Using the family covenant in planning end-of-life care: obligations and promises of patients,families, and physicians

Physicians and families need to interact more meaningfully to clarify the values and preferences at stake in advance care planning. The current use of advance directives fails to respect patient autonomy. This paper proposes using the family covenant as a preventive ethics process designed to improve end-of-life planning by incorporating other family members--as agreed to by the patient and those family members--into the medical care dialogue. The family covenant formulates advance directives in conversation with family members and with the assistance of a physician, thereby making advance directives more acceptable to the family, and more intelligible to other physicians. It adds the moral force of a promise to the obligation of respecting a patient's preferences about end-of-life care. These negotiations between patient, family, and physician, from early planning phases through implementation, should greatly reduce the incidence of family disagreements on what the patient would have wanted. The family covenant ensures advance directive discussions within the family, promotes and respects the autonomy of other family members, and might even spur others in the family to complete advance directives through additional covenants. The family covenant holds the potential to transform moral quagmires into meaningful moral conversation.     

Clinical decision support in the neonatal ICU

Clinical Decision Support (CDS) tools help the healthcare team diagnose, monitor, and treat patients more efficiently and consistently by executing clinical practice guidelines and recommendations. As a result, CDS has a direct impact on the delivery and healthcare outcomes. This review covers the fundamental concepts, as well as the infrastructure needed to create a CDS tool and examples of its use in the neonatal setting. This article also serves as a primer on what to think about when proposing the development of a new CDS tool, or when upgrading an existing one. We also highlight important elements that influence CDS development, such as informatics methodologies, data and device interoperability, and regulation.     

Assessment of US Radiology Residency Program Websites in the COVID-19 Era

ObjectiveTo provide an updated evaluation of radiology residency program websites in light of virtual interviewing during the COVID-19 pandemic and encourage programs to improve the quality of their online website presence.MethodsWe evaluated the websites of 197 US radiology residency programs between November and December 2021 for the presence or absence of 30 metrics. The metrics chosen are those considered important by applicants when choosing a program and have been used in other similar papers.ResultsOf the 197 programs, 192 (97.5%) had working websites. The average radiology residency website had 16 of 30 (54%) metrics listed on their websites. Five programs did not have accessible websites and were not included in the analysis. The most comprehensive website had 29 of 30 (97%) of metrics listed and the least comprehensive website had 2 of 30 (7%). There is a statistically significant difference in website comprehensiveness between top 20 and non–top 20 radiology program websites.ConclusionAlthough radiology residency program websites have generally become more comprehensive over time, there is still room for improvement, especially in times of virtual interviews when residency applicants are becoming more and more reliant on program websites to gain essential information about a program. Some key areas to include are diversity and inclusion initiatives, resident wellness, applicant information, program benefits, and showcase of people in the program.     

Usability of Hospital Price Estimators for Lumbar Spine MRI

PurposeThe aim of this study was to evaluate the usability of online hospital price estimators for a common imaging examination using surrogate patients.MethodsUsing the Amazon Mechanical Turk platform, the authors recruited adult English-speaking US residents as surrogate patients to find the cash price for a noncontrast lumbar spine MRI examination for a self-pay patient using price estimator tools at four hospitals. All were asked to view a 3-min tutorial video and report their experiences with the task, including the System Usability Scale (SUS) for the estimator, through a paid survey. Participants were queried about demographics, insurance, prior imaging exposure, and assessed health literacy and health insurance literacy using validated measures. Multivariable analysis for correct price identification and price estimator SUS were performed.ResultsOf 660 respondents, 476 met eligibility criteria (72.7% <45 years of age, 41.7% female, 86.1% white); 76.9% found all four estimators, and 9.2% were unable to locate any. Only 27.7% found the correct price at all four hospitals, with 67.4% being able to find at least one correct cash price. Average SUS score for the hospitals’ estimators ranged between 62.4 and 77.5. The hospital with a similar estimator to that used in the tutorial video had the highest SUS score. Accuracy of price identification improved with later tasks. Higher health insurance literacy was associated with higher identification of at least one correct price (odds ratio, 1.21; 95% confidence interval, 1.02-1.44) and higher SUS score (B = 1.68; 95% confidence interval, 1.07-2.29).ConclusionsSurrogate patients were able to locate hospital price estimators but unable to effectively use them to obtain correct prices. Tutorial videos improved SUS score, but correct price identification improved with practice.     

