lunes, 27 de diciembre de 2010

In Pursuit of a Mind Map, Slice by Slice

In Pursuit of a Mind Map, Slice by Slice

CAMBRIDGE, Mass — Dr. Jeff Lichtman likes his brains sliced thin — very, very thin.
C.J. Gunther for The New York Times
TEAM LEADER Dr. Jeff Lichtman, with a 3-D image of a section of mouse brain and a magnified section of a dendrite (red), in his office at Harvard.

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C.J. Gunther for The New York Times
ILLUMINATING A section of a mouse brain about 30 nanometers thick, ready for an electron microscope at Harvard. Researchers liken the cutting to shaving off the surface of a football field at a thickness of one-hundredth of an inch.
Dr. Lichtman and his team of researchers at Harvard have built some unusual contraptions that carve off slivers of mouse brains as part of a quest to understand how the mind works. Their goal is to run slice after minuscule slice under a powerful electron microscope, develop detailed pictures of the brain’s complex wiring and then stitch the images back together. In short, they want to build a full map of the mind.
The field, at a very nascent stage, is called connectomics, and the neuroscientists pursuing it compare their work to early efforts in genetics. What they are doing, these scientists say, is akin to trying to crack the human genome — only this time around, they want to find how memories, personality traits and skills are stored.
They want to find a connectome, or the mental makeup of a person.
“You are born with your genes, and they don’t change afterward,” said H. Sebastian Seung, a professor of computational neuroscience at the Massachusetts Institute of Technology who is working on the computer side of connectomics. “The connectome is a product of your genes and your experiences. It’s where nature meets nurture.”
The task is arduous and years from fruition, and even the biggest zealots acknowledge that their work may not pay off. But connectomics has gotten some meaningful financing: In September, the National Institutes of Healthhanded out $40 million in grants to researchers at Harvard, Washington University in St. Louis, the University of Minnesota and the University of California, Los Angeles, to pursue connectomics. Together, their research efforts comprise the Human Connectome Project.
Since the 1970s, researchers have only had one connectome to play with — that of a worm with a measly 300 neurons. Now they are trying a mouse brain, with its 100 million neurons. So far the notion of creating a human-scale connectome — which would illuminate all of the connections among more than 100 billion neurons and unravel the millions of miles of wires in the brain — has proved too daunting.
The task at hand is somewhat similar to trying to untangle a bowl of spaghetti. Each individual spaghetti strand may touch tens of other strands as it weaves in a contorted fashion through the bowl. In this case, the researchers want to do the equivalent of seeing where all the strands connect at the atom level.
And because the brain’s wiring is so densely packed, building a connectome stands as one of the most formidable data collection efforts ever concocted. About one petabyte of computer memory will be needed to store the images needed to form a picture of a one-millimeter cube of mouse brain, the scientists say. By comparison, it takes Facebook about one petabyte of data storage space to hold 40 billion photos.
“The world is not yet ready for the million-petabyte data set the human brain would be,” Dr. Lichtman said. “But it will be.”
Neuroscientists say that a connectome could give them myriad insights about the brain’s function and prove particularly useful in the exploration of mental illness. For the first time, researchers and doctors might be able to determine how someone was wired — quite literally — and compare that picture with “regular” brains. Surgeons armed with a connectome might also be able to make more calculated cuts in the brain.
“The connectome project is going to show where all the white matter — all the connecting fibers — are,” said Stanley Klein, a professor of optometry and vision science at theUniversity of California, Berkeley. “The whole goal in something like a surgery for epilepsyis to delicately slice out some of the white matter without removing any cortex.”
Dr. Klein says he has “zero question” that this type of surgery could benefit from developing a connectome.
Other scientists doubt that the results will match the effort. The comparisons to the genome prove haunting, and critics suggest that the connectome fans are wastingvaluable research dollars and setting themselves up for a huge letdown.
“There are people that argue we still just don’t know enough about the brain to know where to look for insights,” said Bradley Voytek, a researcher at the Helen Wills Neuroscience Institute at the University of California, Berkeley. “They also contend that there is no possible way you can build a full connectome in any realistic time frame.”
What’s more, even if the researchers succeed, they will only produce a static picture of a brain frozen in time, rather than something that shows how a brain responds to different types of stimuli.
Scientists around the world, including Stephen J. Smith, a neuroscience professor at Stanford, and Gerald M. Rubin, a researcher with the Howard Hughes Medical Institute, have pushed past the naysayers and developed varying techniques for mapping the brains and nervous systems of human as well as other creatures.
“There are some people who say, ‘Maybe you don’t need this information, and given the expense of it, maybe you should put it off,’ ” said Dr. Lichtman, a professor of molecular and cellular biology at Harvard. “It’s a fair controversy.”
Harvard recruited Dr. Lichtman to push the connectome quest to its limits by tackling an entire mouse brain at the finest scale and allowed him to set up his own connectome research laboratory, staffed with four other people.
In the basement quarters that house Lichtman Lab, the researchers go to work anesthetizing mice, slicing open their rib cages and using the animals’ circulatory systems to spread concoctions that preserve the flesh and tune it for the electron microscope. Now and again, a researcher will reach into a box of mouse food pellets littered around the lab for sustenance during the tedious work.
“They’re not too bad,” said Bobby Kasthuri, one of the researchers.
With the body prepared, the slicing can begin.

