Ethics Seminars: The Ethical Debate on Practicing Procedures on the Newly Dead

Emergency medicine and its academic teaching programs face an ethical dilemma surrounding the question of practicing procedures on the newly dead. For many years, procedures have been practiced on the newly dead, but few institutions have had policies addressing the practice. This article considers the ethical arguments both for and against practicing procedures on the newly dead without consent, reviews the empirical studies on the subject, and presents the positions of other professional societies, before concluding with the position of the Society for Academic Emergency Medicine (SAEM). SAEM strongly encourages all emergency medicine training programs to develop a policy and make that policy available to the institution, educators, trainees, and the public. The practice should not occur behind closed doors or on an ad hoc basis without clearly articulated guidelines. With improvements in technology, including patient simulation and virtual reality, the need for the practice may decrease, but there is no current evidence that is compelling regarding the best methods of teaching procedural skills. Given the importance of protecting trust in the profession of medicine and the existing evidence that the public would expect that consent be obtained, SAEM recommends that families be asked for consent prior to practicing procedures on the newly dead.     

Decreased strength and mobility in patients after anterior cervical diskectomy compared with healthy subjects

OBJECTIVE: To evaluate whether patients acquired normal physical function after cervical disk prolapse and surgery compared with healthy matched controls. DESIGN: Cross-sectional study. SETTING: Hospital in central Finland. PARTICIPANTS: Fifty-three patients with cervical diskectomy and 53 healthy matched controls. INTERVENTIONS: Not applicable.Main Outcome Measures: Postoperative physical function was studied by measuring muscle strength and range of motion (ROM) values of the neck and grip strength. Disability was assessed by the neck and shoulder pain index and by the Oswestry index, mood by the Short Depression Inventory; and pain on a visual analog scale (VAS). RESULTS: Most patients recovered well after the operation. Forty-three percent of the patients still experienced moderate or high pain (VAS score, >30mm). Subjective pain and disability were associated with decreased neck movement and strength. Both ROM and cervical muscle strength values were significantly lower (P<.001) in all the measured directions in cervical disk surgery patients compared with healthy controls. ROM was mostly confined in extension (25%). Muscle strength of the neck was mostly confined in both rotation directions (38%). No statistically significant difference in grip strength was found between the groups. CONCLUSION: The loss of muscle strength and ROM is clearly visible postoperatively and thus the effectiveness of the early identification and rehabilitation of these deficits merits further studies.     

睾丸支持细胞的研究现状及应用前景

目的:综合分析睾丸支持细胞的研究动态及意义。资料来源:应用计算机检索Pubmed1995-01/2006-02有关睾丸支持细胞研究的文章,检索词为"sertolicell,application,transplantation"等,限定语言种类为英文。同时检索中国期刊网全文数据库1995-01/2006-02有关睾丸支持细胞研究的文章,检索词为"睾丸支持细胞,应用,移植",并限定语言种类为中文。资料选择:对资料进行初审,选择与睾丸支持细胞研究进展及应用前景相关的文章,筛选与以上要求无明显关系的文章以及重复性研究。同一领域的文献则选择近5年来在权威刊物上发表的文章。资料提炼:共收集到57篇文献,其中32篇符合要求。排除25篇,为重复性文章。资料综合:由于睾丸支持细胞具有分泌多种营养因子和免疫豁免功能,睾丸支持细胞已成为细胞培养技术、组织工程及器官移植领域的研究热点之一,在临床移植领域中有良好的应用前景。结论:睾丸支持细胞为器官移植、帕金森病及糖尿病等疾病的治疗提供了新的治疗途径,虽然还有许多问题尚需解决,但对睾丸支持细胞的研究已经取得了一系列可喜的成果,在临床应用中具有良好的应用前景,也将会给人类临床事业的发展作出巨大贡献。     

Reduction of matrix metalloproteinase 8-neutrophil collagenase levels during long-term doxycycline treatment of reactive arthritis.

The aim of this work was to determine whether human polymorphonuclear neutrophilic interstitial collagenase (matrix metalloproteinase 8 [MMP-8]) levels are reduced during long-term doxycycline treatment in humans with reactive arthritis. Serum MMP-8 levels were reduced (mean +/- standard error of the mean, 678.9 +/- 185.6 versus 491.2 +/- 144.8 ng of MMP-8 per ml), but not statistically significantly. However, the reduction of salivary MMP-8 levels was statistically significant (3,729 +/- 1,905.3 versus 1,866 +/- 780.0 ng of MMP-8 per ml, P < 0.05). This study demonstrated that a 2-month regimen of doxycycline can reduce MMP-8 levels in serum and especially in body fluids (i.e., saliva) containing inflammatory exudates and thus may contribute to reduced tissue destruction.     

