Non-Cardiac Perioperative Mortality Factors at a Single Urban Veterans Affairs Medical Center.

Background: The Veterans affairs (VA) surgical quality improvement program was established to evaluate the quality of VA surgical care to over nine million United States Veterans. Patient demographics vary by region, with urban areas correlating with higher mortality rates. This study attempts to determine the factors associated with 30-day mortality at a single VA medical center in an urban setting. Methods: Patients included in the study were at least 18 years of age and underwent a surgical procedure between January 2013 and June 2023. Baseline demographics included preoperative comorbidities, American Society of Anesthesiology (ASA) class, and preoperative lab values. Clinical outcomes included postoperative mortality within 30 days of the procedure. Chi-square, t-test, ANOVA, and multivariate logistic regressions were used to determine relationships, using P < .05 to determine significance. Results: A total of 11,547 patients with complete data were included, of which 92 patients (0.8%) died within 30 days of surgery. A higher preoperative hematocrit was protective against 30-day mortality. A perioperative transfusion, bleeding disorder, chronic obstructive pulmonary disease (COPD), history of a myocardial infarction, higher ASA class, and an emergency procedure all increased the likelihood of perioperative mortality. Conclusions: Veterans who seek surgical care at Veterans Health Administration centers receive high quality care with a low mortality rate. Identifying risk factors for perioperative mortality provides the opportunity to stratify those veterans at highest risk.

Death-row organ donation, revisited.

In 2011, bioethicists turned their attention to the question of whether prisoners on death row ought to be allowed to be organ donors. The discussion began with a provocative anti-procurement article by Arthur Caplan and prompted responses from an impressive lineup of commentators. In the 10 years since, the situation for death-row inmates seeking to donate has hardly changed: U.S. prison authorities consistently refuse to allow death-row procurement. We believe that it is time to revisit the issue. While Caplan's commentators rebutted his narrow contention that organ procurement would undermine the goals of deterrence and retribution, none of them attempted to make a positive, nonconsequentialist case for organ donation as a right of death-row inmates. That is the task we take up in this paper. After sketching and briefly defending a theory of punishment, we show how denial of organ donation is inconsistent with punishment's basic logic.

Dignity and the Founding Myth of Bioethics.

In this article, I reject the "principlism" of Tom Beauchamp and James Childress and argue that respect for autonomy is, and ought to be, the fundamental value of bioethics. To do so, I offer a reconstruction of what I call the field's "founding myth," a genealogy that affords primacy to the right to be respected as a human being with dignity. Next, I examine the relationship between this basic right and a derivative right of autonomy. I suggest that principlism has promulgated an uncharitable understanding of respect for autonomy, one that ensures that the principle cannot occupy the central position I claim for it. Finally, I sketch a more plausible understanding of respect for autonomy and explore its implications.

Are conscientious objectors morally obligated to refer?

In this paper, we argue that providers who conscientiously refuse to provide legal and professionally accepted medical care are not always morally required to refer their patients to willing providers. Indeed, we will argue that refusing to refer is morally admirable in certain instances. In making the case, we show that belief in a sweeping moral duty to refer depends on an implicit assumption that the procedures sanctioned by legal and professional norms are ethically permissible. Focusing on examples of female genital cutting, clitoridectomy and 'normalizing' surgery for children with intersex traits, we argue that this assumption is untenable and that providers are not morally required to refer when refusing to perform genuinely unethical procedures. The fact that acceptance of our thesis would force us to face the challenge of distinguishing between ethical and unethical medical practices is a virtue. This is the central task of medical ethics, and we must confront it rather than evade it.

The Ethics of Elective Growth Hormone Therapy in Children with Idiopathic Short Stature.

In this article, we analyze the ethics of elective growth hormone (GH) therapy in children with idiopathic short stature (ISS). We discuss recent clinical research regarding the efficacy, side-effects, and risks of GH therapy, and argue that GH therapy is ethically unjustifiable for most children with ISS.

Mental Health Outcome Measures in Environmental Design Research: A Critical Review.

AIM: During the last several decades, researchers have produced abundant evidence of the environmental impacts on stress, attention, and physical activity. More recently, scholars have turned their focus to the influence environments have on mental wellness. Therefore, a critical review of this more recent research is both timely and crucial for setting the future research agenda. METHODS: In this article, we examined 65 papers published between 2008 and 2019 that examined the environmental correlates of a wide variety of mental health outcomes. We coded each study by type of environment, research design, mental health measurement scale used, and p-value. RESULTS: We categorized the research studies into six groups based on mental health outcomes: emotions, moods, vitality, executive function, stress, and general well-being. Our review revealed several trends among the studies, including a heavy focus on nature and outdoor environments with little attention to workplace or residential environments; a lack of consensus on how to operationalize the environment; a heavy reliance on self-reported ratings using a wide variety of scales, many focused on the same outcome; and a disproportionate focus on short-term health effects. CONCLUSIONS: There is a need for greater consensus on research constructs and health outcome measurements, focused on a wider variety of environmental settings and scales, in order to better inform evidence-based environmental design practice.

