Managing erotic feelings in the physician-patient relationship.

In spite of prohibitions against the sexual involvement of physicians with their patients, erotic feelings sometimes arise in physician-patient relationships. The authors suggest that physicians can protect themselves and their patients from the harm that results from sexual involvement by establishing behavioural limits for their professional relationships, responding to patients'' sexual overtures in a firm but nonjudgemental manner, examining their own sexual feelings rationally, seeking consultation if necessary and terminating the relationship if sexual feelings are compromising patient care. The challenge for physicians is to acknowledge that sexual feelings can arise and to manage such feelings for the sake of their own and their patients'' well-being.     

21世纪医患关系的伦理学评判

随着医疗技术的迅猛发展,医疗水平不断提高,为人们带来福音的同时,使得医患关系的矛盾尤为凸显。21世纪的医患矛盾已经不仅仅是医生和患者之间的矛盾与冲突,而是两大社会群体之间的问题。在法律还无法规范的前提下,医学伦理学的评判标准可以为新时期医患关系提出更根本的指引与解释。     

Futility without a dichotomy: towards an ideal physician-patient relationship

The futility debate may be considered as an effort to provide a clear and justified borderline between physician and patient decision–making authority. In this paper we argue that the search for a definition of futility that provides physicians with a final argument in discussions about life–prolonging treatment, is misplaced. An acceptable and meaningful criterion of futility that satisfies this effort seems impossible. As a consequence, we reject a dichotomous domain of decision–making power as the starting point for definitions of futility. A good decision about withholding life–sustaining treatment should be justified from the perspectives of both physician and patient. In this light, a range of definitions of futility is still useful as it can clarify intuitions that a treatment is inappropriate.     

Younger and older chronic somatoform pain patients in psycho-diagnostics,physician-patient relationship and treatment outcome

Introduction

Patients with chronic pain are found with highly variable clinical presentation and differing physical complaints. They are seen as a heterogenic group. Based on clinical observations, elderly patients seem to differ from younger patients with chronic pain. We examined whether there were systematic differences between young and old pain patients.

Methods

As part of a routine evaluation of university hospital care, a newly developed psychosomatic treatment model for chronic somatoform pain disorders was examined. The basis for treatment efficacy was a target-oriented, specific somatic and psychological intervention that included a stable physician-patient relationship. Particular attention was paid to differences in treatment outcome with regard to changes in both physical and psychopathological symptom levels. We hypothesised that younger pain patients had higher psychological burden and benefitted more from our treatment than older pain patients.

Results

Overall, 179 inpatients (57.5% women) with chronic pain were examined (age between 16 and 79 years). The group as a whole yielded high scores on the somatisation dimension (SCL-90) and showed a considerable amount of psychopathological symptoms, such as depressive mood and anxiety (HADS) and a great emotional instability (FPI-R). Age differences were only found with regards to patients’ degree of aggression (SCl-90): younger patients showed higher aggressive tendencies than older ones (p< 0.05). The treatment offered helped patients in both age groups especially with regard to reduction of depressive mood (HADS, p< 0.01) and anxiety levels (HADS, p< 0.01). Regression analysis showed different age groups and gender as significant predictors of anxiety reduction under therapy (R²=.108; model: p< 0.01).

Discussion and conclusion

Results show that younger chronic pain patients suffer more from a considerable amount of psychological distress than older ones, but our treatment approach was equally effective in both groups. However, age and gender differences, as well as the patient’s baseline level of anxiety influenced the outcome. These factors need to be studied in future research.

     

The somatically preoccupied patient in primary care: use of attachment theory to strengthen physician-patient relationships

Background

Individuals with somatic preoccupation constitute a substantial number of primary care patients. Somatically preoccupied patients are challenging to primary care physicians for several reasons including patient complaints consuming a great deal of physician time, expense to diagnose and treat and strain on the physician-patient relationship. This paper examines and discusses how disruptions in early attachment relationships such as often occurs when a female is a victim of child sexual abuse may result in somatic preoccupation in adulthood.

