bluuebunny/crossref_metadata_2025 huggingface dataset:
Elevation of cardiac troponins in exacerbation of chronic obstructive pulmonary disease
Authors: Harvey Martyn G , Hancox Robert J
Published: June 2004

Objectives:   To investigate the prevalence of serum troponin elevation in patients admitted to hospital with an exacerbation of chronic obstructive pulmonary disease (COPD).

Methods:  We examined the records of all patients admitted to hospital for treatment of COPD for serum troponin measurement, clinical features of myocardial ischaemia, oxygenation (pulse oximetry, arterial blood gas analysis), spirometry, and duration of admission.

Results:  Troponin elevation was observed in 58 of 235 (25%) presentations in which troponin was measured. Despite the troponin result, only seven of these 58 patients had been diagnosed with an acute coronary syndrome. New ECG evidence of ischaemia was uncommon. Patients with raised troponins tended to be older (75.7 vs 70.0 years, P = 0.001), had lower pulse oximetry (85.6% vs 89.6%, P = 0.003), were more acidotic (pH 7.34 vs 7.40, P= 0.002) and more hypercapnoeic (pCO2 58.0 vs 49.1, P = 0.04). There were no significant differences in serum creatine kinase. Patients with raised troponins had significantly longer admissions (5 vs 3 days, P = 0.001).

Conclusions:  Serum troponins are commonly raised in acute exacerbations of COPD and appear to reflect the severity of the exacerbation. In the majority of patients there is insufficient evidence to support the diagnosis of an acute coronary syndrome.
Risk factors for recent domestic physical assault in patients presenting to the emergency department
Authors: Stuart Peter
Published: June 2004

Objective:  To identify risk factors for physical or sexual assault as a result of domestic violence in patients presenting to the ED.

Methods:  Backward prevalence study of two urban teaching hospital emergency departments measuring the 1‐year period prevalence, acute incidence of ED presentation and risk factors of domestic physical assault.

Results:  Of the 1326 patients (62% female) completing the study, 115 (9% CI 7%, 10%) reported assault by a partner or ex‐partner within the preceding 12 months and 31 (2% CI 1.6%, 2.3%) reported domestic physical assault as the cause of their presentation. Risk factors for recent domestic physical assault included female gender (prevalence rate ratio, (PRR) 1.5 CI 1.0 2.2), age 17 to < 25 years (PRR 6.8 CI 1.7 27.7) or 25 to < 35 years (PRR 5.7 CI 1.4 23.0), past presentation to an ED for assault (PRR 2.5 CI 1.7 3.7) and a past history of child abuse (PRR 2.2 CI 1.5 3.1). There was no association between health service utilization or mental illness and the reporting of recent domestic physical assault.

Conclusion:  The study characterizes ED patients at high risk of injury from domestic violence.
Infantile Henoch‐Schönlein purpura
Authors: Wong Christina T , Harrington John W
Published: June 2004

We present an infant with generalized palpable purpura, arthritis and fever, whose findings were atypical for classic childhood Henoch‐Schönlein purpura (HSP). By describing the clinical symptoms and prognostic differences seen in infants versus school age children, we encourage physicians to be aware of infantile HSP in their differential diagnosis when they encounter a non‐toxic infant with generalized purpura.
The changing role of the emergency department in the Northern Territory: A Delphi study
Authors: Meuleners Lynn B , Lee Andy H , Zhao Yuejen , Intrapanya Methinee
Published: June 2004

Objective:  To explore the changing role of EDs in Northern Territory hospitals.

Methods:  A two‐round Delphi study was undertaken by recruiting a panel of health professionals from the EDs of the five Northern Territory public hospitals. Participants in round one were asked to list changes they have encountered and how these changes have affected health service delivery, as well as five factors that were responsible for the changes. During the second round they prioritized the factors identified in order of importance.

Results:  Twenty‐four ED staff returned their questionnaire. Global changes identified were more verbal/physical abuse from patients, followed by increase in acuity of patient presentations. The most important factor perceived as responsible for the changes was budget cuts, resulting in fewer inpatient beds, an increase in access block and sicker patients being discharged too early.

Conclusion:  The Delphi evaluation provided insights into the problems facing the ED from the staff perspective and offered some suggestions to deal with the emerging issues.
Glyphosate herbicide formulation: A potentially lethal ingestion
Authors: Stella Julian , Ryan Matthew
Published: June 2004

Glyphosate surfactant herbicide (GlySH) toxicity is an uncommon poisoning. We report two fatalities involving suicidal ingestion of this herbicide. Both deaths occurred despite early recognition of the serious nature of the poisoning and aggressive treatment. The deaths in this series are analysed in the context of a review of existing literature. Although traditionally regarded as minimally toxic, many deaths have been reported following suicidal ingestion. Severe GlySH toxicity may be refractory even to the most intensive supportive care. The triad of pulmonary oedema, metabolic acidosis and hyperkalaemia portends poor outcome. While containing a carbon phosphorus moiety, GlySH does not exhibit organophosphate toxicity. A clinical guide to assessing severity of GlySH toxicity is proposed and treatment modalities discussed.
Political issues in emergency medicine: The United States
Authors: Hoekstra James , McNamara Robert , Schafermeyer Robert W , Hamilton Glenn C
Published: June 2004

