Traumatic Brain Injury: A Longitudinal Cohort Analysis of 175 Patients from a Prospective Registry.

BACKGROUND: The prevalence of traumatic brain injury (TBI) continues to rise, in part as a reflection of a growing elderly population. Concomitantly, nihilism may exist following substantial neurotrauma from a myriad of commonplace mechanisms, such as traffic incidents, assaults, or falls. OBJECTIVE: This study assesses long-term outcomes following aggressive surgical intervention with invasive neuromonitoring to guard against nihilism, especially for patients with advantageous characteristics such as younger age. METHODS: A consecutive series of patients with severe TBI treated between 2008 and 2018 and enrolled into the Brain Trauma Research Center (BTRC) database, an Institutional Review Board (IRB 19030228) approved prospective, longitudinal cohort study, were extracted. Demographic and clinical data were analyzed. Long-term functional outcome was recorded with the eight-point Glasgow Outcome Scale-Extended (GOS-E) score at 3-, 6-, 12-, and 24-months by trained, qualified neuropsychology technicians. Chi-squared and analysis of variance tests were used to evaluate the relationship of age groups between different variables. RESULTS: For this analysis, 175 patients with severe TBI who were enrolled in the BTRC database and required decompressive hemicraniectomy during the study period were included. Over one-third of the patients with a severe TBI, who were aged 35 years and younger, had a favorable outcome. CONCLUSIONS: Despite enduring a severe TBI, a substantial percentage of younger patients achieved favorable outcomes following aggressive treatment. As such, establishing a prognosis should be deferred to allow for recovery via individualized rehabilitation, multidisciplinary support, and community reintegration programs to cope with various long-term psychological, cognitive, and functional disabilities.

The failure of drug repurposing for COVID-19 as an effect of excessive hypothesis testing and weak mechanistic evidence.

The current strategy of searching for an effective treatment for COVID-19 relies mainly on repurposing existing therapies developed to target other diseases. Conflicting results have emerged in regard to the efficacy of several tested compounds but later results were negative. The number of conducted and ongoing trials and the urgent need for a treatment pose the risk that false-positive results will be incorrectly interpreted as evidence for treatments' efficacy and a ground for drug approval. Our purpose is twofold. First, we show that the number of drug-repurposing trials can explain the false-positive results. Second, we assess the evidence for treatments' efficacy from the perspective of evidential pluralism and argue that considering mechanistic evidence is particularly needed in cases when the evidence from clinical trials is conflicting or of low quality. Our analysis is an application of the program of Evidence Based Medicine Plus (EBM+) to the drug repurposing trials for COVID. Our study shows that if decision-makers applied EBM+, authorizing the use of ineffective treatments would be less likely. We analyze the example of trials assessing the efficacy of hydroxychloroquine as a treatment for COVID-19 and mechanistic evidence in favor of and against its therapeutic power to draw a lesson for decision-makers and drug agencies on how excessive hypothesis testing can lead to spurious findings and how studying negative mechanistic evidence can be helpful in discriminating genuine from spurious results.

The Platinum Rule: A New Standard for Person-Centered Care.

How decisions are made and patients cared for are often guided by the Golden Rule, which would have us treat patients as we would want to be treated in similar circumstances. But when patients' lived experiences and outlooks deviate substantively from our own, we stop being a reliable barometer of their needs, values, and goals. Inaccurate perceptions of their suffering and our personal biases may lead to distorted compassion, marked by an attitude of pity and therapeutic nihilism. In those instances, The Platinum Rule, which would have us consider doing unto patients as they would want done unto themselves, may be a more appropriate standard for achieving optimal person-centered care. This means knowing who patients are as persons, hence guiding treatment decisions and shaping a tone of care based on compassion and respect.

Reversing physician hesitancy to recommend COVID-19 vaccination for pregnant patients.

