Medical Dilemma Research Articles

Clinical dilemmas in the management of transgender men.

To explore the medical and surgical clinical dilemmas in the management of trans (transgender) men, a growing population receiving more attention than in the past. Testosterone therapy is commonly prescribed to trans men for masculinization. Nonetheless, the optimal formulations and doses of testosterone therapy for trans men have not been well established. Testosterone therapy has been associated with increased levels of hemoglobin and triglycerides, as well as diabetes. Periodic monitoring of hemoglobin, cholesterol, and fasting glucose is therefore recommended. As compared to non-transgender women, trans men have lower age-specific rates of breast cancer and cervical cancer which can be attributed, in part, to surgeries such as bilateral mastectomies and hysterectomies. The frequency in which to recommend mammograms and Pap smears (in patients with intact cervices) is uncertain in this population because of a lack of evidence-based data. Many trans men desire and undergo bilateral mastectomies with much fewer undergoing metoidioplasty or phalloplasty. For trans men, most clinicians target serum testosterone concentrations in the normal male reference range. The frequency of screening for breast and cervical cancer should be individualized based upon anatomy, patient age, age of initiation of testosterone therapy, and other factors.

Octreotide therapy and restricted fetal growth: pregnancy in familial hyperinsulinemic hypoglycemia

SummaryHypoglycemia during pregnancy can have serious health implications for both mother and fetus. Although not generally recommended in pregnancy, synthetic somatostatin analogues are used for the management of blood glucose levels in expectant hyperinsulinemic mothers. Recent reports suggest that octreotide treatment in pregnancy, as well as hypoglycemia in itself, may pose a risk of fetal growth restriction. During pregnancy, management of blood glucose levels in familial hyperinsulinemic hypoglycemia thus forms a medical dilemma. We report on pregnancy outcomes in a woman with symptomatic familial hyperinsulinemic hypoglycemia, type 3. During the patient’s first pregnancy with a viable fetus octreotide treatment was instituted in gestational age 23 weeks to prevent severe hypoglycemic incidences. Fetal growth velocity declined, and at 37 weeks of gestation, intrauterine growth retardation was evident. During the second pregnancy with a viable fetus, blood glucose levels were managed through dietary intervention alone. Thus, the patient was advised to take small but frequent meals high in fiber and low in carbohydrates. Throughout pregnancy, no incidences of severe hypoglycemia occurred and fetal growth velocity was normal. We conclude that octreotide treatment during pregnancy may pose a risk of fetal growth restriction and warrants careful consideration. In some cases of familial hyperinsulinemic hypoglycemia, blood glucose levels can be successfully managed through diet only, also during pregnancy.Learning points:Gain-of-function mutations in GCK cause familial hyperinsulinemic hypoglycemia.Hypoglycemia during pregnancy may have serious health implications for mother and fetus.Pregnancy with hyperinsulinism represents a medical dilemma as hypoglycemia as well as octreotide treatment may pose a risk of fetal growth restriction.In some cases of familial hyperinsulinemic hypoglycemia, blood glucose levels can be successfully managed through diet only.

Renouncement of renal replacement therapy: withdrawal and refusal.

Renouncement of renal replacement therapy (RRT) is a medical dilemma. This review covers the concept, the magnitude, the prognosis, and discusses strategies and management approaches about this subject in patients with CKD and AKI. Evidence suggests that refusal is more frequent and carries a more guarded prognosis than withdrawal of RRT. When RRT is not expected to be beneficial in terms of survival or quality of life, conservative treatment and palliative care are alternatives. We review the historical evolution of guidelines about renouncement of RRT and palliative care, and highlight the absence of specific recommendations in Brazil. However renouncement of RRT may be ethically and legally accepted in Brazil, as the right to a dignified death. Longer life expectancy, economic pressures, and greater awareness will require a more detailed discussion about indications and sustainable use of RRT, and possibly the elaboration of national guidelines.

