Search

Background To compare clinical presentation, diagnostic and treatment strategies, and outcome between pediatric and adult patients with chronic non-bacterial osteomyelitis (CNO). Methods Retrospective single-centre comparative study of pediatric and adult patients diagnosed with chronic recurrent multifocal osteomyelitis (CRMO)/CNO or synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome treated at the Medical University of Graz. Results 24 pediatric patients diagnosed with CRMO/CNO and 10 adult patients diagnosed with SAPHO syndrome were compared. Median age at diagnosis was 12.3 years (range 7.9–18.9) in the pediatric group and 32.5 years (range 22–56) in the adult group. Median time to diagnosis was shorter in children than in adults (0.3 vs. 1.0 years). Initial clinical presentation, laboratory and histopathological findings were similar in children and adults. Mean numbers of bone lesions were comparable between pediatric and adult patients (3.1 vs. 3.0), as were rates of skin involvement (33% vs. 30%). Sternal involvement was more frequent in adults whereas involvement of clavicle and long bones was more frequent in children (41.7% vs.10, 33% vs. 10%). Computerized tomography (CT) was used more often in adults, whereas whole-body magnetic resonance imaging (MRI) was used only in children. Bisphosphonates were applied more often in children and outcome was better in children than in adults (62.5% vs.30%). Conclusion Results of our study suggest that CNO/CRMO and SAPHO syndrome in children and adults might represent a single clinical syndrome that needs a similar diagnostic and therapeutic approach.

The purpose of this article is to propose a tax on meat consumption. The idea draws inspiration from the taxation of cigarettes for reasons of public health. Eating meat increases the risk of suffering from serious illnesses, and taxes would serve both as a deterrent and as a means to offset the associated healthcare costs imposed on society. There are further costs imposed by meat consumption: it sustains a major part of the demand of the world's production of crops, which elevates their prices while much of the nutritional value of the crops used to produce meat is wasted. The production of meat is also highly polluting and it contributes very significantly to global warming. Finally, meat-eaters are in effect supporting the cruel practices commonly inflicted on the animals themselves. By applying a tax on meat it is hoped that patterns of consumption would change, thereby reducing the mentioned costs. En el presente artículo se propone gravar con impuestos el consumo de carne. La idea está inspirada en los impuestos sobre el tabaco, que se justifican por motivos de salud pública. Comer carne aumenta el riesgo de padecer enfermedades graves, y un impuesto podría servir como factor disuasorio y además como un medio para compensar los costes médicos que dicho consumo impone sobre la sociedad. Pero el consumo de carne tiene también otros costes: sostiene gran parte de la demanda de la producción mundial de cultivos, elevando el precio de éstos. Sin embargo, se desperdicia gran parte de su valor nutricional cuando se emplean para producir carne. La producción de carne es también muy contaminante y contribuye significativamente al calentamiento global. Por último, los consumidores de carne sustentan las prácticas crueles que comúnmente se aplican sobre los propios animales. La introducción de un impuesto sobre la carne podría contribuir a un cambio en los hábitos de consumo, con la consiguiente reducción de los costes mencionados.

There is too much that we do not know about COVID-19. The longer we take to find it out, the more lives will be lost. In this paper, we will defend a principle of risk parity: if it is permissible to expose some members of society (e.g. health workers or the economically vulnerable) to a certain level of ex ante risk in order to minimize overall harm from the virus, then it is permissible to expose fully informed volunteers to a comparable level of risk in the context of promising research into the virus. We apply this principle to three examples of risky research: skipping animal trials for promising treatments, human challenge trials to speed up vaccine development, and low-dose controlled infection or “variolation.” We conclude that if volunteers, fully informed about the risks, are willing to help fight the pandemic by aiding promising research, there are strong moral reasons to gratefully accept their help. To refuse it would implicitly subject others to still graver risks.

Fund and study these priorities for natural and social sciences to meet a gaping need, urge Abdallah S. Daar, Trillium Chang, Angela Salomon and Peter A. Singer. Fund and study these priorities for natural and social sciences to meet a gaping need.

The Global Kidney Exchange (GKE) programme seeks to facilitate kidney transplants by matching donor–recipient pairs across high-income, medium-income, and low-income countries. The GKE programme pays the medical expenses of people in medium-income and low-income countries, thus enabling them to receive a kidney transplantation they otherwise could not afford. In doing so, the programme increases the global donor pool, and so benefits people in high-income countries by improving their chances of finding a donor match. Nevertheless, the GKE has been accused of being a form of organ trafficking, exploiting the poor, and involving coercion and commodification of donors. We refute these claims, arguing that the GKE promotes global justice and reduces the potential for people in need of kidneys in low-income and medium-income countries to be exploited. Misguided objections should not be allowed to prevent the GKE from realising its potential to reduce suffering and save the lives of rich and poor patients alike.

