The public''s willingness to discuss their preference for organ donation with family members

We sought to assess the public's willingness to discuss their preference for organ donation with family members and to identify factors associated with willingness to discuss donation. We categorized individuals (N = 4365) with a preference for donation according to their willingness to discuss donation and used ordinal logistic regression analysis to identify factors related to their level of willingness. About half of those who want to donate have discussed this with a family member. Others were at various stages with respect to their commitment to discuss donation. Those in the more committed stages were more likely than others to have signed an organ donor card, to have seen information about organ donation, to be male, to be white or Hispanic, to know about donation issues, and to be comfortable with the idea of their own death. The decision to donate is ultimately made by family members of a suitable candidate for donation, yet nearly half of those who wish to donate have not made their wishes known. Interventions targeted to individuals at different stages of commitment are needed so that more family members can respond in accordance with their loved one's wishes.     

Ethics of delivering the message of impending death]

Two questions are discussed: 1. our relation to death. Contrary to the saying "shadows of the death" and to it's modern concealment this contribution states: death gives light: it enables to be conscious of one's self and to bow to the inevitable, it shows the valuables of earthly and mortal beings, and even allows us to hope. 2. Solidarity in the situation of death. This situation means the experience of being abandoned and in the same time the challenge to release the other (and to allow him to live [respectively to go]). Against the ego-centralizing power of pain and dread especially the dying needs aid--only to face to (the "hour of") truth. The decisive help is the helper: his being there and remaining by under the common fate.     

Technical requirements to become an osteopathic physician

A person must possess specific abilities in order to become an osteopathic physician. The acquisition of knowledge, the ability to apply the knowledge and the ability to perform appropriate treatment are necessary for students in training. A student needs to have the ability to develop a skill set to progress to the level necessary in both learning and skill acquisition before matriculating into an osteopathic training institution. The abilities necessary for a person to be able to progress to a practicing DO are discussed in this article, as well as the issues that led to the development of a recommended technical standards document. Potential issues are raised, and the currently accepted skills are also discussed.     

Studies of introital colonization in women with recurrent urinary infections. VII. The role of bacterial adherence.

The susceptibility of the vaginal introitus to colonization by enterobacteria appears to be the biologic defect that separates women who experience recurrent urinary infection from those resistant to recurrent infection. Colonization of a mucosal surface is mediated in part by the ability of an organism to adhere to the surface. We describe an in vitro model that measures the capacity of different bacterial species to adhere to human vaginal epithelial cells. Different bacteria are demonstrated to vary in their adhesive properties. Escherichia coli is shown to adhere more readily to vaginal cells from women with recurrent urinary infection than to similar cells from control women resistant to urinary infection (p less than 0.001). These studies suggest that biologic susceptibility to recurrent urinary infections in women is related to a defect at the cellular level that encourages or favors bacterial adherence.     

Adherence to physiotherapy clinical guideline acute ankle injury and determinants of adherence: a cohort study

Background  

Clinical guidelines are considered important instruments to improve quality in health care. In physiotherapy, insight in adherence to guidelines is limited. Knowledge of adherence is important to identify barriers and to enhance implementation. Purpose of this study is to investigate the ability to adherence to recommendations of the guideline Acute ankle injury, and to identify patient characteristics that determine adherence to the guideline.     

Diagnostic delay in colorectal cancer.

Recent guidelines recommend early diagnosis of colorectal cancer. Little data exists for comparison or to set standards. The aims of this study were to calculate the time to diagnosis for colorectal cancer from first hospital attendance and to identify any remedial factors felt to contribute to an undue delay in diagnosis. A one year retrospective audit was undertaken in a specialist teaching hospital. There were 59 patients and the median time to diagnosis was 17 days after first hospital consultation (mean 52 days). Some 34% had to wait more than one month for diagnosis. Incomplete examination or initial referral to a non-surgical specialty appeared to contribute to delay. Greater awareness of guidelines across the breadth of hospital specialties may reduce time to diagnosis.     

