Is opportunistic disease prevention in the consultation ethically justifiable?

To access publisher version of this article. Please click on the hyperlink in Additional Links fieldTo access full text version of this article. Please click on the hyperlink "View/Open" at the bottom of this pageMedical resources are increasingly shifting from making patients better to preventing them from becoming ill. Genetic testing is likely to extend the list of conditions that can be screened for. Is it time to stop and consider whom we screen and how we approach it

The use of embryonic stem cells for medical-therapeutical purposes: a study of attitudes among Icelandic physicians, lawyers and clergymen

Neðst á síðunni er hægt að nálgast greinina í heild sinni með því að smella á hlekkinn View/OpenObjective: To study the bioethical standpoints among three groups of Icelandic professionals in relation to the use of embryonic stem cells for medical-therapeutical purposes. Material and methods: In June 2002, a questionnaire was sent by mail to a random sample of 284 doctors and 293 lawyers, as well as all 168 practicing clergymen in Iceland. The participants' position in relation to the use of embryonic stem cells for therapeutical purposes was elicited through general questions as well as case examples. 290 questionnaires (39%) were returned. Results: 62% of participants believed the embryo to have an ethical status superior to that of biologically comparable life forms. 20% of respondents considered its status as equal to that of a grown human being, whilst 18% considered it equal to biologically comparable primitive life forms. There was a difference between the respondent groups (p<0,05). A vast majority believed the use of embryonic stem cells for therapeutical purposes to be justifiable, although the origin of the stem cells appeared to make a difference to many respondents. 8% of participants took an unconditional position against the use of embryonic stem cells. Among those who considered the use of embryonic stem cells with a therapeutic aim to be justifiable, 71% believed that embryonic stem cells should only be utilized to treat diseases of a severe nature. 64% of participants defended the idea of therapeutic cloning with the intention to treat a patient with Parkinson's disease, but the case history elicited considerable difference between professional groups. Clergymen and lawyers tended to hold firmer attitudes, clergymen against and lawyers for the use of stem cells, whilst medical doctors as a group positioned themselves more towards the middle. Female respondents generally took a more modest stand whilst males were more likely to take a firmer stand in both directions. A vast majority (87%) of the participants believed there to be a need for public debate in relation to the use of embryonic stem cells for therapeutical purposes. Conclusion: Overall, participants views in relation to the use of embryonic stem cells for medical purposes were rather liberal. There were however significant differences between professional groups. The relatively high tolerance in regard to therapeutic cloning is interesting in view of the considerable controversy over this topic in many countries. There appears to be fertile ground for a public debate about the use of embryonic stem cells for medical purposes in Iceland.Tilgangur: Markmið rannsóknarinnar var að fá vísbendingu um afstöðu lækna, lögfræðinga og presta til notkunar á stofnfrumum úr fósturvísum til lækninga. Efniviður og aðferðir: Úr markhópunum voru valdir með slembiaðferð 284 læknar og 293 lögfræðingar og allir starfandi prestar á Íslandi, samtals 168. Sendur var út spurningalisti til að kanna siðferðilega afstöðu þessara aðila til notkunar stofnfrumna úr fósturvísum til lækninga. Alls bárust 290 svör (39% svörun). Niðurstöður: Rúmlega 60% þátttakenda taldi að fósturvísir hefði ákveðna siðferðilega sérstöðu umfram aðrar lífverur á sambærilegu þroskaskeiði. Þeir sem töldu fósturvísi hafa siðferðilegt gildi á við manneskju voru um 20% og tæplega 18% að fósturvísar nytu ekki siðferðisréttar umfram aðra frumuklasa. Munur var á milli stétta (p<0,05). Mikill meirihluti áleit notkun stofnfrumna úr fósturvísum til lækninga réttlætanlega, en í huga margra skipti það máli með hvaða hætti fósturvísirinn hefði orðið til. Tæplega 8% þátttakenda setti sig alfarið á móti lækningum með stofnfrumur. Af þeim sem álitu notkun stofnfrumna í læknisfræðilegum tilgangi réttlætanlega töldu 71% að eðli sjúkdómsins skipti máli og að aðeins eigi að beita slíkum aðferðum þegar fengist er við alvarlega sjúkdóma. 64% lækna og 68% lögfræðinga taldi einræktun í því skyni að meðhöndla Parkinsons-sjúkling réttlætanlega samanborið við 40% presta (p<0,01) og heldur fleiri karlar en konur (p<0,01), 64% karla borið saman við 52% kvenna (p<0,01). Mikill meirihluti (87%) taldi þörf á þjóðfélagslegri umræðu um þessi mál. Ályktanir: Almennt eru þátttakendur frjálslyndir gagnvart notkun stofnfrumna úr fósturvísum til lækninga. Frjálslyndi gagnvart einræktun í lækningaskyni er athyglisvert, en mikill styr hefur staðið um slíkar aðgerðir í flestum ríkjum. Þörf er á upplýsingu og umræðu

Estimating the high risk group for cardiovascular disease in the Norwegian HUNT 2 population according to the 2003 European guidelines: modelling study.

