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Non-medical sex selection: ethical issues
Introduction
This paper aims to provide a concise review of the ethical issues that are commonly raised in the UK debate on non-medical sex selection. Background information on sex selection technologies is provided, as is a description of the relevant UK legislation. Arguments for and against non-medical sex selection will be explained and compared and conclusions will be drawn. It is finally suggested that the international debate on non-medical sex selection ought to be regarded as an important area of related interest.
Sources of data
Data were obtained from a search of existing ethics and policy literature focusing on sex selection.
Areas of agreement
There are very few areas of universal agreement in the debate.
Areas of controversy
There is much disagreement between critics over what harms are likely to be caused by sex selection and whether such harms are morally significant. The issue of whether governments can legitimately place limitations upon individual reproductive autonomy, and if so, to what degree, remains controversial.
Pulmonary hypertension: advances in pathogenesis and treatment
Pulmonary hypertension is an orphan disease that until recently has received limited attention within the wider medical community. This has changed distinctly in the last 10 years with the advent of new classes of therapy and a renewed interest in mechanisms of pathogenesis. This review utilized information gathered from recent conferences, and a review of the literature was conducted using MedLine and Pubmed. Accepted mechanisms of pathogenesis and currently available treatments are presented. We will discuss interesting new concepts in pathogenesis, including the importance of genetic forms of the disease and in particular the transforming growth factor receptor superfamily and the evolving evidence of the contribution of dysregulated immunity. Areas of research may yield therapeutic benefits in the not-too-distant future, including anti-proliferative therapies and stem cell therapy.
Living-donor liver transplantation in adults
Introduction
The technique of paediatric living-donor liver transplantation (LDLT) has become standardized. In adults, however, there is scope for innovation. Unlike cadaveric whole-size liver transplantation and paediatric LDLT, size matching between the liver graft and the recipient by body weight has been a major challenge in adult LDLT because it is important to provide an adequate graft mass to the recipient while leaving a sufficient mass of remnant liver in the donor to ensure donor safety.
Growing points
In adult LDLT, liver grafts have been selected to meet graft-recipient size-matching requirements. In 1996, the Hong Kong group pioneered the use of the right-lobe grafts vein to overcome the volume insufficiency often encountered with the left-lobe liver grafts. Subsequently, the Asan group introduced modified right-lobe grafting with interposition vein grafts to drain the venous outflow of the anterior sector, thus increasing the functioning hepatocyte mass, and this group initiated dual left-lobe liver grafts to overcome both donor risk and volume insufficiency.
Areas of agreement and controversy
Although the surgical procedures for both donors and recipients are more complex for adult LDLT than for whole-organ deceased donor transplantation, the outcomes in large-volume centers are now similar. Accordingly, the indications for adult LDLT are continually being expanded.
Areas timely for developing research
In performing these procedures, it is crucial to minimize the risks of morbidity and mortality to the healthy live donor. This review focuses on the current technical development and discusses the ethical issues of adult LDLT.
New technologies for the detection of circulating tumour cells
The vast majority of cancer-related death is due to the metastatic spread of the primary tumour. Circulating tumour cells (CTC) are essential for establishing metastasis and their detection has long been considered as a possible tool to assess the aggressiveness of a given tumour and its potential of subsequent growth at distant organs. Conventional markers are not reliable in detecting occult metastasis and, for example, fail to identify ~40% of cancer patients in need of more aggressive or better adjusted therapies. Recent studies in metastatic breast cancer have shown that CTC detection can be used as a marker for overall survival and assessment of the therapeutic response. The benefits of CTC detection in early breast cancer and other solid tumours need further validation. Moreover, optimal CTC detection techniques are the subject of controversy as several lack reproducibility, sensitivity and/or specificity. Recent technical advances allow CTC detection and characterization at the single-cell level in the blood or in the bone marrow. Their reproducibility propels the use of CTC in cancer staging and real-time monitoring of systemic anticancer therapies in several large clinical trials. CTC assays are being integrated in large clinical trials to establish their potential in the management of cancer patients and improve our understanding of metastasis biology. This review will focus on the techniques currently used, the technical advancements made, the limitations of CTC detection and future perspectives in this field.
