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PubMed2006

Escaping the tyranny of the embryo? A new approach to ART regulation based on UK and Australian experiences.

The early legislative responses to fertilization of human oocytes in vitro exaggerated the protection of the embryo at the expense of the interests of other parties. Although more recent legislative changes have lessened this embryonic grip, it nonetheless still distorts legal thinking and is fundamentally in conflict with biological understanding. Drawing largely on experiences in the UK and Australia, a proposal is explored that reframes the legislative approach to the regulation of assisted reproductive technology (ART) with the following objectives: (i) to align more closely the legal and biological understandings of the earliest stages of human development; (ii) to place the legislative focus on objective, intent and outcome; and in the process (iii) to disentangle legally and conceptually the status of the embryo from that of the potential child. Experiences in the UK and Australia are drawn on, because these two jurisdictions have a common legal heritage and were among the earliest players both scientifically and legally but have pursued very different legal routes to their current legislative practices.

Australia↗

PubMed2006

ART outcome in HIV-infected patients.

BACKGROUND: To assess assisted reproductive technique (ART) outcome in couples affected by human immunodeficiency virus (HIV). METHODS: Intrauterine insemination (IUI), IVF and ICSI were performed in 85 couples affected by HIV between January 2000 and June 2005. RESULTS: In 33 of the 85 couples, women were HIV positive-the clinical pregnancy rate (CPR) and cancellation rate (CR) after 34 IUI cycles were, respectively, 25 and 18%. The CPR after 26 IVF and 30 ICSI cycles were, respectively, 37.5 and 18.8% with CRs of 38.5 and 46.7%, respectively. In 38 couples, men were infected-the CPR and CR after 85 IUI cycles were, respectively, 14.7 and 20%; 62 ICSI cycles were performed leading to CPR of 23.4% with a CR of 25%. In 14 couples, the two partners were infected: none of the four IUI cycles carried out was successful (CR, 20%); the CPR and CR after 35 ICSI cycles were, respectively, 12.5% with 31%. All children born had a negative HIV test. CONCLUSION: In couples affected by HIV, an acceptable pregnancy rate was obtained. The worst results were obtained when both partners were infected. The CR was elevated among HIV-infected couples.

Adult↗

PubMed2006

Safety of sperm washing and ART outcome in 741 HIV-1-serodiscordant couples.

BACKGROUND: To evaluate the safety of sperm washing and assisted reproduction technique (ART) outcome offered to serodiscordant couples with a human immunodeficiency virus-1 (HIV-1)-positive male. METHODS: Sperm washing was performed and checked by RT-PCR on each semen sample before its fresh usage. Intrauterine insemination (IUI) or IFV/ICSI was offered according to fertility profile of each couple. Non-infected women underwent HIV testing 2 weeks before each procedure and for up to 6 months after. RESULTS: Seven hundred and forty-one couples entered the study of a possible 2011 serodiscordant couples counselled over 4 years. Superovulation and IUI were performed in 581 couples, where the pregnancy rate per cycle and pregnancy rate per couple were 19 and 78%, respectively, with multiple pregnancy rate being 4%. One hundred and sixty couples were treated by IVF/ICSI, where pregnancy rate per cycle and per couple were 22 and 41%, respectively, with multiple pregnancy rate being 10%. All female partners were still HIV-1 negative at follow-up. CONCLUSION: Sperm washing within a programme of reproductive counselling was proved to be safe in this large series of serodiscordant couples. The overall pregnancy rate (70.3%), independent of the procedure used (IUI or IVF/ICSI), justifies the effort of the medical team in setting up and implementing dedicated centres and of the individual patient in seeking a safe pregnancy.

Acquired Immunodeficiency Syndrome↗

PubMed2003

Developing evidence-based clinical indicators: a state of the art methods primer.

OBJECTIVE: To describe steps in developing and testing clinical indicators based on state of the art methods in previous literature and experience in the Danish National Indicator Project. ANALYSIS: The development process includes a planning phase, where the clinical area to be evaluated is chosen and the measurement team selected and organized. The planning phase is followed by a development phase where clinical indicators are prioritized and selected by the measurement team on the basis of documentation and knowledge from the scientific literature. When clinical indicators have been selected, specific measure specifications should be designed, including inclusion and exclusion criteria for the target population, description of a risk adjustment strategy, identification of data sources, description of data collection procedures, and an analytical plan for data analyses. Before clinical indicators are implemented they should be tested for reliability and validity. Preliminary tests may identify areas requiring further modifications and specifications of the indicators. CONCLUSION: Using clinical indicators for quality assessment represents an important approach to documenting the quality of care. Consumers of indicator information (clinicians, administrators, purchasers, regulators, and patients) need reliable and valid information for benchmarking, making judgments, and determining priorities, accountability and quality improvement. This underlines the fact that clinical indicators must be developed and tested with scientific rigor in a transparent process.

