bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of renal replacement therapies on olfactory ability: results of a cross-sectional case control study
Authors: Iacono Valentina , Lombardi Gianmarco , Ottaviano Giancarlo , Gambaro Giovanni , Zaza Gianluigi
Published: February 2021

Introduction

Several studies have suggested that chronic kidney disease (CKD) may be associated with olfactory impairment. However, to date, the impact of renal replacement therapies has only been partly defined.

Methods

We tested the olfactory function of 235 participants [50 kidney transplant recipients (KT), 49 hemodialyzed patients (HD), 30 peritoneal dialysis patients (PD), 51 patients with CKD not on dialysis (ND-CKD) and 55 healthy subjects (HS)] by the Sniffin’ Sticks test (Burghardt®, Wedel, Germany), including the sub-tests for the determination of odor threshold (T), odor discrimination (D), odor identification (I). Each subtest result was then summed up to a composite score, known as the TDI score. The Sino-Nasal Outcome Test-22 (SNOT22), Montreal Cognitive Assessment (MoCA) test and olfactory function Visual Analogue Scale (ofVAS) were also performed.

Results

The mean TDI score was significantly lower (and consistent with hyposmia), in HD, PD and ND-CKD compared to HS and KT (ANOVA p < 0.001). Similar results were observed in the I and D tests, and with the T score, though with regard to the latter, only in PD and ND-CKD patients. Multiple comparisons among groups demonstrated no significant differences between KT and HS. After adjustments for confounding factors, a significant linear association was found between both urea (β − 0.03, p < 0.003) and eGFR (β 0.08, p < 0.001) with TDI score. No significant association was observed between the TDI score and the ofVAS score (p = 0.293).

Conclusions

Olfactory impairment affects a large number of CKD patients in the pre-dialysis phase as well as those on dialysis. Kidney transplantation may reverse this condition with a possible positive impact on the quality of life and social behaviors/relationships.

Graphic abstract
Die Cally-App
Authors: Widhalm Kurt , Schöber Victoria , Schmiedl Grischa
Published: February 2021

Hintergrund

Adipositas im Kindesalter ist ein alarmierendes Problem, welches es unerlässlich macht, effektiv in dessen Prävention zu investieren. Das Eddy-Young-2-Projekt war eine Präventionsstudie, die mit schulbasierten Ernährung- und Bewegungsinterventionen arbeitete. Zusätzlich wurde eine Gesundheits-App entwickelt.

Methodik

Im Schuljahr 2017/18 nahmen 52 Kinder (8–11 Jahre) einmal pro Woche an der Eddy-Intervention teil. Zusätzlich wurde den Kindern die „Cally-App“ vorgestellt, in der sie ein virtuelles Haustier ausgewogen ernähren sollten. Die Benutzung der App blieb freiwillig.

Ergebnisse

Die Benutzungsdauer der App im Schuljahr 2017/18 lag durchschnittlich bei 10,34 Spieltagen (arithmetisches Mittel). Der Median lag bei 4 Tagen.

Conclusio

In den ersten Unterrichtsstunden zeigten die Kinder eine große Begeisterung für die App, jedoch wurde diese, entgegen unseren Erwartungen, im Laufe des gesamten Schuljahres nur wenig benutzt. Um Apps längerfristig bei Kindern einsetzen zu können, sollte überlegt werden, mit einem Belohnungssystem oder mit Gamification-Elementen zu arbeiten.
Embedding autonomy in large-scale IoT ecosystems using CAO and L4G-CAO
Authors: Michailidis Iakovos T. , Kapoutsis Athanasios Ch. , Korkas Christos D. , Michailidis Panagiotis T. , Alexandridou Kyriaki A. , Ravanis Christos , Kosmatopoulos Elias B.
Published: February 2021

Recently, special attention has been paid in developing methodologies and systems for embedding autonomy within smart devices (Things). Moreover, as Things typically operate in an interconnected IoT ecosystem, autonomous operation must be performed in a cooperative fashion so the different Things coordinate their autonomous actions towards meeting high-level objectives and policies. Embedding Things with cooperative autonomy typically requires a tedious and costly effort not only during the original ecosystem deployment but throughout its lifetime. The current study describes CAO (Cognitive Adaptive Optimization)—and its distributed counterpart L4G-CAO (Local for Global Cognitive Adaptive Optimization)—which can overcome this shortcoming. CAO and L4G-CAO—which have recently been introduced and tested in a variety of IoT applications—can embed Things with cooperative autonomy in a plug-n-play fashion, i.e., without requiring the aforementioned tedious and costly effort. Results of the application of the aforementioned approaches in three different application domains (smart homes and districts, intelligent traffic systems and coordinated swarms of robots) are also presented. The presented results demonstrate the potential, of both approaches, to exploit the IoT automation functionalities in order to significantly improve the overall IoT performance without tedious effort.
This Way Up: The Effectiveness of Mobile Vertical Video Marketing
Authors: Mulier Lana , Slabbinck Hendrik , Vermeir Iris
Published: February 2021

