Pain management in pediatric age. An update

Differently from the adult patients, in paediatric age it is more difficult to assess and treat efficaciously the pain and often this symptom is undertreated or not treated. In children, a selection of appropriate pain assessment tools should consider the age, the cognitive level, the presence of eventual disability, the type of pain and the situation in which it is occurring. Improved understanding of developmental neurobiology and paediatric analgesic drug pharmacokinetics should facilitate a better management of childhood pain. The objective of this update is to discuss the current practice and the recent advances in pediatric pain management.  Using PubMed and the Cochrane Library we conducted an extensive literature analysis on pediatric pain assessment and commonly used analgesic agents in this kind of patients. According to our results, a multimodal analgesic regimen provides a better pain control and a functional outcome in children. Cooperation and communication among the anaesthesiologist, the surgeon and the paediatrician remains essential for successful anaesthesia and pain management in childhood.

Contactless: a new personalised telehealth model in chronic pediatric diseases and disability during the COVID-19 era

BACKGROUND

Suspending ordinary care activities during the COVID-19 pandemic made it necessary to find alternative routes to comply with care recommendations not only for acute health needs but also for patients requiring follow-up and multidisciplinary visits. We present the 'Contactless' model, a comprehensive operational tool including a plurality of services delivered remotely, structured according to a complexity gradient, aimed to cover diagnostic procedures and monitor disease progression in chronic pediatric patients.

METHODS

A multidisciplinary and multiprofessional project team was recruited, in collaboration with patients' associations, to map a panel of available Evidence-Based solutions and address individual needs in full respect of the concept of personalized medicine. The solutions include a number of services from videoconsultations to more structure videotraining sessions.

RESULTS

A modular framework made up of four three Macro-levels of complexity - Contactless Basic, Intermediate and Advanced - was displayed as an incremental set of services and operational planning establishing each phase, from factors influencing eligibility to the delivery of the most accurate and complex levels of care.

CONCLUSION

The multimodal, multidisciplinary 'Contactless' model allowed the inclusion of all Units of our Pediatric Department and families with children with disability or complex chronic conditions. The strengths of this project rely on its replicability outside of pediatrics and in the limited resources needed to practically impact patients, caregivers and professionals involved in the process of care. Its implementation in the future may contribute to reduce the duration of hospital admissions, money and parental absence from work.

Cytokines in the Nasal Washes of Children with Respiratory Syncytial Virus Bronchiolitis

Although respiratory syncytial (RS) virus is the major cause of bronchiolitis and pneumonia in young children, the factors that regulate the associated lung inflammation have not been defined. The levels of interleukin (IL)10, IL-12, and interferon (IFN) were determined in the nasal wash samples from 20 infants with a clinical diagnosis of bronchiolitis, seven with confirmed RS virus infections and 9 control children without respiratory illnesses. IL-10 levels were significantly higher in acute nasal wash samples (1–4 d post-hospitalization) from RS virus- infected infants than in convalescent samples from these children (14–21 d post-hospitalization), from children with other forms of bronchiolitis and from control children. In contrast, only one RS virus-infected infant had detectable IL-12 in an acute nasal wash sample. IFN activity was not detected in any samples from RS virus-infected children. RS virus infection stimulates IL-10 expression but not IL-12 and IFN, possibly contributing to an ineffective cell-mediated immune response.

Forensic bitemark identification: weak foundations, exaggerated claims

Several forensic sciences, especially of the pattern-matching kind, are increasingly seen to lack the scientific foundation needed to justify continuing admission as trial evidence. Indeed, several have been abolished in the recent past. A likely next candidate for elimination is bitemark identification. A number of DNA exonerations have occurred in recent years for individuals convicted based on erroneous bitemark identifications. Intense scientific and legal scrutiny has resulted. An important National Academies review found little scientific support for the field. The Texas Forensic Science Commission recently recommended a moratorium on the admission of bitemark expert testimony. The California Supreme Court has a case before it that could start a national dismantling of forensic odontology. This article describes the (legal) basis for the rise of bitemark identification and the (scientific) basis for its impending fall. The article explains the general logic of forensic identification, the claims of bitemark identification, and reviews relevant empirical research on bitemark identification-highlighting both the lack of research and the lack of support provided by what research does exist. The rise and possible fall of bitemark identification evidence has broader implications-highlighting the weak scientific culture of forensic science and the law's difficulty in evaluating and responding to unreliable and unscientific evidence.

