Am J Public Health. 2014 Jul 17:e1-e4. [Epub ahead of print]

Potential Effects of California's New Vaccine Exemption Law on the Prevalence and Clustering of Exemptions.

Jones M1, Buttenheim A.

Author information

• 1Malia Jones is with the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles. Alison Buttenheim is with the School of Nursing and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.

Abstract

Exemptions from childhood immunizations required for school entry have continued to increase among California kindergartners, and exemptions show spatial clustering within the state. A 2014 change in California's school-entry vaccine exemption law requires parents filing for an exemption to submit signed documents from a health care provider. However, the evidence presented here suggests that the policy change will probably not be sufficient to reverse the growing trend in vaccine refusals. 

Camb Q Healthc Ethics. 2014 Jul 17:1-14. [Epub ahead of print]

Pathologizing Suffering and the Pursuit of a Peaceful Death.

Rich BA.

Abstract

The specialty of psychiatry has a long-standing, virtually monolithic view that a desire to die, even a desire for a hastened death among the terminally ill, is a manifestation of mental illness. Recently, psychiatry has made significant inroads into hospice and palliative care, and in doing so brings with it the conviction that dying patients who seek to end their suffering by asserting control over the time and manner of their inevitable death should be provided with psychotherapeutic measures rather than having their expressed wishes respected as though their desire for an earlier death were the rational choice of someone with decisional capacity. This article reviews and critiques this approach from the perspective of recent clinical data indicating that patients who secure and utilize a lethal prescription are generally exercising an autonomous choice unencumbered by clinical depression or other forms of incapacitating mental illness.

Camb Q Healthc Ethics. 2014 Jul 17:1-14. [Epub ahead of print]

Dignity and the Ownership and Use of Body Parts.

Foster C.

Abstract

Property-based models of the ownership of body parts are common. They are inadequate. They fail to deal satisfactorily with many important problems, and even when they do work, they rely on ideas that have to be derived from deeper, usually unacknowledged principles. This article proposes that the parent principle is always human dignity, and that one will get more satisfactory answers if one interrogates the older, wiser parent instead of the younger, callow offspring. But human dignity has a credibility problem. It is often seen as hopelessly amorphous or incurably theological. These accusations are often just. But a more thorough exegesis exculpates dignity and gives it its proper place at the fountainhead of bioethics. Dignity is objective human thriving. Thriving considerations can and should be applied to dead people as well as live ones. To use dignity properly, the unit of bioethical analysis needs to be the whole transaction rather than (for instance) the doctor-patient relationship. The dignity interests of all the stakeholders are assessed in a sort of utilitarianism. Its use in relation to body part ownership is demonstrated. Article 8(1) of the European Convention of Human Rights endorses and mandates this approach.

Camb Q Healthc Ethics. 2014 Jul 17:1-9. [Epub ahead of print]

Why Physicians Should Not Be Involved in Hostile Interrogations.

Davis M.

Abstract

The purpose of this article is to provide a moral foundation for Heilig's argument (published in the same issue) that physician participation in torture is a violation of medical ethics. The argument needs a moral foundation because it is unconventional by the standards of academic biomedical ethics. There is little about the "principles of bioethics", the nature of medicine, the physician-patient relationship, the physician's "social role," or the like. Instead, Heilig rests his argument primarily on the AMA's Code of Ethics (and international equivalents)-what most bioethicists tend to treat as mere custom, etiquette, law, or statements of opinion (when they do not ignore it altogether). This article explains why the AMA Code of Ethics can set the standard for ethical conduct for physicians-given a certain understanding of "ethics" and "profession" largely absent from biomedical ethics but common in professional ethics generally. The article also responds to six likely objections.

Camb Q Healthc Ethics. 2014 Jul 17:1-11. [Epub ahead of print]

The Ethical Imperative to Think about Thinking.

Stark M, Fins JJ.

