Animal derived products may conflict with religious patients' beliefs

Decellularized Bovine Skeletal Muscle Scaffolds: Structural Characterization and Preliminary Cytocompatibility Evaluation

Skeletal muscle degeneration is responsible for major mobility complications, and this muscle type has little regenerative capacity. Several biomaterials have been proposed to induce muscle regeneration and function restoration. Decellularized scaffolds present biological properties that allow efficient cell culture, providing a suitable microenvironment for artificial construct development and being an alternative for in vitro muscle culture. For translational purposes, biomaterials derived from large animals are an interesting and unexplored source for muscle scaffold production. Therefore, this study aimed to produce and characterize bovine muscle scaffolds to be applied to muscle cell 3D cultures. Bovine muscle fragments were immersed in decellularizing solutions for 7 days. Decellularization efficiency, structure, composition, and three-dimensionality were evaluated. Bovine fetal myoblasts were cultured on the scaffolds for 10 days to attest cytocompatibility. Decellularization was confirmed by DAPI staining and DNA quantification. Histological and immunohistochemical analysis attested to the preservation of main ECM components. SEM analysis demonstrated that the 3D structure was maintained. In addition, after 10 days, fetal myoblasts were able to adhere and proliferate on the scaffolds, attesting to their cytocompatibility. These data, even preliminary, infer that generated bovine muscular scaffolds were well structured, with preserved composition and allowed cell culture. This study demonstrated that biomaterials derived from bovine muscle could be used in tissue engineering.

Evaluation of a hydroxyapatite-crosslinked fish gelatin membranes

Background/purpose

Porcine collagen is widely used in regenerative therapies to generate membranes for bone augmentation. However, porcine or bovine gelatin or collagen is often not appropriate for patients with creed and religious beliefs or for allergic reasons. In this study, we evaluated the potential of fish gelatin to generate membranes.

Materials and methods

Fish gelatin and hydroxyapatite (HAp) were used at three different ratios (2:0, 2:1, 2:1.5, and 2:2) to prepare gelatin-hydroxyapatite (G-HAp) membranes via freeze-drying and heat-crosslinking. The surface morphology and cell attachment of G-HAp membranes were observed using scanning electron microscopy and confocal laser microscopy. G-HAp membrane was placed at the bottom of a well plate, and MC3T3-E1 cells were seeded on it. Cell viability and cytotoxicity were tested after 1 and 3 days of culture. Alkaline phosphatase (ALP) and alizarin red staining was performed at 10 and 21 days, respectively.

Results

Viability of cells on G-HAp membrane with the gelatin:HAp ratio of 2:1.5 was significantly higher than that on membranes with other gelatin:HAp ratios. ALP and alizarin red staining showed that ALP-positive areas and calcium deposition were the highest on G-HAp membrane with the gelatin:HAp ratio of 2:1. These membranes showed negligible cytotoxicity.

Conclusion

Fish-derived G-HAp membranes have the potential to promote osteogenic differentiation of MC3T3-E1 cells with negligible cytotoxicity.

A Novel Comprehensive Therapeutic Approach to the Challenges of Chronic Wounds: A Brief Review and Clinical Experience Report

Following the clinical perspective and concept that a healthy body will not develop chronic wounds, the central approach for the treatment described here is based on an understanding of how the body transforms the wound microenvironment from a non-healing to a healing state. As part of a comprehensive treatment regimen that includes OCM™ (complete matrix), wound preparation, and skin protectant formulations, the OCM contains components for complete wound healing by attending to the individual needs required to promote the closure of each unique chronic wound. During application of the comprehensive treatment regimen in independent investigator-led trials, the total wound percentage average reduction over the first 4 weeks of treatment was 60% across multiple wound types; median time to total wound closure was 6.9 weeks. Safety testing of the OCM formulation shows no potential allergenicity, no potential sensitization, and no known product-related adverse events. Clinical trials evaluating the OCM formulation as part of the comprehensive treatment regimen of multiple wound types are underway. Results of clinical trials and real-world experiences will expand current knowledge of the wound-healing potential of this novel product.

Animal products in neurosurgery - navigating informed consent

Informed consent is an ethical and legal requirement integral to modern surgical practice. Clinicians have a duty to consider, disclose and discuss risks and concerns relevant to an individual patient. With medical advances there are now a significant number of animal-derived products and adjuncts available for use in modern neurosurgical practice, which may be relevant when consenting patients for specific procedures if such products are used. This paper highlights commonly used products in neurosurgery that contain animal-derived constituents with the aim of facilitating an informed discussion between the neurosurgeon and patient. We have reviewed the commonly used products in the centres of the authors and their commercial equivalents. The product information is taken from the manufacturer's instructions or the Federal Drug Administration documents regarding the product. Animal products commonly available to neurosurgeons can be broadly categorised into haemostatic agents, dural substitutes, dural sealants and bone cements. Many products contain a variety of animal (or human) derived products. In order to ensure informed consent and shared decision making, it is important to establish any relevant patient beliefs or views regarding the use of animal-derived products. Given the wide availability and use of neurosurgical adjuncts containing human or animal derived products, coupled with the heterogeneity within ethnic, religious, and social groups, each patient must be approached individually to ensure patient-specific concerns are identified and alternatives offered when appropriate.

Are vegans being overlooked in our prescribing practices: An orthopaedic perspective from Bristol, United Kingdom

Aim

Bristol is considered the vegan capital of the UK. The UK vegan index reveals that Bristol has 360,000 Google searches each month for Vegan content. However, the possible animal source of the medications we prescribe is not commonly contemplated. Medications in the UK must pass through animal trials prior to licensing and therefore cannot be vegan. There are, alternatives available for some medications, that do not contain animal products. The aim of this study is to review the presence of content of animal origin (CAO) in common medicines in Trauma and Orthopaedics (T&O) and explore alternatives.

Methods

We evaluated the presence and source of CAO in commonly used medications in T&O practice. The British National Formulary (BNF), our local pharmacy guidelines and the online Summary of Product Characteristics (SPCs) for the medications were reviewed. We also assessed the suitability of current COVID-19 vaccines for patients who have reservations against CAO.

Results

All unfractionated or standard heparin is porcine in origin; Fondaparinux is a simple alternative. Cholecalciferol (vitamin D3) manufacture involves the use of lanolin from sheep's wool. Vitamin D2 (ergocalciferol) is an alternative with no CAO. All widely available Covid-19 vaccines in the UK are suitable for administration to vegans and all religious faiths. Propofol, widely used as an anaesthetic agent, contains egg proteins.

