Kirsten Brukamp

Nephrotic Syndrome after Hematopoietic Cell Transplantation: Do Glomerular Lesions Represent Renal Graft-versus-Host Disease?

Glomerular disease associated with nephrotic syndrome has rarely been recognized as a distinct complication of allogeneic hematopoietic cell transplantation. Case reports in the English and Japanese literature since 1988 have described variable glomerular histology, comprising mainly membranous glomerulonephritis (MGN) in almost two thirds and minimal change disease (MCD) in nearly one quarter of patients. Review of the literature reveals a close temporal relationship between the development of nephrotic syndrome shortly after cessation of immunosuppression and the diagnosis of chronic graft-versus-host disease (GVHD). An association of glomerular disease with simultaneous GVHD was seen in 47% of patients overall. Nephrotic syndrome followed GVHD within 5 months in 60% of the combined MCD and MGN reports. A decrease in immunosuppressive medication use was linked to nephrotic syndrome occurrence within 9 months in 63% of patients with MCD and MGN. MCD occurred earlier after hematopoietic cell transplantation, was diagnosed sooner after medication change, and exhibited a better prognosis in comparison with MGN. Glomerular lesions after hematopoietic cell transplantation may therefore represent the renal manifestation of GVHD. Further studies are warranted to delineate the pathogenesis of this complication.

Better Brains or Bitter Brains? The Ethics of Neuroenhancement

The topic of enhancement emerges as a novel, contemporary problem in medical ethics. In particular, neuroenhancement reveals itself as a challenging subject due to the advancements of neuroscience. At present, pharmacological neuroenhancement is widely debated, but only scarce empirical data exist regarding its prevalence. Arguments for and against neuroenhancement relate to various disciplines, such as medicine, anthropology, sociology, and classical ethics. Medical considerations caution against the use of pharmaceutical neuroenhancers because of medical risks, the lack of evidence-based medicine, and financial challenges to health care systems. Perspectives on neuroenhancement from the humanities involve the concepts of human nature, virtue ethics, liberty, and justice. The purposes behind neuroenhancement are disputable with regard to their social value. In conclusion, neuroenhancement appears to remain a controversial phenomenon.

Neuroenhancement - A Controversial Topic in Contemporary Medical Ethics

Neuroenhancement will become an important topic of medical ethics in future years and decades, due to the increasing insights of neuroscience into the functions of the brain and the growing possibilities of meaningful interventions. Consequently, several crucial topics need to be discussed in order to address this emerging issue, and these topics correspond to the following sections of this article:

Transplant Nephrectomy: Histologic Findings - A Single Center Study

Aims: To identify the histopathological features of transplant nephrectomy (TN) specimens. Methods: We performed retrospective analysis of 73 nephrectomies to review the histopathology in detail and correlate the Banff grading characteristics of TN specimens with time post engraftment and clinical features. Retrospective data on donor-specific antibodies (DSA) were also collected. Results: The majority of patients who had TN in less than 3 months posttransplant (n = 20; median time to TN: 4 days) had hemorrhagic infarction; 7 patients (35%) had grade 3 acute rejection (AR). Patients who had TN later than 3 months posttransplant (n = 53; median time to TN: 67 months) had AR, grade 2B (21%) and 3 (43%), coexisting with advanced vascular injury in the form of interstitial hemorrhage, extensive interstitial fibrosis and tubular atrophy (IF/TA) as well as the presence of DSAs. Overall, the majority of patients without DSA pre-TN developed DSA post-TN. Conclusions: Our data revealed extensive inflammation and ongoing immunologic activity in a subset of patients with a failed graft. Careful and individualized approach based on clinical and laboratory data should guide the decision for transplant nephrectomy. i 2014 S. Karger AG, Basel

[Motor-independent communication by severely physically challenged patients: neuroscientific research results and patient autonomy].