Physician hesitancy is said to occur when physicians do not recommend COVID-19 vaccination, and it is a contributing factor for the low vaccination rate for COVID-19 in pregnant women. Physician hesitancy has become a major, unaddressed problem with regard to the quality and safety of obstetrical care. We identify 3 root causes of physician hesitancy and describe how professional ethics in obstetrics should guide in reversing these root causes. They are clinical misapplications of key components of professionally responsible obstetrical practice: therapeutic nihilism, shared decision-making, and respect for patient autonomy. Therapeutic nihilism directs the obstetrician to avoid any clinical interventions during pregnancy to prevent teratogenic effects that might be unknown. Therapeutic nihilism is misapplied when there is a documented net clinical benefit with no evidence of clinical harm. Shared decision directs the obstetrician to only offer but not recommend clinical management. Shared decision-making plays a major role when there is uncertainty in clinical judgment but is misapplied when it becomes a universal model. It does not apply when there is a net clinical benefit. When there is a net clinical benefit, clinical management should be recommended, not simply offered. The ethical principle of respect for patient autonomy plays an indispensable role in decision-making with patients. It is misapplied when it is assumed that respect for autonomy requires physicians not to make recommendations and to defer to and implement patients' decisions without exception. There is evidence that the obstetrician's recommendations about the management of pregnancy are the most important factor in a pregnant woman's decision-making. Simply deferring to the patient's decisions makes for misapplied respect for patient autonomy. Obstetricians must end physician hesitancy about COVID-19 vaccination of pregnant women by reversing these 3 root causes of physician hesitancy. Reversing the root causes of physician hesitancy is an urgent matter of patient safety. The longer physician hesitancy continues and the longer the low vaccine acceptance rate of pregnant women lasts, preventable serious diseases, deaths of pregnant women, intensive care unit admissions, stillbirths, and other maternal and fetal complications of unvaccinated women will continue to occur. Physician hesitancy should not be permitted to influence the response to future pandemics.

When the World Breaks Down: A 3-Stage Existential Model of Nihilism in Schizophrenia.

The existential crisis of nihilism in schizophrenia has been reported since the early days of psychiatry. Taking first-person accounts concerning nihilistic experiences of both the self and the world as vantage point, we aim to develop a dynamic existential model of the pathological development of existential nihilism. Since the phenomenology of such a crisis is intrinsically subjective, we especially take the immediate and pre-reflective first-person perspective's (FPP) experience (instead of objectified symptoms and diagnoses) of schizophrenia into consideration. The hereby developed existential model consists of 3 conceptualized stages that are nested into each other, which defines what we mean by existential. At the same time, the model intrinsically converges with the phenomenological concept of the self-world structure notable inside our existential framework. Regarding the 3 individual stages, we suggest that the onset or first stage of nihilistic pathogenesis is reflected by phenomenological solipsism, that is, a general disruption of the FPP experience. Paradigmatically, this initial disruption contains the well-known crisis of common sense in schizophrenia. The following second stage of epistemological solipsism negatively affects all possible perspectives of experience, that is, the first-, second-, and third-person perspectives of subjectivity. Therefore, within the second stage, solipsism expands from a disruption of immediate and pre-reflective experience (first stage) to a disruption of reflective experience and principal knowledge (second stage), as mirrored in abnormal epistemological limitations of principal knowledge. Finally, the experience of the annihilation of healthy self-consciousness into the ultimate collapse of the individual's existence defines the third stage. The schizophrenic individual consequently loses her/his vital experience since the intentional structure of consciousness including any sense of reality breaks down. Such a descriptive-interpretative existential model of nihilism in schizophrenia may ultimately serve as input for future psychopathological investigations of nihilism in general, including, for instance, its manifestation in depression.

A re-evaluation of the modern psychiatric hospital from the standpoint of the Kyoto school's critique of modernity.

Michel Foucault defines the modern psychiatric hospital as an institution of power that excludes and disciplines those who are deemed immoral, perverse, or abnormal in society. Rather than a facility for healing, as Foucault has taught us, the psychiatric hospital operates more as a punitive method of the body. But what is not considered in Foucault's historical account of the psychiatric institution are the epistemological preconditions that allowed for its original formation. Drawing on the Kyoto School philosophers' critique of modernity, this article will discuss how the biomedical model underlying modern psychiatric care is rooted in a prior epistemological duality that was developed even earlier within Western intellectual history-a duality we will call the "epistemology of nihilism." Foucault's political technology of the body is therefore a symptom of the epistemology of nihilism, that which leads to consequences beyond mere panoptical surveillance. This article will discuss such consequences, in particular the mechanization of human life derived from the excesses of scientific technology, in the service of introducing a new way of thinking about the limits of psychiatric treatment in today's world.

Searching for Meaning with Victor Frankl and Walker Percy.