The format of the paper is to allow three authors to discuss what they believe are the most significant political issues facing emergency medicine (EM) in their country or region. Each author writes independently and does not see any other contributing author's work, therefore potential overlap of subject matter is inevitable. However, we were soliciting their individual opinions about the serious issues confronting us today, rather than a consensus. An additional author, well familiar with the topics being discussed, wrote the Commentary from an overview perspective on the writings of the other authors. This supplemental opinion was offered as a method for enhanced cohesiveness in describing the political situations impacting the specialty of emergency medicine. The three authors for the United States are James Hoekstra, Professor and Chair, Wake Forest University Health Sciences; Robert McNamara, Professor and Chair, Temple University School of Medicine, and Robert Schafermeyer, Associate Chair, Department of Emergency Medicine, North Carolina School of Medicine. Between them, they represent more than 50 years experience in clinical and academic emergency medicine. They write from a personal perspective. Their views are their own, and do not represent any organization(s) with which they may have or had affiliations.
Current political issues facing emergency medicine in Canada
Authors: Holroyd Brian R , Rowe Brian H , Sinclair Douglas
Published: June 2004

Health care in Canada is universal, accessible, transferable and publicly funded. Each of Canada's provinces has the responsibility for health care funding and delivery through its ministry of health, controlled by the governing provincial party and overseen by a Minister of Health. The Federal Government is responsible for ensuring the provinces conform to the spirit and regulations within the Canada Health Act and for broad programme funding, through the federal Minister of Health. As such, access to emergency health services is available to all Canadians free of direct charge. Some aspects of health care are the direct responsibility of citizens, such as ambulance services, medications (for those who can afford them), and ‘non‐essential’ services. For most Canadians, however, care for acute illness and injury is provided without barriers in EDs while generalists such as family physicians and paediatricians provide primary care.
How shunting inhibition affects the discharge of lumbar motoneurones: a dynamic clamp study in anaesthetized cats
Authors: Brizzi L. , Meunier C. , Zytnicki D. , Donnet M. , Hansel D. , D'Incamps B. Lamotte , Van Vreeswijk C.
Published: June 2004

In the present work, dynamic clamp was used to inject a current that mimicked tonic synaptic activity in the soma of cat lumbar motoneurones with a microelectrode. The reversal potential of this current could be set at the resting potential so as to prevent membrane depolarization or hyperpolarization. The only effect of the dynamic clamp was then to elicit a constant and calibrated increase of the motoneurone input conductance. The effect of the resulting shunt was investigated on repetitive discharges elicited by current pulses. Shunting inhibition reduced very substantially the firing frequency in the primary range without changing the slope of the current–frequency curves. The shift of the I–f curve was proportional to the conductance increase imposed by the dynamic clamp and depended on an intrinsic property of the motoneurone that we called the shunt potential. The shunt potential ranged between 11 and 37 mV above the resting potential, indicating that the sensitivity of motoneurones to shunting inhibition was quite variable. The shunt potential was always near or above the action potential voltage threshold. A theoretical model allowed us to interpret these experimental results. The shunt potential was shown to be a weighted time average of membrane voltage. The weighting factor is the phase response function of the neurone that peaks at the end of the interspike interval. The shunt potential indicates whether mixed synaptic inputs have an excitatory or inhibitory effect on the ongoing discharge of the motoneurone.
The possum sphincter of Oddi pumps or resists flow depending on common bile duct pressure: a multilumen manometry study
Authors: Grivell Marlene B. , Woods Charmaine M. , Grivell Anthony R. , Neild Timothy O. , Craig Alexander G. , Toouli James , Saccone Gino T. P.
Published: June 2004

The sphincter of Oddi (SO) regulates trans‐sphincteric flow (TSF) by acting primarily as a pump or as a resistor in specific species. We used the Australian possum SO, which functions similarly to the human SO, to characterize SO motility responses to different common bile duct (CBD) and duodenal pressures. Possum CBD, SO and attached duodenum (n= 18) was mounted in an organ bath. External reservoirs were used to impose CBD (0–17 mmHg) and duodenal (0, 4, 7 mmHg) pressure. Spontaneous SO activity was recorded using four‐lumen pico‐manometry and TSF was measured gravimetrically. Temporal analysis of manometric and TSF recordings identified three functionally distinct biliary‐SO regions, the proximal‐SO (juxta‐CBD), body‐SO and papilla‐SO. At CBD pressures < 3 mmHg the motor activity of these regions was coordinated to pump fluid. Proximal‐SO contractions isolated fluid within the body‐SO. Peristaltic contraction through the body‐SO pumped this fluid through the papilla‐SO (17–27 μl contraction), which opened to facilitate flow. CBD pressure > 3.5 mmHg resulted in progressive changes in TSF to predominantly passive ‘resistor’‐type flow, occurring during proximal‐SO–body‐SO quiescence, when CBD pressure exceeded the pressure at the papilla‐SO. Progression from pump to resistor function commenced when CBD pressure was 2–4 mmHg greater than duodenal pressure. These results imply that TSF is dependent on the CBD–duodenal pressure difference. The papilla‐SO is pivotal to TSF, relaxing during proximal‐SO–body‐SO pumping and closing during proximal‐SO–body‐SO quiescence. The pump function promotes TSF at low CBD pressure and prevents bile stasis. At higher CBD pressure, the papilla‐SO permits TSF along a pressure gradient, thereby maintaining a low pressure within the biliary tract.
The role of oxygen in determining phosphocreatine onset kinetics in exercising humans
Authors: Haseler Luke J. , Kindig Casey A. , Richardson Russell S. , Hogan Michael C.
Published: June 2004

