Have we treated AIDS too well? Rationing and the future of AIDS exceptionalism.

During the past decade, medical therapy for AIDS has become more effective but also prohibitively expensive. A medical tragedy has been transformed into a financial crisis, and society has responded by establishing special programs and sources of funding for AIDS. These maneuvers parallel earlier approaches to HIV testing and reporting that have collectively come to be known as 'exceptionalism.

A proactive, data-based determination of the standard of medical care in pediatrics.

A 3-week-old infant awoke with a fever. He was taken to the doctor who noted that the child was irritable. The doctor took him to the hospital where a resident performed a spinal tap, started an intravenous (IV) line, and ordered antibiotics.

[Surgical trauma induced by laparoscopic cholecystectomy].

The objective demonstration of improved postoperative recovery suggests that surgical injury induced by the laparoscopic approach is less intense than that after open surgery. Forty-two patients diagnosed as having noncomplicated gallstones were studied prospectively. They were operated on by laparoscopy (LC, n = 21) or open surgery (OC, n = 21).

Community equipoise and the architecture of clinical research.

We have argued for a revision of Freedman's concept of clinical equipoise to a broader sense of community that includes physicians and patients. Community equipoise is an essential condition for physicians and patients to answer these questions: Should there be a trial? If so, what kind? We have argued that community equipoise exists because of changes in the knowledge gap between physicians and patients and in the moral justification of medical decision-making. Finally, we have briefly examined the social aspect of medical knowledge to argue that it necessarily includes patients and their values.

Resource allocation in neonatal and medical ICUs. Epidemiology and rationing at the extremes of life.

This study compared resource allocation to patients who eventually die in neonatal ICUs (NICUs) and adult medical ICUs (MICUs). It was performed via retrospective, chart review study at ICUs at the University of Chicago-an inner city, tertiary care, academic medical center. All patients were admitted to the neonatal, general medical, or coronary ICU during 1 calendar yr.

Physicians' experience with allegations of medical malpractice in the neonatal intensive care unit.

Objective: To assess the personal experience of all practitioners of neonatal intensive care unit (NICU) medicine in the United States with the medical malpractice system; in particular, to assess the circumstances of malpractice allegations in which they themselves had personal experience, and to extrapolate from their individual experiences to the field of neonatology in general.

Design: Written survey of all MDs practicing NICU medicine in the US.

Participants: Two thousand four hundred ninety-eight NICU physicians as determined from three sources: a) the American Board of Medical Specialists; b) the American Academy of Pediatrics Section of Neonatal/Perinatal Medicine; and c) a listing of neonatologists provided by Ross Laboratories.

Inflammatory mediators and surgical trauma regarding laparoscopic access: neutrophil function.

Polymorphonuclear leukocytes (PMN) are well recognised as being the principal cells in the inflammatory response reaction. The current investigation was designed to evaluate the stimulated state of neutrophils in patients undergoing open (OC) and laparoscopic cholecystectomy (LC). The superoxide radical generation of isolated PMN and its lag time, and PMN elastase were measured in peripheral venous blood samples collected from 42 patients.

Cardioprotection during heart ischemia-reperfusion.

Oxygen reactive species play a significant role in reperfusion tissue damages. In this study we aimed to investigate the mechanisms of injury regarding changes of neutrophil function. In our experiments the left descending coronary artery (LAD) was ligated in Beagle dogs for 1 hour followed by one hour reperfusion.

Monitoring of plasma total antioxidant status in different diseases.

The pathological increase of oxygen free radical generation has already been recognised in more than one hundred diseases. To gain information about the consequences of oxidative stress the investigation of plasma antioxidants seems to be plausible. In our study we used a new kit (RANDOX, England) for measurement of total antioxidant status (TAS) to determine whether it has diagnostic value in comparison with our earlier results of measuring other parameters of oxidative stress in the following diseases: i.

The effects of bisaramil and antiarrhythmics on free radical generation of isolated neutrophil granulocytes.

The aim of this study was to investigate the effect of bisaramil--an antiarrhythmic drug under clinical trials--on free radical generation of isolated polymorph neutrophil granulocytes (PMN) and to compare its activity with well-known antiarrhythmics. PMNs were isolated from healthy beagle dogs, and superoxide radical generation was induced by phorbol-myristate-acetate. Free radical generation capacity of stimulated PMNs were measured.

Inflammatory mediators and surgical trauma regarding laparoscopic access: acute phase response.

Numerous studies have tried to compare different aspects of patient response to laparoscopic cholecystectomy (LC) versus open cholecystectomy (OC). Our study focused on the acute phase response in order to clarify the better patient recovery following LC. Sixteen patients scheduled for elective cholecystectomy were equally allocated into groups of OC and LC.

Inflammatory mediators and surgical trauma regarding laparoscopic access: free radical mediated reactions.

In this prospective study the free radical mediated reactions, the changes of endogenous antioxidant defense mechanism and activation of leukocytes were measured from the blood of patients undergoing elective cholecystectomy because of symptomatic cholecystolithiasis. The patients were randomised into two groups. Group one contained 21 patients treated by open cholecystectomy(OC).