Establishing the preoperative diagnosis and long-term prognosis of differentiated thyroid cancer (DTC) remain challenging in some patients. Myeloid-derived suppressor cells (MDSC) are tumor-induced cells mediating immune tolerance that are detectable in the peripheral blood of cancer patients. The authors previously developed a novel clinical assay to detect the phenotypes of two human MDSC subsets in peripheral blood, and hypothesize that higher MDSC levels measured by this assay correlate positively with both malignancy and worse patient outcomes.A prospective observational pilot study was performed of patients undergoing thyroidectomy for a solitary thyroid nodule. The presence of a thyroid nodule1 cm was confirmed sonographically, and fine-needle aspiration biopsy performed prior to surgery in all cases. Peripheral blood collected preoperatively was analyzed using a novel flow cytometry-based immunoassay to detect and quantify two subsets of human MDSC. Circulating MDSC levels were compared by histopathologic diagnosis, stage, and presence of persistent disease after treatment.Of 50 patients included in this study, MDSC measurement was successful in 47 (94%). One patient was found to have a concurrent cancer, leaving 46 patients for primary analysis. The cytologic diagnoses were benign in five (10.8%), atypia or follicular lesion of undetermined significance in five (10.8%), suspicious for follicular neoplasm in five (10.8%), suspicious for malignant in three (6.5%), and malignant in 28 (60.1%) of the 46 nodules. Final histopathology was benign in 11 (24%) and DTC in 35 (76%), encompassing 34 PTC cases and one follicular thyroid carcinoma. Mean percentages of CD11b(+)HLA-DR(low)HIF1a(+) MDSC (CD11b(+)MDSC) were 14.0 ± 6.2% and 7.9 ± 3.6% in DTC versus benign nodules, respectively (p 0.005). A cutoff of 12% yielded a specificity of 0.91, a sensitivity of 0.72, and a likelihood ratio of 7.9. Mean CD11b(+)MDSC levels increased linearly with higher TNM stage (p 0.01), and were 19.4 ± 5.4 in patients with persistent cancer after surgery compared with 13.2 ± 6.8 in those without evidence of disease (p 0.05).MDSC measurement using this flow cytometry-based assay represents a novel approach for preoperatively assessing malignancy risk and cancer extent in patients with thyroid nodules. While further validation is needed, these data suggest that MDSC assessment may serve as a useful adjunct when cytology is indeterminate, and predict tumor stage and recurrence risk in cases of thyroid cancer.

In a two-stage survey, a cross-section of Australians were questioned about the importance of costs in setting priorities in health care. Generally, respondents felt that it is unfair to discriminate against patients who happen to have a high cost illness and that costs should therefore not be a major factor in prioritising. The majority maintained this view even when confronted with its implications in terms of the total number of people who could be treated and their own chance of receiving treatment if they fall ill. Their position cannot be discarded as irrational, as it is consistent with a defensible view of utility. However, the results suggest that the concern with allocative efficiency, as usually envisaged by the economists, is not shared by the general public and that the cost-effectiveness approach to assigning priorities in health care may be imposing an excessively simple value system upon resource allocation decision-making.

Dr. Mark Siegler is a founding figure in the field of clinical medical ethics. His seminal publications asserted clinical medical ethics as a worthwhile field and demonstrated its necessity within the practice of medicine. Dr. Siegler further encouraged the development of this field through the foundation of a fellowship training program in which hundreds of physician and other medical workers have learned the principles of clinical medical ethics. Through the efforts of Dr. Siegler and his many fellows, the field of clinical medical ethics is now taught, studied, and practiced internationally. By expanding the field as such, Dr. Siegler can be credited with improving the quality of health care for patients across the modern world.

To give priority to the young over the elderly has been labelled `ageism'. People who express "ageist" preferences may feel that, all else equal, an individual has a greater right to enjoy additional life years the fewer life years he or she has already had. We shall refer to this as egalitarian ageism. They may also emphasise the greater expected duration of health benefits in young people that derives from their greater life expectancy. We may call this utilitarian ageism. Both these forms of ageism were observed in an empirical study of social preferences in Australia. The study lends some support to the assumptions in the QALY approach that duration of benefits, and hence also age, should count in prioritising at the budget level in health care.

