Ethics education for health professionals: A values based approach

It is now widely accepted that ethics is an essential part of educating health professionals. Despite a clear mandate to educators, there are differing approaches, in particular, how and where ethics is positioned in training programmes, underpinning philosophies and optimal modes of assessment. This paper explores varying practices and argues for a values based approach to ethics education. It then explores the possibility of using a web-based technology, the Values Exchange, to facilitate a values based approach. It uses the findings of a small scale study to signal the potential of the Values Exchange for engaging, meaningful and applied ethics education.     

Coronary revascularization: a procedure in transition from on-pump to off-pump? The role of glucose-insulin-potassium revisited in a randomized,placebo-controlled study

OBJECTIVE: To investigate an optimized glucose-insulin-potassium (GIK) solution regimen as an alternate myocardial protective strategy in off-pump coronary artery bypass graft (OP-CAB) surgery and as a supplement to conventional coronary artery bypass graft (CABG) surgery using cardiopulmonary bypass (CPB). DESIGN: Prospective, randomized, placebo-controlled. SETTING: Single institution, cardiothoracic specialty hospital. PARTICIPANTS: Forty-four patients scheduled for elective multivessel coronary artery surgery using either conventional CPB (n = 22) or OP-CAB techniques (n = 22). INTERVENTIONS: Preischemic, ischemic, and postischemic administration of GIK solution was carried out, optimally dosed to ensure nonesterified fatty acid (NEFA) suppression, and supplemented with magnesium, a glycolytic enzymatic cofactor. MEASUREMENTS AND MAIN RESULTS: GIK solution therapy reduced plasma NEFA levels (p < 0.001) in OP-CAB surgery and CPB groups but failed to affect the incidence of non-Q wave perioperative myocardial infarction, incidence of postoperative atrial fibrillation, incidence of postoperative infection, reduction in creatinine clearance, or duration of postoperative intensive care unit or hospital length of stay. After adjusting for GIK solution therapy, OP-CAB surgery resulted in significantly less ischemic injury (troponin I >15 microg/L, 19.0% v 91.3%; p = 0.0001) and reduced postoperative infections (14.3% v 43.5%; p = 0.049). CONCLUSION: GIK solution therapy achieved NEFA suppression and an insignificant trend toward reduced biochemical parameters of ischemic injury in OP-CAB surgery and CPB groups, but no major clinical benefit (perioperative myocardial infarction, intensive care unit length of stay, or hospital length of stay) was shown after elective CABG surgery in low-risk patients. Compared with CPB, OP-CAB surgery significantly reduced ischemic injury and postoperative infections.     

Inhibitors of apoptosis proteins in prostate cancer cell lines

BACKGROUND: The caspases are the central executioners of apoptosis. The inhibitors of apoptosis proteins (IAPs) are a family of recently described caspase inhibitors. We hypothesised that tumor resistance to apoptosis could be due in part to IAP expression. METHODS: The expression of NAIP, cIAP-1, cIAP-2, XIAP, and survivin was investigated in the prostate cancer cell lines LNCaP, PC3, and DU145. RNase protection assays and Western blotting were used to assess RNA and protein expression. Apoptotic susceptibility was determined using etoposide and assessed by propidium iodide (PI) DNA incorporation using flow cytometry. RESULTS: DU145 and PC3 cells were more resistant to apoptosis than LNCaP cells. All the IAPs were identified in the cell lines with variation in IAP expression between different cell types. Immunohistochemistry demonstrated cIAP-1 expression in PC3 cells was nuclear, while the expression of cIAP-2 and XIAP was perinuclear. Growing LNCaP cells in charcoal-stripped or androgen-supplemented medium resulted in no alteration in IAP expression. CONCLUSIONS: This study characterises the expression of IAP in three of the most commonly used prostate cancer cells. IAP may make an important contribution to apoptotic resistance in patients with prostate cancer.     

Risk factors leading to midurethral sling revision: a multicenter case-control study

Introduction and hypothesis

To determine risk factors for sling revision after midurethral sling (MUS) placement.

