Drawing on ethical and legal frameworks in the Netherlands, the United States and France, we examine whether physicians are expected to inform patients about potentially relevant opportunities for expanded access to investigational drugs. While we found no definitive legal obligation, we argue that physicians have a moral obligation to discuss opportunities for expanded access with patients who have run out of treatment options to prevent inequality, to promote autonomy, and to achieve beneficence.

Cerebral air embolism (CAE) is a common, often lethal, complication in blunt and penetrating chest trauma. The factors affecting the outcome of CAE patients are poorly understood, and there is no generally accepted treatment algorithm. In this report, we present the case of a 28-year-old male motorcyclist with a massive CAE, including bilateral internal carotid artery air on computed tomographic examination following blunt chest trauma. With prehospital intubation, oxygen, transfusion, and open laparotomy but without any specific treatment regarding the CAE, a follow-up computed tomography (CT) scan approximately 6 hours later showed resolution of the cerebrovascular air. Recovery was unremarkable, and the patient was discharged neurologically intact after 22 days.

Introduction:The aim of this study was to assess Veterans' and primary care clinic staff's knowledge about, and experiences with, tobacco cessation services available through their Department of Veterans Affairs (VA) medical facility. Methods:Qualitative, semi-structured, in-depth interviews and surveys were conducted with 7 patients and 12 providers/clinic staff members at three VA primary care clinics serving large numbers of rural Veterans. Interviews were transcribed and coded for the- matic content. Results:Five primary themes emerged: (1) lack of knowledge about available cessation services, (2) smoking cessation services provided to patients, (3) perceived barriers to cessation and the provision of treatment, (4) patient receptiveness to treatment and primary care provider involvement, (5) recommended strategies for improving smoking cessation services. Discussion:Our findings suggest there is a considerable lack of knowledge regarding available tobacco cessation services in VA primary care clinics serving rural Veterans. While many patients expressed the opinion that VA was providing adequate care for nicotine dependence, they also identified important barriers to cessation and offered opinions regarding what more could be done to help them to quit smoking. Clinicians/staff also provided insight into barriers they encounter in the delivery of cessation services. Future work should focus on attempting to address these barriers.

There is increasing emphasis on including patients in decision making about treatment. In order to do this, they need to have access to appropriate information about treatment options. The study reported here reports initial work carried out in the development of a decision analysis tool to assist women about treatment for menorrhagia. Women referred to secondary care with a diagnosis of heavy menstrual bleeding were interviewed. Our study shows that women had limited and often inaccurate knowledge of most treatment options. They expressed feelings of diagnostic uncertainty, the need for a ‘label’ for their symptoms and a perception of the failure of the general practitioner (GP) to provide this. The women in our study referred to secondary care with a diagnosis of menorrhagia do not seem to have had their concerns about their menstrual symptoms addressed prior to the referral. In addition, the women in this study do not feel that their GP has communicated a diagnosis to them. Women must be able to feel that they have been diagnosed in order that treatment options can then be properly discussed, and a shared management decision reached. Reasons for the apparent lack of adherence to guidelines are discussed. There is a need for a decision aid for use in primary care to assist women and their doctors in the management of menorrhagia.