ViscoGel, a chitosan-based hydrogel, has earlier been shown to improve humoral and cell-mediated immune responses in mice. In this study, a Phase I/IIa clinical trial was conducted to primarily evaluate safety and secondarily to study the effects of ViscoGel in combination with a model vaccine, Act-HIB to Haemophilus influenzae type b, administered as a single intramuscular injection. Healthy volunteers of both sexes, ages 22-50 and not previously vaccinated to HIB, were recruited. The trial had two phases. In Phase A, three ascending dose levels of ViscoGel (25, 50 and 75mg) were evaluated for safety in 3×10 subjects. Phase B had a single-blind, randomised, parallel-group design evaluating safety and efficacy in five groups, 20 subjects/group, comparing vaccination with 0.2μg or 2μg Act-HIB alone or combined with ViscoGel (50mg) and one group receiving the standard Act-HIB dose (10μg). No safety or tolerability concerns were identified. Local, transient reactions at the injection site were the most common adverse events. These were more frequent in groups receiving Act-HIB+ViscoGel, while other AEs were recorded at similar frequency in Act-HIB and Act-HIB+ViscoGel groups. Efficacy was evaluated by measuring serum anti-HIB antibodies and cellular responses in peripheral blood mononuclear cells (PBMC). There was a large variation in baseline anti-HIB antibody titres and no adjuvant effect was observed on the anti-HIB antibody production in groups vaccinated with Act-HIB+ViscoGel. ELISpot analyses revealed increased interferon-γ (IFN-γ) responses to Act-HIB in PBMCs from subjects vaccinated with Act-HIB in combination with ViscoGel, compared to groups receiving Act-HIB alone. Moreover, ViscoGel counteracted an inhibitory effect of Act-HIB vaccination on the IFN-γ response to both the vaccine itself and an irrelevant influenza antigen. In summary, ViscoGel was found to be safe and well-tolerated, supporting further examination of ViscoGel as a new innovative vehicle for vaccine development.

The competition for limited health care resources is intensifying. We urgently need an acceptable method for deciding how they should be allocated. But the goods that health care produces are of very different kinds. Health care can extend the lives of children and of older people. It can make it possible for a person to walk, when without health care that person would be permanently bedridden; and it can reduce the pain and distress of people who are terminally ill. How can we possibly decide which of these - and many more - diverse achievements of health care are more deserving than others? We need a common unit by which we might be able to measure these very different goods. The Quality-Adjusted Life Year, or QALY, is the most developed proposal for such a unit of measure. In this book a distinguished team of ethicists and economists defend the core of the QALY proposal: that health care resources should be used so as to produce more years of life, of the highest possible quality. This leads to a discussion of such fundamental questions as whether all lives are of equal value, whether health care should be allocated on the basis of need and whether the QALY approach incorporates an adequate account of fairness or justice. The result is the most thorough account yet of the ethical issues raised by the use of the QALY as a basis for allocating health care resources.

Objective: Hypothyroidism has multiple etiologies and manifestations. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions. This paper describes evidence-based clinical guidelines for the clinical management of hypothyroidism in ambulatory patients.Methods: The development of these guidelines was commissioned by the American Association of Clinical Endocrinologists (AACE) in association with American Thyroid Association (ATA). AACE and the ATA assembled a task force of expert clinicians who authored this article. The authors examined relevant literature and took an evidence-based medicine approach that incorporated their knowledge and experience to develop a series of specific recommendations and the rationale for these recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach outlined in the American Association of Clinical Endocrinologists Protocol for Standardized Production of ...

Hintergrund: Langkettige Omega-3-Fettsauren sind in einzelnen Korpergeweben bzw. -organen in unterschiedlichen Mengen enthalten, bei Erkrankungen kann sich der Gehalt andern. Blutlipidanalysen spiegeln diese Veranderungen jedoch nicht oder nur unzureichend wider. Methode: Ubersichtsarbeit Ergebnisse: Durch Leberbiopsien wurde nachgewiesen, dass mit zunehmender Leberverfettung Eicosapentaensaure (EPA) in der Triglyzeridfraktion stark abfallt. Dies ist mit einer Zunahme histologischer Entzundungszeichen verbunden. In einer Therapiestudie konnte durch die Zufuhr von Omega-3-Fettsauren (1g/Tag) eine Reduktion von Leberfett sowie Entzundungszeichen erreicht werden. Schlussfolgerung: Daraus kann sich eine bisher weitgehend unbekannte Indikation fur die Behandlung der nicht alkoholischen Fettleber (NAFLD) sowie des metabolischen Syndroms ergeben.

