bluuebunny/crossref_metadata_2025 huggingface dataset:
Introducing the First Black Bachelorette: Race, Diversity, and Courting Without Commitment
Authors: Monk-Payton Brandeise
Published: May 2019

Since its premiere in 2002, The Bachelor (ABC) and its spinoffs have entertained television audiences with their depiction of individuals vying for love. However, the franchise has been critiqued for the lack of racial diversity in its contestant pool. This article examines the racialized and gendered logics of representation that frame the casting of the first black Bachelorette Rachel Lindsay. This article discusses the industrial conditions of possibility at the ABC network that led to Lindsay’s casting in 2017, which center on the cultivation of diversity in primetime programming. Yet the courting of a black female lead is done without a commitment to the specificities of targeting a black woman to be at the forefront of the competition to find love. This article details the construction of the African American female lead’s romantic journey and audience response at the intersections of race, gender, and the cultural politics of desire.
Isolated reoperation for tricuspid regurgitation after left-sided valve surgery: technique evolution
Authors: Chen Jinmiao , Hu Kui , Ma Wenrui , Lv Minzhi , Shi Yu , Liu Ju , Wei Lai , Lin Yi , Hong Tao , Wang Chunsheng
Published: May 2019

OBJECTIVES

This study aimed to compare the isolated replacement and repair of severe tricuspid regurgitation after left-sided valve surgery (LSVS) and to report the evolution of this surgical technique.

METHODS

From January 2005 to August 2018, 118 patients underwent isolated tricuspid valve replacement (iTVR, n = 93) or repair (iTVr, n = 25) for severe tricuspid regurgitation after LSVS. The surgical protocol at our institution has significantly changed since 2015, implementing the right thoracotomy approach (95.5%) and peripheral cannulation strategy with the vacuum-assist single venous drainage technique (93.2%) with a concomitant enhancement in preoperative right heart function optimization. Patients were followed up for 32.5 ± 34.6 (1.6–158.7) months.

RESULTS

The operative mortality rate was 8.5% (8.6% in iTVR and 8.0% in iTVr, P = 0.924) with a significant decrease from 23.3% (2005–2014) to 3.4% (2015–2018) (P < 0.001), which was associated with preoperative New York Heart Association functional class IV [odds ratio (OR) 14.73, 95% confidence interval (CI) 2.68–80.90; P = 0.002] and anaemia (OR 6.60, 95% CI 1.03–42.22; P = 0.046). After adjusting the logistic regression model, the vacuum-assist single venous drainage technique was also associated with lower operative mortality and composite adverse outcomes. The overall 1- and 5-year survival rates were 91.5% (95% CI 84.8–95.3%) and 77.9% (95% CI 60.0–88.3%), respectively, and no difference was found between the iTVR and iTVr groups (P = 0.813).

CONCLUSIONS

Isolated tricuspid valve reoperation for severe tricuspid regurgitation after LSVS is historically a high-risk procedure, but satisfactory results are achievable with advanced surgical techniques and improved perioperative management. Bioprosthetic iTVR is a reliable alternative for severe tricuspid regurgitation after LSVS.
Gene-drive-mediated extinction is thwarted by population structure and evolution of sib mating
Authors: Bull James J , Remien Christopher H , Krone Stephen M
Published: May 2019

Background and objectives

Genetic engineering combined with CRISPR technology has developed to the point that gene drives can, in theory, be engineered to cause extinction in countless species. Success of extinction programs now rests on the possibility of resistance evolution, which is largely unknown. Depending on the gene-drive technology, resistance may take many forms, from mutations in the nuclease target sequence (e.g. for CRISPR) to specific types of non-random population structures that limit the drive (that may block potentially any gene-drive technology).

Methodology

We develop mathematical models of various deviations from random mating to consider escapes from extinction-causing gene drives. A main emphasis here is sib mating in the face of recessive-lethal and Y-chromosome drives.

Results

Sib mating easily evolves in response to both kinds of gene drives and maintains mean fitness above 0, with equilibrium fitness depending on the level of inbreeding depression. Environmental determination of sib mating (as might stem from population density crashes) can also maintain mean fitness above 0. A version of Maynard Smith’s haystack model shows that pre-existing population structure can enable drive-free subpopulations to be maintained against gene drives.

Conclusions and implications

Translation of mean fitness into population size depends on ecological details, so understanding mean fitness evolution and dynamics is merely the first step in predicting extinction. Nonetheless, these results point to possible escapes from gene-drive-mediated extinctions that lie beyond the control of genome engineering.

