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Decision to withdraw life-sustaining medical intervention(LSMI) is a common ethical issue in clinical practice. This paper reviews and analyzes the ethical arguments for withdrawing LSMI from three aspects: respect for autonomy, medical futility and patients' best interests. The authors argue that withdrawal of LSMI can be ethically justified when any of the following conditions is met: when patient gives valid consent, LSMI is judged to be medically futile, or it is in the patients' best interests. This paper proposes practical suggestions for the withdrawal of LSMI in clinical practice, and presents several policy suggestions. Finally, the authors identify several challenges of withdrawing LSMI in practice and possible approaches to addressing them.

The emerging issue of rising gabapentinoid misuse is being recognized alongside the lack of current evidence supporting the safe and effective deprescribing of gabapentinoids. This scoping review aimed to assess the extent and nature of gabapentinoid deprescribing interventions in adults, either in reducing dosages, or prescribing of, gabapentinoids. Electronic databases were searched on 23 February 2022 without restrictions. Eligible studies included randomized, non‐randomized and observational studies that assessed an intervention aimed at reducing/ceasing the prescription/use of a gabapentinoid in adults for any indication in a clinical setting. The research outcomes investigated the type of intervention, prescribing rates, cessations, patient outcomes and adverse events. Extracted outcome data were categorized as either short (≤3 months), intermediate (>3 but <12 months) or long (≥12 months) term. A narrative synthesis was conducted. The four included studies were conducted in primary and acute care settings. Interventions were of dose‐reducing protocols, education and/or pharmacological‐based approaches. In the randomized trials, gabapentinoid use could be ceased in at least one third of participants. In the two observational trials, gabapentinoid prescribing rates decreased by 9%. Serious adverse events and adverse events specifically related to gabapentinoids were reported in one trial. No study included patient‐focused psychological interventions in the deprescribing process, nor provided any long‐term follow‐up. This review highlights the lack of existing evidence in this area. Due to limited available data, our review was unable to make any firm judgements on the most effective gabapentinoid deprescribing interventions in adults, highlighting the need for more research in this area. [ABSTRACT FROM AUTHOR]

Vernonia cinerea (VC) has been used for smoking cessation. A previous meta-analysis (MA) reported the efficacy of VC in smoking cessation. However, there have been updated randomized controlled trials (RCTs) on the efficacy of VC for smoking cessation, and the previous MA lacked pooled adverse events (AEs) related to VC. The objective of this study was to systematically review and perform an updated MA on the efficacy of VC for smoking cessation continuous abstinence rate (CAR), prevalence abstinence (PAR), and AE. The research articles were retrieved via electronic databases including PubMed, Science Direct, Web of Science, Thai-Journal Citation Index Center (TCI), and ThaiLis. Ten RCTs published prior to 2019 were included in this study. The number of participants in the studies ranged from 35 to 172, and the follow-up duration for the primary outcomes was 2-12 weeks. Our updated MA found that VC could significantly improve CAR2 (RR=1.54; 95% CI = 1.06, 2.23), CAR4 (RR=1.65; 95% CI = 1.25, 2.17), CAR 8 (RR=1.85; 95% CI = 1.25, 2.75), CAR12 (RR=2.56; 95% CI = 1.66, 3.95), and CAR16 (RR=2.21; 95% CI = 1.03, 4.73). Moreover, VC improved PAR2 (RR=1.47; 95% CI = 1.06, 2.04), PAR4 (RR=1.35; 95% CI = 1.02, 1.79), PAR8 (RR=1.60; 95% CI = 1.11, 2.31), and PAR12 (RR=1.70; 95% CI = 1.25, 2.30). There was no significant difference in the AE between the two groups. The study substantiates claims that VC products are effective in assisting with smoking cessation.

