["I do the right thing only against payment": A critique of pay for performance in psychiatry]

This paper takes a critical look at pay for performance (P4P) as a model for introducing new incentives in psychiatry. This model is to be seen as a tool of commercialism, and such a restructuring of psychiatry represents a wide-reaching political maneuver which actively introduces economical parameters into the field and will have a great impact on psychiatry. P4P starts with the false premise that medicine has to be structured like industry. This premise is false because psychiatry has to do with relationships to patients, and not with the production of a product. Therefore, it is essential to reflect critically upon the premises and consequences of P4P for psychiatry. Only this critical reflection can help psychiatry to keep its identity as a humane service for suffering people.

Medicine and the holistic understanding of the human being: ultrasound examination as dialog

Ultrasound can capture the living nature of a person. This capturing of life depends greatly on experience as well as sense of touch, intuition, sense of speech, and not least a sense for the distinctiveness of every person. Performing ultrasound is not simply the application of a technique but rather a merging of man and technology in the framework of an interpersonal encounter. Therefore, as much should be invested in the interpersonal nature of the encounter as in the development of the technical principles of the ultrasound probe. To effectively perform ultrasound, it is necessary to avoid viewing ultrasound from a purely technical view and to always remember the importance of the relationship to the patient, particularly during the technical examination.

Empirical standard mass equation for Salmo marmoratus

Total length (L(T)) (range 24-1000 mm; mean ±S.E. = 170.21 ± 0.36 mm) and mass (W) (range 0.10-9590 g; mean ±S.E. = 76.03 ± 0.87 g) of 36,460 specimens of marble trout Salmo marmoratus were used to compute a standard mass (W(s)) equation for this species by means of the empirical percentile (EmP) method. The EmP W(s) equation calculated was: log(10) W(s) = -5.208 + 3.202 log(10) L(T) - 0.046 (log(10) L(T))(2) (L(T) range 90-570 mm) and it is valid throughout the species' area of distribution across Europe.

[Helping as a matter of expedience? Ethical objections against prioritization in medicine]

The paper discusses the question whether it could be ethically appropriate to "resolve" the problem of scarce resources in health care via priority lists. It is argued that such a schematical priority list could only be undisputed in ethical respects if it represented a broad consensus on the question what a good life would be. Priority lists are always implicit decisions about specific concepts of the good life. Using a priority list only in consideration of a mere cost-benefit ratio means to accept a mere utilitarian way of defining good life. Such a definition goes with neglect of the interests of people with chronic diseases, of patients with incurable diseases, of patients with a limited life expectancy. To neglect the interests of these patients means to abandon the core of medical identity, because medicine has the mission to help those above all who are most in need and those who cannot help themselves. And so we have to realize that for medicine there are some values which are more important than economic considerations. The physician is a person who gives a promise, the promise to be there for the patient. If the physician now is becoming a businessman, this promise is no longer valid. The businessman doesn't give any other promise than not to act against the contract. But the main need of the patient, his longing for a human person whom he can trust, cannot become part of a contract. Especially in our time medicine has to fight for the core of its identity.

Proposed standard mass equations for European chub Leuciscus cephalus in Italy

Total length (L(T)) and mass measurements of 28,596 specimens of European chub Leuciscus cephalus, collected from a variety of waterways across Italy, were used to compute standard mass (W(s)) equations by both empirical percentile (EmP) and regression line percentile (RLP) methods. The use of the EmP W(s) equation [log(10) W(s) = -4·79 + 2·68log(10) L(T) + 0·10(log(10) L(T))(2)] to compute relative mass (W(r)) of L. cephalus in Italy is suggested, as it was not influenced by length-related bias (L(T) range of application = 70-470 mm).

[Ethical insolvency?]

The current DRG system has not only changed the economic structure of clinical medicine but also has profound effects on its original mission. In the present paper we discuss the fundamental limits of the DRG system and make a case for placing more emphasis on time and communication in health care.

[What's an ideal physician? Ethical reflections on the transformation of medical practice today]

Today the physician is often reduced to a mere technician who is fulfilling the wish of the patient. Such a concept is lacking the aspect of care which is essential for the identity of the physician and which is important for patients in need. It is suggested to understand care as a prerequisite to respect autonomy. Autonomy without care is not medicine.

