bluuebunny/crossref_metadata_2025_split huggingface dataset:
Political issues in emergency medicine: The United States
Authors: Hoekstra James , McNamara Robert , Schafermeyer Robert W , Hamilton Glenn C 
Published: June 2004

AbstractThe 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

AbstractHealth 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.
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.
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.
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.
The law and ethics of male circumcision: guidance for doctors
Authors:   British Medical Association
Published: June 2004

1. Aim of the guidelines2. Principles of good practice3. Circumcision for medical purposes4. 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 objection5. Useful addresses
MULTISCALE NUMERICAL METHODS FOR SINGULARLY PERTURBED CONVECTION-DIFFUSION EQUATIONS
Authors: PARK PETER J. , HOU THOMAS Y. 
Published: June 2004

We present an efficient and robust approach in the finite element framework for numerical solutions that exhibit multiscale behavior, with applications to singularly perturbed convection-diffusion problems. The first type of equation we study is the convection-dominated convection-diffusion equation, with periodic or random coefficients; the second type of equation is an elliptic equation with singularities due to discontinuous coefficients and non-smooth boundaries. In both cases, standard methods for purely hyperbolic or elliptic problems perform poorly due to sharp boundary and internal layers in the solution. We propose a framework in which the finite element basis functions are designed to capture the local small-scale behavior correctly. When the structure of the layers can be determined locally, we apply the multiscale finite element method, in which we solve the corresponding homogeneous equation on each element to capture the small scale features of the differential operator. We demonstrate the effectiveness of this method by computing the enhanced diffusivity scaling for a passive scalar in the cellular flow. We also carry out the asymptotic error analysis for its convergence rate and perform numerical experiments for verification. For a random flow with nonlocal layer structure, we use a variational principle to gain additional information in our attempt to design asymptotic basis functions. We also apply the same framework for elliptic equations with discontinuous coefficients or non-smooth boundaries. In that case, we construct local basis function near singularities using infinite element method in order to resolve extreme singularity. Numerical results on problems with various singularities confirm the efficiency and accuracy of this approach.
Apolipoprotein B100 Metabolism in Autosomal-Dominant Hypercholesterolemia Related to Mutations inPCSK9
Authors: Ouguerram Khadija , Chetiveaux Maud , Zair Yassine , Costet Philippe , Abifadel Marianne , Varret Mathilde , Boileau Catherine , Magot Thierry , Krempf Michel 
Published: June 2004

Objective—We have reported further heterogeneity in familial autosomal-dominant hypercholesterolemia (FH) related to mutation in proprotein convertase subtilisin/kexin type 9 (PCSK9) gene previously named neural apoptosis regulated convertase 1 (Narc-1). Our aim was to define the metabolic bases of this new form of hypercholesterolemia.Methods and Results—In vivo kinetics of apolipoprotein B100-containing lipoproteins using a 14-hour primed constant infusion of [2H3] leucine was conducted in 2 subjects carrying the mutation S127R inPCSK9, controls subjects, and FH subjects with known mutations on the low-density lipoprotein (LDL) receptor gene (LDL-R). Apo B100 production, catabolism, and transfer rates were estimated from very LDL (VLDL), intermediate-density lipoprotein (IDL), and LDL tracer enrichments by compartmental analysis.PCSK9mutation dramatically increased the production rate of apolipoprotein B100 (3-fold) compared with controls or LDL-R mutated subjects, related to direct overproduction of VLDL (3-fold), IDL (3-fold), and LDL (5-fold). The 2 subjects also showed a decrease in VLDL and IDL conversion (10% to 30% of the controls). LDL fractional catabolic rate was slightly decreased (by 30%) compared with controls but still higher than LDL-R–mutated subjects.Conclusion—These results showed that the effect of the S127R mutation ofPCSK9on plasma cholesterol homeostasis is mainly related to an overproduction of apolipoprotein B100.
Direct bacterial protein PAMP recognition by human NK cells involves TLRs and triggers α-defensin production
Authors: Chalifour Anick , Jeannin Pascale , Gauchat Jean-François , Blaecke Aline , Malissard Martine , N'Guyen Thien , Thieblemont Nathalie , Delneste Yves 
Published: June 2004

AbstractAlthough human CD56+CD3- natural killer (NK) cells participate in immune responses against microorganisms, their capacity to directly recognize and be activated by pathogens remains unclear. These cells encode members of the Toll-like receptor (TLR) family, involved in innate cell activation on recognition of pathogen-associated molecular patterns (PAMPs). We therefore evaluated whether the 2 bacterial protein PAMPs, the outer membrane protein A from Klebsiella pneumoniae (KpOmpA) and flagellin, which signal through TLR2 and TLR5, respectively, may directly stimulate human NK cells. These proteins induce interferon-γ (IFN-γ) production by NK cells and synergize with interleukin-2 (IL-2) and proinflammatory cytokines in PAMP-induced activation. Similar results were obtained using CD56+CD3+ (NKR-expressing) T cells. NK cells from TLR2-/- mice fail to respond to KpOmpA, demonstrating TLR involvement in this effect. Defensins are antimicrobial peptides expressed mainly by epithelial cells and neutrophils that disrupt the bacterial membrane, leading to pathogen death. We show that NK cells and NKR-expressing T cells constitutively express α-defensins and that KpOmpA and flagellin rapidly induce their release. These data demonstrate for the first time that highly purified NK cells directly recognize and respond to pathogen components through TLRs and evidence defensins as a novel and direct cytotoxic pathway involved in NK cell-mediated protection against microorganisms. (Blood. 2004;104:1778-1783)
Targeted delivery of adenoviral vectors by cytotoxic T cells
Authors: Yotnda Patricia , Savoldo Barbara , Charlet-Berguerand Nicolas , Rooney Cliona , Brenner Malcolm 
Published: June 2004

Abstract
Effective targeting of vectors to tumor cells that have metastasized to multiple different tissue sites remains a major challenge for gene therapy. Tumor-specific cytotoxic T lymphocytes (CTLs) have been shown in animal models and in humans to be able to cross tissue barriers and traffic to tumor cells. However, their capacity to eliminate malignancy has been limited by tumor immune evasion strategies. We now use a model of Epstein-Barr virus–mediated malignancy to show that human CTLs themselves may be modified to release therapeutic vectors following engagement of their antigen-specific receptors and that these vectors will effectively transduce and destroy tumor targets. We generated EBV-specific CTLs that were transgenic for the adenoviral E1 gene under the control of the cell activation-dependent CD40 ligand (CD40L) promoter. Following transduction with E1-deficient adenoviral vectors, these CTLs produced infectious virus when exposed to HLA-matched EBV-expressing targets, but not on exposure to major histocompatibility complex (MHC)–mismatched or otherwise irrelevant cells. This approach provides a means of delivering oncolytic/therapeutic vectors not only to locally accessible macroscopic tumors as is presently the case, but also to disseminated metastatic disease, while avoiding the risks associated with systemic administration of large doses of adenoviral vectors.