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Selecting neonatal ethics.

Nontreatment of handicapped newborns has disturbed American society, prompting heated debate and new attempts by government at regulation. Robert Weir's new book reviews the elements of this controversy as argued by concerned doctors, lawyers and ethicists. Unfortunately, we do not know the magnitude or scope of the problem. We know little about how often or under what circumstances physicians practice nontreatment. In discussing the issues, Weir and others have paid inadequate attention to medical uncertainty. The inability to accurately predict outcome makes clinical judgment harder than most philosophers and others acknowledge. Many legal arguments are outdated. The concept of personhood Weir and ethicists invoke confounds decision making. Complex or uncertain medicomoral dilemmas will not be resolved more easily by ethics committees. This procedural solution to a substantive quandry creates new problems. More attention must be paid to patients' current and future suffering when deciding whether to treat severely handicapped infants.

Persons with Disabilities↗

Highlights from the 5th Annual Meeting of the Italian Society of Virology.

The 5th National Congress of the Italian Society of Virology (SIV) was attended by junior- and senior-level virologists to promote interactions and scientific collaborations among the different areas of Virology and allied sciences. The invited and selected lecturers covered the following topics: General Virology and Viral Genetics; Virus-host Interaction and Pathogenesis; Viral Oncogenesis; Viral Immunology and Vaccines; Anti-viral Therapy; Innovative Diagnostics; Viral Biotechnologies and Cell and Gene Therapy. As in the previous editions (Salata and Palù, 2004; Salata et al., 2005), a specific topic was thoroughly covered in a roundtable. This year the elected subject was "HIV: determinants of pathogenicity and clinical implications." The final program and the abstract book can be found at the web site http://www.siv-virologia.it. This report summarizes the lessons learned from the plenary lectures and the selected oral presentations of the 2005 meeting.

Humans↗

Which infants should live? On the usefulness and limitations of Robert Weir's Selective Nontreatment of Handicapped Newborns.

The moral dilemmas of selective nontreatment of handicapped newborns have been widely discussed in the United States since the early 1970s. Weir's book is the first systematic ethical analysis of the pertinent legal and medical factors. His book is reviewed in light of the current government regulations and the formation of Infant Care Review Committees in U.S. hospitals. Weir develops ethical criteria for decision-making about malformed infants and suggests decisions about treatment be made on the basis of disease categories. The implications of Weir's recommendations for a number of critical cases are discussed.

Persons with Disabilities↗

Mapping the literature of pediatric nursing.

BACKGROUND: Pediatric nurses work in an interdisciplinary field and face ever-increasing demands on their time and knowledge. Selection tools for librarians serving this group are available, but only one bibliometric analysis has examined citations to aid collection development. METHOD: The "Mapping the Literature of Nursing Project" protocol was used. Three source journals were selected, and a citation analysis of articles from 1998 to 2000 was conducted. RESULTS: The frequency of journal citation was tabulated, and a list of the most frequently cited journals was created. Just over 1% of the cited journals produced 33% of the citations. PubMed/MEDLINE, Science Citation Index, and Social Sciences Citation Index provided the most complete indexing coverage of all types of the journals, while CINAHL providing the most complete coverage of nursing journals. Books were the second-most frequently cited format. CONCLUSIONS: Citation analysis of journal articles from pediatric nursing journals may be helpful in selecting journals for libraries serving pediatric nurses and those who conduct pediatric nursing research. Librarians should consider adding indexes to their collection in addition to PubMed/MEDLINE to access the broad range of journals useful to this specialty.

Abstracting and Indexing↗

Laparoscopic surgery: an excellent approach in elderly patients.