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The present study investigated the respective roles of withdrawal, language, and context-inappropriate (CI) anger in the development of emotion knowledge (EK) among a subsample of 4 and 5 year-old preschoolers (n = 74). Measures included parent-reported withdrawn behavior, externalizing behavior, and CI anger, as well as child assessments of receptive language and EK. Ultimately, findings demonstrated that receptive language mediated the relationship between withdrawn behavior and situational EK. However, CI anger significantly interacted with receptive language, and, when incorporated into a second-stage moderated mediation analysis, moderate levels of CI anger rendered the indirect effect of withdrawn behavior on situational EK via receptive language insignificant. Cumulatively, these findings demonstrate a mechanism by which withdrawal may impact EK. They also indicate that such an effect may be attenuated in children with moderate levels of CI anger. Implications of these findings are discussed. [ABSTRACT FROM AUTHOR]

Abstract Background Withdrawal of disease-modifying anti-rheumatic drugs (DMARDs) once disease remission is achieved is endorsed by current international rheumatoid arthritis (RA) management guidelines. However, very little data exists concerning patients’ views of this practice. In this qualitative study, we aimed to explore patients’ perspectives on DMARD withdrawal in the setting of established RA. Methods In this qualitative interview study, patients with stable established RA were recruited from rheumatology outpatient clinics at a large UK teaching hospital. The perceived advantages and disadvantages of DMARDs and views on DMARD withdrawal were explored in semi-structured interviews. Interview transcripts were analysed using standard qualitative techniques to construct an analytical framework. Results Thirteen participants (8 female, median [IQR] age 65 [61–73]) expressed their views of DMARD treatment in the context of their “normal lives”. For some patients, disadvantages such as medication side-effects and the inconvenience of safety monitoring were sufficient hindrances to their lifestyle to justify DMARD withdrawal. However, patients who were vulnerable to loss of physical function, or who had prior experience of severe rheumatoid arthritis, expressed a strong preference against DMARD withdrawal, viewing the potential for increased pain and future disability as unacceptable risks. Conclusions Patients view DMARD withdrawal in the context of either restoring or threatening their “normal lives”. In this model, social and personal factors play a crucial role in influencing patients’ opinions of DMARD therapy beyond a simple consideration of medication side-effects alone. A formulaic approach to DMARD withdrawal determined and imposed by clinicians would not be successful. Instead, the discussion of DMARD withdrawal should take place with the identification of patients’ priorities and in the context of their personal disease experiences. Trial registration clinicaltrials.gov (NCT02064400), retrospectively registered 17 February 2014.

In order for land managers and policy makers to manage excessive soil phosphorus (P) concentrations and reduce the risk of this particular source of P from impacting water bodies, models of soil P decline under various scenarios are needed. We modelled the decrease in calcium chloride-extractable P (CaCl2-P), and sodium bicarbonate-extractable P (Olsen-P and Colwell-P) using data from six Australian grazed pasture soils with contrasting P sorption properties, over a period of 4.5 years. Each soil had four initial soil P concentrations (Pinit), each of which received four on-going rates of P fertiliser (Pfert). The model predicts the final P concentration (Pfinal) by taking into account the P concentration previously measured (CaCl2-P, Olsen-P or Colwell-P), Pfert applied since measurement, and time since previous measurement: Final P concentration = (previously measured P concentration + ep x P fertiliser applied) exp (-dp x years since previous P concentration measurement). Where ep is the increase in soil P for each unit of applied P and dp is the decay constant representing how quickly the soil P decreased. The greatest decreases in proportion to Pinit occurred for CaCl2-P, followed by Olsen-P, and then Colwell-P. The model tended to fit the dataset well for Olsen-P and Colwell-P, with mean overestimation (modelled Pfinal concentration greater than actual Pfinal) of the Pfinal concentrations of 6.1 (32%) and 4.3 mg/kg (10%), respectively. Although there was less CaCl2-P data, the model successfully described it, with a mean overestimation of Pfinal CaCl2 of 3.1 mg/kg (26%). The overestimation of Pfinal CaCl2 was possibly due to the high CaCl2-P concentrations of the low P buffering index soils. The model predicted an average of 32 years (ranging from 26 to 49 years) for Olsen-P concentrations of between 55 and 96 mg/kg to decrease to an agronomic optimum of 17 mg/kg. Agronomic optimum was not a reliable indicator of environmental risk as some soils did not exceed the CaCl2-P environmental threshold until Olsen-P concentrations were twice the agronomic optimum, whereas low P sorbing soils tended to exceed the threshold before reaching agronomic optimum. Further work with more soils is required to examine the influence of soil properties – such as P sorption – on decreases in soil P.