The values of detection of free radical mediated reactions in patients.

The peroxidative processes and individual antioxidant protection were measured in patients with different cardiovascular diseases. We concluded that monitoring of this system we were able to detect not only the actual changes of lipid peroxidation and antioxidant defence mechanisms, but additionally the therapeutic efficacy of the treatment.

Reassessing medical students' willingness to treat HIV-infected patients.

Background: Past research has demonstrated that some physicians do not feel obligated to care for patients infected with the human immunodeficiency virus (HIV). This study sought to characterize the attitudes that affect medical students' willingness to treat HIV-infected patients and to determine which attitudes are most amenable to intervention.

Method: All 414 matriculating medical students at three Chicago schools were surveyed in 1994.

The relationship between physician behaviors and blood gas values in the first hours of life--implications for "standards" of medical care for infants with respiratory distress.

It is standard practice for physicians to use blood gas (BG) evaluations when evaluating neonates with respiratory distress. In this study we addressed two questions: (1) What is the distribution of BG values in a population of infants receiving BG evaluation in the first 4 hours of life; and (2) How does the behavior of physicians correlate with BG values in these infants? We discuss the implications of our findings for claims about "standards" of medical care for newborn infants with respiratory distress. We reviewed medical records for 226 infants with birthweight > 2000 grams who were not intubated at the time of first BG determination.

Distributive justice across generations. Epidemiology of ICU care for the very young and the very old.

Babies of extremely low birthweight and elderly adults both require expensive and scarce resources, and both have a relatively poor prognosis for survival if they require intensive care. Thus, proposals for rationing often target one or both of these groups. We suspected that although mortality rates might be higher in the neonatal intensive care unit (NICU) than in the adult intensive care unit (ICU), NICU care might nevertheless be more cost effective, where cost efficiency is measured along the dimension of resources targeted to survivors.

Expert testimony, legal reasoning, and justice. The case for adopting a data-based standard of care in allegations of medical negligence in the NICU.

Sunstein has written, "First, and most obviously, judgments about specific cases must be made consistent with one another. A requirement of coherence, or principled consistency, is a hallmark of analogic reasoning (as it is of reasoning of almost all sorts)." In cases of alleged medical negligence, our current system of malpractice litigation supports the possibility that inaccurate anecdotal testimony by expert witnesses may be credited equally or even preferred to more accurate testimony based on empiric data.

Can and should level II nurseries care for newborns who require mechanical ventilation?

Perinatal regionalization was conceived roughly 25 years ago to provide centralized care for critically ill newborn infants. As for many 25-year-old concepts, the obligatory centripetal design of many regionalization policies may need to be modified. This article presents the outcomes of 408 surviving patients who required mechanical ventilation (136 born in one community hospital and 272 birthweight-matched infants born in our tertiary center), and were cared for in our perinatal network.

Cardiopulmonary resuscitation on television. Miracles and misinformation.

Background: Responsible, shared decision making on the part of physicians and patients about the potential use of cardiopulmonary resuscitation (CPR) requires patients who are educated about the procedure's risks and benefits. Television is an important source of information about CPR for patients. We analyzed how three popular television programs depict CPR.

Effects of bisaramil on coronary-occlusion-reperfusion injury and free-radical-induced reactions.

The aim of this study was to determine whether bisaramil-an antiarrhythmic compound under clinical investigation-influences the reperfusion-induced arrhythmias and biochemical parameters characterizing occlusion-reperfusion-induced free-radical reactions. The left descending coronary artery (LAD) was occluded for 60 min in anaesthetized dogs followed by one hour of reperfusion. Blood samples were taken at different times of the occlusion and reperfusion for the determination of plasma concentration of malondialdehyde (MDA), reduced (GSH) and oxidized glutathione (GSSG); furthermore of the activity of catalase and superoxide dismutase (SOD).

Birth weight-specific mortality for extremely low birth weight infants vanishes by four days of life: epidemiology and ethics in the neonatal intensive care unit.

Background: The persistent differences between those who question the appropriateness of aggressive resuscitative measures for many extremely low birth weight (ELBW) infants (birth weight < 1001 g) and those who generally initiate such treatment has been a source of ongoing tension for physicians, parents, judges, and policymakers. We believe that much of this tension may be a result of the way the issue is framed. We began this study with the intuition that although many ELBW infants die, most succumb quickly.

Effects of lidocaine on cerebral lipid peroxidation and neutrophil activation following complete compression ischemia.

The effect of lidocaine on brain lipid peroxidation, as reflected by jugular vein malondialdehyde concentrations, and of polymorphonuclear leukocyte activation in peripheral venous blood samples following transient global cerebral ischemia, were studied. In normothermic dogs subjected to a 10 min elevation of cerebrospinal fluid pressure and a subsequent 60 min reperfusion, the malondialdehyde concentration during the first 3 min of reperfusion increased significantly (p < 0.05) in the jugular vein.