ZusammenfassungMotorunabhängige Kommunikation ist eine neuartige, sich momentan in der Entwicklung befindende diagnostische und therapeutische Methode, um die Kommunikation mit körperlich hochgradig eingeschränkten Patienten zu ermöglichen. Einige Patienten mit Locked-in-Syndromen oder mit chronischen Bewusstseinsstörungen sind in der Lage, ihre Gehirnaktivitäten willentlich so zu modulieren, dass letztere durch Einsatz neurowissenschaftlicher Technologien, wie beispielsweise der funktionellen Magnetresonanztomographie, hinsichtlich kommunikativer Intentionen analysiert werden können. Die wissenschaftliche Weiterentwicklung und ein zunehmender klinischer Einsatz der motorunabhängigen Kommunikation werden dazu beitragen, dass wesentliche Qualitätskriterien durch diese Methode erfüllt werden können. Insbesondere sind die Bedingungen zu klären, unter denen sie einsatzfähig ist, Patienten ihre eigenen Therapieentscheidungen zu ermöglichen, um Patientenautonomie zu verwirklichen. Mit technologisch vermittelter Kommunikation geht die Hoffnung einher, die Lebensqualität körperlich hochgradig eingeschränkter Patienten wesentlich zu verbessern.SummaryMotor-independent communication is a novel diagnostic and therapeutic method that is currently in development in order to enable communication with severely physically challenged patients. Some patients with locked-in syndromes or with chronic disorders of consciousness are capable of modulating their brain activities to such a degree that the latter can be analyzed regarding communicative intentions with neuroscientific technologies, such as functional magnetic resonance imaging. Further scientific development and an increasing clinical use of motor-independent communication will aid in meeting essential quality standards for this method. In particular, the requirements need to be clarified under which the method may be utilized to support the patients’ autonomy by enabling them to make their own decisions about therapeutic interventions. Communication mediated by technology promises to significantly improve the quality of life for severely physically challenged patients.Motor-independent communication is a novel diagnostic and therapeutic method that is currently in development in order to enable communication with severely physically challenged patients. Some patients with locked-in syndromes or with chronic disorders of consciousness are capable of modulating their brain activities to such a degree that the latter can be analyzed regarding communicative intentions with neuroscientific technologies, such as functional magnetic resonance imaging. Further scientific development and an increasing clinical use of motor-independent communication will aid in meeting essential quality standards for this method. In particular, the requirements need to be clarified under which the method may be utilized to support the patients autonomy by enabling them to make their own decisions about therapeutic interventions. Communication mediated by technology promises to significantly improve the quality of life for severely physically challenged patients.

Motorunabhängige Kommunikation durch körperlich hochgradig eingeschränkte Patienten

ZusammenfassungMotorunabhängige Kommunikation ist eine neuartige, sich momentan in der Entwicklung befindende diagnostische und therapeutische Methode, um die Kommunikation mit körperlich hochgradig eingeschränkten Patienten zu ermöglichen. Einige Patienten mit Locked-in-Syndromen oder mit chronischen Bewusstseinsstörungen sind in der Lage, ihre Gehirnaktivitäten willentlich so zu modulieren, dass letztere durch Einsatz neurowissenschaftlicher Technologien, wie beispielsweise der funktionellen Magnetresonanztomographie, hinsichtlich kommunikativer Intentionen analysiert werden können. Die wissenschaftliche Weiterentwicklung und ein zunehmender klinischer Einsatz der motorunabhängigen Kommunikation werden dazu beitragen, dass wesentliche Qualitätskriterien durch diese Methode erfüllt werden können. Insbesondere sind die Bedingungen zu klären, unter denen sie einsatzfähig ist, Patienten ihre eigenen Therapieentscheidungen zu ermöglichen, um Patientenautonomie zu verwirklichen. Mit technologisch vermittelter Kommunikation geht die Hoffnung einher, die Lebensqualität körperlich hochgradig eingeschränkter Patienten wesentlich zu verbessern.SummaryMotor-independent communication is a novel diagnostic and therapeutic method that is currently in development in order to enable communication with severely physically challenged patients. Some patients with locked-in syndromes or with chronic disorders of consciousness are capable of modulating their brain activities to such a degree that the latter can be analyzed regarding communicative intentions with neuroscientific technologies, such as functional magnetic resonance imaging. Further scientific development and an increasing clinical use of motor-independent communication will aid in meeting essential quality standards for this method. In particular, the requirements need to be clarified under which the method may be utilized to support the patients’ autonomy by enabling them to make their own decisions about therapeutic interventions. Communication mediated by technology promises to significantly improve the quality of life for severely physically challenged patients.Motor-independent communication is a novel diagnostic and therapeutic method that is currently in development in order to enable communication with severely physically challenged patients. Some patients with locked-in syndromes or with chronic disorders of consciousness are capable of modulating their brain activities to such a degree that the latter can be analyzed regarding communicative intentions with neuroscientific technologies, such as functional magnetic resonance imaging. Further scientific development and an increasing clinical use of motor-independent communication will aid in meeting essential quality standards for this method. In particular, the requirements need to be clarified under which the method may be utilized to support the patients autonomy by enabling them to make their own decisions about therapeutic interventions. Communication mediated by technology promises to significantly improve the quality of life for severely physically challenged patients.