Radical liberal values-based practice.

Values based practice is a radical view of the place of values in medicine which develops from a philosophical analysis of values, illness and the role of ethical principles. It denies two attractive and traditional views of medicine: that diagnosis is a merely factual matter and that the values that should guide treatment and management can be codified in principles. But it goes further in the adoption of a radical liberal view: that right or good outcome should be replaced by right process. I describe each of these three claims but caution against the third

ViSiGi 3D™ vs. Bougie Dilator for Sleeve Gastrectomy Calibration

ViSiGi 3D™ vs. Bougie Dilator for Sleeve Gastrectomy Calibration Nicholas Schiavone1 Richard Boorse M.D.1,2 1Department of Surgery, Lehigh Valley Health Network 2Research Scholar Program Mentor Abstract This paper is the start of a quality improvement project to decrease cost, length of stay, and various problems that are uncommon, but known to happen with laparoscopic sleeve gastrectomies. This will be accomplished by comparing the standard bougie used in laparoscopic sleeve gastrectomies with a newer technology called the ViSiGi 3DTM which is a suction calibration system. A database has been completed that tracks patient information and various important details from surgery to discharge that will allow for analysis of pros and cons of each calibration device pending approval from the IRB. Background Bariatric surgical procedures are rapidly becoming the most performed in the field of general surgery. Specifically the laproscopic sleeve gastrectomy is gaining popularity as an effective weight loss tool. Laparoscopic sleeve gastrectomy involves resection of 70% of the stomach leaving a narrow tube referred to as a “sleeve” (Fig. 1). The sleeve gastrectomy helps patients lose weight in two ways: the first being restricting volume of oral intake and the second being reduction in the “hunger hormone” ghrelin by removal of the gastric fundus where the hormone is produced. There are several important tools used in the completion of a laparoscopic sleeve gastrectomy, and this paper will focus on only one of them, the bougie. The bougie is plastic tubing that is inserted by the anesthetist through the mouth, down the esophagus, and rests against the pyloric sphincter in the stomach. This is then used as a guide for the surgeon to staple alongside of and form the new sleeve. The problem with a traditional weighted bougie (Fig. 2) is that the anesthetist needs to continually adjust and readjust the bougie so that the sleeve is uniform in shape and size. We started using a ViSiGi 3D calibration device (Fig. 3) and are planning to compare the results with those of a standard bougie. The advantages of a ViSiGi 3D calibration device are that not only does it serve the purpose of the standard bougie, it also compresses the stomach uniformly due to the suction acting on all surfaces of the stomach equally, it empties the stomach of all contents, as well as holding the stomach in place which removes the need for constant readjustment. The aim of this paper is to discuss the database that was created, and the process that was used to create it that will be used to compare and contrast the ViSiGi 3D calibration device to the standard weighted bougie. Methodology This study will be a retrospective chart review that will be broken up into two cohorts. The first cohort is comprised of the 100 sleeve gastrectomy cases preceding the use of the ViSiGi 3D suction calibration system in which a weighted bougie was used. The second cohort consisted of the first 100 sleeve gastrectomy cases using the ViSiGi 3D system. Both cohorts had procedures that were either stand-alone sleeve gastrectomies or a conversion of a band to a sleeve. All of the procedures were performed by either Dr. Boorse or Dr. Harrison using nearly identical techniques. Dispersed throughout these procedures were additional surgeries completed such as cholecystectomy, hiatal hernia repair, umbilical hernia repair, and/or lysis of adhesions which will be taken into consideration when determining the length of procedure. The first step in completing this project, following the completion of the 200 cases, was to make a database that outlined all the variables of interest, of which there were 110. These are listed in table 1. The importance of these variables is twofold. The first is that it will allow us, once we receive IRB approval, to analyze the data points which are truly important to our future paper. The second is that it has already allowed us to create an entire bariatric database that will be used to gather important data points on all future bariatric procedures performed at LVHN and will allow for continuous quality improvement analysis that is not limited to only laparoscopic sleeve gastrectomies. That data used in the database was gathered using a combination of EHMR as well as the newly implemented system of EPIC Hyperspace. Results There are no results at this time because the database has not yet been analyzed due to all the criteria not being fully collected at the time that this paper was written. Discussion However, there are several early impressions that the surgeons have made since using the ViSiGi 3d suction calibration system that we will be expecting to be confirmed once statistical analysis is performed. The first is a decrease in staple load fires. The second is that, due to the diminished need to constantly readjust the bougie, the overall length of procedure will decrease. The third is that leakage rates will be decreased. The fourth is that the overall length of stay will decrease. The fifth is that the rate of 30 day readmissions will decrease. We are hoping that, due to the aforementioned benefits, the cost will decrease more than the additional cost of the ViSiGi 3D. If any of the above is true the ViSiGi 3D may be made the new standard of care in the LVHN hospital network. Conclusion The goal of this paper was to give background on the differences between the standard bougie and the ViSiGi 3D suction calibration system, outline the database being used for storage of vital information pertaining to future quality improvement projects, as well as outline the goal for any future quality improvement projects that will be performed once all data has been collected. This paper is a promising start to a strong quality improvement project using the ViSiGi 3D suction calibration system during laparoscopic sleeve gastrectomies. It also provides the groundwork in the form of an all-encompassing bariatric database that will be used to compare all procedural outcomes with one another rather than just sleeve to sleeve comparisons. The future aim of Dr. Boorse and his colleagues is to statistically evaluate the pros and cons, if any, of using the ViSiGi 3D suction calibration system versus a standard bougie. Appendix Last Name First Name Date of Birth Medical Record Number Encounter Number Age Race Sex Smoking Status Pre Op Weight Pre Op BMI History of Pulmonary Embolism History of Deep Vein Thrombosis Cholelithiasis/Previous Cholecystectomy Sleep Apnea Diabetes Mellitus If “Yes” Type 1 or 2 Gastro Esophageal Reflux Disease Hypertension Hyperlipidemia Cardiac Disease Chronic Anticoagulation Meds Myocardial Infarction Musculoskeletal problems (i.e. arthritis, disc disease, or both) Anxiety Depression Barrett’s Esophagus Pre Op Hpylori Result EGD Result of Hiatal Hernia Surgery Date What Procedure The surgeon which performed the procedure Whether a ViSiGi bougie was used If “yes” what size Whether a Standard Bougie was used If “yes” what size How many of each staple was fired White, Blue, Green, Gold, Black Cost of Surgery Length of the Procedure What additional surgeries the patient had Cholecystectomy, hiatal hernia repair, umbilical hernia repair, and/or lysis of adhesions Admit Date Discharge Date Length of Stay If the length of stay was greater than 36 hours what was the reason Nausea, Fever, PO intolerance, Urinary Retention, Bleeding, and/or Other If an upper GI was performed If “yes” what were the findings Leak, Obstruction, Stricture, or Normal If the patient was readmitted within 30 days If “yes” what was the reason Nausea Vomiting, Dehydration, Superficial Site Infection, Deep Site Infection, Leak, Diarrhea, Respiration Failure, Pneumonia, Incisional Hernia, Deep Vein Thrombosis, C-Diff, Intestinal Obstruction, Stricture, Bleeding, Pain, Anastomotic Ulcer, Biliary Disease, and/or Other What was the weight lost at each successive post op visit? First initial, 1 month, 3 month, 6 month, 1 year, 2 year, 3 year, 4 year, and 5 year Comorbidity resolution I.e. Diabetes Mellitus, Hypertension, etc. If cholelithiasis developed post operatively what was the date it was diagnosed Intraoperative complications Conversion from laparoscopic to open What was the reason if there was one? Mortality If “yes” how soon after the surgery What was the cause? Figure 1. Diagram of sleeve gastrectomy Figure 2. example of standard weighted bougie dilator Figure 3. ViSiGi 3D suction calibration syste

