Books Reviewed

Reviews of Why Men Rebel, The Mugging and The police and the Publi

Comprehensive Health Planning and Procedures: The California Experience

This Article deals with the historical evolution of hospital planning and regulation, on the one hand, and the unique procedural aspects of obtaining voluntary governmental comprehensive health planning approval of a hospital or hospital addition, on the other

Ethical Decision-Making Aid for Patients with Diminished Capacity

Many patients, especially the elderly and those with mental illness, have diminished or no capacity to participate in decision-making. Consider, for example, the patient who influenced by her paranoid schizophrenia refuses to allow her aortic stenosis to be managed by catheritization with valvuloplasty even though her prognosis is excellent if she does so and poor if she does not. Another example is the patient without any next of kin who has dementia, diabetes, and osteomyelitis with gangrene who needs an amputation of his foot and rehabilitation but who refuses. A last example is the medically fragile young adult with severe developmental delay who simply cannot understand the importance of dental extraction of a mesioangular impacted wisdom tooth. In these and similar cases, patients often can still express, sometimes very forcefully, their will – through words or deeds: the patient who wants to leave the hospital; the patient who makes threatening physical gestures when staff approach; or the patient pulls out a nasogastric tube or, worse, a PEG tube. Moreover, a surrogate may agree to an intervention or care plan justified by the patient’s “best interests” however that plan may be contrary to the patient’s “expressed” will. Is it fair to the patient to simply follow the surrogate or, in the absence of a surrogate, to simply move ahead based on a presumption that the patient must be protected from his or her lack of capacity? In other words, is the consent of a surrogate or the benefit of a clinical plan sufficient to ethically justify moving ahead regardless of the patient’s expressed will? This paper will address the ethical significance of the incapacitated will of a patient and offer a methodology for caregivers to use to address the ethical issues of these types of patients who need, but do not want, beneficial care. It will do so by exploring the ethical rationale for keeping the decision as close to the patient as possible and will offer a decision aid used in our ethics consultations to guide decisions and care planning for patients with diminished capacity

How do small rural primary health care services sustain themselves in a constantly changing health system environment?

BACKGROUND: The ability to sustain comprehensive primary health care (PHC) services in the face of change is crucial to the health of rural communities. This paper illustrates how one service has proactively managed change to remain sustainable. METHODS: A 6-year longitudinal evaluation of the Elmore Primary Health Service (EPHS) located in rural Victoria, Australia, is currently underway, examining the performance, quality and sustainability of the service. Threats to, and enablers of, sustainability have been identified from evaluation data (audit of service indicators, community surveys, key stakeholder interviews and focus groups) and our own observations. These are mapped against an overarching framework of service sustainability requirements: workforce organisation and supply; funding; governance, management and leadership; service linkages; and infrastructure. RESULTS: Four years into the evaluation, the evidence indicates EPHS has responded effectively to external and internal changes to ensure viability. The specific steps taken by the service to address risks and capitalise on opportunities are identified. CONCLUSIONS: This evaluation highlights lessons for health service providers, policymakers, consumers and researchers about the importance of ongoing monitoring of sentinel service indicators; being attentive to changes that have an impact on sustainability; maintaining community involvement; and succession planning

Pax5 loss imposes a reversible differentiation block in B-progenitor acute lymphoblastic leukemia

Loss-of-function mutations in hematopoietic transcription factors including PAX5 occur in most cases of B-progenitor acute lymphoblastic leukemia (B-ALL), a disease characterized by the accumulation of undifferentiated lymphoblasts. Although PAX5 mutation is a critical driver of B-ALL development in mice and humans, it remains unclear how its loss contributes to leukemogenesis and whether ongoing PAX5 deficiency is required for B-ALL maintenance. Here we used transgenic RNAi to reversibly suppress endogenous Pax5 expression in the hematopoietic compartment of mice, which cooperates with activated signal transducer and activator of transcription 5 (STAT5) to induce B-ALL. In this model, restoring endogenous Pax5 expression in established B-ALL triggers immunophenotypic maturation and durable disease remission by engaging a transcriptional program reminiscent of normal B-cell differentiation. Notably, even brief Pax5 restoration in B-ALL cells causes rapid cell cycle exit and disables their leukemia-initiating capacity. These and similar findings in human B-ALL cell lines establish that Pax5 hypomorphism promotes B-ALL self-renewal by impairing a differentiation program that can be re-engaged despite the presence of additional oncogenic lesions. Our results establish a causal relationship between the hallmark genetic and phenotypic features of B-ALL and suggest that engaging the latent differentiation potential of B-ALL cells may provide new therapeutic entry points.Grace J. Liu, Luisa Cimmino, Julian G. Jude, Yifang Hu, Matthew T. Witkowski, Mark D. McKenzie, Mutlu Kartal-Kaess, Sarah A. Best, Laura Tuohey, Yang Liao, Wei Shi, Charles G. Mullighan, Michael A. Farrar, Stephen L. Nutt, Gordon K. Smyth, Johannes Zuber, and Ross A. Dickin