Freedom from discrimination or freedom to discriminate? Discursive tensions within discrimination policies in medical education

Advances in Health Sciences Education - The importance of advancing equity, diversity, and inclusion for all members of the academic medical community has gained recent attention. Academic medical...     

Oral and intravenous thyroxine (T4) achieve comparable serum levels for hormonal resuscitation protocol in organ donors: a randomized double-blinded study

Background

Thyroxine (T4) administration is advocated in the management of organ donors; however, the bioavailability of oral thyroxine is unknown in this patient population.

Objective

The primary objective of this study was to compare the percentage of the study time (from study drug administration to organ procurement) that patients in the oral vs the intravenous group required inotropic support. Secondary objectives included plasma levels of T3 and T4 and number of organs donated following oral vs intravenous T4 administration.

Design

Randomized double-blinded study.

Setting

Adult medical-surgical intensive care unit.

Patients

Thirty-two adult solid organ donors.

Interventions

Patients were randomized to receive either an oral or intravenous dose of T4 (2 μg·kg^?1). All patients received an oral and intravenous study drug preparation, one of which was a placebo. The study was double-blinded, and randomization occurred in blocks of four and six.

Measurements

The number and duration of inotropic/vasopressor therapies and free serum levels of T3 and T4 were determined hourly until procurement.

Main results

Following T4 administration, all patients remained on inotropic/vasopressor therapy for the same mean (SD) duration [93 (3)%] of the study period. There was a similar and gradual decrease in the number and dosages of inotropes/vasopressors required in both groups. There was no difference in T3 or T4 levels between groups. Oral bioavailability of T4 was 93% of the intravenous group at six hours and 91% overall. At six hours, the mean area under the curve for T4 was similar between the intravenous group [92.2 (33); 95% confidence interval (CI) 76 to 108.4] and the oral group [86.1 (14); 95% CI 79.4 to 92.8].

Conclusions

Orally administered T4 is well absorbed and achieves a bioavailability of approximately 91-93% of intravenous T4 in organ donors. Inotropic/vasopressor requirements and hemodynamic responses following oral or intravenous thyroxine administration were comparable. Oral T4 is suitable for hormonal therapy for organ donors. This trial was registered at www.clinicaltrials.gov: NCT00238030.     

The impact of delayed critical care outreach team activation on in-hospital mortality and other patient outcomes: a historical cohort study

Purpose

Early warning scores (EWS) and critical care outreach teams (CCOT) have been developed to respond to decompensating patients. Nevertheless, controversy exists around their effectiveness. The primary objective of this study was to determine if a delay of ≥ 60 min between when a patient was identified as meeting EWS criteria and the CCOT was activated impacted in-hospital mortality.

Methods

This was a historical cohort study evaluating all new CCOT activations over a four-year study period (1 June 2007 to 31 August 2011) for inpatients ≥ 18 yr of age at two academic tertiary care hospitals in London, Ontario, Canada. Multivariable logistic regression accounting for repeated measures was used to determine the effect of delayed CCOT activation on in-hospital mortality (primary outcome). Differences in outcomes between medical and surgical patients were also examined.

Results

There were 3,133 CCOT activations for 1,684 (53.8%) medical patients and 1,449 (46.2%) surgical patients during the study period. The CCOT was activated < 60 min of a patient meeting EWS criteria in 2,160 (68.9%) cases and ≥ 60 min in 973 (31.1%) cases. Patients with ≥ 60 min delay were more likely be admitted to the intensive care unit (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.07 to 1.47) and to suffer in-hospital mortality (OR, 1.30; 95% CI, 1.08 to 1.56). Irrespective of delay, surgical patients were less likely to experience in-hospital mortality than medical patients (OR, 0.46; 95% CI, 0.39 to 0.55).

Conclusion

Including the rates of delay in CCOT activation and the admitting service could be an additional step in exploring the conflicting results seen in the current literature assessing the impact of CCOT on patient outcomes.

     

Exploring the premise of lost altruism: content analysis of two codes of ethics

As an ideal, altruism has long enjoyed privileged status in medicine and medical education. As a practice, altruism is perceived to be in decline in the current generation. A number of educational efforts are underway to reclaim this “lost value” of medicine. In this paper we explore constructions of altruism over a defined period of time through a content analysis of the Canadian and Australian Medical Associations (CMA and AMA respectively) Codes of Ethics. We analyzed all editions of both Codes (1868–2004), using a content analysis approach, including thematic analysis. We coded as altruistic or non-altruistic, respectively, statements in which the interest of the patient is placed ahead of the physician’s and statements in which the interest of the physician is given primacy. We examined the pattern of appearance and disappearance of these statements over time. We identified 13 altruistic and 2 non-altruistic statements across all editions. There is a gradual and uneven loss of altruistic content over time. The CMA Codes of 1938, 1970 and 2004 and the AMA code of 1992 represent significant change points. The most recent versions of both Codes contain only 1 altruistic statement and both non-altruistic statements. We conclude that altruism appears to be a fluid and changing concept over time. Loss of altruism is not merely a current generational issue but extends through the past century and is likely due to political and social forces. These results call into question current educational attempts to reclaim altruism, and point to the social evolution of the ideal.     

