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 Whereas the specific medical recommendations are obviously outdated, Maimonides' perceptive insights into professional responsibilities and medical ethics remain as useful guides even in our postmodern era.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.

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.

Content analysis of ethical codes written by medical students compared with other codes of medical ethics.

INTRODUCTION: Swearing to a medical oath is a common practice in medical schools today. Students at the Medical School for International Health (MSIH) participate in an elaborate physician's oath ceremony held in the first year of studies. At this ceremony, students read a code of ethics written by their class, the content of which includes the ethical principles the class as a whole deems significant. METHODS: 9 codes of ethics, written by students at the MSIH between 1998 and 2006, as well as the oaths of Hippocrates and Maimonides, were collected and the principles contained within them were analyzed and compared. The oaths were broken up into preamble, covenant, code, and peroration sections, each encompassing various content domains. RESULTS: Principles discussed in both the oaths of Hippocrates and Maimonides, as well in two-thirds or more of the student-written codes, included loyalty to one's colleagues, the profession, and one's teachers, as well as acting with beneficence. Attributes including compassion, integrity, and honesty, were mentioned in two-thirds or more of the student-written codes but neither the oath of Hippocrates nor Maimonides. Controversial issues, such as abortion and discussing God were not included in codes written by students. CONCLUSIONS: Ethical codes written by students at the MSIH contained some similar principles to those contained within the traditional oaths; however, there was more emphasis on attributes that establish a good physician-patient relationship in the codes written by students. Future studies need to examine the content of other student-written codes.

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.

A national study on lipid management.

BACKGROUND: Hyperlipidemia remains a major cause of morbidity in Western countries. The objective of this study was to document the percentage of adults who underwent periodical LDL measurement, and the percentage of patients with diabetes and post-angioplasty who were treated to goal. METHODS: Using a national database, data were obtained on the percentage of adults who had an LDL performed and the percentage of adults with an LDL at pre-specified levels. We also assessed the attainment of target LDL levels in diabetic and post-angioplasty patients. Data were also collected from patients with an acute coronary syndrome (ACS) admitted to seven hospitals within a 5 year period (2000-2004). RESULTS: Primary prevention: In 2005, 64.6% of the total population of 754,910 aged 35-44 had at least one record of LDL cholesterol measurement documented. This figure was 79.6% in the 717,617 adults aged 45-54. Secondary prevention: Of 253,233 diabetics in 2005, 220,023 (86.9%) have undergone at least one annual LDL measurement. The percentage of patients on statin therapy 3 and 12 months after an ACS admission increased significantly during the years 2000-2004 and reached 87%. Of the 42,292 patients who underwent PTCA during 2005, 34,346 (81.2%) have purchased at least 3 prescriptions of statins during 2005, 35,261 (83.4%) have performed at least one LDL measurement and 57.8% attained an LDL level of <100 mg/dl. CONCLUSIONS: We have shown an improvement in primary and secondary preventions of CV disease as documented by LDL measured and attainment of treatment goals, but further efforts are needed.

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.

Do patients with diabetes and low socioeconomic status receive less care and have worse outcomes? A national study.

PURPOSE: The objective of the study was to assess the influence of socioeconomic status (SES) on the care of patients with diabetes. METHODS: Quality indicators for patients who were taking medication for diabetes were established. Overall compliance with the quality indicators, as well as prevalence of diabetes by age, were obtained from a national database. Patients with national tax exemptions (used as a marker for low SES) were compared to those without. RESULTS: Of 4,110,852 citizens aged 18-74, 210,988 (5.1%) were receiving medication for diabetes. The prevalence of diabetes reached 19.9% in people aged 65-74. 495,392 citizens had an exemption, and they had a higher prevalence of diabetes that those who did not (15.4% vs. 3.7%). Patients with an exemption had a higher rate of having a yearly HbA1c done, a yearly LDL level done, a yearly eye exam, a yearly urinary protein exam, of being treated with insulin for an elevated HbA1c than those without an exemption. In patients with an exemption there was a lower percentage with an HbA1c less than 7%, a higher percentage with an HbA1c greater than 9%, and a lower percentage with an LDL less than 130. Multivariate analysis showed that exemption status was a predictor of better performance on process measures (LDL test done, OR-1.03, 95% CI 1.01-1.06, HbA1c test done, OR 1.03, 95% CI- 1.01-1.05) and of worse outcomes (high LDL, OR 0.92, 95% CI, 0.90-0.95 and high HbA1c, OR, 0.85, 95% CI, 0.83-0.87). CONCLUSIONS: In a country with universal healthcare, patients from a lower SES had an increased prevalence of diabetes and had greater adherence to preventive healthcare measures However, they were less successful in meeting target treatment goals.

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.