Conclusion

Disclosure of animal content would help patients make informed choices. With an increasingly informed population and ethnic diversity, we should be aware of the drugs that may contain animal products so that we can offer alternatives. Sometimes, pharmaceutical companies cannot guarantee or differentiate the specific sources of animal-derived ingredients, as various suppliers are used in the manufacturing process and the sources can change on a regular basis. Patients are more likely to adhere to prescribed medicines if they have been involved in prescribing decisions.

A 13-year experience with biologic and biosynthetic absorbable mesh reinforced laparoscopic paraesophageal hernia repair

BACKGROUND

Mesh reinforced cruroplasty during laparoscopic paraesophageal hernia repair remains controversial due to wide variation in surgical technique and mesh composition. This study aims to review outcomes and rates of recurrence following laparoscopic paraesophageal hernia repair (LPEHR) with mesh reinforced cruroplasty utilizing absorbable mesh at a single institution.

METHODS

A retrospective review of all patients who underwent LPEHR with mesh was performed. Medical records were reviewed for patient reported, radiographic or endoscopic evidence of recurrence, defined as > 2 cm of vertical intrathoracic stomach. If no studies were available for review, patients were considered to have no recurrence. Outcomes and mesh-related complications were also reviewed.

RESULTS

Between 10/2008 and 9/2021, 473 patients underwent LPEHR with absorbable mesh; 1.3% type 2 hernias, 86.0% type 3 hernias, 12.7% type 4 hernias. Three types of mesh were used: initially biologic mesh (n = 83), then heavyweight synthetic bioabsorbable mesh (n = 261), and finally lightweight synthetic bioabsorbable mesh (n = 111). There were no significant differences in age, ASA, BMI, gender, smoking status, chronic steroid use, preoperative acid suppression, hernia type, or recurrent hernia between groups. There were no significant differences in 30-day postoperative outcomes. Reflux Symptom Index, GERD-HRQL, and Dysphagia Scores at 1- and 2-year postoperative timepoints were not significantly different. The overall recurrence rate was 16.7%, with no significant differences in recurrence rates between biologic, heavyweight or lightweight biosynthetic absorbable mesh through 2 years after surgery. A shorter median time to recurrence (10 months, p = 0.016) was seen in the lightweight group.

CONCLUSION

LPEHR with absorbable mesh reinforced cruroplasty is feasible and safe, with equivalent patient-reported outcomes, including dysphagia, up to 2-years postop regardless of mesh choice. No significant differences in recurrence rates between biologic, heavyweight, or lightweight synthetic bioabsorbable mesh were seen up to 2 years after LPEHR.

"What is the problem with vaccines?" A typology of religious vaccine skepticism

Research has identified religion as one of numerous factors that may contribute to delay or refusal of vaccination. The influence of religion on vaccine decisions may be accidental, or it may involve explicit religious objections. By presenting a typology of religious vaccine skepticism, this article seeks to give a comprehensive overview of the essence of these objections and to clarify differences and similarities between them. This knowledge is useful for policy-makers and others who wish to better understand the influence of religion on vaccine decision-making. The typology consists of five main types: (1) a worldview clash type, in which vaccines do not make sense as a health intervention; (2) a divine will type, which represents a form of passive fatalism; (3) an immorality type, which considers some vaccines unethical because of their production or effect; (4) an impurity type, pointing to ingredients that will defile the body; and (5) a conspiracy type, in which a vaccine plot is targeting a religious group.

Perioperative Management of Spontaneous Intracranial Hemorrhage in a Patient With Hemophilia A in a Resource Limited Country

Intracranial hemorrhage (ICH) is a serious complication of hemophilia A with high morbidity and mortality. The management of such cases is complicated by nonspecific and often delayed presentation, increased frequency of rebleeding, low awareness regarding clotting factor replacement, and debate regarding the efficacy of surgical interventions. We report a case of an 18-year-old male patient with hemophilia A, who first presented to the emergency department in India in a comatose state. Neuroimaging revealed subdural hematoma with midline shift and uncal herniation. The patient was successfully managed with perioperative cryoprecipitate and factor VIII replacement, tiered intracranial pressure lowering strategies, and early decompressive craniectomy with clot evacuation. In India, there are no standardized guidelines for screening and routine care for hereditary diseases like hemophilia. In a resource-deficient country, management was complicated by the limited availability of factor VIII in the emergent setting, as well as the inability to obtain serial factor levels in the postoperative period. We hope that this article helps to guide the management of ICH and hemophilia in resource-limited countries.

Perioperative implications of patients with alpha gal allergies

Alpha Gal Syndrome (AGS) is an emerging immune response to mammalian products (MP) containing the oligosaccharide galactose-α-1,3 galactose (α-Gal) which includes meats and inactive ingredients in certain medications. This becomes clinically important in the perioperative realm as MPs are commonly found in the operating room, and pre- and post-operative settings, and can trigger responses as severe as anaphylaxis. In this review, authors discuss the epidemiology, diagnosis and treatment of AGS reactions. Additionally, strategies are explored in order to screen and prevent exposure to MP with a multidisciplinary approach. While this emerging allergy is still not fully understood, it is of paramount importance that all anesthesia providers recognize the implications of MP exposure in AGS patients and ultimately prevent harm in this highly vulnerable population.

Navigating Cultural Diversity in the Selection of Cardiovascular Device Treatments: A Comprehensive Review

In cardiology, patients' cultural beliefs, linguistic differences, lack of knowledge, and socioeconomic status can create barriers to choosing device treatment. To address this issue, we conducted a thorough literature review using online databases such as PubMed, Google Scholar, and Texas Tech University Health Sciences Center's research portal. Our review found that cultural, religious, and linguistic barriers can contribute to patients' apprehension and reservations about device placement. These barriers can also impact patients' adherence to treatment and clinical outcomes. Patients from lower socioeconomic backgrounds may have difficulty accessing and affording device-based treatments. Additionally, fear and inadequate understanding of surgical procedures can deter patients from accepting device treatment in cardiology. To overcome these cultural barriers, healthcare providers must raise awareness about the benefits of device treatment and provide better training to overcome these challenges. It is crucial to address the unique needs of patients from different cultural backgrounds and socioeconomic statuses to ensure they receive the care they need.

The Need to Adjust the Informed Consent for Jewish Patients for Treatments Involving Porcine Medical Constituents

In order to obtain full informed consent for medical treatments, it is imperative to provide patients of diverse ethnic backgrounds with all relevant information. Since the pig is considered an impure animal in Judaism, Jewish patients may wish to be informed of porcine-derived substances used in treating. The present study is the first to explore the level of knowledge of Jewish participants as to whether the medical use of pig is permitted by their religion, and the extent to which they believe it should be permitted. 714 Jewish participants completed a study questionnaire that included 15 medical uses of pigs. Findings indicated that the knowledge of Jewish law regarding these uses is a significant mediator in predicting the attitude toward the permissibility of these uses. I conclude with practical recommendations as to how to enhance cultural competence and improve the informed consent process when treating Jewish patients with porcine-derived constituents.