Physician complicity in human rights violations: Involuntary sterilization among women from Mexico and Central America seeking asylum in the United States

Involuntary sterilization is a violation of human rights and grounds for asylum in the United States. Forensic medical evaluations can be useful in documenting this form of persecution and supporting asylees’ claims for immigration relief. We conducted a retrospective case analysis of the personal and medical affidavits of 14 asylum-seeking women from four Latin America countries who all reported they had been involuntarily sterilized. Sixty-four percent said that “consent” was coerced; the remainder were unaware of having been sterilized at the time of the procedure. In all cases, findings on hysterosalpingogram were consistent with sterilization, revealing that all 14 had undergone a tubal ligation. Eighty-six percent of the women had been sterilized at the time of childbirth. The healthcare providers involved in the 14 cases failed to obtain informed consent, misled patients about sterilization, engaged in discriminatory behavior, and/or breached patient confidentiality regarding their HIV-status. All 14 asylum cases were defensive; of the 7 cases (50%) that have been decided to date, 100% have been granted asylum.     

Feasibility and Timing of Prehospital Administration of Reteplase in Patients with Acute Myocardial Infarction

Background: In myocardial infarction patients undergoing thrombolysis, treatment delays negatively impact outcomes. This pilot study was conducted to determine the feasibility and timing of field administration of intravenous double bolus reteplase in patients with ST-elevation myocardial infarction. Methods: Sixty three patients with symptoms and EKG changes consistent with acute myocardial infarction of less than six hours duration received the first bolus of reteplase before arriving at the emergency department. A second bolus of reteplase was given in the emergency department. Subsequent resolution of ST-segment elevation was measured. Mean time from symptom onset to paramedic dispatch, and paramedic arrivals to first bolus of reteplase were measured. The mean time from the first bolus of reteplase to heparin bolus in an emergency department was also measured. All patients with evidence of ST-elevation and suspected acute myocardial infarction gave consent for the thrombolytic therapy. There were no refusals of therapy among those candidates eligible for thrombolysis. Results: The mean times from the first bolus of reteplase to heparin bolus in the emergency department was substantially longer than the in-field times. Resolution of ST-segment elevation was recorded in 52 of the 63 patients and the times of resolution ranged from five minutes after the first bolus dose to 190 minutes after the second bolus of reteplase. Resolution of ST-segment elevation and relief of pain occurred almost simultaneously. Conclusions: These results demonstrated that in-field administration of thrombolytic therapy is a viable option to reduce the delay from symptom onset to initiation of thrombolysis. They demonstrated that satisfactory resolution of ST-segment elevation can be recorded in the field. The reduction in mortality observed in this study is comparable to previously published studies on inpatients. Abbreviated Abstract. This open-label pilot study was conducted to determine the feasibility and timing of field administration of intravenous double-bolus reteplase and to measure subsequent resolution of ST elevation in 63 patients with symptoms and ECG changes consistent with acute myocardial infarction for less than 6 hours. These results demonstrated that in-field administration of thrombolytic therapy is a viable option to reduce the delay from symptom onset to initiation of thrombolytic therapy.     

Lipoprotein(a) and aortic valve stenosis: A casual or causal association?

AimsThis review aims to provide an update of available methods for imaging calcification activity and potential therapeutic options.Data SynthesisAortic valve calcification represents the most common heart valve condition requiring treatment among adults in Western societies. No medical therapies are proven to be effective in treating symptoms or reducing disease progression. Therefore, surgical or transcatheter aortic valve replacement remains the only available treatment option. Elevated circulating concentrations of lipoprotein(a) is strongly associated with degenerative aortic stenosis. This relationship was first observed in prospective observational studies, and the causal relationship was confirmed in genetic studies.ConclusionsNew therapeutic targets have been identified and new imaging techniques could be used to test the effectiveness of new agents and further clarify the pathophysiology of AVS. No therapy that specifically lowers Lp (a) levels has been approved for clinical use.     