Lay summary

Recent gene drive technologies promise to suppress and even eradicate pests and disease vectors. Simple models of gene-drive evolution in structured populations show that extinction-causing gene drives can be thwarted both through the evolution of sib mating as well as from purely demographic processes that cluster drive-free individuals.
Acoustic radiation and reflection of a logging-while-drilling dipole source
Authors: Wei Zhoutuo , Tang Xiaoming , Cao Jingji
Published: May 2019

With the comparison to the resistivity ultra-deep measurement, the single-well reflection survey in acoustic logging-while-drilling (ALWD) measurement lags far behind, especially ALWD dipole measurement has long been thought to be little added value. In this paper, we extended the dipole shear-wave (S-wave) reflection survey technology in wireline logging into ALWD and demonstrated the theoretical feasibility of adopting a dipole source–receiver system to perform ALWD reflection survey. For this purpose, we investigated the radiation patterns of radiantSH, SV and P waves, the energy fluxes of guided and radiant waves and their acoustical radiation efficiencies from an LWD dipole acoustic source by comparisons with the wireline results. The analysis results reveal that a dominant excitation-frequency band does exist in ALWD dipole S-wave reflection. Consequently, the expected excitation frequency should be located in the band of the signal with high radiation efficiency, guaranteeing the best radiation performance. In fast formations, SH wave is the best candidate for ALWD reflection survey due to its highest radiation efficiency. In contrast, the dominant excitation-frequency band of SH wave gets wider in a slow formation. Besides, the SV- and P-wave radiation efficiencies are also remarkable, implying that both waves can also be used for ALWD reflection survey in slow formations. We expounded the SH-, SV- and P-reflection behaviours at three typical excitation frequencies by our 3-D finite difference. Simulations to single-well reflection validate the key role of dominant excitation-frequency band and demonstrate the theoretical feasibility of applying the technology to ALWD. Our results can guide the design and measurement methods of ALWD dipole S-wave reflection survey tool, which could have extensive application prospect for geo-steering.
Pressure injury to the chest wall caused by vascular graft and endograft after thoracic and thoraco-abdominal aortic repair
Authors: Mansour Wassim , Sirignano Pasqualino , Capoccia Laura , Speziale Francesco
Published: May 2019

Thoracic and thoraco-abdominal aortic repair remains a challenging issue in vascular surgery, and long-term complications are well described. We report 2 cases of octogenarians with unusual long-term complications after open and endovascular thoracic aortic repair of chest wall pressure injury from the vascular prosthesis. In the first case, a computed tomographic scan of an 80-year-old man showed a pressure injury of the chest wall and rib erosion caused by a Dacron graft. The second case was an 81-year-old woman who presented with external bleeding from the left posterior chest wall. A computed tomographic scan showed a type IA endoleak and chest wall damage with rib erosion and thoracic cutaneous fistulae from the endovascular graft. Both patients were treated by relining the endovascular graft; debriding the surgical fistula was done only in the second case. In our experience, endovascular repair is a good option to avoid a complete open surgical repair.
Open radial artery harvesting better preserves endothelial function compared to the endoscopic approach
Authors: Gaudino Mario F , Lorusso Roberto , Ohmes Lucas B , Narula Navneet , McIntire Patrick , Gargiulo Antonella , Bucci Maria Rosaria , Leonard Jeremy , Rahouma Mohamed , Di Franco Antonino , He Guo-Wei , Girardi Leonard N , Tranbaugh Robert F , Di Lorenzo Annarita
Published: May 2019

OBJECTIVES

Both the open and endovascular techniques are commonly used for harvesting the radial artery (ORAH and ERAH, respectively), and yet, very little is known about the effects of these 2 techniques on endothelial integrity and function of the radial artery (RA). The aim of this study was to assess the endothelial integrity and function of RA harvested using the 2 approaches.

METHODS

Two independent surgical teams working in the same institution routinely use the RA for coronary artery bypass grafting exclusively employing either ORAH or ERAH. Thirty-nine consecutive patients were enrolled in this comparative study. Endothelial function after ORAH or ERAH was assessed by using the wire myograph system. The integrity of the RA endothelium was evaluated by immunohistochemical staining for erythroblast transformation specific-related gene.

RESULTS

The vasodilation in response to acetylcholine was significantly higher in RA harvested with ORAH (P ≤ 0.001 versus ERAH). Endothelial integrity was not different between the 2 groups.

CONCLUSIONS

ORAH is associated with a significantly higher endothelium-dependent vasodilation. Further investigation on the potential implications of these findings in terms of graft spasm and patency as well as clinical outcomes are needed.
Evaluating Population Genomic Candidate Genes Underlying Flowering Time in Arabidopsis thaliana Using T-DNA Insertion Lines
Authors: Chong Veronica K , Stinchcombe John R
Published: May 2019