Abstract

While the medical ethics literature has well explored the harm to patients, families, and the integrity of the profession in failing to disclose medical errors once they occur, less often addressed are the moral and professional obligations to take all available steps to prevent errors and harm in the first instance. As an expanding body of scholarship further elucidates the causes of medical error, including the considerable extent to which medical errors, particularly in diagnostics, may be attributable to cognitive sources, insufficient progress in systematically evaluating and implementing suggested strategies for improving critical thinking skills and medical judgment is of mounting concern. Continued failure to address pervasive thinking errors in medical decisionmaking imperils patient safety and professionalism, as well as beneficence and nonmaleficence, fairness and justice. We maintain that self-reflective and metacognitive refinement of critical thinking should not be construed as optional but rather should be considered an integral part of medical education, a codified tenet of professionalism, and by extension, a moral and professional duty.

West African Ebola: "This outbreak is unprecedented for many reasons..."

Assistant Professor of Africana Studies Donna Patterson Emphasizes Global Nature of Public Health

The ongoing West African Ebola epidemic is officially the most deadly on record, and the number of infected persons is steadily rising. Donna Patterson, assistant professor of Africana studies, writes and teaches about Africa and global health issues and has been traveling to the region most affected by the outbreak for almost 20 years. She reflects on why we should be paying close attention to the outbreak. 
.........................

She writes:

This outbreak is unprecedented for many reasons: the speed and sustained pattern of infection, its existence in some high-density settings, and its emergence in the West African subregion. It arrived without any forewarning and within a matter of two weeks 80 cases were confirmed. By late May, it seemed as if the epidemic would subside like previous cases but in June, cases and deaths spiked and the disease began to take hold in new areas.

 - See more at: http://www.wellesley.edu/news/2014/july/node/44174#sthash.byOPMsdq.dpuf

Prev Med. 2014 Jul 12. pii: S0091-7435(14)00246-1. doi: 10.1016/j.ypmed.2014.07.005. [Epub ahead of print]

Nicotine reduction as an increase in the unit price of cigarettes: A behavioral economics approach.

Smith TT1, Sved AF2, Hatsukami DK3, Donny EC4.

Author information

• 1Department of Psychology, University of Pittsburgh. Electronic address: tgt4@pitt.edu.
• 2Department of Psychology, University of Pittsburgh; Department of Neuroscience, University of Pittsburgh.
• 3Department of Psychiatry, University of Minnesota.
• 4Department of Psychology, University of Pittsburgh. Electronic address: edonny@pitt.edu.

Abstract

Urgent action is needed to reduce the harm caused by smoking. Product standards that reduce the addictiveness of cigarettes are now possible both in the U.S. and in countries party to the Framework Convention on Tobacco Control. Specifically, standards that required substantially reduced nicotine content in cigarettes could enable cessation in smokers and prevent future smoking among current non-smokers. Behavioral economics uses principles from the field of microeconomics to characterize how consumption of a reinforcer changes as a function of the unit price of that reinforcer (unit price=cost / reinforcer magnitude). A nicotine reduction policy might be considered an increase in the unit price of nicotine because smokers are paying more per unit of nicotine. This perspective allows principles from behavioral economics to be applied to nicotine reduction research questions, including how nicotine consumption, smoking behavior, use of other tobacco products, and use of other drugs of abuse are likely to be affected. This paper reviews the utility of this approach and evaluates the notion that a reduction in nicotine content is equivalent to a reduction in the reinforcement value of smoking-an assumption made by the unit price approach.

CAP Archives: Alterations in the Expression of p53, KLF4, and p21 in Neuroendocrine Lung Tumors

José Manuel Naranjo Gómez, Jose Fernando Val Bernal, Pilar García Arranz, Servando Lazuén Fernández, and Jose Javier Gómez Roman (2014) Alterations in the Expression of p53, KLF4, and p21 in Neuroendocrine Lung Tumors. Archives of Pathology & Laboratory Medicine: July 2014, Vol. 138, No. 7, pp. 936-942.

ORIGINAL ARTICLES

Alterations in the Expression of p53, KLF4, and p21 in Neuroendocrine Lung Tumors

José Manuel Naranjo Gómez, MD, PhD; Jose Fernando Val Bernal, MD, PhD; Pilar García Arranz, MD; Servando LazuénFernández, MD; Jose Javier Gómez Roman, MD, PhD

From the Departments of Thoracic Surgery (Dr Naranjo Gómez) and Pathology (Drs Val Bernal, García Arranz, Lazuén Fernández, and Gómez Roman), Hospital Universitario Marqués de Valdecilla, Santander, Spain.