HYPOTHESIS: A review of the literature will show that laparoscopy is safe and effective for the treatment of surgical diseases in elderly patients. DATA SOURCES: An electronic search using the PubMed and MEDLINE databases was performed using the term laparoscopy in elderly patients. Literature published in the English language in the past decade was reviewed. Pertinent references from articles and books not identified by the search engines were also retrieved. Relevant surgical textbooks were also reviewed. STUDY SELECTION: All relevant studies that could be obtained regardless of the study design were included. DATA EXTRACTION: All studies that contained material applicable to the topic were considered. Data on patient characteristics and surgical outcomes were abstracted. DATA SYNTHESIS: Sixteen studies evaluated laparoscopic cholecystectomy in the elderly. Compared with open cholecystectomy, elderly patients undergoing the laparoscopic procedure had a lower incidence of complications and a shorter hospitalization. In the 4 studies reporting the results of laparoscopic antireflux surgery in the elderly, the morbidity, mortality, and length of hospital stay were similar to those of younger patients. The elderly had equally good postoperative symptom relief. Ten reports of laparoscopic colon resection in the elderly demonstrated earlier return of bowel function, shorter hospitalization, and less cardiopulmonary morbidity. CONCLUSIONS: Despite underlying comorbidities, individuals older than 65 years tolerate laparoscopic procedures extremely well. Complications and hospitalization are lower than in open procedures. Surgeons need to inform primary care physicians of the excellent result of laparoscopic procedures in the elderly to encourage earlier referrals.

Aged↗

Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures.

BACKGROUND: Hip fracture patients have a high risk of thromboembolic complications following surgical management. OBJECTIVES: To examine the effects of heparin (unfractionated (U), and low molecular weight (LMW) heparins), and physical methods (compression stockings, calf or foot pumps) for prevention of deep venous thrombosis (DVT) and pulmonary embolism after surgery for hip fracture in the elderly. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, Embase, and reference lists of published papers and books. We contacted trialists and other workers in the field. Date of most recent search: September 1996. SELECTION CRITERIA: Randomised and quasi-randomised trials evaluating the use of heparins and physical agents for prevention of DVT and pulmonary embolism in patients undergoing surgery for hip fracture. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodological quality and extracted data. Trials were grouped into four categories (heparin versus control, mechanical versus control, LMW heparin versus U heparin, and miscellaneous) and results pooled where possible. MAIN RESULTS: The 26 included trials involved 2600 predominantly female and elderly patients. Overall, trial quality was disappointing. Ten trials involving 826 patients which compared U heparin with control, and four trials of 471 patients which compared LMW heparin with control, showed a reduction in the incidence of lower limb DVT (121/511 (24%) versus 203/519 (39%); Peto odds ratio 0.41; 95% confidence interval 0.31 to 0.55). There were insufficient data to confirm the efficacy of either agent in the prevention of pulmonary embolism. There was a non significant increase in overall mortality in the heparin group (46/420 (11%) versus 35/423 (8%); Peto odds ratio 1.39; 95% confidence interval 0. 86 to 2.23). Data were inadequate for all other outcomes including wound complications. There is insufficient evidence from five trials, involving 644 patients, to establish if LMW heparin was superior to U heparin. Most trials evaluating heparins had methodological defects. Four trials, involving 442 patients, testing mechanical pumping devices were also methodologically flawed, and so pooled results need to be viewed cautiously. Mechanical pumping devices may protect against DVT (12/202 (6%) versus 42/212 (19%); Peto odds ratio 0.24; 95% confidence interval 0.13 to 0.44). Although the limited data indicated a potential benefit, they were inadequate to establish any effect on the incidence of pulmonary embolism and overall mortality. Problems with skin abrasion and compliance were reported. REVIEWER'S CONCLUSIONS: U and LMW heparins protect against lower limb DVT. There is insufficient evidence to confirm either protection against pulmonary embolism or overall benefit, or to distinguish between various applications of heparin. Foot and calf pumping devices appear to prevent DVT, may protect against pulmonary embolism, and reduce mortality, but compliance remains a problem. Good quality trials of mechanical methods as well as direct comparisons with heparin should be considered.

Anticoagulants↗

Influence of sex hormones on the periodontium.

OBJECTIVES: Sex hormones have long been considered to play an influential role on periodontal tissues, bone turnover rate, wound healing and periodontal disease progression. The objectives of this review article are to (1) address the link between sex hormones and the periodontium, (2) analyse how these hormones influence the periodontium at different life times and (3) discuss the effects of hormone supplements/replacement on the periodontium. MATERIALS AND METHODS: Two autonomous searches were performed in English language utilizing Medline, Premedline and Pubmed as the online databases. Publications up to 2002 were selected and further reviewed. In addition, a manual search was also performed including specific related journals and books. RESULTS: It is certain that sexual hormones play a key role in periodontal disease progression and wound healing. More specifically, these effects seem to differentiate by gender as well as lifetime period. In addition, the influence of sex hormones can be minimized with good plaque control and with hormone replacement. CONCLUSION: Despite profound research linking periodontal condition with sex hormones kinetics, more definitive molecular mechanisms and therapy still remain to be determined.