Population genomic scans have emerged as a powerful tool to detect regions of the genome that are potential targets of selection. Despite the success of genomic scans in identifying novel lists of loci potentially underlying adaptation, few studies proceed to validate the function of these candidate genes. In this study, we used transfer-DNA (T-DNA) insertion lines to evaluate the effects of 27 candidate genes on flowering time in North American accessions of Arabidopsis thaliana. We compared the flowering time of T-DNA insertion lines that knock out the function of a candidate gene obtained from population genomic studies to a wild type under long- and short-day conditions. We also did the same for a collection of randomly chosen genes that had not been identified as candidates. We validated the well-known effect of long-day conditions in accelerating flowering time and found that gene disruption caused by insertional mutagenesis tends to delay flowering. Surprisingly, we found that knockouts in random genes were just as likely to produce significant phenotypic effects as knockouts in candidate genes. T-DNA insertions at a handful of candidate genes that had previously been identified as outlier loci showed significant delays in flowering time under both long and short days, suggesting that they are promising candidates for future investigation.
The Rhetoric of Medicine
Authors: Nicholson Nigel , Selden Nathan
Published: May 2019

The Rhetoric of Medicine explores problems that confront medical professionals today by first examining similar problems that confronted physicians in ancient Greece. This framework provides illuminating entry points into issues in the practice of medicine, enabling readers to understand more clearly their shape and operation in the modern context—as well as their possible solutions. Topics covered include larger cultural ideas about the body, the problems posed to physicians by working for money, how to compete with alternative healthcare providers, the restrictions on political involvement that come with identifying as a physician, how to maintain the autonomy and judgment central to the concept of professionalism, mentoring that is effective but not exclusive, and how physicians can recognize themselves as both professionals and patients. Ultimately, the book asks us to interrogate the narratives and ideas that shape medical care today and to revise and replace those that do not serve patient health.
Competition
Authors: Nicholson Nigel , Selden Nathan R.
Published: May 2019

Chapter 3 explores ways in which physicians should distinguish their practice from other healthcare workers. One of Bacchylides’ odes exposes how Greek physicians sought to differentiate themselves from athletic trainers. These efforts were motivated by trainers’ success at winning business rather than concerns about their quality. The recent decision to unite postgraduate training in allopathic and osteopathic medicine in the United States offers a positive model for addressing competition, driven by concern for optimal patient care. Distinctions between healthcare practitioners should be rooted in demonstrated differences in outcomes, while all legitimate practitioners should be embraced. The goal is to provide the fundamental elements of care that patients value, including successful treatment outcomes and the affiliative and compassionate care.
Optic Neuritis
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Optic neuritis is the most frequent cause of acute-onset optic neuropathy in young adults and is often encountered in clinical practice. In this chapter, we begin by reviewing the cardinal signs of optic neuropathy. We review the clinical characteristics and workup of optic neuritis. We review factors that increase the risk for developing multiple sclerosis. We discuss atypical clinical and imaging findings that should prompt further evaluation for other causes of optic neuritis, such as neuromyelitis optica. Lastly, we discuss the management options for optic neuritis, with reference to the findings from the Optic Neuritis Treatment Trial, and the prognosis for visual recovery.
Arteritic Ischemic Optic Neuropathy
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Arteritic ischemic optic neuropathy occurs in the setting of giant cell arteritis and often produces devastating irreversible vision loss. It is a medical emergency because there is a high risk of fellow eye involvement if high-dose corticosteroid treatment is not initiated in a timely fashion. In this chapter, we begin by reviewing the clinical features of anterior and posterior ischemic optic neuropathy. We next review the clinical features of arteritic ischemic optic neuropathy. We then discuss the clinical features and workup for giant cell arteritis. Lastly, we review the initial and long-term management approach for ischemic optic neuropathy occuring in the setting of giant cell arteritis.
Nonarteritic Ischemic Optic Neuropathy
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Nonarteritic anterior ischemic optic neuropathy is the most frequent cause of acute-onset optic neuropathy in older adults. Its exact pathogenesis remains uncertain, although it often occurs in patients with a small, structurally congested optic disc (“disc at risk”). In this chapter, we begin by reviewing the clinical features of nonarteritic anterior ischemic optic neuropathy. We then discuss the prognosis for recovery of vision and fellow eye involvement. We review the risk factors and precipitating factors for this condition. We list the medications that have been associated with this condition. Lastly, we review the workup and management approach for this common condition.
Compressive Optic Neuropathy
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Optic nerve compression results in progressive, and often painless, vision loss. In this chapter, we begin by reviewing the clinical features of anterior and posterior compressive optic neuropathy. We next review the common causes of compressive optic neuropathy, which include orbital tumors (e.g., optic nerve sheath meningioma, optic glioma, and capillary hemangioma), orbital infection, orbital inflammation, intracranial tumors (e.g., pituitary macroadenoma, meningioma, and craniopharyngioma), aneurysm, and thyroid eye disease. We then review the workup for compressive optic neuropathy and discuss the various imaging options. Lastly, we discuss the clinical features, imaging findings, management options, and prognosis for visual recovery for patients with optic nerve sheath meningioma.
Leber Hereditary Optic Neuropathy
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Leber hereditary optic neuropathy in an important cause of acute painless monocular vision loss. It most often occurs in young men. Almost all patients develop fellow eye involvement within a few months, resulting in severe irreversible binocular vision loss. In this chapter, we begin by reviewing the differential diagnosis of acute optic neuropathy. We next discuss the genetic basis for Leber hereditary optic neuropathy and list the three common mitochondrial DNA mutations that cause it. We then review the clinical features and natural history of Leber hereditary optic neuropathy. Lastly, we discuss the treatment approach for this condition and review promising treatment options.
Papilledema
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Papilledema is the cardinal clinical sign of increased intracranial pressure. In this chapter, we begin by reviewing the symptoms and signs of increased intracranial pressure. We next review potential causes of increased intracranial pressure, which include intracranial masses, obstruction of the ventricular system, obstruction of cerebral venous outflow, decrease in cerebrospinal fluid absorption, increase in cerebrospinal fluid secretion, cerebral edema, medications, and idiopathic intracranial hypertension. We then review the approach to the diagnostic evaluation of increased intracranial pressure, including the recommended neuroimaging studies and cerebrospinal fluid evaluation. Lastly, we discuss the basic management approach for the patient with symptoms and signs of increased intracranial pressure.
Pseudopapilledema
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