To access publisher full text version of this article. Please click on the hyperlink in Additional Links fieldOBJECTIVE: To estimate the high risk group for cardiovascular disease in a well defined Norwegian population according to European guidelines and the systematic coronary risk evaluation system. DESIGN: Modelling study. SETTING: Nord-Tröndelag health study 1995-7 (HUNT 2), Norway. PARTICIPANTS: 5548 participants of the Nord-Tröndelag health study 1995-7, aged 40, 50, 55, 60, and 65. MAIN OUTCOME MEASURES: Distribution of risk categories for cardiovascular disease, with emphasis on the high risk group. MAIN RESULTS: At age 40, 22.5% (95% confidence interval 19.3% to 25.7%) of women and 85.9% (83.2% to 88.6%) of men were at high risk of cardiovascular disease. Corresponding numbers at age 50 were 39.5% (35.9% to 43.1%) and 88.7% (86.3% to 91.0%) and at age 65 were 84.0% (80.6% to 87.4%) and 91.6% (88.6% to 94.1%). At age 40, one out of 10 women and no men would be classified at low risk for cardiovascular disease. CONCLUSION: Implementation of the 2003 European guidelines on prevention of cardiovascular disease in clinical practice would classify most adult Norwegians at high risk for fatal cardiovascular disease

The Intangible Legacy of the Indonesian Bajo

The Sama-Bajau, or Bajo diaspora, extends from the southern Philippines and Sabah (Malaysian Borneo) to the eastern part of Indonesia. The Indonesian Bajo, now scattered along the coasts of Sulawesi (Celebes) and East Kalimantan, the Eastern Lesser Sunda Islands and Maluku, were once mostly nomadic fishermen of the sea or ocean freight carriers. Today, the Bajo are almost all fishermen and settled. Their former and present ways of life made them favour intangible forms of culture: it is impossible to transport bulky artefacts when moving frequently by boat, or when living in stilt houses, very close to the sea or on a reef. It is therefore an intangible legacy that is the essence of the Bajo\u27s culture. Sandro healers have a vast range of expertise that allows them to protect and heal people when they suffer from natural or supernatural diseases. On the other hand, music and especially oral literature are very rich. In addition to song and the pantun poetry contests, the most prestigious genre is the iko-iko, long epic songs that the Bajo consider to be historical rather than fictional narratives. The Bajo\u27s intangible heritage is fragile, since it is based on oral transmission. In this article, I give a description of this heritage, dividing it into two areas: the knowledge that allows them to “protect and heal” on the one hand, and to “distract and relax”, on the other

Body Configuration as a Predictor of Mortality: Comparison of Five Anthropometric Measures in a 12 Year Follow-Up of the Norwegian HUNT 2 Study

Background: Distribution of body fat is more important than the amount of fat as a prognostic factor for life expectancy. Despite that, body mass index (BMI) still holds its status as the most used indicator of obesity in clinical work. Methods: We assessed the association of five different anthropometric measures with mortality in general and cardiovascular disease (CVD) mortality in particular using Cox proportional hazards models. Predictive properties were compared by computing integrated discrimination improvement and net reclassification improvement for two different prediction models. The measures studied were BMI, waist circumference, hip circumference, waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR). The study population was a prospective cohort of 62,223 Norwegians, age 20–79, followed up for mortality from 1995–1997 to the end of 2008 (mean follow-up 12.0 years) in the Nord-Trøndelag Health Study (HUNT 2). Results: After adjusting for age, smoking and physical activity WHR and WHtR were found to be the strongest predictors of death. Hazard ratios (HRs) for CVD mortality per increase in WHR of one standard deviation were 1.23 for men and 1.27 for women. For WHtR, these HRs were 1.24 for men and 1.23 for women. WHR offered the greatest integrated discrimination improvement to the prediction models studied, followed by WHtR and waist circumference. Hip circumference was in strong inverse association with mortality when adjusting for waist circumference. In all analyses, BMI had weaker association with mortality than three of the other four measures studied. Conclusions: Our study adds further knowledge to the evidence that BMI is not the most appropriate measure of obesity in everyday clinical practice. WHR can reliably be measured and is as easy to calculate as BMI and is currently better documented than WHtR. It appears reasonable to recommend WHR as the primary measure of body composition and obesity

Trends in absolute and relative educational inequalities in health during times of labour market restructuring in coastal areas : The HUNT Study, Norway

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Beyond multimorbidity:What can we learn from complexity science?