Diagnosis and management of subclavian artery stenosis prior to coronary artery bypass grafting in the current era

There are several approaches to managing subclavian artery stenosis (SAS) prior to coronary artery bypass grafting (CABG) with an intended internal thoracic artery (ITA) graft to the left anterior descending (LAD) artery. We herein review the incidence of and various diagnostic modalities for detecting SAS. Published relevant clinical studies from the interventional cardiovascular and cardiac surgical literature are summarized. Particular emphasis is placed on the efficacy of various approaches to the patient diagnosed with SAS prior to CABG. Stenting the subclavian artery prior to bypass surgery and using an in situ ITA is compared to using the ITA as a "free" graft. The incidence of restenosis after subclavian artery angioplasty or stenting is not trivial and has been reported to occur at a rate of 6% to 21%; however, the average rate of restenosis with stenting appears to be in the mid-teens. Subacute subclavian stent thrombosis or occlusion is exceptionally rare, suggesting that a percutaneous approach to SAS is reasonable prior to CABG. For patients requiring emergent revascularization, placement of a free ITA graft to the LAD appears to be a safe and durable treatment as patency rates are comparable to that of an in situ LITA to the LAD. In summary, although no randomized clinical trials address the optimal management of SAS prior to CABG, both percutaneous and surgical options appear to be safe and reasonably durable.     

HIV prevention is not enough: child survival in the context of prevention of mother to child HIV transmission

Clinical and epidemiologic research has identified increasingly effective interventions to reduce mother to child HIV transmission in resource‐limited settings These scientific breakthroughs have been implemented in some programmes, although much remains to be done to improve coverage and quality of these programmes. But prevention of HIV transmission is not enough. It is necessary also to consider ways to improve maternal health and protect child survival. A win‐win approach is to ensure that all pregnant and lactating women with CD4 counts of <350 cells/mm³ have access to antiretroviral therapy. On its own, this approach will substantially improve maternal health and markedly reduce mother to child HIV transmission during pregnancy and delivery and through breastfeeding. This approach can be combined with additional interventions for women with higher CD4 counts, either extended prophylaxis to infants or extended regimens of antiretroviral drugs to women, to reduce transmission even further. Attempts to encourage women to abstain from all breastfeeding or to shorten the optimal duration of breastfeeding have led to increases in mortality among both uninfected and infected children. A better approach is to support breastfeeding while strengthening programmes to provide antiretroviral therapy for pregnant and lactating women who need it and offering antiretroviral drug interventions through the duration of breastfeeding. This will lead to reduced HIV transmission and will protect the health of women without compromising the health and well‐being of infants and young children.     

Motives and decision making of potential living liver donors: comparisons between gender, relationships and ambivalence

The motives and decision making of potential living liver donors are critical areas for transplant clinicians evaluating these candidates to understand, yet these topics remain relatively unstudied. Thus, we surveyed 77 prospective living liver donors at the point of donation evaluation using structured instruments to gather more information on their approach to and concerns about donation. We collected information on donation decision making, motives for donation and anticipated social and physical concerns about postdonation outcomes. We examined three additional characteristics of donors: gender, the relationship of the donor to the intended recipient and the presence of ambivalence about donation. Women had more concerns about their family/social responsibilities. Those donating to nonimmediate family were more likely to have been asked to donate but less likely to feel they had to donate. However, ambivalent donors were the most distinct having difficulties and concerns across most areas from their motivations for donating, to deciding to be tested and to donate, to concerns about the postdonation outcomes. We discuss the clinical relevance of these findings to donor evaluation and preparation.     

Indications for surgery from the viewpoints of surgeon and juror

Whether an operation is indicated or not is a question that is a frequent subject of discussion between physicians and the legal front. As the state has the duty to protect its citizens, any physical surgical operation is legally seen as a personal injury. Only if the patient completely agrees to the surgery after being carefully informed about it is the element of criminal offense (personal injury) revoked. The obligation to disclose medical information on the surgery applies to information on the operation itself and on the possible consequences to the patient in his/her physical and mental social environment. In particular, the patient must be given all information about the risks that could arise during and after the surgery. The legislative aim of this is not to treat a list of questions and to mention all possible risks, but the legislator wants to oblige physicians to give patients who have reached the age of majority full information on diagnosis and therapy and to enable them to consider the pros and cons of the surgery carefully and then to agree to the operation or to refuse it. Besides the obligation to disclose medical information in emergency cases, the obligation to disclose medical information to minors also makes heavy demands on the physician. Examples of contraindications are given.     

Come affrontare e prevenire le complicanze e gli insuccessi nelle fratture laterali del collo del femore trattate con l’inchiodamento endomidollare

Complications of treatment with intramedullary nail of lateral femoral fractures can be divided in intraoperative and postoperative. Intraoperative complications are usually related to poor fracture reduction, to the target device, to inadequate X-ray control and to incorrect nail introduction. Postoperative complications are usually related to synthesis malpositioning, to poor fracture reduction, to lateral fractures engaging the femoral neck and generating an unstable fracture, to bone stock loss in low proximal femoral fractures and to fracture non-union.     