31P‐magnetic resonance spectroscopy was used to study phosphocreatine (PCr) onset kinetics in exercising human gastrocnemius muscle under varied fractions of inspired O2 (FIO2). Five male subjects performed three identical work bouts (5 min duration; order randomised) at a submaximal workload while breathing 0.1, 0.21 or 1.0 FIO2. Either a single or double exponential model was fitted to the PCr kinetics. The phase I τ (0.1, 38.6 ± 7.5; 0.21, 34.5 ± 7.9; 1.0, 38.6 ± 9.2 s) and amplitude, A1 (0.1, 0.34 ± 0.03; 0.21, 0.28 ± 0.05; 1.0, 0.28 ± 0.03,% fall in PCr) were invariant (both P > 0.05) across FIO2 trials. The initial rate of change in PCr hydrolysis at exercise onset, calculated as A1/τ1 (%PCr reduction s−1), was the same across FIO2 trials. A PCr slow component (phase II) was present at an FIO2 of 0.1 and 0.21; however, breathing 1.0 FIO2 ablated the slow component. The onset of the slow component resulted in a greater (P≤ 0.05) overall percentage fall in PCr (both phase I and II) as FIO2 decreased (0.43 ± 0.05, 0.34 ± 0.05, 0.28 ± 0.03) for 0.1, 0.21 and 1.0 FIO2, respectively. These data demonstrate that altering FIO2 does not affect the initial phase I PCr onset kinetics, which supports the notion that O2 driving pressure does not limit PCr kinetics at the onset of submaximal exercise. Thus, these data imply that the manner in which microvascular and intracellular PO2 regulates PCr hydrolysis in exercising muscle is not due to the initial kinetic fall in PCr at exercise onset.
AMPA‐receptor activation regulates the diffusion of a membrane marker in parallel with dendritic spine motility in the mouse hippocampus
Authors: Richards D. A. , De Paola V. , Caroni P. , Gähwiler B. H. , McKinney R. A.
Published: June 2004

Dendritic spines are the site of most excitatory connections in the hippocampus. We have investigated the diffusibility of a membrane‐bound green fluorescent protein (mGFP) within the inner leaflet of the plasma membrane using Fluorescence Recovery After Photobleaching. In dendritic spines the diffusion of mGFP was significantly retarded relative to the dendritic shaft. In parallel, we have assessed the motility of dendritic spines, and found an inverse correlation between spine motility and the rate of diffusion of mGFP. We then tested the influence of glutamate receptor activation or blockade, and the involvement of the actin cytoskeleton (using latrunculin A) on spine motility and mGFP diffusion. These results show that glutamate receptors regulate the mobility of molecules in the inner leaflet of the plasma membrane through an action upon the actin cytoskeleton, suggesting a novel mechanism for the regulation of postsynaptic receptor density and composition.
Functional interaction between extracellular sodium, potassium and inactivation gating in HERG channels
Authors: Mullins Franklin M. , Stepanovic Svetlana Z. , Gillani Niloufar B. , George Alfred L. , Balser Jeffrey R.
Published: June 2004

We have studied the interaction between extracellular K+ (K+o) and extracellular Na+ (Na+o) in human ether‐à‐go‐go related gene (HERG)‐encoded K+ channels expressed in Chinese hamster ovary (CHO‐K1) cells, using the whole‐cell voltage clamp technique. Prior studies indicate that Na+o potently inhibits HERG current (IC50 3 mm) by binding to an outer pore site, and also speeds recovery from inactivation. In this study, we sought to explore the relationship between the Na+o effect on recovery and Na+o inhibition of HERG current, and to determine whether inactivation gating plays a critical role in Na+o inhibition of HERG current. Na+o concentration–response relationships for current inhibition and speeding of recovery were different, with Na+o less potent at speeding recovery. Na+o inhibition of HERG current was relieved by physiological [K+]o, while Na+o speeded recovery from inactivation similarly in the absence or presence of physiological [K+]o. To examine the link between Na+o block and inactivation using an independent approach, we studied hyperpolarization‐activated currents uncoupled from inactivation in the S4–S5 linker mutant D540K. Depolarization‐activated D540K currents were inhibited by Na+o, while hyperpolarization‐activated currents were augmented by Na+o. This result reveals a direct link between Na+o inhibition and a depolarization‐induced conformational change, most likely inactivation. We attempted to simulate the disparate concentration–response relationships for the two effects of Na+o using a kinetic model that included Na+o site(s) affected by permeation and gating. While a model with only a single dynamic Na+o site was inadequate, a model with two distinct Na+o sites was sufficient to reproduce the data.
Isoflurane depresses glutamate release by reducing neuronal excitability at the Drosophila neuromuscular junction
Authors: Sandstrom David J.
Published: June 2004

