Science in the Service of Patients: Lessons from the Past in the Moral Battle for the Future of Medical Education

Medical schools instill a classic moral standoff in which the responsibility for the betterment of the patient stands at odds with the responsibility for the betterment of society. In critical ways, the latter, in the form of a robust research and technology-driven enterprise, has taken precedence over the former, resulting in harm to patients and individual dignity. This tradeoff can be traced to Abraham Flexner, the father of American medical education. In the wake of the Flexner report, American medicine set out on a course of exponential scientific advancement, but the mistreatment of research subjects and the erosion of the doctor-patient relationship in a health care system that is increasingly unaffordable, complex, and impersonal suggest that such progress has come at a price. Recent efforts by medical schools to emphasize humanism in their curricula and admissions processes have shown promise in orienting the values of academic medicine toward the individual patient’s well-being.     

Off‐Shoring Clinical Research: Exploitation and the Reciprocity Constraint

The last 20 years have seen a staggering growth in the practice of off‐shoring clinical research to low‐and middle‐income countries (LICs and MICs), a growth that has been matched by the neoliberal policies adopted by host countries towards attracting trials to their shores. A recurring concern in this context is the charge of exploitation, linked to various aspects of off‐shoring. In this paper, I examine Alan Wertheimer's approach and offer an alternative view of understanding exploitation in this context. I will suggest that the justification for the enterprise of research is largely dependent on its integration within a health system from which participants regularly benefit and I argue that an attention to a principle of reciprocity will enable us to better recognize and address exploitation in international research.     

The Case for Intervention Bias in the Practice of Medicine

Bias is an inclination to present or hold a partial perspective at the expense ofpossibly equal or more valid alternatives. In this paper, we present a series ofconditional arguments to prove that intervention bias exists in the practice ofmedicine. We then explore its potential causes, consequences, and criticisms. Weuse the term to describe the bias on the part of physicians and the medicalcommunity to intervene, whether it is with drugs, diagnostic tests, non-invasiveprocedures, or surgeries, when not intervening would be a reasonablealternative. The recognition of intervention bias in medicine is criticallyimportant given today’s emphasis on providing high-value care and reducingunnecessary and potentially harmful interventions.     

Focus: Sex and Gender Health: Patient Preference for Physician Gender in the Emergency Department

Despite historical gender bias against female physicians, few studies have investigated patients’ physician gender preference in the emergency department (ED) setting. We sought to determine if there is an association between ED patient demographics and physician gender preference. We surveyed patients presenting to an ED to determine association between patient demographics and patient physician gender preference for five ED situations: 1) ‘routine’ visit, 2) emergency visit, 3) ‘sensitive’ medical visit, 4) minor surgical/‘procedural’ visit, and 5) ‘bad news’ delivery. A total of 200 ED patients were surveyed. The majority of ED patients reported no physician gender preference for ‘routine’ visits (89.5 percent), ‘emergent’ visits (89 percent), ‘sensitive’ medical visits (59 percent), ‘procedural’ visits (89 percent) or when receiving ‘bad news’ (82 percent). In the setting of ‘routine’ visits and ‘sensitive’ medical visits, there was a propensity for same-sex physician preference.     

Bioethics and practical justice in the post‐COVID‐19 era

The ethical concept of justice, as it relates to the development and deployment of innovative health technologies, commands the fair and equitable distribution of burdens and benefits. In bioethics, specific guidance on practical strategies for achieving what this concept of justice demands are somewhat elusive. Drawing on issues of justice arising or likely to arise in the context of the search for a vaccine or cure for COVID‐19, this paper argues for a focus on the concept of “practical justice” in post‐pandemic bioethics work. To illustrate the value and promise of this concept, the paper reflects on an approach to achieving practical justice in health biotechnology research that is grounded in a commitment to offer technical assistance to developing and under‐resourced nations.     

哈尔滨市综合医院急诊科病人安全管理现状与对策研究

运用分层随机抽样的方法,在哈尔滨市抽取5家三级和5家二级综合医院的急诊科作为研究对象,从人力资源管理、工作量、核心制度管理、沟通与协作、急救设施管理、医疗差错管理等6个方面进行了急诊科病人安全管理现状研究。     

Interaction between Paracoccidioides brasiliensis conidia and the coagulation system: involvement of fibrinogen

The infectious process starts with an initial contact between pathogenand host. We have previously demonstrated that Paracoccidioidesbrasiliensis conidia interact with plasma proteins includingfibrinogen, which is considered the major component of the coagulation system.In this study, we evaluated the in vitro capacity of P.brasiliensis conidia to aggregate with plasma proteins andcompounds involved in the coagulation system. We assessed the aggregation ofP. brasiliensis conidia after incubation with human serumor plasma in the presence or absence of anticoagulants, extracellular matrix(ECM) proteins, metabolic and protein inhibitors, monosaccharides and othercompounds. Additionally, prothrombin and partial thromboplastin times weredetermined after the interaction of P. brasiliensis conidiawith human plasma. ECM proteins, monosaccharides and human plasma significantlyinduced P. brasiliensis conidial aggregation; however,anticoagulants and metabolic and protein inhibitors diminished the aggregationprocess. The extrinsic coagulation pathway was not affected by the interactionbetween P. brasiliensis conidia and plasma proteins, while theintrinsic pathway was markedly altered. These results indicate that P.brasiliensis conidia interact with proteins involved in thecoagulation system. This interaction may play an important role in the initialinflammatory response, as well as fungal disease progression caused byP. brasiliensis dissemination.     