A diagnostic dilemma often arises when a patient with headaches is found to have optic nerve head elevation. In this chapter, we begin by reviewing the potential causes of optic nerve head elevation, which include papilledema, optic disc edema from another cause, optic nerve head infiltration, and anomalous optic nerve head elevation that mimics optic disc edema (pseudopapilledema). We next list the common causes of pseudopapilledema and discuss strategies that help to distinguish pseudopapilledema from papilledema. We then review the clinical features and diagnostic evaluation of optic nerve head drusen, a common cause of pseudopapilledema, and describe ophthalmic imaging techniques that can help to distinguish optic nerve head drusen from papilledema.
Chiasmal Syndromes
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Dysfunction of the optic chiasm typically produces bitemporal hemianopic visual field defects. Optic chiasmal dysfunction most often results from compression by extrinsic lesions, such as pituitary macroadenomas and meningiomas. In this chapter, we begin by describing the various bitemporal hemianopic visual field defects that can occur with optic chiasmal dysfunction. We next list potential causes of optic chiasmal dysfunction. We then review the clinical features and evaluation of pituitary apoplexy, which results from infarction of (or hemorrhage into) a pituitary macroadenoma. Lastly, we discuss the management of pituitary apoplexy, including the indications for and timing of surgical decompression, and review factors that affect the prognosis for visual recovery.
Unexplained Vision Loss
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

When visual complaints are out of proportion to examination findings, nonorganic vision loss or a disorder of higher visual function may be suspected. However, certain ophthalmic causes of vision loss should also be considered. In this chapter, we begin by reviewing potential causes of unexplained vision loss, including refractive error, corneal disorders (e.g., keratoconus), optic neuropathy, and occult retinopathy. We next discuss clinical strategies and investigations that can help to identify certain causes of unexplained vision loss. Lastly, we discuss the clinical features, causes, and diagnostic evaluation of occult retinopathy, with a focus on conditions that cause cone photoreceptor dysfunction, such as cone dystrophy, cancer-associated retinopathy, and autoimmune retinopathy.
Intermittent Diplopia
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Intermittent diplopia is a common complaint that has a broad differential diagnosis. In this chapter, we begin by discussing the crucial role of the history in the evaluation of intermittent diplopia. We next review the differential diagnosis for intermittent diplopia, which includes conditions involving the eye, extraocular muscle, neuromuscular junction, cranial nerve, brainstem, and cerebellum. We emphasize the importance of distinguishing monocular diplopia from binocular diplopia when determining the appropriate diagnostic approach. We then review the symptoms, signs, pathogenesis, and diagnostic evaluation of superior oblique myokymia. We discuss practical strategies for detecting the ocular oscillations of superior oblique myokymia. Lastly, we review the medical and surgical management options for superior oblique myokymia.
Infranuclear Ophthalmoplegia
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Infranuclear ophthalmoplegia is characterized by global weakness of the extraocular and levator muscles. It has a broad differential diagnosis that varies depending on the tempo of onset. In this chapter, we begin by describing how to differentiate nuclear-infranuclear ophthalmoplegia from supranuclear ophthalmoplegia at the bedside. We next list the common causes of acute onset infranuclear ophthalmoplegia, which include Miller Fisher syndrome, Guillain-Barré syndrome, stroke, and ocular myasthenia. We then list the common causes of chronic progressive infranuclear ophthalmoplegia, which include mitochondrial disorders, oculopharyngeal muscular dystrophy, and myotonic dystrophy. We discuss the clinical features and diagnostic workup of chronic progressive external ophthalmoplegia due to mitochondrial disease. Lastly, we briefly discuss the management of ptosis and diplopia in the setting of chronic progressive external ophthalmoplegia.
Saccadic Intrusions and Dysmetria
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Saccadic dysmetria, intrusions, and oscillations are often encountered in association with certain cerebellar and neurodegenerative diseases. When severe, they can give rise to visual symptoms, such as difficulty with reading and oscillopsia. In this chapter, we begin by reviewing the clinical features of saccadic dysmetria, in which the saccadic amplitude is inappropriately calibrated. We next review the clinical features of saccadic intrusions and oscillations, which include square-wave jerks, macrosaccadic oscillations, ocular flutter, and opsoclonus. We review the common causes of these entities and discuss the diagnostic workup. Lastly, we discuss potential medical treatments to reduce the magnitude and frequency of saccadic intrusions and oscillations.
Introduction
Authors: McLaughlin Janice , Lindemann Hilde , Verkerk Marian A.
Published: May 2019