Machines built by Kenneth J. Hayworth, another one of the researchers, can sheer off slices of a mouse brain just 29.4 nanometers thin using a diamond knife blade. To provide a sense of the accomplishment, the researchers liken the cutting to shaving off the entire surface of a football field at a thickness of one-hundredth of an inch.
Mr. Hayworth devised techniques for floating the brain slivers across a tiny puddle of water where surface tension carries them to a clear plastic tape. The tape backing adds some sturdiness to the slivers and makes it possible to place scores of them on a silicon wafer that then goes under the electron microscope.
At Lichtman Lab, the researchers are marching across a mouse brain in linear fashion, gathering the slices, imaging them and then putting the puzzle back together. Once assembled by a computer, the images of the brain are beautiful.
Dr. Lichtman and his colleagues give individual brain cells unique colors, making it easier to follow the wiring of a single neuron’s extensive axon and dendrite branches. The microscopes and computers they use can twist and turn these psychedelic images and zoom in and out at will.
It takes about three days for the researchers to carve 7,000 sections of a mouse’s cerebral cortex.
“The cutting is easy,” Dr. Lichtman said. “The big time sink is imaging.”
Dr. Lichtman estimates it will be several years before they can contemplate a connectome of a mouse brain, but there are some technological advances on the horizon that could cut that time significantly. Needless to say, a human brain would be far more complex and time-consuming.
“Hopefully, we are returning with a burst of new energy to the question of how the brain is wired up,” said Gary S. Lynch, a well-known brain researcher at the University of California, Irvine. “Lacking a blueprint, we’re never going to get anywhere on the most profound and fun questions that drew everyone to neuroscience in the first place: what is thought, consciousness?”
A connectome would provide a far more detailed look at the brain’s inner workings than current techniques that measure blood flow in certain regions. The researchers contend that it would literally show how people are wired and illuminate differences in the brains of people with mental illness.
As Mr. Kasthuri, the Harvard researcher, put it: “It will either be a great success story or a massive cautionary tale.”

Curso patológico de la enfermedad de Alzheimer

Curso patológico de la enfermedad de Alzheimer imprimir
28/12/2010Redacción
Investigadores suecos han estudiado el cerebro de un enfermo de alzheimer para observar los depósitos amiloides durante la progresión de la enfermedad y después de la muerte. El resultado de estos análisis, que se publican en la revista Brain, ofrece una imagen detallada de cómo se desarrolla la enfermedad de Alzheimer. Se descubrieron altas concentraciones de placas amiloides en una etapa temprana de la enfermedad, cuando el paciente sufrió una pérdida leve de memoria. Los niveles se mantuvieron sin cambios durante el curso de la enfermedad, en contraste con el metabolismo energético en el cerebro que, como la memoria del paciente, se deterioró progresivamente.
También se observó que la mayor acumulación de placa se acompaña de una reducción en el número de receptores nicotínicos neuronales en el cerebro. Esto demuestra que los receptores se ven afectados desde el principio en el desarrollo de la enfermedad. 
Además, se midieron los cambios inflamatorios en las regiones del cerebro con bajos niveles de placas, amiloide lo que sugiere que los fenómenos de inflamación asociados a la enfermedad de Alzheimer podrían tener una causa diferente,y evolucionar en diferentes fases de la enfermedad, en comparación con la de la acumulación de proteína amiloide.
[Brain 2010]
Kadir A, Marutle A, Gonzalez D, Schöll M, Almkvist O, Mousavi M, et al.
Palabras Clave: Enfermedad de Alzheimer. Depósitos amiloides. Metabolismo energético. Progresión. Receptores nicotínicos