Emergency Preservation and Resuscitation Trial: A Philosophical Justification for Non‐Voluntary Enrollment

In a current clinical trial for Emergency Preservation and Resuscitation (EPR), Dr. Samuel Tisherman of the University of Maryland aims to induce therapeutic hypothermia in order to ‘buy time’ for operating on victims of severe exsanguination. While recent publicity has framed this controversial procedure as ‘killing a patient to save his life’, the US Army and Acute Care Research appear to support the study on the grounds that such patients already face low chances of survival. Given that enrollment in the trial must be non‐voluntary, the study has received an exemption from federal standards for obtaining informed consent. How exactly, if at all, is non‐voluntary enrollment morally justifiable? In this essay, I appeal to the notable work of Hans Jonas in an effort to defend the EPR trial's use of non‐voluntary enrollment. It is often thought and, as I show, it may appear that Jonas has called for the end of experimental medical practice. Still, I derive from Jonas a principle of double‐effect upon which physicians may be seen as morally permitted to pursue innovations in emergency medicine but only as a byproduct of pursuing therapeutic success. With this position, I argue that the EPR trial can be granted a stronger philosophical justification than simply waiving the requirement of obtaining informed consent. The double‐effect justification would obtain, perhaps regardless of the success of such innovative procedures as therapeutic hypothermia.     

Nematicides and Nonconventional Soil Amendments in the Management of Root-Knot Nematode on Cotton

Granular and liquid commercial humates, with micronutrients, and a microbial fermentation product were compared in several combinations with nematicides for their effects on cotton lint yield and root-knot nematode suppression. Fumigant nematicides effectively reduced cotton root galling caused by root-knot nematodes, and cotton lint yields increased. Organophosphates and carbamates were not effective. Occasionally, cotton lint yields were increased or maintained with combination treatments o f humates, micronutrients, and a microbial fermentation product, but galling o f cotton roots by root-knot nematodes was usually not reduced by these treatments.     

The oral biome in the aetiology and management of dental disease: Current concepts and ethical considerations

Our understanding of the complexity of the oral biome and of the role of the various constituent bacteria in the aetiology of dental disease is growing. Probiotics and their relationship with prebiotics, as well as other microbiome‐based interventions, could be useful in preventing and treating dental disease and in promoting oral health. However, given the promise and early stage of this treatment approach, there are also a number of ethical, social and regulatory issues associated with innovative probiotic therapy. In this article, a brief update is given on contemporary theories of the aetiology and management of the two commonest dental diseases, and on the roles of pre‐ and probiotics and oral biome transplant in the management of these diseases. The focus is primarily on four core issues: informed consent, risk–benefit assessment, how to determine suitable healthy donors, and commercialization and regulation. We discuss the safety and benefits of oral probiotics, not only concerning the products and quality control during their manufacture, but also regarding the depth of public knowledge about this topic. We point out that the requirement of listing ingredients honestly might be insufficient, and that the prevalent rhetoric of ‘natural’ and ‘organic’ as well as some health claims in the translational, innovative probiotic industry and markets are themselves misleading and should be carefully scrutinized. Finally, we suggest an ethical imperative to find a balance between scientific research and industry, and public health in the regulation of probiotics.     

Between Relativism and Imperialism: Navigating Moral Diversity in Cross‐Cultural Bioethics

The need for explicit theoretical reflection on cross‐cultural bioethics continues to grow as the spread of communication technologies and increased human migration has made interactions between medical professionals and patients from different cultural backgrounds much more common. I claim that this need presents us with the following dilemma. On the one hand, we do not want to operate according to an imperialist ethical framework that denies and silences the legitimacy of cultural values other than our own. On the other hand, we do not want to backslide into a form of cultural relativism that is unable to critically appraise cultural practices that are harmful, unjust, or oppressive. I examine two prominent attempts – the principlism of Tom Beauchamp and James Childress and the Contractarianism of Robert Baker – to frame cross‐cultural bioethics between these two extremes and argue that both approaches have significant flaws. The principlist approach fails to provide a non‐question begging way to identify cross‐cultural norms that does not already assume the universal legitimacy of moral principles dominant in North American society. Baker's contractarianism cannot grapple with the realities of political power imbalances that often characterize cross‐cultural moral disputes. I suggest that a naturalized feminist framework, though not free of its own theoretical difficulties, provides the best alternative for approaching moral diversity respectfully and critically.     