Context.—Neuroendocrine lung neoplasms are a heterogeneous group of tumors with different clinical behavior and prognosis.

Objectives.—To evaluate the expression of p53, KLF4, and p21 in neuroendocrine lung neoplasms and to analyze the influence that expression has on the prognosis of those tumors.

Design.—All neuroendocrine lung neoplasms (N = 109) resected in our institution were reviewed, with the collection of histologic slides and paraffin blocks of 47 typical carcinoids (43%), 9 atypical carcinoids (8%), 35 large cell neuroendocrine carcinomas (32%), and 18 small cell lung carcinomas (17%), as well as 10 tumorlets (100%). Four tissue microarrays were performed. Follow-up was assessed in all cases (119 of 119; 100%).

Results.—p53 protein immunostaining results were negative in both the tumorlets and typical carcinoids and were overexpressed in 11% (1 of 9) of the atypical carcinoids and in 68% (36 of 53) of the carcinomas. KLF4 results were positive in all tumorlets (10 of 10; 100%), 32% (15 of 47) of the typical carcinoids, 44% (4 of 9) of the atypical carcinoids, and 62% (33 of 53) of the carcinomas. p21 expression did not differ among the groups. The lack of KLF4 and p21 expression was associated with an accumulation of aggressive features in typical carcinoids (P = .04 and P = .004, respectively, Fisher exact test).

Conclusions.—p53, KLF4, and p21 showed altered expression patterns in pulmonary neuroendocrine neoplasms. Lack of KLF4 and p21 expression was associated with accumulation of aggressive features in typical carcinoids.

CAP Archives: Significance of Proximal Margin Involvement in Low-Grade Appendiceal Mucinous Neoplasms

Thomas Arnason, Michal Kamionek, Michelle Yang, Rhonda K. Yantiss, and Joseph Misdraji (2014) Significance of Proximal Margin Involvement in Low-Grade Appendiceal Mucinous Neoplasms. Archives of Pathology & Laboratory Medicine In-Press.

Early Online Release

Significance of Proximal Margin Involvement in Low-Grade Appendiceal Mucinous Neoplasms

Thomas Arnason, MD; Michal Kamionek, MD; Michelle Yang, MD; Rhonda K. Yantiss, MD; Joseph Misdraji, MD

Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston (Drs Arnason, Kamionek, and Misdraji)

Division of Anatomical Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada (Dr Arnason)

Department of Pathology, University of Massachusetts Memorial Medical Center, Worcester (Dr Yang); and

Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York (Dr Yantiss). Dr Kamionek is now located at the Carolinas Pathology Group, Carolinas Medical Center, Charlotte, North Carolina.

Context.— Appendiceal adenomas and low-grade appendiceal mucinous neoplasms (LAMNs) confined to the appendix are cured by appendectomy. However, involvement of the proximal margin raises concern for residual disease. Some patients with a positive margin at appendectomy undergo cecal resection to eliminate a perceived risk for tumor recurrence or dissemination, although that likelihood is assumed rather than demonstrated.

Objective.— To determine whether involvement of the proximal appendiceal resection margin by adenoma or LAMN is a risk factor for local development of recurrence or pseudomyxoma peritonei.

Design.— Appendiceal adenomas and LAMNs confined to the appendix were considered for the study if they showed neoplasia or dissecting mucin at the proximal margin. The presence or absence of residual tumor in cecal resections was determined. Follow-up data were obtained from clinical records.

Results.— 16 patients (14 female, 2 male) with LAMN (n = 15) or adenoma (n = 1) and an involved proximal resection margin were identified, including 9 with neoplastic epithelium within the lumen and 7 with acellular mucin in the appendiceal wall at the margin. Six patients underwent cecal resection and the others were nonsurgically followed. No cecal resection had residual neoplasia. No patient developed recurrence or pseudomyxoma peritonei (mean follow-up, 4.7 years).