The mobile environment of the 2020s is experiencing a vertical video revolution. The portrait, or vertical, screen format is replacing the traditional landscape, or horizontal, format to become the default for mobile video production and consumption. With the increasing use of vertical videos, an important, yet unanswered, question is how mobile users respond to this format. Therefore, we examine the effectiveness of mobile vertical versus horizontal video advertisements in terms of consumer interest, engagement, and processing fluency, as well as the underlying mechanism of the effort of watching the video ad on a smartphone in three studies. In a large-scale field study, we demonstrate that mobile vertical video ads increase consumer interest and engagement compared to horizontal video ads. In two experimental studies, we further show that mobile users process vertical video ads more fluently than horizontal video ads. Exploring the underlying mechanism for this effect, we find that mobile users experience less effort when watching a video ad vertically (vs. horizontally) on the smartphone in full-screen, as watching a vertical video does not require turning the phone. Importantly, we find that mobile users’ age moderates this indirect effect, as younger mobile users (Generation Z) process mobile vertical video ads more fluently than older Generations X and Y. This article closes with implications for theory and suggestions for mobile marketers.
Measures to Increase Use of Multiple Arterial Grafts for Isolated Coronary Artery Bypass Grafting
Authors: Velez Ana K. , Canner Joseph K. , Etchill Eric , Giuliano Katherine , Alejo Diane E. , Choi Chun , Kilic Ahmet , Schena Stefano , Whitman Glenn Joseph Robert , Lawton Jennifer S.
Published: February 2021

BACKGROUND:

Use of multiple arterial grafts (MAGs) provides superior patency and long-term survival benefit compared with venous grafts during coronary artery bypass grafting (CABG). However, MAGs are used infrequently for CABG. We hypothesized that specific measures introduced at our institution would lead to an increase in the use of MAGs.

STUDY DESIGN:

Use of MAGs before and after introduction of bundled measures was compared. Measures included increased education in arterial graft harvesting, inclusion as a quality metric, and hiring of surgeon champions. Patients younger than 70 years who underwent first time, isolated CABG using at least 1 arterial graft were included. Number and type of grafts used were compared between time periods using chi-square test. Secondary outcomes included postoperative complications. Complications were compared between time periods, as well as between MAG and non-MAG recipients before and after propensity score matching using Fisher exact test and univariate logistic regression. Multivariable logistic regression was used to determine patient characteristics associated with MAG use.

RESULTS:

There were 2,169 patients included from 2012 to 2019. MAG use increased significantly after introduction of measures (21.1% to 41.9%; p < 0.001). Radial artery use with an internal mammary artery (0.3% to 16%; p < 0.001) and the use of triple arterial grafts increased significantly (0% to 2.4%; p < 0.001). MAG use in the entire cohort was associated with decreased 30-day mortality and postoperative cardiac arrest that was not significant after propensity matching.

CONCLUSIONS:

A programmatic emphasis on the use of MAGs for CABG is an effective method to increase its use.
Judging at the Interface
Authors: Shirlow Esmé
Published: February 2021

This book explores how the Permanent Court of International Justice, the International Court of Justice, the European Court of Human Rights, and investment treaty tribunals have used deference to recognise the decision making authority of States. It analyses the approaches to deference taken by these four international courts and tribunals in 1,714 decisions produced between 1924 and 2019 concerning alleged State interferences with private property. The book identifies a large number of techniques capable of achieving deference to domestic decision-making in international adjudication. It groups these techniques to identify seven distinct 'modes' of deference reflecting differently structured relationships between international adjudicators and domestic decision-makers. These differing approaches to deference are shown to hold systemic significance. They reveal the shifting nature and structure of adjudication under international law and its relationship to domestic decision making authority.
Testimonial Smothering and Domestic Violence Disclosure in Clinical Contexts
Authors: Warman Jack
Published: February 2021

Domestic violence and abuse (DVA) are at last coming to be recognised as serious global public health problems. Nevertheless, many women with personal histories of DVA decline to disclose them to healthcare practitioners. In the health sciences, recent empirical work has identified many factors that impede DVA disclosure, known as barriers to disclosure. Drawing on recent work in social epistemology on testimonial silencing, we might wonder why so many people withhold their testimony and whether there is some kind of epistemic injustice afoot here. In this paper, I offer some philosophical reflections on DVA disclosure in clinical contexts and the associated barriers to disclosure. I argue that women with personal histories of DVA are vulnerable to a certain form of testimonial injustice in clinical contexts, namely, testimonial smothering, and that this may help to explain why they withhold that testimony. It is my contention that this can help explain the low rates of DVA disclosure by patients to healthcare practitioners.
Roadwork: Long-Distance Causeways at Uci, Yucatan, Mexico
Authors: Hutson Scott R. , Welch Jacob A.
Published: February 2021