The mechanisms through which volatile general anaesthetics exert their behavioural effects remain unclear. The accessibility of the Drosophila larval neuromuscular junction to genetic and neurophysiological analysis has made it an attractive model system for identification of anaesthetic targets. This study provides a mechanistic basis for the genetic analysis of anaesthetic action, by analysing the neurophysiological effects of the volatile anaesthetic isoflurane on axonal and synaptic function in the Drosophila larva. The most robust effect of isoflurane was a reversible decrease in the amplitude and area of glutamatergic excitatory junctional currents (EJCs) evoked at the neuromuscular junction. Isoflurane did not affect postsynaptic glutamate receptor function detectably, in that the amplitudes, areas and decay times of spontaneous miniature EJCs were unchanged at any concentration. Therefore, decreased EJC amplitude resulted from reduction of neurotransmitter release. Reduced neurotransmitter release was associated with decreased presynaptic excitability, measured as increased delay to EJC onset and reduced axonal conduction velocity. EJC amplitude was rescued to control levels by direct electrotonic stimulation of the synapse in the presence of tetrodotoxin, indicating that isoflurane inhibits neurotransmitter release by reducing presynaptic excitability. In addition, isoflurane reduced release probability, measured as increased paired‐pulse facilitation. The EC50 for suppression of larval locomotion was similar to that for reduction of transmitter release, indicating that the axonal and synaptic effects were occurring in a behaviourally relevant range. These results provide a cellular context for ongoing genetic and neurophysiological analyses of volatile anaesthetic action in Drosophila, and suggest candidate anaesthetic target molecules.
Knockout of the ASIC2 channel in mice does not impair cutaneous mechanosensation, visceral mechanonociception and hearing
Authors: Roza Carolina , Puel Jean‐Luc , Kress Michaela , Baron Anne , Diochot Sylvie , Lazdunski Michel , Waldmann Rainer
Published: June 2004

Mechanosensitive cation channels are thought to be crucial for different aspects of mechanoperception, such as hearing and touch sensation. In the nematode C. elegans, the degenerins MEC‐4 and MEC‐10 are involved in mechanosensation and were proposed to form mechanosensitive cation channels. Mammalian degenerin homologues, the H+‐gated ASIC channels, are expressed in sensory neurones and are therefore interesting candidates for mammalian mechanosensors. We investigated the effect of an ASIC2 gene knockout in mice on hearing and on cutaneous mechanosensation and visceral mechanonociception. However, our data do not support a role of ASIC2 in those facets of mechanoperception.
Bradykinin decreases K+ and increases Cl− conductances in vagal afferent neurones of the guinea pig
Authors: Oh Eun Joo , Weinreich Daniel
Published: June 2004

Bradykinin (BK) is an inflammatory mediator that can excite and sensitize primary afferent neurones. The nature of the ionic channels underlying the excitatory actions of BK is still incompletely understood. Using whole‐cell patch‐clamp recording from acutely dissociated nodose ganglion neurones (NGNs) we have examined the ionic mechanism responsible for BK's excitatory effect. Bath‐applied BK (0.1 μm) depolarized the membrane potential (29 ± 3.1 mV, n= 7), evoked action potentials, and induced an inward ionic current (IBK) with two distinctive membrane conductances (gm). Initially, gm decreased; the ionic current associated with this gm had a reversal potential (Erev) value of −87 ± 1.1 mV (n= 26), a value close to EK (−89 mV). Subsequently, gm increased; the ionic current associated with this gm had an estimated Erev of 49 ± 4.3 mV (n= 23). When the second component was isolated from the first component, by replacing [K+]o with Cs+, Erev was 20 ± 4.7 mV (n= 10). Replacing external NaCl with NMDG‐Cl or choline‐Cl, or reducing [Ca2+]o did not significantly diminish IBK. After replacing external NaCl with sodium isethionate, Erev for the second component shifted to 56 ± 8.8 mV (n= 4), a value close to the ECl (66 mV). The second component was inhibited by intracellular BAPTA or by bath application of niflumic acid (100 μm), a Ca2+‐activated Cl− channel blocker. These results suggest that the first and second components of IBK are produced by a decrease in K+ conductance and an increase in Ca2+‐activated Cl− conductance, respectively. The BK‐evoked Cl− conductance in NGNs may be the first demonstration of an inflammatory mediator exciting primary afferents via an anion channel.
Supplementation with vitamins C and E inhibits the release of interleukin‐6 from contracting human skeletal muscle
Authors: Fischer Christian P. , Hiscock Natalie J. , Penkowa Milena , Basu Samar , Vessby Bengt , Kallner Anders , Sjöberg Lars‐Börje , Pedersen Bente K.
Published: June 2004