Analysis of Work Assignments After Medical Ethics Workshop for First-Year Residents at Siriraj Hospital

Background: Upon entering the residency training program, all 1 st -year residents at Siriraj Hospital must join medical ethics workshop held by the Division of Postgraduate Studies. At the end of the workshop, the residents were given a work assignment to write a clinical ethics situation they have encountered in their past practice. Methods: This study is an analysis of content described in the work assignments in order to gain the information regarding common medical ethics dilemmas, which the physicians faced in the early days of practice. Results: 740 work assignments were reviewed. The 4 most common ethical principle mentioned in these assignments were autonomy (144, 19.5%), palliative care (133, 18.0%), beneficence (121, 16.4%), and confidentiality (110, 14.9%). More than half of the situations described were during their internship (474, 64.1%) and tended to distributed equally among community hospital (39.1%), university hospital (28.0%), and general hospital (24.3%). Conclusion: This study should raise the awareness of the medical educator towards these medical ethics issues during curriculum planning.

Cladribine, Cytarabine and Mitoxantrone As Treatment Intensification for Patients with Acute Myeloid Leukemia with the Excess of Bone Marrow Blasts on Day 14 of the First Induction. Prospective, Multicenter Study By the Polish Adult Leukemia Group (PALG)

ObjectivesThe treatment results of acute myeloid leukemia (AML) patients (pts) younger than 60yo are still unsatisfactory. The strategy of double induction in AMLis based on two courses of chemotherapy depends on percentage of bone marrow (BM) blast at 7-14 days of treatment. This therapy intensification may induce higher response rate but toxicity appeared as early death (ED) rates still a medical dilemma. The advantage from addition of cladribine (2CdA) to standard induction and reinduction treatment was previously confirmed in PALG's trials.AimThe aim of this study was an estimation of efficacy and toxicity of treatment intensification based on BM blast at 14 day (D14) by second early induction, CLAM (2CdA + cytarabine + mitoxantron)MethodsWe performed multicenter, prospective, non-randomized trial where pts received DAC induction treatment with subsequent second early induction according as D14 BM biopsy results. When BM examination revealed >10% of blast without hypocellular marrowand pts met all criteria to intensive chemotherapy, second intensive induction with CLAM protocol (2CdA 5mg/m2 iv days 1-5, Cytarabine 2g/m2 iv days 1-5, Mitoxantron 10mg/m2 iv days 1-3) from day 16 was applied. The pts were allocated to risk-adjusted postremission treatment with high-dose cytarabine (HD-AraC) for low-risk group according to European Leukemia Net (ELN) classification and allogeneic stem cell transplantation (allo-SCT) recommended for intermediate and high-risk group.ResultsOne hundred seventy one newly diagnosed AML pts from 8 PALG's centers were enrolled to the study. The median age was 47 yo (range19-60). According to WHO 2008 classification, our group consisted of 9% AML with recurrent genetic abnormalities, 19% AML related to myelodysplasia, 3% therapy-related AML and 69% AML not otherwise classified. Analysis of cytogenetic-molecular risk factors based on ELN classification revealed favorable, intermediate-1, intermediate-2, poor-risk groups in 17%, 44%, 18% and 21% AML pts, respectively. Twenty-six (15%) out of 171 pts had elevated BM infiltration of blasts at D14, with the median 44% (range 11-100%). Overall, 22 of 26 pts were judged as eligible to receive second induction, reasons for exclusion being in all cases active infection.Response evaluation was available in 150 pts, 21 pts were still ongoing in the protocol. Complete remission (CR) rate after single DAC induction course was 71% (n=106), partial remission (PR), non-remission (NR) and ED was 8% (n=12), 18% (n=28) and 3% (n=4), respectively. Response after double induction was evaluated in 21 out of 22 cases; one patient still has not reached time of measurement. CR was observed in 14/21 pts (67%), NR in 5% (n=1), ED 28% (n=6). The CR rate after inductiontreatment applied to first hospitalization (DAC or DAC+ CLAM) was 81% (n=120). Twelve pts who had <10% of blasts at day 14 and achieved PR after first induction were allocated to second DAC induction. Six out of them achieved CR leading to the overall CR rate 85%.In 27 pts who achieved CR allo-SCT was performed till June 2016, however there are pts who are still awaiting allo-SCT.The median duration of hospital stay was 31 (11-73) and 66 (52-76) days respectively for the DAC and the DAC + CLAM induction. During the single DAC induction the median number of days with neutropenia <0.5 G/l was 24 (12-101), and with thrombocytopenia <20 G/l was 12 (0-51). The median number of transfused packed red blood cell (PRBC) was 9 (0-32) and the number of platelet concentrate units was 15 (2-124). During DAC+CLAM double induction the median number of days of the neutropenia <0.5 G/l was 53 (17-73) and thrombocytopenia <20 G/l was 19 (4-57). The median number of PRBC was 18 (10-44) and the number of platelet concentrate units was 30 (5-153).With the median time of follow-up 16 months the median overall survival (OS) was not reached. The probability of 1-year OS was 59% and the probability of 1-year disease free survival was 83% (Figure 1, Panel A and B).ConclusionThe preliminary results of our study suggest that early second induction CLAM is a feasible and effective treatment option in younger AML patients which further improves the CR rate and do not compromise the feasibility of allo-SCT. [Display omitted] DisclosuresGrzybowska-Izydorczyk:BMS: Honoraria; Novartis: Honoraria. Warzocha:BMS: Consultancy, Honoraria; Novartis: Consultancy, Honoraria. Robak:Pharmacyclics, LLC, an AbbVie Company: Consultancy, Honoraria, Research Funding; AbbVie: Consultancy, Honoraria, Research Funding; Janssen: Consultancy, Honoraria, Research Funding. Wierzbowska:Novartis: Consultancy, Honoraria; Janssen Cilag: Consultancy.

