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PubMed1988

Giving life, giving death: ethical problems of high-technology medicine.

High-technology medicine, such as dialysis and transplantation is limited and nowhere can all potential beneficiaries receive it. Although very successful, high-technology medicine sometimes makes dying to a cruel spectacle and patients whose lives depend on a machine want to stop. The resulting ethical questions revolve around just distribution of life support - giving life, and withdrawal of life support in giving death. We investigated distributive justice of life-support by setting the number of patients accepted for dialysis in relation to those who died of renal failure and by setting the transplanted patients in relation to those waiting on chronic dialysis. In both Sweden and in the USA, and in both dialysis and transplantation, older patients received less treatment than younger ones. Seventy-year old people had less than 1/10 the chance of 20-40 year old of receiving dialysis and less than 1/30 chance of receiving a transplant. Women had between 70%-90% the chance of men of receiving dialysis and transplantation in both countries. Black people were more often dialyzed, but less often transplanted in the USA. Neither in Sweden, nor in the USA has distributive justice been achieved in dialysis and transplantation. Similar problems have been reported in other areas of high-technology medicine. We studied withdrawal, i.e. passive euthanasia, in chronic dialysis patients and found that 10% of all patients who begun dialysis died because it was stopped, although there was no medical or technical reason. Stopping caused 22% of all dialysis deaths. Half of those who died because dialysis was stopped, made the decision to stop treatment themselves. The other half was incompetent and families and physicians decided to discontinue treatment and let the patient die. The competent and incompetent patients were similar and the decisions seem to have been made on the same ground in both groups suggesting that families and physicians are appropriate surrogate decision-makers for incompetent patients. Home dialysis patients withdrew from dialysis, three times more often than center dialysis patients. The decision did not seem to harm the surviving relatives, but the relatives complained of poor physician communication. Old patients had shorter survival on dialysis, were more often excluded from, and stopped dialyses ten times more often than young patients. However, the ratio of mortality on dialysis compared to the mortality in the population at large was higher in young than in old patients and the self-reported quality of life of the old patients was particularly high.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1983

A double-blind controlled study comparing temazepam with papaveretum as premedication for fibreoptic bronchoscopy.

One hundred patients undergoing routine fibreoptic bronchoscopy were randomly allocated to receive premedication with either intramuscular papaveretum or oral temazepam in a double-blind manner. They all received atropine before and oxygen during the procedure. Patients found the drugs equally acceptable in terms of discomfort, anxiety and the possibility of repeat bronchoscopy, but more had recall of the procedure with papaveretum. There was no difference in secretions, coughing, relaxation and consciousness, as assessed by the bronchoscopist, but patients who had received papaveretum were more cooperative. Arterial blood gases were performed before and 45 minutes after bronchoscopy. Those given papaveretum had a significant fall in mean arterial oxygen tension of 0.96 kPa, while there was no significant change in the temazepam group. There was also a small mean rise in arterial carbon dioxide tension in both groups, with the mean rise in the papaveretum group (0.625 kPa) being significantly higher than the temazepam group (0.2 kPa). Premedication with temazepam is a useful alternative to papaveretum and has the advantage of oral administration and causing less respiratory depression.

Anti-Anxiety Agents↗
PubMed1997

Effect of medroxyprogesterone acetate on the quality of life of the oncologic patient: a multicentric cooperative study.

Anorexia and cachexia, major problems in patients with cancer, lead to decreased caloric intake and weight loss. Successful treatment of these conditions has a positive effect on patients' quality of life. Among the pharmacologic treatments, partial effects have been observed following administration of corticosteroids, anabolizing drugs and synthetic progestogens such as megestrol acetate and medroxyprogesterone acetate (MPA). The aim of the present study was to evaluate whether MPA is able to influence the quality of life of neoplastic patients undergoing different chemotherapeutic regimens and/or radiotherapy for different tumor types. A series of 279 cancer patients undergoing either chemotherapy and/or radiotherapy treatment for different tumor types was randomly allocated to receive either MPA or no treatment. We explored the effect of MPA oral suspension at the daily dose of 1000 mg for 12 weeks (group A) or no treatment (group B). Our data show an increase of body weight in group A patients and improvement in performance status. The outcome of the present study strongly demonstrates that therapy with MPA plays a fundamental role in ameliorating the complex symptomatology of cancer patients in intermediate or advanced stage of the disease undergoing casual treatment with chemotherapy and/or radiotherapy.

Adult↗
PubMed1996

[Problems raised by representation of activities in urology. Cooperative study by the urology services of the AP - HP (Public Services - Paris Hospitals)].