Treatment utilizing attachment theory

Attachment theory provides a useful framework for primary care physicians to conceptualize somatic preoccupation. Utilization and containment techniques grounded in an understanding of attachment dynamics aid the physician in developing a sound physician-patient relationship. Successfully engaging the patient in treatment prevents misunderstandings that frequently derail medical care for somatically preoccupied patients.     

Linking life‐history theory and metabolic theory explains the offspring size‐temperature relationship

Temperature often affects maternal investment in offspring. Across and within species, mothers in colder environments generally produce larger offspring than mothers in warmer environments, but the underlying drivers of this relationship remain unresolved. We formally evaluated the ubiquity of the temperature–offspring size relationship and found strong support for a negative relationship across a wide variety of ectotherms. We then tested an explanation for this relationship that formally links life‐history and metabolic theories. We estimated the costs of development across temperatures using a series of laboratory experiments on model organisms, and a meta‐analysis across 72 species of ectotherms spanning five phyla. We found that both metabolic and developmental rates increase with temperature, but developmental rate is more temperature sensitive than metabolic rate, such that the overall costs of development decrease with temperature. Hence, within a species’ natural temperature range, development at relatively cooler temperatures requires mothers to produce larger, better provisioned offspring.     

The developing relationship between the study of fungal communities and community ecology theory

Plant and animal systems had a head start of several decades in community ecology and have largely created the theoretical framework for the field. I argue that the lag in fungal community ecology was largely due to the microscopic nature of fungi that makes observing species and counting their numbers difficult. Thus the basic patterns of fungal occurrence were, until recently, largely invisible. With the development of molecular methods, especially high-throughput sequencing, fungal communities can now be “seen”, and the field has grown dramatically in response. The results of these studies have given us unprecedented views of fungal communities in novel habitats and at broader scales. From these advances we now have the ability to see pattern, compare it to existing theory, and derive new hypotheses about the way communities are assembled, structured, and behave. But can fungal systems contribute to the development of theory in the broader realm of community ecology? The answer to this question is yes! In fact fungal systems already have contributed, because in addition to many important natural fungal communities, fungi also offer exceptional experimental communities that allow one to manipulate, control, isolate and test key mechanisms. I discuss five well-developed systems and some of the contributions they have made to community ecology, and I briefly mention one additional system that is amenable to development.     

Neutral theory, phylogenies, and the relationship between phenotypic change and evolutionary rates

The neutral theory of molecular evolution predicts that rates of phenotypic change are largely independent from genotypic change. A recent study by Bromham et al. (2002) confirmed this expectation, finding no evidence for correlated phenotypic and molecular evolutionary rates in animals. We reevaluate this hypothesis, sampling at different taxonomic levels in plants and animals, using Bayesian inference to reconstruct phylogenetic trees and estimate rates of molecular evolution. We use independent contrasts in branch lengths to maximize the information extracted from each of the trees and nodal posterior probabilities to assess the influence of phylogenetic error. Our results indicate that in vascular plants between 2% and 11% of the variation in phenotypic rates of change can be explained by the rate of genotypic change. These results may be explained by the idea that processes that affect general evolutionary rates, such as body size, may also be expected to influence rates of morphological change.     

A unifying evolutionary theory for the biomass–diversity–fertility relationship

Although a widely accepted ecological theory predicts that more diverse plant communities should be better able to capture resources and turn carbon dioxide into biomass, the most productive communities known are low diversity agricultural ones. This paradox has fuelled a long running controversy in ecology surrounding the nature of the relationship between diversity, productivity and fertility. Here, an evolutionary computer model is used which demonstrates that given the opportunity, species-rich communities may evolve under high fertility conditions. In contrast to low diversity, highly productive agricultural communities are shown to probably be a recent phenomenon. In simulations where fertility was applied to communities that had evolved under lower nutrient conditions, a few species had the ability to become ‘dominant’. These species were responsible for the loss of diversity and for the majority of biomass production. These results are consistent with complementarity theory applying in nature in old co-evolved low nutrient communities, whereas in recently established fertile agricultural communities, dominant species appear to regulate biomass production. Understanding the nature of these ‘dominant’ species throws light on our understanding of phenotypic plasticity and the ecology of invasive species. The appendices files are currently available at .     

