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PubMed2004

Physicians and strikes: can a walkout over the malpractice crisis be ethically justified?

Malpractice insurance rates have created a crisis in American medicine. Rates are rising and reimbursements are not keeping pace. In response, physicians in the states hardest hit by this crisis are feeling compelled to take political action, and the current action of choice seems to be physician strikes. While the malpractice insurance crisis is acknowledged to be severe, does it justify the extreme action of a physician walkout? Should physicians engage in this type of collective action, and what are the costs to patients and the profession when such action is taken? I will offer three related arguments against physician strikes that constitute a prima facie prohibition against such action: first, strikes are intended to cause harm to patients; second, strikes are an affront to the physician-patient relationship; and, third, strikes risk decreasing the public's respect for the medical profession. As with any prima facie obligation, there are justifying conditions that may override the moral prohibition, but I will argue that the current malpractice crisis does not rise to the level of such a justifying condition. While the malpractice crisis demands and justifies a political response on the part of the nation's physicians, strikes and slow-downs are not an ethically justified means to the legitimate end of controlling insurance costs.

American Medical Association↗
PubMed1998

Beneficent voluntary active euthanasia: a challenge to professionals caring for terminally ill patients.

Euthanasia has once again become headline news in the UK, with the announcement by Dr Michael Irwin, a former medical director of the United Nations, that he has helped at least 50 people to die, including two between February and July 1997. He has been quoted as saying that his 'conscience is clear' and that the time has come to confront the issue of euthanasia. For the purposes of this article, the term 'beneficient voluntary active euthanasia' (BVAE) will be used: beneficient from the prima facie principle of beneficience, to do good, and voluntary to indicate that this must be carried out at the request of a competent client. This implies adherence to another prima facie principle, that of respect for autonomy. Active implies that something is done or given with the intention of hastening death. The word euthanasia itself simply means 'good death'. This article examines the moral positions of two nurses and one junior doctor towards the subject of BVAE and an attempt is made to represent the main conflicting moral positions. The central arguments against BVAE and counterarguments are presented. The conclusion reached is that consenting adults should not be prevented from availing themselves of BVAE if another consenting adult (a medical doctor) is available and capable of carrying out their wishes. This being the case, it is suggested that BVAE should be available as an option in hospices and in the community. The aims of this article are: to generate debate among professionals; to present a three-way discussion that might be useful as a focus for educational purposes, particularly at undergraduate level; to challenge professionals to confront the issue of euthanasia; and to plead the case of those who request assistance in exercising autonomy by gaining control over their own deaths.

Adult↗
PubMed1987

The evaporation path of seawater and the coprecipitation of Br- and K+ with halite.

Brines and salt were sampled at the Morton Bahamas solar salt production facility on Great Inagua Island in the Bahamas. The brines were analyzed by ion chromatography to define more precisely than heretofore the evaporation path of seawater to the end of the halite facies. At Inagua, calcium carbonate begins to precipitate at a brine concentration factor of 1.8 times that of seawater. Gypsum begins to precipitate at a brine concentration of 3.8 times seawater, and halite at a concentration factor of 10.6. Three of the most concentrated brines from Inagua (40 times seawater) were evaporated further in the laboratory. Magnesium sulfate first precipitated at brine concentrations about 70 times those of seawater, and potassium-bearing phases began to precipitate for these brines at concentrations greater than 90 times those of seawater. The distribution of coefficients of Br- and K+ between brines and halite were determined by combining analytical data for the Inagua brines with measurements of the Br- and K+ content of halites from Inagua and of halite which had precipitated from Inagua brines during storage. The observed average value of DBr- is 0.032, in good agreement with some of the previous measurements. The measured values of DK+ are highly variable (0.001 to 0.021); DK+ for halite precipitated early in the halite facies is in the vicinity of 0.015.

Bahamas↗
PubMed1991

The preembryo as potential: a reply to John A. Robertson.

... In conclusion, let me agree with Robertson that reasonable persons may indeed disagree on concrete conclusions touching preembryo freezing, discard, research, and diagnosis. But it is one of the challenges to reasonable people to give reasons for their conclusions. When Robertson notes that preembryo research "has been found acceptable by most bodies that have examined the subject," he leaves unstated the fact that many of these bodies have not given reasons for their conclusions. This is especially true of the Warnock Committee. It is definitely not true of John Robertson. He has attempted to give analytic support for his rather permissive positions. I find this support too fragile for its assigned task, though I hasten to say that this does not mean that only a totally prohibitive position is defensible or is mine. Prima facie still means prima facie.

