Identifying Data :

Full Name: Mr. VR

Address: Flushing, NY
Date of Birth: February 17 , 1984

Age: 37 yo
Date & Time: November 9, 2021 9:20 am
Location: NYPQ, Flushing, NY
Religion: None
Source of Information: Self
Reliability: Reliable
Source of Referral: Primary Care Physician

Chief Complaint : “Blocked nephrostomy and burning.” X5 days

History of Present Illness :
37 year old male patient with a past medical history of cholelithiasis and ureteral stent presents to the ED for a clogged nephrostomy. Patient states nephrostomy became blocked on the evening of 11/5/21 but did not want to come to the ED over the weekend. He also experiences burning in his right lower flank rated a 8/10 with no radiation. He took Percocet for the pain but does not remember how much. Patient also states the nursing home gave him antibiotics for a urinary tract infection. Patient denies itching or burning at the site of nephrostomy opening. He has experienced this several times before, up to 1-2 times a year in the 5 years he has had a nephrostomy. Patient denies fever, nausea, vomiting, diarrhea, constipation, shortness of breath, or chest pain. Denies recent travels, dizziness, and loss of consciousness.

Past Medical History

• Cholelithiasis – 2014

• Immunizations – Up to date; flu vaccine yearly

Past Surgical History

• Uretral Stent – 2014
• Nephrostomy – 2016

Medications

Currently On :

• Percocet 10 mg PO PRN

Allergies

• Denies food allergies
• Allergy to Polymxcin 

Family History

• Mother – Aged 60 yo, alive, hypertension
• Father – Aged 62, alive, no significant medical history

• Sister – Aged 40, alive, no significant medical history
• No Children, Never married

• Denies family medical history of cancer or respiratory complications

Social History

Mr. VR is a 37 year old male who lives in a nursing home. Patient is unemployed and lives a sedentary lifestyle. He has not seen his family in several years. Patient is not currently in a relationship and does not have any pets. 

Habits : Patient used to drink heavily around 3 – 4x a week with 2-3 standard drinks each time. He has cut down drinking to special occasions in the past two years. Patient has tried to stop smoking cigarettes for the past 5 years. He smokes 1 – 2 cigarettes a day and smokes marijuana daily.

Travel : Denies recent travel. 

Diet : Patient eats a bland a balanced diet served at the nursing home. Meals typically consist of rice, chicken, and steamed vegetables. 

Exercise : Patient maintains a predominantly sedentary lifestyle due to nephrostomy tubing.  

Sexual History : Heterosexual, never married and no current partners. States he has not been sexually active in the last 5 years. Denies history of sexually transmitted diseases.

Review of Systems

General – Patient appears weak, tired, and with poor pallor. Patient is mentally alert while laying down. Patient experiences weakness. Denies loss of appetite, fever, chills, night sweats. 

Skin, hair, nails – Denies excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus.

Head – Denies headaches, vertigo, head trauma, coma, or fractures. 

Eyes –  Denise dry eyes visual disturbances, lacrimation, photophobia, pruritus, or use of reading glasses. Last eye exam was 1 year ago.

Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids. 

Nose/sinuses – Denies discharge, obstruction, or epistaxis. 

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, use of dentures. Last dental exam was over 2 years ago – normal. 

Neck – Denies neck stiffness, decreased range of motion, localized swelling, or lumps.

Breast – Denies lumps, pain, or discharge.

Pulmonary system – Denies dyspnea, dyspnea on exertion, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND). 

Cardiovascular system – Denies hypertension, edema in calves, ankles, chest pain, palpitations, or syncope.

Gastrointestinal system – Denies nausea, vomiting, constipation or diarrhea. Denies intolerance to specific foods, dysphagia, pyrosis, abdominal pain, diarrhea, hemorrhoids, constipation, rectal bleeding.  

Genitourinary system – Patient experiences right flank pain for the past 5 days. Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, or awakening at night to urinate.

Menstrual and Obstetrical — N/A

Nervous – Denies seizures, headache, loss of consciousness, or change in mental status / memory. 

Musculoskeletal System – Patient experiences weakness. Denies aching, swelling, or redness. Denies coldness or tingling in extremities. 

Peripheral Vascular System – Denies coldness, edema, weakness, or tingling in extremities. Denies trophic or color changes.

Hematological System – Denies anemia, echymosis, lymph node enlargement, history of DVT/PE, or drug infusions.

Endocrine System – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating or goiter.

Psychiatric – Denies depression, anxiety, OCD, or ever seeing a mental health professional. Not suicidal or homicidal.

