Caregiver and elder experiences of Cambodian, Vietnamese, Soviet Jewish, and Ukrainian refugees

Our purpose was to describe and compare Cambodian, Vietnamese, Soviet Jewish, and Ukrainian refugee caregivers and elders on life experiences, health status, and knowledge of available services. Detailed interviews were conducted with 105 female caregivers and 52 elders. Similar patterns emerged across all groups with regard to filial obligation, minimal knowledge of services, impact of immigration, and retention of cultural ties. Findings confirmed the special health and social service needs of refugee families in transition.

Time to heal medical education?

In Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care, Kenneth Ludmerer presents a penetrating narrative and analytic account of the daunting economic, organizational, social, and value problems facing medical education that are threatening its excellence and its sense of purpose. The new conditions have the potential not only to seriously undermine the scientific and clinical quality and vibrancy of the education that medical students and housestaff receive, but also to subvert the development of core elements of a "Samaritan" concern for the care, the suffering, and the well-being of patients and of dedication to the public good. American medical schools have a long tradition of trying to improve medical education through periodic curriculum reforms. Since the famous and influential Flexner report in 1910, at least 24 other major reports advocating such reform have been issued, and they have been strikingly similar in their prescriptions. The resulting modifications have, however, been "reform without change" because of medical educators' failure to address the basic social, organizational, and financial problems with which medical schools have been progressively confronted. Ludmerer considers that today's problems, however formidable they may be, are not as profound as those that faced medical educators a century ago--and that there is time and opportunity for visionaries and leaders to act. This may be true but only if they can properly diagnose the present problems of medical education, amply understand their roots, identify effective means to remedy them, and galvanize medical educators to make the systemic, institutional changes, locally and nationally, that are called for.

Bis(5-hydroxy-2-hydroxymethyl-pyran-4-one-6-yl)methane: a novel ligand for the intracellular mobilisation of ferritin-bound iron

The efficacy of a novel tetradentate iron(III) ligand for the in vitro mobilisation of ferritin-bound iron is measured in direct comparison to the clinically approved agents, 1,2-dimethyl-3-hydroxypyridin-4-one and desferrioxamine.

Perish and publish: non-heart-beating organ donation and unduly iterative ethical review

In the expanding repertoire of practices designed to increase the supply of organs for transplantation, non-heart-beating cadaver organ donation has generated an ongoing debate in the literature. The continuing stream of articles is disquieting in part because it documents a troubling "trial-and-error ethics" approach to the formulation of organ procurement policy, and because it raises serious questions about the reasons that the development of this policy is being mediated by published communication. In the light of concerns about the implicit support and credibility that professional publications give to organ procurement policies, restraint in publishing articles about non-heart-beating organ donation as well as in devising such policies is strongly advocated.

Noninvasive mechanical ventilation via face mask in patients with acute respiratory failure who refused endotracheal intubation

OBJECTIVE

To evaluate the response to noninvasive ventilation in a group of terminally ill patients with acute respiratory failure who refused endotracheal intubation.

DESIGN

Case series.

SETTING

Medical intensive care units (ICUs) in a university health science center.

PATIENTS

Eleven patients, nine with hypercapnic and two with hypoxemic acute respiratory failure. Mean age of patients was 64 yrs.

INTERVENTION

Mechanical ventilation was delivered via a face mask. The initial ventilatory setting was continuous positive airway pressure mode, with pressure-support ventilation of 10 to 20 cm H2O, titrated to achieve a respiratory rate of < 25 breaths/min and a tidal volume of 5 to 7 mL/kg. Ventilatory settings were adjusted based on results of arterial blood gases. Mean duration of mechanical ventilation was 44 hrs.