Alveolar Bone Loss↗

Life albums in long-term care: resident, family, and staff perceptions.

A life album is a collection of selected memorabilia, photographs, and archival and other material that describes an individual's life in a photograph book format. During a summer research program, 13 long-term care residents created life albums that contained material from their past and current life. Some pages were left unfilled to allow material to be added in the future. These albums provided residents, families, and staff members with a means to recall life events. This article reports their perceptions of creating such albums.

Aged↗

Demography or respect?: work group demography versus organizational dynamics as determinants of meaning and satisfaction at work.

This article tests two competing models of meaning and satisfaction at work. First, meaning and satisfaction at work can be influenced by the demographic composition of work groups, especially their racial and gender compositions. Second, meaning and satisfaction can be influenced by management behaviour, especially by leadership in maintaining a productive environment and by respect for workers' rights. We evaluate these determinants, along with more traditional determinants that focus on socio-technical characteristics, using a unique data set derived from content analysing the reports provided by book-length organizational ethnographies (N = 108). Work group composition is found to have only a minor and selective influence on meaning at work. In contrast, management leadership and respect for workers' rights are found to have much stronger and more widespread effects. The well established role of socio-technical factors such as job autonomy as foundations for meaning and satisfaction in work is also replicated in the analysis. When contrasted with both work group demography and traditional job and organizational characteristics, a well run organization is found to be the single most important underpinning for a meaningful and satisfying work life. In the concluding section we develop the implication of these findings for organizational analysis.

Demography↗

Predictors of maternal HIV infection at the primary care level in inner city Ibadan.

National HIV prevalence rate is derived from the sentinel surveys, which are carried out once in two years and remain anonymized. Epidemiological data are largely unavailable on the pregnant HIV-positive mothers particularly at the grass root level. This information is urgently needed when developing a realistic intervention programme. Three hundred and forty-three consenting pregnant women attending a randomly selected primary health care clinic in inner city Ibadan from April to November 2001 were enrolled at booking and followed up till delivery of their babies. Sociodemographic and reproductive health data were collected by questionnaire and all mothers were screened for HIV/AIDS using an enzyme-linked immunosorbent assay based rapid test. Results showed that about one in three teenage mothers screened positive, having the highest HIV rate. HIV prevalence rate reduced, though not significantly, in mothers 20-29 years and those 30-39 years with mothers in these groups having similar rates. No mother over 39 years screened positive. Following logistic regression analysis, young age 15-19 years, was associated with a significantly increased risk for infection at the primary health care level (P =0.046). Christian religion was associated with a lower risk (P =0.038), and mothers who booked late in pregnancy (P =0.025) or had husbands in the lower socio-economic class (P =0.001) were less likely to be infected. None of the women were aware of their HIV status prior to the study. With a predominantly heterosexual mode of HIV transmission, it is necessary to identify infected pregnant women early through voluntary counselling and testing (VCT), so that they can be given the option to take preventive drugs, which would among other benefits reduce mother-to-child transmission, and help infected mothers stay healthy and productive for longer.

Adolescent↗

Prevention of intravascular catheter-related infections.