Clinical trial registration, reporting, publication and FDAAA compliance: a cross-sectional analysis and ranking of new drugs approved by the FDA in 2012

OBJECTIVE

To evaluate clinical trial registration, reporting and publication rates for new drugs by: (1) legal requirements and (2) the ethical standard that all human subjects research should be publicly accessible to contribute to generalisable knowledge.

DESIGN

Cross-sectional analysis of all clinical trials submitted to the Food and Drug Administration (FDA) for drugs approved in 2012, sponsored by large biopharmaceutical companies.

DATA SOURCES

Information from Drugs@FDA, ClinicalTrials.gov, MEDLINE-indexed journals and drug company communications.

MAIN OUTCOME MEASURES

Clinical trial registration and results reporting in ClinicalTrials.gov, publication in the medical literature, and compliance with the 2007 FDA Amendments Acts (FDAAA), analysed on the drug level.

RESULTS

The FDA approved 15 drugs sponsored by 10 large companies in 2012. We identified 318 relevant trials involving 99 599 research participants. Per drug, a median of 57% (IQR 32-83%) of trials were registered, 20% (IQR 12-28%) reported results in ClinicalTrials.gov, 56% (IQR 41-83%) were published, and 65% (IQR 41-83%) were either published or reported results. Almost half of all reviewed drugs had at least one undisclosed phase II or III trial. Per drug, a median of 17% (IQR 8-20%) of trials supporting FDA approvals were subject to FDAAA mandated public disclosure; of these, a median of 67% (IQR 0-100%) were FDAAA-compliant. 68% of research participants (67,629 of 99,599) participated in FDAAA-subject trials, with 51% (33,405 of 67,629) enrolled in non-compliant trials. Transparency varied widely among companies.

CONCLUSIONS

Trial disclosures for new drugs remain below legal and ethics standards, with wide variation in practices among drugs and their sponsors. Best practices are emerging. 2 of our 10 reviewed companies disclosed all trials and complied with legal disclosure requirements for their 2012 approved drugs. Ranking new drugs on transparency criteria may improve compliance with legal and ethics standards and the quality of medical knowledge.

Thymic and bone marrow output in individuals with 22q11.2 deletion syndrome

BACKGROUND

The 22q11.2 deletion syndrome (22q11.2DS) is a congenital multisystem anomaly characterized by typical facial features, palatal anomalies, congenital heart defects, hypocalcemia, immunodeficiency, and cognitive and neuropsychiatric symptoms. The aim of our study was to investigate T- and B-lymphocyte characteristics associated with 22q11.2DS.

METHODS

Seventy-five individuals with 22q11.2DS were tested for T and B lymphocytes by examination of T-cell receptor rearrangement excision circles (TRECs) and B-cell κ-deleting recombination excision circles (KRECs), respectively.

RESULTS

The 22q11.2DS individuals displayed low levels of TRECs, while exhibiting normal levels of KRECs. There was a significant positive correlation between TREC and KREC in the 22q11.2DS group, but not in controls. Both TREC and KREC levels showed a significant decrease with age and only TREC was low in 22q11.2DS individuals with recurrent infections. No difference in TREC levels was found between 22q11.2DS individuals who underwent heart surgery (with or without thymectomy) and those who did not.

CONCLUSION

T-cell immunodeficiency in 22q11.2DS includes low TREC levels, which may contribute to recurrent infections in individuals with this syndrome. A correlation between T- and B-cell abnormalities in 22q11.2DS was identified. The B-cell abnormalities could account for part of the immunological deficiency seen in 22q11.2DS.

Low-power silicon-organic hybrid (SOH) modulators for advanced modulation formats

We demonstrate silicon-organic hybrid (SOH) electro-optic modulators that enable quadrature phase-shift keying (QPSK) and 16-state quadrature amplitude modulation (16QAM) with high signal quality and record-low energy consumption. SOH integration combines highly efficient electro-optic organic materials with conventional silicon-on-insulator (SOI) slot waveguides, and allows to overcome the intrinsic limitations of silicon as an optical integration platform. We demonstrate QPSK and 16QAM signaling at symbol rates of 28 GBd with peak-to-peak drive voltages of 0.6 V(pp). For the 16QAM experiment at 112 Gbit/s, we measure a bit-error ratio of 5.1 × 10⁻⁵ and a record-low energy consumption of only 19 fJ/bit.

