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VALUTAZIONE MULTIDIMENSIONALE CLINICA, PSICOMETRICA, NEUROPSICOLOGICA E NEURORADIOLOGICA DELLA CAPACITÀ DI PRESTARE CONSENSO INFORMATO AL TRATTAMENTO IN PAZIENTI CON SCHIZOFRENIA
No full textIl consenso informato costituisce oggigiorno un momento imprescindibile della attività medica. Esso rappresenta l'accettazione che il paziente esprime a un determinato trattamento sanitario, in maniera libera e non mediata da condizionamenti, dopo essere stato informato sulle modalità di esecuzione, sui benefici, sugli effetti collaterali, sui rischi ragionevolmente prevedibili e sull'esistenza delle eventuali alternative terapeutiche.
L'informazione costituisce una parte essenziale del processo dialettico del consenso informato. La persona cosciente e capace non può essere sottoposta passivamente a qualsiasi trattamento sanitario. Ogni accertamento diagnostico, terapia, o qualsivoglia intervento medico, non potrà essere effettuato se non con il valido consenso della persona interessata, che lo presterà dopo essere stata adeguatamente informata, così che possa valutare il trattamento cui sarà sottoposta e i rischi che da tale trattamento potrebbero derivare ed eventualmente scegliere trattamenti diagnostico-terapeutici alternativi.
Tali presupposti traggono fondamento dagli articoli 2, 13 e 32 della Costituzione, sul tema della libertà personale e della volontarietà dei trattamenti sanitari. Ne deriva che il medico non è legittimato ad agire, se non in presenza di una esplicita o implicita (nei casi di routine clinica) manifestazione di volontà del paziente. Viene fatta eccezione nei casi di necessità (art 54 cp) e nei casi in cui esistano alterazioni psichiche tali da richiedere urgenti interventi terapeutici, qualora essi non possano essere attuati tempestivamente in ambito extraospedaliero, con il trattamento sanitario obbligatorio, istituito dalla legge 180/1978 (legge Basaglia). Tale legge restituisce dignità al paziente psichiatrico, riconoscendolo come “soggetto” cui va riconosciuta l’autodeterminazione e il cui consenso al trattamento sanitario va ricercato e raggiunto in ogni situazione. Resta tuttavia il problema di come valutare il consenso in pazienti con un disturbo psichiatrico in quanto, se è vero che la diagnosi di per sé non basta a giudicare la competenza, d’altro canto è vero che questi soggetti hanno spesso difficoltà di ordine cognitivo che possono interferire con le capacità universalmente riconosciute essere alla basse della capacità di prestare consenso informato al trattamento, ovvero la comprensione, il ragionamento, la valutazione e la capacità di esprimere una scelta (Roth et al., 1977). Sulla base di questi assunti sono stati costruiti diversi strumenti per la valutazione del consenso informato al trattamento e sono state utilizzate diverse batterie di test neuropsicologici. Resta tuttavia un argomento sul quale si trovano interpretazioni contrastanti: sull’utilità o meno della valutazione attraverso strumenti standardizzati, sull’utilità o meno di utilizzare batterie neuropsicologiche, sull’attendibilità del solo colloquio clinico per la valutazione di una capacità così complessa. Ciò è particolarmente vero quando si ha a che fare con pazienti psichiatrici, in particolare con pazienti affetti da schizofrenia, un disturbo caratterizzato dalla presenza di sintomi di alterazione del pensiero, del comportamento e dell’affettività, tali da compromettere la capacità decisionale. Inoltre va considerata la fluttuazione nel tempo dei sintomi, risultando indispensabile una valutazione volta per volta della competenza.
Queste problematiche verranno affrontate nel corso del presente lavoro, nel quale sarà delineata la teoria del consenso informato nella parte introduttiva.
Nella parte sperimentale verranno descritti due diversi studi sulla capacità di prestare consenso informato al trattamento da parte di soggetti affetti da schizofrenia. Nel primo studio si affronterà la tematica della validazione di un nuovo strumento di valutazione della capacità di prestare consenso informato, che sia utilizzabile in ogni ambito medico e che fornisca punteggi di cut-off oggettivi, parziali e globale. Nel secondo studio si affronterà la tematica di quale sia il modello cognitivo sottostante tale capacità, attraverso il confronto tra soggetti affetti da schizofrenia competenti e non competenti e soggetti di controllo, riguardo alle variabili cliniche e neuropsicologiche. Verranno valutate anche le base neurobiologiche della capacità decisionale attraverso uno studio di risonanza magnetica, per confermare il modello cognitivo.