The use of genetic engineering to enhance the natural capacity of microorganisms for remediation has become very promising with new scientific discoveries occurring every year. Unfortunately, the application and commercialization of this technology has not kept pace with these research discoveries. This article uses two examples of genetically engineered microorganisms that were designed but never deployed in the clean-up of wastes to show how the application of genetically engineered microbes for bioremediation has not progressed in line with other biotechnological innovations. We argue that a more risk-based regulatory environment that fosters commercialization is important. In addition, we show how scientists could foster the commercialization of genetically engineered microbes for bioremediation through the use of technical safeguards and the consideration of regulatory challenges at the onset of their research. The lessons provided by these challenges could be applicable to current biotechnological innovations that face similar regulatory challenges.

Recombinant human thyrotropin (rhTSH) stimulation is frequently used to assess the disease status of patients treated for differentiated thyroid cancer (DTC) when basal (unstimulated) thyroglobulin (b-Tg) is below the assay sensitivity limit. The objective of this study was to determine relationships between the b-Tg and the 72-hour rhTSH-stimulated Tg (rhTSH-Tg) using a second-generation immunochemiluminometric assay with a functional sensitivity of 0.05 ng/mL (microg/L).Serum Tg was measured in paired b-Tg and rhTSH-Tg specimens from 1029 rhTSH tests performed on 849 TgAb-negative patients during long-term monitoring for DTC.Basal Tg correlated with rhTSH-Tg across b-Tg concentrations ranging from 0.05 to 1000 ng/mL (microg/L) (r = 0.85, p0.0001). The b-Tg concentration was unrelated to age, sex, basal TSH, 72-hour TSH, or the Tg fold response (rhTSH-Tg/b-Tg). Further, only 2/655 (0.3%) tests with b-Tg below 0.1 ng/mL (microg/L) had rhTSH-Tg above 2.0 ng/mL (microg/L) (2.9 and 3.8 ng/mL [microg/L], respectively). Thirty-three patients with three or more rhTSH tests performed over a 2- to 5-year period displayed high indexes of individuality for both the 72-hour TSH and the Tg fold response (indexes of individuality = 0.30 and 0.38, respectively). Basal Tg measured using a first-generation assay with a functional sensitivity of 0.9 ng/mL (microg/L) failed to reliably detect an rhTSH-Tg response above 2.0 ng/mL (microg/L).An rhTSH-Tg response above 2.0 ng/mL (microg/L) was highly unlikely when b-Tg was below 0.1 ng/mL (microg/L). Second-generation b-Tg measurements correlated with the degree of rhTSH-Tg stimulation and thus the likelihood of having rhTSH-Tg above the customary cut-off of 2.0 ng/mL (microg/L), whereas b-Tg measured by a first-generation assay did not. Correlations between four different assays showed that the use of a fixed Tg cut-off was influenced by assay selection. Patients receiving repetitive rhTSH tests had highly reproducible rhTSH-Tg/b-Tg fold responses, suggesting that repetitive testing is unnecessary and that second-generation measurement of b-Tg trends without rhTSH stimulation would be satisfactory for the long-term monitoring of most patients with DTC.

Object Following successful transsphenoidal surgery in patients with growth hormone (GH)–secreting pituitary adenomas, a characteristic fluid diuresis has been described. In this paper the authors aimed to further analyze the degree of fluid diuresis as it relates to postoperative GH levels. Methods Between 2000 and 2008, 85 patients underwent transsphenoidal surgery for a GH-secreting adenoma at the USC University Hospital. A retrospective chart review was conducted. Postoperative fluid intake, output, and balance within 48 hours following surgery, as well as endocrinological data were recorded and analyzed. Patients with postoperative diabetes insipidus and those with insufficient data were excluded from analysis. Results Seventy-one patients were included in the analysis. The mean age was 46 years (range 16–74 years). There were 36 males (51%) and 35 females (49%). Patients with negative fluid balances at 48 hours after surgery were more than twice as likely to have a GH level of < 1.5 ng/ml (55 vs 25%, p = 0.023). At 48 hours after surgery, patients with a negative overall fluid balance had a significantly lower median GH level than those with a positive overall fluid balance (1.3 vs 2.4 ng/ml, p = 0.039). This difference was even more pronounced in patients with microadenomas and a negative overall fluid balance. By 48 hours following surgery, patients with postoperative Day 1 GH levels < 1.5 ng/ml had, on average, experienced diuresis of fluid > 1.1 L (median 1.5 L) more than patients with GH levels > 1.5 ng/ml. Conclusions Successful resection of GH-secreting adenomas is associated with a more pronounced fluid diuresis and negative overall fluid balance within 48 hours following transsphenoidal surgery. Patients with a negative fluid balance by postoperative Day 2 have a higher likelihood of having significantly reduced postoperative GH levels that may correlate with long-term surgical remission.

