Professionalization of Clinical Ethics Consultants: A Need for Liability Protection?

Clinical Ethics Consultation (CEC) has grown significantly in the last decade, and efforts are being made to professionalize the practice. The American Society for Bioethics and Humanities (ASBH) has been instrumental in this process, having published the Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants and founded and endorsed the creation of the Healthcare Ethics Consultant Certified (HCEC) Certification Commission. The ASBH also published "core competencies" for healthcare ethics consultants and has delineated a clear identity and role of such consultants distinct from that other healthcare professionals. In addition, more enter the field armed with advanced degrees (MA and PhD) or certification in clinical ethics consultation. While some have questioned the trend toward professionalization, the momentum is clearly in its favor. This paper explores three questions: Does the professionalization of healthcare ethics consultation expose those engaged in the field to the types of liability claims faced by professionals in other fields? What specific liabilities could affect a healthcare ethics consultant? And finally, what should healthcare ethics consultants do to protect themselves against liability claims? We conclude that while the risk of liability remains low, those engaged in the field should accept that risk just as part of their status as professionals and, like those in allied professions, seek appropriate protection in the form of liability insurance.

Antifungal stewardship: the Latin American experience.

Antifungal stewardship is a critical component of healthcare management that focuses on optimizing the use of antifungal medications to improve patient outcomes, minimize resistance, and reduce healthcare costs.  In resource-limited settings, the prevalence of fungal infections remains a significant health concern, often exacerbated by factors such as compromised immune systems, inadequate diagnostic capabilities, and limited access to antifungal agents. This paper reviews the current state of antifungal stewardship practices in developing countries, addressing the unique socioeconomic and healthcare landscape.

COVID-19 patients display changes in lymphocyte subsets with a higher frequency of dysfunctional CD8lo T cells associated with disease severity.

This work examines cellular immunity against SARS-CoV-2 in patients from Córdoba, Argentina, during two major waves characterized by different circulating viral variants and different social behavior. Using flow cytometry, we evaluated the main lymphocyte populations of peripheral blood from hospitalized patients with moderate and severe COVID-19 disease. Our results show disturbances in the cellular immune compartment, as previously reported in different cohorts worldwide. We observed an increased frequency of B cells and a significant decrease in the frequency of CD3+ T cells in COVID-19 patients compared to healthy donors (HD). We also found a reduction in Tregs, which was more pronounced in severe patients. During the first wave, the frequency of GZMB, CD107a, CD39, and PD-1-expressing conventional CD4+ T (T conv) cells was significantly higher in moderate and severe patients than in HD. During the second wave, only the GZMB+ T conv cells of moderate and severe patients increased significantly. In addition, these patients showed a decreased frequency in IL-2-producing T conv cells. Interestingly, we identified two subsets of circulating CD8+ T cells with low and high CD8 surface expression in both HD and COVID-19 patients. While the percentages of CD8hi and CD8lo T cells within the CD8+ population in HD are similar, a significant increase was observed in CD8lo T cell frequency in COVID-19 patients. CD8lo T cell populations from HD as well as from SARS-CoV-2 infected patients exhibited lower frequencies of the effector cytokine-producing cells, TNF, IL-2, and IFN-γ, than CD8hi T cells. Interestingly, the frequency of CD8lo T cells increased with disease severity, suggesting that this parameter could be a potential marker for disease progression. Indeed, the CD8hi/CD8lo index helped to significantly improve the patient's clinical stratification and disease outcome prediction. Our data support the addition of, at least, a CD8hi/CD8lo index into the panel of biomarkers commonly used in clinical labs, since its determination may be a useful tool with impact on the therapeutic management of the patients.

High-dimensional analysis of 16 SARS-CoV-2 vaccine combinations reveals lymphocyte signatures correlating with immunogenicity.

