Do physicians have an ethical obligation to care for patients with AIDS?

This paper responds to the question: Do physicians have an ethical obligation to care for patients with acquired immunodeficiency syndrome (AIDS)? First, the social and political milieu in which this question arises is sampled. Here physicians as well as other members of the community are found declaring an unwillingness to be exposed to people with AIDS. Next, laws, regulations, ethical codes and principles, and the history of the practice of medicine are examined, and the literature as it pertains to these areas is reviewed. The obligation to care for patients with AIDS, however, cannot be located in an orientation to morality defined in rules and codes and an appeal to legalistic fairness. By turning to the orientation to morality that emerges naturally from connection and is defined in caring, the physicians'' ethical obligation to care for patients with AIDS is found. Through an exploration of the writings of modern medical ethicists, it is clear that the purpose of the practice of medicine is healing, which can only be accomplished in relationship to the patient. It is in relationship to patients that the physician has the opportunity for self-realization. In fact, the physician is physician in relationship to patients and only to the extent that he or she acts virtuously by being morally responsible for and to those patients. Not to do so diminishes the physician''s ethical ideal, a vision of the physician as good physician, which has consequences for the physician''s capacity to care and for the practice of medicine.     

Patients’ attitudes to the summary care record and HealthSpace: qualitative study

Objective To document the views of patients and the public towards the summary care record (SCR, a centrally stored medical record drawn from the general practice record) and HealthSpace (a personal health organiser accessible through the internet from which people can view their SCR), with a particular focus on those with low health literacy, potentially stigmatising conditions, or difficulties accessing health care.Design 103 semistructured individual interviews and seven focus groups.Setting Three early adopter primary care trusts in England where the SCR and HealthSpace are being piloted. All were in areas of relative socioeconomic deprivation.Participants Individual participants were recruited from general practice surgeries, walk-in centres, out of hours centres, and accident and emergency departments. Participants in focus groups were recruited through voluntary sector organisations; they comprised advocates of vulnerable groups and advocates of people who speak limited English; people with HIV; users of mental health services; young adults; elderly people; and participants of a drug rehabilitation programme.Methods Participants were asked if they had received information about the SCR and HealthSpace and about their views on shared electronic records in different circumstances.Results Most people were not aware of the SCR or HealthSpace and did not recall receiving information about it. They saw both benefits and drawbacks to having an SCR and described a process of weighing the former against the latter when making their personal choice. Key factors influencing this choice included the nature of any illness (especially whether it was likely to lead to emergency care needs); past and present experience of healthcare and government surveillance; the person’s level of engagement and health literacy; and their trust and confidence in the primary healthcare team and the wider NHS. Overall, people with stigmatising illness were more positive about the SCR than people who claimed to speak for “vulnerable groups.” Misconceptions about the SCR were common, especially confusion about what data it contained and who would have access to it. Most people were not interested in recording their medical data or accessing their SCR via HealthSpace, but some saw the potential for this new technology to support self management and lay care for those with chronic illness.Conclusion Despite an extensive information programme in early adopter sites, the public remains unclear about current policy on shared electronic records, though most people view these as a positive development. The “implied consent” model for creating and accessing a person’s SCR should be revisited, perhaps in favour of “consent to view” at the point of access.     

Can health care databases be used to identify incident cases of osteonecrosis?

Introduction  

Osteonecrosis (ON) is a rare disease associated with alcohol and glucocorticoid use. Identifying additional risk factors is difficult as the number of cases at any single center is small. We investigated whether data available in large health care databases can be used to identify incident ON cases.     

Nursing role to improve care to infarct patients and patients undergoing heart surgery: 10?years’ experience

Background

The nurse practitioner may be the ideal healthcare worker to create a new environment and may facilitate in the process of expediting discharge and improving patient safety. They can play an intermediary role between the consultants, nurses and patients, thereby combining the aspects of care (nursing) and cure (physicians).

Method

We describe the contribution and role of the nurse practitioner in a teaching hospital and provide an overview of the changes in care and cure that were facilitated by two nurse practitioners in the treatment of cardiac surgery patients or non-complicated acute coronary syndrome patients.

Results

The nurse-led clinic for postoperative patients has registered 1967 patients in the past 10 years. These patients were transferred at a mean of 5.5 days after their bypass operation. All patients had an uneventful clinical course in our hospital and were discharged alive. The period between discharge and outpatient clinic visit could be set at 4 weeks.The post-acute coronary syndrome (ACS) group included 1236 patients. Mortality in this patient cohort was 4% while 0.4% of these patients experienced a re-myocardial infarction. Additional surgery was needed in only 2% of these stable post-infarction patients. The mean length of stay was 5.9 ± 14.5 days.

Conclusion

This observational study confirms that a nurse-led postoperative care unit and post-ACS care unit is feasible and effective for the treatment of patients returning from cardiac surgery or transferred after uncomplicated ACS to a general cardiology ward.     

How many physicians does Canada need to care for our aging population?