Le conclusioni del presente lavoro cercheranno di riassumere i risultati dei diversi studi presentati alla luce della letteratura sull’argomento, sottolineandone le criticità, nell’intento di gettare nuova luce su un’annosa questione. Infine saranno tracciate alcune suggestioni ed idee per lavori futuri nell’ambito del consenso informato al trattamento
Schizophrenia and bipolar disorder: The road from similarities and clinical heterogeneity to neurobiological types
No full textAlthough diagnosis is a central issue in medical care, in psychiatry its value is still controversial. The function of diagnosis is to indicate treatments and to help clinicians take better care of patients. The fundamental role of diagnosis is to predict outcome and prognosis. To date serious concern persists regarding the clinical utility and predictive validity of the diagnosis system in psychiatry, which is at the most syndromal. Schizophrenia and bipolar disorder, which nosologists consider two distinct disorders, are the most discussed psychiatric illnesses. Recent findings in different fields of psychiatric research, such as neuroimaging, neuropathology, neuroimmunology, neuropsychology and genetics, have led to other conceptualizations. Individuals with schizophrenia or bipolar disorder vary greatly with regard to symptoms, illness course, treatment response, cognitive and functional impairment and biological correlates. In fact, it is possible to find heterogeneous correlates even within the same syndrome, i.e., from one stage of the disorder to another. Thus, it is possible to identify different subsyndromes, which share some clinical and neurobiological characteristics. The main goal of modern psychiatry is to ovethrow these barriers and to obtain a better understanding of the biological profiles underlying heterogeneous clinical features and thus reduce the variance and lead to a homogeneous definition. The translational research model, which connects the basic neuroscience research field with clinical experience in psychiatry, aims to investigate different neurobiological features of syndromes and of the shared neurobiological features between two syndromes. In fact, this approach should help us to better understand the neurobiological pathways underlying clinical entities, and even to distinguish different, more homogeneous, diagnostic subtypes
Decisional capacity to consent to clinical research involving placebo in psychiatric patients
No full textEvidence from a few studies indicates the existence of several issues related to psychiatric patients’ decisional capacity to give
informed consent to clinical research. Clinicians often face difficulties in acquiring valid informed consent in clinical practice and even more so
in drug trials. Participants often fail to fully understand or retain information regarding the actual implications of research protocols. The Brief
Assessment for Consent to Clinical Research (BACO) was developed to investigate capacity to consent to clinical trials and further compare
patients with schizophrenia and healthy comparisons’ decisional capacity. A method to avoid possible confounding effects of choosing a treatment
regarding a current disease was applied. The study groups were administered the BACO and the MacArthur Competence Assessment Tool
for Clinical Research. Psychiatric patients performed poorer in comprehending, appreciating, and reasoning abilities, than their healthy counterparts.
Impaired cognitive functioning and psychiatric symptoms severity were associated with reduced capacity to consent
Neural foundation of human moral reasoning. an ale meta-analysis about the role of personal perspective
No full textMoral sense is defined as a feeling of the rightness or wrongness of an action that knowingly causes harm to people other than the agent. The large amount of data collected over the past decade allows drawing some definite conclusions about the neurobiological foundations of moral reasoning as well as a systematic investigation of methodological variables during fMRI studies. Here, we verified the existence of converging and consistent evidence in the current literature by means of a meta-analysis of fMRI studies of moral reasoning, using activation likelihood estimation meta-analysis. We also tested for a possible neural segregation as function of the perspective used during moral reasoning i.e., first or third person perspectives. Results demonstrate the existence of a wide network of areas underpinning moral reasoning, including orbitofrontal cortex, insula, amygdala, anterior cingulate cortex as well as precuneus and posterior cingulate cortex. Within this network we found a neural segregation as a function of the personal perspective, with 1PP eliciting higher activation in the bilateral insula and superior temporal gyrus as well as in the anterior cingulate cortex, lingual and fusiform gyri, middle temporal gyrus and precentral gyrus in the left hemisphere, and 3PP eliciting higher activation in the bilateral amygdala, the posterior cingulate cortex, insula and supramarginal gyrus in the left hemisphere as well as the medial and ventromedial prefrontal cortex in the right hemisphere. These results shed some more light on the contribution of these areas to moral reasoning, strongly supporting a functional specialization as a function of the perspective used during moral reasoning
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Variations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
Appropriate Similarity Measures for Author Cocitation Analysis
Full text linkWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
Dispelling the Myths Behind First-author Citation Counts
Full text linkWe conducted a full-scale evaluative citation analysis study of scholars in the XML research field to explore just how different from each other author rankings resulting from different citation counting methods actually are, and to demonstrate the capability of emerging data and tools on the Web in supporting more realistic citation counting methods. Our results contest some common arguments for the continued
use of first-author citation counts in the evaluation of scholars, such as high correlations between author rankings by first-author citation counts and other citation
counting methods, and high costs of using more realistic citation counting methods that are not well-supported by the ISI databases. It is argued that increasingly available digital full text research papers make it possible for citation analysis studies to go beyond what the ISI databases have directly supported and to employ more
sophisticated methods
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