The transplantation of solid organs from HIV-positive donors to HIV-negative recipients: ethical implications.

HIV-positive individuals have traditionally been barred from donating organs due to transmission concerns, but this barrier may soon be lifted in the USA in limited settings when recipients are also infected with HIV. Recipients of livers and kidneys with well-controlled HIV infection have been shown to have similar outcomes to those without HIV, erasing ethical concerns about poorly chosen beneficiaries of precious organs. But the question of whether HIV-negative patients should be disallowed from receiving an organ from an HIV-positive donor has not been adequately explored. In this essay, we will discuss the background to this scenario and the ethical implications of its adoption from the perspectives of autonomy, beneficence/non-maleficence and justice.

Maimonides Reincarnated.

The writings of Maimonides, the 12th-century physician, Talmudic and philosophic scholar, are remarkably relevant for modern medicine. Whereas the specific medical recommendations are obviously outdated, Maimonides' perceptive insights into professional responsibilities and medical ethics remain as useful guides even in our postmodern era.

To repent or to rationalize: three physicians exchange letters on the ethics of experimentation in postwar medicine.

In the late 1990s, three prominent figures of 20th-century medicine-Paul Beeson, Howard Burchell, and Shimon Glick-exchanged private letters on the ethics of experimentation in the years following World War II. What began as a brief published back-and-forth blossomed into a long correspondence filled with humor and wisdom even in the face of continued disagreement. The history of postwar investigation unfolds memorably in their letters, starting with the whistleblowing of Beecher and Pappworth and moving into the 21st century. The heart of the discussion focuses on the ethics of consent and legitimate risk in clinical investigation, and on the prevalence of violations of patients' rights. Glick openly discusses his views about the widespread practice of their subjection to experiments without benefit or unrelated to their conditions. In opposition, Burchell claims that accusations of ethical misconduct during this period were exaggerated, and that most of these studies would pass review boards today. Just when things seem to reach an immutable impasse, Beeson weighs in with keen insight and personal experience. The debate provides not only an intimate perspective on some of the most influential physician investigators of the last half-century, but also a context for productively approaching ethical questions of today.

Quo vadis, bioethics.

The recent paper by Giubilini and Minerva suggesting the ethical permissibility of infanticide of normal newborns, calling it "postbirth abortion," represents a dangerous deterioration of generally accepted ethical norms. Their proposal represents a clear example of the so-called slippery slope and we caution against abandoning the age-old traditions of the medical profession assigning intrinsic value to human life from birth. This article discusses the proposed concept, makes comparisons with earlier similar trends of thought, and highlights the dangers of the proposal.

The Israeli terminally ill patient law of 2005.

Israel, like many other countries, is struggling with numerous bioethical dilemmas due to its cultural and religious diversity. Until recently there was no legal guidance for how to deal with end-of-life issues. However, in 2005 a law was passed regulating the treatment of dying patients. Its most controversial aspect is the distinction it makes between withholding therapy (which is allowed) and withdrawing continuous therapy (which is not allowed). In this formulation, the law attempted to strike a balance between respecting the autonomy of the patient and respecting the sanctity of life. The law respects autonomy by establishing the right of the patient to refuse treatment; it respects the sanctity of life by prohibiting active euthanasia and physician-assisted suicide. However, this compromise was not acceptable to all members of the public advisory body that framed the law. Some argued that there was no moral basis for the distinction between withholding and withdrawing treatment.

Mentoring in internal medicine.

Mentoring is a relationship aimed at fostering the development of the less experienced person. The internal medicine community has recently recognized the importance of this relationship in the advancement of careers in the profession. Preliminary evidence points to the importance of mentoring in achieving the mentee's goals without much suggestion that it could be harmful. It can be particularly helpful to women and minority junior faculty. We encourage academic institutions to help forge these relationships by developing their own formal systems of mentoring and to evaluate and report their efforts.

Urinothorax: An unexpected cause of pleural effusion.