Methods

This multicenter case-control study included patients who underwent MUS placement and subsequent revision secondary to voiding dysfunction from January 1999–2007 from nine Urogynecology centers across the USA. Direct logistic regression analysis was used to determine which diagnostic variables predicted sling revision.

Results

Of the patients, 197 met the study criteria. Patient demographics, urodynamic findings, and operative differences did not increase the risk for sling revision. Risk factors for sling revision did include: pre-existing voiding symptoms (OR 2.76, 95% CI 1.32–5.79; p?=?0.004) retropubic sling type (OR?=?2.28, 95% CI 1.08–4.78; p?=?0.04) and concurrent surgery (OR?=?4.88, 95% CI 2.16–11.05; p?<?0.001)

Conclusions

This study determined that pre-existing obstructive voiding symptoms, retropubic sling type, and concurrent surgery at the time of sling placement are risk factors for sling revision.     

Dyslexia and across-hands finger localization deficits

Two experiments on finger localization are reported. Experiment 1 compared children who were poor readers with two groups of children matched to poor readers for sex and either age (CA controls) or reading age (RA controls). The participant's hands were kept out of his or her sight in a semi-open box while the fingers of one hand were lightly touched by the experimenter. The participant's task was to indicate, using the thumb of either the same hand (within-hand condition) or the opposite hand (across-hands condition) to respond, the finger(s) which had been touched by the experimenter. Performance was significantly impaired in the across-hands condition compared with the within-hand condition. Experiment 2 was carried out with dyslexic adults and a control group of normal readers. Using the same method of responding as in Experiment 1, a significant deficit in the across-hands condition compared to the within-hand condition was found for both groups. The effect was also obtained for both groups when participants were required to point to the relevant fingers on a photograph of a hand rather than use the thumb of the opposite hand to respond. The results are discussed in relation to the hypothesis of a deficit in inter-hemispheric transfer of tactile information in dyslexia.     

BCL-XL expression levels influence differential regional astrocytic susceptibility to 1,3-dinitrobenzene

The selective vulnerability of brainstem astrocytes to 1,3-dinitrobenzene is mediated by a 10-fold lower threshold for opening of the cyclosporin A-inhibitable mitochondrial permeability transition pore (mtPTP). BCL-XL, BAX and BCL-2 are members of the BCL-2 protein family known to regulate both apoptotic and necrotic cell death signaling at the mtPTP. The levels at which these proteins are expressed relative to one another, where in the cell they are located and whether they are post-translational modified contributes greatly to the balance in active agonistic to active antagonistic BCL-2 proteins, and this critical balance has been hypothesized to dictate regional astrocytic susceptibility to DNB. The effects of DNB on the balance in expression of the BCL-2 family proteins have been evaluated in F344 rat DNB-sensitive (brainstem) and non-sensitive (cortical) tissue homogenates and primary astrocytes. No significant treatment-related alterations in BCL-XL, BAX or BCL-2 protein expression are observed in rat tissue homogenates or primary astrocytes. However, moderate increases in BCL-XL are observed only in DNB-treated rat cortical astrocytes, and these increases may be sufficient to shift the constitutive balance in expression of antagonistic to agonistic BCL-2 proteins from a ratio which favors BAX to one in which BAX and BCL-XL are comparably expressed. Rat primary brainstem and cortical astrocytes are also transiently transfected with bcl-xl to evaluate whether or not moderate enhancement of BCL-XL protein expression levels are sufficient to alter regional sensitivity to DNB in vitro. BCL-XL overexpression minimizes DNB-induced inhibition of succinate dehydrogenase (complex II) activity and increases significantly the concentration of DNB required to induce MPT onset in primary brainstem and cortical astrocytes. Results from the current investigation suggest that modest region-specific alterations in the balance in expression of antagonistic to agonistic BCL-2 proteins may adequately explain differential regional sensitivity to DNB-induced mitochondrial dysfunction.     