MEASUREMENTS AND MAIN RESULTS

Mechanical ventilation via face mask was effective in correcting gas exchange abnormalities in seven of 11 patients, all of whom survived and were discharged from the ICU. Four patients with hypercapnic acute respiratory failure died. Mechanical ventilation via face mask was effective in improving respiratory acidosis in three patients and had no effect in one patient. Two of the four patients could not be weaned from mechanical ventilation and opted for discontinuation of this method. Removal of the ventilator while retaining the mask for oxygen supplementation was a nontraumatic experience to the patient and family. Even when respiratory failure did not resolve, mechanical ventilation via face mask was effective in lessening dyspnea and allowed the patient to maintain autonomy and continuous verbal communication.

CONCLUSIONS

We conclude that mechanical ventilation via face mask offers an effective, comfortable, and dignified method of supporting patients with end-stage disease and acute respiratory failure.

"An ignoble form of cannibalism": reflections on the Pittsburgh protocol for procuring organs from non-heart-beating cadavers

The author discusses the ways in which she finds the University of Pittsburgh Medical Center protocol for procuring organs from "non-heart-beating cadaver donors" medically and morally questionable and irreverent. She also identifies some of the factors that contributed to the composition of this troubling protocol, and to its institutional approval.

Post-Jurassic mammal-like reptile from the Palaeocene

Mammal-like reptiles of the order Therapsida document the emergence of mammals from more primitive synapsids and are of unique zoological and palaeontological interest on that account. Therapsids, first appearing in the Early Permian, were thought to become extinct in the Middle Jurassic, soon after the Late Triassic origin of mammals. Here, however, we report the discovery of a therapsid from the late Palaeocene, 100 million years younger than the youngest previous occurrence of the order. This discovery nearly doubles the stratigraphic range of therapsids and furnishes their first record from the Cenozoic. The documenting fossils, an incomplete dentary containing three teeth, and four isolated teeth from other, conspecific individuals (Fig. 1), are from the Paskapoo Formation, at Cochrane, Alberta, Canada, from beds yielding a diverse mammalian fauna of early Tiffanian age. These specimens are catalogued in the collections of the University of Alberta Laboratory for Vertebrate Paleontology (UALVP) and provide the basis for a new taxon, as named and described below: (see text)

Noninvasive face mask mechanical ventilation in patients with acute hypercapnic respiratory failure

Mechanically assisted intermittent positive-pressure ventilation effectively provides ventilatory support in patients with respiratory failure but it requires placing an artificial airway. We have previously reported our successful experience delivering mechanical ventilation via a face mask (FMMV) rather than with an endotracheal tube in a pilot study of patients with acute respiratory failure. The present investigation evaluated an additional 18 patients with hypercapnic respiratory failure to determine the efficacy of FMMV in a more homogeneous group and to determine factors predicting its success. FMMV was successful in avoiding intubation in 13 of the 18 patients. A significant initial improvement in PCO2 (greater than 16 percent decrease) and in pH (from less than 7.30 to greater than 7.30) predicted success. The five patients who failed on FMMV required endotracheal intubation because of inability to improve gas exchange (three patients), apnea due to sedatives (one patient), and management of secretions (one patient). FMMV was generally well accepted with only two patients withdrawn because of intolerance of the mask. The mean duration of FMMV was 25 h. Complications were seen in only two patients (11 percent): aspiration (one patient) and mild skin necrosis (one patient). Seven patients entered the study by meeting entrance criteria after an unsuccessful extubation attempt and therefore received both forms of mechanical ventilation. All but one patient avoided reintubation, and the face mask proved to be as effective as the endotracheal tube as a conduit for delivering the mechanical tidal volume and improving gas exchange. Our findings indicate that FMMV is a viable option for short-term (one to four days) ventilatory support of patients with hypercapnic respiratory failure and insufficiency.

Medical uncertainty and the autopsy: occult benefits for students

The autopsy has been of great importance in educating students regarding medical uncertainty. The marked decline in the use of the autopsy in medical education and continuing education has contributed significantly to the current discomfort among physicians regarding medical uncertainty and medical errors, which, in turn, has furthered the decline of the autopsy. Inordinate guilt, denial, and other defensive behaviors that many physicians marshall in response to uncertainty and error prevent these individuals from learning from their mistakes. The autopsy experience during medical school, properly utilized, helps students to confront fallibility and sets the stage for later successful management of uncertainty and error.