Diferencias raciales y socioeconómicas en pacientes con Parkinson

Diferencias raciales y socioeconómicas en pacientes con Parkinson imprimir
28/12/2010Redacción
Los afroamericanos y aquellos con un menor nivel socioeconómico parecen tener un parkinsonismo más grave y con mayores niveles de discapacidad, según un informe publicado en la revista Archives of Neurology, en el que se estudió a 1.159 pacientes con Parkinson que fueron evaluados por especialistas en trastornos del movimiento entre 2003 y 2008. Menores ingresos y menor nivel educativo se asociaron también con una mayor gravedad de la enfermedad y discapacidad.

Las disparidades también se observaron en los patrones de tratamiento. Se prescribieron menos medicamentos para tratar el Parkinson en la primera visita clínica (61,9% recibieron medicación, en comparación con 77,6% de los pacientes de raza blanca). Entre los pacientes afroamericanos, al 20,6% se les prescribió nuevos medicamentos dopaminérgicos, en comparación con el 41,1% de los pacientes de raza blanca, mientras que un 12,7% de los afroamericanos recibieron tratamiento con antipsicóticos en comparación con el 6,1% de los pacientes blancos.
[Arch Neurol 2010]
Hemming JP, Gruber-Baldini AL, Anderson KE, Fishman PS, Reich SG, Weiner WJ, et al.
Palabras Clave: Afroamericanos. Blancos. Discapacidad. Educación. Nivel socioeconómico. Parkinsonismo. Tratamiento

Tratamiento farmacológico de la mujer embarazada: fármacos contraindicados durante la gestación

Tratamiento farmacológico de la mujer embarazada:
fármacos contraindicados durante la gestación



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Oftalmología basada en evidencias: evaluación crítica de los ensayos clínicos sobre tratamiento



Archivos de la Sociedad Española de Oftalmología




Oftalmología basada en evidencias: evaluación crítica de los ensayos clínicos sobre tratamiento






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Etiología y manejo de la neuropatía diabética dolorosa

Revista de la Sociedad Española del Dolor


Etiología y manejo de la neuropatía diabética dolorosa
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En este día...

On This Day in HistoryMonday, December 27th
The 361st day of 2010.
There are 4 days left in the year.
Go to a previous date.
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Today's Highlights in History
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NYT Front PageSee a larger version of this front page.
On Dec. 27, 1979, Soviet forces seized control of Afghanistan. President Hafizullah Amin, who was overthrown and executed, was replaced by Babrak Karmal. (Go to article.)On Dec. 271901Marlene Dietrich,the magnetic movie star and singer who was considered an international symbol of glamour, was born.Following her death on May 61992,her obituary appeared in The Times.(Go to obit. | Other Birthdays)
Editorial Cartoon of the Day

On December 27, 1879Harper's Weekly featured a cartoon about Senator Thomas Bayard of Delaware, a leading contender for the Democratic presidential nomination in 1880. (See the cartoon and read an explanation.)

On this date in:
1831British naturalist Charles Darwin set out on a voyage to the Pacific Ocean aboard the HMS Beagle. Darwin's discoveries during the nearly five-year journey helped form the basis of his theories on evolution.
1927The musical "Show Boat," with music by Jerome Kern and libretto by Oscar Hammerstein II, opened at the Ziegfeld Theater in New York City.
1932Radio City Music Hall opened in New York City.
1945The World Bank was created with an agreement signed by 28 nations.
1947The children's TV program "Howdy Doody" debuted on NBC.
1949Queen Juliana of the Netherlands granted sovereignty to Indonesia after more than 300 years of Dutch rule.
1968Apollo 8, the first spaceflight to orbit the moon, returned to Earth.
1970"Hello, Dolly!" closed on Broadway after a run of 2,844 performances.
1985Naturalist Dian Fossey, who had studied gorillas in the wild, was found hacked to death at a research station in Rwanda.
2001U.S. officials announced that Taliban and al-Qaida prisoners would be held at the U.S. naval base at Guantanamo Bay, Cuba.
2004Viktor Yushchenko won a runoff in Ukraine's presidential election, completing the country's "Orange Revolution."
2005Indonesia's Aceh rebels formally abolished their 30-year armed struggle for independence under a peace deal born out of the 2004 tsunami.
2007Former Pakistani Prime Minister Benazir Bhutto was assassinated in a bomb and shooting attack as she left an election rally in Rawalpindi.