A Vertically Placed Clip for Weight Loss: a 39-Month Pilot Study

Morbid obesity remains one of society's significant medical dilemmas. It is rapidly worsening and expected to affect 35% of the US population by the year 2020. Common current bariatric procedures exist and include, but not limited to, the adjustable gastric band, gastric bypass, and the sleeve gastrectomy. Although beneficial to morbidly obese patients, they also alter the patient's anatomy and involve resections, or require maintenance. The goal of the trial is to show a new minimally invasive vertical gastric clip technique that produces significant weight loss but requires no resection, no change in anatomy, and is reversible. From November 2012 to February 2016, prospective collected data from 117 patients was included in the gastric clip trial. The clip consists of a silicone-covered titanium backbone with an inferior hinged opening that separates a medial lumen from an excluded lateral gastric pouch. The inferior opening allows the gastric juices to empty from the fundus and the body of the stomach into the distal antrum. Weight loss and comorbidities were evaluated among 117 patients over a 39-month period. 66.7% excess weight loss was seen with minimal adverse events. Average length of surgery was 69min. Average length of stay was 1.3days. Fifteen of the originally implanted clips were electively removed based on the original protocol, and the other two were removed for displacement of the device. The vertical, gastric clip trial has shown that excellent weight loss can be achieved without some of the complications seen with historical bariatric procedures. This clip is placed without requiring stapling, resection, malabsorption, change in anatomy, or maintenance. It is also easily reversible.