Benchmarking↗

PubMed2002

Low voltage FE-STEM for characterization of state-of-the-art silicon SRAM.

Low voltage (30 kV) field emission scanning transmission electron microscopy (FE-STEM) has been employed in the characterization of state-of-the-art semiconductor static random access memory (SRAM) using specimens prepared at several different thicknesses (70-180 nm). A focused ion beam (FIB) system, a FIB-SEM compatible specimen holder and an in-lens FE-SEM have been employed for alternating between FIB milling and SEM/ STEM imaging. As a result, ion implanted atom damage during manufacturing, grains in aluminium interconnects, poly silicon gates, thin metal barriers and a thin gate oxide layer were observed by low voltage FE-STEM. STEM, in-lens FESEM, FIB

Letter↗

PubMed1998

Cohort study of art glass workers in Tuscany, Italy: mortality from non-malignant diseases.

This investigation studies cause-specific mortality of art glass workers employed in 17 industrial facilities in Tuscany, Italy. A cohort of 3,390 workers employed for at least 1 year was enumerated from company payrolls. Follow-up was between the start of employment in each factory and 31 December 1993. The cause-specific expected mortality was computed relative to Tuscany rates and specified for gender, 5-year age groups and calendar year. Separate analyses were carried out for the jobs of makers and formers and for batch mixers. Among males (3, 180 individuals) observed mortality for non-cancer causes was higher than expected for hypertensive disease [standardized mortality ratio (SMR) = 178, 90% confidence interval (90% CI) = 96-301], pneumoconiosis (SMR = 200, 90% CI = 94-376) and diseases of the genitourinary system (SMR = 169, 90% CI = 95-279). Increases for the above causes were shown also among makers and formers: hypertensive disease (SMR = 182, 90% CI = 85-341), pneumoconiosis (SMR = 250, 90% CI = 109-493) and diseases of the genitourinary system (SMR = 224, 90% CI = 121-380). For batch mixers an increase was present for cerebrovascular disease. The observed mortality for cancer causes was above the expected for cancers of the larynx, lung, stomach and brain. This study points to the existence for Tuscan glass workers of health effects in addition to cancer; previously observed carcinogenic effects were also confirmed.

Adult↗

PubMed1990

Breathing exercises for the medical patient: the art and the science.

The art of breathing exercises can be traced to the late 1800s. In the past 10 years, the increased demand for treatment for respiratory muscle failure of dysfunction has resulted in numerous studies evaluating methods of treatment or training. This article provides an overview of research and practice, focused on treating the medical patient experiencing dyspnea or loss of respiratory muscle strength and endurance.

Breathing Exercises↗

PubMed2000

Process-based models for forest ecosystem management: current state of the art and challenges for practical implementation.

Recent progress toward the application of process-based models in forestmanagement includes the development of evaluation and parameter estimation methods suitable for models with causal structure, and the accumulation of data that can be used in model evaluation. The current state of the art of process modeling is discussed in the context of forest ecosystem management. We argue that the carbon balance approach is readily applicable for projecting forest yield and productivity, and review several carbon balance models for estimating stand productivity and individual tree growth and competition. We propose that to develop operational models, it is necessary to accept that all models may have both empirical and causal components at the system level. We present examples of hybrid carbon balance models and consider issues that currently require incorporation of empirical information at the system level. We review model calibration and validation methods that take account of the hybrid character of models. The operational implementation of process-based models to practical forest management is discussed. Methods of decision-making in forest management are gradually moving toward a more general, analytical approach, and it seems likely that models that include some process-oriented components will soon be used in forestry enterprises. This development is likely to run parallel with the further development of ecophysiologically based models.

Journal Article↗

PubMed1993

The arts of war and medicine: a study in symbiosis.