BACKGROUND: There is concern that the aging of Canada''s population will strain our health care system. The authors address this concern by examining changes in the physician supply between 1986 and 1994 and by assessing the availability of physicians in 1994 relative to population growth and aging, and relative to supply levels in the benchmark province of Alberta. METHODS: Physician numbers were obtained from the Canadian Institute for Health Information. The amount of services provided by each specialty to each patient age group was analysed using Manitoba physician claims data. Population growth statistics were obtained from Statistics Canada. Age- and specialty-specific utilization data and age-specific population growth patterns were used to estimate the number and type of physicians that would have been required in each province to keep up with population growth between 1986 and 1994, in comparison with actual changes in the physician numbers. Physician supply in Alberta was used as a benchmark against which other provinces were measured. RESULTS: Overall, Canada''s physician supply between 1986 and 1994 kept pace with population growth and aging. Some specialties grew much faster than population changes warranted, whereas others grew more slowly. By province, the supply of general practitioners (GPs) grew much faster than the population served in New Brunswick (16.6%), Alberta (6.5%) and Quebec (5.3%); the GP supply lagged behind in Prince Edward Island (-5.4%). Specialist supply outpaced population growth substantially in Nova Scotia (10.4%), Newfoundland (8.5%), New Brunswick (7.3%) and Saskatchewan (6.8%); it lagged behind in British Columbia (-9.2%). Using Alberta as the benchmark resulted in a different assessment: Newfoundland (15.5%) and BC (11.7%) had large surpluses of GPs by 1994, whereas PEI (-21.1%), New Brunswick (-14.8%) and Manitoba (-11.1%) had substantial deficits; Quebec (37.3%), Ontario (24.0%), Nova Scotia (11.6%), Manitoba (8.2%) and BC (7.6%) had large surpluses of specialists by 1994, whereas PEI (-28.6%), New Brunswick (-25.9%) and Newfoundland (-23.8%) had large deficits. INTERPRETATION: The aging of Canada''s population poses no threat of shortage to the Canadian physician supply in general, nor to most specialist groups. The marked deviations in provincial physician supply from that of the benchmark province challenge us to understand the costs and benefits of variations in physician resources across Canada and to achieve a more equitable needs-based availability of physicians within provinces and across the country.     

Biomedical engineer’s guide to the clinical aspects of intensive care mechanical ventilation

Background

Mechanical ventilation is an essential therapy to support critically ill respiratory failure patients. Current standards of care consist of generalised approaches, such as the use of positive end expiratory pressure to inspired oxygen fraction (PEEP–FiO₂) tables, which fail to account for the inter- and intra-patient variability between and within patients. The benefits of higher or lower tidal volume, PEEP, and other settings are highly debated and no consensus has been reached. Moreover, clinicians implicitly account for patient-specific factors such as disease condition and progression as they manually titrate ventilator settings. Hence, care is highly variable and potentially often non-optimal. These conditions create a situation that could benefit greatly from an engineered approach. The overall goal is a review of ventilation that is accessible to both clinicians and engineers, to bridge the divide between the two fields and enable collaboration to improve patient care and outcomes. This review does not take the form of a typical systematic review. Instead, it defines the standard terminology and introduces key clinical and biomedical measurements before introducing the key clinical studies and their influence in clinical practice which in turn flows into the needs and requirements around how biomedical engineering research can play a role in improving care. Given the significant clinical research to date and its impact on this complex area of care, this review thus provides a tutorial introduction around the review of the state of the art relevant to a biomedical engineering perspective.

Discussion

This review presents the significant clinical aspects and variables of ventilation management, the potential risks associated with suboptimal ventilation management, and a review of the major recent attempts to improve ventilation in the context of these variables. The unique aspect of this review is a focus on these key elements relevant to engineering new approaches. In particular, the need for ventilation strategies which consider, and directly account for, the significant differences in patient condition, disease etiology, and progression within patients is demonstrated with the subsequent requirement for optimal ventilation strategies to titrate for patient- and time-specific conditions.

Conclusion

Engineered, protective lung strategies that can directly account for and manage inter- and intra-patient variability thus offer great potential to improve both individual care, as well as cohort clinical outcomes.

     

Can fungal biomarkers be used to improve antifungal therapy in the intensive care unit?

Invasive fungal infections have an increasing incidence worldwide, and patients in intensive care settings are particularly vulnerable to them. Candidemia is the third most common bloodstream pathogen in intensive care units (ICUs) in the United States, and a number of reports have recently been published regarding the increasing incidence of invasive aspergillosis in ICUs throughout the world. Because research has shown that early antifungal therapy is associated with better outcomes, clinicians are starting to explore new diagnostic fungal markers, which are more sensitive and faster than the traditional diagnostic standards of culture and histopathology.     

Adaptive switch from infanticide to parental care: how do beetles time their behaviour?

Abstract In species where parents may commit infanticide, temporal kin recognition can help ensure parents kill unrelated young but care for their own offspring. This is not true recognition, but rather depends on accurate timing of the arrival of young and a behavioural switch from killing to caring for offspring. Mistakes have clear fitness consequences; how do species that use temporal kin recognition ensure accurate timing? We manipulated photic cues and show that the switch from infanticide to parental care in the burying beetle Nicrophorus vespilloides depends on day‐length inputs. Extending the light period after carcass discovery influenced timing of both oviposition and the cessation of infanticide. Manipulation of the light : dark cycle after oviposition also influenced timing of the switch to parental care. The timing mechanism is therefore sensitive to photic cues and access to a carcass and is not triggered by oviposition. The behavioural switch is directly related to the timing mechanism rather than changes in reproductive physiology. Given the conserved nature and extensive homology of genetic influences on biological timing, we speculate that the molecular mechanisms regulating circadian behaviour may have been co‐opted to allow beetles to determine how much time has passed after carcass discovery even though this is over 50 h.