Paris public hospital urology departments conducted a study which had three objectives: - to test the indicators of activity to determine whether they were well adapted to measurement of the surgical activity performed, - to determine the contribution of the PMSI to the measurement of this activity, - to propose actions designed to improve the representation of the surgical activity actually performed by urology departments. The results of this study show that one half of the operations performed do not correspond to the field of PMSI (day-only admissions, outpatients department). The indicators currently used for budget allocation or interdepartment comparisons of activity are inadequate and, most importantly, induce deformities, variable from one department to another, which severely affect the image of the activity produced by these indicators. Two main reasons can explain these deformities: - the use of the NGAP and the score to measure activity: there is a marked variation of the score for the same operation, from one department to another. - the very poor census of activity performed in outpatient surgery. These two reasons are not related to the medical activity. Definition of a unique nomenclature for surgical procedures would constitute a great progress, provided that this nomenclature allows us to accurately describe our activity and can be modified according to our needs. Although the PMSI is a marked improvement of the information system, its application, in its current state, will not radically change the situation. The PMSI must be enlarged in one way or another, to outpatient activity including procedures performed in the outpatients department. For these measuring tools of activity, which determine the calculation of our budgets, to be adapted to our practice, we must be able to analyse their relevance and introduce changes. We need to develop this field of medico-economic research in urology.

Paris↗
PubMedDate not supplied

Prognostic factors from a randomized clinical trial in resected lung cancer.

Prognostic information has three main uses: prediction of the course of evolution of disease, decisions about treatment and limitation of complementary tests. Using data from a randomized controlled clinical trial of immunotherapy in resected lung cancer, we identified factors of prognostic importance. In particular we demonstrated that a time-consuming and expensive cell-mediated immunity test is not of prognostic value. Our cooperative group decided to cancel this test in the routine examination of patients with resected lung cancer. Disease stage was confirmed as the main prognostic factor.

Clinical Trials as Topic↗
PubMed2001

What is chronic fatigue syndrome? Heterogeneity within an international multicentre study.

OBJECTIVE: We sought to compare the characteristics of patients presenting with chronic fatigue (CF) and related syndromes in eight international centres and to subclassify these subjects based on symptom profiles. The validity of the subclasses was then tested against clinical data. METHOD: Subjects with a clinical diagnosis of CF completed a 119-item self-report questionnaire to provide clinical symptom data and other information such as illness course and functional impairment. Subclasses were generated using a principal components-like analysis followed by latent profile analysis (LPA). RESULTS: 744 subjects returned complete data sets (mean age 40.8 years, mean length of illness 7.9 years, female to male ratio 3:1). Overall, the subjects had a high rate of reporting typical CF symptoms (fatigue, neuropsychological dysfunction, sleep disturbance). Using LPA, two subclasses were generated. Class one (68% sample) was characterized by: younger age, lower female to male ratio; shorter episode duration; less premorbid, current and familial psychiatric morbidity; and, less functional disability. Class two subjects (32%) had features more consistent with a somatoform illness. There was substantial variation in subclass prevalences between the study centres (Class two range 6-48%). CONCLUSIONS: Criteria-based approaches to the diagnosis of CF and related syndromes do not select a homogeneous patient group. While substratification of patients is essential for further aetiological and treatment research, the basis for allocating such subcategories remains controversial.

Adult↗
PubMed1985

Lay obligations in professional relations.

Little has been written recently about the obligations of lay people in professional relationships. Yet the Code of Medical Ethics adopted by the American Medical Association in 1847 included an extensive statement on "Obligations of patients to their physicians'. After critically examining the philosophical foundations of this statement, I provide an alternative account of lay obligations in professional relationships. Based on a hypothetical social contract and included in a full specification of professional as well as lay obligations, this account requires lay people to honor commitments and disclose relevant information. Ethically, the account assumes that all parties in lay-professional relationships should be given equal consideration and respect in determining rights and obligations. Factually, it assumes that the treatment of many illnesses and injuries required collaboration and cooperation among lay persons and health professionals, that medical resources and personnel are limited, and that medicine, nursing, and related health professions, are, in MacIntyre's sense, practices.

American Medical Association↗
PubMed1992

Variance analysis refines overhead cost control.

Many healthcare organizations may not fully realize the benefits of standard cost accounting techniques because they fail to routinely report volume variances in their internal reports. If overhead allocation is routinely reported on internal reports, managers can determine whether billing remains current or lost charges occur. Healthcare organizations' use of standard costing techniques can lead to more realistic performance measurements and information system improvements that alert management to losses from unrecovered overhead in time for corrective action.

Accounting↗
PubMed2001

[Experimental research of protective and therapeutic effects of zinc and vitamin E on mouse liver radiational damage].