Pathophysiology and implications for treatment of acute respiratory distress syndrome

Acute respiratory distress syndrome is a complex group of signs and symptoms caused by direct or indirect lung injury. In spite of decades of research, it is still associated with a high mortality rate. Pathogenesis of this disease is related to alveolar endothelial and epithelial cell injury and associated release and sequestration of inflammatory mediators and cells, including cytokines and neutrophils, respectively. Pharmacologic interventions have been largely unsuccessful, and ventilation strategies to support oxygenation while limiting ventilator associated lung injury have not demonstrated any significant reductions in the mortality rate. However, novel therapies are in development, based on the knowledge of the pathologic processes of acute respiratory distress syndrome. In this article an overview of the disease process and mediator involvement is presented, followed by a review of pharmacologic and ventilation treatments currently in use or under study.     

Triiodothyronine replacement in critically ill adults with non-thyroidal illness syndrome

Purpose

Non-thyroidal illness syndrome is commonly encountered in critically ill patients, many of whom are treated with thyroid hormones despite uncertainty regarding their safety and effectiveness. This retrospective observational study sought to evaluate the utilization, safety, and effectiveness of triiodothyronine (T3) supplementation in critically ill adults admitted to either of two non-cardiac surgery mixed-medical/surgical intensive care units (ICU).

Methods

Consecutive adults admitted to an ICU and treated with enterally administered T3 were identified over a two-year period. Data pertaining to demographics, T3 utilization, safety, and clinical outcomes were collected.

Results

Data were extracted from the medical records of 70 consecutive patients. All had baseline serum free T3 concentrations below the lower limit of our laboratory’s reference range and 22 (31%) patients also had low thyroxine (T4) concentrations. The most commonly prescribed replacement doses were 25 and 50 µg for a median of seven days and almost half of the patients also received concomitant T4 supplementation. Serum thyroid hormones were available in 48 of 70 patients (69%) at a median [interquartile range (IQR)] of 7 [6-38] days. Normalization of free T3 serum concentrations occurred in 30 of 48 patients (63%) at a median [IQR] of 8 [7-33] days. A dose-response relationship was identifiable. New adverse events (atrial fibrillation/flutter, hypertension, sinus tachycardia, myocardial infarction) during therapy were less frequent than at baseline.

Conclusions

This study suggests that with T3 supplementation there was evidence of serum free T3 normalization without evidence of associated harms. A definitive trial is needed to evaluate clinical effectiveness.

     

An efficient and flexible system for construction of adenovirus vectors with insertions or deletions in early regions 1 and 3.

Human adenoviruses (Ads) are attracting considerable attention because of their potential utility for gene transfer and gene therapy, for development of live viral vectored vaccines, and for protein expression in mammalian cells. Engineering Ad vectors for these applications requires a variety of reagents in the form of Ads and bacterial plasmids containing viral DNA sequences and requires different strategies for construction of vectors for different purposes. To simplify Ad vector construction and develop a procedure with maximum flexibility, efficiency, and cloning capacity, we have developed a vector system based on use of Ad5 DNA sequences cloned in bacterial plasmids. Expanded deletions in early region 1 (3180 bp) and early region 3 (2690 or 3132 bp) can be combined in a single vector that should have a capacity for inserts of up to 8.3 kb, enough to accommodate the majority of cDNAs encoding proteins with regulatory elements. Genes can be inserted into either early region 1 or 3 or both and mutations or deletions can be readily introduced elsewhere in the viral genome. To illustrate the flexibility of the system, we have introduced a wild-type early region 3 into the vectors, and to illustrate the high capacity for inserts, we have isolated a vector with two genes totaling 7.8 kb.     

A quantitative study on the postnatal development of the cerebellar vermis of mouse

The postnatal changes in the cross-sectional area of the cortex and white matter in the median sagittal section of the cerebellum of mouse were studied quantitatively. That of the cortex increases about 20 fold from birth to maturity, increasing slowly during the first five days following birth, then sharply during the next five days to resume slow increase again after the tenth day. There is very little increase after the fifteenth day. That of the white matter increases only four-fold during the same period. By the end of the second week it has attained only half of its adult value and continues to increase even after the thirtieth day. The increase in the cross-sectional area of the cerebellar cortex is mainly due to rapid expansion of the cortical surface which forces the white matter to be arranged into medullary rays (actually ridges) to keep in contact with the rapidly expanding cortex, thus cerebellar fissures are formed. The number of mitotic figures (uncorrected for fragments) in the superficial granular layer in a median sagittal section 10 m? thick increases from about 22 at birth to a peak of 230 at seven days then falls to less than 36 at 15 days of age, after which the entire layer disappears.