This collection examines the ethics of the intersection between families and social care as well as healthcare. The authors begin from the assumption that relationships of intimacy give rise to responsibilities and that these responsibilities can be tracked as family members assume them, deflect them, contest them, and so on. The collection gives a strong priority to engaging with the implications for policy and practice. Themes explored include, among others, how familial relationships inform people’s approach to living with illness or disability, the choices they make around treatment options, and the influence of broader social and cultural values on the responsibilities they enact with others and expect to have enacted for them. Two key themes unite the varied contributions of our chapter authors: (1) questions of responsibility and (2) understandings of narrative.
Why Families Matter
Authors: Lindemann Hilde
Published: May 2019

Families are valuable for many reasons, but here the focus is on two: their function of creating and maintaining the identities of those within them, and their function of caring. These give rise to an ethos that is common in structures of intimacy but not shared by healthcare providers. The tension between the two systems of ethics creates problems unless healthcare providers understand the difference.
Lesbian Parents’ Search for the “Right Way” to Disclose Donor Conception to Their Children
Authors: Provoost Veerle
Published: May 2019

This case provides an illustration of the importance of drawing relationality into healthcare. It will do so by exemplifying how a bioethics approach that merely protects the rights and interests of individuals is inapt as it comes to capturing the full picture of how decisions— in this case related to reproduction and reproductive medical treatment— are made within families. This case describes lesbian family initiators’ experiences of constructing and narrating their family story around the conception of their children.
The Family Imperative in Genetic Testing
Authors: Cowley Lorraine
Published: May 2019

The context of this case study, based on empirical qualitative research, is genetic testing for cancer susceptibility. Within genetics, information may have shared significance for family members, but not everyone necessarily has the same desire to know their genetic probability of developing cancer. Professional ethics codes in the UK dictate that genetic testing is offered as an individual choice, not a shared one, although in practice family members may be invited to, or request, shared appointments. Here the ideal of individual choice comes into contact with pressures of family dynamics, and these may influence how people engage with choice as individuals.
What Counts as a Family—And Who Is to Decide?
Authors: Hydén Margareta
Published: May 2019

This case study seeks to explore some of the complexities involved in a child’s and later a young woman’s efforts to be recognized by the adult world as a human being in deep trouble. It originates from an interview with Mary, a twenty-three-year-old woman who participated in a study of social network responses to young people with health problems. Since her family was the locus of her troubles, she had tried to get recognition from adults in a number of ways. Her narrative brings to the fore some essential questions for a relational bioethical approach to healthcare, such as: What counts as a family—and who is to decide? What kind of ethical dilemmas will personnel in a family-oriented healthcare system have to face if they meet children who introduce them to family forms that are not self-evident?
Negotiating Responsibilities
Authors: Verkerk Marian A.
Published: May 2019

In this chapter a moral case is made for family care. Two arguments are put forward in defense of this position: first, there is a moral familial responsibility and second, in taking care of a family member, a certain social good is derived that cannot be obtained otherwise. Family can be understood as a caring practice in which special responsibilities are distributed and negotiated. While family relationships count, the history of that relationship and the particulars of the situation also count in determining the moral weight of responsibilities that we have toward each other. If and how we have a particular responsibility toward a family member depends on the moral shape of the situation. Political and social considerations, such as considerations of justice and equity, are also part of this moral shape. The practice of assigning responsibilities is only intelligible against the background of existing practices and the normative expectations arising from them—practices that themselves need to be evaluated. In sum, family care can be seen as a contested practice in which responsibilities to care are negotiated.
Healthcare Decisions
Authors: Kihlbom Ulrik , Munthe Christian
Published: May 2019