Multimorbidity - the occurrence of two or more long-term conditions in an individual - is a major global concern, placing a huge burden on healthcare systems, physicians, and patients. It challenges the current biomedical paradigm, in particular conventional evidence-based medicine's dominant focus on single-conditions. Patients' heterogeneous range of clinical presentations tend to escape characterization by traditional means of classification, and optimal management cannot be deduced from clinical practice guidelines. In this article, we argue that person-focused care based in complexity science may be a transformational lens through which to view multimorbidity, to complement the specialism focus on each particular disease. The approach offers an integrated and coherent perspective on the person's living environment, relationships, somatic, emotional and cognitive experiences and physiological function. The underlying principles include non-linearity, tipping points, emergence, importance of initial conditions, contextual factors and co-evolution, and the presence of patterned outcomes. From a clinical perspective, complexity science has important implications at the theoretical, practice and policy levels. Three essential questions emerge: (1) What matters to patients? (2) How can we integrate, personalize and prioritize care for whole people, given the constraints of their socio-ecological circumstances? (3) What needs to change at the practice and policy levels to deliver what matters to patients? These questions have no simple answers, but complexity science principles suggest a way to integrate understanding of biological, biographical and contextual factors, to guide an integrated approach to the care of people with multimorbidity

Current European guidelines for management of arterial hypertension: Are they adequate for use in primary care? Modelling study based on the Norwegian HUNT 2 population

<p>Abstract</p> <p>Background</p> <p>Previous studies indicate that clinical guidelines using combined risk evaluation for cardiovascular diseases (CVD) may overestimate risk. The aim of this study was to model and discuss implementation of the current (2007) hypertension guidelines in a general Norwegian population.</p> <p>Methods</p> <p>Implementation of the current <it>European Guidelines for the Management of Arterial Hypertension </it>was modelled on data from a cross-sectional, representative Norwegian population study (The Nord-Trøndelag Health Study 1995-97), comprising 65,028 adults, aged 20-89, of whom 51,066 (79%) were eligible for modelling.</p> <p>Results</p> <p>Among individuals with blood pressure ≥120/80 mmHg, 93% (74% of the total, adult population) would need regular clinical attention and/or drug treatment, based on their total CVD risk profile. This translates into 296,624 follow-up visits/100,000 adults/year. In the Norwegian healthcare environment, 99 general practitioner (GP) positions would be required in the study region for this task alone. The number of GPs currently serving the adult population in the study area is 87 per 100,000 adults.</p> <p>Conclusion</p> <p>The potential workload associated with the European hypertension guidelines could destabilise the healthcare system in Norway, one of the world's most long- and healthy-living nations, by international comparison. Large-scale, preventive medical enterprises can hardly be regarded as scientifically sound and ethically justifiable, unless issues of practical feasibility, sustainability and social determinants of health are considered.</p

Adaptive molecular evolution of the Major Histocompatibility Complex genes, DRA and DQA, in the genus Equus

<p>Abstract</p> <p>Background</p> <p>Major Histocompatibility Complex (MHC) genes are central to vertebrate immune response and are believed to be under balancing selection by pathogens. This hypothesis has been supported by observations of extremely high polymorphism, elevated nonsynonymous to synonymous base pair substitution rates and trans-species polymorphisms at these loci. In equids, the organization and variability of this gene family has been described, however the full extent of diversity and selection is unknown. As selection is not expected to act uniformly on a functional gene, maximum likelihood codon-based models of selection that allow heterogeneity in selection across codon positions can be valuable for examining MHC gene evolution and the molecular basis for species adaptations.</p> <p>Results</p> <p>We investigated the evolution of two class II MHC genes of the Equine Lymphocyte Antigen (ELA), <it>DRA </it>and <it>DQA</it>, in the genus <it>Equus </it>with the addition of novel alleles identified in plains zebra (<it>E. quagga</it>, formerly <it>E. burchelli</it>). We found that both genes exhibited a high degree of polymorphism and inter-specific sharing of allele lineages. To our knowledge, <it>DRA </it>allelic diversity was discovered to be higher than has ever been observed in vertebrates. Evidence was also found to support a duplication of the <it>DQA </it>locus. Selection analyses, evaluated in terms of relative rates of nonsynonymous to synonymous mutations (<it>d</it>_N<it>/d</it>_S) averaged over the gene region, indicated that the majority of codon sites were conserved and under purifying selection (<it>d</it>_N<<it>d</it>_S). However, the most likely evolutionary codon models allowed for variable rates of selection across codon sites at both loci and, at the <it>DQA</it>, supported the hypothesis of positive selection acting on specific sites.</p> <p>Conclusions</p> <p>Observations of elevated genetic diversity and trans-species polymorphisms supported the conclusion that balancing selection may be acting on these loci. Furthermore, at the <it>DQA</it>, positive selection was occurring at antigen binding sites, suggesting that a few selected residues may play a significant role in equid immune function. Future studies in natural equid populations will be valuable for understanding the functional significance of the uniquely diverse <it>DRA </it>locus and for elucidating the mechanism maintaining diversity at these MHC loci.</p