The concept of health: Beyond normativism and naturalism

Philosophical discussions of health and disease have traditionally been dominated by a debate between normativists, who hold that health is an inescapably value-laded concept and naturalists, such as Christopher Boorse, who believe that it is possible to derive a purely descriptive or theoretical definition of health based upon biological function. In this paper I defend a distinctive view which traces its origins in Aristotle\u27s naturalistic ethics. An Arisotelian would agree with Boorse that health and disease are ubiquitous features of the natural world and thus not mere projections of human interests and values. She would differ from him in rejecting the idea that value is a non-natural quality. I conclude my discussion with some comments of the normative character of living systems

BCS Model in Tsallis' Statistical Framework

We show that there is an effect of nonextensivity acting upon the BCS model for superconductors in the ground state that motivates its study in the Tsallis' statistical framework. We show that the weak-coupling limit superconductors are well described by $q \sim 1$, where q is a real parameter which characterizes the degree of nonextensivity of the Tsallis' entropy. Nevertheless, small deviations with respect to q = 1 provide better agreement when compared with experimental results. To illustrate this point, making use of an approximated Fermi function, we show that measurements of the specific heat, ultrasonic attenuation and tunneling experiments for tin (Sn) are better described with q = 0.99.Comment: 13 pages, amssym

The right not to hear: The ethics of parental refusal of hearing rehabilitation

Objective: To explore the ethics of parental refusal of auditory–oral hearing rehabilitation. Study Design: Case study with medical ethical discussion and review. Methods: Two young brothers present with severe‐to‐profound congenital sensorineural hearing loss. The parents, both of whom have normal hearing and work as sign language interpreters, have decided to raise their children with American Sign Language as their only form of communication. They have chosen not to pursue cochlear implantation nor support the use of hearing aids. Discussion: This case raises significant questions concerning whether hearing rehabilitation should be mandated, and if there are circumstances in which parental preferences should be questioned or overridden with regard to this issue. In addition, legal concerns may be raised regarding the possible need to file a report with Child Protective Services. Although similar cases involving the Deaf community have historically favored parental rights to forego hearing rehabilitation with either cochlear implantation or hearing aids, we explore whether conclusions should be different because the parents in this case are not hearing impaired. Conclusions: The ethics of parental rights to refuse hearing rehabilitation are complex and strikingly context‐dependent. A comprehensive appreciation of the medical, practical, and legal issues is crucial prior to intervening in such challenging situations.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/86840/1/21886_ftp.pd

A Unifying Theory of Biological Function

A new theory that naturalizes biological function is explained and compared with earlier etiological and causal role theories. Etiological theories explain functions from how they are caused over their evolutionary history. Causal role theories analyze how functional mechanisms serve the current capacities of their containing system. The new proposal unifies the key notions of both kinds of theories, but goes beyond them by explaining how functions in an organism can exist as factors with autonomous causal efficacy. The goal-directedness and normativity of functions exist in this strict sense as well. The theory depends on an internal physiological or neural process that mimics an organism’s fitness, and modulates the organism’s variability accordingly. The structure of the internal process can be subdivided into subprocesses that monitor specific functions in an organism. The theory matches well with each intuition on a previously published list of intuited ideas about biological functions, including intuitions that have posed difficulties for other theories