Assessing the artificial heart. The clinical moratorium revisited

Viewed in relation to the vast amount of clinical research in the United States, the number of total artificial heart (TAH) implants is so small as to be statistically invisible. And while the results of those implants to date may seem dubious in terms of the recipients' outcomes, theyare in fact very similar to those of many other innovative therapies when they are first tried ondesperately ill patients. Why, then, has the artificial heart been the object and subject of suchextraordinary interest and controversy? It has been the subject of special federal studies, reports, and hearings for 20 years; has been perceived and portrayed as a unique chapter in the annals of human experimentation and therapeutic innovation; has attracted medically unprecedented media attention; and, in the case of permanent implants, has received unusually exhaustive and restrictive regulatory supervision.

The Daedalus effect: changes in ethical questions relating to hepatitis B virus

The Daedalus myth is a metaphor for aspects of the scientific process. When a problem is solved it often raises others, and when these in turn are solved they generate additional questions. Although perfect solutions may not be possible, major improvements can be made in many cases. Research on the hepatitis B virus is an example. The ability to detect carriers of hepatitis B virus contributed to the control of post-transfusion hepatitis but raised social and ethical problems inherent to the identification of carriers in the community. Partial solutions to this problem resulted from the ability to distinguish infectious from noninfectious carriers by the use of the hepatitis B antigen (HBeAg) test and the development of an effective vaccine against hepatitis B virus. These solutions will undoubtedly lead to other problems and their solutions, which will in turn lead to other ethical and medical questions.

Personhood, medicine, and American Society

The problems of personhood with which this conference--and our society--grapples are significantly interwoven with modern medicine, its technology, and its science. More importantly, the conceptual language and recurrect themes of personhood questions are shaped by moral philosophers and jurists: "individualism" and "connectedness" are at the core of debates. Existing institutional arrangements have been inadequate to arrive at an effective societal consensus.

Critical care at Tianjin's First Central Hospital and the fourth modernization

This case study of the Critical Care Unit at Tianjin's First Central Hospital, its physician-director, and one of its patients provides a portrait of how the policy of the four modernizations is being applied to the field of medicine in the People's Republic of China. On this unit of an urban hospital the "fourth modernization," science and technology, is systematically brought to bear on the problems of critically ill patients. The Chinese dualities and dilemmas that this "scaling the heights" policy entails are continually played out on the Critical Care Unit. An intricate balancing is involved between modern Western and traditional Chinese medicine, and between rural public health programs and primary and tertiary care services, within a medical morality framework that combines present-day political ideology with age-old ethical precepts. At this juncture the overall balance seems to be moving in the direction of modern, city-based, curative medicine.

The sting of death in American society

A collective interest in death and dying has progressively developed in American society since the 1960s. Among the factors associated with it are demographic shifts; medical, scientific, and technological advances; changes in the statuses, roles, and outlook of medical professionals, patients, and women; and the affirmation and broadening of individual rights. Life-and-death issues have moved increasingly from private to public spheres of the society and are appearing more frequently in the courts, the media, and the arts. They are also principal foci of several social movements. This pervasive preoccupation with death seems related to deep cultural changes occurring in our society and in its world view.

The evolution of medical uncertainty

Modern developments of scientific medicine have uncovered and created uncertainties and risks that were previously not known or experienced; the stakes have become very much higher. The rise in public expectation, however, is paralleled by a lowered tolerance of uncertainty. Metaphors of "deliverance" and "disaster" abound in discussions of scientific discovery, reflecting differing conceptions and philosophies about errors and mistakes, and the role they play in the physical universe, the biosphere, and human affairs. These concerns highlight the difficulties and dilemmas of finding scientifically adequate, culturally appropriate, and socially effective ways of appraising and controlling risk.