Silicon-organic hybrid (SOH) frequency comb sources for terabit/s data transmission

We demonstrate frequency comb sources based on silicon-organic hybrid (SOH) electro-optic modulators. Frequency combs with line spacings of 25 GHz and 40 GHz are generated, featuring flat-top spectra with less than 2 dB power variations over up to 7 lines. The combs are used for WDM data transmission at terabit/s data rates and distances of up to 300 km.

Novel SMARCAL1 bi-allelic mutations associated with a chromosomal breakage phenotype in a severe SIOD patient

PURPOSE

Chromosomal instability syndromes include a group of rare diseases characterized by defective DNA-damage-response and increased risk of chromosomal breakage. Patients display defects in the recognition and/or repair of DNA damage, with a subsequent high rate of malignancies and abnormal gene rearrangements. Other clinical manifestations, such as immunodeficiency, neurodevelopmental delay and skeletal abnormalities, are present in some of these syndromes. We studied a patient with profound T-lymphocyte defect, neurodevelopmental delay, facial dysmorphism, nephrotic syndrome and spondyloepiphyseal bone dysplasia typical of SIOD.

METHODS

Karyotype and chromosome fragility assays on patients' peripheral blood mononuclear cells showed an abnormal rate of spontaneous breaks. Cell cycle analysis of patient's fibroblasts following replication stress induced by hydroxyhurea revealed a delay in their release from S-phase to G2. When using higher concentrations of hydroxyhurea no patient fibroblast colonies could survive, compared with control fibroblasts. Whole-exome sequencing revealed novel compound heterozygote mutations in SMARCAL1 gene, resulting in putative frame shifts of encoded SMARCAL1 from each allele and no detected protein in patient's cells. The patient's youngest brother was found to have similar manifestations of SIOD but of less severity, including short stature, facial dysmorphism and typical osseous dysplasia, but no clinical findings suggestive of immunodeficiency and no chromosomal fragility. Similar to his sister, the brother carries both bi-allelic mutations in SMARCAL1 gene.

CONCLUSIONS

We present here the first evidence of intrinsic chromosomal instability in a severe SMARCAL1-deficient patient with a clinical picture of SIOD. Our results are consistent with the recently outlined role of SMARCAL1 protein in DNA damage response.

Newborn screening for severe T and B cell immunodeficiency in Israel: a pilot study

BACKGROUND

Enumeration of T cell receptor excision circles (TREC) was recently adopted as a neonatal screening assay for severe combined immunodeficiency (SCID). Enumeration of kappa-deleting recombination excision circle (KREC) copy numbers can be similarly used for early assessment of B cell lymphopenia.

OBJECTIVE

To assess the ability of TREC and KREC counts to identify patients with combined T and B cell immunodeficiency in a pilot study in Israel.

METHODS

We studied seven children born in Israel during the years 2010-2011 and later diagnosed with SCID, and an additional patient with pure B cell immunodeficiency. TREC and KREC in peripheral blood upon diagnosis and in their neonatal Guthrie cards were analyzed using real-time quantitative polymerase chain reaction, as were Guthrie cards with dried blood spots from healthy newborns and from normal and SCID-like controls.

RESULTS

The first features suggestive of SCID presented at age 3.1 +/- 2.4 months in all patients. Yet, the diagnosis was made 4.1 +/- 2.9 months later. Their TREC were undetectable or significantly low at their clinical diagnosis and in their originally stored Guthrie cards, irrespective of the amount of their circulating T cells. KREC were undetectable in six SCID patients who displayed B cell lymphopenia in addition to T cell lymphopenia. KREC were also undetectable in one patient with pure B cell immunodeficiency.

CONCLUSIONS

TREC and KREC quantification are useful screening tests for severe T and B cell immunodeficiency. Implementation of these tests is highly important especially in countries such as Israel where a high frequency of consanguinity is known to exist.

Second-order nonlinear silicon-organic hybrid waveguides

We describe a concept for second-order nonlinear optical processes in silicon photonics. A silicon-organic hybrid (SOH) double slot waveguide is dispersion-engineered for mode phase-matching (MPM). The proposed waveguide enables highly efficient nonlinear processes in the mid-IR range. With a cladding nonlinearity of χ(2) = 230 pm/V and 20 dBm pump power at a CW wavelength of 1550 nm, we predict a gain of 14.7 dB/cm for a 3100 nm signal. The suggested structure enables for the first time efficient second-order nonlinear optical mixing in silicon photonics with standard technology.