Purpose – This paper aims to show through empirical examples how five foresight methods have provided value in medicine and global health, and to argue for greater use of health foresight.Design/methodology/approach – Through evaluation, literature search, and personal experiences, five approaches were identified where health foresight has shown strong value: forecasting, scenario planning, Delphi, technology roadmapping, and mass collaboration. For each approach, compelling examples are given, and usage and potential discussed.Findings – There is great opportunity to learn from and expand on past successes, and to customize foresight methods to help decision making in medicine and global health. The range of novel applications to date provides clear evidence that applying foresight methods to health can help prepare for the future, including development of policy and health interventions.Research limitations/implications – Metrics for the impact of health foresight are not widely used, and could be a foc...

Despite a challenging business environment, entrepreneurial health biotech companies in South Africa are finding ways to succeed.

Without global biotech research on disease, agriculture, and the environment, efforts to secure the world from biothreats are bound to falter—and vice versa.

One potential outcome of investing in genomic medicine is the provision of tools for creating a more cost-effective health-care system. Partly with this aim in mind, Thailand has launched two genotyping initiatives: the Thai SNP Discovery Project and the Thai Centre for Excellence in Life Sciences Pharmacogenomics Project. Together, these projects will help Thailand understand the genomic diversity of its population and explore the role that this diversity has in drug response and disease susceptibility in its population. A major future challenge will be for Thailand to integrate genomic medicine in its relatively young universal health-care system.

Governments around the world have focused on issues of sustainability, innovations and priority setting within their health systems. Tension exists between governments' desire to increase biotechnology innovation and the need to address health system sustainability. This commentary will: (1) review government initiatives in biotechnology in health innovation; (2) discuss how innovation, specifically biopharmaceuticals, challenges health system sustainability; and (3) explore how the tension between innovation and sustainability can be addressed using fairness and legitimacy. It is evident that a uni-jurisdictional approach may not be optimal in promoting innovation while ensuring a sustainable health system. Harmonization of biotechnology policies across the federal, provincial, and territorial governments will ensure consistent policies across all branches in order to circumvent the possibility of one governmental branch refusing to reimburse the very innovations other branches are promoting.

Brazil boasts world-class biomedical science, but tension between the public and private sectors hinders progress in health biotech innovation.

Background: Demand for organisational ethics capacity is growing in health organisations, particularly among managers. The role of clinical ethicists in, and perspective on, organisational ethics has not been well described or documented in the literature. Objective: To describe clinical ethicists’ perspectives on organisational ethics issues in their hospitals, their institutional role in relation to organisational ethics, and their perceived effectiveness in helping to address organisational ethics issues. Design and Setting: Qualitative case study involving semi-structured interviews with 18 clinical ethicists across 13 health organisations in Toronto, Canada. Results: From the clinical ethicists’ perspective, the most pressing organisational ethics issues in their organisations are: resource allocation, staff moral distress linked to the organisation’s moral climate, conflicts of interest, and clinical issues with a significant organisational dimension. Clinical ethicists were consulted in particular on issues related to staff moral distress and clinical issues with an organisational dimension. Some ethicists described being increasingly consulted on resource allocation, conflicts of interest, and other corporate decisions. Many clinical ethicists felt they lacked sufficient knowledge and understanding of organisational decision-making processes, training in organisational ethics, and access to organisational ethics tools to deal effectively with the increasing demand for organisational ethics support. Conclusion: Growing demand for organisational ethics expertise in healthcare institutions is reshaping the role of clinical ethicists. Effectiveness in organisational ethics entails a re-evaluation of clinical ethics training to include capacity building in organisational ethics and organisational decision-making processes as a complement to traditional clinical ethics education.

Chinese government support and 'sea turtles' are spurring the sector, but investors lack exits. Supplementary information The online version of this article (doi:10.1038/nbt0108-37) contains supplementary material, which is available to authorized users.

contributions, little funding was available for scientific discovery to address the major health needs of the world’s billions of poor. The financial stimulus of the Gates Foundation, along with investments from other foundations and governments and contributions from the private sector, has improved the situation dramatically. Now many public-private partnerships, such as the Medicines for Malaria Venture (MMV) and the Foundation for Innovative New Diagnostics (FIND), focus on product development to fill a hitherto largely empty product pipeline.

India's home-grown biotech companies must strike a balance between domestic and international markets.