The range of vaccines developed against severe acute respiratory syndrome coronavirus 2 (SARS­CoV­2) provides a unique opportunity to study immunization across different platforms. In a single-center cohort, we analyzed the humoral and cellular immune compartments following five coronavirus disease 2019 (COVID-19) vaccines spanning three technologies (adenoviral, mRNA and inactivated virus) administered in 16 combinations. For adenoviral and inactivated-virus vaccines, heterologous combinations were generally more immunogenic compared to homologous regimens. The mRNA vaccine as the second dose resulted in the strongest antibody response and induced the highest frequency of spike-binding memory B cells irrespective of the priming vaccine. Priming with the inactivated-virus vaccine increased the SARS-CoV-2-specific T cell response, whereas boosting did not. Distinct immune signatures were elicited by the different vaccine combinations, demonstrating that the immune response is shaped by the type of vaccines applied and the order in which they are delivered. These data provide a framework for improving future vaccine strategies against pathogens and cancer.

Different cytokine and chemokine profiles in hospitalized patients with COVID-19 during the first and second outbreaks from Argentina show no association with clinical comorbidities.

Background: COVID-19 severity has been linked to an increased production of inflammatory mediators called "cytokine storm". Available data is mainly restricted to the first international outbreak and reports highly variable results. This study compares demographic and clinical features of patients with COVID-19 from Córdoba, Argentina, during the first two waves of the pandemic and analyzes association between comorbidities and disease outcome with the "cytokine storm", offering added value to the field. Methods: We investigated serum concentration of thirteen soluble mediators, including cytokines and chemokines, in hospitalized patients with moderate and severe COVID-19, without previous rheumatic and autoimmune diseases, from the central region of Argentina during the first and second infection waves. Samples from healthy controls were also assayed. Clinical and biochemical parameters were collected. Results: Comparison between the two first COVID-19 waves in Argentina highlighted that patients recruited during the second wave were younger and showed less concurrent comorbidities than those from the first outbreak. We also recognized particularities in the signatures of systemic cytokines and chemokines in patients from both infection waves. We determined that concurrent pre-existing comorbidities did not have contribution to serum concentration of systemic cytokines and chemokines in COVID-19 patients. We also identified immunological and biochemical parameters associated to inflammation which can be used as prognostic markers. Thus, IL-6 concentration, C reactive protein level and platelet count allowed to discriminate between death and discharge in patients hospitalized with severe COVID-19 only during the first but not the second wave. Conclusions: Our data provide information that deepens our understanding of COVID-19 pathogenesis linking demographic features of a COVID-19 cohort with cytokines and chemokines systemic concentration, presence of comorbidities and different disease outcomes. Altogether, our findings provide information not only at local level by delineating inflammatory/anti-inflammatory response of patients but also at international level addressing the impact of comorbidities and the infection wave in the variability of cytokine and chemokine production upon SARS-CoV-2 infection.

Invasive Candidiasis: Update and Current Challenges in the Management of This Mycosis in South America.

Invasive candidiasis encompassing Candida bloodstream infections and deep-seated candidiasis can become a persistent health problem. These infections are caused by Candida species and have high morbidity and mortality rates. Species distribution, access to diagnosis, treatment and mortality are different around the world. The mortality rate is high in South America (30-70%), and Candida albicans is the most prevalent species in this region. However, a global epidemiological shift to non-albicans species has been observed. In this group, C. parapsilosis is the species most frequently detected, followed by C. tropicalis, and at a slower rate, C. glabrata, which has also increased, in addition to the emerging C. auris, resistance to several drugs. This article summarizes relevant aspects of candidemia pathogenesis, such as the mechanisms of fungal invasion, immune response, and the impact of genetic defects that increase host susceptibility to developing the infection. We also discuss relevant aspects of treatment and future challenges in South America.