Contracting human skeletal muscle is a major contributor to the exercise‐induced increase of plasma interleukin‐6 (IL‐6). Although antioxidants have been shown to attenuate the exercise‐induced increase of plasma IL‐6, it is unknown whether antioxidants inhibit transcription, translation or translocation of IL‐6 within contracting human skeletal muscle. Using a single‐blind placebo‐controlled design with randomization, young healthy men received an oral supplementation with either a combination of ascorbic acid (500 mg day−1) and RRR‐α‐tocopherol (400 i.u. day−1) (Treatment, n= 7), or placebo (Control, n= 7). After 28 days of supplementation, the subjects performed 3 h of dynamic two‐legged knee‐extensor exercise at 50% of their individual maximal power output. Muscle biopsies from vastus lateralis were obtained at rest (0 h), immediately post exercise (3 h) and after 3 h of recovery (6 h). Leg blood flow was measured using Doppler ultrasonography. Plasma IL‐6 concentration was measured in blood sampled from the femoral artery and vein. The net release of IL‐6 was calculated using Fick's principle. Plasma vitamin C and E concentrations were elevated in Treatment compared to Control. Plasma 8‐iso‐prostaglandin F2α, a marker of lipid peroxidation, increased in response to exercise in Control, but not in Treatment. In both Control and Treatment, skeletal muscle IL‐6 mRNA and protein levels increased between 0 and 3 h. In contrast, the net release of IL‐6 from the leg, which increased during exercise with a peak at 3.5 h in Control, was completely blunted during exercise in Treatment. The arterial plasma IL‐6 concentration from 3 to 4 h, when the arterial IL‐6 levels peaked in both groups, was ∼50% lower in the Treatment group compared to Control (Treatment versus Control: 7.9 pg ml−1, 95% confidence interval (CI) 6.0–10.7 pg ml−1, versus 19.7 pg ml−1, CI 13.8–29.4 pg ml−1, at 3.5 h, P < 0.05 between groups). Moreover, plasma interleukin‐1 receptor antagonist (IL‐1ra), C‐reactive protein and cortisol levels all increased after the exercise in Control, but not in Treatment. In conclusion, our results show that supplementation with vitamins C and E attenuated the systemic IL‐6 response to exercise primarily via inhibition of the IL‐6 protein release from the contracting skeletal muscle per se.
Dissection of the Mammalian Midbody Proteome Reveals Conserved Cytokinesis Mechanisms
Authors: Skop Ahna R. , Liu Hongbin , Yates John , Meyer Barbara J. , Heald Rebecca
Published: June 2004

Cytokinesis is the essential process that partitions cellular contents into daughter cells. To identify and characterize cytokinesis proteins rapidly, we used a functional proteomic and comparative genomic strategy. Midbodies were isolated from mammalian cells, proteins were identified by multidimensional protein identification technology (MudPIT), and protein function was assessed in
Caenorhabditis elegans
. Of 172 homologs disrupted by RNA interference, 58% displayed defects in cleavage furrow formation or completion, or germline cytokinesis. Functional dissection of the midbody demonstrated the importance of lipid rafts and vesicle trafficking pathways in cytokinesis, and the utilization of common membrane cytoskeletal components in diverse morphogenetic events in the cleavage furrow, the germline, and neurons.
Control of Stochasticity in Eukaryotic Gene Expression
Authors: Raser Jonathan M. , O'Shea Erin K.
Published: June 2004

Noise, or random fluctuations, in gene expression may produce variability in cellular behavior. To measure the noise intrinsic to eukaryotic gene expression, we quantified the differences in expression of two alleles in a diploid cell. We found that such noise is gene-specific and not dependent on the regulatory pathway or absolute rate of expression. We propose a model in which the balance between promoter activation and transcription influences the variability in messenger RNA levels. To confirm the predictions of our model, we identified both
cis
- and
trans
-acting mutations that alter the noise of gene expression. These mutations suggest that noise is an evolvable trait that can be optimized to balance fidelity and diversity in eukaryotic gene expression.
Three-Dimensional Polarimetric Imaging of Coronal Mass Ejections
Authors: Moran Thomas G. , Davila Joseph M.
Published: June 2004

We present three-dimensional reconstructions of coronal mass ejections (CMEs), which were obtained through polarization analysis of single-view images recorded with the use of the Large Angle and Spectrometric Coronagraph (LASCO) C2 coronagraph on board the Solar and Heliospheric Observatory (SOHO) spacecraft. Analysis of a loop-like CME shows a complex three-dimensional structure centered at 40° from the plane of the sky, moving radially at 250 kilometers/second. Reconstruction of two halo CMEs suggests that these events are expanding loop arcades.
Medical futility and physician discretion
Authors: Wreen M
Published: June 2004

Some patients have no chance of surviving if not treated, but very little chance if treated. A number of medical ethicists and physicians have argued that treatment in such cases is medically futile and a matter of physician discretion. This paper critically examines that position.

According to Howard Brody and others, a judgment of medical futility is a purely technical matter, which physicians are uniquely qualified to make. Although Brody later retracted these claims, he held to the view that physicians need not consult the patient or his family to determine their values before deciding not to treat. This is because professional integrity dictates that treatment should not be undertaken. The argument for this claim is that medicine is a profession and a social practice, and thus capable of breaches of professional integrity.

Underlying professional integrity are two moral principles, one concerning harm, the other fraud. According to Brody both point to the fact that when the odds of survival are very low treatment is a violation of professional integrity.