Innovation culture is synonymous in many people's minds with industrially advanced countries. Several developing countries have, however, singled out health biotechnology and attempted to promote indigenous innovation in the field. This essay will discuss case studies on health-biotechnology innovation in seven developing countries: Brazil, China, Cuba, Egypt, India, South Africa, and South Korea. All have scientific and technological capacity in the health-biotechnology field; they represent different parts of the world and present significant differences in income levels and population size. We will start by briefly reviewing the literature on the transfer of technology for promoting development to provide a general context for examining health-biotechnology development in these countries. We will then discuss in detail the comparative case studies on health-biotechnology innovation in these seven developing countries and explore their successes, discuss the main characteristics of the innovation in these countries, and delineate lessons on how they have been able to foster such innovation. [End Page 178]

Object The goal of this study was to assess the incidence of symptomatic and occult hyponatremia in patients who had undergone transsphenoidal pituitary surgery. Methods Patients who underwent transsphenoidal surgery at the University of Southern California University Hospital between 1997 and 2004 had serum sodium levels drawn on an outpatient basis on postoperative Day 7. Patient records were retrospectively reviewed to determine the incidence of, and risk factors for, symptomatic and asymptomatic hyponatremia. Two hundred forty-one patients had routine serum sodium levels drawn as outpatients on postoperative Day 7. Twenty-three percent of these patients were found to be hyponatremic (Na ≤ 135 mEq/L). The overall incidence rate of symptomatic hyponatremia in the 241 patients was 5%. The majority of hyponatremic patients (80%) remained asymptomatic, whereas 20% became symptomatic. In patients with symptomatic hyponatremia, the mean sodium level at diagnosis was 120.5 mEq/L, compared with 128.4 mEq/L in asymptomatic, hyponatremic patients (p < 0.0001). Female patients were more likely to develop hyponatremia than male patients (33% compared with 22%, p < 0.03). Fifty-two percent of patients who had transient diabetes insipidus (DI) early in their postoperative course subsequently developed hyponatremia, compared with 21% of those who did not have DI (p < 0.001). Patient age, tumor type, and tumor size did not correlate with development of delayed hyponatremia. Outpatients with moderately and severely low sodium levels were 5 and 12.5 times more likely, respectively, to be symptomatic than were patients with mild hyponatremia. Conclusions Delayed hyponatremia occurs more frequently than was previously suspected in patients who have undergone transsphenoidal surgery, especially in female patients and those who have previously had transient DI. The majority of hyponatremic patients remain asymptomatic. Obtaining a serum sodium value on an outpatient basis 1 week after pituitary surgery is helpful in recognition, risk stratification, and subsequent intervention, and may prevent potentially serious complications.

Innovation is central to reaching the sustainable development goals on women’s, children’s, and adolescents’ health. The task now is to scale up these innovations in a sustainable way, say Haitham El-Noush and colleagues

The role of leadership in health care priority setting remains largely unexplored. While the management leadership literature has grown rapidly, the growing literature on priority setting in health care has looked in other directions to improve priority setting practices--to health economics and ethical approaches. Consequently, potential for improvement in hospital priority setting practices may be overlooked. A qualitative study involving interviews with 46 Ontario hospital CEOs was done to describe the role of leadership in priority setting through the perspective of hospital leaders. For the first time, we report a framework of leadership domains including vision, alignment, relationships, values and process to facilitate priority setting practices in health services' organizations. We believe this fledgling framework forms the basis for the sharing of good leadership practices for health reform. It also provides a leadership guide for decision makers to improve the quality of their leadership, and in so doing, we believe, the fairness of their priority setting.

Climate change is an ethical issue, because it involves the distribution of a scarce resource - the capacity of the atmosphere to absorb our waste gases without producing consequences that no one wants. Various principles might be used to decide what distribution is just. This commentary argues that on any plausible principle, the industrialised nations should be doing much more than they are doing now, and much more than they are required to do by the Kyoto protocol, to reduce their greenhouse gas emissions. The commentary also responds specifically to some issues raised by MacCracken, Toman and Gardiner, including feasibility, the discount rate, and grounds for pessimism.

Objective: Limited resources mean that decision-makers must set priorities among competing opportunities. Programme budgeting and marginal analysis (PBMA) is an economic approach that focuses on optimizing benefits with available resources. Accountability for reasonableness (A4R) is an ethics approach that focuses on ensuring fair priority-setting processes. PBMA and A4R have been used separately to provide decision-makers with advice about how to set priorities within limited resources. The goals of this research were to use the A4R framework to evaluate the fairness of using PBMA for priority setting and to assess how A4R might make PBMA fairer. Methods: Qualitative case studies to describe priority setting using PBMA in the Calgary Health Region (Alberta, Canada) evaluated using A4R as a conceptual framework. Results: The use of PBMA for priority setting was fairer than previous priority setting because of its emphasis on explicit rational decision-making. However, there were opportunities to improve the process, particularly by collecting data related to the decision criteria, by developing a communication plan to engage internal and external stakeholders about priority-setting, and by providing a formal mechanism to review priority-setting decisions and resolve disputes. Conclusions: There is potential for combining A4R and PBMA in a more comprehensive approach to priority setting, which uses a fair priority-setting process to reach decisions aimed at achieving optimal benefits with available resources.

