Treatment refusal is a common encounter in clinical practice. The process of deciding to refuse treatment is often complex. It is our responsibility to try and understand this process of decision making and the underlying reasons for treatment refusal. Many of these reasons are often rational in the context where the decision is made. The patients could be making the best decision for themselves even if these decisions are not necessarily the best in our mind. We should at all times discuss our treatment options and assess their ability to make decisions in achieving common goals. These goals should balance our best treatment strategies and the patients’ best interest. This article discusses the reasons underlying treatment refusal and how we can achieve a common goal with our patients.
Patients ; decision ; Treatment Refusal ; therapeutic aspects ; treatment options

Objective: This study explored the stress and coping strategies among retired people in Malaysia. Methods: In-depth interviews were conducted with 36 elderly Malaysian subjects. This protocol was approved by the Ethics Committee of the Management and Science University. The data obtained were sorted into various categories. Results: A total number of 36 retired elderly people participated in this study. The majority of them were in the age group of 55-59 years old, females, Malay and married. The majority defined stress as pressure or tension. Financial difficulties, family and work problems were the main causes of stress in the majority. Also, the majority of respondents mentioned that they coped with stress by sharing problems with others, by resting and relaxing, and/or by doing housework during their free time. A few of them coped with stress by hanging out with friends, going shopping, doing photography, travelling, going fishing, and doing sports. Conclusion: Financial difficulties, family and work problems were the main causes of stress among elderly people. They coped with stress by sharing problems with others, resting and relaxing, and/or doing housework during their free time.

Predictive biomarkers are important to the future of oncology; they can be used to identify patient populations who will benefit from therapy, increase the value of cancer medicines, and decrease the size and cost of clinical trials while increasing their chance of success. But predictive biomarkers do not always work. When unsuccessful, they add cost, complexity, and time to drug development. This perspective describes phases 2 and 3 development methods that efficiently and adaptively check the ability of a biomarker to predict clinical outcomes. In the end, the biomarker is emphasized to the extent that it can actually predict.
Biomarkers, Tumor ; genetics ; metabolism ; Clinical Trials as Topic ; methods ; Decision Support Techniques ; Evidence-Based Medicine ; Humans ; Neoplasms ; diagnosis ; genetics ; metabolism ; Predictive Value of Tests ; Program Development ; methods

SUMMARY Constitutional full trisomy 21 is a common disorder in which abnormal spermatogenesis has been previously described. However, constitutional mosaic trisomy 21 in an otherwise normal but infertile male has not been explored. We report a case with low level mosaic trisomy 21 in a non-syndrome but azoospermic patient. We also propose that the patient's azoospermia may be related to the constitutional mosaic trisomy 21 and thus resulting in a late onset of testicular failure.

Objective To study whether physiological and psychological stresses during parachuting jumps may result in biochemical changes of plasma in parachutists. Method Differences in the levels of hormones (cortisol, growth hormone, insulin, pancreatic glucagon, endothelin, angiotonin I and II, aldosterone), activities of enzymes (superoxide dismutase, glutathione peroxidase, glutathione S transferase), levels of the free radical damage indicator malondialdehyde (MDA), tumor necrosis factor alpha (TNF-α), and the main heat stress protein, HSP70,in the plasma and serum were investigated in control (non-parachuting) and parachuting paratroops. Result Significantly higher levels of serum hormones such as growth hormone, insulin, angiotonin I, renin activities, as well as MDA and plasma TNF-α and HSP70 were observed in the parachuting group. Conclusion Whether these changes can potentially serve as useful biomarkers to assess possible abnormal stress in parachutists and to evaluate the health condition and to select parachutists remains to be further studied.

Electrophysiological studies can provide objective and quantifiable assessments of movement disorders. They are useful in the diagnosis of hyperkinetic movement disorders, particularly tremors and myoclonus. The most commonly used measures are surface electromyography (sEMG), electroencephalography (EEG) and accelerometry. Frequency and coherence analyses of sEMG signals may reveal the nature of tremors and the source of the tremors. The effects of voluntary tapping, ballistic movements and weighting of the limbs can help to distinguish between organic and functional tremors. The presence of Bereitschafts-potentials and beta-band desynchronization recorded by EEG before movement onset provide strong evidence for functional movement disorders. EMG burst durations, distributions and muscle recruitment orders may identify and classify myoclonus to cortical, subcortical or spinal origins and help in the diagnosis of functional myoclonus. Organic and functional cervical dystonia can potentially be distinguished by EMG power spectral analysis. Several reflex circuits, such as the long latency reflex, blink reflex and startle reflex, can be elicited with different types of external stimuli and are useful in the assessment of myoclonus, excessive startle and stiff person syndrome. However, limitations of the tests should be recognized, and the results should be interpreted together with clinical observations.

