1Division of Vascular Diseases & Surgery, Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio. Electronic address: firstname.lastname@example.org.
2Sarasota Vascular Specialists, Sarasota, Fla.
3Division of Vascular Diseases & Surgery, Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio.
Evolving changes in health care in the United States are causing new graduates and self-employed physicians to consider employment with large groups and health systems. Familiarity with the principles, proper conduct, and mechanics of negotiating an employment agreement will be important for vascular surgeons making such a decision. The various components of compensation packages and contract language need to be critically evaluated. To facilitate an understanding of the complexities involved in employment contracts, strategies to avoid making negotiating mistakes are discussed.
1Department of Cell & Developmental Biology, Institute of Life Sciences and Center for Research on Pain, The Hebrew University of Jerusalem, Jerusalem, Israel.
Pain has variously been used as a means of punishment, extracting information, or testing commitment, as a tool for education and social control, as a commodity for sacrifice, and as a draw for sport and entertainment. Attitudes concerning these uses have undergone major changes in the modern era. Normative convictions on what is right and wrong are generally attributed to religious tradition or to secular-humanist reasoning. Here, we elaborate the perspective that ethical choices concerning pain have much earlier roots that are based on instincts and brain-seated empathetic responses. They are fundamentally a function of brain circuitry shaped by processes of Darwinian evolution. Social convention and other environmental influences, with their idiosyncrasies, are a more recent, ever-changing overlay. We close with an example in which details on the neurobiology of pain processing, specifically the question of where in the brain the experience of pain is generated, affect decision making in end-of-life situations. By separating innate biological substrates from culturally imposed attitudes (memes), we may arrive at a more reasoned approach to amorality of pain prevention.
1Division of Histopathology and Cytopathology, PO Sant'Andrea ASL5., Via Mario Asso n. 2. 19124 La Spezia, Italy. email@example.com.
Malignant mesothelioma (MM) is a particularly aggressive type of primary tumor, associated with exposure to asbestos, and characterized by high mortality. To date, there is no curative therapy for MM. The receptor anaplastic lymphoma kinase (ALK) was found to be mutated in many cases of cancer and used as a target in biological therapies. We investigated whether this pharmacological treatment could also be applicable to MM.
MATERIALS AND METHODS:
The state of ALK was analyzed by immunohistochemistry and fluorescent in situ hybridization in 63 MM tissue specimens.
None of the 63 MM samples showed overexpression or translocation of ALK.
Our preliminary data exclude the utility of analysis of the ALK gene in MM and suggest that ALK inhibitor therapy is not applicable to MM.
1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and.
There is evidence that the neurosurgical procedure of cranioplasty is as ancient as its better-known counterpart, trephination. With origins in pre-Incan Peru, cranioplasty remains an important reconstructive procedure for modern craniofacial surgery teams to master. Solutions to the often challenging problem of repairing skull defects continue to evolve to improve patient outcomes. Throughout recorded history, advances in cranioplasty have paralleled major military conflicts due to survivorship after trephination or decompressive craniectomy. Primitive skull coverings used in Peru were later replaced during the Middle Ages by grafts obtained in animals and humans. Improved survivorship secondary to advances in anesthesia and battlefield medicine during the Crimean War and the American Civil War allowed the use of tantalum and acrylic cranioplasty to evolve during World Wars I and II. In the modern era of the Iraq and Afghanistan conflicts, greater survivorship after cranial injury due to improvements in protective armor, medical evacuation, and early "far-forward" neurosurgical treatment have occurred. Consequently, the last decade has seen great advancement in cranial defect reconstruction, including custom-fabricated alloplast implants and the emergence of regenerative cranial treatments such as distraction osteogenesis, protected bone regeneration, and free tissue transfers. Comprehensive rehabilitation after neurotrauma has emerged as the new standard of care.
Within the field-dominating, multidimensional theory of burnout, burnout is viewed as a work-specific condition. As a consequence, the burnoutsyndrome cannot be investigated outside of the occupational domain. In the present paper, this restrictive view of burnout's scope is criticized and a rationale to decide between a work-specific and a generic approach to burnout is presented. First, the idea that a multidimensional conception ofburnout implies a work-restricted scope is deconstructed. Second, it is shown that the burnout phenomenon cannot be confined to work because chronic, unresolvable stress - the putative cause of burnout - is not limited to work. In support of an integrative view of health, it is concluded that the field-dominating, multidimensional theory of burnout should abandon as groundless the idea that burnout is a specifically job-related phenomenon and define burnout as a multi-domain syndrome. The shift from a work-specific to a generic approach would allow both finer analysis and wider synthesis in research on chronic stress and burnout.
1*To whom correspondence should be addressed; Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria; tel: +43-512-504-23669, fax: +43-512-504-25267, e-mail: Wolfgang.firstname.lastname@example.org.