Ist die ästhetische Chirurgie überhaupt noch Medizin? Eine ethische Kritik

Aesthetic surgery has evolved in the past years from a genuine medical practice to a mere commodity. From an ethical point of view one must ask whether this evolution creates more problems than it solves. The present paper elaborates four arguments against this evolution and shows that an aesthetic surgery which works only according to market categories runs the risk of losing the view for the real need of patients. An aesthetic surgery that understands itself as part of a market will be nothing else than a part of a beauty industry which has the only aim to sell something, but not the aim to help people. Such an aesthetic surgery makes profit from the ideology of a society that serves only vanity, youthfulness and personal success and which is losing the sight for real values. The real value of man cannot be reduced to its appearance and medicine as an art should feel the obligation to resist these modern ideologies and should help people to get a more authentic attitude to themselves. If aesthetic surgery fails to think about these implications it will lose its identity as medicine which would be a too great loss.

Submento-submandibular intubation: is the subperiosteal passage essential? Experience in 107 consecutive cases

Adequate treatment of panfacial injuries often requires tracheostomy or alternating intubation through the nose and the mouth to keep the field free during the operation. Altemir's submental technique is an attractive option in these patients. We used the method with a slight modification in 107 operations in our unit to treat panfacial injuries. We had a low rate of complications and no increased operative time.

A randomized controlled trial of pegylated interferon alpha-2a (40 KD) or interferon alpha-2a plus ribavirin and amantadine vs interferon alpha-2a and ribavirin in treatment-naïve patients with chronic hepatitis C

We determined whether triple therapy comprising amantadine (AMA), ribavirin (RBV) and either peginterferon (PEG-IFN) alpha-2a or conventional IFN alpha-2a would improve sustained virological response (SVR) rates over dual therapy with IFN alpha-2a and RBV in patients with chronic HCV infection. A total of 362 treatment-naïve patients were randomized to 48 weeks of treatment with: PEG-IFN alpha-2a 180 microg/week (group A) or IFN alpha-2a 3 MU tiw (groups B and C). All patients received RBV 1000 or 1200 mg/day and those in groups A and B received AMA 200 mg/day. SVR was defined as an undetectable HCV RNA after 24 weeks of untreated follow-up. At the end of therapy, 74.4% (95% CI 0.66-0.82) of patients in group A were HCV RNA-negative compared with 42.5% (95% CI 0.33-0.50) of those in group B (P = 0.0001) and 48.8% (95% CI 0.40-0.56) of those in group C. SVR was achieved in a significantly greater proportion of patients in group A compared with groups B and C: 65.3% (95% CI 0.53-0.56), 33.3% (95% CI 0.25-0.41) and 44.6% (95% CI 0.36-0.53; P = 0.0001) respectively. In patients with genotype 1, SVR rates were 55.2, 22.8 and 28.8% with the three regimens respectively. Factors independently associated with SVR were HCV genotype 2 or 3, therapy with PEG-IFN, female gender and age. In treatment-naive patients with chronic hepatitis C, triple therapy with PEG-IFN alpha-2a, RBV and AMA produces higher SVR than dual or triple therapy with conventional IFN alpha-2a.

Treatment of patients with HCV infection with or without liver biopsy

Expert consensus recommends liver biopsy before therapy for chronic hepatitis C. A cost effectiveness analysis suggested that the best strategy in the management of patients was to treat without biopsy. We compared therapy in patients who did, or did not undergo biopsy. Hepatitis C virus (HCV)-positive patients (78) who did not agree to (n = 57) or with contraindications to liver biopsy (n = 21) (group A) were matched for age, sex and genotype with those who consented (group B). Before therapy (interferon/ribavirin for 12 months), a clinical diagnosis of chronic hepatitis, on the basis of standard biochemical and ultrasonographic parameters. The two groups showed similar baseline characteristics. A noninvasive, diagnosis of chronic hepatitis was made in 75.6% of group A, and in 83.3% of group B (P = 0.26). Concordance between clinical and histological diagnosis in group B amounted to 91%. End-of-therapy virological response was 52.6% in group A, and 57.7% in group B (P = 0.63). Sustained virological response was 41.0% [95% confidence interval (CI) 30.1-51.9] and 43.6% (95% CI 32.6-54.6) in the two groups (P = 0.87). Predictors of sustained response were noninvasive diagnosis of chronic hepatitis (P = 0.006), lack of portal hypertension (P = 0.037), platelets >10(5)/mm3 (P = 0.007), prothrombin >70% (P = 0.02), and genotype 2 or 3 (P < 0.0001). At multivariate analysis, genotype (P < 0.0001) and platelets (P = 0.004) maintained their predictive power. In most patients with HCV infection, virological clearance after therapy can be achieved irrespective of whatever a liver biopsy might show.