Interview: A perspective on personalized medicine: Dr David Korn

David Korn speaks to Tarryn Greenberg, Managing Commissioning Editor David Korn (BA, scl, MD, cl; Harvard University, MA, USA) stepped down from his position as Harvard University's inaugural Vice-Provost for Research on June 30, 2011. He is presently Consultant in Pathology and member of the medical staff at the Massachusetts General Hospital, Boston, MA, USA and Professor of Pathology at Harvard Medical School. Dr Korn has been a member of the editorial boards of the American Journal of Pathology, The Journal of Biological Chemistry, and Human Pathology, and for many years was an Associate Editor of the latter. He has sat on many societies, councils and boards. He has written many scientific articles, ranging from bacteriophage biochemistry and genetics to the biochemistry and molecular biology of DNA replication in human cells. During the past two decades his work, writings and lectures have focused on issues of academic values and integrity, research integrity, and health and science policy, and he is presently regarded as a national authority on matters of financial conflicts of interest in academic research.

Instantiating a vision: creating the new pathology department at Stanford Medical School

This review represents my best effort to recreate and memorialize events that occurred 44 years ago, when I was invited to join the Stanford University faculty to create, essentially de novo, what rapidly became and remains today one of the very best and most admired departments of pathology in the world. That I was able to accomplish this challenging task I attribute to my holding fast to a somewhat inchoate vision of where the science and practice of pathology would go in future decades, a little bit to my gut instincts and innate ability to spot up-and-coming talent, but a lot to circumstances and good fortune in leading me to a small nucleus of wonderful young professionals of outstanding promise who were willing to join me in "betting the house" that, working together, we could pull off this once-in-a-lifetime opportunity--and we did.

Reduced propagation loss in silicon strip and slot waveguides coated by atomic layer deposition

When silicon strip and slot waveguides are coated with a 50 nm amorphous titanium dioxide (TiO2) film, measured losses at a wavelength of 1.55 μm can be as low as (2 ± 1)dB/cm and (7 ± 2)dB/cm, respectively. We use atomic layer deposition (ALD), estimate the effect of ALD growth on the surface roughness, and discuss the effect on the scattering losses. Because the gap between the rails of a slot waveguide narrows by the TiO2 deposition, the effective slot width can be back-end controlled. This is useful for precise adjustment if the slot is to be filled with, e. g., a nonlinear organic material or with a sensitizer for sensors applications.

42.7 Gbit/s electro-optic modulator in silicon technology

CMOS-compatible optical modulators are key components for future silicon-based photonic transceivers. However, achieving low modulation voltage and high speed operation still remains a challenge. As a possible solution, the silicon-organic hybrid (SOH) platform has been proposed. In the SOH approach the optical signal is guided by a silicon waveguide while the electro-optic effect is provided by an organic cladding with a high χ(2)-nonlinearity. In these modulators the optical nonlinear region needs to be connected to the modulating electrical source. This requires electrodes, which are both optically transparent and electrically highly conductive. To this end we introduce a highly conductive electron accumulation layer which is induced by an external DC "gate" voltage. As opposed to doping, the electron mobility is not impaired by impurity scattering. This way we demonstrate for the first time data encoding with an SOH electro-optic modulator. Using a first-generation device at a data-rate of 42.7 Gbit/s, widely open eye diagrams were recorded. The measured frequency response suggests that significantly larger data rates are feasible.

New physician-investigators receiving National Institutes of Health research project grants: a historical perspective on the "endangered species"

CONTEXT

Although concerns have persisted for decades about the production of new physician clinical scientists and their success in receiving and sustaining research supported by the National Institutes of Health (NIH), no comprehensive analysis documents the experiences of first-time investigators with an MD over a long period.

OBJECTIVE

To ascertain the perseverance and comparative success of physician-scientists competing for NIH research (R01) grants awarded over 40 years.

DESIGN, SETTING, AND PARTICIPANTS

A longitudinal, comparative study of all first-time applicants and recipients of NIH R01 grants between 1964 and 2004 stratified by the principal investigators' major degrees (MD, PhD, or MD and PhD) and their proposed involvement in research of humans or human tissues.