Current Birthdays
Emilie de Ravin turns 29 years old today.

AP Photo/Evan Agostini Actress Emilie de Ravin ("Lost") turns 29 years old today.

86James A. McClure
Former U.S. senator, R-Idaho
79Scotty Moore
Rock musician
71John Amos
Actor
67Cokie Roberts
Broadcast journalist
66Mick Jones
Rock musician (Foreigner)
62Gerard Depardieu
Actor
58Tovah Feldshuh
Actress
54Karen Hughes
Former White House aide
51Andre Tippett
Football Hall of Famer
46Theresa Randle
Actress
41Sarah Vowell
Author
36Masi Oka
Actor ("Heroes")
32Deuce McAllister
Football player
31Carson Palmer
Football player
27Cole Hamels
Baseball player
22Hayley Williams
Rock singer (Paramore)
Historic Birthdays
Marlene Dietrich
 
12/27/1901 - 5/6/1992
German-born American actress 

(Go to obit.)

59Louis Bromfield
12/27/1896 - 3/18/1956
American novelist and essayist

95Cyrus Eaton
12/27/1883 - 5/9/1979
Canadian-born American industrialist and philanthropist

93Sir Mackenzie Bowell
12/27/1823 - 12/10/1917
Canadian prime minister

72Louis Pasteur
12/27/1822 - 9/28/1895
French biologist and chemist; invented pasteurization process

84Sir George Cayley
12/27/1773 - 12/15/1857
English aerial navigator

62William Johnson
12/27/1771 - 8/4/1834
American Supreme Court justice

58Johannes Kepler
12/27/1571 - 11/15/1630
German astronomer

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SOURCE: The Associated Press
Front Page Image Provided by UMI