Cell-Laden Marine Gelatin Methacryloyl Hydrogels Enriched with Ascorbic Acid for Corneal Stroma Regeneration

Corneal pathologies from infectious or noninfectious origin have a significant impact on the daily lives of millions of people worldwide. Despite the risk of organ rejection or infection, corneal transplantation is currently the only effective treatment. Finding safe and innovative strategies is the main goal of tissue-engineering-based approaches. In this study, the potential of gelatin methacryloyl (GelMA) hydrogels produced from marine-derived gelatin and loaded with ascorbic acid (as an enhancer of the biological activity of cells) was evaluated for corneal stromal applications. Marine GelMA was synthesized with a methacrylation degree of 75%, enabling effective photocrosslinking, and hydrogels with or without ascorbic acid were produced, encompassing human keratocytes. All the produced formulations exhibited excellent optical and swelling properties with easy handling as well as structural stability and adequate degradation rates that may allow proper extracellular matrix remodeling by corneal stromal cells. Formulations loaded with 0.5 mg/mL of ascorbic acid enhanced the biological performance of keratocytes and induced collagen production. These results suggest that, in addition to marine-derived gelatin being suitable for the synthesis of GelMA, the hydrogels produced are promising biomaterials for corneal regeneration applications.

Current status of biopsy markers for the breast in clinical settings

INTRODUCTION

A breast biopsy marker is a very small object that is introduced into the breast to serve as a tissue marker. The placement of a breast marker following a biopsy or to mark an abnormality in the breast has become standard practice in the clinical setting. Breast biopsy markers offer a wide range of benefits which includes the prevention of re-biopsy of a benign tumor, differentiating multiple lesions within the breast, evaluation of the extent of a tumor, and increased precision during surgery.

AREAS COVERED

This review article presents a range of breast biopsy markers used in clinical practice. First, an overview of the necessity of breast markers in healthy breast management. Second, it summarizes the diversity in composition, shape, unique properties and features, and bio-absorbable carriers of breast biopsy markers. Finally, it also discusses the possible use of clinically approved breast biopsy markers in various scenarios and their implications.

EXPERT OPINION

This review serves as a guide in the selection of an appropriate breast marker. We believe that some of the common drawbacks associated with current breast biopsy markers can be overcome by developing novel polymer-metal and composite-based breast biopsy markers.

The Use of Porcine-Derived Materials for Medical Purposes: What do Muslim and Jewish Individuals Know and Opine About It?

Porcine-derived medical products represent an effective solution for a wide range of human suffering, yet this may contradict Muslim and Jewish religious prohibitions against consuming pig. The present study evaluated the level to which Muslim and Jewish participants are knowledgeable about the conditions permitting porcine-based treatments and explored their attitudes toward the permissibility of these treatments. A questionnaire that presented fifteen medical uses of porcine-derived products was completed by 809 Muslims and 714 Jews. Neither Muslim nor Jewish participants are knowledgeable about the religious rulings of their religions which permit the use of pig for life saving. Participants of both groups objected to the view that porcine-derived materials should be permitted. The findings imply that the attitude toward porcine-derived materials for medical use is contingent upon the knowledge or lack thereof that individuals have regarding the permissibility of such use. We offer useful recommendations to improve the informed consent process before conducting porcine-based treatments.

Safety and effectiveness of fondaparinux as a postpartum thromboprophylaxis during puerperium among muslim women: A single centre prospective study

Background: Venous thromboembolism (VTE) remains one of the leading causes of maternal morbidity and mortality, with postpartum period carrying the greatest risk. Perinatal thromboprophylaxis is often administered based on risk-factor assessment. Low molecular weight heparin has a proven safety profile in the obstetrics population, however, its porcine-derived content may lead to reduced uptake amongst certain religious groups. We aimed to evaluate the safety of fondaparinux as an alternative postpartum thromboprophylaxis.

Methods: We conducted a prospective, single arm, open label study from September 2017 until March 2018. Women who fulfilled the criteria for post natal thromboprophylaxis based on the 2015 RCOG guidelines were recruited. Each patient received subcutaneous injection of Fondaparinux, 2.5 mg daily for 10 days. A telephone interview was conducted on day 10 post delivery. Each woman was subsequently reviewed in the outpatient clinic 6 weeks postpartum. The primary outcome measure was occurrence of pulmonary embolism or deep vein thrombosis suggestive by clinical symptoms and assessment. Secondary outcome measures were allergic reaction and bleeding tendency such as secondary post-partum haemorrhage, spinal site bleeding and wound haematoma. Allergic reaction and bleeding tendency in neonates were also recorded.

Results: Sixty women were included in the analysis. There were no VTE cases amongst our cohort. No major bleeding was recorded. Two patients (3.3%) had wound haematoma, one of which occurred 3 weeks post delivery. No adverse effect in neonates was noted.

Conclusion: Fondaparinux is a safe alternative thromboprophylaxis for postpartum women.

Biosynthetic cellulose compared to porcine xenograft in the treatment of partial-thickness burns: A randomised clinical trial

AIM

The aim was to compare two dressing treatments for partial-thickness burns: biosynthetic cellulose dressing (BsC) (Epiprotect® S2Medical AB, Linköping, Sweden) and porcine xenograft (EZ Derm®, Mölnlycke Health Care, Gothenburg, Sweden).

METHODS

Twenty-four adults with partial-thickness burns were included in this randomized clinical trial conducted at The Burn Centers in Linköping and Uppsala, Sweden between June 2016 and November 2018. Time to healing was the primary outcome. Secondary outcomes were wound infection, pain, impact on everyday life, length of hospital stay, cost, and burn scar outcome (evaluated with POSAS).

RESULTS

We found no significant differences between the two dressing groups regarding time to healing, wound infection, pain, impact on everyday life, duration of hospital stay, cost, or burn scar outcome at the first follow up. Burn scar outcome at the 12-month follow up showed that the porcine xenograft group patients scored their scars higher on the POSAS items thickness (p = 0.048) and relief (p = 0.050). This difference was, however, not confirmed by the observer.

CONCLUSIONS

The results showed the dressings performed similarly when used in adults with burns evaluated as partial thickness.

Exploring Muslims' Health-Related Behaviours in Portugal: Any Impact on Quotidian Community Pharmacy Practice?