Background/Aims: In Taiwan, due to budget limitations, the National Health Insurance only allows for a limited period of biologics use in treating moderate to severe Crohn's disease (CD). We aimed to access the outcomes of CD patients following a limited period use of biologics, specifically focusing on the relapse rate and remission duration; also the response rate to second use when applicable.Methods: This was a multicenter, retrospective, observational study and we enrolled CD patients who had been treated with adalimumab (ADA) according to the insurance guidelines from 2009 to 2015.Results: A total of 54 CD patients, with follow-up of more than 6 months after the withdrawal of ADA, were enrolled. The average period of treatment with ADA was 16.7±9.7 months. After discontinuing ADA, 59.3% patients suffered a clinical relapse. In the univariate analysis, the reason for withdrawal was a risk factor for relapse (P=0.042). In the multivariate analysis, current smoker became an important risk factor for relapse (OR, 3.9; 95% CI, 1.2−14.8; P=0.044) and male sex was another risk factor (OR, 2.9; 95% CI, 1.1−8.6; P=0.049). For those 48 patients who received a second round of biologics, the clinical response was seen in 60.4%, and 1 anaphylaxis occurred.Conclusions: Fifty-nine percent of patients experienced a relapse after discontinuing the limited period of ADA treatment, and most of them occurred within 1 year following cessation. Male sex and current smoker were risk factors for relapse. Though 60.4% of the relapse patients responded to ADA again.

The decision to continue or withdraw the antiepileptic drugs (AEDs) should be taken jointly by the patient, family and/or caregivers, and the specialist physician, after extensive information and discussion about the risks and benefits of withdrawing the AED. The patient and family members must understand that there is a risk of the recurrence of seizures with and without AED. The type of epilepsy, the prognosis, and the patient's lifestyle should be taken into account. Withdrawal should be carried out under the supervision of a specialist (clinical neurologist) and will be considered when the patient has been seizure free for at least 2 years. The treatment must be withdrawn gradually for a period of at least 2-3 months and the antiepileptics must be removed one by one. Withdrawal of benzodiazepines and barbiturates should be slower, in 6 months or more. An agreement must be made that in the event of a seizure relapse, the patient must return to taking the last dose before the dose in which the relapse was presented and request assessment by clinical neurologist. [ABSTRACT FROM AUTHOR]

Introduction: The long time use of opium has some effects on serums biochemical factors, the determination of this variation is a new approach in understanding off addiction and relive of drug abuser health. Hence in this study, these indicators in person who were withdrawing of opium have been studied. Materials and Methods: In this cross-sectional study bloods biochemical factors such as fasting blood sugar (FBS), sodium (Na), calcium (Ca), uric acid (UA), blood urea nitrogen (BUN), creatinine, cholesterol, triglyceride, total protein, and fibrinogen in three groups serum were studied: (1) Who had been permanent opium users more than 2 years (case). (2) Dependent person who has taken one month addiction withdrawal course (control). (3) A healthy group that had been demographically similar to the other groups. Results: According to these study findings, FBS serum level in the case group is lower than control group. Serum level of Na, creatinine, and blood triglyceride (TG) in case study are higher than group control. Concentration of potassium, Ca, UA, BUN, cholesterol, total serum protein, fibrinogen, and thrombin time in case study and group control showed no significant difference. Also, in withdrawing case serum level of Na, Ca, UA, BUN, creatinine, and TG significantly increase and thrombin time decrease. Conclusion: According to this study not only the longtime use of opium but also opium with drawerin opium dependent people can change their serum biochemical factors. So recognition, treatment, and prevention of this change could be a new step in improving of health and condition of patients.