Successful living donor intestinal transplantation in crossmatch positive recipients: Initial experience

Sensitized patients tend to have longer waiting times on the deceased donor list and are at increased risk of graft loss from acute or chronic rejection compared to non-sensitized candidates. Desensitization protocols are utilized to decrease the levels of alloantibodies and to convert an initial positive cross-match to prospective donors into a negative crossmatch. These procedures are mostly available in the setting of living donation. Due to the elective nature of the procedure, desensitization protocols can be extended until the desire result is obtained prior to transplantation. We present two cases of successful desensitization protocol applied to living donor intestinal transplant candidates that converted to negative cross-match to their donors. We present two cases of intestinal transplant candidates with a potential living donor to whom they are sensitized. Both cases underwent successful transplantation after desensitization protocol. No evidence of humoral rejection has occurred in either recipient. Living donor intestinal transplantation in sensitized recipients against the prospective donors provides the ability to implement a desensitization protocol to convert to negative crossmatch.     

Good urodynamic practice adaptations during the COVID-19 pandemic

Urodynamics testing forms the cornerstone of investigations when it comes to lower urinary tract dysfunction. It has to be done to the highest standards by following the International Continence Society Good Urodynamics Practice protocols. However, with the COVID-19 pandemic, certain adaptations to the urodynamics procedure need to be considered especially when it comes to quality control. This article aims to define these adaptations to help urodynamicists in their daily practice.     

Locally increased metastatic efficiency as a reason for preferential metastasis of solid tumors to lymph nodes.

Metastases from solid tumors to lymph nodes do not portend as poor a prognosis as metastases to other sites. The authors wished to determine whether specific subpopulations of cells metastasized to lymph nodes and whether they have different properties than cells metastatic to visceral sites. Repetitive selection for "spontaneous" metastases of a B16 melanoma to either lung or lymph node increased the incidence of lymph node metastases. Cells derived from pulmonary and lymph node metastases were assayed for their ability to adhere to cryostat sections of lung and lymph node and respond to target organ-conditioned media in serum-free conditions. Both cell types were four times more adherent to lymph node than lung, and consistently attached to the hilar and subcapsular sinuses. Attachment of cells derived from pulmonary metastases to either tissue was threefold greater than that of cells derived from nodal metastases. Lung-conditioned media stimulated proliferation of both cell types, and transiently induced differentiated morphology in cells derived from lymph node metastases, but not in cells from pulmonary metastases. Neither effect was found in lymph-node-conditioned medium. These results suggest that cells metastasize to lymph nodes preferentially not because of a specific predilection for lymph node, but because it is an easy site to colonize. Adhesive interactions in the lymph node rather than trophic ones appear to account for this effect. Cells metastatic to lymph node may be less "malignant" than cells metastatic to visceral sites because less has been required for them to succeed as a metastatic focus.     

Driving a decade of change: HIV/AIDS,patents and access to medicines for all

Since 2000, access to antiretroviral drugs to treat HIV infection has dramatically increased to reach more than five million people in developing countries. Essential to this achievement was the dramatic reduction in antiretroviral prices, a result of global political mobilization that cleared the way for competitive production of generic versions of widely patented medicines. Global trade rules agreed upon in 1994 required many developing countries to begin offering patents on medicines for the first time. Government and civil society reaction to expected increases in drug prices precipitated a series of events challenging these rules, culminating in the 2001 World Trade Organization's Doha Declaration on the Agreement on Trade‐Related Aspects of Intellectual Property Rights and Public Health. The Declaration affirmed that patent rules should be interpreted and implemented to protect public health and to promote access to medicines for all. Since Doha, more than 60 low‐ and middle‐income countries have procured generic versions of patented medicines on a large scale. Despite these changes, however, a “treatment timebomb” awaits. First, increasing numbers of people need access to newer antiretrovirals, but treatment costs are rising since new ARVs are likely to be more widely patented in developing countries. Second, policy space to produce or import generic versions of patented medicines is shrinking in some developing countries. Third, funding for medicines is falling far short of needs. Expanded use of the existing flexibilities in patent law and new models to address the second wave of the access to medicines crisis are required. One promising new mechanism is the UNITAID‐supported Medicines Patent Pool, which seeks to facilitate access to patents to enable competitive generic medicines production and the development of improved products. Such innovative approaches are possible today due to the previous decade of AIDS activism. However, the Pool is just one of a broad set of policies needed to ensure access to medicines for all; other key measures include sufficient and reliable financing, research and development of new products targeted for use in resource‐poor settings, and use of patent law flexibilities. Governments must live up to their obligations to protect access to medicines as a fundamental component of the human right to health.     