On Forgiveness

December 26, 2010, 5:30 PM

On Forgiveness

The StoneThe Stone is a forum for contemporary philosophers on issues both timely and timeless.
We are in a season traditionally devoted to good will among people and to the renewal of hope in the face of hard times.  As we seek to realize these lofty ideals, one of our greatest challenges is overcoming bitterness and divisiveness.  We all struggle with the wrongs others have done to us as well as those we have done to others, and we recoil at the vast extent of injury humankind seems determined to inflict on itself.  How to keep hope alive?  Without a constructive answer to toxic anger, addictive cycles of revenge, and immobilizing guilt, we seem doomed to despair about chances for renewal.  One answer to this despair lies in forgiveness.
What is forgiveness? When is it appropriate? Why is it considered to be commendable?  Some claim that forgiveness is merely about ridding oneself of vengeful anger; do that, and you have forgiven.  But if you were able to banish anger from your soul simply by taking a pill, would the result really be forgiveness?  The timing of forgiveness is also disputed. Some say that it should wait for the offender to take responsibility and suffer due punishment, others hold that the victim must first overcome anger altogether, and still others that forgiveness should be unilaterally bestowed at the earliest possible moment.  But what if you have every good reason to be angry and even to take your sweet revenge as well?  Is forgiveness then really to be commended? Some object that it lets the offender off the hook, confesses to one’s own weakness and vulnerability, and papers over the legitimate demands of vengeful anger.  And yet, legions praise forgiveness and think of it as an indispensable virtue.  Recall the title of Archbishop Desmond Tutu’s book on the subject: “No Future Without Forgiveness.”
If you claim you’ve forgiven someone then take revenge, you’re either dishonest or ignorant of the meaning of the term.
These questions about the what, when, and why of forgiveness have led to a massive outpouring of books, pamphlets, documentaries, television shows, and radio interviews.  The list grows by the hour. It includes hefty representation of religious and self-help perspectives, historical analysis (much of which was sparked by South Africa’s famed Truth and Reconciliation Commission), and increasingly, philosophical reflection as well.  Yet there is little consensus about the answers.  Indeed, the list of disputed questions is still longer. Consider: may forgiveness be demanded, or must it be a sort of freely bestowed gift?  Does the concept of “the unforgivable” make sense?  And what about the cultural context of forgiveness: does it matter? Has the concept of “forgiveness” evolved, even within religious traditions such as Christianity? Is it a fundamentally religious concept?
On almost all accounts, interpersonal forgiveness is closely tied to vengeful anger and revenge.  This linkage was brought to the fore byBishop Joseph Butler (1692-1752) in his insightful sermons on resentment (his word for what is often now called vengeful anger) and forgiveness.  These sermons are the touchstone of modern philosophical discussions of the topic. Butler is often interpreted as saying that forgiveness requires forswearing resentment, but what he actually says is that it requires tempering resentment and forswearing revenge. He is surely right that it requires at least that much.  If you claim you’ve forgiven someone and then proceed to take revenge, then you are either dishonest or ignorant of the meaning of the term.  Forgiveness comes with conditions, such as the giving up of revenge.  What are other conditions?
If you seethe with vengeful thoughts and anger, or even simmer with them, can you be said to have forgiven fully?  I would answer in the negative.  That establishes another condition that successful forgiveness must meet.  In the contemporary literature on forgiveness, the link between forgiveness and giving up vengefulness is so heavily emphasized that it is very often offered as the reason to forgive: forgive, so that you may live without toxic anger.
However, if giving up revenge and resentment were sufficient to yield forgiveness, then one could forgive simply by forgetting, or through counseling, or by taking the latest version of the nepenthepill.  But none of those really seems to qualify as forgiveness properly speaking, however valuable they may be in their own right as a means of getting over anger.  The reason is that forgiveness is neither just a therapeutic technique nor simply self-regarding in its motivation; it is fundamentally a moral relation between self and other.
Consider its genesis in the interpersonal context: one person wrongs another.  Forgiveness is a response to that wrong, and hence to the other person as author of that action.  Forgiveness retains the bilateral or social character of the situation to which it seeks to respond.  The anger you feel in response to having been treated unjustly is warranted only if, in its intensity and its target, it is fitting.  After all, if you misidentified who did you wrong, then forgiving that person would be inappropriate, indeed, insulting.  Or if the wrongdoer is rightly identified but is not culpable, perhaps by virtue of ignorance or youth, then once again it is not forgiveness that is called for but something else — say, excuse or pardon.  (One consequence: as philosopher Jeffrie Murphy points out in his exchange with Jean Hampton in their book “Forgiveness and Mercy,” “they know not what they do” makes Christ’s plea on the cross an appeal for excuse rather than forgiveness.)  Moreover, it is not so much the action that is forgiven, but its author.  So forgiveness assumes as its target, so to speak, an agent who knowingly does wrong and is held responsible.  The moral anger one feels in this case is a reaction that is answerable to reason; and this would hold too with respect to giving up one’s anger.  In the best case, the offender would offer you reasons for forswearing resentment, most obviously by taking a series of steps that include admission of responsibility, contrition, a resolve to mend his or her ways and recognition of what the wrong-doing felt like from your perspective.
Forgiveness is fundamentally a moralrelation between self and other.