Muslims are a growing community in European countries. General health habits, including therapy-related behaviours, have been described, though implications to pharmacy practice might vary with the local dominant culture and setting. This exploratory study aimed to describe Muslims’ prevalent health and medication-related practices and possible implications for culturally competent community pharmacy practice. A descriptive cross-sectional survey was administered to a convenient sample of 100 participants at Lisbon Central Mosque, Portugal. Demographics, dietary, Traditional Arabic and Islamic Medicine (TAIM) and religious practices were examined, including health conditions and conventional biomedical treatments. Participant reported ailments (26%) were aligned with prevalent conditions in the general population. Ill participants were significantly associated with TAIM and Islamic dictates (p < 0.05), particularly Zam-Zam water and milk thistle usage. Participants’ orientation to dietary options and Qur’an restrictions were observed regarding forbidden substances in medication, raising issues on medication adherence for some oral dosage forms. TAIM and religious beliefs supplement illness recovery and health improvement instead of replacing conventional healthcare in a religious minority well integrated within the dominant culture. Portuguese community pharmacists should not neglect religious specificities if seamless care is delivered, enhancing professionals’ collaboration skills with multicultural patients.

Dentistry in a multicultural society: the impact of animal-based products on person-centred care

Cultural competence of healthcare professionals requires a combination of awareness, knowledge and skills to provide healthcare services to culturally and lingually diverse populations. The aim of this paper is to raise awareness regarding animal-based constituents in dental products which may not be acceptable to patients from different cultural, spiritual, or religious backgrounds. Animal-based products are used widely in medicine and dentistry. However, patients and sometimes even dental professionals may not be aware of this. This paper identifies some common products used in clinical dentistry which are derived from animal-based sources and discusses the implications of their use in a multicultural society.

Clinical applications of acellular dermal matrices: A review

INTRODUCTION

The extracellular matrix (ECM) plays an integral role in wound healing. It provides both structure and growth factors that allow for the organised cell proliferation. Large or complex tissue defects may compromise host ECM, creating an environment that is unfavourable for the recovery of anatomical function and appearance. Acellular dermal matrices (ADMs) have been developed from a variety of sources, including human (HADM), porcine (PADM) and bovine (BADM), with multiple different processing protocols. The objective of this report is to provide an overview of current literature assessing the clinical utility of ADMs across a broad spectrum of applications.

METHODS

PubMed, MEDLINE, EMBASE, Scopus, Cochrane and Web of Science were searched using keywords 'acellular dermal matrix', 'acellular dermal matrices' and brand names for commercially available ADMs. Our search was limited to English language articles published from 1999 to 2020 and focused on clinical data.

RESULTS

A total of 2443 records underwent screening. After removing non-clinical studies and correspondence, 222 were assessed for eligibility. Of these, 170 were included in our synthesis of the literature. While the earliest ADMs were used in severe burn injuries, usage has expanded to a number of surgical subspecialties and procedures, including orthopaedic surgery (e.g. tendon and ligament reconstructions), otolaryngology, oral surgery (e.g. treating gingival recession), abdominal wall surgery (e.g. hernia repair), plastic surgery (e.g. breast reconstruction and penile augmentation), and chronic wounds (e.g. diabetic ulcers).

CONCLUSION

Our understanding of ADM's clinical utility continues to evolve. More research is needed to determine which ADM has the best outcomes for each clinical scenario.

LAY SUMMARY

Large or complex wounds present unique reconstructive and healing challenges. In normal healing, the extracellular matrix (ECM) provides both structural and growth factors that allow tissue to regenerate in an organised fashion to close the wound. In difficult or large soft-tissue defects, however, the ECM is often compromised. Acellular dermal matrix (ADM) products have been developed to mimic the benefits of host ECM, allowing for improved outcomes in a variety of clinical scenarios. This review summarises the current clinical evidence regarding commercially available ADMs in a wide variety of clinical contexts.

Intra-operative use of biological products-Are we aware of their derivatives?

INTRODUCTION

Global medical advances within healthcare have subsequently led to the widespread introduction of biological products such as grafts, haemostats, and sealants. Although these products have been used for many decades, this subject is frequently not discussed during the consent process and remains an area of contention.

METHODS

A nationwide confidential online survey was distributed to UK-based junior registrars (ST3-5), senior registrars (ST6-8), post-CCT fellows, specialist associates/staff grade doctors and consultants working in general/vascular surgery, neurosurgery, otolaryngology, oral and maxillofacial surgery and plastic surgery.

RESULTS

Data were collected from a total of 308 survey respondents. Biological derivatives were correctly identified in surgical products by only 25% of survey respondents, only 19% stated that they regularly consent for use of these products. Our results demonstrate that most participants in this study do not routinely consent (81%) to the intra-operative use of biological materials. An overwhelming 74% of participants agreed that further education on the intra-operative use of biological materials would be valuable.

DISCUSSION

This study highlights deficiencies in knowledge that results in potential compromise of the consenting process for surgical procedures. A solution to this would be for clinicians to increase their awareness via educational platforms and to incorporate an additional statement on the consent form which addresses the potential intraoperative use of biological products and what their derivatives may be.

CONCLUSION

Modernising the current consent process to reflect the development and use of surgical biological products will help to ensure improved patient satisfaction, fewer future legal implications as well as a better surgeon-patient relationship.

Patients' Perspectives of Grafting Materials in Implant Dentistry: A Qualitative Analysis

AIMS

The aim of this study was to evaluate the cultural, psychological, and religious influences on the choice of autografts, allografts, xenografts, and synthetic bone products for the grafting procedure and with implant placement.

MATERIALS AND METHODS

A qualitative methodology was employed, using the principles of the constant comparative method of the grounded theory; to investigate how people perceive and understand their experiences regarding the graft materials in implant dentistry. The data were collected using detailed qualitative interviews, till saturation was achieved, from 10 patients.

RESULTS

The three main themes that emerged in the analysis were: (a) grafting material preference, (b) religious and psychological influences, and (c) trust the doctor and cost influences. The three themes that emerged seemed to be interrelated. There were many statements of preference or rejection of choice based on religious, cultural, and psychological influences.

CONCLUSIONS

Within the limitations of this study, three themes emerged and they indicated that the influence on the grafting material's choice is unique to every individual; it also shares similarities, based on common religious and cultural values.

Why we should stop using animal-derived products on patients without their consent

Medicines and medical devices containing animal-derived ingredients are frequently used on patients without their informed consent, despite a significant proportion of patients wanting to know if an animal-derived product is going to be used in their care. Here, I outline three arguments for why this practice is wrong. First, I argue that using animal-derived medical products on patients without their informed consent undermines respect for their autonomy. Second, it risks causing nontrivial psychological harm. Third, it is morally inconsistent to respect patients' dietary preferences and then use animal-derived medicines or medical devices on them without their informed consent. I then address several anticipated objections and conclude that the continued failure to address this issue is an ethical blind spot that warrants applying the principles of respect for autonomy and informed consent consistently.

