Medical Considerations Research Articles

Fertility preservation in prepubertal female patients: Medical and ethical considerations of offering ovarian tissue cryopreservation in pediatric patients

In the USA, one child in 285 children is diagnosed with cancer every year, but thanks to improvements in medicine, the survival rate has reached 80%. However, cancer treatments, such as chemotherapy and radiation, are likely to affect their fertility later in life, limiting their ability to conceive. To reduce this risk, ovarian tissue cryopreservation is a surgical procedure that allows the ovarian tissue to be retrieved and cryopreserved in order to be reimplanted back into the abdomen and restore ovarian function in children who become infertile due to gonadotoxic treatments. A case study published in 2014 offered recommendations to help assess whether such a procedure should be offered to female patients who have not yet entered puberty. This paper will investigate whether, in light of more recent and updated literature, their recommendations may need to be revised.

A case report of hemorrhagic presentation of diffuse neonatal hemangiomatosis (DNH) associated to obstructive hydrocephalus: Medical and neurosurgical considerations

BackgroundDiffuse neonatal hemangiomatosis (DNH) is a rare disorder typically recognized at birth or during the neonatal period. DNH involves three or more organ systems, including the central nervous system (CNS). In these cases, serious complications such as hemorrhages and obstructive hydrocephalus can develop.Case reportWe present a case of DNH with intracranial hypertension and CNS hemorrhagic lesions on the mesencephalic aqueduct, resulting in triventricular hydrocephalus, treated with endoscopic ventriculocisternostomy (ETV) and medical therapy.DiscussionDNH is a rare condition that can involve the CNS with serious complications. From a review of the literature, we highlighted only two cases of DNH with brain involvement treated surgically. We report the successful outcome of ETV, along with surgical considerations, imaging findings, and the complete resolution of cerebral and skin lesions following medical therapy.ConclusionsMedical therapy is not standardized and must be individualized. In patients who develop severe neurological symptoms such as obstructive hydrocephalus, surgery may be considered to avoid neurological sequelae.

Osteoporosis and Vertebral Column.

Osteoporosis is an age-related metabolic disease which has a significant impact on bone health and overall quality of life. It is gaining importance as a major medical consideration with the rapid increase in geriatric population globally. It increases the risk of vertebral fractures, progressive spinal deformities and neurological complications, contributing significantly to morbidity and mortality. Increase in life expectancy and advancement of medical technology has led to an increase in the proportion of geriatric patients undergoing orthopaedic procedures. It is becoming vital to adequately evaluate, investigate and treat osteoporosis before planning spinal surgery, especially spinal fusions and instrumentation. Historically, osteoporosis was considered a contraindication to spine surgery adding to the burden of Disability Adjusted Life Years (DALYs) and mortality. Conversely, osteoporotic patients who underwent spine surgery were not adequately optimized, leading to an increase in failure and complication rates. Better understanding of the pathophysiology of osteoporosis and the biomechanics of an osteoporotic spine with knowledge of current standards of treatment of osteoporosis facilitate the timely and adequate management of this disease. Advances in surgical and anaesthetic techniques facilitate successful surgeries on high-risk elderly and osteoporotic patients with multiple comorbidities allowing for a significantly high predictability for long-term positive outcomes.This article discusses the biomechanics of the osteoporotic spine, the diagnosis and management of osteoporotic patients with spinal disease, and the new treatments, recommendations, surgical indications, strategies and advances in instrumentation in patients with osteoporosis who require spinal surgery. In this article, the authors aim to provide a generalized overview for better understanding of the pathophysiological processes underlying osteoporosis in the vertebral column. This review provides a comprehensive set of guidelines for overall health and management of spine patients with pathologies, either caused by or compounded with osteoporosis. An overview of current techniques, strategies and technologies designed to address the challenges associated with spine surgery in osteoporotic patients is also outlined. Content for this article has been sourced from routinely cited articles available via PubMed, from National Institute of Health consensus development conference, from the recommendations by World Health Organization technical report series, from previous articles by the authors and from the protocols established by the authors in their clinical practice based on experience and detailed case reviews.

Replacing Potassium in the Emergency Department May Not Decrease the Hospital Mortality in Mild Hypokalemia: A Propensity Score Matching Analysis.