TF7 A Novel Integrated Learning Approach for Pre-Clinical Medical Students Through Early Procedural Exposure and Simulation

Much of existing pre-clinical basic science curriculum consists of lecture, reading, and standardized tests. Outside of the anatomy lab, many first- and second-year medical students (MS-1s, MS-2s) lack hands-on experiential learning. For visual and kinesthetic learners who thrive in a student-centered learning environment, new curricula must be offered to accommodate adult learners. The goal of this project is to offer MS-1s and MS-2s a novel integrated learning approach to medical curricula in their pre-clinical years through early procedural and simulation exposure. Four separate workshops occur over the course of a year to encourage diagnostic reasoning and procedural intervention. Through practical application of theoretical knowledge, students will dynamically engage with real-world medical cases and diagnostic dilemmas. During this series of workshops, the learner will be expected to (1) recall existing pre-clinical knowledge, (2) build knowledge though videos, online, and in-person curricula, (3) synthesize basic science knowledge with real-world application, (4) propose differential diagnoses and formulate treatment plans, and (5) perform hands-on procedures and practice clinical skills. In relation to entrustable professional activities (EPAs) medical students will: 1- Gather a history and perform a physical exam, 2- Prioritize a differential diagnosis, 3- Recommend and interpret common diagnostic and screening tests, 4- Form clinical questions and retrieve evidence to advance patient care, 5- Recognize a patient requiring urgent or emergent care and initiate evaluation and management, 6- Obtain informed consent for tests and/or procedures, and 7- Perform general procedures. The instruction will occur in a series of four workshops offered over 12 months (4 quarterly four-hour sessions), which is independent of, but complementary to, the pre-clinical curriculum. Each workshop has a pre-test and content overview including videos and interactive online materials. The in-person workshop consists of integrating diagnostic reasoning and procedural skills through case simulations. Students will rely on their classroom-based knowledge and underlying understanding of systems-based disease processes to work through the patient cases. Through scenarios such as headache with altered mental status (lumbar puncture), sepsis (central line), trauma (laceration repair/splinting), and vision loss (slit lamp exam, tonometry) students will perform procedures firsthand. The curriculum will guide the learners through independent study, group collaboration, critical reasoning, hands-on skills practice, and reflection. Students complete a post-test immediately following the workshop and at 3 months to gauge retention of the material covered. The curriculum was successfully piloted for MS-1s and MS-2s. 100% felt the curriculum was successful. Using a Likert scale of 1 (poor) to 5 (excellent), the average score was 4.8. In the future, the curriculum will be expanded in breadth of content and variety of teaching modalities. Further curriculum evaluation is needed to justify adding the proposed workshop-based curriculum to pre-clinical medical education and continued in perpetuity.

Attending patient funerals: Practices and attitudes of Australian medical practitioners

ABSTRACTThe appropriateness of attending a patient’s funeral is a medical dilemma. This article focuses on 437 doctors who participated in an online survey. Seventy-one percent of general practitioners, 67% of oncologists, 67% of psychiatrists, 63% of palliative medicine specialists, 52% of surgeons, and 22% of intensive care specialists had attended patient funerals. Significant differences in demographics and between specialties were identified in terms of barriers and benefits associated with attendance. Although attendance is a personal decision, there is a need for open discussions in medical education and professional development concerning death and the role of doctors after a patient dies.

Critical evaluation of advance statements from patients lacking mental capacity

Advance refusals of medical treatment present complex dilemmas with ethical, moral and legal facets. A competent patient may refuse any treatment, even where the decision may lead to an untimely death. The same holds true with respect to an incompetent patient with an advance directive made when that patient was competent and there is no reason to believe that the patient has changed his or her mind. Advance statements arise from respect of patient autonomy and the introduction of The Mental Capacity Act 2005, which aims to provide consistently better protection and greater empowerment for vulnerable people and their autonomous rights. This article outlines how the patient's right to choose in advance how they are to be treated if not competent to make his own treatment decisions is a positive development in the law. However, it may be of limited effect, as the majority of people will probably never make an advance statement. As a result, we should educate both patients and doctors about their rights in relation to medical decision-making, particularly as our increasing ability to prolong life makes decisions to terminate life-sustaining treatment more common. In order to respect patient autonomy, avoid harm to patients and reduce the risk to paramedics of civil or criminal liability, paramedics need to determine the legal validity of advance directives before making their treatment decision. In cases of uncertainty treatment decisions should be made in the patient's best interests while legal advice is sought as to the validity of the directive.