The aim of this chapter is to outline how different relational aspects of families may ground obligations on the part of healthcare professionals toward patients and their families in the decision-making process. The exploration starts from the core idea within person-centered care of having patients’ general life situation, experiences, wants, and values to be a substantial topic of concern in a process of shared decision making. If relational decision-making paradigms are to be minimally functional, healthcare professionals’ stances need to involve complex schemes of including people closely related to patients, who will have to be recognized as legitimate stakeholders and partners in, as well as resources for, clinical care.
Annie’s Problem
Authors: Leach Scully Jackie
Published: May 2019

This case study illustrates nondirected, paired, or pooled organ donation schemes. Paired donation schemes have been established relatively recently in a number of countries, including the US and Korea. Pooled donation can include pairs and single altruistic donors, in a chain of interventions. On the face of it, the schemes are promising solutions (or at least partial solutions) to the sociomedical problem of donor scarcity, but do involve ethical issues.
Device-Associated Infections in the Neonatal Intensive Care Unit (NICU)
Authors: Quach Caroline
Published: May 2019

Infants, especially preterm, in neonatal intensive care units (NICU) are especially susceptible to healthcare-associated infections (HAI), given their immature immune system, the acuity of care that they need, and the frequency of invasive procedures performed. Moreover, HAIs have major impacts on premature infant outcomes. HAIs in the NICU have been associated with a twofold increase in the risk of death. This chapter reviews several strategies to prevent healthcare-associated infections, including central line–associated bloodstream infection, ventilator-associated pneumonia, and catheter-associated urinary tract infection, in the neonatal intensive care unit setting. The importance of the neonatal microbiome in the prevention of infections is emphasized.
Prevention of Infections with Multidrug-Resistant (MDR) Organisms
Authors: Rubin Lorry G. , Ostovar Gholamabbas Amin
Published: May 2019

Multidrug-resistant organisms (MDROs) may cause infections in pediatric patients that are severe and difficult to treat because of a limited armamentarium of antimicrobial agents. For most infections, antimicrobial therapy is initiated empirically prior to the results of cultures and susceptibility testing, and commonly prescribed empiric choices lack activity against MDR pathogens. This may result in a delay of initiation of antimicrobial therapy active against the pathogen and an increase in morbidity and mortality. Therefore, prevention of transmission and infection with MDROs is of paramount importance. This chapter reviews strategies to prevent transmission of multidrug-resistant organisms, specifically focusing on bacterial pathogens: methicillin-resistant Staphylococcus aureus (MRSA), gram-negative bacilli (GNB), and vancomycin-resistant enterococci (VRE). Isolation precautions, laboratory screening for colonization, and environmental cleaning are emphasized. Decolonization strategies for MRSA are described.
Breast Milk Handling and Misadministration
Authors: Fisher Donna
Published: May 2019

Human milk is the preferred nutritional source for all newborns, including ill infants and premature neonates. The ability of a mother to provide milk for her infant may be hindered by maternal illness or poor milk production, and may be influenced by cultural expectations and personal preferences. The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of life. Infectious risks to the newborn from a single feeding of the wrong mother’s breast milk are not generally measurable; however, studies of viruses and bacteria potentially transmissible in human milk can be used to inform a rational approach when misadministration occurs. In healthcare settings, administration of breast milk to the incorrect infant is generally treated like a blood and body fluid exposures. This chapter reviews the pathogens that can be transmitted via breast milk and suggests approaches to prevent administration of expressed breast milk to the wrong infant. This chapter also provides guidance on managing a breast milk misadministration incident (disclosure; post-exposure testing of source and recipient).
Hospital-Based Playrooms, Classrooms, and Pet Therapy
Authors: Gould Jane M.
Published: May 2019

A unique feature of most pediatric healthcare facilities is that they provide opportunities for both inpatients and outpatients to participate in play with developmentally appropriate toys during their medical care. Reasons for play in hospitalized pediatric patients may include providing mechanisms to educate children about their particular medical conditions, providing stress reduction during frightening procedures, assisting in the development of coping strategies, and attempting to maintain a sense of normalcy during long hospitalizations. Although toys and playroom environments provide a vital psychosocial and quality-of-life function, however, they are also known to contribute to the transmission of infectious agents. This chapter provides guidance on minimizing transmission of pathogens in hospital-based playrooms and classrooms: pathogens that are commonly found in pediatric healthcare facilities. This chapter also discusses the transmission challenges with pet therapy programs for children, and suggests approaches for safe implementation of these programs. Sample policies are included.
Pediatric Long-Term Care, Behavioral Health, Residential Facilities, and Similar Settings
Authors: Johnson Candace , Murray Meghan , Jackson Olivia , Neu Natalie
Published: May 2019