Conclusions.— In patients with LAMNs confined to the appendix, involvement of the appendectomy margin by neoplastic epithelium or acellular mucin does not predict recurrence of disease, even without further surgery. A conservative approach to managing these patients can be justified.

Semin Respir Crit Care Med. 2014 Jun;35(3):336-51. doi: 10.1055/s-0034-1381229. Epub 2014 Jul 9.

Clinical presentation of sarcoidosis and diagnostic work-up.

Valeyre D1, Bernaudin JF2, Uzunhan Y1, Kambouchner M3, Brillet PY4, Soussan M5, Nunes H1.

Author information

• 1Pneumology Department, Avicenne Universitary Hospital, Bobigny, France.
• 2Histology and Cytology Department, Tenon Universitary Hospital, Paris, France.
• 3Pathology Department, Avicenne Universitary Hospital, Bobigny, France.
• 4Université Paris 13, Sorbonne Paris Cité, EA 2363, Hypoxie et poumon, Bobigny, France.
• 5Nuclear Medicine Department, Avicenne Universitary Hospital, Bobigny, France.

Abstract

Sarcoidosis is a systemic disease of unknown cause characterized by the formation of immune granulomas which most often involve the lung and the lymphatic system. Sarcoidosis may encompass numerous different clinical presentations. Typical presentations often prompt a rapid diagnosis while in 25 to 50% of cases, diverse and less typical presentations may lead to delayed diagnosis. The mediastinopulmonary sphere is involved in 85 to 95% of cases, associated with extrapulmonary localizations in half of cases while extrapulmonary localizations without lung involvement may be seen in 5 to 15% of cases. Bilateral hilar lymphadenopathy is the most typical sign at chest radiography. Computed tomography (CT) is essential face for atypical manifestations of the disease to avoid confusion with differential diagnoses and, sometimes, comorbidities. CT typically evidences diffuse pulmonary perilymphatic micronodules, with a perilobular and fissural distribution and upper and posterior predominance, even when an atypical CT pattern is predominant. CT allows deciphering pulmonary lesions in cases of pulmonary fibrosis, pulmonary hypertension, and airflow limitation. Pulmonary function tests generally correlate with the overall disease process. Forced vital capacity is the simplest and most accurate parameter to reflect the impact of pulmonary sarcoidosis. Cardiopulmonary exercise testing helps in understanding the mechanism behind dyspnea of uncertainorigin. Endoscopic transbronchial needle aspiration is an extra tool to support diagnosis in addition to more classical biopsy means. Bronchoalveolar lavage (BAL) may be used for individual patients while it is not really decisive for the diagnosis of sarcoidosis for most patients. Diagnosis relies on compatible clinical and radiological presentation, evidence of noncaseating granulomas and exclusion of other diseases with a similar presentation or histology. The probability of diagnosis at presentation is variable from case to case and may often be reinforced with time. Some investigations are mandatory at diagnosis to assess organ involvement and disease activity. However, there are important variations in diagnostic work-up due to diverse expressions of sarcoidosis and differences in clinical practices among physicians.

From Wake Forest: Use of St. John's Wort in Potentially Dangerous Combinations

J Altern Complement Med. 2014 Jul;20(7):578-9. doi: 10.1089/acm.2013.0216. Epub 2014 Jun 23.

Use of St. John's Wort in Potentially Dangerous Combinations.

Davis SA1, Feldman SR, Taylor SL.

Author information

• 11 Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine , Winston-Salem, NC.

Abstract

Objectives: The objective of this study was to assess how often St. John's wort (SJW) is prescribed with medications that may interact dangerously with it. 

Design: The study design was a retrospective analysis of nationally representative data from the National Ambulatory Medical Care Survey. Settings: The study setting was U.S. nonfederal outpatient physician offices. Subjects: Those prescribed SJW between 1993 and 2010 were the subjects. Outcome Measures: The outcome measures were medications co-prescribed with SJW. 

Results: Twenty-eight percent (28%) of SJW visits involved a drug that has potentially dangerous interaction with SJW. These included selective serotonin reuptake inhibitors, benzodiazepines, warfarin, statins, verapamil, digoxin, and oral contraceptives. 