Variation in the oxytocin receptor gene (OXTR) is associated with differences in moral judgment.

Moral judgments are produced through the coordinated interaction of multiple neural systems, each of which relies on a characteristic set of neurotransmitters. Genes that produce or regulate these neurotransmitters may have distinctive influences on moral judgment. Two studies examined potential genetic influences on moral judgment using dilemmas that reliably elicit competing automatic and controlled responses, generated by dissociable neural systems. Study 1 (N = 228) examined 49 common variants (SNPs) within 10 candidate genes and identified a nominal association between a polymorphism (rs237889) of the oxytocin receptor gene (OXTR) and variation in deontological vs utilitarian moral judgment (that is, judgments favoring individual rights vs the greater good). An association was likewise observed for rs1042615 of the arginine vasopressin receptor gene (AVPR1A). Study 2 (N = 322) aimed to replicate these findings using the aforementioned dilemmas as well as a new set of structurally similar medical dilemmas. Study 2 failed to replicate the association with AVPR1A, but replicated the OXTR finding using both the original and new dilemmas. Together, these findings suggest that moral judgment is influenced by variation in the oxytocin receptor gene and, more generally, that single genetic polymorphisms can have a detectable effect on complex decision processes.

Ganglioneuroblastoma during pregnancy – A rare case report

Purpose: To report a rare case of ganglioneuroblastoma encountered rarely in adults, especially during pregnancy. Materials and Methods: The authors present a case of ganglioneuroblastoma relapse during the third trimester of pregnancy in a patient previously treated for ganglioneuroblastoma who had a eight-year disease-free interval. Late manifestation of neurological symptoms (vestibular syndrome, nystagmus, slightly right motor deficit) was perhaps influenced by the hormonal pregnancy effects. In this case the option was for caesarean section under general anesthesia at 36 weeks. Results: Based on MRI result, the neurosurgical consultation stated the need of postpartum brain tumor excision. Recovery of the mother was complication-free with persistent, constant postoperative neurological symptoms. It resulted in a healthy newborn, not requiring special follow-up. Conclusions: Pregnancy and brain tumor have mutual negative effect on the patient. Therapeutic management in this case was a medical dilemma regarding mode setting and timing of delivery, taking into account the maternal-fetal risk-benefit.

Family planning, pregnancy and breastfeeding in multiple sclerosis.

Multiple sclerosis often affects women of childbearing age. The availability of more effective immunomodulatory therapy may increase the number of afflicted women wanting to fulfil their desire to have children. The purpose of this article is to provide an up-to-date review of medical issues and dilemmas related to family planning and pregnancy in multiple sclerosis.

Work-Related Burden on Physicians and Nurses Working in Neonatal Intensive Care Units: A Survey

Aim: This study aimed at exploring the type, degree, and duration of work-related burden on neonatal physicians and nurses working in tertiary level neonatal intensive care units, its impact on their private life, and at assessing which coping strategies were found helpful. Methods: Transversal descriptive study using an anonymous questionnaire. Results: Fifty-two neonatal physicians and 60 nurses took part in this survey (response rate 77%). Altogether, 78% stated that the difficult medical and ethical dilemmas represent a burden to them. 87% experienced this work burden as momentary, and 12% as long-lasting. In 40% of the respondents, their private life was affected. Exhaustion was the most frequently cited stress symptom (physicians 25%, nurses 15%). Close to 90% of the caregivers were offered a platform for team debriefings and discussions or pastoral assistance by their hospital, but most of the respondents found relief from stress through discussions with family members and friends (20%), and through their hobbies (15%), or both (43%). Conclusion: Working in a NICU environment represents a burden for the majority of neonatal health care providers. Exhaustion was the most frequent symptom. Social contacts with family and friends and hobbies are the coping strategies found most helpful. Staff meetings, debriefing platforms and pastoral assistance help alleviate work-related stress. Keywords: Coping; Coping behavior; Exhaustion; Work-related stress; NICU

Respiratory syncytial virus, an ongoing medical dilemma: an expert commentary on respiratory syncytial virus prophylactic and therapeutic pharmaceuticals currently in clinical trials.