A multiyear field project focused on long-distance causeways between Uci and Cansahcab in Yucatan, Mexico, supports their use for processions and pilgrimages, their role in the creation of multisite polities, and their involvement in the constitution of local authority. Yet details of the causeways’ construction suggest that people contested this authority. Work was central to these dynamics and comes in the form of labor as practice, investments in the maintenance of relations with other-than-human beings, and the ways that causeways produced embodied experiences that were ideal for their use in pilgrimages.
Immigrant Political Representation and Local Ethnic Concentration: Evidence from a Swedish Refugee Placement Program
Authors: Lindgren Karl-Oskar , Nicholson Michael D. , Oskarsson Sven
Published: February 2021

This study leverages population registry data from Sweden to examine whether immigrants who live in areas with a high concentration of ethnic minorities are more or less likely to be nominated for political office. It exploits a refugee placement program in place in Sweden during the late 1980s and early 1990s that restricted refugees' opportunities to freely choose their place of residence. The article presents evidence that immigrants who live in areas with a high ethnic density are less likely to be nominated for political office. The findings have important implications for local integration policies as well as refugee placement policies, as many countries consider local context when resettling refugees.
Constructed Attitudes toward the Roma: A French Case
Authors: Gagnon Audrey
Published: February 2021

Forty per cent of Europeans refuse to have Roma as their neighbours, while 80 per cent of these do not even have direct contact with them. Using these statistics as a point of departure, this study analyzes how attitudes toward Roma are constructed. It proposes to investigate this process in two similar environments but where local integration policies directed toward Roma differ, resulting in disparate forms of intergroup contact. The analysis is premised on two theoretical assumptions: that the integration of migrants is a local public policy issue and that intergroup contact frames attitudes between majority and minority groups. From semi-structured interviews in the French municipalities of La Courneuve and Ivry-sur-Seine, four theories are empirically tested: the contact theory, the halo effect, the impact of local immigrant integration policies and media influence. This study demonstrates that the implementation of municipal policies in favour of Roma integration can improve their living conditions and thus deconstruct prejudices attributable to their precarious situation. In addition, it illustrates how the media activate, maintain or solidify the way Roma are perceived.
Effect of grouping on behaviour of dairy heifers and cows in the transition period
Authors: Soonberg Maria , Kass Marko , Kaart Tanel , Barraclough Rosie , Haskell Marie J. , Arney David R.
Published: February 2021

Regrouping dairy cows is a common feature of dairy farm management. Cows are grouped based on lactation stage, age, milk yield and other factors. Regrouping cows during the dry period (from far-off area to close up area and from close up area to the main herd) brings new challenges. This is especially true for heifers who, after being confirmed gravid, may be grouped into a new pen with dried off cows. The aims of this study were to determine how grouping affects activity, nearest neighbour relationships and aggression, and how heifers’ acclimatization to a new group differs from cows. Therefore, the hypotheses were that regrouping cows has less of an effect on older cows compared to heifers, and cows' individuality affects acclimatization to a new group. Aggression data were recorded using a video camera that was directed at the feed bunk, and activity was recorded with activity monitors that were attached around the right hind leg. Synchrony and distance to nearest neighbour were recorded, as was the cows' location on the first 3 d from the day they returned to the main herd. Motion index, mean number of steps and number of lying bouts were significantly higher after calving compared to the week before calving and the difference was higher amongst heifers compared to cows (P < 0.001). Both cows and heifers lay down more in the strawyard compared to cubicle housing (P < 0.01) and cows were more aggressive than heifers in both housing systems (P < 0.001 and P < 0.05, respectively). As hypothesized, heifers were more affected by regrouping and cows with more experience settled quicker to their new environment.
Health Care Cost-Containment Regulation: Prospects and an Alternative
Authors: Havighurst Clark C.
Published: February 2021

Regulation of the health care system to achieve appropriate containment of overall costs is characterized by Professor Havighurst as requiring public officials to engage, directly or indirectly, in the rationing of medical services. This rationing function is seen by the author as peculiarly difficult for political institutions to perform, given the public's expectations and the symbolic importance of health care. An effort on the part of regulators to shift the rationing burden to providers is detected, as is a trend toward increasingly arbitrary regulation, designed to minimize regulators’ confrontations with sensitive issues. Irrationality and ignorance are found to plague regulatory decision making on health-related issues, even though it is the consumer who is usually thought to suffer most from these disabilities. The author argues that consumer choice under some cost constraints is a preferable mechanism for allocating resources because it better reflects individuals’ subjective preferences, has a greater capacity for facing trade-offs realistically, and can better contend with professional dominance of the resource allocation process.