Secular Clinical Ethicists Should Not Be Neutral Toward All Religious Beliefs: An Argument for a Moral-Metaphysical Proceduralism

Secular clinical ethics has responded to the problem of moral pluralism with a procedural approach. However, defining this term stirs debate: H. Tristram Engelhardt Jr. has championed a contentless proceduralism (P1), while others, conversely, argue for a proceduralism that permits some content in the form of moral claims (P2). This paper argues that the content P2 permits ought to be expanded to include some metaphysical commitments, in an approach referred to as P2+. The need for P2+ is demonstrated by analyzing and rejecting three standards (the best interest or harm principle, internal reasonability, and the child's right to an open future) used by P2 to justify overriding religiously motivated refusals of treatment for children. These approaches fail because each maintains a neutral stance regarding the truth of religious belief. This paper drives at the broader thesis that the proceduralism of secular clinical ethics requires some moral and metaphysical commitments.

Optimized expression and purification of a soluble BMP2 variant based on in-silico design

Bone morphogenetic protein 2 (BMP2¹) is a highly interesting therapeutic growth factor due to its strong osteogenic/osteoinductive potential. However, its pronounced aggregation tendency renders recombinant and soluble production troublesome and complex. While prokaryotic expression systems can provide BMP2 in large amounts, the typically insoluble protein requires complex denaturation-renaturation procedures with medically hazardous reagents to obtain natively folded homodimeric BMP2. Based on a detailed aggregation analysis of wildtype BMP2, we designed a hydrophilic variant of BMP2 additionally containing an improved heparin binding site (BMP2-2Hep-7M). Consecutive optimization of BMP2-2Hep-7M expression and purification enabled production of soluble dimeric BMP2-2Hep-7M in high yield in E. coli. This was achieved by a) increasing protein hydrophilicity via introducing seven point mutations within aggregation hot spots of wildtype BMP2 and a longer N-terminus resulting in higher affinity for heparin, b) by employing E. coli strain SHuffle® T7, which enables the structurally essential disulfide-bond formation in BMP2 in the cytoplasm, c) by using BMP2 variant characteristic soluble expression conditions and application of l-arginine as solubility enhancer. The BMP2 variant BMP2-2Hep-7M shows strongly attenuated although not completely eliminated aggregation tendency.

Porcine Xenograft and Epidermal Fully Synthetic Skin Substitutes in the Treatment of Partial-Thickness Burns: A Literature Review

Background and Objectives: Porcine xenografts have been used successfully in partial thickness burn treatment for many years. Their disappearance from the market led to the search for effective and efficient alternatives. In this article, we examine the synthetic epidermal skin substitute Suprathel^® as a substitute in the treatment of partial thickness burns. Materials and Methods: A systematic review following the PRISMA guidelines has been performed. Sixteen Suprathel^® and 12 porcine xenograft studies could be included. Advantages and disadvantages between the treatments and the studies’ primary endpoints have been investigated qualitatively and quantitatively. Results: Although Suprathel had a nearly six times larger TBSA in their studies (p < 0.001), it showed a significantly lower necessity for skin grafts (p < 0.001), and we found a significantly lower infection rate (p < 0.001) than in Porcine Xenografts. Nonetheless, no significant differences in the healing time (p = 0.67) and the number of dressing changes until complete wound healing (p = 0.139) could be found. Both products reduced pain to various degrees with the impression of a better performance of Suprathel^® on a qualitative level. Porcine xenograft was not recommended for donor sites or coverage of sheet-transplanted keratinocytes, while Suprathel^® was used successfully in both indications. Conclusion: The investigated parameters indicate that Suprathel^® to be an effective replacement for porcine xenografts with even lower subsequent treatment rates. Suprathel^® appears to be usable in an extended range of indications compared to porcine xenograft. Data heterogeneity limited conclusions from the results.

The Use of Bovine Pericardial Patches in Vascular Surgery: Where do we Draw the Line in Obtaining Informed Consent?

For a patient undergoing a carotid endarterectomy, induction with propofol, administration of heparin at the time of vessel clamping, use of a bovine pericardial patch for angioplasty, covering the wound with a hydrocolloid dressing and post-operative aspirin administration exposes the patient to animal products at every stage, from the moment they walk through the door. A number of articles have advocated obtaining informed consent when using animal products in healthcare but where should the line be drawn?

METHODS

A narrative review of the literature, specifically focussing on secular and religious beliefs about the use of animal products in healthcare. Application of ethical principles and GMC guidance to formulatea discussion with regards to the use of bovine pericardium in vascular surgery. Advanced literature search carried out using Pubmed and Google Scholar databases comparing patch material used forcarotid endarterectomy.

RESULTS

Disclosing the use of animal derived constituents in surgery is warranted under Beauchamp and Childress' four principals and highlighted in GMC guidance. Obtaining consent for the use of animalderived constituents at the time of surgery is something that should become a fundamental component of the written consent process and alternatives should be sought where available and practicable.

CONCLUSION

This review highlights the evidence available and discusses our current standpoint from both a legal and ethical aspect.

Synthetic Nanoclay Gels Do Not Cause Skin Irritation in Healthy Human Volunteers

Synthetic clays are promising biomaterials for delivery of therapeutic molecules in regenerative medicine. However, before their use can be translated into clinical applications, their safety must be assessed in human volunteers. The aim of this study was to test the hypothesis that a synthetic nanoclay (LAPONITE) does not cause irritation to the human skin. To achieve this, a nanoclay gel at two different concentrations (1.5 and 3% w/v) was applied on the forearm of healthy volunteers for 24 h. 1% sodium lauryl sulfate (SLS) and 3% (w/v) polyacrylic acid were used as the positive and negative controls, respectively. The compromise in the skin barrier function was measured by trans-epidermal water loss (TEWL), erythema by spectroscopic measurements, and skin inflammatory biomarkers (IL-1α and IL-1RA) by the enzyme-linked immunosorbent assay. We found that the nanoclay caused no prolonged increase in TEWL, erythema, or induction of inflammatory cytokines. This was in contrast to 1% SLS, a known irritant, which induced significant increases in both skin erythema and TEWL. We conclude that the nanoclay is not an irritant and is thus suitable for therapeutic interventions at the skin surface.

Animal-derived medications: cultural considerations and available alternatives

CONTEXT

Cultural competency is a cornerstone of patient-centered health care. Religious doctrines may define appropriate consumption or use of certain animals and forbid use of others. Many medications contain ingredients that are animal-derived; these medications may be unacceptable to individual patients within the context of their religious beliefs and lifestyle choices. Knowledge of animal-derived medications as a component of cultural competency can facilitate a dialogue that shifts focus from the group to the individual, away from cultural competency toward cultural humility, and away from a paternalistic provider/patient dynamic toward one of partnership.