Beginning of Human Life↗
PubMedDate not supplied

Clinical and radiological aspects in Melnick-Needles syndrome.

Melnick-Needles syndrome is an X-linked dominant bone dysplasia, lethal in males, characterized by a typical facies and characteristic radiological findings: including sclerosis of skull base and mastoids. S-shaped appearance of tibia; cortical irregularities with a ribbon appearance of the ribs. About 48 well-documented cases have been reported, most of them were sporadic. Parental transmission has been published in only 11 kindreds. We are presenting the first Brazilian family with mother-daughter transmission. The proposita presented the typical clinical and radiological features with characteristic facies, severe thoracic cage restriction and pulmonary hypertension. Her mother was more mildly affected.

Adolescent↗
PubMed2002

Familial association of pseudohypoparathyroidism and psoriasis: case report.

CONTEXT: The association between psoriasis and hypoparathyroidism has been reported by several authors, and it has been suggested that abnormalities in calcium homeostasis may be involved in the development or exacerbation of psoriasis. However, so far there have only been two reports of pseudohypoparathyroidism associated with psoriasis. OBJECTIVE: To describe the familial occurrence of this association for the first time. CASE REPORTS: Two siblings with psoriasis associated with pseudohypoparathyroidism were presented. The first patient was a 24-year-old white male with disseminated erythrodermic pustular psoriasis that began 2 months before admission. He had had a history of mental retardation, recurrent otitis, seizures and arthralgia from the age of 11 years onwards. He presented the characteristic phenotype of Albright osteodystrophy: short stature, obesity, round facies, broad forehead, short neck and brachydactylia. He adopted a position of flexed limbs and showed proximal muscle weakness and a positive Trousseau sign. He had clinical signs of hypocalcemia (0.69 mmol/l ionized calcium and 3.2 mg/dl total calcium), hyperphosphatemia (6.6 mg/dl), hypomagnesemia (1.0 mEq/l), hypoalbuminemia (3.1 g/dl), normal serum intact PTH levels (45.1 pg/ml), primary hypothyroidism (13.2 mU/ml TSH, and 4.7 mg/dl total T(4)), hypergonadotrophic hypogonadism (116.0 ng/ml LH, 13.2 mU/ml FSH and 325.0 ng/dl testosterone), osteoporosis, and diffuse calcifications in soft tissues and in the central nervous system. The second case was a 14-year-old white girl with a history of psoriasis vulgaris from the age of five years onwards, and antecedents of mental retardation. She presented signs of Albright osteodystrophy (short stature, round facies, obesity, short neck, brachydactylia), hypocalcemia (ionized calcium of 1.08 mmol/l and total calcium of 6.7 mg/dl) hyperphosphatemia (9.4 mg/dl), elevated serum PTH levels (223.0 pg/ml), osteoporosis, and hypergonadotrophic hypogonadism (7.0 mU/ml LH, 9.3 mU/ml FSH and undetectable estradiol levels).

Abnormalities, Multiple↗
PubMed1976

Gingiva and periodontium in lepromatous leprosy. A clinical, radiological, and microscopical study.

Thirty patients with lepromatous leprosy of long duration were examined for gingival and periodontal changes. All patients presented with chronic gingivitis and periodontitis of an unspecific type. Etiologic factors affecting the development of gingival and periodontal changes in this disease are: lack of oral hygiene with severe plaque and calculus formation due to the inability of the patients to perform oral hygiene, mouth breathing, specific granulomatous infiltrations, and a possible specific drug action. Specific changes in form of 'facies leprosa' are not pathognomonic of lepromatous leprosy but may be found in 20% of the cases among Thai and Chinese patients. Occurrence and pathogenesis of 'facies leprosa' is described.

Adult↗
PubMed1990

Alagille syndrome. A case report.

A 5-year-old physically and mentally retarded female child born of non-consanguineous parents, who had had disseminated skin lesions for 4 1/2 years, is presented. She had persistent neonatal jaundice associated with clay-coloured stools and generalized pruritus which receded by the age of 2 years. Examination revealed characteristic facies, moderate hepatosplenomegaly, cardiac murmur and widespread smooth yellow papules and nodules on ears, trunk, bony prominences and palms. Ophthalmic examination revealed corneal opacities. Liver function tests and lipidogram were abnormal. A diagnosis of Watson-Alagille Syndrome was made on the basis of characteristic facies, xanthomatosis and cholestatic jaundice.