In view of the unlikelihood of regulation that is both sensitive and effective in containing costs, the author proposes that we rely primarily on consumer incentives to reform the system. A simple change in the tax treatment of health insurance or other health plan premiums, to strengthen consumers’ interest in cost containment while also subsidizing needy consumers, is advocated. Steps to improve opportunities for innovation in cost containment by health insurers, HMOs, and other actors are outlined briefly.
Genetically Defective Children: Emerging Legal Considerations
Authors: Shaw Margery W.
Published: February 2021

Despite modern medical advances, births of genetically defective children still occur. The author outlines the problem of genetic disease, and describes the medical and legal advances that now make possible a reduction in its incidence. Then she cites—and briefly comments upon— some court cases brought by parents of genetically defective children against their physicians for allegedly failing to predict or to diagnose genetic defects in those children in time for the parents to exercise any procreative options such as sterilization, contraception, or abortion. In addition, the author speculates on various questions that may arise in future litigation in this area—among them, the question of whether or not courts someday will endow genetically defective children with a cause of action against their parents for bringing them into the world.
A Look at the Massachusetts Malpractice Tribunal System
Authors: McLaughlin Walter H.
Published: February 2021

In this Oration, the retired Chief Justice of the Massachusetts Superior Court offers some personal observations on the American medical malpractice crisis and examines the Massachusetts malpractice tribunal system, which is aimed at reducing the incidence of malpractice litigation that is either frivolous or involves simply an “unfortunate medical result” for which the health care provider should not be held accountable. First, the author relates some of his impressions of the evolution of the malpractice crisis and identifies its salient characteristics. Next, he provides a description and an evaluation of the Massachusetts tribunal system. Under that system, the plaintiff in any malpractice action must argue before a special tribunal—composed of a Superior Court judge, an attorney, and a surgeon—that his case raises a “legitimate question of liability.” If the tribunal finds that such a question exists, the plaintiff may pursue his case in the normal manner. But if the tribunal finds that the case involves “merely an unfortunate medical result,” and if the plaintiff still wishes to press his claim, he must, before proceeding, post a $2,000 bond, which is used to help pay the defendant’s litigation costs if the defendant prevails at the trial. The author offers data to support his contention that this tribunal system already is screening out a significant number of inappropriate malpractice claims. Nevertheless, he suggests that the system has substantial problems. He identifies those problems, and proposes methods for solving them.
Psychiatric Expert Witnesses: Proposals for Change
Authors: Needell James E.
Published: February 2021

Psychiatric experts are now called more frequently than in the past to testify in courtroom proceedings. Often, however, their testimony leads, to non-productive "battles of the experts." This Note examines various plans that seek to minimize the conflicts in expert testimony due, not to legitimate psychiatric disputes, but rather to inaccurate or biased testimony offered by one or both psychiatrists. It concludes that either of two plans would be effective: the first provides for a panel similar to existing medical malpractice tribunals; the second mandates court appointment of an inde pendent expert to testify in addition to those called by adversaries.
Assuring ‘Detached but Passionate Investigation and Decision’: The Role of Guardians Ad Litem in Saikewicz-type Cases
Authors: Baron Charles H.
Published: February 2021

The author focuses this Article upon the aspect of the Saikewicz decision which determines that the kind of “proxy consent” question involved in that case requires for its decision “the process of detached but passionate investigation and decision that forms the ideal on which the judicial branch of government was created.” This aspect of the decision has drawn much criticism from the medical community on the ground that it embroils what doctors believe to be a medical question in the adversarial processes of the court system. The author criticizes the decision from an entirely opposite perspective, arguing that the court's opinion fails in not laying down guidelines that would assure a truly adversary process in Saikewicz-type cases. He agrees with the Saikewicz court that our democratic institutional structure and societal commitment to individual liberty require that persons not competent to consent for themselves to acts of euthanasia be protected by a process of “detached but passionate investigation and decision.” However, he points out that this ideal of the court system was not realized in Saikewicz itself and is not likely to be realized in other cases without reform of some of the procedures currently being employed by the courts in “proxy consent” cases. Drawing on previous articles that he has written in related areas, he then proposes a set of guidelines that he believes not only will remove existing procedural deficiencies, but also may reform some aspects of the existing system that have drawn criticism from the medical community.
Judicial Determination of the Sexual Identity of Post-Operative Transsexuals: A New Form of Sex Discrimination
Authors: Taitz Jerold
Published: February 2021

Transsexualism is a condition in which an individual's psychological gender is the opposite of his or her anatomical sex. A “sex-change” operation can bring anatomical sex into line with gender, but it cannot create a new biological sex capable of procreation. The operation is expensive, dangerous and lengthy, yet in 1983 there were an estimated 6,000 post-operative transsexuals in the United States. Certain European countries have legislation recognizing the post-operative transsexual's new sex. Case law in the United Kingdom and the United States, however, prevent post-operative transsexuals from gaining legal recognition. The author does see some hope, however, for a change in the trend against recognition of transsexuals’ post-operative sex. This Article discusses the reasons behind this trend and concludes that the greater danger would be a consensus of medical opinion holding that sex-change surgery is unnecessary, questioning the very existence of post-operative transsexuals. Finally, the author calls for legislative action to remove judicially-imposed obstacles and to give legal recognition to the postoperative transsexual's new sex and identity.
Who's Monitoring the Quality of Mammograms? The Mammography Quality Standards Act of 1992 Could Finally Provide the Answer
Authors: Cocca Suzanne V.
Published: February 2021

