Stalking: evil, illness, or both?

This article considers the definition and impact of stalking behaviours, and describes recent examples, as well as the characteristics and behaviours of stalkers. Current legal frameworks and their application are reviewed, including recent changes in the law. Management and treatment issues as well as attention to minimising a violent outcome and general ethical matters are discussed.     

Interactions of anesthetics with their targets: non-specific, specific or both?

What makes a general anesthetic a general anesthetic? We shall review first what general anesthesia is all about and which drugs are being used as anesthetics. There is neither a unique definition of general anesthesia nor any consensus on how to measure it. Diverse drugs and combinations of drugs generate general anesthetic states of sometimes very different clinical quality. Yet the principal drugs are still considered to belong to the same class of 'general anesthetics'. Effective concentrations of inhalation anesthetics are in the high micromolar range and above, and even for intravenous anesthetics they do not go below the micromolar range. At these concentrations, many molecular and higher level targets are affected by inhalation anesthetics, fewer probably by intravenous anesthetics. The only physicochemical characteristic shared by anesthetics is the correlation of their anesthetic potencies with hydrophobicity. These correlations depend on the group of general anesthetics considered. In this review, anesthetic potencies for many different targets are plotted against octanol/water partition coefficients as measure of hydrophobicity. Qualitatively, similar correlations result, suggesting several but weak interactions with proteins as being characteristic of anesthetic actions. The polar interactions involved are weak, being roughly equal in magnitude to hydrophobic interactions. Generally, intravenous anesthetics are noticeably more potent than inhalation anesthetics. They differ considerably more between each other in their interactions with various targets than inhalation anesthetics do, making it difficult to come to a decision which of these should be used in future studies as representative 'prototypical general anesthetics'.     

Health plan accreditation: NCQA, JCAHO, or both?

Currently the National Committee for Quality Assurance (NCQA) and the Joint Commission on the Accreditation of Healthcare Organizations (the Joint Commission) accredit managed care organizations (MCOs), but is competition in the market for plan accreditation beneficial or counterproductive? This paper presents the results from two surveys that were administered to a group of large public and private purchasers, and representatives from the American Association of Health Plans and the Centers for Disease Control, who attended the Lovelace Health System (LHS) "Accreditation Experience" program. The LHS program was designed to inform purchasers about the NCQA and Joint Commission accreditation processes. The surveys captured purchaser views about the advantages and disadvantages of both accreditation processes, the value of accreditation, and the use of plan performance measures.     

The hard art of soft science: Evidence-Based Medicine, Reasoned Medicine or both?

In the past 14 years, Evidence-Based Medicine (EBM) has enjoyed unprecedented developments and gained widespread acceptance among health professionals. However, should we be content with producing, critically appraising and using the best evidence available for our understanding of health problems and decision making about them? Are our convictions about EBM's relevance, our conviction and intellectual satisfaction with its mastery and adoption enough? Should we continue pushing forward along this promising path, or should we further diversify the content and scope of EBM? Is EBM the only way to view medicine in the near future? This paper presents some options to choose from in terms of direction and content as well as questions to answer given the current EBM crossroads. More intensive and extensive EBM combined with 'other features'-based medicines may be the preferred strategy to follow in the future to determine the development, use and evaluation of EBM. Argument-based medicine or Reasoned Medicine is one of the options that can be integrated into the mainstream of medical reasoning and decision making.     

Acute lung injury, overhydration or both?

Acute lung injury or acute respiratory distress syndrome (ALI/ARDS) in the course of sepsis is thought to result from increased pulmonary capillary permeability and resultant edema. However, when the edema is assessed at the bedside by measuring the extravascular thermal volume by transpulmonary dilution, some ALI/ARDS patients with sepsis may have normal extravascular lung water (EVLW). Conversely, a raised EVLW may be present even when criteria for ALI/ARDS are not met, according to GS Martin and colleagues in this issue of Critical Care. This commentary puts the findings into a broader perspective and focuses on the difficulty, at the bedside, in recognizing and separating various types of pulmonary edema. Some of these forms of edema, classically differentiated on the basis of increased permeability and cardiogenic/hydrostatic factors, may overlap, whereas the criteria for ALI/ARDS may be loose, poorly reproducible, relatively insensitive and nonspecific, and highly therapy-dependent. Overhydration is particularly difficult to recognize. Additional diagnostics may be required to improve the delineation of pulmonary edema so as to redirect or redefine treatment and improve patient morbidity and, perhaps, mortality. Monitoring EVLW by single transpulmonary thermal dilution, for instance, might have a future role in this process.     