Background: Hypokalemia is associated with considerable morbidity and mortality, highlighting the timely correction of potassium levels as a critical medical consideration. However, the management of mild hypokalemia remains a subject of ongoing debate. This study explores the relationship between potassium replacement in the emergency department (ED) and hospital mortality in patients with mild hypokalemia. Methods: This retrospective cohort study was conducted at a tertiary care hospital, including patients who presented to the ED with mild hypokalemia, defined as potassium levels between 3.0 and 3.4 mmol/L, between 2020 and 2021. Patients diagnosed with acute coronary syndrome, diabetic ketoacidosis, hyperglycemic hyperosmolar state, and major cardiac arrhythmias were excluded. The patient cohort was then divided into two groups, based on whether they received potassium replacement in the ED. A propensity score analysis was employed to account for potential pretreatment confounding factors, including age, gender, time on ED arrival, insurance, comorbidities, serum potassium and creatinine levels, and ED length of stay. Subsequently, a multivariable logistic regression analysis, incorporating hospital length of stay and acute comorbidities, was performed post-matching to further adjust for predictive factors. The primary outcome was all-cause hospital mortality. Results: This study included a total of 1931 patients, of which 724 were matched for analysis (362 with potassium replacement and 362 without). The average age was 53.9 years, and most were male (58.5%). After adjusting for confounding factors using propensity score analysis, there was no significant difference in hospital mortality between the potassium replacement and control groups (adjusted odds ratio 0.81, 95% CI 0.36-1.79, p = 0.60). Conclusions: This study's findings indicate that replacing potassium in the ED may not lower the risk of hospital mortality in patients with mild hypokalemia. Consequently, the customary practice of potassium replacement in hospitalized patients may lack justification, and deferring the replacement until after patients leave the ED could be considered.

Medication Considerations in a Cancer Patient with a Jejunostomy Tube (J-tube).

Medication Considerations in a Cancer Patient with a Jejunostomy Tube (J-tube).

Joint family consultations for psychiatric inpatients with severe eating disorders transitioning to adulthood: psychoanalytic design of a therapeutic setting.

While family work is acknowledged as relevant in the care of eating disorders (EDs), not much literature has explored it in the period of transition from adolescence to young adulthood (16-18 to 30 y.o.). Yet this period is of significant importance in the prognosis and evolution of EDs; but its particular stakes require specific therapeutic settings-especially for inpatient EDs. In this paper, we start from the paradoxical observation that some families refuse this type of work in its usual form, with a family-dedicated therapist, and require to only exchange with the psychiatrist in charge of the treatment plan. We use a psychosomatic-informed psychoanalytic approach to shed light on this refusal as a latent denial of the contribution of family dynamics to the current symptom, and an unconscious tendency to stick to a dependency-laden family scheme. We then explain the conception of a specifically dedicated therapeutic setting, designed to address this specific type of resistance, offered to families as a therapeutic compromise designed to give them a specific position in the care of their child. In our joint therapeutic consultations, family dynamics are addressed on the basis of exchanges regarding treatment and in particular feeding. While such exchanges start from medical considerations, the therapeutic couple (psychiatrist-psychologist) uses them to address the parent and patient expectations underlying the symptom. We propose to call this act "inscription"; it enables a separation from the underlying dependency-oriented family scheme, while stressing the importance to care for associated parental anxieties.

Veterinary assessment of behaviour cases in cats and dogs

Background: Clients typically turn to their local veterinary practice as the first point of call when they are concerned about their pet's behaviour, unless they think it is purely a training problem. Therefore, it is essential that the whole veterinary team are aware of the medical considerations that can affect behaviour (including routine training). Many cases involve medical aspects which should be addressed as part of a multimodal approach to problem behaviour management, which may be the most efficient and effective way to support these cases.Aim of the article: This article outlines the medical considerations that should be made in first‐opinion practice when presented with a behaviour case in cats and dogs. It also discusses the role of the first‐opinion vet in case management and how good collaboration between the vet, a behavioural specialist and the pet owner can aid successful resolution.