OBJECTIVE: To study the effects of zinc and vitamin E on lipid peroxide (LPO) contents and glutathione peroxidase (GSH-Px) activities in liver homogenates of radiational damage mice. METHODS: Two hundred and forty mice were divided randomly into five groups: normal control group (Group A), 60Co gamma-ray irradiator group (Group B), 60Co + zinc (Zn) group (Group C), 60Co + vitamin E(VE) group (Group D), and 60Co + Zn + VE group (Group E). After irradiated with 60Co gamma-ray 7.5 Gy, the mice were protectively treated with Zn and VE at different times. LPO contents and GSH-Px activities in liver homogenates of the mice were determined. RESULTS: The level of liver LPO was significantly higher (P < 0.01), but the level of liver GSH-Px was significantly lower (P < 0.01) in Group B than those in Group A; the content of liver GSH-Px was markedly higher in Group C and Group D than that in Group B (P < 0.01), while the content of liver LPO was markedly lower in Group D than that in Group B (P < 0.05); the concentration of liver GSH-Px was markedly higher in Group E than that in Group D (P < 0.01). CONCLUSIONS: VE may play an important role in lowering liver LPO contents and raising liver GSH-Px activities in radiational damage mice. vitamin E can cooperate with zinc in raising liver GSH-Px activities, stopping liver cells from lipids peroxidation and keeping integrity of liver cell membrane.

Animals↗
PubMedDate not supplied

Strategies for advancing evidence-based practice in clinical settings.

Evidence-based practice (EBP) is a problem-solving approach that incorporates the best available scientific evidence, clinicians' expertise, and patients' preferences and values. Melnyk and Fineout-Overholt have developed the ARCC (Advancing Research and Clinical practice through close Collaboration) model for the purpose of implementing EBP. A pilot study was conducted to test the ARCC model at two acute-care sites. This article shares information learned from the pilot study about what is necessary for successful implementation of EBP in the acute-care setting. These essentials include identifying EBP champions, redefining nurses' roles to include EBP activities, allocating time and money to the EBP process, and creating an organizational culture that fosters EBP. In addition, practical strategies for implementing EBP are presented to encourage implementation of EBP.

Academic Medical Centers↗
PubMed1992

Testing for HIV in the public and private sectors--Oregon, 1988-1991.

Counseling and testing persons for human immunodeficiency virus (HIV) infection is a key component of the public health strategy for reducing transmission of HIV in the United States (1,2). In 1991, the federal government allocated $100 million to state and local health agencies to provide counseling and testing programs in public clinics for at-risk persons, including persons who may not otherwise use public health services. However, the relative contribution of HIV-testing in public clinics to HIV testing in the private sector is unknown. To compare HIV testing in Oregon public clinics to overall HIV testing, the Health Division (HD) of the Oregon Department of Human Resources, in cooperation with CDC, reviewed data collected from September 1, 1988, through August 31, 1991, on public and private HIV testing in Oregon. This report summarizes findings for HIV testing rates and assesses the importance of publicly funded testing in identifying HIV-seropositive persons.

Adolescent↗
PubMed1989

Management consultant review of three departments of pharmacy to identify cost-reduction opportunities.

A review by a management consulting firm to identify cost-reduction opportunities at three hospital pharmacy departments is described. A multihospital corporation hired a management consulting firm to review the operating procedures of several departments, including pharmacy, and recommend measures for reducing costs. A team approach was adopted to enable the pharmacy department managers and the consultants to freely contribute their expertise; input was also solicited from staff members. A review of each pharmacy department's operating costs showed that drugs and i.v. supplies consumed 60-67% of the expenses, and salaries and wages 27-36%. Estimates of the full-time equivalents allocated to inpatient, clinical, support, and ambulatory and outside contract service activities were compared. The relative costs of personnel allocated to all inpatient drug distribution activities were also compared. Cost-reduction recommendations were divided into short- and long-term measures. Short-term measures involved decreasing drug expenditures, decreasing the number of personnel, and limiting decentralized services in one of the departments; savings of $500,000 were projected. Long-term recommendations involved increasing the use of technology, expanding the use of technicians, and consolidating the management staffs among the hospitals. Management consultants, in cooperation with pharmacy department managers and staff members, can identify cost-reduction opportunities without compromising patient care.

Centralized Hospital Services↗
PubMed1991

A novel human multi-locus DNA family detected by pJU78 (DF31).

pJU78 is a 2.9-kb cloned human DNA segment derived from Xq24-q26. When used as a hybridization probe, it detects some 25 related sequences dispersed over the genome, including several autosomes and the X and Y chromosomes. Several pJU78-related sequences were chromosomally allocated and five different restriction fragment length polymorphisms detected and partially characterized in population and family studies. This sequence family was not found in non-primate species. The sequence appears to lack CpG-island character and is not detectably expressed in a variety of human tissues.

Animals↗
PubMed1988

Priority allocation of cadaver kidneys to highly presensitized transplant recipients. Collaborative Transplant Study.