Vitals

Blood Pressure 

(R) 132/80 (L) 125/80 seated

(R) 132/80 (L) 125/80 supine

Pulse Rate – 70 bpm, regular

Respiratory Rate – 16/min, unlabored

Temp – 98.2 °F (axillary)

O2 Sat – 99% room air

Height – 5’5

Weight – 135 lbs

BMI – 22.5

Physical Exam

General: Male patient appears weak, with poor pallor, and good-hygiene while seated. He is alert and looks tired. Patient does not appear to be in respiratory or cardiac distress.

Skin: Poor pallor. Warm and moist with good turgor. Non-icteric, no lesions, masses, scars, tattoos, or bruising.

Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koiconychia, or paronychia.

Head: Skull is normocephalic and non-tender to palpation. Hair is full, greasy, average texture, and good luster.

Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus. 

Visual Acuity : Corrected – 20/20 OS, 20/20 OD, 20/20 OU

Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU. 

Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally. 

Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation. 

Lips: Pink, moist. No cyanosis, masses, lesions, swelling, or fissures. 

Mucosa: Pink, well hydrated. No masses lesions noted. No leukoplakia. No thrush.

Palate: Pink, well hydrated. No lesions, masses, scars.  

Teeth: Teeth intact, no dentures. White and no cavities. 

Gingivae: Pink, moist. No hyperplasia, recession, masses, lesions, erythema or discharge.

Tongue: Pink, well papillated. No masses, lesions, or deviation.

Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0.  Uvula pink, no edema.

Neck – Trachea midline. No masses, lesions, scars, pulsations noted.  Supple, non-tender to palpation.   Good range of motion. No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.

Thyroid – Non-tender to palpation. No palpable masses or thyromegaly.

Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.

Respiratory: Clear to auscultation and percussion bilateral. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits symmetric throughout. No adventitious sounds.

Cardiovascular: History of hypertension for JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdominal: Two nephrostomy openings present in the RLQ and suprapubic region.Abdomen is round with no striae or pulsations. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation.  Bowel sounds normoactive in all four quadrants. No CVA tenderness.

Genital : Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.

Rectal : No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus Stool brown and Hemoccult negative

Neurologic: 

Mental Status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good repetition, comprehension, and naming. He recalls 3/3 objects at 5 minutes.

Cranial Nerves :

CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract. 

CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.

CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. Negative for diplopia and ptosis. Convergence is intact. 

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.

CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in anterior 2/3 of the tongue. 

CN VIII: Hearing is intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally. 

CN IX, X: Palate elevates symmetrically. Phonation is normal.

CN XI: Head turning and shoulder shrug are intact.

CN XII: Tongue is midline with normal movements and no atrophy.

Motor/Cerebellar :

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout.  Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory :

Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes :

R L R L

Brachioradialis 2+ 2+ Patellar 0 0

Triceps 2+ 2+ Achilles 0 0

Biceps 2+ 2+ Babinski neg neg

Abdominal 2+/2+ 2+/2+ Clonus negative

Meningeal Signs :

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.

Muscoloskelteal : No soft tissue swelling, erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. Full active range of motion with no crepitus in all upper and lower extremities bilaterally.  Full spinal range of motion with no deformities.

Assessment & Plan

37 year old male with past medical history of cholelithiasis and ureteral stents presents with blocked catheter and lower right flank pain. His examination is notable for rounded abdomen and tenderness to palpation on the lower right flank. 

Problem List :

• Blocked Nephrostomy 

D/Dx : 

• Cholelithiasis – Patient has a history of cholelithiasis that resulted in the placement of a urinary stent and nephrostomy. As patient currently presents with lower flank pain and obstruction of nephrostomy, the likelihood of cholelithiasis is high.

• Pyelonephritis – Infection of the kidney is highly likely has patient delayed admission to the ED for blocked nephrostomy and presents with severe pain.

• Urinary Tract Infection– Infection of the urinary tract is highly likely as the patient had a urinary stent for 2 years, nephrostomy for 5 years, and frequent nephrostomy obstructions.

• Hydronephrosis – Patient delayed admission to ED for nephrostomy obstruction. Patient also presents with severe pain in right flank. Hydronephrosis is highly likely. 

• Cancer – Patient presents with blocked nephrostomy. Cancer should be considered as a possible source of obstruction. 

Plan : 

• Abdominal Ultrasound – evaluate for cholelithiasis 
• Urine Culture – evaluate for UTI and causative agent
• Ceftriaxone 1 g IV once daily or Piperacillin-Tazobactam 3.375 g IV x 6 hrs → for acute UTI without presence of multidrug-resistant gram-negative organism
• Piperacillin-Tazobactam 3.375 g IV x 6 hrs or Antipseudonomal Carbapenem 500 mg IV x 6 hours or Meropenem 1g IV x 8 hours → for acute UTI with presence of multidrug-resistant gram-negative organisms

• Discuss nephrostomy hygiene and care to patient
• Contact family or nursing home to arrange appointment with nephrologist 
• Follow-up in 48 – 72 hours after discharge

• Medication Review : Patient states using opioids for pain management but does not have any medical conditions that suggests need for continual use. 