Euthanasia: Right to die with dignity

Euthanasia, a highly controversial and emotionally charged topic, revolves around the deliberate act of ending a person's life to alleviate their suffering. It is a subject that intertwines complex ethical, legal, and medical considerations. The aim of this article is to provide an in-depth analysis of euthanasia, considering its various forms, arguments for and against, legal status, and the broader implications for society. To facilitate further exploration, this article will also include superscript references to reputable sources. In one of a recent study done 200 consenting medical professionals in a tertiary care center in the North-Western region of India. The age of the respondents was between 23 to 58 years and years of experience ranged between 3 months to 37 years. Results of the study showed that 80% of the participants were in favor of Euthanasia for terminally ill patients.

Analysis of Tuberculosis Disease Case Growth From Medical Record Data, Viewed Through Clustering Algorithms (Case Study: Islamic Hospital Bogor)

Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis infection. Tuberculosis can spread from one person to another through airborne transmission. This disease is most commonly found in the Asian region. Currently, Indonesia ranks second after India in terms of tuberculosis cases. The discovery of tuberculosis cases by province in Indonesia reveals that West Java Province is one of the contributors to the highest tuberculosis cases. It is known that the tuberculosis case rate in Bogor Regency is one of the highest in West Java. This serves as the foundation for the focus of this research, which will be conducted at Islamic Hospital Bogor, to determine the average age and gender of patients who are more susceptible to tuberculosis. One way to understand the growth of tuberculosis cases is through clustering using Data Mining Techniques, specifically several clustering algorithms such as k-means clustering, fuzzy c-means, and Gaussian mixture. These techniques aim to identify the growth of tuberculosis cases based on age range and gender. Therefore, the research results are expected to provide new insights, which could be valuable for decision-makers in various capacities, such as preventive measures, healthcare facility provision, and medication considerations.

The Efficiency of TB LAM Antigen Test to Xpert MTB/RIF Ultra Test for the Diagnosis of Tuberculous Pericarditis Using Pericardial Fluid Samples.

Medical considerations for early diagnosis of tuberculous pericarditis (TBP) include Xpert MTB/RIF Ultra and TB lipoarabinomannan (LAM) antigen (Ag) tests, with immunological status influencing the performance of the latter. An evaluation of the efficiency of Xpert MTB/RIF Ultra and TB LAM Ag in detecting TBP was conducted using pericardial fluid samples from 46 patients with suspected TBP. Fifteen patients (34.1%) were diagnosed with TBP according to culture results. TB LAM Ag's sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) were 33.3%, 100%, 100%, 74.4%, 0, and 0.67, respectively. The sensitivity, specificity, PLR, NLR, PPV, and NPV of Xpert MTB/RIF Ultra were 80%, 93.1%, 11.6, 0.21, 85.7%, and 90%, respectively. There was an association observed between a positive TB LAM Ag test and HIV status. When compared to the Xpert MTB/RIF Ultra test, TB LAM Ag has lower accuracy for the detection of microbiologically proven tuberculous pericarditis, yet its usage in HIV-positive populations may be worth exploring. The TB LAM Ag assay is not the best first-line test for the diagnosis of tuberculous pericarditis, and it should be used in conjunction with other diagnostic tests.

95 Do Not Attempt Resuscitation: all or nothing?

Abstract Background Do Not Attempt Resuscitation (DNAR) orders may be implemented when patients do not wish to receive Cardio-Pulmonary Resuscitation (CPR) or when CPR is deemed non-beneficial. Complex ethical and medical considerations influence these decisions, emphasising the need for accurate documentation as per national policies. Our aim was to assess comprehensive documentation of DNAR decisions and healthcare providers’ opinions on managing patients with DNAR orders. Methods We conducted a point-prevalence chart review of adult inpatients with a DNAR order on March 2nd, 2023.We surveyed healthcare providers using a structured tool and analysed the data using Excel. Results We identified 22 (n = 22) charts for review. All charts had a DNAR form, but only 31.8% (7) had documented discussion details. 54.5% (12) lacked a discussion with the patient regarding the DNAR decision, and 58.3% (7) lacked documentation explaining the reasoning. 72.7% (16) lacked clear documentation on the reasoning for the DNAR status decision. Regarding healthcare providers’ opinions on patients with DNAR status, we received 46 completed questionnaires (n = 46). Most respondents believed simple bedside investigations and non-invasive interventions were appropriate for DNAR patients. However, there was a discrepancy in opinion regarding more invasive interventions, such as Naso-Gastric Tube placement (52%) or inotropic support (48%). 84.8% (39) of staff believe there is a distinction between palliative patients and those designated as DNAR. 80.4% (37) of nursing staff reported hesitancy in discussing DNAR status with doctors when patients deteriorate. 58.7% (27) of staff believed their approach to care changes when a patient is labelled DNAR. Conclusion Our audit demonstrates the need for improved DNAR status documentation. Current practices do not meet national guidelines, creating ambiguity and subsequent confusion during emergencies. This may be exacerbated by disparities in hospital staff opinion regarding DNAR patients, highlighting the importance of establishing local policies to improve staff education and patient care.