Breast Cancer remains a leading cause of death among American women, yet little is known about its etiology and prevention. Screening mammography is currently the best preventative measure available to women, but comprehensive oversight of this procedure is necessary in order to minimize and, ultimately, eliminate “errors” that compromise quality and accuracy and give too many women a false sense of security. This Note describes our nation's battle against Breast Cancer, emphasizes the need for uniform, mandatory quality and safety standards for screening mammography, and outlines The Mammography Quality Standards Act of 1992, which seeks to provide the framework necessary to implement such standards and restore the preventative power of this procedure. This Note analyzes the terms of the Act and concludes that the Act could provide women with the true sense of security that has eluded so many women - too many women - for so long.
Outcomes Assessment in Health Care Reform: Promise and Limitations
Authors: Mariner Wendy K.
Published: February 2021

If the fundamental goals of the health care reform effort are to ensure universal access to an acceptable quality of health care at an affordable cost, then the threshold question for reform is: What health care services should be provided in an efficient, equitable system?

Answering this question requires weighing a complex mix of medical and social policy factors, a process not attempted in this article. But the starting point for that process should be determining what health care services “work” and what they cost. Outcomes assessment holds considerable promise in finding answers to these subsidiary questions, because it is intended to assess the effectiveness of health care services, that is, what works and what does not work for patients. It holds promise, not only for improving the quality of care, but also for identifying unnecessary or wasteful practices that increase health care costs.
Redefining Quality by Reassigning Responsibility
Authors: Morreim E. Haavi
Published: February 2021

Implicit in any discussion of quality in health care are ideas about responsibility: who is responsible to define quality, who is responsible to deliver it, and who is responsible when the quality of care is unsatisfactory. The thesis of this article is that due to economics, ethics, and law, we have placed these responsibilities almost exclusively on physicians, but that powerful economic changes now require a reallocation of the responsibilities of providers, patients, and payers in defining and delivering quality in health care.

In the past half-century an extraordinarily generous, uncritical reimbursement system has empowered physicians to define and deliver quality that is interventionist and highly technological. Longstanding ethical precepts hold that physicians are responsible for their patients, and modern economic arrangements have encouraged physicians to focus on their patients’ welfare, virtually to the exclusion of costs or other competing considerations.
Quality Assessment of Ethics in Health Care: The Accountability Revolution
Authors: Wolf Susan M.
Published: February 2021

Writing in 1988, Arnold Relman heralded the dawning of the “third revolution“ in medical care. The first revolution, at the end of World War II, had inaugurated an Era of Expansion, with an explosion of hospitals, physicians, and research. Medicare and Medicaid were passed, and medicine experienced a golden age of growth. Inevitably, according to Relman, this yielded to an Era of Cost Containment starting in the 1970s. The federal government and private employers revolted against soaring costs, brandishing the weapons of prospective payment, managed care, and global budgeting. Yet these blunt instruments of cost-cutting eventually produced concern over how to evaluate the quality of health care, to promote the good while trimming the bad. Thus Relman announced the arrival of the Era of Assessment and Accountability.

This chronology helps explain the current importance of quality. Quality assessment and more recently, quality improvement techniques, occupy a central place in this new era.
Medical Malpractice Litigation: Do the British Have a Better Remedy?
Authors: Miller Frances H.
Published: February 2021

Medical malpractice claims are filed nearly ten times more frequently in America than they are in Great Britain. British patients generally adopt a less adversarial stance toward medical malpractice than do American patients. This Article examines the British malpractice system, as compared with the American system, and explores the differences between the two, in terms of costs and fees, liability rules, statutory provisions, and judicial attitudes toward malpractice litigation. The Article also discusses British social and institutional factors, such as the “taint” of litigation and the National Health Service, and evaluates how these factors affect British malpractice litigation. The Article presents the alternative forums available to British patients in seeking satisfaction for their medical service complaints. The Article concludes with an evaluation of how these factors achieve the three societal objectives of malpractice litigation: reparation, emotional vindication and deterrence.
Patient Dumping in the Hospital Emergency Department: Renewed Interest in an Old Problem
Authors: Enfield Lisa M. , Sklar David P.
Published: February 2021

Alarm about the adverse effects of transferring emergency patients for economic reasons has resulted in federal legislation aimed at curbing the practice. We review the history of common law hospital liability for denial of emergency care and analyze the federal legislation designed to restrict the transfer of medically indigent patients with emergency problems. We conclude that the currently proposed solutions to patient dumping will have limited effectiveness without more specific incentives for the provision of health care to the medically indigent.
Expert Psychiatric Evidence in Sexual Misconduct Cases Before State Medical Boards
Authors: Hyams Andrew L.
Published: February 2021