Ethical Considerations in Vaccine Allocation.

In an effort to establish a consensus position on the ethical principles and ideals that should guide vaccine allocation during the Covid-19 pandemic, various organizations, including the Centers for Disease Control (CDC) and National Academies of Science, Engineering, and Medicine, released sample allocation frameworks to help guide government entities charged with distributing vaccine doses. One area of agreement among these reports is that front line health care workers, especially those who come into regular contact with Covid-19 patients, ought to be afforded highest priority. But this convergence, though significant, raises questions concerning the ethics of vaccine distribution among those highest-priority health care workers: If a hospital has inadequate supply to vaccinate its entire workforce, which of its essential workers should it prioritize? In this paper, we begin with a general overview of ethical questions of vaccine administration before narrowing our focus to some of the most pressing theoretical and practical issues hospital officials must face in building justifiable and actionable frameworks for vaccinating their workers. We discuss and assess some potential ambitions of hospital allocation plans, concentrating especially on the goal of protecting the community from catastrophic loss of life. Finally, we consider some specific questions hospitals will encounter when developing distribution guidelines that aim to realize this aspiration.

The need for a unified ethical stance on child genital cutting.

The American College of Nurse-Midwives, American Society for Pain Management Nursing, American Academy of Pediatrics, and other largely US-based medical organizations have argued that at least some forms of non-therapeutic child genital cutting, including routine penile circumcision, are ethically permissible even when performed on non-consenting minors. In support of this view, these organizations have at times appealed to potential health benefits that may follow from removing sexually sensitive, non-diseased tissue from the genitals of such minors. We argue that these appeals to "health benefits" as a way of justifying medically unnecessary child genital cutting practices may have unintended consequences. For example, it may create a "loophole" through which certain forms of female genital cutting-or female genital "mutilation" as it is defined by the World Health Organization-could potentially be legitimized. Moreover, by comparing current dominant Western attitudes toward female genital "mutilation" and so-called intersex genital "normalization" surgeries (i.e. surgeries on children with certain differences of sex development), we show that the concept of health invoked in each case is inconsistent and culturally biased. It is time for Western healthcare organizations-including the American College of Nurse-Midwives, American Society for Pain Management Nursing, American Academy of Pediatrics, and World Health Organization-to adopt a more consistent concept of health and a unified ethical stance when it comes to child genital cutting practices.

Tolerance for Uncertainty and Professional Development: a Normative Analysis.

Scholars from a range of disciplines including medicine, sociology, psychology, and philosophy have addressed the concepts of ambiguity and uncertainty in medical practice and training. Most of this scholarship has been descriptive, focusing on defining and measuring ambiguity and uncertainty tolerance or tracking clinicians' responses to ambiguous and uncertain situations. Meanwhile, scholars have neglected some fundamental normative questions: Is tolerance of uncertainty good; if so, to what extent? Using a philosophical approach to these questions, we show that neither tolerance nor intolerance of uncertainty is necessarily a good or bad trait. Rather, both tolerance and intolerance of uncertainty can give physicians advantages while at the same time exposing them to pitfalls in clinical practice. After making this case, we argue that cultivating certain virtues-like courage, diligence, and curiosity-could help clinicians avoid the dangers of excessive tolerance and intolerance of uncertainty. Finally, we suggest that medical educators develop curricula and career counseling beginning with matriculation and proceeding through specialty choice and residency training that explicitly address trainees' responses to clinical uncertainty. These programs should encourage trainees, students and residents, to be mindful of their reactions to uncertainty and help them develop virtues that will allow them to avoid the hazards of extreme tolerance or intolerance of uncertainty.

Thirty-day complication rates do not differ by race among patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma.

BACKGROUND AND OBJECTIVES: Black patients with pancreatic ductal adenocarcinoma (PDAC) are less likely to receive multimodality treatment and have worse survival compared to White patients. However, little is known regarding racial differences in postoperative outcomes. The primary aim of this study was to determine if 30-day complication rates following pancreaticoduodenectomy (PD) differ by race. METHODS: A retrospective cohort study of patients who underwent PD for PDAC from 2014 to 2016 within the ACS-NSQIP pancreatectomy-specific data set was performed. Primary outcomes were 30-day pancreas-specific and overall major complications. RESULTS: A total of 6936 patients were identified, including 91.4% (N = 6337) White and 8.6% (N = 599) Black. Pathologic stage and rates of neoadjuvant therapy were similar among Whites and Blacks. Rates of pancreas-specific (23.9% vs. 23.1%, p = .88) and major postoperative complications (39.2% vs. 39.9%, p = .55) were similar between Whites and Blacks. By multivariable regression analysis, there was no association between race and odds of pancreas-specific complications (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.89-1.37) or overall major complications (OR 1.13, 95% CI 0.95-1.36). CONCLUSIONS: Among patients undergoing PD for PDAC, Black race is not associated with increased pancreas-specific or overall 30-day postoperative complications. Short-term postoperative outcomes do not appear to explain the increase in pancreatic cancer mortality among Black patients.