Priority setting tends to take place in health care settings that are hierarchical and politically complex. Fair processes, as defined for example by Daniels' and Sabin's accountability for reasonableness framework, have been identified as essential for securing socially acceptable priority setting decisions. However, power differences in the decision-making context can pose a serious impediment to fair priority setting in health care organizations. Comparatively little attention has been paid to examining the institutional conditions within which priority setting decisions are made. We review a case study of priority setting in hospital operational planning in Toronto, which had been designed by executive leaders to be broadly inclusive of senior and middle-level clinical and administrative leaders. We report three power differences that arose as limiting factors on the inclusiveness of the priority setting process. We argue that these findings have significant theoretical implications for the accountability for reasonableness framework and propose a fifth condition, the "empowerment condition", which states that there should be efforts to minimise power differences in the decision-making context and to optimise effective opportunities for participation in priority setting.

Objective: To describe and evaluate priority setting in the context of hospital priority setting and more specifically to evaluate the use of an appeals process. Design: Qualitative case study and evaluation using the ethical framework ‘accountability for reasonableness’. Setting: The University Health Network (UHN), a network of three large urban teaching hospitals affiliated with the University of Toronto in Toronto, Canada. This study focused on Clinical Activity Target Setting (CATS), the final component of the strategic planning process. Participants: Sixty-six board members, senior administrators, managers, clinical leaders and other hospital staff who participated in the hospital strategic planning exercise. Data collection: Three primary sources of data were used: key documents, interviews with participants and stakeholders and observations of group deliberations. Data analysis: Open and axial coding using an explicit conceptual framework ‘accountability for reasonableness’. Results: This was the first time an appeal process has been described and evaluated. The appeals process was found to be a fundamental component to overall perceived fairness of the priority setting process. The appeals process also enhanced the involvement of stakeholders and increased overall participant satisfaction. In addition, four areas of ‘good practice’ and ten recommendations for improvement of the larger priority setting process were identified. Conclusions: This case study has provided an in-depth analysis of a priority setting process at a hospital, with a particular focus on the appeals process. Also, we compared the lessons learned from this study with those from a previous study at a different hospital.

The "lone" clinical bioethicist working in a large, multisite hospital faces considerable challenges. While attempting to build ethics capacity and sustain a demanding range of responsibilities, he or she must also achieve an acceptable level of integration, sustainability, and accountability within a complex organisational structure. In an effort to address such inherent demands and to create a platform towards better evaluation and effectiveness, the Clinical Ethics Group at the Joint Centre for Bioethics at the University of Toronto is implementing the Hub and Spokes Strategy at seven hospitals. The goal of the Hub and Spokes Strategy is to foster an ethical climate and strengthen ethics capacity broadly throughout healthcare settings as well as create models in clinical bioethics that are excellent and effective.

Background Bioethics education has been recommended as a formal component of surgical residency training. The best method for teaching bioethics to residents is unclear. We compared the effectiveness of a standardized patient (SP)-based seminar to a traditional seminar format for teaching bioethics to surgical residents. Methods We randomized 31 first- and second-year surgical residents to either a SP-based seminar or a traditional seminar on informed consent. Immediately after the seminars, we evaluated resident performance in patient encounters on informed consent by using an objective structured clinical examination. Their knowledge of informed consent was also evaluated by using a 20-question short-answer written examination immediately after the seminars and then 3 weeks later. Results Twenty-nine residents completed the study; two withdrew because of an emergency. The SP seminar group had lower SP interview scores on the 22 item checklist compared with the traditional seminar group (57% versus 66%; difference −9%; 95% confidence interval [CI], −17% to −1%, P = .03). The SP seminar group also had lower knowledge scores on the questionnaire immediately after the seminar (60% versus 73%; difference −13%; 95% CI, −21% to −4%, P = .003). The difference in knowledge scores persisted at 3 weeks (41% for the SP group, 59% for the traditional seminar group; difference −18%; 95% CI, −29% to −7%; P = .002). Conclusions A traditional seminar was superior to an SP-based seminar for teaching informed consent to surgical residents.

Priority setting is a challenge for health services organizations across health systems. Because demand for health services exceeds available resources, health services priorities must be set to ensure resources are used appropriately to meet the community's health needs. Various approaches have been developed to assist decision-makers to set priorities in their organizations. The dominant approaches come from evidence-based medicine, economics and ethics.