The growing problem of physician sexual misconduct has captured the attention not only of the medical and legal communities, but of the public as well. State medical boards, administrative agencies with generous rules of evidence and varying levels of expertise, face the difficult task of responding to patients’ allegations of physician sexual abuse. This Article, based in large part on the author's survey of current state medical board practice, reveals an increasing reliance on expert psychiatric testimony to explain the behavior of complainants and accused physicians. Drawing analogies from the use of psychiatric evidence in child sexual abuse cases, the author examines the factors that boards must consider in determining the admissibility of expert testimony in physician sexual misconduct cases, and calls upon states to establish clear evidentiary rules to govern the use of such testimony in administrative hearings.
Foregoing Life-Sustaining Treatment for Adult, Developmentally Disabled, Public Wards: A Proposed Statute
Authors: McKnight Deborah K. , Bellis Maureen
Published: February 2021

This Article proposes a procedure for making decisions to forego life-sustaining treatment for adult, developmentally disabled, public wards who are not competent to make health care decisions. Few commentators or cases address the special considerations involved in making life-sustaining treatment decisions for this patient population. The proposal attempts to fill this gap with a patient-centered process that allows decisionmakers, without prior judicial approval, to forego lifesustaining treatment for adult, developmentally disabled, public wards who have been reliably diagnosed with specific medical conditions.
Short-Sheeting the Psychiatric Bed: State-Level Strategies to Curtail the Unnecessary Hospitalization of Adolescents in For-Profit Mental Health Facilities
Authors: Sperber Marc N.
Published: February 2021

Over the past decade, there has been an increase in the hospitalization of minors in private, for-profit, psychiatric facilities. This increase suggests a tension between what is medically necessary and what is financially desirable. This Note discusses the hospitalization of minors in private, for-profit, mental health facilities and its attendant implications. This Note then examines various state efforts aimed at protecting minors from inappropriate psychiatric hospitalization. Finally, while there is no catch-all solution to the problem, this Note offers specific recommendations for reforming the for-profit psychiatric industry.
Regulating Transfer and Use of Fetal Tissue in Transplantation Procedures: The Ethical Dimensions
Authors: Constantine Bell Nikki Melina
Published: February 2021

For twenty years scientists have worked to find an effective treatment to ease the quivering, the stiffness, and the difficulty in controlling bodily movements which are the primary symptoms of Parkinson's disease. The disease can be treated with L-dopa, a drug that mimics the dopamine that coordinates neural transmission in the human brain, which Parkinson's sufferers have ceased to produce in sufficient quantities. The L-dopa, however, produces damaging side-effects and sometimes proves ineffectual. Researchers discovered in animal experiments that the effects of a laboratory-developed disease simulating Parkinson's disease could be mitigated using fetal brain tissue transplants, which produced the natural dopamine the animals’ cells failed to produce adequately.

These experiments were replicated with human subjects, and fetal tissue transplants have shown great potential as a treatment for Parkinson's disease. Fetal tissue is ideal for transplantation because it is in a stage of primitive development in which it adjusts easily to a new environment.
Protecting the Consumer From Getting Burned: the FDA, the Administrative Process, and the Tentative Final Monograph on Over-the-Counter Sunscreens
Authors: Jones Patrick R.
Published: February 2021

As consumers have become enlightened to the dangers of the sun, they have turned increasingly to sunscreens to stave off not only a sunburn but also life-threatening skin cancer. In the last decade, the incidence of skin cancer has grown a startling 500%. The increase in the number of skin cancers in adults is most likely the result of exposure to the sun as a child. Therefore, the current and continued rise in the number of skin cancers in adults is not remediable. However, as adult consumers seek to prevent further damage to their skin and protect their children from the same fate, the market for sunscreens has grown and is estimated to be worth between $170 and $650 million dollars. The increased demand for sunscreens, combined with the incorporation of sunprotection ingredients into everyday products such as makeup and skin lotions, has led the United States Food and Drug Administration (FDA) to subject sunscreens to increased regulatory scrutiny.
Assisted Reproductive Technologies and the Pregnancy Process: Developing an Equality Model to Protect Reproductive Liberties
Authors: Daar Judith F.
Published: February 2021