Lepidium meyenii （ Maca ） improved semen parameters in adult men

Aim: The present study was designed to determine the effect of a 4-month oral treatment with tablets of Lepidium meyenii (Maca) on seminal analysis in nine adult normal men aged 24 - 44 years old. Methods: Nine men received tablets of Maca (1500 or 3000 mg/day) for 4 months. Seminal analysis was performed according to guidelines of the World Health Organization (WHO). Serum luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin (PRL), testosterone (T) and estradiol (E2) were measured before and after treatment. Results: Treatment with Maca resulted in increased seminal volume, sperm count per ejaculum, motile sperm count, and sperm motility. Serum hormone levels were not modified with Maca treamaent. Increase of sperm count was not related to dose of Maca. Conclusion: Maca improved sperm production and sperm motility by mechanisms not related to LH, FSH, PRL, T and E2.     

Complete fundoplication is not associated with increased dysphagia in patients with abnormal esophageal motility

Abnormal esophageal motility is a relative contraindication to complete (360-degree) fundoplication because of a purported risk of postoperative dysphagia. Partial fimdoplication, however, may be associated with increased postoperative esophageal acid exposure. Our aim was to determine if complete fundoplication is associated with increased postoperative dysphagia in patients with abnormal esophageal motor function. Medical records of 140 patients (79 females; mean age 48 ±1.1 years) who underwent fundoplication for gastroesophageal reflux disease (GERD) were reviewed retrospectively to document demographic data, symptoms, and diagnostic test results. Of the 126 patients who underwent complete fundoplication, 25 met manometric criteria for abnormal esophageal motility (≤30 mm Hg mean distal esophageal body pressure or ≤80% peristalsis), 68 had normal esophageal function, and 33 had incomplete manometric data and were therefore excluded from analysis. Of the 11 patients who underwent partial fundoplication, eight met criteria for abnormal esophageal motility, two had normal esophageal function, and one had incomplete data and was therefore excluded. After a median follow-up of 2 years (range 0.5 to 5 years), patients were asked to report heartburn, difficulty swallowing, and overall satisfaction using a standardized scoring scale. Complete responses were obtained in 72%. Sixty-five patients who underwent complete fundoplication and had manometric data available responded (46 normal manometry; 19 abnormal manometry). Outcomes were compared using the Mann-Whitney U test. After complete fundoplication, similar postoperative heartburn, swallowing, and overall satisfaction were reported by patients with normal and abnormal esophageal motility. Likewise, similar outcomes were reported after partial fundoplication. This retrospective study found equally low dysphagia rates regardless of baseline esophageal motility; therefore a randomized trial comparing complete versus partial fundoplication in patients with abnormal esophageal motility is warranted. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 2l–24, 2000 (poster presentation).     

Baseline and time-averaged fluid removal affect technique survival in peritoneal dialysis in a non-linear fashion

AIM: The longevity of peritoneal dialysis (PD) is limited by technique failure and patient mortality. The authors assessed the influence of baseline and time-averaged fluid removal on patient, technique and death-censored technique survival. METHODS: Peritoneal and total fluid removal was measured 1 month after commencing PD, then 6 monthly, in 225 incident patients (mean age 55.3+/-15.8 years, 52% male). A Cox proportional hazards model regression analysis was performed to identify variables independently predictive of technique and patient survival. RESULTS: Seventy (31.9%) patients were transferred to haemodialysis and 39 (17.63%) died. Technique survival was greatest in the middle tertile of baseline total fluid removal (mean survival time 3.5 vs 2.5 and 2.2 years for the lower and upper tertiles, respectively, log rank 6.5, P=0.039). The middle tertile of both baseline and time-averaged total fluid removal were significant predictors of PD survival (adjusted hazard ratio (HR) 0.476, 95% CI 0.286-0.795, P=0.005 relative to the upper tertile and HR 0.573, 95% CI 0.350-0.939, P=0.027 for baseline and time-averaged, respectively). Other significant variables on multivariate analysis were body mass index (HR 1.044 per kg/m2, 95% CI 1.005-1.084, P=0.028), creatinine (HR 0.999 per micromol, 95% CI 0.998-1.000, P=0.048) and residual Kt/V (HR 0.418, 95% CI 0.233-0.747, P=0.003). Patient survival was not affected by fluid removal. CONCLUSION: Patients with moderate total fluid removal both at baseline and throughout their PD career have improved technique survival. Attention should be paid to optimizing total fluid removal.