Phytoalexins and their Role in the Resistance of Plants to Nematodes

Phytoalexins are antibiotic compounds synthesized in an infected plant in response to infection. Nematodes are capable of eliciting phytoalexins in resistant plants. Resistant lima bean (Phaseolus lunatus) infected by Pratylenchus penetrans produces the phytoalexin coumestrol; soybean (Glycine max) infected by Meloidogyne incognita produces glyceollin; cotton (Gossypium hirsuturn) infected by M. incognita produces terpenoid aldehydes.     

Investigating assumptions of vulnerability: A case study of the exclusion of psychiatric inpatients as participants in genetic research in low‐ and middle‐income contexts

Psychiatric genetic research investigates the genetic basis of psychiatric disorders with the aim of more effectively understanding, treating, or, ultimately, preventing such disorders. Given the challenges of recruiting research participants into such studies, the potential for long‐term benefits of such research, and seemingly minimal risk, a strong claim could be made that all non‐acute psychiatric inpatients, including forensic and involuntary patients, should be included in such research, provided they have capacity to consent. There are tensions, however, regarding the ethics of recruiting psychiatric inpatients into such studies. In this paper our intention is to elucidate the source of these tensions from the perspective of research ethics committee interests and decision‐making. We begin by defining inpatient status and outline some of the assumptions surrounding the structures of inpatient care. We then introduce contemporary conceptions of vulnerability, including Florencia Luna’s account of vulnerability which we use as a framework for our analysis. While psychiatric inpatients could be subject to consent‐related vulnerabilities, we suggest that a particular kind of exploitation‐related vulnerability comes to the fore in the context of our case study. Moreover, a subset of these ethical concerns takes on particular weight in the context of genetic research in low‐ and middle‐income countries. At the same time, the automatic exclusion of inpatients from research elicits justice‐related vulnerabilities.     

Domestic,peridomestic and wild hosts in the transmission of Trypanosoma cruzi in the Caatinga area colonised by Triatoma brasiliensis

The role played by different mammal species in the maintenance of Trypanosoma cruzi is not constant and varies in time and place. This study aimed to characterise the importance of domestic, wild and peridomestic hosts in the transmission of T. cruzi in Tauá, state of Ceará, Caatinga area, Brazil, with an emphasis on those environments colonised by Triatoma brasiliensis. Direct parasitological examinations were performed on insects and mammals, serologic tests were performed on household and outdoor mammals and multiplex polymerase chain reaction was used on wild mammals. Cytochrome b was used as a food source for wild insects. The serum prevalence in dogs was 38% (20/53), while in pigs it was 6% (2/34). The percentages of the most abundantly infected wild animals were as follows: Thrichomys laurentius 74% (83/112) and Kerodon rupestris 10% (11/112). Of the 749 triatomines collected in the household research, 49.3% (369/749) were positive for T. brasiliensis, while 6.8% were infected with T. cruzi (25/369). In captured animals, T. brasiliensis shares a natural environment with T. laurentius, K. rupestris, Didelphis albiventris, Monodelphis domestica, Galea spixii, Wiedomys pyrrhorhinos, Conepatus semistriatus and Mus musculus. In animals identified via their food source, T. brasiliensis shares a natural environment with G. spixii, K. rupestris, Capra hircus, Gallus gallus, Tropidurus oreadicus and Tupinambis merianae. The high prevalence of T. cruzi in household and peridomiciliar animals reinforces the narrow relationship between the enzootic cycle and humans in environments with T. brasiliensis and characterises it as ubiquitous.     

Extensive genomic reshuffling involved in the karyotype evolution of genus Cerradomys (Rodentia: Sigmodontinae: Oryzomyini)

Rodents of the genus Cerradomys belong to the tribe Oryzomyini and present high chromosome variability with diploid numbers ranging from 2n=46 to 60. Classical cytogenetics and fluorescence in situ hybridization (FISH) with telomeric and whole chromosome-specific probes of another Oryzomyini, Oligoryzomys moojeni (OMO), were used to assess the karyotype evolution of the genus. Results were integrated into a molecular phylogeny to infer the hypothetical direction of chromosome changes. The telomeric FISH showed signals in telomeres in species that diverged early in the phylogeny, plus interstitial telomeric signals (ITS) in some species from the most derived clades (C. langguthi, C. vivoi, C. goytaca, and C. subflavus). Chromosome painting revealed homology from 23 segments of C. maracajuensis and C. marinhus to 32 of C. vivoi. Extensive chromosome reorganization was responsible for karyotypic differences in closely related species. Major drivers for genomic reshuffling were in tandem and centric fusion, fission, paracentric and pericentric inversions or centromere repositioning. Chromosome evolution was associated with an increase and decrease in diploid number in different lineages and ITS indicate remnants of ancient telomeres. Cytogenetics results corroborates that C. goytaca is not a junior synonym of C. subflavus since the karyotypic differences found may lead to reproductive isolation.     