Candidiasis invasora: un enfoque a la infección en el sistema nervioso central

Resumen La candidemia es la micosis invasora más frecuente en los pacientes internados en hospitales de alta complejidad en el mundo. La infección fúngica en el sistema nervioso central constituye una complicación potencialmente mortal que agrava el pronóstico de los pacientes. El presente artículo aborda aspectos relevantes sobre las características clínicas de esta enfermedad, los mecanismos de invasión del hongo, la respuesta inmunitaria local frente a Candida albicans y el impacto de los defectos genéticos en receptores de la inmunidad innata, que aumentan la susceptibilidad a la neurocandidiasis.

Moral Distress Entangled: Patients and Providers in the COVID-19 Era.

Moral distress is defined as the inability to act according to one's own core values. During the COVID-19 pandemic, moral distress in medical personnel has gained attention, related to the impact of pandemic-associated factors, such as the uncertainty of treatment options for the virus and the accelerated pace of deaths. Measures to provide aid and mitigate the long-term pandemic effect on providers are starting to be designed. Yet, little has been said about the moral distress experienced by patients and the relational and additive effect on provider moral distress. Pandemic-associated factors affecting moral distress in patients include the constraining effects of isolation on spiritual and religious traditions as well as the intentional separation of patients from their families. This paper will explore the idea that patients are suffering their own moral distress and further how this impacts the intensity of moral distress experienced by the providers-nurses and physicians. The paucity of research in this area with the implications on patient's distress, decision making, and distress experienced by providers compels further investigation and analysis.

Exploring values among three cultures from a global bioethics perspective.

The United Nations Educational, Scientific and Cultural Organisation's (UNESCO) Declaration on Bioethics and Human Rights refers to the importance of cultural diversity and pluralism in ethical discourse and care of humanity. The aim of this meta-narrative review is to identify indigenous ethical values pertaining to the Ojibway (Canada), Xhosa (South Africa), and Mayan (Mexico and Central American) cultures from peer-reviewed sources and cultural review, and to ascertain if there are shared commonalities. Three main themes were identified, namely illness, healing, and health care choices. Illness was described with a more complex and dynamic picture than from the western view, as illness is not considered to be one dimensional. Healing needs to take place on various levels in order to restore a state of equilibrium between the different spheres. Health care choices were also considered from a multi-level perspective. In all three of the indigenous cultures explored, good decision-making is seen to have occurred when choices are informed by commitments to one's moral and ethical responsibilities towards the community, nature, and the spirit world.

Efecto de selladores endodónticos sobre el pH del medio al cual son inmersos / Effect of endodontic sealers on pH of the medium in which they are immersed

INTRODUCTION: The endodontic sealers are essential for three-dimensional root canal obturation. The sealers are based on epoxy resin, AH Plus and bioceramic sealers, Bio-C Sealer and BioRoot RCS, which are bioactive materials due to the ability to cause a specific biologic reaction in integration with the receptor tissue, with a pH of 12,5. OBJECTIVE: To evaluate in vitro, the capacity of different endodontic sealers to modify the pH of the solution in which they are immersed, at different time. MATERIALS AND METHODS: Fifteen samples of sealers were prepared and placed into holes of blister packs, which set for 24 hours in store at 37 degrees Celsius. Then, each sample was immersed in sterile plastic bottles with 30 millimeters of physiological solution. Samples were divided into three groups(n=5) according to the sealer: 1) BioRoot RCS, 2) Bio-C Sealer and 3) AHPlus. The pH measurements were performed in different periods of time with a digital pH meter: immediate, 40 min, 24 and 48 hs, 7, 14, 21 and 30 days. Data were made by means of the Variance Analysis Test with repeated measurements. RESULTS: The pH of AH Plus did not change during the experience. At 24 hs, both bioceramic sealers increased medium pH up to alkaline value, which was maintained with BioRoot sealer (mean 11,54) until 30 days. At 7 days, the pH of the medium with Bio-C Sealer started decreasing. Evolution of sealers pH along the time revealed statistical significant difference (p<0,001). CONCLUSION: AH Plus sealer did not modifie the pH of the medium Both bioceramic sealers increased the pH, reaching to the maximum alkaline value at 7 days, which was maintained with BioRoot RCS and lightly decreased with Bio-C Sealer at 30 days.