The details of this skeletal argument are exposed and explained, and the full argument is criticised. On a number of counts, it is found wanting. If anything, professional integrity points to the opposite conclusion.
Community based trials and informed consent in rural north India
Authors: DeCosta A , D’Souza N , Krishnan S , Chhabra M S , Shihaam I , Goswami K
Published: June 2004

Disease control has increasingly shifted towards large scale, disease specific, public health interventions. The emerging problems of HIV, hepatitis, malaria, typhoid, tuberculosis, childhood pneumonia, and meningitis have made community based trials of interventions a cost effective long term investment for the health of a population. The authors conducted this study to explore the complexities involved in obtaining informed consent to participation in rural north India, and how people there make decisions related to participation in clinical research.
One into two will not go: conceptualising conjoined twins
Authors: Bratton M Q , Chetwynd S B
Published: June 2004

This paper is written in response to controversial judicial decisions following separation surgery on conjoined twins “Jodie” and “Mary”. The courts, it is argued, seem to have conceptualised the twins as “entangled singletons” requiring medical intervention to render them physically separate and thus “as they were meant to be”, notwithstanding the death of the weaker twin, “Mary”. In contrast, we argue that certain notions, philosophical and biological, of what human beings are intended to be, are problematic. We consider three compelling conceptualisations of conjoined twins and advocate a model that conceives them as two psychologically separate individuals who happen to share a body, the sharing of a body being integral to the individuality of each twin. While we reject an “essentialist” view of the conjoined state, a view which might render separation surgery unthinkable in all cases, we nevertheless argue against an “adversarial” interpretation of conjoined twins’ respective best interests. We maintain that the physical entanglement should be regarded as a shared problem rather than one posed by one twin to the other. And if, after deliberation, separation surgery is deemed the “least detrimental alternative” or the “lesser of two evils”, then there should be recognition of what conjoined twins will lose, as well as gain, through separation. The current drive to separate twins at all costs may evince a deeper unease with bodily configurations that appear to threaten the premium that the Western ethical and legal tradition places on personal sovereignty, and the physical circumscription that such sovereignty assumes.
Certainty and mortality prediction in critically ill children
Authors: Marcin J P , Pretzlaff R K , Pollack M M , Patel K M , Ruttimann U E
Published: June 2004

Objectives:The objective of this study is to investigate the relationship between a physician’s subjective mortality prediction and the level of confidence with which that mortality prediction is made.

Design and participants:The study is a prospective cohort of patients less than 18 years of age admitted to a tertiary Paediatric Intensive Care Unit (ICU) at a University Children’s Hospital with a minimum length of ICU stay of 10 h. Paediatric ICU attending physicians and fellows provided mortality risk predictions and the level of confidence associated with these predictions on consecutive patients at the time of multidisciplinary rounds within 24 hours of admission to the paediatric ICU. Median confidence levels were compared across different ranges of mortality risk predictions.

Results:Data were collected on 642 of 713 eligible patients (36 deaths, 5.6%). Mortality predictions greater than 5% and less than 95% were made with significantly less confidence than those predictions <5% and >95%. Experience was associated with greater confidence in prognostication.

Conclusions:We conclude that a physician’s subjective mortality prediction may be dependent on the level of confidence in the prognosis; that is, a physician less confident in his or her prognosis is more likely to state an intermediate survival prediction. Measuring the level of confidence associated with mortality risk predictions (or any prognostic assessment) may therefore be important because different levels of confidence may translate into differences in a physician’s therapeutic plans and their assessment of the patient’s future.
The influence of risk and monetary payment on the research participation decision making process
Authors: Bentley J P , Thacker P G
Published: June 2004

Objectives:To determine the effects of risk and payment on subjects’ willingness to participate, and to examine how payment influences subjects’ potential behaviours and risk evaluations.

Methods:A 3 (level of risk) × 3 (level of monetary payment), between subjects, completely randomised factorial design was used. Students enrolled at one of five US pharmacy schools read a recruitment notice and informed consent form for a hypothetical study, and completed a questionnaire. Risk level was manipulated using recruitment notices and informed consent documents from hypothetical biomedical research projects. Payment levels were determined using the payment models evaluated by Dickert and Grady as a guide. Five dependent variables were assessed in the questionnaire: willingness to participate, willingness to participate with no payment, propensity to neglect to tell about restricted activities, propensity to neglect to tell about negative effects, and risk rating.

Results:Monetary payment had positive effects on respondents’ willingness to participate in research, regardless of the level of risk. However, higher monetary payments did not appear to blind respondents to the risks of a study. Payment had some influence on respondents’ potential behaviours regarding concealing information about restricted activities. However, payment did not appear to have a significant effect on respondents’ propensity to neglect to tell researchers about negative effects.

Conclusions:Monetary payments appear to do what they are intended to do: make subjects more willing to participate in research. Concerns about payments blinding subjects to risks could not be substantiated in the present study. However, the findings do raise other concerns—notably the potential for payments to diminish the integrity of a study’s findings. Future research is critical to make sound decisions about the payment of research subjects.
Consent for anaesthesia
Authors: White S M
Published: June 2004

“Informed consent” is a legal instrument that allows individuals to define their own interests and to protect their bodily privacy. In current medical practice, patients who have consented to surgery are considered to have implied consent to anaesthesia, even though anaesthesia is associated with its own particular set of risks and consequences that are quite separate from those associated with surgery. In addition, anaesthetists often perform interventions that are the only medical treatment received by a patient. Anaesthetists, therefore, should always obtain separate consent for anaesthesia, and should regard the process of consent as a stimulus for active, fluid reciprocal discussion with patients about treatment options.
The stipulations of one institutional review board: a five year review
Authors: Sansone R A , McDonald S , Hanley P , Sellbom M , Gaither G A
Published: June 2004

Objectives:This study was designed to explore the prevalence and types of stipulations (such as clarifications or changes) required of investigators by the institutional review board (IRB) of one institution over a five year period.