Within a prospective program of priority kidney allocation to highly presensitized recipients, 100 first and second cadaver transplants were performed from April 1985 to July 1987. The patient survival rate was 93% at 1 year. Graft survival at 1 year was 71% for first transplants and 68% for second transplants. There was a statistically significant correlation of graft outcome with matching for HLA-DR (P less than 0.02) and for HLA-B and -DR (P less than 0.02). The results demonstrate that multicenter cooperation is advantageous for the transplantation of highly presensitized recipients and that acceptable success rates can be obtained.

Antilymphocyte Serum↗
PubMed1993

Factors contributing to the formation of experimentally-induced ovarian cysts in prepubertal gilts.

Manipulation of an ovary during the follicular phase in cycling gilts or prepubertal gilts treated with PMSG and hCG results in formation of cysts on manipulated ovaries and corpora lutea (CL) of normal appearance on nonmanipulated ovaries. In contrast, cysts did not form after manipulation in luteal phase gilts. In the present experiment, daily administration of 50 mg progesterone to prepubertal gilts treated with PMSG and hCG established luteal phase concentrations of progesterone but did not lessen the incidence of manipulated-induced cysts. Number of cysts formed was associated with the number of follicles > or = 5 mm at manipulation, which was inversely related to serum concentrations of progesterone. Number of receptors for LH/hCG in follicular tissues did not differ between manipulated and nonmanipulated ovaries but was greater in granulosa (P < .05) and theca (P < .08) from follicles with diameters > or = 7 mm compared to 5 and 6 mm. Contents of estradiol, androstenedione, testosterone, progesterone and prostaglandins E2 and F2 alpha in follicular fluid, granulosa and theca were not different between follicles > or = 5 mm destined to form cysts. Profiles of progesterone and estradiol in peripheral serum and duration of luteal phase concentrations of progesterone were not different for gilts with induced cysts and gilts with CL. In conclusion, manipulation of follicles resulted in a failure to ovulate. Subsequent formation of cysts did not result from or result in a loss of steroidogenic function or the ability to bind LH to follicular receptors. These results demonstrate that the mechanism for ovulation is independent of other follicular processes, since ovulation can be disrupted without altering follicular steriodogenesis or subsequent luteinization.

Animals↗
PubMed1989

Efficacy of adjuvant chemotherapy in high-risk node-negative breast cancer. An intergroup study.

We randomly assigned 536 women who had undergone either a modified radical mastectomy or a total mastectomy with low axillary-node dissection for potentially curable breast carcinoma to receive adjuvant chemotherapy or no-treatment observation. The patients were considered at high risk for recurrence because they had either an estrogen-receptor-negative tumor of any size or an estrogen-receptor-positive tumor at least 3 cm in diameter with no histopathological evidence of axillary-node involvement. The chemotherapy consisted of six four-week cycles of cyclophosphamide (100 mg per square meter of body-surface area orally on days 1 through 14), methotrexate (40 mg per square meter intravenously on days 1 and 8), fluorouracil (600 mg per square meter intravenously on days 1 and 8), and prednisone (40 mg per square meter orally on days 1 through 14). Treatments were balanced with respect to patients' characteristics. The analysis included 406 eligible patients who were entered in the study before October 1, 1987. The overall disease-free survival among patients treated with the four-drug regimen was 84 percent, as compared with 69 percent for the control group, at a median follow-up of three years (P = 0.0001). A treatment benefit was also observed in premenopausal and postmenopausal patients as well as in patients with estrogen-receptor-positive or with estrogen-receptor-negative tumors. Severe or life-threatening hematologic toxicity was encountered in 33 percent of the treated patients, with one death. Our results indicate that adjuvant chemotherapy with six cycles of cyclophosphamide, methotrexate, fluorouracil, and prednisone is effective in improving three-year disease-free survival among high-risk patients with axillary-node-negative, operable breast cancer. An analysis of the effect of treatment on survival awaits a longer follow-up.

Adult↗
PubMed1989

Recruiting family physicians as participants in research.

Obtaining the voluntary participation of family physicians in quality of care research is a major problem in family practice research. An innovative approach was therefore required to recruit 120 randomly selected family physicians in southern Ontario in a quality of care study by the College of Family Physicians of Canada. A network of physician recruiters oriented to the study was organized for each district. This recruitment method resulted in an 84.5% participation rate. The relationship of these physician recruiters to the candidate and the method of approach were important factors in the enrolment process: the highest participation rate (95%) was obtained when the recruiters were friends of the candidate and when a personal meeting was arranged (91%). Recruiters were given an information package to help them in the recruitment process and rated the most useful items as follows: a policy statement about confidentiality, a description of the study and reprints of a published feasibility study. These results illustrate that cooperation in research in family physicians' offices can become a reality.

Confidentiality↗