OBJECTIVES

To explore how animal-derived drug components may impact medication selection and acceptability from the perspective of patients, physicians, and religious leaders as evidenced by studies that explore the question via survey or questionnaire. A secondary objective is to use the context of animal-derived drug products as a component of cultural competency to build a framework supporting the development of cultural humility.

METHODS

A systematic search was performed in the PubMed, CINAHL, Cochrane, and ProQuest databases using combinations of the following terms: "medication selection," "medication," "adherence," "pharmaceutical preparations," "religion and medicine," "religion," "animal," "dietary," "porcine," and "bovine." Studies that reported using surveys or questionnaires to examine patient, physician, or religious leader perspective on animal-derived medications published in English between 1990 and 2020 were included. Review articles, opinion pieces, case reports, surveys of persons other than patients, religious leaders, or physicians, and studies published in languages other than English were excluded. Three authors independently reviewed articles to extract information pertaining to perspectives on animal-based medication ingredients.

RESULTS

Eight studies meeting the described criteria were found that queried beliefs or knowledge of patients, religious leaders, or physicians regarding medications and medical products of biologic origin. Those studies are described in full in this review.

CONCLUSIONS

Knowledge of animal-derived ingredients may help open conversations with patients around spiritual history and cultural competency, particularly for those patients belonging to religious sects with doctrines that define appropriate use of human- or animal-derived products. Further formal study is needed to explore more fully the extent to which religious beliefs may impact selection of animal- or human-derived medications. Guidelines developed from this knowledge may aid in identifying individual patients with whom the discussion may be particularly relevant. More studies are needed to quantify and qualify beliefs regarding animal-derived medication constituents.

Glycerolised skin allografts for extensive burns in low- and middle-income countries

Introduction:

There has been a significant improvement in the outcome of treatment of large surface area burns in developed countries. A major contributory factor is an early excision and skin grafting of burn wounds. The initial coverage of large surface area deep burn wounds requires the use of temporary skin substitutes such as allografts due to limited skin autografts. Cadaveric skin allografts are the commonest source of skin allografts in use; however, there may be religious, cultural, cost, or other factors mitigating its availability and routine use in low- and middle-income countries (LMICs). Human skin allografts may be used fresh or stored in tissue banks to ensure its ready availability. The purpose of this review is to promote glycerolised skin allografts as a means of skin preservation in low-resource countries above other modalities cryopreservation due to its cost advantages and relative ease of operation.

Materials and Methods:

A literature search for articles related to human skin allograft use in burn care, skin banks, and glycerolised skin allografts in LMICs was done using PubMed, EMBASE, and Web of Science databases. The key words used were ‘allograft’ and ‘burn’ with a filter in the search for human studies. The relevant references in the articles obtained were also searched for and included in the review

Results:

Sixty-three journal articles were reviewed for contents in line with the objectives of this study.

Conclusion:

Glycerolised skin graft is a viable option for coverage of extensive burns in LMICs.

"Religious Belief": An Undervalued Ethical Inclusion Criterion for Clinical Trials on Bone Grafting Procedures

The aim of the present review was to assess randomized controlled trials (RCTs) on bone grafting procedures that included religious belief as an eligibility criterion. Indexed databases were searched up to and including February 2019 using different search strategies. In strategy 1, the following terms were used: (a) belief; (b) bone graft; (c) faith; (d) inclusion; (e) exclusion; (f) eligibility; (g) criteria; (h) randomized clinical trial; (i) religion; and (j) xenograft. In strategy 2, the following terms were used in addition to those used in strategy 1: Xenografts AND oral surgery OR xenografts AND maxillofacial OR xenografts AND dental implants. These searches were filtered using the terms "Randomized clinical trial" and "human studies". The initial search yielded 3932 studies. Filtration of results using the terms "Randomized clinical trial" and "human studies" showed 0 studies. Evaluation of patients' religious beliefs seems to be undervalued in RCTs related to the placement of xenografts. This is an essential and ethical criterion that should be taken into consideration prior to inclusion of participants and signing the informed consent form for RCTs related to the placement of bone grafts.

Topical Hemostatic Agents at Time of Obstetric and Gynecologic Surgery: ACOG Committee Opinion, Number 812

There are three broad categories of hemostatic agents: 1) caustic, 2) physical, and 3) biologic. Because of the paucity of data on the use of topical hemostatic agents in gynecologic and obstetric surgery, indications for use are extrapolated from data on the use of these agents in other types of surgeries and are based on expert opinion. Topical hemostatic agents can be a useful adjunct to assist in the management of intraoperative bleeding in select circumstances. Topical hemostatic agents most commonly are used in situations where the use of electrocautery or sutures for hemostatic control of surgical bleeding is not ideal or safe, including bleeding in areas with nearby vulnerable structures or in the presence of diffuse bleeding from peritoneal surfaces or cut surfaces of solid organs. When managing intraoperative bleeding, there is no substitute for meticulous surgical technique. When possible, the surgeon should attempt to control intraoperative bleeding with sutures, clips, or electrosurgery before the use of hemostatic agents. It is essential for surgeons to understand the appropriate use, contraindications, and cost of these agents in order to make the most informed decision for patient care.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Jewish Patients

Judaism, one of the world's oldest religions, claims an estimated 14.3 million members worldwide. There is great diversity in terms of identity, practice, and belief among people who identify as Jewish. As of 2017, 40% of the global Jewish community resided in the United States, making it essential for palliative care clinicians to understand religious and cultural issues related to their serious illness care. In this article, we will discuss 10 important concepts relevant to the inpatient care, advance care planning, and bereavement needs of Jewish patients and families.

A review of the use of biological mesh products in modern UK surgical practice: a religious and cultural perspective

INTRODUCTION

The UK is an increasingly multicultural society. This change coincides with an increasing use of animal products in medicine and surgery and a change in the UK law of consent. The refusal of Jehovah's Witnesses to accept blood products is well known, but the use of animal products in surgery is a neglected topic. As society becomes more diverse and medicine becomes ever more advanced, there is increasing potential for a mismatch between what is medically possible and what is acceptable from a religious perspective.

METHODS

Surgical products were identified by searching the literature and contacting manufacturing companies. Literature was identified by using PubMed and OVID (MEDLINE). Religious views were established by contacting national bodies for each group.

FINDINGS

The views of common UK religious groups and the constituent parts of biological meshes are summarised in tables intended to be used as a reference during clinical practice. On an elective basis, the Islamic, Hindu. Sikh and Jain leaders contacted had strong views on avoiding animal derived products. The Christian and Jewish leaders contacted did not. All religious leaders contacted accepted the use of mesh derived from human tissue. All products, including those of porcine and bovine origin, were acceptable to all leaders contacted if the procedure was performed to save life. The highlighting of this issue should prompt earlier consideration and discussion in the surgical planning and the consenting process with all final decisions taken by both the surgeon and the individual patient.