Patients present to physicians searching for more than scientific names to call their maladies. They rather enter examination rooms with value-laden narratives of illness, suffering, hopes, and worries. One potentially helpful paradigm, inspired in part by existentialism, is to see patients on a search for meaning. This perspective is particularly important in the seemingly meaningless ruins of modernity. Here, we will summarize Victor Frankl's account of logotherapy found in his much-circulated book Man's Search for Meaning and assess the limitations imposed by his religious agnosticism. At best he can offer patients a finite, impersonal meaning this side of the grave. Following Kierkegaard's depiction of the religious sphere of existence, American novelist Walker Percy will be shown to supplement logotherapy with a theological mooring. The spiritual crisis of the modern world is treatable only by Christian faith supplying ultimate meaning. Taken together, Frankl and Percy show how Catholic physicians can be guides in their patients' personal searches for meaning. This paradigm may prove chiefly beneficial in goals of care conversations, encountering "aesthetic" patients living only for pleasure, and engaging patients amidst tragedy-ridden circumstances. Although only Christian faith will ultimately satisfy the search for meaning, we first of all need encouragement to take responsibility for seeking meaning, and confidence that even the most hopeless situation can become meaningful. SUMMARY: Victor Frankl's Man's Search for Meaning can enlighten clinical encounters for physicians to see patients on a search for meaning, particularly amidst suffering and tragedy in a post-modern world lacking transcendence. As shown in Walker Percy's literature, however, ultimate meaning can only be found in Christian faith where the Word became flesh and continues to dwell among us.

Pharmacotherapeutic strategies for treating cocaine use disorder-what do we have to offer?

BACKGROUND: Cocaine use contines to be a significant public health problem world-wide. However, despite substantial research efforts, no pharmacotherapies are approved for the treatment of cocaine use disorder (CUD). ARGUMENT: Studies have identified positive signals for a range of medications for treating CUD. These include long-acting amphetamine formulations, modafinil, topiramate, doxazosin and combined topiramate and mixed amphetamine salts extended-release (MAS-ER). However, valid conclusions about a medication's clinical efficacy require nuanced approaches that take into account behavioural phenotypes of the target population (frequency of use, co-abuse of cocaine and other substances, genetic subgroups, psychiatric comorbidity), variables related to the medication (dose, short-/long-acting formulations, titration speed, medication adherence) and other factors that may affect treatment outcomes. Meta-analyses frequently do not account for these co-varying factors, which contributes to a somewhat nihilistic view on pharmacotherapeutic options for CUD. In addition, the predominant focus on abstinence, which is difficult for most patients to achieve, may overshadow more nuanced therapeutic signals. CONCLUSION: While there is an emphasis on finding new medications with novel mechanisms of action for treating CUD, currently available medications deserve further investigation based on the existing literature. Evaluating refined metrics of treatment success in well-defined subgroups of patients, and further exploring combination therapies and their synergy with behavioural/psychosocial interventions, are promising avenues to establishing effective therapies for CUD.

Entre o desistir e o resistir: notas sobre o cotidiano docente na educação superior / Between giving up and withstanding: notes on everyday teaching in superior education / Entre desistir y resistir: notas sobre la enseñanza diaria en la educación superior

O artigo intenta evidenciar uma dimensão sensível das práticas educacionais, por meio de uma estilística não estandardizada de produção de conhecimento. O texto-script permeia o fazer artístico de uma atriz, ao mesmo tempo em que revela o palco-sala de aula onde se encena o fazer docente, corporificando dilemas existenciais contemporâneos do trabalho com educação. O exercício da escrita ficcional, como propõem Bottoni e Costa, configura a estratégia metodológica que costura o estudo. Esta estratégia objetiva revelar paradoxos de uma prática profissional diante do niilismo predominante que toma os corpos dos atores, no contexto definido por Han como "sociedade do cansaço". Como criar movimentos de resistência onde apenas parece haver cansaço? Como inventar linhas de fuga quando tudo parece convidar à desistência? Esses são os questionamentos que se insinuam ao longo do enredo, chamando à análise acerca do educar em tempos que não somente convidam à desistência, mas também incitam resistências.

This study aims to bring into evidence a sensitive dimension of educational practices, through a non-standardized style of knowledge production. The text-script permeates an actress’ artistic performance while unveiling the stage-classroom where teaching is performed, embodying contemporary existential dilemmas pertaining to working with education. The exercise of fictional writing, as proposed by Bottoni and Costa, sets up the methodological strategy that interweaves this study. This strategy aims to reveal paradoxes of a professional practice in face of the predominant nihilism that takes the actors’ bodies, in the context defined by Han as "society of the weariness". How to develop resistance movements, where just weariness seems to exist? How to build up escape lines, when everything seems to invite to relinquishment? These are the questions suggested throughout the plot. They call for the analysis of education in times that not only invite to give up, as also incite resistances.