Introduction: Alcohol withdraw syndrome (AWS) and delirium tremens (DTs) are part of the clinical picture of alcohol dependence (AD). The mechanisms by which these conditions develop are not entirely understood, but there are data suggesting that several factors are largely responsible for the emergence of the AWS and DTs. According to some authors, with the prolongation of the AD and increasing tolerance, the AWS aggravates, somatic and neurovegetative manifestations worsen. Russian authors accept that the degree of clinical manifestations depends on the individual characteristics of the response to ethanol. Materials and methods: The present work is a systematic study of 28 alcohol-dependent patients that developed clinical signs and symptoms of pre-delirium and delirium during alcohol detoxification treatment. Results: The relationship between sex, age, type and duration for abuse, type of alcoholic beverage, and the clinical picture has been analyzed and discussed as well as the criteria for their diagnosis and follow-up. Conclusion: Our analysis of the development and the manifestations of pre-delirium and DTs, during detoxification of AD patients, underlines the protracted course of the illness and the need for multidisciplinary intensive care. Dynamic monitoring of the patients and timely correction of the therapeutic program guarantee the success of the detoxification. [ABSTRACT FROM AUTHOR]

Background: The long time use of opium has some effects on serums biochemical factors, the determination of this variation is a new approach in understanding off addiction and relive of drug abuser health. Hence in this study, these indicators in person who were withdrawing of opium have been studied. Methods: In this cross-sectional study bloods biochemical factors such as fasting blood sugar (FBS), sodium (Na), calcium (Ca), uric acid (UA), blood urea nitrogen (BUN), creatinine, cholesterol, total protein, and fibrinogen in three groups serum were studied: (1) Who had been permanent opium users more than 2 years (case). (2) Dependent person who has taken one month addiction withdrawal course (control). (3) A healthy group that had been demographically similar to the other groups. Findings: According to these study findings, FBS serum level in the case group is lower than control group. Serum level of Na, creatinine, and blood triglyceride (TG) in case study are higher than group control. Concentration of potassium, Ca, UA, BUN, cholesterol, total serum protein, fibrinogen, and thrombin time in case study and group control showed no significant difference. Also, in withdrawing case serum level of Na, Ca, UA, BUN, creatinine, and TG significantly increase and thrombin time decrease. Conclusion: According to this study not only the longtime use of opium but also opium with drawerin opium dependent people can change their serum biochemical factors. So recognition, treatment, and prevention of this change could be a new step in improving of health and condition of patients. [ABSTRACT FROM AUTHOR]

The first year of college continues to be a critical period for student persistence, learning, and development. College students are under increasing pressure to make commitments to major and career plans at a very early stage in their undergraduate experience, often without the programmatic support to do so. First-year experience professionals, who are knowledgeable about student development theory and professionally committed to facilitating the transition of students to collee, are well position to fill the void in support for early academic and career decision-making. Provision of proactive and personalized support to meet the current demands for early educational and vocational decision-makingmay be pivotal for ensuring the success of today's first-year students in general, and today's growing number of first-generation students in particular.

In this paper I argue, against the current consensus, that the right to withdraw from research is sometimes alienable. In other words, research subjects are sometimes morally permitted to waive their right to withdraw. The argument proceeds in three major steps. In the first step, I argue that rights typically should be presumed alienable, both because that is not illegitimately coercive and because the general paternalistic motivation for keeping them inalienable is untenable. In the second step of the argument, I consider three special characteristics of the right to withdraw, first that its waiver might be exploitative, second that research involves intimate bodily access, and third that it is irreversible. I argue that none of these characteristics justify an inalienable right to withdraw. In the third step, I examine four considerations often taken to justify various other allegedly inalienable rights: concerns about treating yourself merely as a means as might be the case in suicide, concerns about revoking all your future freedoms in slavery contracts, the resolution of coordination problems, and public interest. I argue that the motivations involved in these four types of situations do not apply to the right to withdraw from research. [ABSTRACT FROM AUTHOR]