INTRODUCCIÓN: El uso de selladores en la obturación endodóntica es fundamental para lograr un sellado tridimensional del conducto radicular. Según su composición, se presentan selladores a base de resina epóxica, como el AH Plus y de biocerámico, como Bio-C Sealer y BioRoot RCS, siendo considerados los últimos como materialesbioactivos, por su capacidad de promover una reacción biológica específica sobre el tejido receptor, por la liberación de calcio y pH alcalino OBJETIVO: Evaluar, in vitro la capacidad de diferentes selladores endodónticos para modificar el pH de la solución en la cual son inmersos, en distintos períodos de tiempo. MATERIALES Y METODOS: Se prepararon 15 probetas de sellador en un molde de plástico. Se dejaron fraguar 24 hs en estufa a 37° C y posteriormente, cada una fue inmersa en un frasco consolución fisiológica. La muestra se dividió en tres grupos (n=5) según el sellador: 1) BioRoot RCS, 2) Bio-C Sealer y 3) AHPlus. Se determinó el pH de la solución de cada grupo en diferentes períodos de tiempo: inmediato, 40 min, 24 y 48 hs, 7, 14, 21 y 30 días. Los resultados fueron analizados estadísticamente mediante Análisis de Varianza con Medidas Repetidas (ANOVA). RESULTADOS: El sellador AH Plus mantuvo constante el pH del medio durante toda la experiencia. Ambos selladores biocerámicos elevaron el pH del medio hasta llegar a ser alcalino (11,2 y 11,5) a las 24 hs, el cual se mantuvo para el grupo BioRoot RCS hasta los 30 días, con un pH promedio de 11.5. Mientras que, a partir de los 7 días, en el grupoBio-C Sealer comenzó a descender el pH del medio. La evolución del pH a lo largo del tiempo arrojó diferencias significativas entre los distintos selladores evaluados (p<0,001). CONCLUSIONES: Bajo las condiciones del presente estudio, AH Plus no modificó el pH del medio y ambos selladores biocerámicos elevaron el pH, alcanzado su máximo valor de alcalinidad a los 7 días; a partir de los cuales, BioRoot RCS mantuvo el pH elevado del medio y con Bio-C Sealer se observó un ligero descenso del pH hasta los 30 días.

Candida albicans Modulates Murine and Human Beta Defensin-1 during Vaginitis.

Vulvovaginal candidiasis (VVC) and recurrent vulvovaginal candidiasis (RVVC) are two forms of a disease caused by Candida spp. ß-defensin (BD) is one of the most important families of antimicrobial peptides in the female genital tract and includes molecules that exert essential local functions as antimicrobial and PMN chemoattractant peptides. However, the information on their role during murine and human VVC and RVVC is limited. Thus, we analyzed the behavior and contribution of BD1 to the local response in a VVC mice model and the local cytokine profile and human BD1 and BD3 expression in cervicovaginal lavage from patients with VVC and RVVC. We demonstrated that, in patients with RVVC BD1, mRNA and protein expression were severely diminished and that the aspartate proteinase and lipase secreted by C. albicans are involved in that decrease. This study provides novel information about the pathogenesis of VVC and describes a highly efficient C. albicans escape strategy for perpetuating the infection; these results may contribute to the development of new or combined treatment approaches.

[Invasive candidiasis: A view to central nervous system infection]. / Candidiasis invasora: un enfoque a la infección en el sistema nervioso central.

Candidemia is the most frequent invasive mycosis in hospitalized patients worldwide. Fungal infection in central nervous system is a life-threatening complication which aggravates patients' prognosis. This article summarizes relevant aspects on the clinical characteristics of this pathology, mechanisms of fungus invasion, local immune response to Candida albicans and the impact of genetic defects on innate immune receptors that increase susceptibility to the acquisition of this form of mycosis.

Globalization and vulnerable populations in times of a pandemic: A Mayan perspective.