El artículo intenta resaltar una dimensión sensible de las prácticas educativas, a través de una producción estilizada, no estandarizada, de conocimiento. El texto-guión conduce la creación artística de una actriz, al mismo tiempo que revela el aula escénica donde se realiza la enseñanza, encarnando los dilemas existenciales contemporáneos de trabajar con la educación. El ejercicio de la escritura ficticia, según lo propuesto por Bottoni y Costa, establece la estrategia metodológica que cose el estudio. Esta estrategia tiene como objetivo revelar las paradojas de una práctica profesional frente al nihilismo predominante que toma los cuerpos de los actores, en el contexto definido por Han como una "sociedad del cansancio". ¿Cómo crear movimientos de resistencia, donde parece haber fatiga? ¿Cómo inventar líneas de escape, cuando todo parece invitar a la retirada? Estas son las preguntas sugeridas a lo largo de la trama para analizar la educación en tiempos que no solo invitan a desistir, sino que también incitan a las resistencias.

Pediatric Acute Kidney Injury-The Time for Nihilism Is Over.

Nihilism has been pervasive in the acute kidney injury field for decades, given that no studies, had been able to reduce AKI rates in hospitalized patients. Furthermore, children with AKI comprise an orphan population, where there is little incentive to develop diagnostics, therapeutics or devices specifically for them. The 3rd International Symposium on Acute Kidney Injury in Children, held in Cincinnati in October 2018, provided a platform to demonstrate the advancements in the diagnosis and treatment of children with, or at-risk for AKI, and also highlighted barriers to advancing care for this population. The progress made in the pediatric AKI since the 2nd International Symposium in 2016, highlighted the positive outcomes emanating from federal agency, private foundation and corporate sponsor investment in pediatric AKI. As a result, the time should be over for nihilism in the pediatric field.

Medical nihilism: The limits of a decontextualised critique of medicine.

In a new and interesting book entitled Medical Nihilism (2018), Jacob Stegenga attempts to convince us that modern medical therapies are less effective than we think. Given the heterogeneity of hypotheses in medicine and the evidence for or against them, I argue that such a decontextualised critique cannot be made unless substantially weakened. Instead, I put forward an alternative, more nuanced and defensible epistemic view of medicine. According to this view, evaluating medical evidence requires analysis of both the methods of research e.g. randomised controlled trial (RCT), and context-specific information. This is because the way a trial (even an RCT) is conducted e.g. the population recruited and how it is intervened on, will vary and will have significant effects on the likelihood of a positive outcome. Moreover, the relationship between the positive outcome of a trial and the actual effectiveness of an intervention (the trial validity) will depend on these context specific factors. I argue for this position against nihilism by showing how each of Stegenga's individual claims about medical trials (trials are biased in favour of positive outcomes etc) can be questioned by taking the context into consideration.

Entre síntoma y fármakon. La organología de la moral de Bernard Stiegler / Between Symptom and Pharmakon. Bernard Stiegler's Organology of Morality / Entre o sintoma e o farmakon. A organologia da Moral de Bernard Stiegler

Propósito/Contexto. Este artículo hace un recorrido por la filosofía de la técnica de Bernard Stiegler, con un enfoque en la dimensión moral de la perspectiva farmacológica. Su propósito está motivado por las cuestiones bioéticas que surgen de la perspectiva stiegleriana, en particular, por lo que concierne a los fenómenos de las adicciones a la tecnología digital y los efectos sociales y cognitivos que el contexto multimedia genera. Metodología/Enfoque. El enfoque metodológico que sustenta la elaboración de este artículo es la perspectiva farmacológica, elaborada por el propio Stiegler, por medio de la cual es posible replantear las bases de la ética y la moral en el contexto digital. Resultados/Hallazgos. El artículo hace una contribución teórica al debate sobre los efectos problemáticos y los beneficios de la adopción de la tecnología digital en todos los campos del saber y de las relaciones sociales, con un énfasis en los trastornos de la atención y los síntomas de malestar psicosocial. Discusión/Conclusiones/Contribuciones. Su contribución está en los elementos útiles que ofrece para un acercamiento metodológico entre la filosofía de la tecnología y la bioética (desde la farmacología y la organología). En este sentido, el trabajo de investigación y análisis del corpus stiegleriano se presenta como una aclaración de las apuestas bioéticas que conviven en la perspectiva farmacológica.