Cytokine Control of Inflammation and Repair in the Pathology of Multiple Sclerosis

Cytokines are secreted signaling proteins that play an essential role in propagating and regulating immune responses during experimental autoimmune encephalomyelitis (EAE), the mouse model of the neurodegenerative, autoimmune disease multiple sclerosis (MS). EAE pathology is driven by a myelin-specific T cell response that is activated in the periphery and mediates the destruction of myelin upon T cell infiltration into the central nervous system (CNS). Cytokines provide cell signals both in the immune and CNS compartment, but interestingly, some have detrimental effects in the immune compartment while having beneficial effects in the CNS compartment. The complex nature of these signals will be reviewed.     

Gametogenesis and the Chromosomes of Meloidogyne nataliei: Not Typical of Other Root-knot Nematodes

Studies of oogenesis and spermatogenesis revealed that Meloidogyne nataliei is a diploid, amphimictic species with four (n), relatively large chromosomes, and possibly with an XX ♀-XY ♂ mechanism of sex determination. It differs considerably from all other amphimictic, or meiotically parthenogenetic, species of Meloidogyne which have 13-18 smaller chromosomes and from Meloidogyne (Hypsoperine) spartinae which has seven. Consequently, the taxonomic position of M. nataliei needs to be re-evaluated. The chromosomes of M. nataliei and their behavior during gametogenesis resemble more closely chromosomes of the genus Heterodera than those of the genus Meloidogyne. This resemblance, however, may not imply a closer phyletic relationship of M. nataliei to heteroderid nematodes.     

Biomarkers of therapeutic responses in chronic Chagas disease: state of the art and future perspectives

The definition of a biomarker provided by the World Health Organization is any substance, structure, or process that can be measured in the body, or its products and influence, or predict the incidence or outcome of disease. Currently, the lack of prognosis and progression markers for chronic Chagas disease has posed limitations for testing new drugs to treat this neglected disease. Several molecules and techniques to detect biomarkers in Trypanosoma cruzi-infected patients have been proposed to assess whether specific treatment with benznidazole or nifurtimox is effective. Isolated proteins or protein groups from different T. cruzi stages and parasite-derived glycoproteins and synthetic neoglycoconjugates have been demonstrated to be useful for this purpose, as have nucleic acid amplification techniques. The amplification of T. cruzi DNA using the real-time polymerase chain reaction method is the leading test for assessing responses to treatment in a short period of time. Biochemical biomarkers have been tested early after specific treatment. Cytokines and surface markers represent promising molecules for the characterisation of host cellular responses, but need to be further assessed.     

急诊危重孕产妇5分钟紧急剖宫产的临床效果及新生儿不良结局的危险因素分析

摘要 目的：探讨急诊危重孕产妇5分钟紧急剖宫产的临床效果,并分析新生儿不良结局的危险因素。方法：回顾性分析2018年1月~2022年6月在河北省儿童医院妇产科收治的急诊危重孕产妇139例的临床资料。根据急诊剖宫产流程分为对照组（n=68,常规紧急剖宫产流程下进行手术）及观察组（n=71,5分钟紧急剖宫产）。观察两组孕产妇的手术情况、手术反应时间、孕产妇并发症、新生儿不良结局发生率。采用多因素Logistic回归模型分析新生儿不良结局的危险因素。结果：两组住院时间、术中出血量、术中输血情况组间对比,未见统计学差异（P>0.05）。与对照组相比,观察组进手术室至手术开始时间、决定手术至胎儿娩出的时间间隔（DDI）、决定手术至进手术室时间、手术开始至胎儿娩出时间均更短,新生儿不良结局发生率、并发症发生率更低（P<0.05）。根据新生儿不良结局将孕产妇分为不良组（n=38）、良好组（n=101）。单因素分析结果显示：新生儿不良结局与受教育程度、新生儿体重、孕周、剖宫产类型、DDI、妊娠合并症、采用辅助生殖技术有关（P<0.05）。多因素Logistic回归分析结果显示,受教育程度为小学及其以下、新生儿体重偏低、剖宫产类型为I类剖宫产、孕周偏短、DDI偏长均是新生儿不良结局的危险因素（P<0.05）。结论：急诊危重孕产妇5分钟紧急剖宫产可缩短各项手术反应时间,降低孕产妇并发症和新生儿不良结局发生率。此外,新生儿不良结局的发生与受教育程度、新生儿体重、剖宫产类型、孕周、DDI等因素有关。