Care and outcomes for people with schizophrenia have improved in recent years, but further progress is needed to help more individuals achieve an independent and fulfilled life. This report sets out the current need, informs policy makers and all relevant stakeholders who influence care quality, and supports their commitment to creating a better future. The authors recommend the following policy actions, based on research evidence, stakeholder consultation, and examples of best practice worldwide. (1) Provide an evidence-based, integrated care package for people with schizophrenia that addresses their mental and physical health needs. (2) Provide support for people with schizophrenia to enter and to remain in their community, and develop mechanisms to help guide them through the complex benefit and employment systems. (3) Provide concrete support, information, and educational programs to families and carers on how to enhance care for an individual living with schizophrenia in a manner that entails minimal disruption to their lives. (4) All stakeholders, including organizations that support people living with schizophrenia, should be consulted to regularly revise, update, and improve policy on the management of schizophrenia. (5) Provide support, which is proportionate to the impact of the disease, for research and development of new treatments. (6) Establish adequately funded, ongoing, and regular awareness-raising campaigns that form an integral part of routine plans of action. Implementation of the above recommendations will require engagement by every stakeholder, but with commitment from all, change can be achieved.
1Institute of Biomedical Ethics, University of Zurich, Zurich, Switzerland.
Aims: This study examined the attitudes of 1,146 Swiss University students to direct-to-consumer (DTC) genomic testing and to genomic research participation.
Methods: Data were collected through a self-completion online questionnaire by students from 2 higher education institutions in Zurich, Switzerland. The survey aimed to capture motivation for undergoing or refraining from genomic testing, reactions to mock genetic risk results, and views about contributing data to scientific research. Descriptive and inferential statistics were used for the analysis.
Results: A total of 1.5% of the students had undergone testing. Most respondents were studying natural sciences and were interested in undergoing DTC genomic testing. The main motive was to contribute their data to scientific research, followed closely by their interest to find out disease risks and personal traits. Overall, 41% of the respondents were not interested in DTC tests. The primary reasons were concerns about receiving potentially worrying results. There was a significant correlation between studying natural sciences, as opposed to the humanities, and interest in undergoing testing. Male respondents were more interested in testing compared to females. There was a strong interest in genetic research participation and notably limited privacy concerns.
Conclusion: Although 59% of the respondents were interested in DTC genomic testing, they were not likely to be affected by them or act upon them. This raises questions about concerns relating to potential risks of DTC genomics users and users' understanding of genetic information including their awareness of privacy risks. Furthermore, the strong interest in genetic research participation signals an underexplored personal utility of genomic testing which needs to be both better understood and better harnessed.
1Director General, Centre for Trauma Research and Psychosocial Interventions, National University of Sciences & Technology (NUST), Islamabad, Pakistan.
This article reviews the behavioral science perspectives of terrorism in Pakistan. It can be argued that Pakistan has gained worldwide attention for "terrorism" and its role in the "war against terrorism". The region is well placed geopolitically for economic successes but has been plagued by terrorism in various shapes and forms. A behavioral sciences perspective of terrorism is an attempt to explain it in this part of the world as a complex interplay of historical, geopolitical, anthropological and psychosocial factors and forces. Drawing from theories by Western scholars to explain the behavioral and cognitive underpinnings of a terrorist mind, the authors highlight the peculiarities of similar operatives at individual and group levels. Thorny issues related to the ethical and human right dimensions of the topic are visited from the unique perspective of a society challenged by schisms and divergence of opinions at individual, family, and community levels. The authors have attempted to minimize the political descriptions, although this cannot be avoided entirely, because of the nature of terrorism.
"According to a recent news release from the University of Texas Medical Branch at Galveston a group of researchers have revealed for the first time that young women who were previously given radiation treatment for cervical cancer may in fact be at greater risk for developing colorectal cancer as a result of the treatment, and thus should be screened earlier for the disease than when is traditionally recommended."
1Department of Oncology, McGill University, Montreal, QC. ; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC.
2Department of Oncology, McGill University, Montreal, QC.