Factors affecting the decline of ventilatory function in chronic bronchitis.

Ninety six middle aged male patients with chronic bronchitis with relatively well preserved ventilatory function who were resident in Queensland, New South Wales, or Victoria took part in a prospective study to determine the relationship of various factors to the rate of decline of the FEV1. Thirty of the subjects withdrew, leaving 66 to be followed for four to six years. The mean rate of decline of the FEV1 was 58.6 (SD 51.4) ml/year. The subjects' ventilatory responses to bronchodilator and to methacholine (measures of bronchial lability) were significantly related to each other and to sputum eosinophilia. With a linear model for the data on 57 patients who had methacholine and skin tests the rate of decline of the FEV1 was found, after adjustment had been made for other variables, to be significantly related to State of residence, current smoking, response to bronchodilator, age, and occupational exposure to dust. Response to bronchodilator was interchangeable with response to methacholine. With the five variables in the model none of the following factors was related to the rate of decline of the FEV1:FEV1 on entry, FEV1% predicted normal, FEV1/VC%, skin test reaction, occupation on entry, history of sinusitis and rhinitis, and height. When data from all 66 subjects were introduced into the model, in addition to the five significant individual variables (FEV1/VC% X response to bronchodilator) was significantly related to the rate of decline of the FEV1. Of these prognostic indices, response to bronchodilator was independent of the initial FEV1, FEV/VC%, and FEV1% predicted. The difference between States, which was not explained by differences due to sampling or withdrawal of subjects, was due to a low rate of decline in Queensland.     

Magnetic resonance imaging of trauma to the thoracic and lumbar spine. The importance of the posterior longitudinal ligament.

Magnetic resonance imaging was used to evaluate 24 patients with injuries to the thoracic, thoracolumbar (T12-L1), or lumbar spine. Correlation of the magnetic resonance imaging findings to surgical therapy and outcome was evaluated, with particular attention to the longitudinal ligaments. The ability of the magnetic resonance imaging to detect the extent of trauma to the spinal cord parenchyma and to the anterior and posterior longitudinal ligaments was found to be important in guiding the surgical approach to these spine fractures.     

Referral to post-acute care following traumatic brain injury (TBI) in the Australian context

The study aimed to describe the types of care allocated at the end of acute care to people diagnosed with TBI and to identify the factors associated with variations in referral to care. A retrospective analysis of medical records of 61 patients was conducted based on a sample from two hospitals. While 60.7% of the study sample were referred to formal rehabilitation care, this was primarily non-inpatient rehabilitation care (32.8%). Discriminant analysis was used to determine medical and non-medical predictors of referral. Results indicated that place of treatment and age contribute to group differences and were significant in separating the inpatient rehabilitation group from the non-inpatient and no rehabilitation groups. Review by a rehabilitation physician was associated with referral to inpatient rehabilitation but was not adequate to explain referral to non-inpatient rehabilitation. An in-depth exploration of post-acute referral is warranted to improve policy and practice in relation to continuity of care following TBI.     

Return to work within the first seven years of severe head injury

The rate and prediction of return to work was examined in 98 severely head injured patients during the first seven years after injury. The employment rate dropped from 86% before injury to 29% after. Younger patients, and those with technical/managerial jobs before injury were more likely to return to work than those over 45 years of age, or in unskilled occupations. Physical deficits were not related to return to work, but the presence of cognitive, behavioural, and personality changes was significantly related to a failure to return to work.     

A prospective evaluation of the Modified Hand Injury Severity Score in predicting return to work

Hand injuries are the main cause of work-related disability in young adults. We have devised the Modified Hand Injury Scoring System to quantify hand, wrist and forearm injuries. This study aims to determine its value in predicting ability and time taken to return to work after such injury. Prospectively-assigned MHISS at presentation was compared with demographic, injury, employment and quality of life information 40-52months after acute hand or forearm injury. MHISS score was the only variable investigated found to predict ability to return to work. Factors not associated included age at injury, occupation, hand injury side or dominance, main earner status and compensation-seeking. Median time to return to work increased from 30 to 760days for Mild and Major MHISS categories respectively. Injury severity quantified using MHISS is an important determinant of return to work after hand or forearm injury. Only 60% of patients return to work following a Major injury and may take over a year to do so. Such information may allow the patient to make early informed personal financial and retraining decisions after their injury.