Understanding and harnessing genomic variation will contribute significantly to improving the health of people in developing countries. We need to explore the nexus between pharmacogenetics, genotyping projects in developing countries, and the evolution of the pharmaceutical industry in both the developed and developing worlds. Here, we argue that, for the foreseeable future, we should focus not on boutique 'personalized' medicine, but on carefully defined differences between populations and ethical ways of using emerging genomics knowledge to develop drugs and improve health.

The present study examined the association of the Tyrosine hydroxylase Val-81-Met polymorphism with alcohol dependence. One hundred and fifty-nine patients in a psychiatric unit with alcohol dependence were genotyped as well as 92 healthy volunteers. The Val allele was more frequent in patients with alcohol dependence (69.5%) than in controls (62.5%). This effect was largely due to the association with early-onset alcoholism (77.8%), whereas no difference was noted between late-onset patients and controls. Our results suggest a role for tyrosine hydroxylase in early-onset alcoholism.

Zusammenfassung: Es wurden alkoholabhängige Patienten unter Stressbedingungen neuropsychologisch untersucht. Fragestellung: Zeigt sich wie bei depressiven Patienten eine abnorme Reaktion auf negative Rückmeldung oder gar eine generelle Stressanfälligkeit? Die alkoholabhängigen Patienten wurden in der Testbatterie zur Aufmerksamkeitsprüfung (TAP) nach negativer Rückmeldung tendenziell langsamer und die Kontrollpersonen tendenziell schneller. Insgesamt ergab sich ein signifikanter Unterschied in Visuellem Scanning und Reaktionswechsel. Damit ist die “abnormal response to negative feedback” nicht spezifisch für depressive Patienten. Unter 90 dBA Lärm als Stressor zeigten sich dagegen keine Effekte auf die Leistungsfähigkeit oder die Stressverarbeitung. Eine Leistungsminderung durch generelle Stressanfälligkeit konnte somit nicht beobachtet werden. Kontinuierliches Stressmonitoring zeigte, dass sich die alkoholabhängigen Patienten wie testängstliche Probanden verhalten und nach negativer Rückmeldung leistungsminderndes Bedrohungs- und Verlusterleben vorherrscht, während gesunde Probanden auch nach negativer Rückmeldung an der Einschätzung als Herausforderung festhalten und sich steigern.

showcased its capability in genomics and its intent to become one of the world’s leading contributors to the field of biotechnology. The country quickly set up major institutions in genomics, the Beijing Genomics Institute and the Chinese National Human Genome Center (with branches in Beijing and Shanghai), equipped with state of the art sequencing facilities and computers. Even though they entered the project relatively late, Chinese researchers successfully sequenced 1% of the human genome with an accuracy rate of 99%. They have continued to demonstrate their strength in the field, and in 2002 sequenced the rice genome of the most widely cultivated subspecies in China 1 . The country’s participation in the Human Genome Project is indicative of how rapidly China has reached world standards in sequencing, and this in turn reflects its general advanced state of development in health biotechnology. Since China initiated research in the field in the late 1980s, it has approved several vaccines and diagnostics and thera

To describe priority setting for admissions in a hospital critical care unit and to evaluate it using the ethical framework of "accountability for reasonableness.Qualitative case study and evaluation using the ethical framework of accountability for reasonableness.A medical/surgical intensive care unit in a large urban university-affiliated teaching hospital in Toronto, Canada.Critical care unit staff including medical directors, nurses, residents, referring physicians, and members of a hospital committee that formulated an admissions policy.Modified thematic analysis of documents, interviews with participants, and direct observation of critical care unit rounds. Evaluation using the four conditions of Daniels and Sabin's accountability for reasonableness: relevance, publicity, appeals/revisions, and enforcement.We examined key features and participants' views about the priority setting process. Decisions to admit patients involve a complex cluster of reasons. Both medical and nonmedical reasons are used, although the nonmedical reasons are less well documented and understood. Medical directors, who are the chief decision makers, differ in their reasoning. Admitting decisions and reasons are usually explained to referring staff but seldom to patients and families, and nonmedical reasons are seldom surfaced. A hospital critical care admissions policy exists but is not used and is not known to all stakeholders. A formal appeals/revisions process exists, but appeals usually involve informal negotiations. The existence of priority programs in the hospital (e.g., transplantation) adds complexity and heightens disagreement by stakeholders.We have described and evaluated admissions decision making in a hospital's critical care unit. The key lesson of our study is not only the specific findings obtained here but also how combining a case study approach with the ethical framework of "accountability for reasonableness" can be used to identify good practices and opportunities for improving the fairness of priority setting in intensive care.