The world of assisted reproductive technologies (ART) has forced our society to confront scenarios that were unimaginable a mere quarter century ago. The birth of Louise Brown in 1978, the first child conceived through in vitro fertilization (IVF), introduced to the world the notion of asexual reproduction. The bitter battle over the parental status of Baby M., a baby born by a surrogate mother in the early 1980s, engendered a public debate over the interaction between contract law, family law and reproductive liberties that still rages today. In 1992, the highly publicized divorce of Junior and Mary Sue Davis focused national attention on the issue of proper disposition of frozen embryos. This case highlighted the fact that conception and pregnancy could be separated by a significant amount of time as a result of cryopreservation. While each of these events marked a step forward in the march toward total technological mastery of human reproduction, they also suggest that future struggles involving ART will grow increasingly fierce and complicated as our fund of knowledge increased. This Article suggests that current disputes over the disposition of frozen embryos are emblematic of that struggle.
Capitation, Advances in Medical Technology, and the Advent of a New Era in Medical Ethics
Authors: Malinowski Michael J.
Published: February 2021

Health care is being capitated throughout the United States, and much of the spread of capitation is attributable to the efforts of insurers to contain costs. The present lack of comprehensive studies evaluating the impact of capitation on overall health care quality leaves vast room for speculation.

Capitation does, however, carry a very fundamental certainty with broad implications. Whether the arrangement calls for a fixed sum for treating a particular ailment, a set fee for meeting all of an individual patient’s health care needs, or a standard charge for supplying all the medication for a specific condition, capitation sets limits. Because the health care costs for any given patient or condition are in reality zero-sum rather than fixed, capitation is about pooling patients and rationing. It involves denying services to some patients despite a general contractual commitment to coverage, presumably so that more patients can be covered or receive better care. The implications of capitation are even more significant when set fully in the context of the overall health care reform now underway. Simultaneously and comprehensively, health care is being managed, made for-profit, and consolidated.
“So Quick Bright Things Come to Confusion”
Authors: Capron Alexander Morgan
Published: February 2021

In the past several decades, the problems facing those of us who labor in the vineyards of health policy and ethics have been the problems of success — first medicine's and then, though to a lesser extent, our own. By this I mean that it has been the remarkable fruits of biomedicine, from research to health care delivery, that have produced the rich harvest of ethical, social and legal issues that have drawn our, and society's, attention.

In the basic science laboratory, scientists have developed means to splice pieces of DNA together, raising questions from workplace safety to the reengineering of homo sapiens. Of more immediate concern, tests for genetic susceptibility to disease in one's self and one's offspring have been developed, thereby generating questions about employment and insurance discrimination, selective abortion, and adverse impacts on self-identity and well-being.
Physician Self Referral Arrangements: Legitimate Business or Unethical “Entrepreneurialism”
Authors: McDowell Theodore N.
Published: February 2021

An emerging legal and ethical controversy in the health care industry centers on physician investment in health care facilities to which they make patient referrals. This Article analyzes the policy debate surrounding these physician self referral arrangements as well as the various responses to such arrangements. The Article asserts that an effective legal or ethical response to self referral arrangements must acknowledge and balance both the possible pro-competitive effects of such arrangements and the inherent potential for abuses in this type of business practice. From this perspective, the most effective form of regulation consists of extensive structural guidelines which focus on the physician's referral behavior and limit restrictions on investment procedures. Such an approach would minimize referral abuses and conflict of interest concerns but promote business and competitive freedom.
The Uniform Status of Children of Assisted Conception Act: Does It Protect the Best Interests of the Child in a Surrogate Arrangement?
Authors: Yoon Mimi
Published: February 2021

Medical technology is easing the plight of many infertile couples by offering such reproductive alternatives as in vitro fertilization, artificial insemination and surrogacy. In response to the changes in our society's definition of family, wrought by scientific advances, the National Conference of Commissioners on Uniform States Laws promulgated the Uniform Status of Children of Assisted Conception Act. The purpose of this Act is to protect the interests of children born through extraordinary medical procedures. This Note analyzes the Act's provisions regarding surrogacy and focuses on how the Commission's regulatory scheme fails to protect the child's interests. The Act's alternative of voiding the surrogacy contract also does not protect the child's interests. A more complete regulatory scheme which protects the adult parties’ interests, as well as the child's, should be devised, as the adequacy of the adult parties’ protection ultimately affects the child's well-being.
Educated Guesses: Health Risk Assessment in Environmental Impact Statements
Authors: Harvey Pamela D.
Published: February 2021

Environmental pollution threatens public health. The search for solutions has advanced the frontiers of science and law. Efforts to protect the environment and public health begin with describing potential adverse consequences of human activities and characterizing the predicted risk. The National Environmental Policy Act requires the preparation of environmental impact statements to describe the effects of proposed federal projects and provide information for agency decisionmakers and the public.