Conclusions: SJW is frequently used in potentially dangerous combinations. Physicians should be aware of these common interactions and warn patients appropriately.

From Stanford U: Lung Volume Reduction After Stereotactic Ablative Radiation Therapy of Lung Tumors: Potential Application to Emphysema

Int J Radiat Oncol Biol Phys. 2014 Jul 8. pii: S0360-3016(14)00625-7. doi: 10.1016/j.ijrobp.2014.05.025. [Epub ahead of print]

Lung Volume Reduction After Stereotactic Ablative Radiation Therapy of Lung Tumors: Potential Application to Emphysema.

Binkley MS1, Shrager JB2, Leung AN3, Popat R4, Trakul N5, Atwood TF1, Chaudhuri A1, Maxim PG6, Diehn M7, Loo BW Jr8.

Author information

• 1Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.
• 2Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California.
• 3Department of Radiology, Stanford University School of Medicine, Stanford, California.
• 4Department of Health Research & Policy, Stanford University School of Medicine, Stanford, California.
• 5Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, California.
• 6Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California.
• 7Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California. Electronic address: Diehn@Stanford.edu.
• 8Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California. Electronic address: BWLoo@Stanford.edu.

Abstract

PURPOSE:

Lung volume reduction surgery (LVRS) improves dyspnea and other outcomes in selected patients with severe emphysema, but many have excessive surgical risk for LVRS. We analyzed the dose-volume relationship for lobar volume reduction after stereotactic ablative radiation therapy (SABR) of lung tumors, hypothesizing that SABR could achieve therapeutic volume reduction if applied in emphysema.

METHODS AND MATERIALS:

We retrospectively identified patients treated from 2007 to 2011 who had SABR for 1 lung tumor, pre-SABR pulmonary function testing, and ≥6 months computed tomographic (CT) imaging follow-up. We contoured the treated lobe and untreated adjacent lobe(s) on CT before and after SABR and calculated their volume changes relative to the contoured total (bilateral) lung volume (TLV). We correlated lobar volume reduction with the volume receiving high biologically effective doses (BED, α/β = 3).

RESULTS:

27 patients met the inclusion criteria, with a median CT follow-up time of 14 months. There was no grade ≥3 toxicity. The median volume reduction of the treated lobe was 4.4% of TLV (range, -0.4%-10.8%); the median expansion of the untreated adjacent lobe was 2.6% of TLV (range, -3.9%-11.6%). The volume reduction of the treated lobe was positively correlated with the volume receiving BED ≥60 Gy (r2=0.45, P=.0001). This persisted in subgroups determined by high versus low pre-SABR forced expiratory volume in 1 second, treated lobe CT emphysema score, number of fractions, follow-up CT time, central versus peripheral location, and upper versus lower lobe location, with no significant differences in effect size between subgroups. Volume expansion of the untreated adjacent lobe(s) was positively correlated with volume reduction of the treated lobe (r2=0.47, P<.0001).

CONCLUSIONS:

We identified a dose-volume response for treated lobe volume reduction and adjacent lobe compensatory expansion after lung tumor SABR, consistent across multiple clinical parameters. These data serve to inform our ongoing prospective trial of stereotactic ablative volume reduction (SAVR) for severe emphysema in poor candidates for LVRS.

From Harvard, Cornell, and Stanford: Within-Family Obesity Associations: Evaluation of Parent, Child, and Sibling Relationships

Am J Prev Med. 2014 Jul 4. pii: S0749-3797(14)00236-0. doi: 10.1016/j.amepre.2014.05.018. [Epub ahead of print]

Within-Family Obesity Associations: Evaluation of Parent, Child, and Sibling Relationships.

Pachucki MC1, Lovenheim MF2, Harding M3.

Author information

• 1Mongan Institute for Health Policy, Massachusetts General Hospital, Division of General Academic Pediatrics, MassGeneral Hospital for Children, and Harvard Medical School, Boston, Massachusetts; National Bureau of Economic Research, Boston, Massachusetts. Electronic address: mpachucki@mgh.harvard.edu.
• 2Department of Human Ecology, Cornell University, Ithaca, New York.
• 3Department of Economics, Stanford University, Stanford, California.

