The beginning of the end of principlism

Book reviewed in this article: Principles of Biomedical Ethics . By Tom L. Beauchamp and James F. Childress.     

The relationship between research and service development: an illustrative example of a pilot study introducing complementary therapies into primary care

In this paper the commissioners of an evaluation and the researchers jointly review the relationship between research and service development at a local level in an evaluated health authority pilot project to introduce complementary therapies into primary care. The article discusses the importance of organisational arrangements between the research and the service development, focusing on the close working relationship between researchers and stakeholders in the research and corresponding service development. The relationship between the research and service development was not linear and the benefits were not based solely on outcomes of the treatment but also on the ways the evaluation gave insight into how the pilot service was delivered. Factors such as personal commitment to the project and close working relationships by all concerned are important. These elements are rarely emphasised but have to be taken into account if evidence-based health care is to achieve its potential.     

Chronic diarrhea: Causes,presentation, and mangement

Important inroads are being made into understanding the pathophysiology of diarrhea. Clear understanding of key mechanisms should suggest new approaches to combat disease. Exciting developments are occurring in terms of super-ORS solutions, particularly with the promise of short chained glucose polymers and glutamine. Perhaps the most important development is the prospect of a good rotavirus vaccine being available before the end of the decade. Chronic diarrhea seems to be on the increase globally, probably because of the success of ORS. The mechanisms that lead to mucosal injury are elusive, and therapy still largely supportive and empiric. Celiac disease continues to be a puzzle, because of the uncomfortable feeling that a majority of cases may be missed because of atypical presentations. The successful use of long term parenteral nutrition has allowed survival and better charaterization of cases that otherwise would have perished as ‘lethal protracted diarrhea’. Microvillus inclusion disease may be the commonest congenital secretory diarrhea. The role of the recently reported high prevalence of glucoamlase deficiency may be important. Lastly, attention to micronutrients, particularly low vitamin A and probably zinc may prove to be important in prevention and amelioration of diarrhea and growth failure.     

Targeted Delivery of Doxorubicin via Sterically Stabilized Immunoliposomes: Pharmacokinetics and Biodistribution in Tumor-bearing Mice

Purpose. To evaluate benefits in tumor localization, availability, and noncancerous organ distribution of doxorubicin (DOX) delivered via small (120 nm) sterically stabilized immunoliposomes targeted against a tumor-associated antigen in fibrosarcoma-bearing mice. Methods. DOX-loaded liposomes were prepared with (i) specific monoclonal IgG₃ antibody (32/2, D-SSIL-32/2); (ii) non-specific IgG₃ (D-SSIL-IgG); or (iii) no IgG (D-SSL) on their surface. Equal DOX amounts were injected intravenously via each type of liposome into BALB/c mice carrying experimental lung metastases of a polyoma virus-induced fibrosarcoma (A9 etc 220) expressing a polyoma virus-induced tumor-associated antigen (PAA) on their surface. Metastases occurred mainly in lung. Mice were treated at 3 stages of tumor development (micrometastases, medium-size metastases, and large, necrotic metastases). Performance evaluation was based on time-dependent quantification of DOX and DOX metabolites (DOX-M) in lung tumor, noncancerous organs, and plasma. Results. (i) DOX delivered via both SSIL retained the prolonged circulation time typical of DOX delivered via D-SSL. (ii) DOX accumulation in noncancerous organs was similar for all preparations. Low levels of DOX-M were obtained for all three preparations in all organs except liver, suggesting a similar processing, (iii) Preparations differed in behavior in lung tumor depending on tumor size and microanatomy. Only at the micrometastases stage were the specifically targeted D-SSIL-32/2 superior to D-SSL and D-SSIL-IgG, delivering 2–4 times more drug into the tumor, (iv) DOX-M level in all three tumor stages was in the following order: D-SSIL-32/2 >> D-SSL >> D-SSIL-IgG, suggesting that DOX delivered as D-SSIL-32/2 is most available to tumor cells. Conclusions. The advantage of specific targeting of sterically stabilized liposomes is expressed mainly in increasing availability of DOX to tumor cells in a way which is dependent on tumor microanatomy. The impact of this advantage to therapeutic efficacy remains to be determined.     

Secondary prevention of excessive alcohol use: assessing the prospects of implementation

BACKGROUND: Alcohol risk and harm reduction is a public health approachthat goes beyond specialized treatments for alcoholism. Thegreatest potential for reducing alcohol risk and harm in a populationdepends on the extent to which health care practitioners usesecondary prevention programmes. OBJECTIVE: We aim to assess the factors that affect the prospects of disseminatingcomprehensive, secondary prevention programmes into mainstreampractice. METHOD: A decision balance was used to assess the prospects of practitionersimplementing comprehensive programmes systematically. The stages-of-changemodel provides perspectives about behaviour change with regardto patients, practitioners and practice settings. RESULTS AND CONCLUSIONS: Programme implementation is extremely unlikely given the currentorganization of health care settings. To maintain the use ofsuch programmes, we need to change the "unit of leverage" inthe system: from the clinical encounter—that is, practitionersworking with individual patients in a case-finding manner—toan organizational level—that is, the appropriate use ofmanagerial and information systems supporting health care settingsto identify at-risk patients systematically as they enter primarycare and hospital settings. With appropriate infrastructuresupport, practitioners will be able to fulfil the potentialfor as well as maintain the use of comprehensive, secondaryprevention programmes to reduce alcohol risk and harm in thepopulation. Keywords. Alcohol abuse, general practice, implementation, secondary prevention.     

Adjustments and Leak Detection of the Adjustable Silicone Gastric Band (ASGB) and Lap-Band™ Adjustable Gastric Band (LAGB) System

Background: The detection of a leakage in the system of the adjustable silicone gastric band (ASGB) may be difficult. Gastrografin injection into the port should be avoided because it acts like a glue and blocks the system. Methods: A syringe containing saline and a syringe containing Thallium-201 chloride is connected to the 4-way stopcock which is connected to the needle. The needle is pushed into the port. The position is confirmed by injection and aspiration of saline. 2 ml of TL-201 chloride (74 MBp) is injected to locate the leakage in the system with planar images with a gamma camera (Elscint SP 6), 30 min, 2, 3, and 24 h after injection. Results: The original ASGB was provided with an injection reservoir which, in our series, was found to be leaking in four cases (3%). Conclusions: Our technique for adjustments and leak detection appears to be simple and effective. Band-related problems such as reservoir leak should disappear with improvement of the material.