The treatment of unipolar major depression: pharmacotherapy,cognitive behaviour therapy or both?

There is no clear-cut line separating normal and abnormal moods. Therefore, psychiatrists often describe patterns of symptoms (syndromes) to suggest the existence of diseases for which no obvious brain abnormalities can be demonstrated. These uncertainties create room for much doubt about the best way of treating unipolar major depression. I present here a case report of a patient with unipolar depression treated with cognitive therapy. The patient had been treated with an SSRI and a tricyclic antidepressant without substantial improvement. This case is discussed in the light of the current controversies in the literature concerning the comparative value of psychotherapy, particularly that designed to treat depression, and pharmacotherapy. We would suggest that cognitive therapy, as well as other depression-specific short psychotherapies, is the treatment of choice in milder depressions. However, there is evidence to support the widespread clinical impression that combined therapy with both psychotherapy and pharmacotherapy is superior to each single mode of therapy for the treatment of more severe, recurrent depressions.     

Apheresis for babesiosis: Therapeutic parasite reduction or removal of harmful toxins or both?

Babesiosis is a potentially life‐threatening illness caused by intraerythrocytic protozoan parasites of the genus Babesia that are transmitted most commonly by Ixodes ticks, and rarely from blood transfusion or congenitally. Clinical presentations of babesiosis include asymptomatic infection, mild to moderate disease, or severe disease. Antibiotics such as atovaquone plus azithromycin or clindamycin and quinine can be used effectively to treat this disease in most cases, however in high risk populations, the mortality rate can be as high as 20% despite therapy. Therapeutic exchange transfusion has been used in severe babesiosis and is of apparent therapeutic benefit. It is not entirely clear through what mechanism therapeutic exchange transfusion may help patients. Data suggests that in addition to parasite load reduction, it is possible that therapeutic exchange transfusion removes toxins generated by babesia infection. There are many remaining questions that need to be addressed regarding exchange transfusion for babesiosis. J. Clin. Apheresis 31:454–458, 2016. © 2015 Wiley Periodicals, Inc.     

Youth type 2 diabetes: insulin resistance, beta-cell failure, or both?

OBJECTIVE: This study evaluates insulin sensitivity, pancreatic beta-cell function (BCF), and the balance between the two in youth with type 2 diabetes and assesses the relationship of diabetes duration and HbA(1c) to insulin sensitivity and BCF. RESEARCH DESIGN AND METHODS: The subjects were 14 adolescents with type 2 diabetes and 20 obese control subjects of comparable age, BMI, body composition, and puberty. Insulin sensitivity was evaluated with a 3-h hyperinsulinemic (80 mU . m(-2) . min(-1)) euglycemic clamp. First-phase insulin secretion (FPIS) and second-phase insulin secretion (SPIS) were evaluated with a 2-h hyperglycemic (12.5 mmol/l) clamp. Fasting glucose rate of appearance was determined with the use of [6,6-(2)H(2)]glucose. RESULTS: Fasting glucose rate of appearance was higher in type 2 diabetic patients than in obese control subjects (16.5 +/- 1.1 vs. 12.3 +/- 0.5 micromol . kg(-1) . min(-1); P = 0.002). Insulin sensitivity was lower in type 2 diabetic patients than in obese control subjects (1.0 +/- 0.1 vs. 2.0 +/- 0.2 micromol . kg(-1) . min(-1) per pmol/l; P = 0.001). Fasting insulin was higher in type 2 diabetic patients than in obese control subjects (289.8 +/- 24.6 vs. 220.2 +/- 18.0 pmol/l; P = 0.007), and FPIS and SPIS were lower (FPIS: 357.6 +/- 42.0 vs. 1,365.0 +/- 111.0 pmol/l; SPIS: 652.2 +/- 88.8 vs. 1,376.4 +/- 88.8 pmol/l; P < 0.001 for both). The glucose disposition index (GDI = insulin sensitivity x FPIS) was approximately 86% lower in type 2 diabetic patients than in obese control subjects. HbA(1c) correlated with FPIS (r = -0.61, P = 0.025) with no relationship to insulin sensitivity. CONCLUSIONS: Despite the impairment in both insulin sensitivity and BCF in youth with type 2 diabetes, the magnitude of the derangement is greater in BCF than insulin sensitivity when compared with that in obese control subjects. The inverse relationship between BCF and HbA(1c) may either reflect the impact of deteriorating BCF on glycemic control or be a manifestation of a glucotoxic phenomenon on BCF. Future studies in youth type 2 diabetes should target the natural course of beta-cell failure and means of retarding and/or preventing it.