Child, Preschool↗
PubMed2000

[Dopamine transporter SPECT in patients with Parkinson's disease].

The major neuropathological feature in Parkinson's disease (PD) is severe degeneration of the dopamine (DA) neurons in the substantia nigra. Dopamine transporter (DAT) is an important protein in the regulation of DA neurotransmission. It has been reported that PD patients show a loss of DAT in striatum. We report here the findings of single photon emission computed tomography (SPECT) of the DAT with 2 beta-carboxymethoxy-3 beta-(4[123I]iodophenyl)tropane ([123I] beta-CIT) to investigate striatal DAT in 10 patients with PD, one patient with vascular parkinsonism (VP), and one patient with dystonia syndrome. Patients were evaluated using the Webster rating scale. Specific/nondisplaceable striatal binding ratio (V3") was obtained in each case. In PD patients, the uptake of [123I] beta-CIT was reduced, especially in the tail of putamen compared with caudate nucleus. Even in the early stage of PD, the uptake of beta-CIT was reduced not only in the severely affected side, but also in the mildly disturbed side of the brain. Putamen caudate ratio was generally low in PD patients. In VP patient, the uptake was reduced, but putamen caudate ratio was not decreased. V3" values showed significant correlation with the severity of clinical symptoms such as self-care, facies, posture, gait, speech, and Hoehn-Yahr's stage. On the other hand, V3" values were not significantly correlated with the degree of tremor, seborrhea, and duration of the illness. In conclusion, we found that SPECT of the [123I] beta-CIT is a useful method for the diagnosis in the patients presenting parkinsonism, and for the clinico-physiological estimation of parkinsonian symptoms such as self-care, facies, posture, gait, and speech.

Adult↗
PubMed2001

[Supravalvular aortic stenosis. Report of 3 cases].

In the following article three cases of supravalvular aortic stenosis are presented: the first two cases refer to two brothers. The older, a 22-year-old man presenting with palpitations, underwent echocardiography and Doppler that showed an hour-glass supravalvular aortic stenosis with a peak gradient of 115 mmHg, associated with dilation of the left main coronary artery and stenosis of the left carotid artery at its origin. The patient's family was evaluated by echocardiography, and an 18-year-old brother was similarly found to have an hour-glass supravalvular aortic stenosis, graded mild to moderate (peak gradient 40 mmHg). Both cases are probably familiar forms of supravalvular aortic stenosis with normal facies and intelligence (autosomal dominant transmission). The elder brother, with severe stenosis, underwent surgical replacement of the ascending aorta. The third patient was a 23-year-old woman with a previous diagnosis of congenital aortic stenosis. Her characteristic elfic facies induced us to suspect the syndrome of Williams-Beuren; transthoracic and transesophageal echocardiographic examination showed an hour-glass supravalvular aortic stenosis with a peak gradient of 60 mmHg. Magnetic resonance imaging showed hypoplasia of the descending aorta and the iliac arteries. Since she was asymptomatic and presented only with a moderate gradient, the patient was not referred to surgical therapy. In this manuscript we present the three cases and review the histopathological, clinical, genetic, diagnostic and therapeutic aspects of this disease and its natural history.

Adolescent↗
PubMed1989

Secular change in chert distribution: a reflection of evolving biological participation in the silica cycle.

In the modern oceans, the removal of dissolved silica from sea water is principally a biological process carried out by diatoms, with lesser contributions from radiolaria, silicoflagellates, and sponges. Because such silica in sediments is often redistributed locally during diagenesis to from nodular or bedded chert, stratigraphic changes in the facies distribution of early diagenetic chert provide important insights into the development of biological participation in the silica cycle. The abundance of chert in upper Proterozoic peritidal carbonates suggests that at this time silica was removed from seawater principally by abiological processes operating in part of the margins of the oceans. With the evolution of demosponges near the beginning of the Cambrian Period, subtidal biogenetic cherts became increasingly common, and with the Ordovician rise of radiolaria to ecological and biogeochemical prominence, sedimented skeletons became a principal sink for oceanic silica. Cherts of Silurian to Cretaceous age share many features of facies distribution and petrography but they differ from Cenozoic siliceous deposits. These differences are interpreted to reflect the mid-Cretaceous radiation of diatoms and their subsequent rise to domination of the silica cycle. Biogeochemical cycles provide an important framework for the paleobiological interpretation of the organisms that participate in them.