Since the early 1950s, Papanicolaou ("Pap") cytology screening has dramatically reduced cervical cancer mortality in most high-income settings. Currently, human papillomavirus (hpv) vaccination has the greatest potential to reduce the global burden of cervical cancer and precancerous lesions. However, as the prevalence of precancerous lesions declines, maintaining cytology as the primary screening test in settings with established programs might become less efficient. A reduction in test performance (sensitivity, specificity, and positive predictive value) would lead to an increase in unnecessary colposcopy referrals. Fortunately, hpv dna testing has emerged as a suitable candidate to replace cytology. Compared with the Pap test, hpv testing is less specific but much more sensitive in detecting high-grade precancerous lesions, less prone to human error, and more reproducible across settings. Linkage of hpv vaccination and screening registries could serve the added role of monitoring vaccine efficacy. As a triagetest, cytology is expected to perform with sufficient accuracy because most hpv-positive smears would contain relevant abnormalities. This approach and others-for example, hpv testing followed by genotyping-are being evaluated in large population studies and have already been recommended in some settings. Other specific biomarkers that might perform well for screening and triage include hpv E6/E7 messenger rna testing, methylation of host or viral genes, and p16INK4a staining. Considering the rapid pace of major discoveries and the anticipated arrival of a nonavalent hpv vaccine (currently in phase iii trials), the evidence base in this field has become an elusive target and will continue to be an obstacle for policymakers.
1Department of Neuroscience, Division of Neurosurgery, University of Torino; Division of Neurosurgery, University of Brescia, Italy.
Background: The prognosis of cerebral metastases (MTS) is linked to progression of both systemic and local disease. The importance of MTS resection has been already pointed out. The observation of a high mortality for not-neurological causes confirms that the modern treatments allow a significant control of the disease within the nervous system. Nevertheless, management difficulties increase with multiple lesions and in these cases the role of surgery has still to be defined.
Materials and Methods: We collected the clinical data of patients operated in two centers for cerebral MTS from lung carcinoma during 8 years. Patient selection for surgery followed definite criteria; the limit for multiple MTS was three. We analyzed the functional and survival outcomes of the cohort.
Results and Conclusions: Our series included 242 patients: 105 had multiple MTS. Statistical analysis did not show significant differences in mean survival and outcomes between patients with single and multiple lesions. The decease occurred for neurological causes in 15.7% of cases. The selection of candidates for surgery requires several considerations and entails the success rate of this treatment. In patients with the multiple lesions who fulfilled the selection criteria we observed a nevertheless satisfying success after the operation. Our results imply that surgery may be applied also in selected patients with more diffuse intracranial disease. A pre-operative accurate patient selection is related to acceptable quality-of-life following the operation even in cases of multiple MTS.
1Center of Brain and Cognition, CBC, Universitat Pompeu Fabra, Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain.
2Center of Brain and Cognition, CBC, Universitat Pompeu Fabra, Barcelona, Spain.
3Department of Psychology, University of Chicago, Chicago, Illinois, United States of America.
4Departament de Psicologia Bàsica, Evolutiva i de l'Educació, Universitat Autònoma de Barcelona, Barcelona, Spain.
5Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain; Department of Economics, Universitat Pompeu Fabra, Barcelona, Spain.
6Department of Human Development and Family Studies, University of Connecticut, Storrs, Connecticut, United States of America.
Should you sacrifice one man to save five? Whatever your answer, it should not depend on whether you were asked the question in your native language or a foreign tongue so long as you understood the problem. And yet here we report evidence that people using a foreign language make substantially more utilitarian decisions when faced with such moral dilemmas. We argue that this stems from the reduced emotional response elicited by the foreign language, consequently reducing the impact of intuitive emotional concerns. In general, we suggest that the increased psychological distance of using a foreign language induces utilitarianism. This shows that moral judgments can be heavily affected by an orthogonal property to moral principles, and importantly, one that is relevant to hundreds of millions of individuals on a daily basis.
1Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
2Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina2now with Medical Corps, US Air Force, Joint Base Langley-Eustis, Virginia.
3Duke Sanford School of Public Policy, Durham, North Carolina4Community and Family Medicine and Nursing, Duke University Medical Center, Durham, North Carolina.
4Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina.
5Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina6Section of Otolaryngology, Durham VA Medical Center, Durham, North Carolina.
Physicians must participate in end-of-life discussions, but they understand poorly their patients' end-of-life values and preferences. A better understanding of these preferences and the effect of baseline attitudes will improve end-of-life discussions.
To determine how baseline attitudes toward quality vs quantity of life affect end-of-life resource allocation.
DESIGN, SETTING, AND PARTICIPANTS
Otolaryngology-head and neck surgery (OHNS) physicians were recruited to use a validated online tool to create a Medicare health plan for advanced cancer patients. During the exercise, participants allocated a limited pool of resources among 15 benefit categories. These data were compared with preliminary data from patients with cancer and their caregivers obtained from a separate study using the same tool. Attitudes toward quality vs quantity of life were assessed for both physicians and patients and caregivers. I
Participation in online assessment exercise.
MAIN OUTCOMES AND MEASURES
Medicare resource allocation.