Background and aims: The prevalence of chronic benzodiazepine use in primary care settings remains high despite clear evidence of adverse health outcomes resulting from long‐term use and the availability of effective alternative behavioural therapies. Eliciting factors influencing past or current usage experience of benzodiazepine users and their future behavioural intention regarding discontinuation or alternative behavioural therapy adoption could be useful in developing informed strategies facilitating successful benzodiazepine withdrawal in long‐term users. The aim of this study was to identify patient factors influencing their current long‐term benzodiazepine use, past withdrawal attempt, and future intention to trial safer alternative behavioural therapies. Additionally, the study also aimed to explore patients' preference for information sources on behavioural therapies. Methods: Point of purchase surveys were conducted with patients obtaining benzodiazepines from selected pharmacies across New South Wales (NSW), Australia. Survey items included the Beliefs about Medicines Questionnaire (BMQ‐specific), questions about patient's sociodemographic characteristics, as well as their views about long‐term benzodiazepine use and behavioural therapies. Results: Seventy‐five patients were recruited from 12 pharmacies across New South Wales (NSW). The surveys were conducted from November 2016 to July 2017. The mean (±SD) age of the participants was 54.3 (±16.7) with a range of 23 to 86 years, and 67% of the participants had been using the benzodiazepine for at least 1 year. Lower‐education levels, stronger beliefs about the necessity of use, and lower concerns about ongoing benzodiazepine use were significantly associated with prolonged use. Sixty‐four percent of the participants were not interested in behavioural therapies, and there was a significant relationship between the participants' future preference for behavioural therapies and their concerns about the potential adverse effects of benzodiazepines. A majority of the participants rated general practitioners (GPs) as their first choice and pharmacists as the second choice for discussing behavioural therapies. Conclusions: Specific individual sociodemographic characteristics of benzodiazepine users and their medication‐related beliefs influence their current benzodiazepine usage and future intention to trial behavioural therapies as an alternative to their benzodiazepines. Based on the reported preferences of benzodiazepine users in this study, developing and evaluating GP‐pharmacist collaborative services to improve the uptake of behavioural therapies as an alternative to benzodiazepines can be recommended. [ABSTRACT FROM AUTHOR]

Background/aims: In Taiwan, due to budget limitations, the National Health Insurance only allows for a limited period of biologics use in treating moderate to severe Crohn's disease (CD). We aimed to access the outcomes of CD patients following a limited period use of biologics, specifically focusing on the relapse rate and remission duration; also the response rate to second use when applicable., Methods: This was a multicenter, retrospective, observational study and we enrolled CD patients who had been treated with adalimumab (ADA) according to the insurance guidelines from 2009 to 2015., Results: A total of 54 CD patients, with follow-up of more than 6 months after the withdrawal of ADA, were enrolled. The average period of treatment with ADA was 16.7±9.7 months. After discontinuing ADA, 59.3% patients suffered a clinical relapse. In the univariate analysis, the reason for withdrawal was a risk factor for relapse ( P =0.042). In the multivariate analysis, current smoker became an important risk factor for relapse (OR, 3.9; 95% CI, 1.2-14.8; P =0.044) and male sex was another risk factor (OR, 2.9; 95% CI, 1.1-8.6; P =0.049). For those 48 patients who received a second round of biologics, the clinical response was seen in 60.4%, and 1 anaphylaxis occurred., Conclusions: Fifty-nine percent of patients experienced a relapse after discontinuing the limited period of ADA treatment, and most of them occurred within 1 year following cessation. Male sex and current smoker were risk factors for relapse. Though 60.4% of the relapse patients responded to ADA again., Competing Interests: Conflict of interest: None.