PURPOSE: To review the literature on prevention of intravascular catheter-related infections. DATA SOURCES: The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles. Primary authors were contacted directly if data were incomplete. STUDY SELECTION: Studies met the following criteria unless otherwise stated: Trials were prospective and randomized; catheters were inserted into new sites, not into old sites over guidewires; catheter cultures were done by using semi-quantitative or quantitative methods; and, for prospective studies, catheter-related bloodstream infection was confirmed by microbial growth from percutaneously drawn blood cultures that matched catheter cultures. DATA EXTRACTION: Data on population, methods, preventive strategy, and outcome (measured as catheter-related bloodstream infections) were gathered. The quality of the data was graded by using preestablished criteria. DATA SYNTHESIS: The recommended preventive strategies with the strongest supportive evidence are full barrier precautions during central venous catheter insertion; subcutaneous tunneling short-term catheters inserted in the internal jugular or femoral veins when catheters are not used for drawing blood; contamination shields for pulmonary artery catheters; povidone-iodine ointment applied to insertion sites of hemodialysis catheters; specialized nursing teams caring for patients with short-term peripheral venous catheters, especially at institutions with a high incidence of catheter-related infection; no routine replacement of central venous catheters; antiseptic chamberfilled hub or hub-protective antiseptic sponge for central venous catheters; and use of chlorhexidine-silver sulfadiazine-impregnated or minocycline-rifampin-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies that do not incorporate antimicrobial agents (for example, maximal barrier precautions). CONCLUSIONS: Simple interventions can reduce the risk for serious catheter-related infection. Adequately powered randomized trials are needed.

Anti-Infective Agents↗

MEDICAL LIBRARY SERVICE IN THE HOSPITAL.

Because of the extent of the medical literature and the wide-ranging interests of medical scientists, it is not feasible today for a hospital library to provide from its own shelves all of the books and journals that are requested by its doctor clientele. The suggested alternative is for the hospital library to select an appropriate medical research library to serve as its reservoir library and to develop a realistic plan for using its collections to supplement its own smaller, working collection. A realistic plan embodies a clear understanding with the reservoir library and a contractual relationship that provides payment for services received. An important part of the plan is a clearly stated policy defining the level and quality of service to be expected from the reservoir library. An essential ingredient is a feasible system for overcoming the inconveniences and delays which tend to be imposed by the distance between hospital library and reservoir; certain devices are suggested for overcoming the distance barrier.

Books↗

An introduction to selected elements of research.

The purpose of this paper, the first in a two-part series, is to provide an introduction to selected elements of research for the practising pharmacist. It is not intended to provide the reader with all the tools necessary to plan, conduct and report a research study. One paper cannot achieve this since entire books have been devoted to single components of research. Through the examination and discussion of the structure of a research report as presented in this paper, the reader should derive a basic understanding of selected aspects of research. A subsequent paper will present an approach to evaluating reports of research studies. The background provided by both papers should make it possible for pharmacists to review more objectively the increasing number of journal articles reporting research studies. Readers should also gain an appreciation of the complexity of the research process and the time required to prepare a paper acceptable for publication. They will not be in a position to evaluate all the details in the research report.

Authorship↗

Motherhood and schizophrenic illnesses: a review of the literature.

OBJECTIVE: To provide an overview of the current knowledge on the impact of motherhood on women with schizophrenia and schizoaffective disorder. METHOD: The published literature was selectively reviewed and assessed, based on a complete MEDLINE and PsychLIT (1971 to current) search, including English and non-English journals and books. RESULTS: Research to date into motherhood and schizophrenic illnesses has been limited by a number of methodological constraints, limiting the ability to draw conclusions and the prevention of relapses and mother-infant difficulties. These constraints have included: a paucity of prospective studies with initial, antenatal recruitment; variable definitions of the length of the puerperium; significant changes in psychiatric classification; the heterogeneity of postpartum psychotic disorders, with the majority being mood or schizoaffective disorder rather than schizophrenia; selection biases inherent in studying mother-baby unit inpatients; difficulties in life events research in general, such as its retrospective nature and confounding, illness factors; and the specificity versus non-specificity of childbirth as a unique or discrete life event. CONCLUSIONS: Further study is required to explore: the impact of child care, parenting and having a partner on the course of women with schizophrenic and schizoaffective disorders during the first postpartum year; whether women with postpartum relapses of these mental illnesses are likely to have slower recoveries than those women with the same diagnoses but without young children; and protective factors against postpartum relapse.

Depression, Postpartum↗

Vaccines for preventing infection with Pseudomonas aeruginosa in people with cystic fibrosis.