As the most important viral cause of severe respiratory disease in infants and increasing recognition as important in the elderly and immunocompromised, respiratory syncytial virus (RSV) is responsible for a massive health burden worldwide. Prophylactic antibodies were successfully developed against RSV. However, their use is restricted to a small group of infants considered at high risk of severe RSV disease. There is still no specific therapeutics or vaccines to combat RSV. As such, it remains a major unmet medical need for most individuals. The World Health Organisations International Clinical Trials Registry Platform (WHO ICTRP) and PubMed were used to identify and review all RSV vaccine, prophylactic and therapeutic candidates currently in clinical trials. This review presents an expert commentary on all RSV-specific prophylactic and therapeutic candidates that have entered clinical trials since 2008.

The anthropological approach challenges the conventional approach to bioethical dilemmas: a Kenyan Maasai perspective.

The cultural background, religion and societal norms have a huge influence on the decision making process for physicians, patients and their families, when faced with medical ethical dilemmas. While the medical professionals, through their training, can rely on the principles of autonomy, justice, beneficence and non-maleficence to guide them, the patients can only draw from their personal and cultural experiences. To explore some of the challenges that face physicians when presented with ethical dilemmas. A review of the literature on the principles of medical ethics and the cultural practices of the Maasai tribe, as well as, interview, interaction and observation of the patients and family during patient. management. In the Maasai community in Kenya, where family is the center of all attention and decision-making, the listed ethical principles and rules have a very different understanding of the self-determination, and autonomy becomes collective rather than individualistic. Medical practitioners when faced with ethical medical dilemmas are neither comfortable in adopting the conventional bioethical guidelines, nor in offering a health care purely based on cultural and historical practice. In our set up, developing culturally relevant principles of bioethics appears to be the most effective solution in addressing medical ethical dilemmas.

Creating, curating, and sharing online faculty development resources: the medical education in cases series experience.

It is difficult to engage clinicians in continuing medical education that does not focus on clinical expertise. Evolving online technologies (e.g., massive open online courses [MOOCs]) are disrupting and transforming medical education, but few online nonclinical professional development resources exist. In August 2013, the Academic Life in Emergency Medicine Web site launched the Medical Education in Cases (MEdIC) series to engage clinicians in an online professional development exercise. Each month, a complex, realistic scenario featuring a nonclinical medical education dilemma is published with accompanying discussion questions. A weeklong discussion is moderated on Twitter and the Web site. This discussion is curated to create a community commentary, which is published alongside presolicited expert responses. Case resources are available for download. The first six MEdIC cases (published August 2013-January 2014) emphasized different CanMEDS and/or Accreditation Council on Graduate Medical Education competencies. Median reader engagement metrics (interquartile range 25%-75%) in the first week following publication were 861 (634-1,114) pageviews, 767 (518-953) unique visitors from 326 (218-405) cities in 45 (32-50) countries, 30 (24-39) comments, 52 (40-56) tweets, 17 (13-30) Facebook Likes, and 5 (5-7) Google Plus +1s. The MEdIC series is proof of concept that online activities can engage clinicians in nonclinical professional development. The early experience suggests the connectivist nature of MEdIC allows for crowdsourcing solutions to ill-defined problems via the wisdom of readers. This methodology may also be effective for other nonclinical and medical education topics.

Mycobacteria and autoimmunity.

