Effect of human albumin administration on clinical outcome and hospital cost in patients with subarachnoid hemorrhage

Ethical Issues Surrounding Quality Improvement Activities

During the past 15 years, issues regarding the ethical conduct of quality improvement activities have emerged. Recently, many have called for regulation of quality improvement studies using institutional review boards. The author reviews the history of the human rights argument within the context of a relevant, newly released study by the Hastings Center and concludes with practical application of the study's findings.

Albumin therapy in acute stroke patients

Preclinical studies have recently shown that albumin has neuroprotective effects for stroke in animal models. Thus, we sought to evaluate the effects of albumin therapy in patients with acute cerebral infarcts. We prospectively studied 49 patients with moderate-to-severe cerebral infarcts within the middle cerebral arterial territory into one of two groups: the control group (N = 18) received saline, whereas the albumin group (N = 31) received either 40 g or 80 g of albumin within 24 h from symptom onset. The modified National Institutes of Health Stroke Scale (mNIHSS) and diffusion-weighted imaging (DWI) were serially checked. There was no adverse effect related to albumin therapy. Although there was no significant difference in both baseline mNIHSS score and DWI lesion volume on admission, the mNIHSS scores at the 14(th) day after treatment and the increase in DWI lesion volume 72-96 h after treatment were significantly reduced in patients of the albumin group (p = 0.001 and 0.012, respectively); these effects were dose- and time- related. The outcome on the 90(th) day after stroke onset was more favorable in the albumin group than in the control group. Within the albumin group, patients who had patent or recanalized vessels showed more significant improvement than patient without recanalization (p = 0.046). Our results indicate that albumin therapy is a safe and effective modality in patients with acute cerebral infarction. This study also suggests that the effects of albumin therapy may vary depending on vessel status of the patient.

Nontherapeutic quality improvement: The conflict of organizational ethics and societal rule of law

OBJECTIVE

Critical care ethics focuses largely on patient autonomy. Cost containment is necessary but requires rationing and limitations on a patient's right to consume beneficial services. No laws address a process of autonomy rights limitation to consume resources in the intensive care unit. We analyzed the frictional interface between necessary cost containment as a quality improvement activity contrasted with individual autonomy in the context of the evolution of research ethics.

DATA SOURCES AND SYNTHESIS

Scholarly books, peer-reviewed articles, congressional record, legal sources, the World Wide Web, and the National Archives and Records Administration were evaluated in the context of current cost-containment-driven nontherapeutic quality improvement activities.

PRINCIPAL FINDINGS

Three generations in the evolution of human research ethics are identified: 1) Hippocrates to Nuremberg Code, 2) Nuremberg to Belmont, and 3) Belmont to present. Similar ethical lapses, which place the individual at risk without disclosure for the good of future patients, have arisen recurrently in the course of history and continue presently when nontherapeutic quality improvement activities are framed as a human research activity with essentially no ethical oversight. Consequently, fiduciary obligations of professionals and their employer-institutions to their mutual patients may be at odds, creating complex layers of conflicted decision making. Nonetheless, professional Hippocratic duty to "the patient" must be congruent with the organizational ethos of limited funding "stewardship" to produce meaningful patient care. Medicine's integrity is legally protected and mandated under the state interests (parens patria doctrine) of the common law.

CONCLUSION

When hospitals (society and its health insurance methods) fail to ration transparently under "cost-containment ethics," they threaten the ethical integrity of the medical profession.

Clinical review: Prevention and therapy of vasospasm in subarachnoid hemorrhage

Vasospasm is one of the leading causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Radiographic vasospasm usually develops between 5 and 15 days after the initial hemorrhage, and is associated with clinically apparent delayed ischemic neurological deficits (DID) in one-third of patients. The pathophysiology of this reversible vasculopathy is not fully understood but appears to involve structural changes and biochemical alterations at the levels of the vascular endothelium and smooth muscle cells. Blood in the subarachnoid space is believed to trigger these changes. In addition, cerebral perfusion may be concurrently impaired by hypovolemia and impaired cerebral autoregulatory function. The combined effects of these processes can lead to reduction in cerebral blood flow so severe as to cause ischemia leading to infarction. Diagnosis is made by some combination of clinical, cerebral angiographic, and transcranial doppler ultrasonographic factors. Nimodipine, a calcium channel antagonist, is so far the only available therapy with proven benefit for reducing the impact of DID. Aggressive therapy combining hemodynamic augmentation, transluminal balloon angioplasty, and intra-arterial infusion of vasodilator drugs is, to varying degrees, usually implemented. A panoply of drugs, with different mechanisms of action, has been studied in SAH related vasospasm. Currently, the most promising are magnesium sulfate, 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors, nitric oxide donors and endothelin-1 antagonists. This paper reviews established and emerging therapies for vasospasm.