MAIN OUTCOME MEASURES

Number of first- and second-time NIH R01 grant applicants and recipients by academic degree and by research type (clinical vs nonclinical).

RESULTS

The annual number of first-time investigators with an MD only as NIH R01 grant applicants remained remarkably stable over 4 decades (41-year mean of 707 [range, 537-983] applicants). Among first-time applicants, those with an MD consistently had less success in obtaining funding (mean annual percentage [MAP], 28%) than either investigators with a PhD (MAP, 31%; P = .03 vs MD only) or both an MD and a PhD (MAP, 34%; P<.001 vs MD only and P = .002 vs PhD only). Among investigators who obtained a first R01 grant, those with an MD were consistently less likely (MAP, 70%) than those with a PhD (MAP, 73%; P = .04 vs MD only) or those with an MD and a PhD (MAP, 78%; P<.001 vs MD only and P = .007 vs PhD only) to obtain a subsequent R01 grant. First-time applicants with an MD were much more likely to propose clinical research (MAP, 67%) than applicants with an MD and a PhD (MAP, 43%) and applicants with a PhD only (39%). First-time applicants with an MD only who proposed clinical research were funded at lower rates than their MD-only counterparts proposing nonclinical research (23% vs 29%, respectively; P<.001).

CONCLUSIONS

From 1964-2004, the number of physician-investigators applying for first R01 grants showed little net change. Physician-investigators consistently experienced higher rates of attrition and failure, even after receiving a first R01 grant, and those proposing clinical research were less successful in obtaining funding than physicians proposing nonclinical research.

Engaging youth about gambling using the internet: The YouthBet.net website

OBJECTIVE

YouthBet.net's (www.youthbet.net) goal is to prevent gambling problems among youth through an interactive, multimedia website based on a public health approach.

PARTICIPANTS

YouthBet.net was designed by youth for youth. A youth working group spent several months designing the look and feel of the site to ensure that it would appeal to youth aged 10-19. In total, 34 youth from the Greater Toronto Area participated in the first 3 phases of the usability testing of the site using Video Capture of User Site Interaction methodology.

SETTING

Urban Toronto.

INTERVENTION

Utilizing public health strategies such as health promotion, harm reduction and problem prevention, YouthBet.net features games, information and help resources to protect youth from gambling-related harm.

OUTCOMES

Youth participants indicated that they liked the interactive way gambling information was presented via realistic games and quizzes, often citing that YouthBet.net would be a fun and educational tool to be used by teachers in the classroom. Participants had no difficulties navigating the site, finding content and playing games. Additionally, all youth said that they would return to the site and would recommend it to a friend if they were having a problem with gambling.

CONCLUSION

YouthBet.net is one of the first comprehensive websites designed for youth gambling. Findings from this research will inform future health promotion, harm reduction and problem prevention efforts for youth gambling using Internet technology.

Promoting translational and clinical science: the critical role of medical schools and teaching hospitals

Academic translational and clinical research in the US faces serious obstacles. Dickler and colleagues outline the Association of American Medical Colleges recommendations for overcoming those barriers.

Cytokines in the nasal washes of children with respiratory syncytial virus bronchiolitis

Although respiratory syncytial (RS) virus is the major cause of bronchiolitis and pneumonia in young children, the factors that regulate the associated lung inflammation have not been defined. The levels of interleukin (IL)10, IL-12, and interferon (IFN) were determined in the nasal wash samples from 20 infants with a clinical diagnosis of bronchiolitis, seven with confirmed RS virus infections and 9 control children without respiratory illnesses. IL-10 levels were significantly higher in acute nasal wash samples (1-4 d post hospitalization) from RS virus-infected infants than in convalescent samples from these children (14-21 d post-hospitalization), from children with other forms of bronchiolitis and from control children. In contrast, only one RS virus-infected infant had detectable IL-12 in an acute nasal wash sample. IFN activity was not detected in any samples from RS virus-infected children. RS virus infection stimulates IL-10 expression but not IL-12 and IFN, possibly contributing to an ineffective cell-mediated immune response.

Should an institution that has commercial rights in a new drug or device be allowed to evaluate the technology?

BACKGROUND TO THE DEBATE

In the United States, the passage of the Bayh-Dole Act in 1980 encouraged universities to license inventions for commercial development. Although this financial incentive can stimulate academic researchers to discover new drugs and devices, there is concern that the possibility of monetary reward could distort investigators' objectivity.