[Psychiatric and ethical aspects of genetic diagnosis exemplified by Huntington chorea]

Huntington's disease is an autosomally dominant, inherited neurodegenerative disorder. Depression, psychotic syndromes, and personality changes are common psychiatric features, frequently occurring before the onset of characteristic motor symptoms. Since 1993, direct genetic testing has been available, which provides predictive diagnosis even in neurologically asymptomatic persons at risk. The prediction of this devastating disease constitutes a massive psychological burden. In particular, since possibilities of prevention or causal therapy are still not known, ethical aspects are of considerable importance. This refers for example to preimplantation diagnostic testing or the testing of children. Besides, it is important to consider paranoid or depressive symptoms restricting the competence of decision making for genetic testing. Early-onset cognitive deficits may also lead to fundamental disability in understanding. In addition, informed consent may be complex due to social or familial issues which may interfere with the autonomy of the applicant. In these circumstances, the counselor may clash between the principle of beneficence/nonmaleficence and respect for the autonomy of the applicant. In the future, genetic tests will be used for an increasing number of inherited diseases; it is therefore necessary to learn from experiences in the predictive testing of Huntington's disease and to develop ethical codices that can be transferred to the practice of counseling in other genetic disorders.

[Bioethics in historical perspective. For a critical approach to bioethics and his relationship to the history of medicine]

What is the history of bioethics? What are the shortcomings of the bioethical approach? And what could the history of medicine do for a better understanding of bioethics as discipline and of bioethical problems themselves? These are the central questions which are stressed in this article. The main conclusion is that bioethics has to be seen as a cultural product which can only be understood if the social context in which this new discipline has emerged is taken into consideration. History of medicine has furthermore the chance to contextualize bioethical problems and in this function history of medicine could be a helpful discipline for a better understanding of current problems in medicine.

The cultural specifity of research ethics--or why ethical debate in France is different

In the search for a globally binding ethical minimal consensus in dealing with research on human beings the awareness of the cultural specificity of such questions will be of central importance. France provides a good example of such cultural specificities. Three basic structures of French discussion on research ethics can be enumerated: first the particular weight placed on therapeutic benefit, second a particular accentuation on freedom and voluntarism, and third its lesser attention to the aspect of ability to give consent. The weak emphasis on the ability to give consent is rooted as much in the traditionally paternalistically imbued physician-patient relationship as in the French legal system, in which the doctrine of consent is not given the fundamental position of importance found in the Anglo-Saxon countries. As an important Roman country, a different accentuation in the ethical discussion on research on humans can be recognised, a discussion in which for a long time the right of self determination was less of a criterion for decision than the teleology of medical action. It is precisely this aspect of latent cultural influence in ethical convictions which is of decisive importance for future discussion on research on humans.

[How do we ethically justify non-resusitation? Arguments within the social system on an ongoing problem in modern medicine]

The question whether to resuscitate or not belongs to the most controversial issues of medical ethics. This paper wants to give an insight into the German way of discussion on this topic. First it gives an overview of the most important codifications concerning resuscitation. Then it treats the question who is to be involved in do-not-resuscitate-decisions. The central point of the paper is the question of futile treatment and the question of the normative structures which are present in German discussion.

[The presentation of disease and medicine in film. Film stereotypes of epilepsy]

Our presentation examines historical changes in the contextualisation of epilepsy by the media. In movies, one may note a particularly long-lasting predominance of traditional complexes of the significance of epilepsy. Epilepsy as an hereditary disease, as a degenerative illness, as a cause of criminality. These are the motifs, established myths, which lived on in movies long beyond the time at which scientific opinion had distanced itself from them. A radical change in the manner of presentation of epilepsy began in the late sixties. From that time on, not only the connotation of epilepsy was altered, but, above all, the presentation of the patient, who henceforth, according to the changing processes of society was shown as a self-aware and active shaper of his life. Thus it is precisely the development during the last fifteen years, in which numerous sensitive motion pictures have tackled the inner perspective of the patient, movies having not only ceased to pass on the established myths, but become promoters of new attitudes toward disease. With this type of representation of disease and patient, due to its direct and broad effect, motion pictures can spread new realities in a manner hardly possible for other media.

Extraction of PCDD/PCDF from soil with supercritical CO2: optimization by a three-level factorial design approach

Two factors (pressure and temperature) varied over three levels were optimized for the extraction of PCDD/F from native contaminated soil with toluene-modified supercritical carbon dioxide. Temperature had a strong positive effect on the recovery. The most efficient extraction was achieved at 120 degrees C. This is in contrast to the influence of the temperature on the extraction of HCH, where a higher recovery is obtained at 60 degrees C than at 150 degrees C. The optimized conditions found for this soil were applied to the analysis of a BCR (European Commission) reference material prepared from contaminated industrial soil. The results are in good agreement with those of an interlaboratory study.