Risks to public health are particularly difficult to quantify because of uncertainty about the relation between exposure to environmental contamination and disease. Risk assessment is the current scientific tool to present estimates of risk. The methodology has created controversy, however, when underlying assumptions and uncertainties are not clearly presented. Critics caution that the methodology is vulnerable to bias. This Note evaluates the use of risk assessment in the environmental impact statement process and offers recommendations to ensure informed decisions.
A Proposal For A Nonreinstatement Rule In Unfair Labor Practice Cases Involving Patient Abuse
Authors: Tully Clare T.
Published: February 2021

Nursing home discharges of employees based on patient abuse raise a difficult issue when the motivating factor for the disciplinary action is union activism. A tension is created between the rights of employees to engage in protected concerted activity and the rights of patients to quality care. In 1974, Congress passed the Health Care Institutions Amendments, which granted to non-profit health care workers collective organizing and bargaining rights substantially similar to those which workers in other industries had enjoyed for decades under the National Labor Relations Act. Congress intended to give health care workers only that degree of parity, however, which is compatible with the provision of high quality patient care. The agency charged with enforcing the Act, the National Labor Relations Board (NLRB), has failed to distinguish employee misconduct in industrial settings from patient abuse in health care institutions when fashioning remedies for discriminatorily discharged union activists. The NLRB typically has ordered the reinstatement, with back pay, of the patient abuser as the patient’s primary care-giver. This Article suggests that a front pay remedy is more appropriate to these cases because it protects the patient’s right to be free from abuse without sacrificing employee unionization rights.
Limits of Guardian Treatment Refusal: A Reasonableness Standard
Authors: Veatch Robert M.
Published: February 2021

The debate concerning the legal and ethical bases of guardian refusal of medical treatment on behalf of incompetent patients often ignores critical distinctions among types of patients and guardians. For example, patients who have expressed preferences regarding treatment while competent are distinguishable from patients who have always lacked the competency requisite to expressing a treatment preference. “Bonded guardians,” whose relationship with the patient preexisted guardianship, should have a different role in the decision-making process than “nonbonded guardians,” who were strangers to the patient prior to the guardian-ward relationship.

This Article proposes criteria for guardian treatment refusal on behalf of incompetent patients. Under the model for guardian decision making presented here, bonded guardians should be preferred over nonbonded guardians, and bonded guardians should be allowed discretion to make treatment choices, limited only by a standard of reasonableness policed by the courts. The Author presents legal and ethical justifications for the bonded guardian's heightened role. Finally, he considers the proper roles of health professionals, hospital ethics committees, and judges in the decision-making process.
Presbyterian Hospital of Dallas v. Harris: A Dubious Consequence of Piecemeal Health Care Legislation
Authors: Berk Deborah K.
Published: February 2021

For almost forty years, legislators have advocated comprehensive measures designed to assure Americans quality health care. Instead of implementing an integrated health care plan, Congress has intermittently enacted statutes which address specific health care delivery problems. At times the judiciary has stretched the ambit of existing health legislation in response to particular plaintiffs’ urgent claims. This Case Comment examines the dilemma of piecemeal legislation and judicial policymaking as exemplified by Presbyterian Hospital of Dallas v. Harris, a Fifth Circuit Court of Appeals health care financing decision whose outcome Congress has flatly rejected.
Health Maintenance Organizations and State DRG Hospital Cost Control Programs: The Need for Federal Preemption
Authors: Blomquist Robert F.
Published: February 2021

The growth of Health Maintenance Organizations (HMOs) as alternatives to the conventional Health care system is the result of HMOs' financial competitiveness and their ability to provide efficient Health care without wasteful and costly medical procedures. An HMO's goal is to minimize the cost of providing responsible medical care. As a result, HMOs attempt to limit the length of stay of a patient in a hospital by providing alternatives to hospital care. They achieve a competitive advantage by utilizing less expensive methods of treatment. The emergence of diagnostically related group (DRG) regulatory systems threaten the viability of HMOs by eliminating their competitive advantage. State-adopted DRG systems require hospitals to charge a fixed rate to all patients with similar diagnoses. This eliminates the advantage an HMO might gain by reducing a patient's length of stay. The Author argues that since HMOs are federally supported, they should be exempt from any DRG system implemented by a state. Further, the Author argues that while federal law ostensibly eliminates the conflict between HMOs and the DRG systems, HMOs are still restrained from free negotiations with hospitals. Accordingly, the Author contends that courts should apply federal statutes that encourage HMOs, preempt state laws, and thus allow HMOs to negotiate freely with hospitals regarding the rates of payment for patients.
The Peer Review Privilege: A Law in Search of a Valid Policy
Authors: Goldberg B. Abbott
Published: February 2021

The peer review privilege prevents patient-plaintiffs from obtaining the hospital records prepared in connection with quality review proceedings. The privilege, created by statute in most states, is rationalized by the need for confidentiality in promoting complete and candid peer review. In this Article, the Author argues that the privilege cannot effectively promote confidentiality since a common exception allows physicians to obtain the records when seeking judicial review of proceedings leading to their exclusion or dismissal from hospital medical staffs. More significantly, the Author notes that while the privilege began as a device to protect physicians from testifying against their will in malpractice suits—a condonation of the “conspiracy of silence”—it has evolved into a vehicle which enables hospitals to conceal the evidence of their own neglect.