There are unique infection prevention issues associated with pediatric long-term care facilities, behavioral health units, rehabilitation hospitals, and other residential facilities. All of these facilities provide care to children with complex, chronic medical conditions. These children are at increased risk for healthcare-associated infection due to factors such as age-related vulnerability to infections, especially respiratory viral infections; chronic exposure to indwelling medical devices such as tracheostomies, gastrostomy tubes, and central venous catheters; and frequent close contact with other children and healthcare providers during therapeutic and social activities. This chapter provides infection prevention and control guidance in special healthcare settings outside of acute care, including pediatric long-term care, behavioral health, and residential facilities. The adaptation of strategies such as transmission-based precautions while maintaining a homelike environment is described. Recommendations for infection surveillance in these setting are provided, along with algorithms for managing respiratory and gastrointestinal illness.
Antimicrobial Stewardship in Pediatrics
Authors: Thorell Emily A. , Olson Jared
Published: May 2019

The rapid emergence of multidrug-resistant bacteria has become a global public health crisis. As antibiotics are the only class of medications where use in one patient can compromise their efficacy in another patient, stewardship is critical to preserve this shared resource. The Centers for Disease Control and Prevention (CDC) have focused on improving antimicrobial use for many years. One effective strategy used to decrease the emergence of multi‐drug-resistant organisms (MDROs) is the antimicrobial stewardship program (ASP): a coordinated healthcare program that seeks to provide optimal antimicrobial treatment to patients to reduce the emergence of MDROs, improve patient outcomes, and decrease cost. This chapter reviews the importance of an antimicrobial stewardship program, reviews core elements of a pediatric hospital ASP, and provides guidance on tracking and reporting antimicrobial prescribing in pediatric healthcare facilities.
Indigenous Women, Health, and Healthcare
Authors: Loppie Charlotte , Kent Alexandra
Published: May 2019

For Indigenous women, gender intersects with cultural and racialized identities to create complex inequities in health and healthcare. The experience of Indigenous women within the Canadian healthcare context is explored using the Xpey’ Relational Environments Framework. Relational environments that shape Indigenous women’s wellness encompass human and non-human interactions, healthcare and community settings, and sociocultural contexts. By framing determinants of Indigenous women’s health in this way, the chapter demonstrates the layered complexity of risk as well as opportunities for healing. Indigenous women over the lifespan are shown to have a disproportionate burden of illnesses and comorbidities that are situated within the foundations of colonialism, racism, violence, and a range of socioeconomic inequities. Sources of strength and resilience that nurture the physical, mental, emotional, and spiritual wellness of Indigenous women are highlighted.
Rural Women
Authors: Simpson Christy , McDonald Fiona
Published: May 2019

Rural women as a group are reported to face a “double disadvantage” due to their gender and rural place of residence. Gendered and place constructions of “good” rural women and the roles “good” women should play in rural communities are shown to intersect with the values of place and community that characterize rural healthcare ethics. While gender and place stereotypes can have positive and negative implications for rural women and rural communities more generally, the intersections between these stereotypes and these values also may impact rural women and their access to health services across multiple dimensions, including availability, affordability, accessibility, acceptability, and accommodation. If the ability of rural women to access health services is influenced by gendered and place constructions of their role and the values of place and/or community, this is important when considering how health services should be designed and delivered.
Ethical Issues in the Care and Support of Women Living with HIV
Authors: Shanker Ruby Rajendra , Underhill Angela , Nicholson Valerie , Kennedy Logan , Jaworsky Denise , Loutfy Mona
Published: May 2019

This chapter aims to explore some of the ethical issues that arise when providing clinical care and support to women living with HIV across the life course. Feminist perspectives and intersectionality inform the authors’ interpretation of the four principles of biomedical ethics as described by Beauchamp and Childress: autonomy, beneficence, non-maleficence, and justice. The analysis also addresses the issues of stigma and oppression. Developed in accordance with the principles of the Greater Involvement of People Living with HIV/AIDS (GIPA) and Meaningful Involvement of People Living with HIV (MIPA), this chapter honors the experiences of a woman living with HIV who, as a peer research associate, knowledge keeper, and front-line warrior, and through her Indigenous identity, lends crucial insight to the discourse. Her experiences enrich the perspectives of a healthcare ethicist, a nurse, a doctoral student, and two physicians who together have three decades of experience working with women living with HIV.
Ethical Issues in Healthcare for Women in the Context of Violence
Authors: Einboden Rochelle , Varcoe Colleen
Published: May 2019

Violence against women is a complex social and health issue. Addressing it meaningfully requires careful ethical reasoning. This chapter offers an overview of the issue of violence against women, beginning with its definition and the link between structural and interpersonal forms of violence. The implications of using traditional bioethical reasoning in this context are analyzed, followed by the use of relational ethics, which is shown to be superior. The chapter ends by focusing on healthcare policies and practices that respond ethically to violence against women. Considered are managing disclosures of violence, establishing trauma- and violence-informed policies, using case finding as an alternative to screening, and ensuring that responses are culturally safe and supportive, do not stigmatize the woman, and consider the context of women’s lives and relationships, especially their caregiving relationships.
Primary Healthcare for Queer Women and Trans People
Authors: Fredericks Erin , Baker Kelly
Published: May 2019