The metaphorical and mythical use of the kidney in antiquity

While the Syrians and the Arabs viewed the liver as the center of life, the kidneys, in contrast, held a primary place of importance in Israel. In Hebrew tradition, they were considered to be the most important internal organs along with the heart. In the Old Testament most frequently the kidneys are associated with the most inner stirrings of emotional life. But they are also viewed as the seat of the secret thoughts of the human; they are used as an omen metaphor, as a metaphor for moral discernment, for reflection and inspiration. This field of tension in metaphoric usage is resolved under the conception of the kidneys as life center. In the Old Testament the kidneys thus are primarily used as metaphor for the core of the person, for the area of greatest vulnerability. For us today, this metaphorical use of the kidneys has lost its meaning. One reason for its disappearance is certainly the monopoly of causal-analytic rationality in science of today. The kidney has developed from myth to organ, and with this transition a variety of perspectives and ways of looking at knowledge inherent in imaginative thought have been lost. But the metaphor uncovers a deeper level of truth, it represents another form of reconstruction of reality which needs not necessarily be subordinate to the scientific rationality. Today as well, these imaginative ideas can provide an approach to an essential level of reality which may otherwise remain hidden.

Hepatitis C virus infection and alanine transaminase levels in the general population: a survey in a southern Italian town

BACKGROUND/AIM

The aim of the study was to estimate the prevalence, risk factors and genotype distribution of hepatitis C virus (HCV) in the general population older than 5 years of age in a southern Italian town. The positive predictive value of alanine transaminase (ALT) screening in identifying HCV positive subjects was also assessed.

METHODS

Cluster random sampling from the census of the general population was used. ELISA and RIBA tests assessed the presence of anti-HCV; nested reverse transcription polymerase chain reaction (RT-PCR) was used to identify HCV-RNA; genotyping was performed by INNO-LIPA III. The association linking anti-HCV seropositivity with potential risk factors was assessed by multiple logistic regression analysis.

RESULTS

Among the 488 subjects enrolled, 79 (16.2%) were anti-HCV positive. The prevalence increased from 1.2% in subjects 6-29 years of age to 42.1% in those > or = 60 years. Forty percent of these positive subjects also had abnormal ALT level and 54.4% were HCV RNA positive by PCR. The positive predictive value of the ALT test in identifying anti-HCV positive subjects was 65%; however, it was 46.7% in subjects younger than 60 years of age and 90.5% in those 60 or older. Genotype 1b was detected in 74% of subjects, type 2c in 23.3%, and type 1a in 2.3%. The only two variables significantly associated with HCV seropositivity in multivariate analysis were age older than 45 years (O.R. 8.5; CI 95%=3.0-24.1) and past use of glass syringes (O.R. 3.4; CI 95%=1.5-7.6).

CONCLUSIONS

These findings confirm that HCV infection is endemic in southern Italy, particularly among the elderly. Percutaneous exposure, such as injections with nondisposable, multiple-use, glass syringes used in the past for medical purposes may have played a major role in the spread of HCV infection. ALT screening is not useful in detecting HCV positive subjects in the general population, particularly among subjects who could benefit from antiviral therapy.

[Informing the patient--but how? Ethics and theory of patient information]

Informed consent is one of the most discussed topics of bioethics. This new emphasis on seeking patient's consent is due to the fact that since the 1960s there has been a considerable change in the ideal of patient-physician relationship. There has been an important shift from a physician-based commitment of promoting well-being to a patient-based right of information arising from individual autonomy instead of a Hippocratic paternalism. Consent requirement is ethically derived from the duty to treat persons as ends, not merely as means. So the physician has a special moral obligation to assure the patient's moral agency by reducing the inequality in information between patient and physician. Therefore a morally valid consent has to be a continuing process rather than a singular event.

Histomorphometric analysis of age-related structural changes in human clitoral cavernosal tissue

PURPOSE

To characterize age-associated histological changes of human clitoral cavernosal tissue and to determine whether age-related histological changes of clitoral cavernosal tissue correlate with vascular disease-related mortality.

MATERIALS AND METHODS

Human clitorises were obtained from 15 fresh cadavers (age: 11 to 90 years) and from 3 patients undergoing clitoral surgery (age: 6 months to 15 years). Cross sections of the clitorises were stained with Masson's trichrome and utilized for computer assisted histomorphometric image analysis to determine the clitoral cavernosal content of smooth muscle and connective tissue.