Practitioners of warfare and medicine have both considered their respective disciplines part art and part science. Each has seen dramatic advances over the past several centuries, and the histories of progress in warfare and medical practice are inextricably intertwined. For example, the congregation of large armies inspired the development of epidemiologic analysis and preventive medicine, which forestalled the disastrous loss of life that typified all wars through the U.S. Civil War. Warfare also helped to clarify the critical distinction between medicine and health in several ways. Battles generate tremendous demands on the trauma surgeon, which triggers advances in understanding of trauma, surgery, fluid and electrolyte management, first aid, and triage. Similarly, the health of soldiers before and after combat is a result of public health measures that physicians have been ill-suited to manage. The dramatic severity of epidemics in armies progressively forced health professionals and politicians to seek solutions to illnesses that had plagued the general population to lesser degrees for millennia. The exigencies of war inspired creation of the nursing profession, with the burden and opportunity falling on women. Women were not allowed to hold positions of responsibility in caring for the sick until the enormity of the Civil War prevented men from occupying all such positions. Because each generation tends to view itself as "modern," its inherent weaknesses often go uncorrected and even unobserved. The interconnected histories of war and medicine provide a warning to remain open to discovering those practices that need radical reform to prevent the current generation of physicians from appearing utterly ridiculous to physicians 100 years hence. This treatise focuses, therefore, on the symbiotic advances in warfare on health before this century because death in war due to trauma was statistically far less important than death due to disease.

Dysentery↗

PubMed2000

Hazards of piercing and facial body art: a report of three patients and literature review.

Piercing has become a widespread fashion trend in Western industrialized nations within recent years. The invasive application of ornaments through cutaneous and mucosal surfaces enables the penetration of various pathogens into subcutaneous tissue. The authors describe the hazards of piercing and facial body art as they apply to 3 patients. Perichondrial auricular abscess, granulomatous perichondritis of the nasal ala, and embedding of a stud in the lower lip were the respective diagnoses. Literature was reviewed for the cultural origins and current practices of piercing, the legal background of piercing as a business, typical medical complications, and treatment recommendations. Numerous communications have been published on medical complications of piercing. The patients presented and the review of the literature illustrate that piercing is not a harmless fashion and that regulations of piercing as a business seem desirable to prevent further complications.

Adolescent↗

PubMed1994

Video-assisted thoracic surgery. Current state of the art.

OBJECTIVE: The author reviews the current state of the art of video-assisted thoracic surgery in the context of modern thoracic surgical practice. SUMMARY BACKGROUND DATA: Thoracoscopy has been a part of thoracic surgical practice for many years, but was used mainly for diagnosis of pleural disease. The development of laparoscopic cholecystectomy awakened a new interest in this technique and led to the development of many new therapeutic and diagnostic applications of video-assisted thoracic surgery. METHODS: Current literature and the author's personal experience with more than 500 cases are reviewed. RESULTS: Video-assisted techniques have proven useful for the performance of a broad spectrum of thoracic surgical procedures. Patients may experience less pain and have a shorter hospital stay after a video-assisted procedure. Definitive proof of less morbidity when compared with the analagous open procedure remains to be determined. Patient acceptance has been high, and most thoracic surgeons use these techniques in their practice. CONCLUSIONS: Video-assisted thoracic surgical procedures have made a significant impact on the practice of thoracic surgery. Advantages and disadvantages of specific procedures remain to be definitively determined. Surgeons have learned these techniques and have kept morbidity to acceptance levels during the learning phase. Where these techniques ultimately fit into the overall practice remains to be determined as more experience is gained.

Humans↗

PubMed2002

Umbilical cord blood transplantation: current state of the art.

Human leukocyte antigen-matched sibling donor umbilical cord blood transplantation, or 0-2 human leukocyte antigen mismatched unrelated donor umbilical cord blood, is now considered an acceptable alternative to the use of bone marrow as a source for hematopoietic stem cells for pediatric hematopoietic stem cell transplantation, and is being investigated in adults. Major advantages of umbilical cord blood include the speed of availability compared with unrelated donor bone marrow, and tolerance of 1-2 human leukocyte antigen mismatch, which offers the opportunity to extend the donor pool. Umbilical cord blood transplantation is associated with durable engraftment and low incidence of severe graft-versus-host disease, even in the 1-2 human leukocyte antigen mismatched setting. Clinical experience has established the importance of graft cell dose in determining engraftment and survival in unrelated donor umbilical cord blood transplantation. More recently, the influence of human leukocyte antigen on outcome has become apparent. This review outlines the state of the art of umbilical cord blood transplantation, with emphasis on practical considerations in umbilical cord blood selection, and describes current research directions for this hematopoietic stem cell source.

Bone Marrow Transplantation↗

PubMed1976

A report on graduates of the Boston University six-year combined liberal-arts--medical program.

Graduates of a six-year combined Liberal-Arts-Medicine Program and their medical school classmates (traditional "eight-year" students) are compared as to their medical school performance and their professional postgraduate activities. On standardized examinations (Medical College Admission Test and examinations of the National Board of Medical Examiners) the six-year group was somewhat better than the eight-year group. In other aspects, such as class ranking, honors at graduation, and medicine clerkship grades, the six- and eight-year groups were similar. The two groups were remarkably similar in their postgraduate professional career choices and in achieving board certification. The data for the first three classes indicate that qualified high school students can succeed academically in an accelerated collegiate-degree program, do well in medical school, achieve postgraduate certification, and begin the practice of medicine at a younger age.

Achievement↗

PubMed1981

Health and society education in a liberal arts college: a curricular strategy.

This paper examines the curricular response of colleges and universities to conflict among scientific and medical experts regarding the application of professional knowledge and technical expertise to public policy and patient care. Two types of interdisciplinary science programs now exist on many campuses: those that attempt to increase the "scientific literacy" of humanities and social science students and those that try to enrich the "social consciousness" of physical and life science students. An alternative philosophy of education is proposed that is based on three objectives: to introduce the logical processes for establishing causes in the health sciences; to identify limits of scientific and technical knowledge in health-related areas; and to develop familiarity with problems of decision-making under conditions of scientific or clinical uncertainty. Illustrative cases in clinical medicine and public health suggest how to apply this educational philosophy. The paper concludes by observing that premedical education reform is impossible without redefining the "liberal arts" tradition of undergraduate education.

Curriculum↗

PubMed1985

Course work and grades of premedical students at two liberal arts colleges.

Choices of courses and academic performances of premedical students were investigated at two liberal arts colleges. Four hypotheses tested related to the areas of science concentration in the students' overall academic programs, breadth of the programs, depth of study in subjects outside science, and the grades achieved in all areas. Altogether, 345 students from the classes of 1982 and 1983 were studied. Premedical students were compared with nonpremedical students studying biology and chemistry and with all other students. Premedical students and other students majoring in biology, chemistry, or other health-related subjects had similar distributions of course credits by academic division and studied a greater breadth of subject matter than did other students. In contrast, the other students tended to study one subject outside their major in greater depth than the premedical students and other students majoring in biology and chemistry, and these subjects were usually in an academic division that did not include their major departments. The students from the two colleges who were admitted to medical schools achieved higher grades than either rejected applicants or nonapplicants from the colleges.

Education, Premedical↗

PubMed1999

The liberal arts physician.

The United States is in the midst of the second revolution in American health care to occur during this century, as Kenneth Ludmerer makes clear in his book Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. The "Flexnerian revolution" eventually led to the closing of a third of the medical schools. Although such closures are not likely this time, familiar arrangements are collapsing, without a clear picture of the shape of things to come. Whatever the outcome of the current revolution, well-trained physicians will be needed to care for the sick. Academic medical centers truly are at risk and increasingly require public support to flourish or even to survive, but medical schools and their teaching hospitals must demonstrate that they deserve this support. These institutions have responded by focusing on the business aspects of medicine, perhaps to the detriment of medical education. Lost in this focus is teaching time, and perhaps even more important, the time for mentoring. Often lacking too is a clear vision of the preparation needed by the student to practice medicine successfully in the future: different specialty mixes, interdisciplinary group practice; vastly increased use of information technologies, and overwhelming amounts of relevant and interrelated information. Yet the answer is the same as it was 75 years ago when Yale introduced the first radical medical curricular reform--the "liberal arts physician," trained in science, the values of medicine, and particularly for uncertainly and with the capacity to adapt.

Academic Medical Centers↗

PubMed1999

The plight of premedical education: myths and misperceptions--Part II: science "versus" the liberal arts.

For decades it has been known that students who major in non-science fields perform as well as science majors who go to medical school. Yet the overwhelming majority of future medical students still major in biology or chemistry, and organic chemistry has come to be the defining premedical science course. This article traces the history of the liberal arts tradition, discusses its importance for medicine, and urges that readers think about the medical college in the age of the university. The author believes that the medical faculties should take a lead in helping to reshape the premedical as well as the medical education of future doctors.

Curriculum↗

PubMed1992

The art of the consultation note.

Inherent in the consultation process is the ability to communicate effectively, yet little emphasis is placed on written communication through consultation notes. The art of writing a consultation note is learned primarily through trial and error or by master/apprentice relationships with senior practitioners. This paper reviews the types of consultations in which advanced practitioners are involved and presents a format for preparing a comprehensive consultation note.

Consultants↗