Understanding Autonomy: An Urgent Intervention.

In this paper, I argue that the principle of respect for autonomy can serve as the basis for laws that significantly limit conduct, including orders mandating isolation and quarantine. This thesis is fundamentally at odds with an overwhelming consensus in contemporary bioethics that the principle of respect for autonomy, while important in everyday clinical encounters, must be 'curtailed', 'constrained', or 'overridden' by other principles in times of crisis. I contend that bioethicists have embraced an indefensibly 'thin' notion of autonomy that uproots the concept from its foundations in Kantian ethics. According to this thin conception, respect for autonomy, if unconditioned by competing principles (beneficence, justice, non-maleficence) would give competent adults the right to do anything they desired to do so long as they satisfied certain baseline psychological conditions. I argue that the dominant 'principlist' model of bioethical reasoning depends on this thin view of autonomy and show how it deprives us of powerful analytical tools that would help us to think seriously about the foundations of human rights, justice, and law. Then, I offer a brief sketch of a 'thick', historically grounded notion of autonomy and show what we could gain by taking it seriously.

What 'Just Culture' doesn't understand about just punishment.

Recent years have seen the rise of 'Just Culture' as an ideal in the patient safety movement, with numerous hospitals and professional organisations adopting a Just Culture response to incidents ranging from non-culpable human error to intentional misconduct. This paper argues that there is a deep problem with the Just Culture model, resulting from its impoverished understanding of the value of punitive, fundamentally backward-looking, practices of holding people accountable. I show that the kind of 'accountability' and 'punishment' contemporary Just Culture advocates endorse disrespects both patients and providers. I claim, first, that punishment is good because it respects participants in the healthcare system by restoring an equilibrium of social and moral status that wrongdoing disturbs, and, second, that it only does so when it communicates a backward-looking message of resentful blame.

Freezing Eggs and Creating Patients: Moral Risks of Commercialized Fertility.

There's no doubt that reproductive technologies can transform lives for the better. Infertile couples and single, lesbian, gay, intersex, and transgender people have the potential to form families in ways that would have been inconceivable years ago. Yet we are concerned about the widespread commercialization of certain egg-freezing programs, the messages they propagate about motherhood, the way they blur the line between care and experimentation, and the manipulative and exaggerated marketing that stretches the truth and inspires false hope in women of various ages. We argue that although reproductive technology, and egg freezing in particular, promise to improve women's care by offering more choices to achieve pregnancy and childbearing, they actually have the potential to be disempowering. First, commercial motives in the fertility industry distort women's medical deliberations, thereby restricting their autonomy; second, having the option to freeze their eggs can change the meaning of women's reproductive choices in a way that is limiting rather than liberating.

Are Physicians Blameworthy for Iatrogenic Harm Resulting from Unnecessary Genital Surgeries?

We argue that physicians should, in certain cases, be held accountable by patients and their families for harm caused by "successful" genital surgeries performed for social and aesthetic reasons. We explore the question of physicians' blameworthiness for three types of genital surgeries common in the United States. First, we consider surgeries performed on newborns and toddlers with atypical sex development, or intersex. Second, we discuss routine neonatal male circumcision. Finally, we consider cosmetic vaginal surgery. It is important for physicians not just to know when and why to perform genital surgery, but also to understand how their patients might react to wrongful performance of these procedures. Equally, physicians should know how to respond to their own blameworthiness in socially productive and morally restorative ways.

Effect of inter-annual variability in pasture growth and irrigation response on farm productivity and profitability based on biophysical and farm systems modelling.