Global health conditions are marked by inequities due mostly to poverty and lack of access to healthcare services. In a Pandemic setting, Mayan Communities in the Quintana Roo State in Mexico are a good example of how these disparities are exacerbated. First, they may have difficulty in adhering to directives to stay home from work because of the nature of their job, and the necessity to work, their living conditions are marked by crowding and sometimes lack of basic sanitation. Other susceptibilities generally considered are the underlying host factors and medical conditions that may increase the risk of disease or of complications of disease. In general, our native communities experience a high degree of socio-economic marginalization and are at disproportionate risk in public health emergencies, becoming even more vulnerable during this global pandemic, owing to factors such as their lack of access to effective monitoring and early-warning systems, and adequate health and social services.

Strangers in a Strange Land: How Our Founding Principles and a Bitter Pill Undo the Assimilation of US Catholics.

Most Catholic physicians work with the comfortable assumption that we can practice our profession and our faith, fully assimilated into modern American culture and society. Increasingly, we have come to realize that to be a Catholic Christian is by nature to be countercultural. American culture, ordered by the founding fathers in concepts of liberty and freedom, has been profoundly affected by the introduction and reliance on a contraceptive pill. This has changed the mores and sexual behaviors of society in ways that are antithetical to Catholic values. The consequences of contraception have directly led to an acceptance of a broad number of behaviors and attitudes that society insists must be tolerated. This challenges the commitments of Catholic physicians both personally and professionally.

[Mucinous cystadenoma of the ileocecal valve. Uncommon intestinal tumor in a oneyear-old boy. Case report]. / Cistoadenoma mucinoso de la vá lvula ileocecal: tumoración intestinal infrecuente en un niñ o de 1 añ o. Reporte de caso.

Mucinous cystadenoma is usually found in the ovary, pancreas and appendix but its presentation in the intestine is extremely rare. In this case report we present an infant with partial intestinal occlusion due to a mucinous cystadenoma of the ileocecal valve. We performed an excision of the terminal ileum, ileocecal valve, cecum and appendix, followed by ileocolic anastomosis. The patient did well after the procedure and recovered uneventfully. To our knowledge, this is the first case report of this tumor in this location.

Cistoadenoma mucinoso de la válvula ileocecal: tumoración intestinal infrecuente en un niño de 1 año. Reporte de caso / Mucinous cystadenoma of the ileocecal valve. Uncommon intestinal tumor in a oneyear-old boy. Case report

RESUMEN El cistoadenoma mucinoso se encuentra usualmente en el ovario, páncreas y el apéndice, pero su presentación en el intestino es extremadamente rara. En este reporte de caso, presentamos a un niño con obstrucción parcial intestinal debido a un cistoadenoma mucinoso en la válvula ileocecal. En la cirugía se retiró el íleo terminal, válvula ileocecal, ciego y apéndice, seguido de anastomosis ileocecal. El paciente evolucionó favorablemente en el postoperatorio y se recuperó sin contratiempos. A nuestro entender, este es el primer reporte de presentación de este tumor en dicha localización.

ABSTRACT Mucinous cystadenoma is usually found in the ovary, pancreas and appendix but its presentation in the intestine is extremely rare. In this case report we present an infant with partial intestinal occlusion due to a mucinous cystadenoma of the ileocecal valve. We performed an excision of the terminal ileum, ileocecal valve, cecum and appendix, followed by ileocolic anastomosis. The patient did well after the procedure and recovered uneventfully. To our knowledge, this is the first case report of this tumor in this location.

Candida lipases: a review on biochemical, molecular and pathogenic aspects. / [Lipasas de especies Candida: una revisión sobre aspectos bioquímicos, moleculares y patogénicos.]