Of course, as the wronged party you don’t always get anything close to that and are often left to struggle with anger in the face of the offender’s unwillingness or inability to give you reason to forswear anger.  But if the offender offered to take the steps just mentioned, you would very likely accept, as that would make it not only psychologically easier to forgive, but would much more perfectly accomplish one moral purpose of forgiveness — namely, restoration of mutual respect and reaffirmation that one is not to be treated wrongly.  A similar logic holds on the flip side: if as the offender you take every step that could reasonably be asked of you, and your victim is unable or unwilling to forgive, you are left to struggle with your sense of being unforgiven, guilty, beholden.  Offered the chance that your victim would set aside revenge and vengefulness, forgive you, and move onto the next chapter of his or her life, you would very probably accept.
The paradigm case of interpersonal forgiveness is the one in which all of the conditions we would wish to see fulfilled are in fact met by both offender and victim.  When they are met, forgiveness will not collapse into either excuse or condonation — and on any account it is essential to avoid conflating these concepts.  One of the several sub-paradigmatic or imperfect forms of forgiveness will consist in what is often called unconditional, or more accurately, unilateral forgiveness — as when one forgives the wrongdoer independently of any steps he or she takes.  Some hold that unilateral forgiveness is the model, pointing to the much discussed case of the Amish unilaterally forgiving the murderer of their children (for an account of this case, see “Amish Grace: How Forgiveness Transcended Tragedy,” by D. B. Kraybill, S. M. Nolt, and D. L. Weaver-Zercher). I contend, by contrast, that the ideal is bilateral, one in which both sides take steps.  I also hold that whether forgiveness is or is not possible will depend on the circumstances and reasons at play; not just anything is going to count as forgiveness.  Establishing the minimal threshold for an exchange to count as “forgiveness” is a matter of some debate, but it must include the giving up of revenge by the victim, and an assumption of responsibility by the offender.
Other familiar cases of imperfect forgiveness present their own challenges, as when one seeks to forgive a wrong done to someone else (to forgive on behalf of another, or what is commonly called third-party forgiveness, as for example when the victim is deceased).  Another case concerns self-forgiveness.  The latter is particularly complicated, as one may seek to forgive oneself for wrongs one has done to others; or for a wrong one has done to oneself (say, degrading oneself) by wronging another; or simply for a wrong one has done only to oneself.  Self-forgiveness is notoriously apt to lapse into easy self-exculpation; here too, conditions must be set to safeguard the integrity of the notion.
Excuse, mercy, reconciliation, pardon, political apology and forgiveness of financial debt are not imperfect versions of interpersonal forgiveness; rather, they are related but distinct concepts.  Take political apology, for example.  As its name indicates, its context is political, meaning that it is transacted in a context that involves groups, corporate entities, institutions, and corresponding notions of moral responsibility and agency.  Many of the complexities are discussed by philosopher Nick Smith in “I Was Wrong: the Meanings of Apologies.”  Apology figures into interpersonal forgiveness too.  But in the case of political apology, the transaction may in one sense be quite impersonal: picture a spokesperson apologizing for a government’s misdeeds, performed before the spokesperson was born, to a group representing the actual victims.  A lot of the moral work is done by representation (as when a spokesperson represents the state).  Further, the criteria for successful apology in such a context will overlap with but nevertheless differ from those pertinent to the interpersonal context.  For example, financial restitution as negotiated through a legal process will probably form an essential part of political apology, but not of forgiveness.
But, one may object, if the wrongdoer is unforgivable, then both interpersonal forgiveness and political apology are impossible (one can pronounce the words, but the moral deed cannot be done).  Are any wrongdoers unforgivable?  People who have committed heinous acts such as torture or child molestation are often cited as examples.  The question is not primarily about the psychological ability of the victim to forswear anger, but whether a wrongdoer can rightly be judged not-to-be-forgiven no matter what offender and victim say or do.  I do not see that a persuasive argument for thatthesis can be made; there is no such thing as the unconditionally unforgivable.  For else we would be faced with the bizarre situation of declaring illegitimate the forgiveness reached by victim and perpetrator after each has taken every step one could possibly wish for.  The implication may distress you: Osama bin Laden, for example, is not unconditionally unforgivable for his role in the attacks of 9/11.  That being said, given the extent of the injury done by grave wrongs, their author may be rightly unforgiven for an appropriate period even if he or she has taken all reasonable steps.  There is no mathematically precise formula for determining when it is appropriate to forgive.
RELATED
More From The Stone
Read previous contributions to this series.
Why forgive?  What makes it the commendable thing to do at the appropriate time?  It’s not simply a matter of lifting the burden of toxic resentment or of immobilizing guilt, however beneficial that may be ethically and psychologically.  It is not a merely therapeutic matter, as though this were just about you.  Rather, when the requisite conditions are met, forgiveness is what a good person would seek because it expresses fundamental moral ideals.  These include ideals of spiritual growth and renewal; truth-telling; mutual respectful address; responsibility and respect; reconciliation and peace.
My sketch of the territory of forgiveness, including its underlying moral ideals, has barely mentioned religion. Many people assume that the notion of forgiveness is Christian in origin, at least in the West, and that the contemporary understanding of interpersonal forgiveness has always been the core Christian teaching on the subject.  These contestable assumptions are explored by David Konstan in “Before Forgiveness: The Origins of a Moral Idea.”  Religious origins of the notion would not invalidate a secular philosophical approach to the topic, any more than a secular origin of some idea precludes a religious appropriation of it.  While religious and secular perspectives on forgiveness are not necessarily consistent with each other, however, they agree in their attempt to address the painful fact of the pervasiveness of moral wrong in human life. They also agree on this: few of us are altogether innocent of the need for forgiveness.