Animals↗
PubMed1991

Response to Erich Loewy: commentary.

The capacity to suffer, the vulnerability with respect to suffering, confers on all animals with that capacity (not just human beings) a prima facie right not to be caused suffering. Nurturing in order to stave off such suffering is the first act of the community toward the individual, primarily in infancy. Hence for Loewy, autonomy, the gradual growth of self-determination in individuals, is grounded in a broader moral commitment of the community, that of beneficence. This is the critical point in his argument, for it represents a wholesale critique of modern libertarianism. Libertarians, in contrast to Loewy's argument, seem to ground the nature of the community in the prima facie right of autonomy. For Loewy, the community not only has an obligation to refrain from harming individuals (nonmaleficence), but it also has an active duty to ameliorate and prevent, as far as possible, the suffering of its members. Thus, if there is a social contract, it is one of nurturing one another to overcome the vulnerability of suffering, not primarily one of protecting autonomy. This is most significant for clinical ethics as well. Once the primary obligation to ameliorate suffering is no longer necessary, when the individual loses or does not have the primary moral worth prompted by the capacity to suffer, then secondary and symbolic obligations emerge. Loewy is thereby able to suggest a "calculus" of moral worth, wherein our obligations to individuals in a permanent vegetative state or to anencephalics (almost always the individual will have lost the capacity to suffer through some cerebral event) must be weighed against other primary obligations. Although Loewy admits that grounding clinical ethics in the capacity to suffer might be "thin," it nevertheless prompts serious discussion about the nature of the "good" in good clinical ethics decisions.

Altruism↗
PubMed1975

Probable Marden-Walker syndrome: evidence for autosomal recessive inheritance.

Two first cousins, the offspring of consanguineous marriages, had features suggestive of Marden-Walker syndrome. Phenotypic similarities and differences for Schwartz-Jampel syndrome have been discussed. Main features of the Marden-Walker syndrome are failure to thrive, marked motor and mental retardation, and multiple malformations in the form of peculiar facies associated wilth poor muscle mass, mild congenital joint contractures, pigeon breast, kyphoscoliosis and arachnodactyly. Peculiar facies is due to blepharophimosis, congenital ptosis, hypoplastic mandible and low-set and malformed ears. Posterior median cleft of the palate as well as cardiac and renal anomalies were noted in the case reported by Marden and Walker. Our Case 2 had dextrocardia. The present report suggests autosomal recessive inheritance of this syndrome.

Abnormalities, Multiple↗
PubMed2003

[Mucolipidoses type II. Case report].

We report a female newborn with type II mucolipidoses. This condition is characterized clinically by Hurler like features, progressive psychomotor retardation and death during the first or second year of life. Most cases present during the first year of life, with poor weight gain and coarse facies features. The cause of this rare autosomal recessive hereditary disease is the deficiency of the enzyme N-acetylglucosamine-1-phosphotransferase, required for the synthesis of mannose-6-phosphate, the ligand that allows the transport of acid hydrolases into lysosomes. The patient had clinical features commonly found in mucolipidosis II, including disproportionate dwarfism, retarded psychomotor development, coarse facies features, gibbous and restricted joint mobility. The diagnosis was proved by an extremely elevated activity of lysosomal enzymes in the serum, secondary to non-regulated secretion and subsequent intracellular depletion of these proteins. The child suffered recurrent pneumonia and died at 22 months of age.

Female↗
PubMed2002

Quality assessment of surface and subsurface water of Damodar river basin.

Hydrogeochemical analyses were carried out on surface and subsurface samples collected from different part of the Damodar river basin. The analytical results show that calcium and bicarbonate are the dominant cations and anions respectively in surface water, while in subsurface water calcium is replaced by sodium in cationic abundance. The TDS content of subsurface water is two to three times higher than of surface water. The higher TDS of subsurface water may be due to longer residence time, favoring acquisition of solutes through rock weathering. Gibbs variation diagram shows that rock weathering mainly controls chemistry of the Damodar river basin. Quality assessment study of Damodar river basin water shows that with few exceptions, subsurface water is suitable for drinking and domestic uses. Based on SAR, RSC and percent Na the surface water fall within the excellent to good quality class and subsurface water within good to permissible limit and it can be used for irrigation without any hazard. However, the high %Na, RSC and SAR values at a few sites restrict its suitability for irrigation purpose. Ca-Na-HCO3 is the dominant hydrochemical facies in surface water while Na-Ca-HCO3 is the common hydrochemical facies in subsurface water.

