Can We Ensure That All Research Subjects Give Valid Consent?
To ensure that research subjects provide valid consent, most commentators direct clinical investigators to formally assess potential subjects who are at increased risk for lacking the capacity to consent. Current data reveal, however, that subjects with no known cognitive impairments often fail to give valid consent. These data imply that the prevailing focus on individuals' capacity to consent is too narrow. To protect subjects, as well as the integrity of clinical research, the actual consent of all subjects should be formally assessed. Recent development of several preliminary consent assessment tools suggests that, in addition to being ethically preferable, with additional research this approach may be practically feasible. Future research should focus on developing a postdecision questionnaire that can be adapted to individual studies and used to assess the voluntariness and understanding of all research subjects.
Cigarette Smoking and Infection
Background: Infectious diseases may rival cancer, heart disease, and chronic lung disease as sources of morbidity and mortality from smoking. We reviewed mechanisms by which smoking increases the risk of infection and the epidemiology of smoking-related infection, and delineated implications of this increased risk of infection among cigarette smokers.
Methods: The MEDLINE database was searched for articles on the mechanisms and epidemiology of smoking-related infectious diseases. English-language articles and selected cross-references were included.
Results: Mechanisms by which smoking increases the risk of infections include structural changes in the respiratory tract and a decrease in immune response. Cigarette smoking is a substantial risk factor for important bacterial and viral infections. For example, smokers incur a 2- to 4-fold increased risk of invasive pneumococcal disease. Influenza risk is severalfold higher and is much more severe in smokers than nonsmokers. Perhaps the greatest public health impact of smoking on infection is the increased risk of tuberculosis, a particular problem in underdeveloped countries where smoking rates are increasing rapidly.
Conclusions: The clinical implications of our findings include emphasizing the importance of smoking cessation as part of the therapeutic plan for people with serious infectious diseases or periodontitis, and individuals who have positive results of tuberculin skin tests. Controlling exposure to secondhand cigarette smoke in children is important to reduce the risks of meningococcal disease and otitis media, and in adults to reduce the risk of influenza and meningococcal disease. Other recommendations include pneumococcal and influenza vaccine in all smokers and acyclovir treatment for varicella in smokers.
Arcavi L, Benowitz NL
Biomechanical Evaluation of Fixation Techniques for Bridging Segmental Mandibular Defects
Objective: To compare biomechanical properties of currently available plating systems used to reconstruct segmental mandibular defects.
Design: Controlled in vitro investigation.
Setting: Academic medical center laboratory.
Interventions: Thirty-two polyurethane mandibles were equally divided among 4 groups: mandibles with a 4-cm lateral segmental defect that was bridged with a (1) 3.0-mm locking-screw reconstruction plate, (2) 2.4-mm low-profile reconstruction plate, or (3) 2.4-mm reconstruction plate and (4) uncut (control) mandibles. All plates were contoured and secured to the synthetic mandibles with 4 bicortical screws on either side of the defect. Three constructs from each group were subjected to contralateral-molar single-load-to-failure testing. Mean yield displacement, yield load, and bending stiffness were quantified and compared among the 4 groups. The single-load-to-failure data were used to establish conditions for fatigue testing; such testing was then performed on the remaining 5 samples in each group. Mean cycles to failure were measured and compared among the 4 groups.
Results: Mean yield displacement, yield load, and bending stiffness were comparable among the plated groups. Both the 3.0-mm locking-screw and 2.4-mm low-profile reconstruction plate designs withstood 1580 and 1124 times more cycles to failure, respectively (P=.005), than did the control group. The other reconstruction plate was also superior to the unplated controls, offering an 865-fold improvement.
Conclusions: All 3 mandibular fixation device systems tested produce comparable levels of single load to failure biomechanical integrity; however, the higher-profile plating system design offered slightly superior fatigue performance. No differences in performance were observed between the locking and nonlocking designs; neither failed at the screw-substrate interface.
Doty JM, Pienkowski D, Goltz M, Haug RH, Valentino J, Arosarena OA
Generational Differences in Practice Patterns of Dermatologists in the United States: Implications for Workforce Planning
Objective: To examine the effect of age and other demographic factors on dermatologists' practice characteristics.
Design: Anonymous practice profile survey.
Participants: Dermatologist members of the American Academy of Dermatology Association.
Main Outcome Measures: Analyzed survey questions included information about legal practice entity, geographic area served, weekly patient care hours, patients seen per hour, and scope of patient care activities.
Results: Of 4090 surveys sent, 1425 (35%) were returned. As the age of the cohorts increased, the percentage practicing in solo practices increased (range, 21%-39%), as did the percentage serving urban areas (range, 31%-46%). Measures of physician productivity increased in the older age cohorts; however, age was not a significant factor after controlling for other variables. More patient-hours per week were associated with male sex (P<.001), solo practices (P<.001), and non-urban-based practices (P = .04), whereas a greater number of patients per hour was associated with non-rural-based practices (P = .02) and male sex (P = .03). As the cohorts progressed in age, more time was spent practicing medical dermatology. The number of hours spent practicing cosmetic dermatology peaked in the 41- to 50-year-old cohort (P = .03).
Conclusions: Practice patterns differ significantly among dermatologists of different ages. As the current cohorts age and new dermatologists emerge from training, changes in scope of practice and generational differences in productivity are likely to cause a contraction in the effective supply of dermatologists, which has important implications for dermatology workforce planning.
Jacobson CC, Resneck JS Jr, Kimball AB.
Abstracts: In Other AMA Journals. Arch Facial Plast Surg. 2005;7(2):146-147. doi: