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PubMed1988

Virtue and the practice of modern medicine.

Robert Veatch has claimed that virtue theory is not only irrelevant but potentially dangerous in medical ethics. I argue that virtue is a far more prominent factor in contemporary medical practice than Veatch admits. Even if 'stranger medicine' is taken as the norm, proper conduct on the part of physicians depends on certain character traits in order to be maintained consistently over a long period of time and in situations which run counter to the physician's own interests. Right conduct, which Veatch argues is the central moral issue in the physician-patient relationship, is intertwined with certain virtues. Moreover, the virtue of integrity and the concept of a unified life-narrative are especially useful in analyzing an important factor missing in modern medicine. And since medicine relies necessarily on some concept of human flourishing I argue that virtue theory can play a central role in helping to determine the goals of medical practice.

Beneficence↗
PubMed1983

The traditionalist Jewish physician and modern biomedical ethical problems.

Recent advances in biomedical technology and therapeutic procedures have generated a moral crisis in modern medicine. The vast strides made in medical science and technology have created options which only a few decades earlier would have been relegated to the realm of science fiction. Man, to a significant degree, now has the ability to exercise control not only over the ravages of disease but even over the very processes of life and death. With the unfolding of new discoveries and techniques, the scientific and intellectual communities have developed a keen awareness of the ethical issues which arise out of man's enhanced ability to control his destiny. In response to the concern for questions of this nature, there has emerged the rapidly developing field of bioethics. Jews, to whom all such questions are quests not only for applicable humanitarian principles but for Divine guidance, must, of necessity, seek answers in the teaching of the Torah. "The Torah of God is perfect" (Psalms 19: 8), and in its teachings the discerning student will find eternally-valid answers to even newly-formulated queries. As physicians and patients turn to Rabbinic authorities for answers, Jewish scholars seek to elucidate and expound the teachings of the Torah in these vital areas of concern. The present essay highlights some of the ethical issues faced by the Jewish physician who faithfully observes his tradition in all matters including his daily practice of medicine. Although more questions are raised than answered, the aim of this essay will have been achieved if the reader is stimulated to pursue these issues in the extending writings on the subject now available in English.

Bioethical Issues↗
PubMed1995

Modern applications for an ancient bean: soybeans and the prevention and treatment of chronic disease.

Soybeans have played an integral part in Asian culture, both as a food and as a medicine, for many centuries. In the West, soybeans are best known for their protein content but increasingly, soyfoods are being recognized as having potential roles in the prevention and treatment of chronic diseases, most notably cancer and heart disease. There are also potential roles for soyfoods with respect to osteoporosis and kidney disease. Although more research is needed, the existing database on the health effects of soyfood intake is quite extensive and clearly warrants greater recognition by the research and clinical communities. Given the ease with which soyfoods can be incorporated into the diet, be it via the traditional soyfoods such as tofu and soymilk, or the more modern soy protein products, such as soy isolates, concentrates and flours, soyfoods may be able to have a significant beneficial impact on public health.

Chronic Disease↗
PubMed1997

Outcomes of modern screening mammography.

The University of California, San Francisco, Mobile Mammography Screening Program is a low-cost, community-based breast cancer screening program that offers mammography to women of diverse ethnic backgrounds (36% nonwhite) in six counties in northern California. Analysis of data collected on approximately 34,000 screening examinations from this program shows that the positive predictive value and sensitivity of modern screening mammography to be lower for women aged 40 to 49 years compared to women aged 50 and older. This lower performance is due to the lower prevalence of invasive breast cancer in younger women and possibly to age differences in breast tumor biology. Because of this lower performance, women in their forties may be subjected to more of the negative consequences of screening, which include additional diagnostic evaluations and the associated morbidity and anxiety, the potential for detecting and surgically treating clinically insignificant breast lesions, and the false reassurance resulting from normal mammographic results. Since the evidence is not compelling that the benefits of mammography screening outweigh the known risks for women aged 40 to 49 years, women considering mammography screening should be informed of the risks, potential benefits, and limitations of screening mammography, so that they can make individualized decisions based on their personal risk status and utility for the associated risks and potential benefits of screening.

Adult↗
PubMed2002

The Big Eye in the 21st century: the role of electron microscopy in modern diagnostic neuropathology.

Electron microscopy (EM) remains a powerful and even essential tool in modern diagnostic neuropathology. tumors are still encountered that defy histological or immunohistochemical classification, and EM can often provide answers in these cases. Tumors of the CNS for which EM is useful include unusual or atypical variants of meningioma, ependymoma, and schwannoma; oligodendroglioma-like tumors composed of small "clear" cells; and small "blue cell" tumors of childhood. EM is of great value in identifying site of origin for metastatic adenocarcinomas of unknown origin-an under-recognized and under-utilized potential for this technique. EM is useful in the diagnosis of peripheral nerve sheath tumors and gastrointestinal autonomic nerve tumors. EM is also important in the evaluation of certain congenital, inherited and metabolic diseases-including ceroid lipofuscinoses, CADASIL syndrome, certain myopathies, and mitochondrial encephalomyopathies--and of certain toxic and drug-induced peripheral neuropathies. An important application of EM is its utility in initiating a workup of an atypical tumor or metabolic condition, for which clinical and histological clues point in no obvious direction. In these situations, EM may provide either an answer outright (including answers to questions not asked) or important clues that guide further workup and narrow the range of diagnostic possibilities.

Central Nervous System Diseases↗
PubMed1996

Application of modern molecular techniques to evaluate sperm sex selection methods.

The aim of this paper is to review modern approaches which have been used to evaluate sex pre-selection procedures. Two approaches can be used, polymerase chain reaction (PCR) and fluorescence in-situ hybridization (FISH). FISH is currently the method of choice for evaluating sex selection procedures because: (i) FISH accurately identifies the sex chromosome of individual spermatozoa using specific probes for the X and Y chromosomes and a two-colour detection system; and (ii) large numbers of spermatozoa can be screened in a short period of time. Of the published sex pre-selection methods tested using FISH, only flow cytometry has been shown to produce a clinically significant enrichment of X- and/or Y-bearing human spermatozoa. Studies have shown that 12-step Percoll gradients produce a slight but clinically insignificant enrichment of X-bearing spermatozoa, swim-up techniques do not appear to enrich either X- or Y-bearing spermatozoa, and discontinuous albumin gradients do not enrich Y-bearing spermatozoa. Despite this evidence, some of these methods continue to be used clinically, so it is vital that sex selection methods are properly evaluated using reliable methods such as double-label FISH before they are introduced for clinical use.

Albumins↗
PubMed2006

Retrospective analysis of surgical complications following cadaveric kidney transplantation in the modern transplant era.

BACKGROUND: Risk factors for surgical complications (SCs) following kidney transplantation in the modern transplant era need to be identified to perform appropriate prophylactic interventions. METHODS: Records from 870 consecutive adult cadaveric kidney transplants done at a single centre were reviewed. SCs were classified into four groups: (i) vascular (12%, thrombosis or stenosis); (ii) haemorrhagic (12%); (iii) ureteral (7.5%, leaks and stenosis) and (iv) wound (16%, lymphocoeles or dehiscences). RESULTS: One or more SCs occurred in 299 (34%) patients, with multiple SCs in 65 (7.4%). By logistic regression analysis, recipient vessel atherosclerosis and delayed graft function (DGF) were significantly associated with both thrombotic complications [odds ratio (OR) 4, 95% confidence interval (CI), 1.4-11, P = 0.010 and OR 3.8, 1.3-12, P < 0.00001, respectively] and graft artery stenosis (OR 2.9, 1.2-6.8, P = 0.015 and OR 5.6, 2.3-13.4, P < 0.0001, respectively). Acute rejection increased the risk of graft artery or ureteral stenosis by 2.5 (CI 1.02-6.4, P = 0.045) and 3.3 (CI 1.1-10, P = 0.034), respectively. Older recipients were related to urinary leak (OR 1.04, CI 1.01-1.07, P = 0.011). Difficult bench surgery, DGF and the use of antiplatelet drugs increased the risk of bleeding by 3.6 (CI 1.9-6.4, P < 0.0001), 2.7 (CI 1.5-4.7, P < 0.0001) and 1.8 (CI 1.03-3.29, P = 0.038), respectively. Each month on dialysis increased the risk by 1.02 (CI 1.01-1.03, P = 0.002). Sirolimus increased the risk for wound SCs by 4.1 (CI 2.1-8.3, P < 0.0001) and obesity, retransplant and acute rejection were additional risk factors. CONCLUSIONS: Adult renal transplant recipients at risk for SCs can be identified by age, DGF, graft vessel and recipient atheromatosis, difficult bench surgery, obesity, rejection and the use of antiplatelet drugs and rapamycin.

Adolescent↗
PubMed1991

Modern management of ovarian hyperstimulation syndrome.

The number of women receiving ovulation induction has markedly increased with the advent of medically assisted reproduction. Consequently, ovarian hyperstimulation syndrome (OHSS) has become a frequent clinical problem. It is a potentially life-threatening situation. In its severe forms it is complicated by haemoconcentration, hypovolaemia, hypotension, acute renal insufficiency and thromboembolism. The pathophysiology of OHSS is poorly understood. The occurrence of OHSS correlates well with the level of oestradiol, the number of follicles, and administration of human chorionic gonadotrophin (HCG). The risk is increased in polycystic ovarian disease. The aim of this paper is to review critically the published literature on prediction, prevention and modern management of OHSS. Complete prevention of OHSS is not possible although several methods are used to predict and reduce its occurrence. Endocrine profile and ultrasonic follicular monitoring are the mainstays of prediction. The presence of a large number of small and intermediate size follicles at sonography is a risk factor. Withholding HCG, continuation of gonadotrophin-releasing hormone analogues and cryopreservation of embryos are optional courses of action for prevention. Mild OHSS is usually self-limiting and requires no active therapy. Moderate and severe cases are treated by correction of fluid and electrolyte imbalance, and by prevention of thromboembolism. The use of surgery is limited to cases of torsion or rupture of ovarian cysts, or the presence of concomitant ectopic pregnancy. Aspiration of the ascitic fluid, preferably by the transvaginal route, is recommended in cases with severe ascites.

Ascitic Fluid↗
PubMed1993

Mitochondrial COII sequences and modern human origins.

The aim of this study is to measure human mitochondrial sequence variability in the relatively slowly evolving mitochondrial gene cytochrome oxidase subunit II (COII) and to estimate when the human common ancestral mitochondrial type existed. New COII gene sequences were determined for five humans (Homo sapiens), including some of the most mitochondrially divergent humans known; for two pygmy chimpanzees (Pan paniscus); and for a common chimpanzee (P. troglodytes). COII sequences were analyzed with those from another relatively slowly evolving mitochondrial region (ND4-5). From class 1 (third codon position) sequence data, a relative divergence date for the human mitochondrial ancestor is estimated as 1/27 th of the human-chimpanzee divergence time. If it is assumed that humans and chimpanzees diverged 6 Mya, this places a human mitochondrial ancestor at 222,000 years, significantly different from 1 Myr (the presumed time of an H. erectus emergence from Africa). The mean coalescent time estimated from all 1,580 sites of combined mitochondrial data, when a 6-Mya human-chimpanzee divergence is assumed, is 298,000 years, with 95% confidence interval of 129,000-536,000 years. Neither estimate is compatible with a 1-Myr-old human mitochondrial ancestor. The mitochondrial DNA sequence data from COII and ND4-5 regions therefore do not support this multiregional hypothesis for the emergence of modern humans.

Animals↗
PubMed2001

Personal dose monitoring of employees at the institute of modern physics, China.

The radiation field at the accelerator facility consists of radiation produced immediately and of secondary radiation induced by activation etc. As the accelerator building and the experimental hall are closed and inaccessible during accelerator operation, the exposure received by the employees at the IMP (Institute of Modern Physics) comes almost totally from the induced radiation. The methods and the results of personal dose monitoring from 1986 to 1999 at the IMP are presented. During the period, the total number of monitored individuals was 1960, and the average annual effective dose was 0.10 mSv. The number recording less than 0.1 mSv of effective dose was 1471 individuals. amounting to 77% of the total. Only six individuals had received effective doses between 5.0 mSv and 10 mSv. The maximum effective dose of 10 mSv was received by workers repairing the accelerator.

Calibration↗
PubMed2004

Atmospheric ammonia is detrimental to the performance of modern commercial broilers.

Atmospheric ammonia inhibits broiler performance. Quantified effects are based on older genetic stock with a BW of 2000 g at 7 wk. In contrast, modern genetic stock reaches 3200 g at 7 wk of age. To assess the impact on present day broilers, 2 trials were conducted exposing male broilers to graded levels (0, 25, 50, and 75 ppm) of aerial ammonia from 0 to 4 wk of age. Sixty, 1-d-old chicks were placed in environmentally controlled chambers, weighed weekly as a group, and processed with yield determined at 7 wk of age. Final BW was significantly depressed by 6 and 9% for the 50 and 75 ppm concentrations of ammonia as compared with 0 ppm. Also, mortality was significantly greater at the 75 ppm ammonia concentration, 13.9% compared with 5.8% for the 0 ppm treatment. Percentage yield of deboned meat per bird decreased slightly with increasing exposure to ammonia but was not statistically significant. Although current genetic stock reaches growout weights that are approximately 60% greater than those 2 decades ago, the relative quantified effects of ammonia exposure were similar. Additionally, statistical analysis of the results provided a simple equation, presented herein, for predicting the decline in BW of male broilers after exposure to ammonia.

Ammonia↗
PubMed2001

Some consequences of ancient mining activities on the health of ancient and modern human populations.

Heavy metal pollutants generated by mining activities in the Jordanian desert c. 2000 years ago will have had detrimental effects on the health of slaves, guards and expert overseers. The pollutants continue to persist and cycle in the modern environment and affect plants, animals and inevitably the humans who are dependent on both. These findings have implications in terms of the public health of human populations living on or in the vicinity of ancient industrial sites around the Mediterranean and in the Middle East. Some effects of heavy metals on human health are examined; issues of bioaccumulation and partitioning are addressed.

Animals↗
PubMed2005

Lessons from my dinners with the giants of modern image science.

The author traces some critical moments in the history of Image Science in the last half century from first-hand or once-removed experience. The Image Science used in the field of medical imaging today had its origins in the analysis of photon detection developed for modern television, conventional photography, and the human visual system. Almost all "model observers" used in image assessment today converge to the model originally used by Albert Rose in his analysis of those classic photo-detectors. A more general statistical analysis of the various "defects" of conventional and unconventional photon-imaging technologies was provided by Shaw. A number of investigators in medical imaging elaborated the work of these pioneers into a synthesis with the general theory of signal detectability and extended this work to the various forms of CT, energy-spectral-dependent imaging, and the further complication of anatomical-background-noise limited imaging. The author calls for further extensions of this work to the problem of under-sampled and thus artefact-limited imaging that will be important issues for high-speed CT and MRI.

Diagnostic Imaging↗
PubMed2002

Experimental rage: the development of medical ethics and the genesis of scientific facts. Ludwik Fleck: an answer to the crisis of modern medicine in interwar Germany?

In 1930, the large-scale introduction of the BCG vaccination in the city of Lübeck in northern Germany led to a major scandal that focused public attention on medical experimentation with human beings as well as reviving criticism of the medical profession that had been voiced before. The trial following the catastrophe raised the first clearly identifiable public discussions on medical ethics in Europe, and led to the establishment of the first regulations for medical research on human beings in the western hemisphere; the German 'Richtlinien' of 1931. In 1935, Ludwik Fleck (1896-1961) published a now classic monograph entitled Genesis and Development of a Scientific Fact. The central hypothesis of this article is that, when Fleck published his book four years after the Lübeck trial, he was proposing answers to questions raised, at least partially, by the Lübeck case, although he never explicitly mentions it. Most interestingly, Fleck proposed a different approach to the fundamental dilemma of modern experimental medicine, the potential opposition between an individual's well-being, and the production and application of scientific knowledge in medicine. Where the standard answer to these questions has, since the 1930s, become moral reasoning and ethical regulation, known today as bioethics, Fleck portrays a different approach that could be characterized as the attempt to foster a deeper and more democratic understanding of science through an examination of its intimate functioning.

Allergy and Immunology↗
PubMed1995

The women of the family? Speculations around early modern British physicians.

In the extensively explored areas of professionalization, domestic ideology, and the relationships between women and medicine, the debate on the British case has given little consideration to issues of identity arising for the male medical practitioner as a result of family life. For the early modern period, these issues can be seen as among a broad-ranging set of problems posed by the female gender connotations of the medical role. Such problems were most pronounced for the élite physicians who sought membership of the London College of Physicians. Their attitudes and dilemmas are important because of their influence, over the long term, on the criteria for professionalization. Using biographical data, a contrast can be shown between the dynastic ideals of physicians, which stressed the male line, and the high incidence among such physicians of celibacy, childlessness, and small families. Families of origin of physicians, on the other hand, tended to be large. Assumptions about the role of women in medical care, especially in clerical and gentry families, entail a recognition of the possible influence of female relatives on the vocations of male physicians. Given the low status of women's work, physicians developed ambivalences which affected the construction of their identities, their families, and the passing on of their skills.

Family↗
PubMed2006

Testing times: the emergence of the practolol disaster and its challenge to British drug regulation in the modern period.

This article analyses how practolol, the first British drug disaster of the modern, post-thalidomide regulatory period, related to the pharmaceutical industry, the medical profession and government regulation of patients' health. Drawing on comparison with the USA, it argues that, contrary to public expectation and perception, the aftermath of thalidomide did not give rise to strident British drug control, imposing the highest possible safety standards on the pharmaceutical industry. Rather, there existed a culture of reluctant regulation that was characterised by continued optimism about, and trust in the purported benefits of new drugs among manufacturers and regulators in the United Kingdom, together with commitment to the protection of the industry and its institutional support for the medical profession. In particular, British regulators were willing to allow new drugs on to the market, fully aware of uncertainty about their safety, but unwilling to be pro-active in issuing warning letters about risks and requiring 'certainty' before acting to withdraw a product. Even after the practolol disaster, the British system was unable to reform itself to construct more rigorous and pro-active monitoring of drug risks. This was because of conflicts with industry interests.

Adrenergic beta-Antagonists↗
PubMed1987

Margin of safety in positioning modern double-lumen endotracheal tubes.

The authors have defined the margin of safety in positioning a double-lumen tube as the length of tracheobronchial tree over which it may be moved or positioned without obstructing a conducting airway. The purpose of this study was to measure the margin of safety in positioning three modern double-lumen tubes (Mallinkrodt [Broncho-Cath], Rusch [Endobronchial tubes], and Sheridan [Broncho-Trach]). The margin of safety in positioning a: 1) left-sided double-lumen tube (all manufacturers) is the length of the left mainstem bronchus minus the length from the proximal margin of the left cuff to left lumen tip; 2) Mallinkrodt right-sided double-lumen tube is the length of the right mainstem bronchus minus the length of the right cuff; and 3) Rusch right-sided double-lumen tube is the length of the right upper lobe ventilation slot minus the diameter of the right upper lobe. The length of the right and left mainstem bronchi were measured by in vivo fiberoptic bronchoscopy (n = 69), in fresh cadavers (n = 42), and in lung casts (n = 55), and the diameter of the right upper lobe bronchus was measured in lung casts (n = 55). The average +/- SD male left and right mainstem bronchial lengths were 49 +/- 8 and 19 +/- 6 mm, respectively, the average +/- SD female left and right mainstem bronchial lengths were 44 +/- 7 and 15 +/- 5 mm, respectively, the average right upper lobe bronchial diameter was 11 mm, the proximal left cuff to left lumen tip distance was 30 mm, the length of the Mallinkrodt right cuff was 10 mm, and the length of the Rusch right upper lobe ventilation slot was 15 mm. The average margin of safety in positioning left-sided double-lumen tubes ranged 16-19 mm for the different manufacturers. The average margin of safety in positioning Mallinkrodt right-sided double-lumen tubes was 8 mm, and the margin of safety in positioning Rusch right-sided double-lumen tubes ranged 1-4 mm, depending on French size. The authors concluded that left-sided double-lumen tubes are much preferable to right-sided double-lumen tubes because they have a much greater positioning margin of safety, and that proper confirmation of proper position of either a left- or right-sided double-lumen tube should be aided by fiberoptic bronchoscopy, because the absolute distances that constitute the margin of safety are extremely small.

Bronchi↗
PubMed1979

Therapeutic and economic impact of a modern amputation program.

The experience with 142 below-knee amputations for vascular occlusive disease and/or diabetes mellitus in 133 patients has been reviewed. The program utilized Xenon(133) skin bloodflow measurement for the selection of amputation level, emphasized the use of the long posterior skin flap as an important part of surgical technique, and employed immediate postoperative prosthesis with accelerated rehabilitation for postoperative management. The results of this program yielded a 0% postoperative mortality, 89% amputation healing, and 100% prosthesis rehabilitation of all unilateral below-knee amputees, and 93% rehabilitation of all bilateral below-knee amputees. The average time interval between amputation and fitting of a permanent prosthesis was 32 days. The use of Xenon(133) clearance as a measurement of capillary skin bloodflow for purposes of amputation level selection continues to be valid. All amputations with flows in excess of 2.6 ml/100 g tissue/min healed primarily, including the last 58 consecutive amputations. The total amputation of the 172 hospital V.A. system was surveyed and a cost analysis, based upon duration of postamputation hospitalization, comparing immediate postoperative prosthesis with conventional techniques, was performed. The savings to the system, taking into account start-up and maintenance costs for a program which employs immediate postoperative prosthesis, was projected to be $80,000,000 over five years. We conclude that a modern amputation program employing Xenon(133) clearance for amputation level selection and immediate postoperative prosthesis with accelerated rehabilitation is well justified based upon reduced morbidity, negligable mortality, and optimum patient prosthetic rehabilitation at a marked reduction in overall cost.

Adult↗