Cell therapy for cardiac repair
Heart failure is a leading cause of morbidity and mortality worldwide. The current strategies for treatment are limited and new therapeutic approaches are needed. This review describes research performed in animal models of cardiac disease and clinical trials and discusses the mechanisms involved in possible beneficial effects of cell therapy. Cell therapy is a promising strategy to treat heart failure, as it aims to replenish the failing myocardium with contractile elements. However, cell therapy with adult progenitor cells induces a small improvement in heart function without significant cardiomyogenesis. Paracrine mechanisms are likely to be important. The most effective cell type for therapy remains unclear. Induced pluripotent stem cells have the greatest potential but more information on the properties of this cell type is needed. The integration of cells in the host myocardium and the routes of delivery remain controversial. The differentiation of cardiac cells from pluri- and multipotent cells and the understanding of their properties are growing points in cell therapy. More research is needed to correctly assess the physiological properties of differentiating cells, to dissect the role of the host environment in the integration and differentiation and to define the stage of differentiation required for cell transplantation.
Rating scales for low back pain
Introduction
During the past decades several rating scales have been developed to assess the functional status of patients with low back pain.
Methods
We performed a search using the keywords ‘spine’ in combination with ‘scoring system’, ‘scale’, ‘scores’, ‘outcome assessment’, ‘low back pain’ and ‘clinical evaluation’.
Results
Twenty-eight scoring systems are currently available for the evaluation of low back pain. Each of them evaluates low back pain using specific variables. All these scoring systems are presented.
Discussion
Although many scoring systems have been used to evaluate the back function, we are still far from a single outcome evaluation system that is reliable, valid and sensitive to clinically relevant changes, taken into account both patients' and physicians' perspective and is short and practical to use.
Conclusion
Further studies are required to evaluate the reliability, validity and sensitivity of the low back pain scoring systems used in the common clinical practice.
Prevention and treatment of microvascular disease in childhood type 1 diabetes
Introduction
The incidence of type 1 diabetes (T1D) is increasing worldwide, particularly in children, and is associated with a significant burden, mainly related to the development of vascular complications. The prevention and treatment of microvascular complications, which include nephropathy, retinopathy and neuropathy, are of paramount importance to decrease the associated mortality and morbidity.
Sources of data
A literature search was performed on Medline and articles on microvascular complications, with particular emphasis on the increasing incidence of childhood T1D and its implications on prevention and treatment of complications, were selected.
Areas of agreement
The incidence of childhood T1D is increasing. Early identification of subjects at risk for long-term complications and early implementation of preventive and therapeutic strategies are fundamental in order to reduce the burden associated with microvascular complications of diabetes. Improving glycaemic control is the principle way of preventing and treating T1D complications.
Areas of controversy
In adults with T1D and microvascular complications, treatment with anti-hypertensive drugs and statins is increasingly common, whereas there are no definitive indications for treatment with these drugs in children and adolescents with early signs of complications.
Growing points
There is growing interest in the development of new preventive and therapeutic strategies targeting specific pathways implicated in the pathogenesis of microvascular complications.
Areas timely for developing research
Investigations to clarify genetic and environmental factors implicated in the pathogenesis of microvascular complications could lead to the identification of biochemical markers with high predictive values, to be used as a guide for screening and intervention programmes.
Tendon augmentation grafts: a systematic review
Introduction
Several biomaterials are available to bridge large tendon defects or reinforce tenuous tendon repairs.