Mycobacterial infections can cause a variety of different manifestations. The increasing incidence of these infections worldwide brought another medical dilemma: immunological manifestations characterized by the presence of many autoantibodies and concomitant presence of autoimmune diseases. The burden of tuberculosis reactivation that emerged with immunosuppressive therapy worsened with the growing use of biological disease-modifying antirheumatic drugs (DMARDs). This review will address the relationship between the immune system and mycobacteria.

The termination of the late pregnancy in Serbian law and comparative European law

The termination of the late pregnancy causes legal, medical and ethical dilemmas. This is due to the development of fetus if pregnancy is late one and complexity of the needed medical procedures. Legal regime of the termination of late pregnancy contains special conditions: legally stipulated indications and special procedure which means getting permission from particular body for the termination. In this article author compares legal regimes in: United Kingdom, France, Germany, Nordic countries, Switzerland, Italy, Russia, Check Republic and Serbia. Universal definition of the late pregnancy does not exist, but pregnancy after 24 weeks is considered late in Dutch law, and in the legal theory in United Kingdom. The time limit for termination of the pregnancy in some legislation is 24 weeks (e.g. Check Republic and Finland). According to Serbian law, there is a distinction of the pregnancy until 10 weeks, when termination is possible on pregnant woman's request, from 10 to 20 weeks when termination is decided by consilium of the physicians and after to 20 weeks when termination is decided by ethical committee. In the domestic law there is no distinction of the necessary indications for termination of the pregnancy after 10 weeks and after 20 weeks. Author suggest amendments to exisiting solutions. One, to postpone the termination on the requets until 12 weeks, and to stipulate different indications necessary for the termination pregnancy from 12 to 24 weeks and after 24 weeks - late pregnancy, in order to make the termination of the late pregnancy really exceptional.

The attitude-behavior discrepancy in medical decision making.

Background:In medical practice, the dissatisfaction of patients about medical decisions made by doctors is often regarded as the fuse of doctor-patient conflict. However, a few studies have looked at why there are such dissatisfactions.Objectives:This experimental study aimed to explore the discrepancy between attitude and behavior within medical situations and its interaction with framing description.Patients and Methods:A total of 450 clinical undergraduates were randomly assigned to six groups and investigated using the classic medical decision making problem, which was described either in a positive or a negative frame (2) × decision making behavior\\attitude to risky plan\\attitude to conservative plan (3).Results:A discrepancy between attitude and behavior did exist in medical situations. Regarding medical dilemmas, if the mortality rate was described, subjects had a significant tendency to choose a conservative plan (t = 3.55, P < 0.01) yet if the survival rate was described, there was no such preference (t = -1.48, P > 0.05). However, regardless of the plan chosen by the doctor, the subjects had a significant opposing attitude (P < .05). Framing description had a significant impact on both decision making behavior and attitude (t behavior = -3.24, P < 0.01；t attitude to surgery = 4.08，P < 0.01；t attitude to radiation = -2.15，P < 0.05).Conclusions:A discrepancy of attitude-behavior does exist in medical situations. The framing of a description has an impact on medical decision-making.

Child-witnessed domestic violence and its adverse effects on brain development: a call for societal self-examination and awareness.

There is substantial evidence indicating that children who witness domestic violence (DV) have psychosocial maladaptation that is associated with demonstrable changes in the anatomic and physiological make up of their central nervous system. Individuals with these changes do not function well in society and present communities with serious medical, sociological, and economic dilemmas. In this focused perspective, we discuss the psychosocially induced biological alterations (midbrain, cerebral cortex, limbic system, corpus callosum, cerebellum, and the hypothalamic, pituitary, and adrenal axis) that are related to maladaptation (especially post-traumatic stress disorder) in the context of child-witnessed DV, and provide evidence for these physical alterations to the brain. Herein, we hope to stimulate the necessary political discourse to encourage legal systems around the world to make the act of DV in the presence of a child, including a first time act, a stand-alone felony.