Botulinum toxin treatment of spastic equinus in cerebral palsy: a randomized trial comparing two injection sites

OBJECTIVE: To explore the clinical relevance of injection site by comparing two different injection techniques in children with cerebral palsy who have spastic equinus gait. DESIGN: A total of 19 children (13 boys, 6 girls; range, 1 yr 6 mos to 7 yrs; nine hemiplegics, eight diplegics, two quadriplegics; levels I to IV with the Gross Motor Function Classification System) participated in the study. The children were randomized into two groups: the proximal group received a botulinum toxin A injection into the proximal part of both heads of the gastrocnemius, and the distal group received a botulinum toxin A injection into the mid-belly of the muscle bulks. A single-point injection of BOTOX, 3 units/kg per site, was used. Assessments of active and passive range of motion, dynamic muscle length (modified Tardieu scale), calf tone (modified Ashworth scale), and video gait analysis (Observational Gait Scale) were performed before treatment and 3, 8, and 16 wks posttreatment. RESULTS: Active and passive dorsiflexion and calf tone in both groups and Observational Gait Scale total scores in the distal group improved at all time points. The median change from baseline values in Observational Gait Scale initial foot contact and total scores at 8 wks showed a significant difference favoring the distal group, but the clinical relevance remained tenuous. CONCLUSIONS: Using the methods described, no major changes in main outcome measures were associated with changing the injection site.     

SEVERE REVERSIBLE ARTERIAL SPASM WITH ERGOTAMINE

SUMMARY A patient is described with marked unilateral arterial spasm of the proximal vessels and severe ischaemia of the left foot as a result of excessive use of ergotamine tartrate. Treatment with intravenous heparin infusion followed by chemical sympathectomy was successful.     

Evolutionary conservation of surface molecules that distinguish T lymphocyte helper/inducer and cytotoxic/suppressor subpopulations in mouse and man

We describe the biochemical properties and cell surface distributions of three human T cell antigens (Leu-1, Leu-2a, and Leu-2b) which we postulate to be the homologues of the Lyt-1, Lyt-2, and Lyt-3 antigens that distinguish functional T cell subsets in the mouse. Leu-l, like Lyt-1, is on all thymocytes and peripheral T cells and is present in greater amounts on the helper/inducer subset than on the cytotoxic/suppressor subset. Both antigens increase in parallel fashion during T cell maturation in the thymus and each antigen is carried on a single 67,000-molecular weight (relative) (M(r)) polypeptide chain. Surprisingly, Leu-1 and Lyt-1 each are also expressed in readily detectable amounts on some B celI Ieukemias but not detectably so on normal B cells. Leu-2a and Leu-2b are antigens found only on suppressor/cytotoxic cells in the human and are very similar to the murine Lyt-2 and Lyt-3 antigens. In both species, the two antigens are on the same disulfide- linked multimeric molecules. Disulfide-bond reduction in both species yields subunits of similar size and charge. Lyt-3 and Leu-2b are extremely sensitive to trypsin digestion on viable cells whereas Lyt-2 and Leu-2a are much less so. A different membrane antigen, Leu-3, is an exclusive marker of the helper/inducer subset in man. No mouse homologue for this 55,000-M(r) protein is known. The maintenance of the homologous molecules on functionally distinct T cell subpopulations in two evolutionarily distant species suggests that the Lyt and Leu antigens perform essential functions for the cells on which they are found.     

Hereditary tyrosinaemia type I: from basics to progress in treatment

Hereditary tyrosinaemia type I is the most common of the diseases caused by defects in tyrosine metabolism. The underlying genetic defect is a mutation in the gene for fumarylacetate hydrolase (FAH), and more than 30 different mutations in this gene have been identified. The main clinical consequences of this defect include hepatic involvement, with a high risk for liver cancer, and renal tubular dysfunction. Restriction of phenylalanine and tyrosine from the diet along with supportive measures can ameliorate the symptoms, but cure has so far been possible only with liver transplantation. Recent discovery of a pharmacological treatment with a peroral inhibitor of tyrosine catabolic pathway, 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione (NTBC), offers a new promising tool for the treatment of patients with hereditary tyrosinaemia type I. Mouse models of FAH deficiency have been successfully used in experimental gene therapy, and these studies indicate that future management of tyrosinaemia with a gene therapeutic approach may become feasible.     

Serum lipids and lipoproteins in children, adolescents and young adults in 1980-1986

A multicentre study on atherosclerosis precursors in young Finns aged three to 18 years was started in 1980 (3596 subjects) serum lipid concentrations (cholesterol, HDL (high density lipoprotein) cholesterol and triglycerides) were determined (n = 3554) and the apolipoproteins A-I and B measured (n = 1355). Two follow-up studies were carried out in 1983 (n = 2851) and 1986 (n = 2489), when HDL-subfractions (HDL-2-cholesterol and HDL-3-cholesterol) were also determined. Apolipoproteins A-I and B were measured again in 1986 (n = 1202). Serum total cholesterol concentration has fallen by about 1% annually during the 1980's from 5.07 mmol/l (1980) to 4.79 mmol/l (1986) in 9- to 18-year old children and adolescents. Mean values of serum triglycerides have slightly increased during the follow-up from 0.79 mmol/l to 0.84 mmol/l, respectively. In children and young adults (3-24 years) the mean cholesterol concentration was highest at the age of six and lowest during puberty. Concentrations of serum cholesterol, LDL (low density lipoprotein) cholesterol apoprotein B and triglycerides were higher in eastern than in western Finland in 1980 and 1983, but these differences were smaller in 1986, with the exception of serum triglycerides. Both in 1983 and in 1986 HDL-2-cholesterol was lower in the west than in the east, whereas HDL-3-cholesterol was higher in the former. The favourable changes in lipid levels should be reflected in future morbidity and mortality rates from coronary heart disease in Finland.     

Bedroom allergen exposures in US households

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