Abstract

BACKGROUND:

How parent and sibling obesity status comparatively shape a child's obesity is unknown.

PURPOSE:

To investigate how the obesity status of different children within the same family is related to a parent or sibling's obesity.

METHODS:

A national sample of adults in 10,244 American households was surveyed during 2011; data were analyzed in 2012-2013. Of these households, 1,948 adults had one or two children; provided sociodemographic information; and reported on adult and child height and weight, physical activity, and food environment. Logistic regression models were estimated in which the outcome of interest was child obesity status, with parent and sibling obesity as key predictors, adjusting for a range of both adult and child social and demographic confounders.

RESULTS:

In one-child households, it was 2.2 times more likely (SE=0.5) that the child would be obese if a parent was obese. In households with two children, having an obese younger sibling was more strongly associated with elder-child obesity (OR=5.4, SE=1.9) than parent's obesity status (OR=2.3, SE=0.8). Having an obese elder sibling was associated with younger-child obesity (OR=5.6, SE=1.9), and parent obesity status was no longer significant. Within-family sibling obesity was more strongly patterned between siblings of the same gender than between different genders, and child physical activity was significantly associated with obesity status.

CONCLUSIONS:

Considering offspring composition and sibling gender may be beneficial in childhood obesity prevention and intervention.

From Johns Hopkins U: Ethics Skills Laboratory Experience for Surgery Interns

J Surg Educ. 2014 Jul 7. pii: S1931-7204(14)00095-6. doi: 10.1016/j.jsurg.2014.03.010. [Epub ahead of print]

Ethics Skills Laboratory Experience for Surgery Interns.

Moon MR1, Hughes MT2, Chen JY3, Khaira K4, Lipsett P5, Carrese JA2.

Author information

• 1Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland; Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland. Electronic address: mmoon4@jhmi.edu.
• 2Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland; Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
• 3Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland.
• 4National College of Natural Medicine, Portland, Oregon.
• 5Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.

Abstract

INTRODUCTION AND PURPOSE:

Ethics curricula are nearly universal in residency training programs, but the content and delivery methods are not well described, and there is still a relative paucity of literature evaluating the effect of ethics curricula. Several commentators have called for more ethics curriculum development at the postgraduate level, and specifically in surgery training. We detail our development and implementation of a clinical ethics curriculum for surgery interns.

METHODS:

We developed curricula and simulated patient cases for 2 core clinical ethics skills-breaking bad news and obtaining informed consent. Educational sessions for each topic included (1) framework development (discussion of interns' current experience, development of a consensus framework for ethical practice, and comparison with established frameworks) and (2) practice with simulated patient followed by peer and faculty feedback. At the beginning and end of each session, we administered a test of confidence and knowledge about the topics to assess the effect of the sessions.

RESULTS:

A total of 98 surgical interns participated in the ethics skills laboratory from Spring 2008 to Spring 2011. We identified significant improvement in confidence regarding the appropriate content of informed consent (<0.001) and capacity to break bad news (<0.001). We also identified significant improvement in overall knowledge regarding informed consent (<0.01), capacity assessment (<0.05), and breaking bad news (0.001). Regarding specific components of informed consent, capacity assessment, and breaking bad news, significant improvement was shown in some areas, while we failed to improve knowledge in others.

CONCLUSIONS:

Through faculty-facilitated small group discussion, surgery interns were able to develop frameworks for ethical practice that paralleled established frameworks. Skills-based training in clinical ethics resulted in an increase in knowledge scores and self-reported confidence. Evaluation of 4 annual cohorts of surgery interns demonstrates significant successes and some areas for improvement in this educational intervention.

Health Promot Pract. 2014 Jul 11. pii: 1524839914541279. [Epub ahead of print]

Forming and Developing Your Professional Identity: Easy as PI.

Goltz HH1, Smith ML2.

Author information

• 1University of Houston-Downtown, Houston, TX, USA Baylor College of Medicine, Houston, TX, USA Michael E. DeBakey VAMC, Houston, TX, USA goltzh@uhd.edu.
• 2The University of Georgia, Athens, GA, USA Texas A&M Health Science Center, College Station, TX, USA.