Ethical and Practical Considerations of Perimortem Gamete Procurement for Palliative Care Providers

Requests for perimortem gamete procurement (PGP) typically arise by a surrogate decision maker after the unexpected death or incapacitation of a reproductive-aged individual. Palliative care clinicians should have a working knowledge of the medical, ethical, and practical considerations pertaining to such requests. In this paper, we describe a case in which the PGP request originated from an incapacitated patient's parents. We review the technologies associated with PGP and posthumous assisted reproduction (PAR) and discuss the ethical and legal issues involved in such cases, including recent position statements from national and international reproductive health groups. Finally, we provider readers with a stepwise approach for considering requests for PGP.

The Intersection of Law and Health: Safeguarding Public Welfare

The intersection of law and health is a critical aspect of safeguarding public welfare. This article explores the multifaceted relationship between law and health, emphasizing the key areas where legal principles and regulations contribute to protecting the well-being of individuals and communities. Effective health legislation and regulatory frameworks establish guidelines and standards for healthcare services, ensuring their safety, equity, and quality. Public health laws enable disease control measures, vaccination programs, and health promotion initiatives, reducing preventable illnesses and improving public health outcomes. Medical ethics and legal considerations guide healthcare professionals in upholding principles such as informed consent, patient confidentiality, and end-of-life decisions, safeguarding patient rights and trust. Law also plays a significant role in promoting healthcare access, equity, and human rights. Medical malpractice laws are also discussed in this paper which establish standards of care, deter negligence, and provide compensation for patients harmed by medical errors, promoting accountability and patient safety.

National Trends in Microtia Repair Cost and Hospital Length of Stay.

Microtia can have deleterious impacts on the functional, psychological, and aesthetic outcomes of affected young children. Reconstructive procedures can alleviate these negative outcomes and significantly improve the quality of life for patients; however, the cost and length of hospital stay (LOS) for such procedures and the factors that impact them have not been well-characterized. This study seeks to understand the hospital-level (institution type, size, and geographic region) and patient-level factors (race, age, and insurance status) that impact cost and LOS in patients who undergo microtia reconstructive surgery. A retrospective data analysis was conducted utilizing the National Inpatient Sample (NIS) database for the years 2008 to 2015. Inclusion criteria included patients who had an International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code for microtia (744.23) as well as a procedure for microtia correction (186×/187×). A total of 714 microtia repair cases met the inclusion criteria and were sampled from the NIS database. Microtia repair cost was significantly increased on the West Coast compared with the Northeast ($34,947 versus $29,222, P =0.020), increased with patient age ($614/y, P =0.012), and gradually increased from 2008 to 2015 ($25,897-$48,985, P <0.001). Microtia LOS was significantly increased with government-controlled hospitals compared with private hospitals (1.93 versus 1.39d, P =0.005), increased with patients on Medicaid compared with private insurance (2.33 versus 2.00d, P =0.036), and overall decreased with patient age (-0.07d/y, P =0.001). The results not only identify the multifactorial impacts that drive cost and LOS in microtia repair but provide insights into the financial and medical considerations patients and their families must navigate.

Perceived impact of ethnocultural competency training on genetic counselors' clinical interactions.