In the last half century there was a significant increase in the incidence of fungal infections being likely to become a global health priority. The sophisticated degree of host-Candida interaction is the product of different virulence strategies used by the fungus to invade the tissues and the various defense mechanisms that it develops to control it. There is a significant amount of literature that indicates that this opportunistic commensal fungus has components that can be considered virulence factors related to the stage of the infectious process. Among the virulence factors of this fungus can be mentioned the adherence to cell surfaces, the formation of biofilms and the production of hydrolytic enzymes. The most studied hydrolases secreted by C. albicans are aspartyl proteinases, phospholipases and esterases, while lipases have been the least studied. These enzymes would have the function to facilitate active penetration into the cells, participating in the digestion and synthesis of lipid esters for their nutrition and contributing to the invasion of the tissue by hydrolyzing the lipid components of the host cell membranes. There is also bibliographic evidence that these enzymes are capable to damage cells and molecules of the immune system to avoid the antimicrobial activity.Taking into account the foregoing, this review provides an updated description of biochemical and molecular characteristics of the lipases secreted by Candida, its role as a virulence factor and its potential for the development of new antifungal drugs.

En el último medio siglo se produjo un aumento significativo en la incidencia de infecciones fúngicas siendo probable que se conviertan en una prioridad de salud global. El sofisticado grado de interacción hospedador-Candida es producto de diferentes estrategias de virulencia que utiliza el hongo para invadir los tejidos y de los diversos mecanismos de defensa que este último desarrolla para controlarlo. Existe bibliografía que indica que este hongo comensal oportunista posee componentes que pueden ser considerados factores de virulencia asociados a la etapa del proceso infeccioso. Dentro de los factores de virulencia de este hongo pueden mencionarse la adherencia a las superficies celulares, la formación de biofilms y la producción de enzimas hidrolíticas. Las hidrolasas secretadas por C. albicans más estudiadas son las aspartil proteinasas, las fosfolipasas y las esterasas, mientras que las lipasas han sido las menos exploradas. Estas enzimas tendrían como función facilitar la penetración activa en las células, participar en la digestión y síntesis de ésteres de lípidos para su nutrición y contribuir a la invasión del tejido al hidrolizar los componentes lipídicos de las membranas celulares del hospedador. También hay evidencia bibliográfica que indica que estas enzimas son capaces de dañar células y moléculas del sistema inmune para evitar la actividad antimicrobiana. Teniendo en cuenta lo precedente, esta revisión, proporciona una actualizada descripción de las características bioquímicas y moleculares de las lipasas secretadas por el hongo Candida, su rol como factor de virulencia y su potencial para el desarrollo de nuevos fármacos antifúngicos.

Oxidative and nitrosative stress responses during macrophage-Candida albicans biofilm interaction.

Candida albicans is an important source of device-associated infection because of its capacity for biofilm formation. This yeast has the ability to form biofilms which favors the persistence of the infection. Furthermore, the innate immune response has a critical role in the control of these infections and macrophages (Mø) are vital to this process. An important fungicidal mechanism employed by Mø involves the generation of toxic reactive oxygen species (ROS) and reactive nitrogen intermediates (RNI). The interaction between biofilms and these immune cells, and the contribution of oxidative and nitrosative stress, that is determinant to the course of the infection, remains elusive. The aim of this study was to investigate this interaction. To this purpose, two models of Mø-biofilms contact, early (model 1) and mature (model 2) biofilms, were used; and the production of ROS, RNI and the oxidative stress response (OSR) were evaluated. We found that the presence of Mø decreased the biofilm formation at an early stage and increased the production of ROS and RNI, with activation of ORS (enzymatic and nonenzymatic). On the other hand, the interaction between mature biofilms and Mø resulted in an increasing biofilm formation, with low levels of RNI and ROS production and decrease of OSR. Dynamic interactions between Mø and fungal biofilms were also clearly evident from images obtained by confocal scanning laser microscopy. The prooxidant-antioxidant balance was different depending of C. albicans biofilms stages and likely acts as a signal over their formation in presence of Mø. These results may contribute to a better understanding of the immune-pathogenesis of C. albicans biofilm infections.