This chapter supports primary healthcare providers in understanding and challenging heteronormativity and cisnormativity in their practice. Healthcare provision for queer women and trans people must be approached with an understanding of the way these patients’ healthcare needs are shaped by systematic and historical oppression in the healthcare system. Heteronormativity and cisnormativity are institutionalized in clinic spaces and procedures, including forms, washrooms, brochures, and interactions with healthcare providers and administrative staff. Preemptive structural changes can be made to clinic forms, procedures, spaces, language, and knowledge to address queer women and trans patients’ needs. Changes within the healthcare interaction that focus less on maintaining healthcare providers’ neutrality and comfort, or on the exoticized aspects of queer and trans identities, will further disrupt cisnormativity and heteronormativity within the patient–provider interaction, build trusting provider–patient relationships, and increase access to quality healthcare for this community.
Technology and the Ethical Practice of Reproductive Care
Authors: Sturgill Laura A. , Shields Sara G. , Candib Lucy M.
Published: May 2019

This chapter applies the lens of woman-centered care to examine the complexity of ethical decision making involving technology in contemporary reproductive health settings. It begins by situating the discussion within an international perspective, revealing that pregnancy is still a highly risky state globally for women, including risk of abuse from both within and outside healthcare. The model of woman-centered care is presented as an ethical strategy to approach a woman considering reproductive options and decisions. Using this model and a series of vignettes, ethical issues involving technology in routine reproductive care during key periods are examined, including contraception and adolescence, genetic screening, woman-centered care in childbirth, technology in labor (induction, informed consent, fetal monitoring), human rights during labor, and infant feeding. Solutions beyond technology are also offered.
The Healthcare System
Authors: Frisse Mark E. , Misulis Karl E.
Published: May 2019

The United States healthcare system ranks the highest in per capita expense but ranks far lower with respect to patient access and health outcomes. An aging and increasingly ill population, family financial distress, changing cultural expectations, and unsustainable healthcare prices will necessitate a radically broader view of clinical care and system change. Clinical informatics will play a critical role in essential transformation efforts aimed at improving care quality in financially sustainable ways.
People
Authors: Frisse Mark E. , Misulis Karl E.
Published: May 2019

Virtually every aspect of healthcare delivery and financing requires effective information management skills by almost every member of an organization. Clinical informatics professionals must therefore ensure their information systems meet the diverse needs of patients, families, clinicians, clinical support staff, and administrators. Focused on care of the individual, clinical information systems should enhance the coordination and collective efforts of these groups. When seeking solutions, clinical informatics professionals must contemplate the needs of each of the stakeholder groups and understand how decisions in data representation, collection, transmission, and aggregation can affect immediate care and long-term administrative, public health, policy, and research needs.
Process
Authors: Misulis Karl E. , Frisse Mark E.
Published: May 2019

The learning health system is both an aspiration and a necessity. It is an iterative approach to healthcare improvement: The data in our electronic health records are combined with data from other sources and known knowledge bases to produce improvement. The LHS tries to break the closed circuit of provider and patient interaction and connect to local and regional data sources. Through systems approaches, learning healthcare systems strive to apply best evidence to every action possible and, from studying the consequences of these actions, contribute to a stronger evidentiary basis for practice and administration. The learning healthcare system will continue to develop because of pressures to remain competitive in the healthcare marketplace by improving outcomes and reducing costs.
Design of the Core Healthcare Operating System
Authors: Dickey Douglas J. , Misulis Karl E. , Frisse Mark E.
Published: May 2019

The term healthcare operating system is new and describes the function of an extended clinical information management system capable of exchanging data with other systems and operating through remote “cloud computing” facilities. This operating system must support an expanded patient-based record capable of incorporating a growing array of data sources and coordinating care activities among providers, patients, and families. In the future, the HOS will allow electronic health records from different vendors, patient portals, patient wearables, medical devices, data repositories, and other outside sources of data to connect seamlessly together in a secured cloud via advanced interoperability. Many of these standards are being set today.
Information Systems Strategy and Administration
Authors: Frieling Jeffrey G. , Misulis Karl E. , Frisse Mark E.
Published: May 2019

Clinical information systems are vital tools to execute on organizational strategy. Clinical information systems support clinical activities that reflect the values and priorities of an organization. An information system’s strategic plan must therefore align with the strategy and operations of the larger organization. Governance of information systems requires coordinated work by experienced professionals. Effective governance and administration are essential. Strategic planning is performed at many levels; those of principal concern here are those of the healthcare enterprise and the information systems division. Strategic planning extends beyond the enterprise. The strategic plan and goals of the clinical information systems should be reviewed periodically.