Incidentes críticos durante anestesia en un país en desarrollo; Una auditoría restrospectiva

Incidentes críticos durante anestesia en un país en desarrollo; Una auditoría restrospectiva
Critical incidents during anesthesia in a developing country: A retrospective audit
AO Amucheazi, OV Ajuzieogu
Department of Anaesthesia, College of Medicine University of Nigeria, Enugu campus, Nigeria
Anesth Essays and Research 2010:4:64-68.   DOI: 10.4103/0259-1162.73508

Background: Critical incidents occur inadvertently where ever humans work. Reporting these incidents and near misses is important in learning and prevention of future mishaps. The aim of our study was to identify the incidence, outcome and potential risk factors leading to critical incidents during anaesthesia in a tertiary care teaching hospital and attempt to suggest preventive strategies that will improve patient care. Materials and Methods: A retrospective audit of all anaesthesia charts for documented critical incidents over a 12 month period was carried out. Age and ASA classification of patient, urgency of surgery, timing of the incident, body system involved and the grade of the anaesthetists were noted. The data collected was analysed using the SPSS software. Results: Fourteen incidents were documented in 54 patients, giving a frequency of 0.071. More females suffered critical incidents. Patients in the 4 th and 5 th decades of life were noted to be more susceptible. Airway and cardiovascular incidents were the commonest. Anaesthetists with less than 6 years experience were involved in more mishaps. Conclusion: We conclude that airway mishaps and cardiovascular instability were the commonest incidents especially in the hands of junior anaesthetists.

Muerte o Daño Neural por Anestesia en Pacientes de Bajo riesgo. Análisis de 25 casos y del Impacto a Largo Plazo en los Anestesiólogos.
Dr. Víctor M. Whizar-Lugo, Dr. Roberto Cisneros-Corral, Lic. Jesús A. Maldonado-Romero
Anestesia en México 2007;19(2):88-98

Resumen
Aunque la anestesia es un procedimiento seguro, tienen una mortalidad de 1 por cada 10,000 casos. Existen por lo menos cuatro causas comunes de falla por anestesia que son responsables de la mayoría de las muertes: intubación difícil, broncoaspiración, ventilación inadecuada, y falla de restitución de volumen. Objetivo. Revisar las muertes por anestesia y daño neurológico severo en pacientes de bajo riesgo anestésico, de los factores implicados y el impacto en los anestesiólogos involucrados. Método. Se trata de un estudio prospectivo, observacional en el cual se revisaron las muertes de 25 pacientes ASA 1 y 2 que murieron en Tijuana de 1985 a 1990 debido a complicaciones por anestesia. Los expedientes médicos y legales se analizaron para determinar las circunstancias, hechos y factores involucrados. También analizamos el impacto a largo plazo de estas muertes en los anestesiólogos involucrados. Resultados. Hubo 25 casos de daño neural severo o muerte por anestesia; 8 hombres, 14 mujeres, con edad de 2 a 69 años (media 35.5), 16 casos fueron manejados con anestesia general (14 muertos, 1 daño cerebral severo 1 daño motor) y 9 con regional (4 muertes, 4 daño neural periférico, 1 daño cerebral). Hubo error humano en 24 casos (17 del anestesiólogo, 4 de la enfermera, 2 de personal no médico). Hubo 9 demandas y un anestesiólogo se suicidó. Discusión. El error humano fue la causa más frecuente de muerte o daño neurológico en nuestros casos de bajo riesgo. Aunque nuestros resultados son incompletos, muestran la necesidad que existe para desarrollar un sistema local orientado a disminuir la morbimortalidad por anestesia en nuestra ciudad.
Palabras clave: Muerte, daño neural, anestesia, bajo riesgo.
Presión de producción, errores médicos, y la verificación preanestésica
Production pressure, medical errors, and the pre-anesthesia checkout
Samuel DeMaria Jr., Steven M. Neustein
M.E.J. ANESTH 20 (5), 2010
Abstract
Medical errors have rightly become an important societal and professional issue. While anesthesiology as a specialty has been at the forefront of the patient safety movement it is also subject to the same pressures for efficiency as any other business. Whether this pressure is at odds with the delivery of safe care is not yet clearly delineated. However, a theoretical framework of unsafe practices as well as a body of literature from other industries such as aviation suggests that production pressure may lead to unsafe practice. Also, it is unlikely that the common pressures encountered in the operating room (e.g., to reduce turnover times) have any positive financial impact for anesthesiology departments unless extra cases can be done each day. We include in this review a potential area for improvement and further research for anesthesiologists, the preanesthesia induction timeout. This crucial period of any anesthetic involves a high workload and is often the most hurried; this combination may be setting practitioners up to make errors. We suggest the use of checklists and timeouts to formalize this period and propose a useful seven-point list of crucial items and events needed before each anesthetic
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Atentamente
Anestesiología y Medicina del Dolor