Huntington's disease (HD) is an autosomal dominant neurodegenerative disease. A cardinal histopathologic feature of HD is the progressive loss of striatal medium spiny neurons. As there is no effective treatment for this fatal disease so far, we explore the therapeutic potential of nortriptyline to identify drugs that might be effective treatments for HD. N548mu [ 1955-128] huntingtin stable ST14A cell line was cultured and incubated in the presence or absence of serial concentrations of nortriptyline. Then R6/2 transgenic HD mice were treated with nortriptyline from five to twenty-one weeks of age. Nortriptyline protected striatal cells expressing mutant huntingtin when shifted to a nonpermissive temperature. Nortriptyline delay the disease onset to 127 d in R6/2 mice as compared with 102 d in saline-treated controls, but nortriptyline did not significantly delay mortality. As a gross marker of lack of systemic toxicity, there was no significant difference in the weight of the treated and control R6/2 mice. The results demonstrate that clinically reasonable doses of one of the identified drugs, nortriptyline, delays disease onset in a mouse model of the disease more than any previously identified compound. The most desirable features of a drug for HD are minimal toxicity and the ability to extend symptom-free living. Nortriptyline appears to be one such good candidate.

BACKGROUNDThe World Health Organization's "Framework Convention on Tobacco Control" came into effect in China in 2006. Since then, a series of tobacco control measures has been undertaken, including the first step to establish a coordinated network of stop-smoking clinics in Chinese hospitals. Training for stop-smoking specialists has been traditionally provided via printed materials. This study evaluated the outcomes of the first two intensive 3-day courses in smoking cessation in China run in collaboration with experts who provide training to UK Specialist Stop Smoking Service.

METHODSEighty-four doctors from 38 cities in China responsible for stop-smoking treatment in 20 provinces and four autonomous regions participated in the training courses. Participants' knowledge competencies and self-efficacy were assessed before and after the authentication training.

RESULTSThe training significantly improved participants' knowledge, skills and self-efficacy across different domains. Forty-eight participants were finally certified as "smoking cessation specialist".

CONCLUSIONSThe UK model of face-to-face training was acceptable and effective in China. A relatively brief intensive training program can generate significant improvements in skills, knowledge, and readiness to engage in smoking cessation activities.

Objective: Based on coronary artery calciifcation (CAC) distribution in the rural population of Yunnan province, we further explored the relationship between coronary artery calciifcation score (CACS) and the pulse pressure difference (PPD).
Methods: A randomly stratiifed cluster sampling method was used to study the rural population of Yunnan province and 16-MDCT scan was performed in 212 subjects for evaluating their CAC and calculating CACS. The subjects were divided into 2 sets of groups according to the age and CACS value. Age (51-60) years group,n=108 and Age (61-71) years group,n=104; CACS<1 group,n=162, 1≤CACS<100 group,n=33 and CACS≥100 group,n=17. The PPD level and the relationship between CACS and PPD were compared among different groups.
Results: The average PPD level in Age (61-71) years group was (44.67±13.87) mmHg and in Age (61-71) years group was (50.00±17.44) mmHg,P=0.015, PPD was positively related to age, rs=0.202,P=0.003. The average PPD level in CACS≥100 group, CACS<1 group and 1≤CACS<100 group were (55.22±18.79) mmHg, (46.87±15.46) mmHg and (45.20±15.89) mmHg respectively,P<0.05. The patients with increased PPD level in CACS≥100 group was 47.1%, in CACS<1 group was 17.3% and in 1≤CACS<100 group was 15.2%,P<0.05. Spearman rank correlation analysis indicated that PPD level was positively related to CACS, rs=0.282,P=0.047, with adjusted confounding factors such as age and blood cholesterol level, the PPD was still positively related to CACS.
Conclusion: PPD as a risk factor of coronary artery disease is related to CACS in rural population of Yunnan province, the CACS increased accordingly with the elevated PPD level.

Objective：To investigate the neurocognition and function of social life among human immunodeficiency virus (HIV) positive subjects infected by plasma donation.Methods:Totally 203 HIV positive subjects infected by plasma donation were recruited.Neuropsychological (NP) battery tests including executive function,verbal fluency,learning,memory,fine motor skill,speed of information processing and working memory domains were performanced among these subjects,as well as the Activity of Daily Living Scale (ADLs).And 198 HIV negative plasma donors were matched in gender,age and years of schooling.The cut-off of Global Deficit Score (GDS) was 0.5.Results：The HIV positive subjects performanced worse in global cognitive function [(45.7±5.9 vs.(49.4±6.0),P<0.01]and 7 cognitive domains than those of HIV negative subjects.HIV and HCV infection interacted on aspect of fine motor skill (F=5.28,P<0.05).The impairment rate of the subjects in asymptomatic stage and AIDS were 29.2% and 43.0% respectively.The HIV positive subjects showed more decline of ADLs scores than that of HIV negative subjects [(0.49±1.32) vs.(0.14±0.75),P<0.01].Working months,individual and family's income of HIV positive subjects were also less than that of HIV negative subjects(P<0.01).The lowest CD4 count in NP-impaired group was lower than that in non-impaired group [(214.3±144.0) vs.(274.8±161.1),P=0.01].Subjects with NP impairment reported more decline of ADLs scores [(0.75±1.58) vs.(0.34±1.13),P<0.01] than those without NP impairment.The global cognitive function scores were correlated with decline of ADLs scores (r=-0.22,P<0.01).Conclusion：HIV positive subjects are impairment on aspect of 7 cognitive domains,and co-infection of HCV can lead to more fine motor skill impairment.The more progression of disease,the higher NP impairment ratio.HIV infected subjects show decline of ADL,poorer occupational function and economical status.The lowest CD4 count may be a predictor to NP impairment.NP impairment is a factor which influenced the activity of daily living and the income of individual and family.