Developing the genotype-to-phenotype relationship in evolutionary theory: A primer of developmental features

For decades, there have been repeated calls for more integration across evolutionary and developmental biology. However, critiques in the literature and recent funding initiatives suggest this integration remains incomplete. We suggest one way forward is to consider how we elaborate the most basic concept of development, the relationship between genotype and phenotype, in traditional models of evolutionary processes. For some questions, when more complex features of development are accounted for, predictions of evolutionary processes shift. We present a primer on concepts of development to clarify confusion in the literature and fuel new questions and approaches. The basic features of development involve expanding a base model of genotype-to-phenotype to include the genome, space, and time. A layer of complexity is added by incorporating developmental systems, including signal-response systems and networks of interactions. The developmental emergence of function, which captures developmental feedbacks and phenotypic performance, offers further model elaborations that explicitly link fitness with developmental systems. Finally, developmental features such as plasticity and developmental niche construction conceptualize the link between a developing phenotype and the external environment, allowing for a fuller inclusion of ecology in evolutionary models. Incorporating aspects of developmental complexity into evolutionary models also accommodates a more pluralistic focus on the causal importance of developmental systems, individual organisms, or agents in generating evolutionary patterns. Thus, by laying out existing concepts of development, and considering how they are used across different fields, we can gain clarity in existing debates around the extended evolutionary synthesis and pursue new directions in evolutionary developmental biology. Finally, we consider how nesting developmental features in traditional models of evolution can highlight areas of evolutionary biology that need more theoretical attention.     

青蒿素及其类似物抗疟构效关系的DFT研究

为了从原子水平上揭示青蒿素及其类似物的结构与抗疟活性之间的关系,运用密度泛函理论DFT方法,在B3LYP/6-31G*水平上对青蒿素及其类似物二氢青蒿素、蒿甲醚和青蒿琥酯的结构和性质进行了理论计算。从分子的平衡构型、Wiberg键级、溶剂化能、偶极矩和静电势等方面分析了青蒿素及其类似物的抗疟构效关系。结果表明,青蒿素及其类似物结构中七元环上的过氧桥键、醚氧键以及六元环上的内酯结构是其抗疟作用的关键活性位,过氧桥键处负的静电势越多,青蒿素与血红素的相互作用越强,分子的抗疟活性越强。理论预测四个药物分子的抗疟活性顺序为:青蒿素<二氢青蒿素<蒿甲醚<青蒿琥酯,与实验活性结果一致。     

A relationship between 13C-chemical-shift displacements and counterion-condensation theory, in the binding of calcium ion by heparin

Characteristics of the interaction between heparin and calcium ion in the presence of sodium ion have been examined by monitoring the 13C-chemical shift changes as a function of the calcium ion concentration and the total ionic strength. The results indicated that the association between the polyanion and the divalent cation is a delocalized process, as opposed to one involving specific binding. The correspondence found between chemical shift and the number of Ca2+ ions bound per charged group, as derived from the Manning counterion-condensation model, showed that the stoichiometry is not a constant quantity but, rather, varies throughout the titration, and approaches a limiting value of 2 at high dilution. Additional measurements of T1 and line-width were consistent with an intramolecular order-disorder conformational process induced by the binding of calcium ion. Moreover, binding does not occur or is relatively weak with N-desulfated heparin, or chondroitin 4-sulfate and 6-sulfate, each of which possesses fewer sulfate groups than heparin. These differences serve to emphasize the importance of the charge-density parameter in the control of counterion condensation according to the Manning model, and suggest that the spacing between the negatively charged groups is an associated factor.