Methods
We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases using various combinations of the commercial names of each scaffold and the keywords ‘tendon’, ‘rotator cuff’, ‘supraspinatus tendon’, ‘Achilles tendon’, ‘scaffold’, ‘biomaterials’, ‘extracellular matrix’, ‘substitute’, and ‘devices’ over the years 1966–2009. All articles relevant to the subject were retrieved, and their bibliographies hand searched for further references in the context to biomaterials for tendon repair.
Results
Many biomaterials are available for tendon augmentation. Scanty evidence is available for the use of these scaffolds.
Discussion
The emerging field of tissue engineering holds the promise to use biomaterials for tendon augmentation. Preliminary studies support the idea that these biomaterials have the ability to provide an alternative for tendon augmentation. However, available data are lacking to allow definitive conclusion on the use of biomaterials for tendon augmentation. Additionally, the prevalence of postoperative complications encountered with their use varies within the different studies.
Conclusion
Rather than providing strong evidence for or against the use of these materials for tendon augmentation, this study instead generates potential areas for additional prospective investigation.
Management of essential hypertension
Introduction
Epidemiological studies have unequivocally shown that hypertension (HT)is a major cardiovascular (CV) risk factor and that a direct linear relationship exists between the severity of the blood pressure (BP) elevation and the occurrence of CV events.
Areas of agreement and controversy
The beneficial effects of the BP-lowering interventions have been recognized since a number of years. These include not only the reduction in CV morbidity and mortality but also the regression (or the delay of progression) of HT-related end-organ damage, such as left ventricular hypertrophy, vascular remodelling, endothelial dysfunction and renal damage. Along with these well-established features, antihypertensive drug treatment still faces a number of unmet goals and unanswered questions, such as the target BP values to achieve in high-risk patients, the threshold of treatment in low-risk patients as well as the choice of the therapeutic approach more likely to offer greater CV protection.
Conclusion
Despite unmet goals, antihypertensive treatment has provided throughout the years successful results. Future efforts will be need to achieve a better BP control in the population and thus to obtain a greater CV protection.
New understanding and approaches to treatment in rheumatoid arthritis
Rheumatoid arthritis (RA) is the most common autoimmune inflammatory polyarthritis. Significant advances in the understanding of its pathogenesis have led in the past two decades to major advancement in its therapy. We used data from articles in Cochrane Database of Systematic Reviews on ‘rheumatoid arthritis’, meta-analyses and randomized controlled trials on adult RA (age >19 years) published in English within the past 5 years and identified in PubMed, and other key papers on management of RA. Appropriate, early and aggressive therapy is required for confirmed active cases of RA. The choice of disease-modifying drugs and different combinations, especially the newer biologic agents in regards of their early and long-term usage remains debated because of high costs and long-term safety concerns. Development of newer biologic agents working on different pathways of inflammation is underway in different stages. It remains to be determined how and when each of these agents will fit in the overall management of RA. Furthermore, post-marketing surveillance of the safety and response sustainability of these drugs is warranted.
Community-associated methicillin-resistant Staphylococcus aureus infections
Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has been recognized for over a decade, and usually refers to MRSA identified in previously healthy individuals with no recognized MRSA risk factors. Infections range from minor skin and soft tissue infections, through to severe pneumonia and necrotizing fasciitis. This review summarizes the current data on the epidemiology and molecular features of CA-MRSA, in addition to diagnosis and therapeutic measures. We also refer to current national guidelines for the management of these infections. Areas of agreement include the important genotypic and phenotypic differences of community MRSA strains compared with hospital strains. Areas of controversy include the precise epidemiological definition of community-acquired/associated MRSA. Fortunately, true CA-MRSA can be differentiated from hospital MRSA by molecular techniques, as discussed herein. Recent interest has focused on the changing epidemiology of CA-MRSA. Worldwide, CA-MRSA is now seen outside of the initial specific population groups, and in the USA, the successful USA300 community strain is beginning to spread back into hospitals. Reasons why USA300 remains relatively uncommon in Europe are unclear. Topics timely for research include the investigation of the epidemiology of infections and evolutionary genomics.
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