Biologics in Acute Burn Injury

There have been significant advances in the care of burns over the past decade. As a result of the improved survival of burn patients, attention has shifted to the optimized management of their wounds. Traditionally, autografts have been described as the gold standard treatment in cases of deep second- and third-degree burn wounds; however, they are limited especially in large surface area burns. As such, advancements have been made in the development of biologic dressings, which attempt to mimic the function of the lost epidermis and/or dermis. The ideal biologic dressing is nontoxic, lacks antigenicity, is immunologically compatible, and is sterile. Additionally, easy storage conditions, long shelf lives, and reasonable costs are key determinants of whether biologic dressings may truly be widely used in the clinical setting. Biologic dressings serve an important role as skin substitutes in the setting of acute burn injury. This review aims to summarize the multitude of available biologic dressings and their applications. METHODS: The PubMed and Google Scholar databases were searched for the following terms either alone or in combination: "burn injury," "biologic membrane," "skin substitutes," "biosynthetic dressings," and "acellular membrane."

Physicochemical Characterization of Bilayer Hybrid Nanocellulose-Collagen as a Potential Wound Dressing

The eminent aim for advance wound management is to provide a great impact on the quality of life. Therefore, an excellent strategy for an ideal wound dressing is being developed that eliminates certain drawbacks while promoting tissue regeneration for the prevention of bacterial invasion. The aim of this study is to develop a bilayer hybrid biomatrix of natural origin for wound dressing. The bilayer hybrid bioscaffold was fabricated by the combination of ovine tendon collagen type I and palm tree-based nanocellulose. The fabricated biomatrix was then post-cross-linked with 0.1% (w/v) genipin (GNP). The physical characteristics were evaluated based on the microstructure, pore size, porosity, and water uptake capacity followed by degradation behaviour and mechanical strength. Chemical analysis was performed using energy-dispersive X-ray spectroscopy (EDX), Fourier transform infrared spectrophotometry (FTIR), and X-ray diffraction (XRD). The results demonstrated a uniform interconnected porous structure with optimal pore size ranging between 90 and 140 μm, acceptable porosity (>70%), and highwater uptake capacity (>1500%). The biodegradation rate of the fabricated biomatrix was extended to 22 days. Further analysis with EDX identified the main elements of the bioscaffold, which contains carbon (C) 50.28%, nitrogen (N) 18.78%, and oxygen (O) 30.94% based on the atomic percentage. FTIR reported the functional groups of collagen type I (amide A: 3302 cm^-1, amide B: 2926 cm^-1, amide I: 1631 cm^-1, amide II: 1547 cm^-1, and amide III: 1237 cm^-1) and nanocellulose (pyranose ring), thus confirming the presence of collagen and nanocellulose in the bilayer hybrid scaffold. The XRD demonstrated a smooth wavy wavelength that is consistent with the amorphous material and less crystallinity. The combination of nanocellulose with collagen demonstrated a positive effect with an increase of Young's modulus. In conclusion, the fabricated bilayer hybrid bioscaffold demonstrated optimum physicochemical and mechanical properties that are suitable for skin wound dressing.

The Social and Material Life of Antimicrobial Clay: Exploring Antimicrobial Resistance, Medicines' Materiality, and Medicines Optimization

While sociologists have made significant theoretical contributions to the antimicrobial resistance (AMR) debate, little attention has been given to the antimicrobial products themselves. Here we advocate a significant new direction which centers on the social and material life of antimicrobials, specifically on what they are made from and how this affects their use. This focus is timely because, in the context of declining efficacy of biomedical antibiotics, diverse materials are increasingly taking center stage in research and drug discovery as potential agents for new antimicrobial treatments. Of particular significance are natural antimicrobials, such as plants, honey and clay, whose antimicrobial potential is well-documented and which are increasingly moving into mainstream antimicrobial research. Alongside this biomedical focus, we suggest that the social and material lives of these antimicrobial materials require attention to (i) highlight the ways they have been, and continue to be, used in diverse cultures globally, (ii) explore ways we might theorize these materials within wider AMR debates, and (iii) examine the impact of antimicrobials' materiality on their use by patients. This article takes the example of clay, whose antimicrobial properties are well-established and which has been used to treat wounds and gastrointestinal problems for millennia. We first locate clay as an exemplar of a wider shift toward natural products drug discovery in pharmaceutical science and antimicrobial research. We then offer a number of theoretical "ways in" for sociologists to begin making sense of clay as it comes under the western biomedical gaze. We map these conceptual lenses on to clay's physical and symbolic mobility from its use in the global south into western biomedical research and commercialization. We particularly concentrate on post-colonial theory as a means to understand clay's movement from global south to north; laboratory studies to examine its symbolic transformation to a black-boxed antimicrobial artifact; and valuation practices as a lens to capture its movement from the margins to the mainstream. We finish by reflecting on the importance of materiality in addressing optimal use of medicines and by advocating an interdisciplinary approach to AMR which positions sociology as a key contributor to AMR solutions.

Biotechnological Applications of Scyphomedusae

As people across the world live longer, chronic illness and diminished well-being are becoming major global public health challenges. Marine biotechnology may help overcome some of these challenges by developing new products and know-how derived from marine organisms. While some products from marine organisms such as microalgae, sponges, and fish have already found biotechnological applications, jellyfish have received little attention as a potential source of bioactive compounds. Nevertheless, recent studies have highlighted that scyphomedusae (Cnidaria, Scyphozoa) synthesise at least three main categories of compounds that may find biotechnological applications: collagen, fatty acids and components of crude venom. We review what is known about these compounds in scyphomedusae and their current biotechnological applications, which falls mainly into four categories of products: nutraceuticals, cosmeceuticals, biomedicals, and biomaterials. By defining the state of the art of biotechnological applications in scyphomedusae, we intend to promote the use of these bioactive compounds to increase the health and well-being of future societies.

Exploring parents' reasons for incomplete childhood immunisation in Indonesia

INTRODUCTION

Immunisation is one of the most successful interventions for controlling infectious diseases but relies on continuous high coverage. Parental vaccine refusal and logistical barriers to access are threats to the success of immunisation programs, with resultant population immunity gaps leading to outbreaks of vaccine-preventable diseases. In Indonesia, coverage of childhood vaccines is suboptimal, with poor coverage of diphtheria-tetanus-pertussis vaccine leading to a large diphtheria outbreak in 2017.

METHODS

To explore the underlying parents' reasons for incomplete childhood immunisation in Indonesia, semi-structured interviews were conducted in Tangerang Selatan, Banten Province, Indonesia. Sixteen purposively selected primary carers of partially and unimmunised children were interviewed. Transcripts were coded and analysed using inductive thematic analysis.