Abstract

Health education and promotion specialists and professional organizations have worked hard to successfully establish and maintain the status of health education/promotion (HE/P) as a unique and essential profession and to solidify practitioners' sense of professional identity. A professional identity is critical to a person's sense of self: It is about connecting with roles, responsibilities, values, and ethical standards unique to a specific profession. Professional identity is a complex issue in the HE/P profession; the distinction between personal and professional identities has been debated repeatedly over the years (e.g., should HE/P professionals be role models for clients?). The purpose of this Tool is to explain the concept of professional identity; provide new, emerging, and experienced HE/P with a greater understanding of what it means to have a professional identity; present processes and benchmarks of professional identity development; and offer specific tips and strategies for developing and enhancing an HE/P professional identity.

PLoS One. 2014 Jul 9;9(7):e101711. doi: 10.1371/journal.pone.0101711. eCollection 2014.

Surviving at any cost: guilt expression following extreme ethical conflicts in a virtual setting.

Cristofari C, Guitton MJ.

Author information

• Institut Universitaire en Santé Mentale de Québec, Quebec City, Quebec, Canada; Faculty of Medicine, Laval University, Quebec City, Quebec, Canada.

Abstract

Studying human behavior in response to large-scale catastrophic events, particularly how moral challenges would be undertaken under extreme conditions, is an important preoccupation for contemporary scientists and decision leaders. However, researching this issue was hindered by the lack of readily available models. Immersive virtual worlds could represent a solution, by providing ways to test human behavior in controlled life-threatening situations. Using a massively multi-player zombie apocalypse setting, we analysed spontaneously reported feelings of guilt following ethically questionable actions related to survival. The occurrence and magnitude of guilt depended on the nature of the consequences of the action. Furthermore, feelings of guilt predicted long-lasting changes in behavior, displayed as compensatory actions. Finally, actions inflicting immediate harm to others appeared mostly prompted by panic and were more commonly regretted. Thus, extreme conditions trigger a reduction of the impact of ethical norms in decision making, although awareness of ethicality is retained to a surprising extent.

From Delta State U-Nigeria: Ethics of clinical trials in Nigeria

Niger Med J. 2014 May;55(3):188-94. doi: 10.4103/0300-1652.132035.

Ethics of clinical trials in Nigeria.

Okonta PI.

Author information

• Department of Obstetrics and Gynaecology, Delta State University, Abraka, Delta, Nigeria.

Abstract

The conduct of clinical trials for the development and licensing of drugs is a very important aspect of healthcare. Drug research, development and promotion have grown to a multi-billion dollar global business. Like all areas of human endeavour involving generation and control of huge financial resources, it could be subject to deviant behaviour, sharp business practices and unethical practices. The main objective of this review is to highlight potential ethical challenges in the conduct of clinical trials in Nigeria and outline ways in which these can be avoided. Current international and national regulatory and ethical guidelines are reviewed to illustrate the requirements for ethical conduct of clinical trials. Past experiences of unethical conduct of clinical trials especially in developing countries along with the increasing globalisation of research makes it imperative that all players should be aware of the ethical challenges in clinical trials and the benchmarks for ethical conduct of clinical research in Nigeria.

Jackie Fox's excellent 10 Commandments of Breast Cancer (great advice; not just for breast cancer patients)

Jackie Fox's excellent 10 Commandments of Breast Cancer

Inspired by my medical students this week to repost this.

Inspired by my medical students this week to repost this.

Fitness to drive and cannabis

Forensic Sci Int. 2014 Jun 4;242C:1-8. doi: 10.1016/j.forsciint.2014.05.014. [Epub ahead of print]

Fitness to drive and cannabis: Validation of two blood THCCOOH thresholds to distinguish occasional users from heavy smokers.

Fabritius M1, Augsburger M1, Chtioui H2, Favrat B3, Giroud C4.

