Which lives and why

Book reviewed in this article: Morality, Mortality: Death and Whom to Save from It. By Frances Kamm.     

Lack of evidence for transmission of human immunodeficiency virus through vaginal intercourse

Research in determining risks for human immunodeficiency virus (HIV) transmission is confounded by many issues. They include lack of clarity or specificity in terminology used, respondents misunderstanding of questions, and lying. The base rate of lying (or social desirability responding) by itself is sufficient to account for the small percentage of Americans and Europeans claiming heterosexual transmission from partners not known to be intravenous drug users. This study integrates the physiological and epidemiological data on risk factors for HIV transmission with the psychological literature on the frequency of anal intercourse and of lying (in this case to researchers and clinicians about risk factors). When these factors are considered, intravenous and anal activities remain the only clear vectors for HIV transmission. Research suggesting that spermicidals are more effective at inactivating HIV than condoms are at physically containing HIV is also noted.     

"Modernity" and polarization of health in Mexico. Living conditions for workers and their families

This article analyzes the characteristics of the modernization process in Mexico and the polarization produced in living and health conditions for the general population as well as workers and their families. We studied socioeconomic and health indicators for this purpose. Infectious diseases occupy a high percentage of general morbidity, yet diseases such as diabetes, hepatic cirrhosis, myocardial infarction, malignant tumors, and accidents and violence are also serious public health problems as causes of morbidity and mortality. In some regions of the country with specific socioeconomic characteristics, polarization of health conditions is even more evident, as in the state of Chiapas as compared to Nuevo León. Deterioration of working conditions and available data on workers' health indicate that the latter should be considered a priority group for health measures. Such data also show the paradoxical trend of the more severe but less frequent work-related accidents and diseases that are subject to compensation as compared to the detection of chronic work-related diseases at an advanced stage, as well as significant differences in occupational morbidity among different branches of manufacturing.     

Umbilical hernia repair in pregnant patients: review of the American College of Surgeons National Surgical Quality Improvement Program

Background

Umbilical hernias present commonly during pregnancy secondary to increased intra-abdominal pressure. As a result, umbilical hernia incarceration or strangulation may affect pregnant females. The purpose of this study is to detail the operative management and 30-day outcomes of umbilical hernias in pregnant patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

Methods

All female patients undergoing umbilical hernia repair during pregnancy were identified within the ACS-NSQIP. Preoperative patient variables, intraoperative variables, and 30-day patient morbidity and mortality outcomes were investigated using a variety of statistical tests.

Results

A total of 126 pregnant patients underwent umbilical hernia repair from 2005 to 2014; 73 (58%) had incarceration or strangulation at the time of surgical intervention. The majority of patients (95%) underwent open umbilical hernia repair. Superficial surgical site infection was the most common morbidity in patients undergoing open umbilical hernia repair.

Conclusions

Based on review of the ACS-NSQIP database, the incidence of umbilical hernia repair during pregnancy is very low; however, the majority of patients required repair for incarceration of strangulation. When symptoms develop, these hernias can be repaired with minimal 30-day morbidity to the mother. Additional studies are needed to determine the long-term recurrence rate of umbilical hernia repairs performed in pregnant patients and the effects of surgical intervention and approach on the fetus.

     

Ethics in primary care: setting aside common misunderstandings

Ethics, as generally defined, tries to answer the question, "What ought to be done in a given situation, all things considered?" Answering this question in primary care is hampered by some common and recurring misunderstandings--some arising from physicians' misunderstanding of ethical concepts and vocabulary and some arising from ethicists' misplaced emphasis and ignorance of medical settings. Examination and clarification of these misunderstandings illuminate the nature of primary care ethics and the role of the practicing physician.     

Ethics: A Theory of Medical Ethics

This book review characterizes Robert Veatch's A Theory of Medical Ethics as a "third-generation" treatise that looks beyond case- and issue-oriented analysis to develop the theoretical bases of a "true system of medical ethics." Veatch proposes a "draft medical ethical covenant" based on a "triple contract" model, in which the moral principles of contract keeping, autonomy, honesty, avoiding killing, and justice govern the physician's relationship to both individual patients and society.     

Resistance to all-trans retinoic acid (ATRA) therapy in relapsing acute promyelocytic leukemia: study of in vitro ATRA sensitivity and cellular retinoic acid binding protein levels in leukemic cells [see comments]

All-trans retinoic acid (ATRA) induces leukemic cell differentiation and complete remission (CR) in a high proportion of patients with acute promyelocytic leukemia (AML3 subtype). However, relapses occur when ATRA is prescribed as maintenance therapy, and resistance to a second ATRA-induction therapy is frequently observed. An induced hypercatabolism of ATRA has been suggested as a possible mechanism leading to reduced ATRA sensitivity and resistance. CRABPII, an RA cytoplasmic binding protein linked to RA's metabolization pathway, is induced by ATRA in different cell systems. To investigate whether specific features of the AML3 cells at relapse could explain the in vivo resistance observed, we studied the CRABP levels and in vitro sensitivity to ATRA of AML3 cells before and at relapse from ATRA. Relapse-AML3 cells (n = 12) showed reduced differentiation induction when compared with "virgin"-AML3 cells (n = 31; P < .05). Dose-response studies were performed in 2 cases at relapse and showed decreased sensitivity to low ATRA concentrations. CRABPII levels and in vitro differentiation characteristics of AML3 cells before and at relapse from ATRA therapy were studied concomittantly in 4 patients. High levels of CRABPII (median, 20 fmol/mg of protein) were detected in the cells of the 4 patients at relapse but were not detected before ATRA therapy. Three of these patients showed a decrease in differentiation induction of their leukemic cells, and a failure to achieve CR with a second induction therapy of ATRA 45 mg/m2/day was noted in all patients treated (n = 3). Results from this study provide evidence to support the hypothesis of induced-ATRA metabolism as one of the major mechanisms responsible for ATRA resistance. Monitoring CRABPII levels after ATRA withdrawal may help to determine when to administer ATRA in the maintenance or relapse therapy of AML3 patients.     

Medical Ethics Resource Network of Michigan: development of a statewide ethics network

The Medical Ethics Resource Network (MERN) of Michigan has, over approximately 5 years, become a viable organization for disseminating educational information and raising the general standard of ethics discussion in a variety of institutional settings. This article reviews the history of the network's development, with special emphasis upon features that may suggest useful strategies for other networks now under formation.     

In the best interests of

Two commentaries examine the validity of the concept of "best interests of the infant" as the moral criterion upon which to base an ethically sound decision concerning medical care. Four opposing lines of argument, that infants have no interests in continued life, that infants' interests are unknowable, that an interests appeal can yield counterintuitive results, and that others' interests also deserve consideration are presented by Brody to show the complexity and ambiguity of treatment decisions. Bartholome argues that, while the concept of best interests does not function well as an objective criterion for analysis of medical ethical problems, it has value as a device that locates what is at stake in a problem and focuses the decision making process.