Ownership and use of tissue specimens for research

Academic and industrial scientists have sharply increased their demand for properly prepared and clinically annotated tissue samples that yield valuable insights into the origins and expressions of human disease. Historically, research on human tissue samples has been relatively unencumbered by federal regulations and occurred without delineation of ownership rights to the specimens, patient data, or research products. As regulations have become increasingly restrictive, and because clear ownership interests have never been established, the presumed right of researchers and institutions to collect, use, and dispose of specimens and their associated patient data has remained undefined and occasionally contentious. Recent examination of these issues by a US federal court resulted in a ruling that individuals do not retain rights of ownership or control of biological materials contributed for research, regardless of whether commercial benefit accrues. This article examines the legal, regulatory, and ethical framework within which human tissue research is currently conducted. We contend that because the benefits of medical knowledge derived from tissue research potentially accrue to all individuals and future generations (rather than a single recipient), society may justify an expansive use of these valuable resources for future studies.

Dares to addiction: youth definitions and perspectives on gambling

BACKGROUND

Over the past decade, there has been a rapid growth of gambling in Canada and internationally. Although youth are a potentially vulnerable group, little is known about what they understand and if they are being affected by the recent increase in gambling.

METHODS

This study examined how youth view gambling using an inductive qualitative research design and analysis based on grounded theory principles. Twelve focus groups were conducted comprising 103 participants (median age = 15 years) with diverse representation of Ontario youth. Focus-group questions were designed to capture youth's experiences and opinions about gambling.

RESULTS

Youth participants defined a spectrum of gambling from a dare and friendly betting to legalized forms of gambling (lotteries, casinos) and addiction. Their opinions varied according to age and gambling type. For example, daring and friendly betting were identified as positive activities used by younger adolescents to relieve boredom and establish social relationships. Gambling was separate from daring because of its association with money. Many participants had minimal awareness of the potential negative impact of gambling. Information technology (Internet) was seen as an attractive medium for playing games and gambling where no money was involved.

CONCLUSION

Lack of awareness of gambling among youth and its consequences underscores the need for public education. The diverse range of gambling behaviour and age-dependent access to money need careful consideration in defining youth gambling "problems" and in designing public health interventions.

Framing public policy towards a public health paradigm for gambling

This paper examines the public policy value of looking at gambling from a public health perspective. The manner in which social issues are framed will either expand or curtail public policy debates. The existing and traditional frames for gambling (e.g. gambling as a matter of individual freedom, gambling as a form of recreation) fail to consider research on the social and economic impacts of gambling. Because a public health frame offers a broad viewpoint of society, it encompasses a number of social and economic impacts not considered in traditional frames. However, the existing gambling frames enjoy varying degrees of cultural, economic, and political support and, as a result, creating a higher profile for a public health framework will encounter a number of barriers. Research can play a decisive role in overcoming these barriers, as it has in a number of related fields (e.g., tobacco use, addiction and product liability, the epidemiology of AIDS). The paper concludes that research that identifies and quantifies the public health factors of gambling will substantially contribute to a public shift toward a public health frame.

Industry, academia, investigator: managing the relationships

Financial self-interests in medical research are again the subject of increasing public and government concern. Proposed new statutes and regulations would prescribe research conduct and oversight, as well as faculty behavior, in ways that would represent an unprecedented interposition of federal authority into areas of traditional university autonomy. Overly zealous regulation could also interdict a fruitful product development pathway of enormous benefit to public health. Yet, the universities and their academic medical centers have failed to respond sufficiently or credibly to the profound transformation of their research culture in the past two decades, which has witnessed a dramatic increase in the privatization of historically public biomedical research, and in the financial self-interests of investigators and institutions in the research they conduct. The author reviews the history of federal regulation of individual conflicts of interest in biomedical research, and examines the always-complex relationships and expectations of research universities with industry and society. While university oversight of individual conflicts of interest demands strengthening, the issues are long debated and well understood. In contrast, the financial interest of institutions in the medical research they conduct is recent, more complicated, poorly understood, and highly sensitive, involving investment decisions that lie at the heart of university autonomy. The author argues that institutions and professional societies must promulgate and enforce transparent standards of conduct, and strengthen oversight and management of financial self-interests, to avoid burdensome federal intervention and corrosive public skepticism. He concludes by reporting three promising responses from academia and major medical journals.