Bicarbonates↗
PubMed1992

[Schwartz-Jampel syndrome (osteochondromuscular dystrophy)].

BACKGROUND: Schwartz-Jampel syndrome is a rare disorder inherited as an autosomal recessive trait and characterized by growth retardation, multiple skeletal abnormalities, myotonia-like muscle disorders and unusual facies. CASE REPORTS: Case n. 1: A boy, aged 3 years 4 months, was admitted for acute respiratory disease. His main abnormalities included rigid facial expression, blepharophimosis, puckered lips, short neck, pectus carinatum, acetabular dysplasia with coxa vara, platyspondyly and marked growth retardation. There was a continuous muscle fiber activity at rest, with abnormal discharges originating in the muscle component of the neuromuscular junction. Blood investigations revealed low values of IgA. The child died at 4 years. Case n. 2: The sister of case n. 1 was examined at 14 months of age. She presented milder facies abnormalities, difficulties of gait because of stiff hips, muscular hypertrophy, coxa vara and growth retardation. X-rays showed skeletal abnormalities and the electromyogram was similar to those of her brother. She had dislocation of her optic lens. CONCLUSION: These 2 sibs have the characteristic manifestations of Schwartz-Jampel syndrome. Parental consanguinity was also present. The IgA deficiency observed in case n. 1 and the lens dislocation in case n. 2 have both been occasionally reported in this syndrome.

Child, Preschool↗
PubMed2004

Vascular anatomy of the radius and ulna diaphyses in their reconstructive surgery.

The vascular factor in the unsuccessful healing of the osteotomised forearm bone is widely discussed in literature at the so-called "level operations" aiming at correcting the "ulna minus" variant in Kienböck's disease. The purpose of our study was to trace the nourishing vessels of the forearm bones from their source from which a. nutritia radii (ANR) and a. nutritia ulnae (ANU) is separated and to locate the foramen nutritium (FN) of the radial and ulnar bones diaphysis. The forearms of 70 upper extremities were dissected and 204 macerated radial bones and 134 macerated ulnar bones were investigated scopically and metrically. The results demonstrated that there is less variability of sources from which ANR was separated as compared to the variability of the sources from which ANU was separated. Foramen nutritium radii (FNR) and foramen nutritium ulnae (FNU) were located mainly along facies anterior and its edges margo anterior and margo interosseus and only in a few cases they were observed along facies posterior. The metrical investigations showed that FNR were located mainly in the second fourth along the bone length, between 30 and 40% from the radial bone length in the distal direction. FNU were located mainly in the second fourth along the bone length, between 30 and 50% from the ulnar bone length in the distal direction. The results for vascular anatomy of the forearm bones give grounds to assume that osteotomy with a subsequent shortening of the radius is more feasible than osteotomy with ulnar lengthening. The distal half of the radius, between the third and fourth quarter in particular, is also recommended as most suitable for surgical intervention.

Aged↗
PubMed2005

[Cavernous sinus syndrome: an initial expression of a breast carcinoma].

Cavernous sinus syndrome (CSS) may be caused by a wide range of pathological process among we include metastatic disease. A case of a woman whose breast neoplasm was initially expressed by a CSS is discussed in this article. We describe a 64-year-old woman with several weeks progressive course of pain and numbness in her left-side facies and occasional diplopia. Neurological examination showed left ptosis, limitation of elevation of left eye and abducens nerve palsy as well as hypoesthesia in the frontal and maxillary regions of her left-side facies. Brain magnetic resonance imaging (MRI) scan revealed the presence of a mass in the orbit and left cavernous sinus. General examination disclosed a sclerotic and retractile lesion in her left breast which involved the nipple suggesting breast carcinoma metastases. The patient underwent a breast fine-needle aspiration biopsy which established the presence of an infiltrating breast carcinoma. This case shows the importance role of the general physical examination to determine the etiology of the CSS. It is necessary and fundamental to perform it on each patient not only to orientate further investigations but also to avoid more invasive diagnostic procedures.

Breast Neoplasms↗