RESULTS

These studies revealed a strong link between increase in age and decreased clitoral cavernosal smooth muscle fibers. In histomorphometry, the percentage of clitoral cavernosal smooth muscle (mean +/- standard error) in an age group of 6 months to 15 years (n = 4) was 65+/-1.5, in 44 to 54 years (n = 7) was 50+/-1.2, and in 55 to 90 years (n = 7) was 37+/-1.3 (ANOVA, p = 0.0001). In the 18 tissues studied, decrease in the percentage of clitoral cavernosal smooth muscle significantly correlated with increase in age (simple regression, r = 0.61). In the age group of 44 to 90 years, clitoral cavernosal fibrosis was significantly greater in the presence of cardiovascular disease-related mortality compared with those without cardiovascular disease-related mortality.

CONCLUSION

This study shows that aging women undergo histological changes in clitoral cavernosal erectile tissue. Vascular risk factors may adversely affect the structure of clitoral cavernosal tissue. These findings may be of importance in the pathophysiology of age-associated female sexual arousal disorders.

Is etiquette relevant to medical ethics? Ethics and aesthetics in the works of John Gregory (1724-1773)

The writings of the Scottish physician and philosopher John Gregory play an important role in the modern codification of medical ethics. It is therefore appropriate to use his work as a historical example in approaching the question how elements of aesthetics were incorporated in 18th century medical ethics. The concept of a "Gentleman" is pivotal to the entire medical ethics of John Gregory as it provides him with the ethical source of the duty to patients. Gregory makes the trustworthiness of the physician a central point of his medical ethics, and it is in this context that Gregory declares good manners as an essential moral quality of a physician. This paper delineates how good manners are ethically justified in Gregory's medical ethics and concludes with an exploration of the importance of Gregory's conception for present day reflection on the inherence of aesthetics in ethical determinations.

Marine fungi in Terra Nova Bay (Ross Sea, Antarctica)

The occurrence of lignicolous marine fungi in Antarctic marine water far from the coast is reported. Thirty-six wooden baits (beech and poplar), hung in a metallic structure were immersed in Penguin Bay (Adelie Cove) at a depth of 50 m for a year. Fourteen species belonging to Deuteromycotina and six Ascomycotina were observed on the baits examined in Italy. Phoma sp., Trichocladium achrasporum, Trichocladium constrictum and Trichocladium lignincola were the predominant species. Phoma sp., the first species, are not typically marine, but rather of terrestrial origin. Penguin dung proximity can explain this occurrence.

Interstitial cystitis: Surgical therapy

Between May 1982 and June 1996 at the Department of Urology of Padua University, 13 patients (12 women and 1 man) underwent augmentation/substitution cystoplasty for interstitial cystitis (CI) refractory to conservative management. Median bladder capacity was 70 ml (less than 400 ml under anesthesia in all cases). Two patients underwent subtotal cystectomy and substitution cystoplasty using sigmoid segment; in 7 patients a supratrigonal cystectomy and substitution cystoplasty with sigma (2 cases) and ileum (5 cases) was performed; in 4 patients simple bladder augmentation after large longitudinal bladder incision was performed. Mean post-operative follow-up was 84 months (range 4-173). Post operative median spontaneous bladder capacity was 290 ml and a subjective and objective good result was obtained in 10 out of 13 patients. Four patients had 5 post operative complications: one stenosis of the sigmoido-vesical junction, one ileal segment retraction, one septic temporary acute renal failure, two persistent complete urinary retention. The first two cases needed reoperation and the last two clean intermittent self-catheterization. Supratrigonal cystectomy with substitution enterocystoplasty, using detubularized/configured bowel segment, is the best surgical option in patients with CI with decreased bladder capacity and pain correlated to bladder filling. Post-operative clean intermittent self-catheterization must always be considered during preoperative evaluation.

Primary malignant melanoma of the female urethra: a case report

A case of primary malignant melanoma of the female urethra is reported. Physical examination and visceral studies confirmed the primary character of the tumour and histologic examination proved it to be nodular malignant melanoma. Less than 100 cases have been previously reported. The role of immunohistochemical stains to substantiate the diagnosis is stressed. Therapy and prognosis are briefly discussed.

Urological manifestations of acute appendicitis: report of two new cases

Clinical manifestations of acute appendicitis are variegated and urologic symptoms may be the first manifestation of the disease. In 1985 we reported on 2 cases of acute appendicitis who presented with irritative bladder symptoms. Here we describe 2 new cases come to our observation because of hematuria and irritative bladder symptoms. A brief review of the literature is also carried out.