Purpose/Context. This article explores Bernard Stiegler's philosophy of technics, focusing on the moral dimension of the pharmacological perspective. Its purpose is motivated by the bioethical questions arising from the Stieglerian standpoint, particularly the phenomena of addictions to digital technology and the social and cognitive effects of the multimedia context. Method/Approach. The methodological approach is Stiegler's pharmacological perspective, whereby we can rethink the bases of ethics and morals in the digital realm. Results/Findings. It makes a theoretical contribution to the debate on the adverse effects and benefits of adopting digital technology for all knowledge domains and social relationships, emphasizing attention disorders and symptoms of psychosocial distress. Discussion/Conclusions/Contributions. It provides useful elements for a methodological rapproachement between the philosophy of technology and bioethics (from pharmacology and organology). Thus, the research and analysis of the Stieglerian corpus clarify the bioethical proposals that coexist from the pharmacological perspective.

Objetivo/Contexto. Este artigo faz um percorrido pela filosofia da técnica de Bernard Stiegler, com abordagem na dimensão moral da perspectiva farma-cológica. Seu propósito é motivado pelas questões bioéticas que surgem da perspectiva stiegleriana, em particular, no que diz respeito aos fenômenos de dependência à tecnologia digital e aos efeitos sociais e cognitivos que o contex-to multimídia gera.Metodologia/Abordagem. A abordagem metodológica que mantem a elabo-ração deste artigo é a perspectiva farmacológica, elaborada pelo próprio Stie-gler, por meio da qual é possível repensar os fundamentos da ética e da moral no contexto digital.Resultados/descobertas. O artigo faz uma contribuição teórica ao debate so-bre os efeitos problemáticos e os benefícios da adoção da tecnologia digital em todos os campos do conhecimento e das relações sociais, com ênfase nos transtornos de atenção e nos sintomas de sofrimento psicossocial.Discussão/Conclusões/Contribuições. A sua contribuição está nos elementos úteis que fornece para uma aproximação metodológica entre a filosofia da tec-nologia e a bioética (a partir da farmacologia e da organologia). Nesse sentido, a pesquisa e análise do corpus stiegleriano apresenta-se como um esclarecimento dos desafios bioéticos que coexistem na perspectiva farmacológica.

['Point of no return' in diabetic neuropathies: a dangerous delusion]. / 'Tochka nevozvrata' pri diabeticheskikh neiropatiiakh: opasnoe zabluzhdenie.

Polyneuropathy in patients with diabetes mellitus is manifested by a lesion of peripheral sensory, motor and autonomic nervous system. Different severity of damage of sensory, motor and autonomic fibers in typical and atypical forms of diabetic polyneuropathy, requires a differentiated approach to therapy, but not the rejection of its implementation. In an interdisciplinary consensus, consultations are held with physicians from different regions of the Russian Federation, and modern methods of diagnosing and assessing the severity of diabetic polyneuropathies, which determine the algorithm for treating patients, are discussed.

Therapeutic nihilism of neurological diseases: A comparative qualitative study.

OBJECTIVE: The notion of therapeutic nihilism may lead to early removal of care based upon perceived poor prognosis. The goal of this study was to examine if differences for nihilism perspectives exist between professions and within professions at the different levels of experience and exposure to neurological conditions. METHOD: Survey methods was used to assess perception of care futility and therapeutic nihilism using six case-based scenarios followed by five questions regarding practitioner care choices and perspective. Participants were student and professional occupational and physical therapists, nurses, and doctors (n = 110). Thematic analysis was completed to determine influences on patient care. RESULTS: Six themes (quality of life, provider experience, prognosis/treatability, medical details, patient's age, and family/patient wishes) emerged that influenced treatment decisions across all participants. All provider groups reported prognosis and treatability as their number one factor for treatment decisions, then therapists mentioned QOL most, nurses cited age, and doctors said medical details. Differences between students and professionals were also apparent. DISCUSSION: The perceived ability of the patient to recover (prognosis/treatability) with medical care was the most commonly cited reason for aggressive measures, with quality of life, medical details, and patient age also representing strong themes across disciplines and level of training.