Urinothorax is an unexpected cause of transudative pleural effusion associated with obstructive uropathy. We present a case of urinothorax in a patient with congestive heart failure who had undergone percutaneous nephrolithotomy. The diagnosis was made after an unexpected enlargement of the pleural effusion after treatment with diuretics.

Adherence to guidelines for patients hospitalized with heart failure: a nationwide survey.

BACKGROUND: Despite significant advances in the therapy of heart failure, many patients still do not receive optimal treatment. OBJECTIVES: To document the standard of care that patients hospitalized with HF in Israel received during a 2 month period. METHODS: The Heart Failure Survey in Israel 2003 was a prospective 2 month survey of patients admitted to all 25 public hospitals in Israel with a diagnosis of HF. RESULTS: The mean age of the 4102 patients was 73 years and 43% were female. The use of angiotensin-converting enzyme/angiotensin receptor blockers and beta blockers both declined from NYHA class I to IV (68.8% to 50.6% for ACE-inhibitor/ARB and 64.1% to 52.9% for beta blockers, P < 0.001 for comparisons). The percentage of patients by NYHA class taking an ACE-inhibitor or ARB and a beta blocker at hospital discharge also declined from NYHA class I to IV (47.5% to 28.8%, P < 0.002 for comparisons). The strongest predictor of being discharged with an ACE-inhibitor or ARB was the use of these medications at hospital admission. Negative predictors for their usage were age, creatinine, disease severity class, and functional status. CONCLUSIONS: Despite the dissemination of guidelines many patients did not receive optimal care for HF. Reasons for this discrepancy need to be identified and modified.

The care of patients with dementia: a modern Jewish ethical perspective.

Patients with dementia and their families can face many difficult and agonizing ethical dilemmas over the course of the illness. An awareness of the Jewish ethical response to some of these issues can help clinicians in treating patients of the Jewish faith and also serve as an example of how one ethical system addresses these questions. The Jewish response is grounded in a profound respect and value for human life in all its forms and man's responsibility to preserve it, but Judaism rejects unproven therapies and recognizes the limitations of modern medicine. Jewish law also codifies normative obligations that children have toward their elderly parents. With these principles in the forefront, this article analyzes a Jewish ethical response to various problems in the care of the demented patient such as truth telling, transfer to a nursing home, artificial nutrition, and end-of-life care, taking into account modern concepts of the doctor-patient relationship and ancient Jewish tradition.

Deliberate self-poisoning with acetaminophen: a comparison with other medications.

BACKGROUND: Acetaminophen is the most common drug employed in deliberate self-poisoning (DSP) in many countries and can lead to acute liver failure. The purpose of the present study was to compare DSP with acetaminophen with DSP with other medications. METHODS: From January 2001 to December 2002, all patients admitted after DSP to Soroka University Hospital in Beer-Sheva, Israel, were identified. Demographic data and medical history were obtained retrospectively. RESULTS: There were 282 incidences of DSP in the study period. The mean age of 94 patients with an acetaminophen overdose was lower than that of patients who had attempted DSP with other medications (24.8 vs. 34.6 years, p<0.001). There was no gender or ethnic difference between the groups. Patients with DSP with acetaminophen were less likely to make recurrent attempts (23.4% vs. 39.9% p=0.006), less likely to have psychiatric disorders (32% vs. 59% p<0.001), and had a shorter hospital stay (1.7 vs. 2.1 days, p=0.05). The acetaminophen group had less of an impairment in level of consciousness (84% vs. 52.1% p<0.001) and had less need for ICU care (6.4% vs. 14.9%, p=0.04). Serum levels were checked in 68 (72.3%) of the patients in the acetaminophen group and they were found to be high in 6 (8.8%) of them (95% CI 2.1-15.5%). CONCLUSION: Taking an overdose of acetaminophen is a common method of DSP, with patients tending to have a more benign presentation and shorter hospital stay than those who attempt DSP with other medications. Further research on the optimal care of these patients and multi-disciplinary approaches to DSP prevention are needed.

Primary aortoduodenal fistula: Pitfalls and success in the endoscopic diagnosis.