OBJECTIVES: To assess the effectiveness of vaccination against Pseudomonas aeruginosa in patients with cystic fibrosis. SEARCH STRATEGY: The Cochrane Cystic Fibrosis and Genetic Disorders Group specialist trials register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and handsearching abstract books of conference proceedings. Date of the most recent search of the Group's specialised register: November 1999. SELECTION CRITERIA: All randomised or pseudorandomised trials (published or unpublished) comparing Pseudomonas aeruginosa vaccines (oral, parenteral or intranasal) with control vaccines or no intervention in patients with cystic fibrosis. DATA COLLECTION AND ANALYSIS: We planned to assess the following outcomes: time to infection with Pseudomonas aeruginosa, pulmonary function, body mass index, Schwachman score, frequency of pulmonary infective exacerbations, days of antibiotic usage, days unable to carry out normal daily activities, adverse events, mortality, antibody levels to Pseudomonas aeruginosa and T cell proliferation and cytokine production in response to Pseudomonas aeruginosa. MAIN RESULTS: One trial which included 17 vaccinated patients, with follow up reported to 10 years met the inclusion criteria. Finding only a single trial, and the lack of information on our predefined outcomes limited analysis. REVIEWER'S CONCLUSIONS: There is a paucity of randomised controlled trials assessing the effectiveness of vaccination against Pseudomonas aeruginosa in cystic fibrosis. Increased understanding of modulation of the immune response by vaccination has led to the development of alternative vaccines. We suggest that there is an urgent need for newer vaccines to be evaluated in adequately-powered, multicentre randomised controlled trials examining clinically relevant end-points in addition to immunological variables. Such a trial should assess effectiveness over several years, and include follow-up of vaccinees who become colonised with Pseudomonas aeruginosa.

Bacterial Vaccines↗

Biphasic versus monophasic oral contraceptives for contraception.

BACKGROUND: Side effects caused by oral contraceptives discourage compliance with, and continuation of, oral contraceptives. Three approaches have been used to decrease these adverse effects: reduction of steroid dose, development of new steroids, and new formulas and schedules of administration. The third strategy led to the biphasic oral contraceptive pill. OBJECTIVES: To compare biphasic with monophasic oral contraceptives in terms of efficacy, cycle control, and discontinuation due to side effects. Our a priori hypotheses were: (a) biphasic oral contraceptives are less effective than monophasic oral contraceptives in preventing pregnancy; (b) biphasic oral contraceptives cause more side effects, give poorer cycle control, and have lower continuation rates. SEARCH STRATEGY: We searched the computerized databases MEDLINE, EMBASE, POPLINE, LILACS and CENTRAL. In addition, we searched the reference lists of all potentially relevant articles and book chapters. We also contacted the authors of relevant studies and pharmaceutical companies in Europe and the USA. SELECTION CRITERIA: We included randomized controlled trials comparing any biphasic with any monophasic oral contraceptive when used to prevent pregnancy. DATA COLLECTION AND ANALYSIS: We examined the studies found during the various literature searches for possible inclusion and assessed their methodology using Cochrane guidelines. We contacted the authors of all included studies and possibly randomized studies for supplemental information about methodology and outcome. We entered the data into RevMan, and calculated Peto odds ratios for the incidence of intermenstrual bleeding, absence of withdrawal bleeding, and study discontinuation due to intermenstrual bleeding. MAIN RESULTS: Only one trial of limited quality compared a biphasic and monophasic preparation. Percival-Smith 1990 examined 533 user cycles of a biphasic pill (500 microg norethindrone/35 microg ethinyl estradiol for 10 days, followed by 1000 microg norethindrone/35 microg ethinyl estradiol for 11 days; Ortho 10/11) and 481 user cycles of a monophasic contraceptive pill (1500 microg norethindrone acetate/30 microg ethinyl estradiol daily; Loestrin). The study found no significant differences in intermenstrual bleeding, amenorrhea and study discontinuation due to intermenstrual bleeding between the biphasic and monophasic oral contraceptive pills. AUTHORS' CONCLUSIONS: Conclusions are limited by the identification of only one trial, the methodological shortcomings of that trial, and the absence of data on accidental pregnancies. However, the trial found no important differences in bleeding patterns between the biphasic and monophasic preparations studied. Since no clear rationale exists for biphasic pills and since extensive evidence is available for monophasic pills, the latter are preferred.

Chemistry, Pharmaceutical↗