Design:Stipulations to research proposals (n = 124) were documented from the minutes of the IRB meetings.

Setting:Community hospital.

Participants:IRB submissions.

Main measurements:Number and type of IRB stipulations.

Results:Nineteen research submissions (15.3%) were approved without any stipulations. For the remainder, the majority of stipulations related to consent forms (74.2%).

Conclusions:Consent forms appear to be at highest risk for IRB stipulations. Being aware of high risk areas before submission of research proposals may reduce the frequency of stipulations required of investigators.
Communicating information on cardiopulmonary resuscitation to hospitalised patients
Authors: Sivakumar R , Knight J , Devlin C , Keir P , Ghosh P , Khan S
Published: June 2004

Aim:The primary aim of the study was to evaluate two different methods of communicating information on cardiopulmonary resuscitation (CPR) to patients admitted to general medical and elderly care wards. The information was either in the form of a detailed information leaflet (appendix I) or a summary document (appendix II). The study examined the willingness of patients in seeking detailed information on cardiopulmonary issues.

Setting:The study was conducted over three months on a general medical ward and an acute elderly care ward in two district general hospitals.

Methods:A detailed information leaflet on CPR was provided to the nursing staff on the wards. An A4 summary document summarising the CPR decision making process and basic information on cardiopulmonary issues was placed in a folder at the foot of each bed on the elderly care ward. On the general medical ward it was displayed prominently over the head of all beds.

Results:Out of the 274 patients admitted to the general medical ward only two requests were received for the detailed information leaflet. On the elderly care ward there were 182 admissions but no patients or their relatives requested the leaflet.

Conclusions:Availability of basic information on cardiopulmonary resuscitation to all patients is practical and does not lead to unnecessary distress or offence to patients or their carers. It makes the decision making process more transparent. Detailed information leaflets are of value for a minority of hospitalised patients.
Evaluation of end of life care in cancer patients at a teaching hospital in Japan
Authors: Tokuda Y , Nakazato N , Tamaki K
Published: June 2004

Objectives:To analyse the decision making for end of life care for patients with cancer at a teaching hospital in Japan at two periods 10 years apart.

Design and setting:Retrospective study conducted in a 550 bed community teaching hospital in Okinawa, Japan.

Patients:There were 124 terminally ill cancer patients (45 women; 79 men; median age, 69 years) admitted either in 1989 and 1999 for end of life care with sufficient data to permit analysis.

Main measurements:Basic demographic data, notification to the patient that he or she had cancer, patient involvement in do not resuscitate (DNR) orders, and various medical interventions which were performed in the month prior to the patient’s death were evaluated.

Results:In 1989 none of the patients were notified of their diagnosis; in 1999 five patients were informed (p = 0.026). Of the 113 (91%) patients with a written DNR order, none were involved in consenting to the DNR order. In the month before death, patients in both groups received non-palliative treatments such as feeding tube placements (five in 1989; five in 1999), total parenteral nutrition (six in 1989; eight in 1999), and intravenous albumin infusion (four in 1989; five in 1999). Morphine use increased (30%) significantly in 1999 compared with the 1989 group.

Conclusions:The majority of patients dying of cancer were still not informed of their diagnosis and were seldom involved in DNR decision making at a teaching hospital in Japan. There was no change in the number of potentially futile interventions that were performed (6–13%) but morphine use increased. Modern ethical education is urgently needed in Japanese medical practice to improve decision making process in the end of life care.
Ideals of patient autonomy in clinical decision making: a study on the development of a scale to assess patients’ and physicians’ views
Authors: Stiggelbout A M , Molewijk A C , Otten W , Timmermans D R M , van Bockel J H , Kievit J
Published: June 2004

Objectives:Evidence based patient choice seems based on a strong liberal individualist interpretation of patient autonomy; however, not all patients are in favour of such an interpretation. The authors wished to assess whether ideals of autonomy in clinical practice are more in accordance with alternative concepts of autonomy from the ethics literature. This paper describes the development of a questionnaire to assess such concepts of autonomy.

Methods:A questionnaire, based on six moral concepts from the ethics literature, was sent to aneurysm patients and their surgeons. The structure of the questionnaire was assessed by factor analysis, and item reduction was based on reliability.

Results:Ninety six patients and 58 surgeons participated. The questionnaire consisted of four scales. Two of the scales reflected the paternalistic and consumerist poles of the liberal individualist model, one scale reflected concepts of Socratic autonomy and of procedural independence, and the fourth scale reflected ideals of risk disclosure.