Farm system and nutrient budget models are increasingly being used in analysis to inform on farm decision making and evaluate land use policy options at regional scales. These analyses are generally based on the use of average annual pasture yields. In New Zealand (NZ), like in many countries, there is considerable inter-annual variation in pasture growth rates, due to climate. In this study a modelling approach was used to (i) include inter-annual variability as an integral part of the analysis and (ii) test the approach in an economic analysis of irrigation in a case study within the Hawkes Bay Region of New Zealand. The Agricultural Production Systems Simulator (APSIM) was used to generate pasture dry matter yields (DMY) for 20 different years and under both dryland and irrigation. The generated DMY were linked to outputs from farm-scale modelling for both Sheep and Beef Systems (Farmaxx Pro) and Dairy Systems (Farmax® Dairy Pro) to calculate farm production over 20 different years. Variation in DMY and associated livestock production due to inter-annual variation in climate was large, with a coefficient of variations up to 20%. Irrigation decreased this inter-annual variation. On average irrigation, with unlimited available water, increased income by $831 to 1195/ha, but when irrigation was limited to 250mm/ha/year income only increased by $525 to 883/ha. Using pasture responses in individual years to capturing the inter-annual variation, rather than the pasture response averaged over 20years resulted in lower financial benefits. In the case study income from irrigation based on an average year were 10 to >20% higher compared with those obtained from individual years.

Developing a Strategy Menu for Community-Level Obesity Prevention.

Childhood obesity is a complex problem influenced by policies, systems, and environments, and its prevention requires changes across a range of community settings. To address this, we developed an obesity prevention strategy menu and an ongoing study to pilot its use and provide technical support for its implementation. The strategy menu is comprised of a set of effective approaches communities can use to develop tailored, context-specific health interventions based on local community needs and capacity. It was developed by a multidisciplinary team of researchers and practitioners who reviewed evidence and organized it to incorporate effective policy, systems, and environmental changes for reducing and preventing childhood obesity. Eventually, it will be part of a web-based point of access that complements the foundational relationships built between communities, researchers, and practitioners. By developing a framework to engage communities in the selection and implementation of multisetting obesity prevention strategies, we aim to create and sustain momentum toward a long-term reduction in obesity in Wisconsin children.

Dramatic Increase in the Incidence and Mortality from Merkel Cell Carcinoma in the United States.

Merkel cell carcinoma is a cutaneous neuroendocrine neoplasm that has been poorly studied in contemporary cohorts. Patients with Merkel cell carcinoma from 1986 to 2011 were identified in the Surveillance Epidemiology and End Results registry. A total of 5211 patients met the inclusion criteria. The mean age was 74.9 years; majority were male (61.4%) and white (94.9%). Patients were divided into two cohorts: Group 1 (1986 and 1999) and Group 2 (1999-2010). Group 2 was more likely to have Stage III disease (14.6 vs 23.3%, P < 0.001) and less likely to have Stage I/II disease (71.8 vs 65.1%, P < 0.0001). The increase in Stage III was likely secondary to increased use of sentinel lymph node biopsy. Disease-specific five-year survival for Stages I/II was 78.1 per cent and Stage III was 54 per cent. Disease-specific five-year survival was unchanged between Groups 1 and 2, 69.9 versus 66.6 per cent, respectively (P = 0.44). Both incidence and mortality significantly increased over the study period with P value for both trends <0.0001. In 1986, incidence and mortality rates per 100,000 were 0.22 and 0.03, respectively, and increased to 0.79 and 0.43 in 2011, respectively. There has been a greater than 333 per cent increase in mortality from Merkel cell carcinoma.

Increasing incidence of duodenal neuroendocrine tumors: Incidental discovery of indolent disease?

BACKGROUND: There has been a marked increase in the recognized incidence of gastroenteropancreatic neuroendocrine tumors (GEP-NETs). Studies have often combined duodenal neuroendocrine tumors (D-NETs) with other small bowel GEP-NETs. As a result, the natural history and clinical ramifications of these D-NETs is poorly understood. METHODS: Patients diagnosed with duodenal "carcinoid" tumors from 1983 to 2010 were identified in the Surveillance Epidemiology and End Results tumor registry. RESULTS: A total of 1,258 patients were identified. The mean age was 64 years. The majority of patients were male (55.6%), white (55.6%), and had stage I disease (66.2%). Patients meeting inclusion criteria were divided into 2 cohorts: (i) era 1 patients diagnosed with GEP-NETs from 1983 to 2005, and (ii) era 2 those diagnosed from 2005 to 2010. There was a clear increase in the incidence rate of D-NETs from 0.27 per 100,000 in 1983 to 1.1 per 100,000 in 2010 (P < .001). Comparison of patients from the different eras revealed that those in era 2 were more likely than era 1 to present with stage I disease (69.9 vs 57.5%; P < .01) and less likely to present with late-stage disease. The 5-year, disease-specific survival improved for era 2 patients compared with era 1 (89.3 vs 85.2%; P = .05); however, multivariate analysis demonstrated that stage but not era was associated with disease-specific survival. CONCLUSION: Prognosis for D-NETs, in contrast with other small bowel NETs, is excellent. There has been a steady increase in the recognized incidence of D-NETs, coincident with the migration to earlier disease stage and improved disease-specific survival.