For genetic counselors to effectively meet the needs of an ever-diversifying multicultural patient population, it is vital that their genetic counseling programs (GCPs) equip future genetic counselors to recognize the impact of a patient's ethnocultural background on clinical interactions (Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed (p. 28). CASSP Technical Assistance Center, Georgetown University Child Development Center, 1989). Concerns about genetic counseling cultural competency training (CCT) including content and delivery have been brought up by GCP students who identify as racial and ethnic minorities (Journal of Genetic Counseling, 29, 303-314). Though GCPs must meet the Accreditation Council of Genetic Counselors' (ACGC) accreditation criteria, there is a gap in knowledge regarding the focus, type, and methods of delivery that GCPs have chosen to incorporate into their CCT, as ACGC does not dictate the exact focus, delivery, or format of training curricula. This quantitative study aimed to (1) characterize the current focus, type, and delivery of ethnocultural competency training in GCPs as perceived by second-year genetic counseling students and recent graduates and (2) highlight their perception of its impact on their levels of preparedness and comfort when interacting with ethnoculturally diverse patients. One hundred and one survey responses were analyzed using descriptive statistics, chi-square analyses, two-sample Wilcoxon rank-sum, and Fisher's exact tests. The results reveal significant variability in the format, type, and delivery of CCT provided by GCPs. Participants perceive that CCT focusing on specific traditions, medical considerations, and systemic healthcare disparities (taught to 74%, 61%, and 94% of students, respectively) related to ethnoculturally diverse patients was more likely to increase their self-reported levels of preparedness and comfort for clinical interactions than training focused on racial or ethnic stereotypes and generalizations (taught to 88% of students). Although 94% of participants perceived their CCT as helpful, 61% reported they received an insufficient amount. In light of these results, we provide suggestions for the improvement of ethnocultural CCT and highlight future opportunities for more intentional and fruitful CCT in GCPs.

Implementation of Abortion Regulations on Medical Emergency Indications in Hospitals Based on Legal Aspects

Abortion is one method to prevent unwanted births. This method was born along with the development of human life with various reasons and considerations, both legal and medical considerations. Abortion is a crucial law in health law. But abortion for several medical reasons is a legal way to provide solutions to safety problems related to pregnancy. As the executors of the abortion act, namely medical personnel who are closely related to existing regulations or policies, it is still a pro and contra polemic. Therefore, it is necessary to do an analysis to determine the clarity of the legality of the implementation of abortion on indications of medical emergencies in hospitals associated with abortion law regulations. The research design used in this study is qualitative through a descriptive analysis approach related to the legality issue of abortion regulations indicating medical emergencies between the Health Act and the Abortion Criminal Code. The sample in this study was an obstetrician with a medical team, namely midwives who worked in the delivery room. This study aims to determine the factors that influence the implementation of abortion regulations based on indications of medical emergencies in hospitals, specifically referring to Health Law No. 36 of 2009 with the Criminal Code on abortion. The factors that influence the implementation of abortion in hospitals are: the discovery of indicators or triggers that an abortion must be carried out in accordance with the Health Law Number 36 of 2009; it must be carried out as soon as possible because it endangers the patient’s life; carried out according to health standards and applicable laws; and the approval of both the parties to carry out official and legal abortion procedures and mechanisms according to legal and applicable rules. Based on this, abortions with indications of medical emergencies are often carried out in hospitals and can be justified by the principle of legitime defense. Legal issues regarding the regulation of abortion indicative of a medical emergency, as long as they refer to the procedures according to the Health Law, the legal issue of the Criminal Code cannot be brought to the surface, because abortion on the indication of a medical emergency is a medical action that must be carried out.&#x0D; Keywords: abortion, health law, hospital

Cleft palate surgical perspectives: A pilot study

ABSTRACT Purpose: The current pilot study aimed to collect craniofacial surgeon’s personal perspectives regarding the timing of cleft palate surgical repair, medical considerations for surgical repair (i.e., age, weight, type of cleft, and potential for surgical complications), and social considerations (i.e., speech–language development, socioeconomic status, and familial support). Materials and Methods: Fifteen plastic surgeons currently practicing cleft palate repair participated in this study. Surveys were distributed electronically to team coordinators of the American Cleft Palate-Craniofacial Association-accredited craniofacial teams and included a combination of Likert scales, closed multiple-choice questions, and open-ended qualitative questions for free-text responses. Results: Preliminary data obtained in this study suggest that the most common age range for palate repair in nonmedically complex infants is 10–11 months of age (n = 10). Notably, 20% of respondents (n = 3) reported a typical surgical repair time of 7–9 months of age. While medical and social priorities differed, all surgeons rated speech–language development as an important factor when determining the timing of surgical intervention. Conclusion: Given the limited consensus on surgical timing and intervention for children with cleft palate, further research is needed to determine the optimal timing of palate repair that considers both medical safety and near age-appropriate speech sound acquisition and production.