Primary aortoenteric fistula is a rare but catastrophic cause of gastrointestinal bleeding. The diagnosis of primary aortoenteric fistula is difficult to make and is usually accompanied by a very high level of clinical suspicion. It should be considered in any elderly patient presenting with upper gastrointestinal bleeding in the context of a known abdominal aortic aneurysm. Prompt surgical intervention is necessary. We present the case of a 78-year-old man with a history of atherosclerotic abdominal aortic aneurysm which is presented with massive upper gastrointestinal bleeding due to a primary aortoduodenal fistula. Initial misdiagnosis led to a delay in treatment and the patient succumbed to the illness.

The epidemiology of primary biliary cirrhosis in southern Israel.

BACKGROUND: The epidemiology of primary biliary cirrhosis has changed significantly over the last decade, with a trend towards increasing prevalence in many places around the world. OBJECTIVES: To determine the overall prevalence of PBC in southern Israel and the specific rates for different immigrant groups between January 1993 and October 2004. METHODS: Multiple case-finding methods were used to identify all cases of PBC in the study region. Age-adjusted prevalence rates were compared among the different immigrant groups. RESULTS: A total of 47 cases of PBC were identified with an overall prevalence of 55 cases per million. All patients were women, and all except for a Bedouin Arab were Jewish. Foreign-born patients comprised 70% of our PBC cohort even though they represent only 45.4% of the regional population. This predominance of immigrants did not change when the rates were adjusted for age (P < 0.001). The prevalence rates were 40, 177, and 58 cases per million for those born in Israel, North Africa or Asia, and Eastern Europe, respectively. The age-specific prevalence rate for women older than 40 years varied from 135 cases per million among those born in Israel to 450 among immigrants from Eastern Europe and the former USSR to 700 cases per million among immigrants from North Africa and Asia. CONCLUSIONS: The prevalence of PBC in southern Israel is similar to that reported from some European countries. The rate is much higher among Jews than Arabs and among immigrants to Israel compared to native Israelis.

Gender-related differences in clinical characteristics and outcomes in patients with diabetic ketoacidosis.

BACKGROUND: Diabetic ketoacidosis (DKA) is 1 of the most common and serious complications of diabetes, and is a significant cause of morbidity and mortality. There is a paucity of data regarding gender-related differences in clinical characteristics and outcomes of patients hospitalized for DKA. OBJECTIVE: The purpose of this study was to assess whether gender plays a role in clinical characteristics and outcome of DKA. METHODS: We performed a retrospective cohort study of patients hospitalized with DKA between January 1, 2003 and January 1, 2010. The outcomes of male and female patients were compared. The primary outcome was in-hospital all-cause mortality. The secondary outcomes were 30-day all-cause mortality and rate of complications: sepsis, respiratory failure, multiple organ failure, stroke, and myocardial infarction. RESULTS: Eighty-nine men and 131 women with DKA were included in the study. Male patients had higher rates of chronic renal failure compared with women (16.9% vs 3.1%; P = 0.001), whereas more women than men received oral hypoglycemic therapy (19.8% vs 9.0%; P = 0.046); women also had higher glycosated hemoglobin levels before admission (11.9% [1.7%] vs 9.9% [2.2%]; P = 0.025). The in-hospital mortality rate was not significantly different for both genders (4.5% in the male group vs 3.8% in the female group; P = 1.0). We did not find significant differences between the 2 groups in the 30-day mortality rate (4.5% vs 6.1%; P = 0.7) or the rate of complications (5.6% vs 6.9%; P = 0.9). Advanced age, mechanical ventilation, and bedridden state were independent predictors of 30-day mortality. CONCLUSIONS: In our study we did not find statistically significant differences in the in-hospital mortality, 30-day all-cause mortality, or rate of complications between men and women hospitalized with DKA. However, women with poorly controlled type 2 diabetes mellitus receiving oral hypoglycemic therapy required particular attention and might benefit from earlier introduction and intensification of insulin therapy to avoid DKA.