RESULTS

Parental reasons were categorised into three interrelated themes of belief barriers, safety concerns, and issues of trust and misinformation. Stark differences were evident in reasons provided by carers of unimmunised children compared to partially immunised children. For parents of unimmunised children, Islamic beliefs, belief in the strength of natural immunity, and the use of alternative medicines strongly influenced behaviours. Safety concerns, issues of trust including distrust in the government, misinformation, and trust in information obtained through social networks were also prominent. In contrast, concerns about mild side-effects and logistical barriers outweighed beliefs among carers of partially immunised children.

CONCLUSIONS

Our findings highlight the complexities in decision making for parents who decide not to vaccinate their children. In the Indonesian context, public health education and engagement of religious leaders to bridge the gap between religious beliefs and vaccine acceptance are needed to address vaccine refusal. Future research on the influence of social networks on vaccine hesitancy in the Indonesian context is also warranted. For parents of partially vaccinated children, interventions should focus on barriers of access to community health staff to encourage timely schedule completion.

Superiority of silver-foam over porcine xenograft dressings for treatment of scalds in children: A prospective randomised controlled trial

AIM

Our aim was to compare two different regimens for the treatment of children with partial-thickness scalds. These were treated with either a porcine xenograft (EZderm^®, Mölnlycke Health Care, Gothenburg, Sweden) or a silver-foam dressing (Mepilex^® Ag, Mölnlycke Health Care, Gothenburg, Sweden).

METHODS

We organised a prospective randomised clinical trial that included 58 children admitted between May 2015 and May 2018 with partial-thickness scalds to The Burn Centre in Linkoping, Sweden. The primary outcome was time to healing. Secondary outcomes were pain, need for operation, wound infection, duration of hospital stay, changes of dressings, and time taken.

RESULTS

The patients treated with silver-foam dressing had a significantly shorter healing time. The median time to 97% healing for this group was 9 (7-23) days compared to 15 (9-29) days in the porcine xenograft group (p = 0.004). The median time to complete healing for the silver-foam group was 15 (9-29) days and for the porcine xenograft group 20.5 (11-42) days (p = 0.010). Pain, wound infection, duration of hospital stay, and the proportion of operations were similar between the groups. Number of dressing changes and time for dressing changes were lower in the silver-foam dressing group (p = 0.03 for both variables).

CONCLUSIONS

We compared two different treatments for children with partial-thickness scalds, and the data indicate that wound healing was faster, fewer dressing changes were needed, and dressing times were shorter in the silver-foam group.

Bone Grafts, Bone Substitutes and Regenerative Medicine Acceptance for the Management of Bone Defects Among French Population: Issues about Ethics, Religion or Fear?

Several techniques exist to manage bone defects in patients: bone grafts (autograft, allograft, xenograft), use of synthetic bone substitutes, or use of the products of bone regenerative medicine. Studies generally focus on their efficacy, but few focus on their acceptance. Our objectives were to assess their theoretical acceptance among the French general population, and to identify issues justifying refusals, by mean of an open e-questionnaire. The questionnaire was submitted to a general French population, and explained these techniques in an understandable way. Participants were asked to say whether they would accept or refuse these techniques, specifying why in case of refusal (fear of the technique, ethical reasons, religious reasons). In total, 562 persons participated. Autograft and use of the products of bone regenerative medicine were the most accepted techniques (93.4% and 94.1%, respectively). Xenograft was the least accepted technique (58.2%). Most refusals were due to fear such as failure, pain, infection (autograft 8%, allograft 14.9%, xenograft 25.3%, synthetic bone substitutes 14.6%, and products of bone regenerative medicine 6.8%). Ethical reasons were mostly mentioned for allograft (6.4%) and xenograft (18.3%). Religious reasons were scarcely mentioned, only for xenograft (1.2%). Thus, acceptance of techniques does not seem to be greatly linked to sociodemographic characteristics in France. However, other countries with their own cultural, religious, and population patterns may show different levels of acceptance. This study shows that bone regenerative medicine is a promising research direction, reaching biological and also humanist quality standards, expected to improve the health of patients. Information is still the cornerstone to defuse issues about fear.

Using animal-derived constituents in anaesthesia and surgery: the case for disclosing to patients

BACKGROUND

Animal-derived constituents are frequently used in anaesthesia and surgery, and patients are seldom informed of this. This is problematic for a growing minority of patients who may have religious or secular concerns about their use in their care. It is not currently common practice to inform patients about the use of animal-derived constituents, yet what little empirical data does exist indicates that many patients want the opportunity to give their informed consent.

DISCUSSION

First we review the nature and scale of the problem by looking at the groups who may have concerns about the use of animal-derived constituents in their care. We then summarise some of the products used in anaesthesia and surgery that can contain such constituents, such as anaesthetic drugs, surgical implants and dressings. Finally, we explore the problem of animal-derived constituents and consent using Beauchamp and Childress' four principles approach, examining issues of autonomy, beneficence, nonmaleficence and justice. Disclosing the use of animal-derived constituents in anaesthesia and surgery is warranted under Beauchamp and Childress' four principles approach to the problem. Although there exist systemic and practical challenges to implementing this in practice, the ethical case for doing so is strong. The Montgomery ruling presents additional legal reason for disclosure because it entails that patients must be made aware of risks associated with their treatment that they attach significance to.

Three Years' Experience of a Novel Biosynthetic Cellulose Dressing in Burns

Objective: The use of porcine xenograft (PX) is widely spread in burn care. However, it may cause immunologic responses and other ethical and cultural considerations in different cultures. Therefore, there is a need for alternatives. The aim of this work is to test a novel biosynthetic cellulose dressing (Epiprotect^®) on burn patients.

Approach: Charts from 38 patients with superficial burns (SBs) (n = 18) or excised burns (n = 20) that got biosynthetic cellulose dressing instead of PX at a national burn center during 3 years were reviewed. Time to healing, length of stay, and wound infection were extracted from the medical records.

Results: SBs hospitalization time was 11 days comparable to PXs reported by others. In the excised group, median duration of hospital stay was 35 days. Time to healing was 28 days. Seven wound infections were confirmed in the superficial group (39%) and 11 infections in the excised group (61%). Patients with superficial wounds reported pain relief on application.

Innovation: A dressing (17 × 21 cm) consisting of biosynthetic cellulose replacing PX.

Conclusion: Outcome of treatment of SBs or temporary coverage of excised deep burns with biosynthetic cellulose is comparable to treatment with PX. However, biosynthetic cellulose has benefits such as providing pain relief on application and ethical or cultural issues with the material is nonexistent.