Pulmonary Hypertension in Congenital Heart Disease: A Scientific Statement From the American Heart Association.

Patients with pulmonary hypertension associated with congenital heart disease make up an increasing proportion of the total pulmonary hypertension population who bring with them added complexity because of underlying anatomical and hemodynamic abnormalities. Currently, no consensus recommendations are available on how to best manage this group of patients for either the primary cardiologist or pulmonary hypertension subspecialist, including timing of referral. The purposes of this document are (1) to describe the various pulmonary hypertension groups and subgroups associated with congenital heart disease, (2) to describe imaging modalities used in patient evaluation, (3) to elucidate medical and surgical management considerations, (4) to highlight disparities within this population, and (5) to identify gaps and future research needs of patients with pulmonary hypertension associated with congenital heart disease.

Regulatory considerations for medical imaging AI/ML devices in the United States: concepts and challenges.

To introduce developers to medical device regulatory processes and data considerations in artificial intelligence and machine learning (AI/ML) device submissions and to discuss ongoing AI/ML-related regulatory challenges and activities. AI/ML technologies are being used in an increasing number of medical imaging devices, and the fast evolution of these technologies presents novel regulatory challenges. We provide AI/ML developers with an introduction to U.S. Food and Drug Administration (FDA) regulatory concepts, processes, and fundamental assessments for a wide range of medical imaging AI/ML device types. The device type for an AI/ML device and appropriate premarket regulatory pathway is based on the level of risk associated with the device and informed by both its technological characteristics and intended use. AI/ML device submissions contain a wide array of information and testing to facilitate the review process with the model description, data, nonclinical testing, and multi-reader multi-case testing being critical aspects of the AI/ML device review process for many AI/ML device submissions. The agency is also involved in AI/ML-related activities that support guidance document development, good machine learning practice development, AI/ML transparency, AI/ML regulatory research, and real-world performance assessment. FDA's AI/ML regulatory and scientific efforts support the joint goals of ensuring patients have access to safe and effective AI/ML devices over the entire device lifecycle and stimulating medical AI/ML innovation.

Evaluation of Awareness of General Practitioners Working in Yazd, Iran, Concerning Oral Diseases in 2015

Background: The incorporation of oral health promotion into general healthcare has been proposed by the World Health Organization. General practitioners (GPs) could play a vital role in the promotion of oral healthcare. Objectives: This study was designed to evaluate the awareness of oral and maxillofacial medicine specialty and its scope of practice among Iranian GPs. Methods: The present cross-sectional study was conducted in Yazd, Iran. A total of 95 GPs randomly filled out a close-ended questionnaire. Responses to the questionnaire were analyzed using descriptive and analytical statistics. The self-administered questionnaire comprised 35 items and covered the demographical details and characteristics of participants, in addition to their awareness of oral and maxillofacial medicine and its scope of practice. Finally, awareness scores were classified as weak, intermediate, and good. The data were analyzed using a t-test and Pearson correlation. A P-value ≤ 0.05 was considered statistically significant for all statistical analyses. Results: Only 24.2% of GPs had enough awareness. The mean score of total awareness about oral diseases was 11.82 ± 3. The mean scores of total awareness for the oral manifestations of systemic diseases, medical considerations in dentistry, and oral lesions were 3.59 ± 1.17, 3.96 ± 1.62, and 4.27 ± 1.65, respectively. Conclusions: According to this study, the awareness of GPs playing a key role regarding oral medicine and oral manifestations of systemic diseases was weak. It is recommended to revise the medical curriculum to incorporate related courses about common oral diseases into the medical curriculum. The aim will only be achieved by improving the coordination between dentists and GPs.