Riesgo de neumonía postoperatoria e inhibidores de la acidez gástrica


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Artículo nº 1583. Vol 12, diciembre 2010.
Autor: Eduardo Palencia Herrejón

Riesgo de neumonía postoperatoria e inhibidores de la acidez gástrica
Artículo original: Postoperative pneumonia in elderly patients receiving acid suppressants: a retrospective cohort analysis. Redelmeier DA, McAlister FA, Kandel CE, Lu H, Daneman N. BMJ 2010; 340: c2608. [Resumen] [Artículos relacionados]

Introducción: Los inhibidores de la acidez gástrica (IAG) aumentan el crecimiento bacteriano en el tracto digestivo, lo que puede favorecer la aparición de infecciones gastrointestinales y respiratorias. A pesar de haberse realizado múltiples estudios tanto en el ámbito ambulatorio como en el hospitalario y en las UCI, los datos son controvertidos.

Resumen: Se identificaron en una base de datos previamente validada todos los 593.265 pacientes mayores de 65 años de la región canadiense de Ontario sometidos a cirugía electiva entre 1992 y 2008, a fin de investigar mediante análisis multivariante si el uso previo de IAG (principalmente omeprazol y ranitidina) se asocia a un mayor riesgo de neumonía postoperatoria. Los que tomaban IAG presentaron un riesgo mayor de neumonía postoperatoria (13 por 1.000 frente a 10 por 1.000; OR 1,3; IC 95% 1,23-1,38; P < 0,001), pero también tenían con mayor frecuencia otros factores de riesgo de neumonía. Después de ajustar por distintos factores de confusión no se encontró aumento del riesgo asociado de forma independiente al uso de IAG (OR ajustada 1,02; IC 95% 0,96-1,09; P = 0,48). No se identificó ningún subgrupo que presentara un riesgo aumentado de neumonía postoperatoria asociado al uso de IAG (inhibidores de la bomba de protones, tratamientos de larga duración, dosis altas, cirugía de alto riesgo...).

Comentario: El estudio se ciñe a ancianos mayores de 65 años, sobre los que recaen la mayoría de los casos de neumonía postoperatoria, y a casos de primera cirugía electiva, pues la cirugía de emergencia y las cirugías sucesivas presentan factores de confusión difíciles de controlar en un estudio observacional. El estudio se realizó con gran rigor metodológico, aunque no analizó la influencia de factores de riesgo potencialmente importantes no recogidos en la base de datos, como tabaquismo, alcoholismo, dependencia funcional, obesidad, espirometría... y encontró factores de riesgo previamente identificados de neumonía postoperatoria (EPOC, neumonía previa, cirugía torácica o abdominal mayor, duración de la cirugía, edad, sexo, inserción de sonda nasogástrica, hipoalbuminemia postoperatoria, comorbilidad, psicofármacos). La neumonía postoperatoria aumenta la estancia hospitalaria en más de diez días y multiplica por diez el riesgo de muerte,y este estudio es relevante porque señalar otros factores de riesgo prioritarios para la investigación y para diseñar intervenciones preventivas. Sus resultados sin embargo no son extrapolables a la cirugía no programada o a situaciones en que los IAG se prescriben por un proceso agudo.

Eduardo Palencia Herrejón
Hospital Infanta Leonor, Madrid
©REMI, http://remi.uninet.edu. Diciembre 2010.

Enlaces:
  1. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians.  Smetana GW, Lawrence VA, Cornell JE; American College of Physicians.Ann Intern Med 2006; 144(8): 581-595. [ PubMed]
Búsqueda en PubMed:
  • Enunciado: Neumonía nosocomial y antisecretores gástricos
  • Sintaxis: nosocomial pneumonia AND (proton pump inhibitors OR H2 receptor antagonists)
  • [Resultados]
Palabras clave: Neumonía postoperatoria, Inhibidores de la secreción ácida gástrica, Riesgo.