Of 9120 OHNS physicians e-mailed, 767 participated. Data collected from this group were compared with data collected from 146 patients and 114 caregivers. Compared with patients and caregivers, OHNS physician allocations differed significantly in all 15 benefit categories except home care. When stratified by answers to 3 questions about baseline attitudes toward quality vs quantity of life, there were 3 categories in which allocations of patients and caregivers differed significantly from the group with the opposite attitude for at least 2 questions: other medical care (question 1, P < .001; question 2, P = .005), palliative care (question 1, P = .008; question 2, P = .006; question 3, P = .009), and treatment for cancer (questions 1 and 2, P < .001). In contrast, physician preferences showed significant differences in only 1, nonmatching category for each attitude question: cash (question 1, P = .02), drugs (question 2, P = .03), and home care (question 3, P = .048).
CONCLUSIONS AND RELEVANCE
Patients with cancer and their caregivers have different preferences from physicians. These preferences are, for these patients and their caregivers, affected by their baseline health attitudes, but physician preferences are not. Understanding the effect of baseline attitudes is important for effective end-of-life discussions.
1Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles2Department of Public Health/Health Policy, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan3Depa.
2Harvard Interfaculty Initiative in Health Policy, Cambridge, Massachusetts5Center for Clinical Epidemiology, St Luke's Life Science Institute, Tokyo, Japan.
3Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles.
4Department of Public Health/Health Policy, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan.
5Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles6Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angele.
Both dietary modification and use of statins can lower blood cholesterol. The increase in caloric intake among the general population is reported to have plateaued in the last decade, but no study has examined the relationship between the time trends of caloric intake and statin use. OBJECTIVE To examine the difference in the temporal trends of caloric and fat intake between statin users and nonusers among US adults.
DESIGN, SETTING, AND PARTICIPANTS
A repeated cross-sectional study in a nationally representative sample of 27 886 US adults, 20 years or older, from the National Health and Nutrition Examination Survey, 1999 through 2010. EXPOSURES Statin use.
MAIN OUTCOMES AND MEASURES
Caloric and fat intake measured through 24-hour dietary recall. Generalized linear models with interaction term between survey cycle and statin use were constructed to investigate the time trends of dietary intake for statin users and nonusers after adjustment for possible confounders. We calculated model-adjusted caloric and fat intake using these models and examined if the time trends differed by statin use. Body mass index (BMI) changes were also compared between statin users and nonusers.
In the 1999-2000 period, the caloric intake was significantly less for statin users compared with nonusers (2000 vs 2179 kcal/d; P = .007). The difference between the groups became smaller as time went by, and there was no statistical difference after the 2005-2006 period. Among statin users, caloric intake in the 2009-2010 period was 9.6% higher (95% CI, 1.8-18.1; P = .02) than that in the 1999-2000 period. In contrast, no significant change was observed among nonusers during the same study period. Statin users also consumed significantly less fat in the 1999-2000 period (71.7 vs 81.2 g/d; P = .003). Fat intake increased 14.4% among statin users (95% CI, 3.8-26.1; P = .007) while not changing significantly among nonusers. Also, BMI increased more among statin users (+1.3) than among nonusers (+0.4) in the adjusted model (P = .02).
CONCLUSIONS AND RELEVANCE
Caloric and fat intake have increased among statin users over time, which was not true for nonusers. The increase in BMI was faster for statin users than for nonusers. Efforts aimed at dietary control among statin users may be becoming less intensive. The importance of dietary composition may need to be reemphasized for statin users.
1Department of Internal Medicine, University of Tennessee College of Medicine, Chattanooga, TN, USA.
2Clinical Informatics, Erlanger Hospital, Chattanooga, TN, USA.
Professionalism is a core competency for residency required by the Accreditation Council of Graduate Medical Education. We sought a means to objectively assess professionalism among internal medicine and transitional year residents.
We established a point system to document unprofessional behaviors demonstrated by internal medicine and transitional year residents along with opportunities to redeem such negative points by deliberate positive professional acts. The intent of the policy is to assist residents in becoming aware of what constitutes unprofessional behavior and to provide opportunities for remediation by accruing positive points. A committee of core faculty and department leadership including the program director and clinic nurse manager determines professionalism points assigned. Negative points might be awarded for tardiness to mandatory or volunteered for events without a valid excuse, late evaluations or other paperwork required by the department, non-attendance at meetings prepaid by the department, and inappropriate use of personal days or leave. Examples of actions through which positive points can be gained to erase negative points include delivery of a mentored pre-conference talk, noon conference, medical student case/shelf review session, or a written reflection.
Between 2009 and 2012, 83 residents have trained in our program. Seventeen categorical internal medicine and two transitional year residents have been assigned points. A total of 55 negative points have been assigned and 19 points have been remediated. There appears to be a trend of fewer negative points and more positive points being assigned over each of the past three academic years.
Commitment to personal professional behavior is a lifelong process that residents must commit to during their training. A professionalism policy, which employs a point system, has been instituted in our programs and may be a novel tool to promote awareness and underscore the merits of the professionalism competency.