Author information

• 1Forensic Toxicology and Chemistry Unit (UTCF), University Center of Legal Medicine (CURML), Rue du Bugnon 21, 1011 Lausanne, Switzerland.
• 2Division of Clinical Pharmacology, Centre Hospitalier Universitaire Vaudois, rue du Bugnon 17, Lausanne, Switzerland.
• 3Unit of Psychology and Traffic Medicine, University Center of Legal Medicine, Rue Saint-Martin 26, 1005 Lausanne, Switzerland; Unit of Psychology and Traffic Medicine, University Center of Legal Medicine, CMU, Rue Michel-Servet 1, 1211 Geneva 4, Switzerland.
• 4Forensic Toxicology and Chemistry Unit (UTCF), University Center of Legal Medicine (CURML), Rue du Bugnon 21, 1011 Lausanne, Switzerland. Electronic address: Christian.giroud@chuv.ch.

Abstract

Many studies based on either an experimental or an epidemiological approach, have shown that the ability to drive is impaired when the driver is under the influence of cannabis. Baseline performances of heavy users remain impaired even after several weeks of abstinence. Symptoms of cannabis abuse and dependence are generally considered incompatible with safe driving. Recently, it has been shown that traffic safety can be increased by reporting the long-term unfit drivers to the driver licensing authorities and referring the cases for further medical assessment. Evaluation of the frequency of cannabis use is a prerequisite for a reliable medical assessment of the fitness to drive. In a previous paper we advocated the use of two thresholds based on 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THCCOOH) concentration in whole blood to help to distinguish occasional cannabis users (≤3μg/L) from heavy regular smokers (≥40μg/L). These criteria were established on the basis of results obtained in a controlled cannabis smoking study with placebo, carried out with two groups of young male volunteers; the first group was characterized by a heavy use (≥10 joints/month) while the second group was made up of occasional users smoking at most 1 joint/week. However, to date, these cutoffs have not been adequately assessed under real conditions. Their validity can now be evaluated and confirmed with 146 traffic offenders' real cases in which the whole blood cannabinoid concentrations and the frequency of cannabis use are known. The two thresholds were not challenged by the presence of ethanol (40% of cases) and of other therapeutic and illegal drugs (24%). Thus, we propose the following procedure that can be very useful in the Swiss context but also in other countries with similar traffic policies: if the whole blood THCCOOH concentration is higher than 40μg/L, traffic offenders must be directed first and foremost toward medical assessment of their fitness to drive. This evaluation is not recommended if the THCCOOH concentration is lower than 3μg/L and if the self-rated frequency of cannabis use is less than 1 time/week. A THCCOOH level between these two thresholds cannot be reliably interpreted. In such a case, further medical assessment and follow-up of the fitness to drive are also suggested, but with lower priority.

PLoS One. 2014 Jul 7;9(7):e101312. doi: 10.1371/journal.pone.0101312. eCollection 2014.

mHealth: A Strategic Field without a Solid Scientific Soul. A Systematic Review of Pain-Related Apps.

de la Vega R, Miró J.

Author information

• Unit for the Study and Treatment of Pain - ALGOS, Research Center for Behavior Assessment, Department of Psychology and Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Tarragona, Spain.

Abstract

BACKGROUND:

Mobile health (mHealth) has undergone exponential growth in recent years. Patients and healthcare professionals are increasingly using health-related applications, at the same time as concerns about ethical issues, bias, conflicts of interest and privacy are emerging. The general aim of this paper is to provide an overview of the current state of development of mHealth.

METHODS AND FINDINGS:

To exemplify the issues, we made a systematic review of the pain-related apps available in scientific databases (Medline, Web of Science, Gale, Psycinfo, etc.) and the main application shops (App Store, Blackberry App World, Google Play, Nokia Store and Windows Phone Store). Only applications (designed for both patients and clinicians) focused on pain education, assessment and treatment were included. Of the 47 papers published on 34 apps in scientific databases, none were available in the app shops. A total of 283 pain-related apps were found in the five shops searched, but no articles have been published on these apps. The main limitation of this review is that we did not look at all stores in all countries.

CONCLUSIONS:

There is a huge gap between the scientific and commercial faces of mHealth. Specific efforts are needed to facilitate knowledge translation and regulate commercial health-related apps.