Discussion:The Ideal Patient Autonomy Scale is a 14 item normative instrument. It is clearly distinct from the generally used psychological preference questionnaires that assess preferences for physician-patient roles.
Finding European bioethical literature: an evaluation of the leading abstracting and indexing services
Authors: Fangerau H
Published: June 2004

Objectives:In this study the author aimed to provide information for researchers to help them with the selection of suitable databases for finding medical ethics literature. The quantity of medical ethical literature that is indexed in different existing electronic bibliographies was ascertained.

Method:Using the international journal index Ulrich’s Periodicals Directory, journals on medical ethics were identified. The electronic bibliographies indexing these journals were analysed. In an additional analysis documentalists indexing bioethical literature were asked to name European journals on medical ethics. The bibliographies indexing these journals were examined.

Results:Of 290 journals on medical ethics 173 were indexed in at least one bibliography. Current Contents showed the highest coverage with 66 (22.8%) journals indexed followed by MEDLINE (22.1%). By a combined search in the top ten bibliographies with the highest coverage, a maximum coverage of 45.2% of all journals could be reached. All the bibliographies showed a tendency to index more North American than European literature. This result was verified by the supplementary analysis of a sample of continental European journals. Here EMBASE covered the highest number of journals (20.6%) followed by the Russian Academy of Sciences Bibliographies (19.2%).

Conclusion:A medical ethics literature search has to be carried out in several databases in order to reach an adequate collection of literature. The databases one wishes to combine should be carefully chosen. There seems to be a regional bias in the most popular databases, favouring North American periodicals compared with European literature on medical ethics.
What are local issues? The problem of the local review of research
Authors: Wainwright P , Saunders J
Published: June 2004

Local review of research by ethics committees in the UK has long been held to be an important right of the local research ethics committee and, even with the introduction of the European Clinical Trials Directive, the governance arrangements for research ethics committees continue to allow for local review of multicentre studies. There is no requirement for local review in either the European Union directive or in the guidelines on good clinical practice, and there is little evidence of it anywhere else in Europe. The idea that there can be “local”, as opposed to “central” ethical issues in research is an interesting one, which raises important issues about the nature of research ethics and ethical review. The aim of this paper is to argue that there are no such things as local issues in research ethics, and suggest that those questions currently addressed as local issues properly belong within the research governance framework.
The law and ethics of male circumcision: guidance for doctors
Authors:   British Medical Association
Published: June 2004

1. Aim of the guidelines

2. Principles of good practice

3. Circumcision for medical purposes

4. Non-therapeutic circumcision

 4.1. The law

  4.1.1. Summary: the law

 4.2. Consent and refusal

  4.2.1. Children’s own consent

  4.2.2. Parents’ consent

  4.2.3. Summary: consent and refusal

 4.3. Best interests

  4.3.1. Summary: best interests

 4.4. Health issues

 4.5. Standards

 4.6. Facilities

 4.7. Charging patients

 4.8. Conscientious objection

5. Useful addresses
The development of professional guidelines on the law and ethics of male circumcision
Authors: Mussell R
Published: June 2004

This paper does not attempt to lay out the arguments relating to male circumcision for non-medical reasons. Rather, the aim is to focus more on the process and the problems of a professional body (in this case the British Medical Association (BMA)) attempting to produce any consensus guidelines for its members on an issue which clearly polarises doctors as much as it divides society as a whole. The legal and ethical considerations of male circumcision are inevitably touched upon here but are not the central issue. In 2003, the BMA published professional guidance on this subject. Some thought this a pointless exercise; others saw it as an initiative which simply failed to go far enough. Reservations centred on the fact that the BMA’s guidance—like that of the statutory body, the General Medical Council—explored the issues without either firmly rejecting or accepting non-therapeutic male circumcision. Was it then a fruitless project or a brave start to grasping the nettle?
Rationalising circumcision: from tradition to fashion, from public health to individual freedom—critical notes on cultural persistence of the practice of genital mutilation
Authors: Hellsten S K
Published: June 2004

Despite global and local attempts to end genital mutilation, in their various forms, whether of males or females, the practice has persisted throughout human history in most parts of the world. Various medical, scientific, hygienic, aesthetic, religious, and cultural reasons have been used to justify it. In this symposium on circumcision, against the background of the other articles by Hutson, Short, and Viens, the practice is set by the author within a wider, global context by discussing a range of rationalisations used to support different types of genital mutilation throughout time and across the globe. It is argued that in most cases the rationalisations invented to provide support for continuing the practice of genital mutilation—whether male or female—within various cultural and religious settings have very little to do with finding a critical and reflective moral justification for these practices. In order to question the ethical acceptability of the practice in its non-therapeutic forms, we need to focus on child rights protection.
2004 REVIEW OF LIGHT CONE FIELD THEORY
Authors: KISSLINGER LEONARD S.
Published: May 2004

We review the basic concepts of the Poincare group in light cone quantum mechanics and light cone field theory. We discuss recent progress in light cone representations of the Bethe–Salpeter equation, with application to the pion form factor, and the quark Schwinger–Dyson equation. Applications are discussed for deeply virtual Compton scattering, particularly for skewed parton distributions of the pion, and rare B to lepton pair decays. Meson light cone wave functions and recent experimental studies of light cone wave functions are also covered. This review was motivated by the LANL Light Cone 2002 International Workshop.