中华麦饭石防治大鼠肝炎,肝硬化和肝癌时微量元素作用

目的：本文旨在探讨中华麦饭石防治大鼠肝炎、肝硬化和肝癌时微量元素的作用方法：给ｗｉｓｔａｒ大鼠食用二甲基奶油黄饲料，同时饮用１０％中华麦饭石浸液共２６周。用ＩＣＰ法检测肝炎、肝硬化和肝癌大鼠全血１０种微量元素。结果：肝炎时实验组仅Ｍｎ显著高于对照组（Ｐ＜００５）。肝硬化时实验组Ｍｎ、Ｓｉ、Ｂａ、Ｆｅ、Ｚｎ和Ｓｅ均显著高于对照组，Ｃｕ显著低于对照组（Ｐ＜００５～０．００１）。肝癌时实验组Ｍｎ、Ｓｉ、Ｂａ、Ｆｅ、Ｚｎ、Ｓｅ和Ｍｏ继续高于对照组，Ｃｕ和Ｃｒ低于对照组（Ｐ＜０００１）。除Ｓｉ外，实验组和正常对照组微量元素差异无显著意义（Ｐ＜００５）。结论：１肝病越重，微量元素变化越明显。２中华麦饭石能维持机体微量元素的正常状态，对大鼠肝炎、肝硬化和肝癌防治具有重要作用。     

Patient preferences

Objective: To assess whether patients can weigh risk comparisons involving mortality and quality of life in an understandable manner based on their willingness to accept risks of complications. Design: Cross-sectional survey of patients. Setting: University-based Department of Veterans Affairs Medical Center. Participants: 230 men patients seen in a general medicine clinic. Measurements: Two survival graphs were used. Each graph contained survival curves for two alternative unidentified treatments for an unidentified medical condition. Graph 2 contained one curve that had a life expectancy that was 14% higher than the life expectancy of the corresponding curve in graph 1. Respondents were randomly assigned one of the two graphs and were asked to indicate which treatment they preferred and what risk of a change in their quality of life (urinary incontinence or impotence) they were willing to accept to achieve longer survival. Patients were also asked whether they had a history of urinary incontinence or impotence. Results and conclusions: Patients tended to be unwilling to accept worse quality of life to achieve increased survival over time. For both curve comparisons, significantly more (p<0.01) patients accepted a treatment associated with higher mortality to avoid a 100% chance of incontinence than to avoid a 100% chance of impotence. Of the 75% (172/230) of patients reporting willingness to accept risk of either urinary incontinence or total impotence or both, 62% reported having at least some symptoms related to urinary incontinence or impotence. Of the 58 patients not willing to accept the complication risks, only 11% reported a history of urinary incontinence or impotence. The results show that patients are able to make distinctions about severity of morbidity, men are less willing to accept the risk of urinary incontinence than that of total impotence, and men patients who are symptomatic with urinary incontinence or impotence are more willing to accept the risks of treatment than are asymptomatic patients. Received from the Department of Veterans Affairs Medical Center, Oregon Health Sciences University, Portland, Oregon.     

生活技能教育与烟草控制教育

目的:让学生掌握生活技能基本知识,并学会在实际生活中应用这些生活技能。方法:2006年9月至11月在北京大学医学部开设《生活技能教育与心理健康促进》本科生选修课,采用参与式教学方法,以培养医学生从健康的生活方式为楔入口,为学生提供生活技能的理论教学与实践培训。通过课程前后2次问卷调查,对本课程教学内容、教学方式、教学效果以及学生健康相关行为和态度进行了评估。结果:课程结束后学生对生活技能的理解有了明显的正确改变,各种心理社会能力得分也有了明显的提高。生活技能教育对大学生烟草使用等不良行为、倡导健康生活方式起到了积极的作用。结论:开设相关生活技能教育课程是必要、有效且可行的,可以在高校推广应用。