Plan :

• Review patient’s use and necessity of opioids
• Contact family or nursing hoe to arrange appointment with a primary care physician 

• General Lifestyle Management : Patient presents with concerning lifestyle factors such as smoking, drinking, and no physical activity that may exacerbate renal complications. 

Plan : 

• Instruct patient to eat a balanced diet with fruits, vegetables, whole carbs, and protein
• Encourage patient to engage in light physical activity
• Educate patient on the risks of cigarette and alcohol use on renal function

Content & Focus – I believe that in person clinical correlation classes strengthened my understanding of the patient cases presented. For my presentations, I became more familiar with using UptoDate and turned towards multiple sources (such as our textbooks, Pance Prep Pearls, and D/Dx on Access Medicine) to ensure that the most relevant information was provided in the class. As a result, I became much more familiar with the landscape of resources available in the medical field to research relevant and peer-reviewed information. Over time, I also noticed how I was able to pull materials learned from previous classes to better interpret the patient case presented.

Logic & Flow Weight – My presentations became more succinct and I became a stronger student in assessing what is most crucial to present to my fellow classmates. In our second semester of clinical correlations, we utilized a timer and focused more on oral rather than powerpoint presentations. Furthermore, I could anticipate that the attention span of the room was maximized in the first five minutes of a presentation. This forced me to only focus on imperative points of our research topics and teach in a comprehensible manner to my peers. 

Analysis – Developing a list of differential diagnoses felt much less foreign by the end of our second semester of clinical correlations. With repetition, this type of thought process became faster. Although my contributions were not necessarily always correct, I felt more confident in thinking of alternative disease states that may cause the patient’s presentation. With practice, I hope to continue in sharpen my skills in developing a differential diagnosis and final diagnosis with greater efficiency and accuracy. 

Communication/Collaboration – Compared to my first semester of clinical correlations, I felt more confident in participating during class. As mentioned prior, the method of developing a differential diagnosis was unfamiliar to me at the very start. I became more proficient in generating a list of possible disease states and thus, was able to contribute more in class. Furthermore, I believe the transition from online to in person helped tremendously in communication. There is a greater sense non-verbal cues and presence that facilitated the act of bouncing off ideas and collaborating with my fellow peers.

Re : Federal Regulation of Marijuana for Recreational Use

Statement of Issue : As of June 2021, eighteen states have fully legalized the sale and use of cannabis. An additional twenty-six states have mixed laws pertaining to cannabis with partially restricted sales regulations. This poses several issues to both health and legal legislation as there is no unified regulation of cannabis. Some states require a patient registry with medical ID cards while other states allow for recreational sales. Meanwhile, some states still classify marijuana as a fully illegal substance. This disjointed regulation presents with confusion as marijuana can be viewed as a recreational product, medical remedy, or criminalized drug. As cannabis is a psychoactive substance, its accessibility should also be handled with care so that its consequences does not range from recreation to incarceration.

• Marijuana remains a Schedule I substance at the federal level, indicating that it has a high potential for dependency and no accepted medical use.

• Cannabis presents a health risk to young adult population. Studies show that cannabis use in the ages of 16 – 18 years old has a strong association with poor attention span, executive function, and reduced verbal intelligence with neurologic structural changes.

• Cannabis shows efficacy in reducing pain in geriatric populations and patients who undergo transplant surgeries. Patients were observed to experience a reduction in neuropathic pain and prescription opioid drug use. 
• Sales of legal marijuana  increases tax revenue, jobs, and small businesses. The Bureau of Labor Statistics estimates an 110% increase of jobs in the marijuana industry in the next ten years. In Colorado, sales of legalized marijuana generated $362,021,103 tax revenue in 2020. This was approximately $100,000,000 more than in the year 2019. 

• Legalization of marijuana reduces crime rates. 545,602 individuals were arrested in 2019 for cannabis-related crimes. These crimes were more often due to possession rather than violent acts. There was also a disproportionate number of arrests in lower socioeconomic communities with a larger black and brown population. Legalization of marijuana would reduce racially-targeted arrest and make better use of taxpayer money towards more violent and dangerous crimes. 

Policy Options

1. A federal mandate where marijuana may only be obtained with a medical license card through a rigorous screening process. This would include a complete physical exam, mental status exam, and thorough past medical and social history. Patients must prove to have a health-related issue such as post-surgery, Alzheimer’s, cancer, or seizures for cannabis use. Additionally, dispensaries are only approved for the sale of medical marijuana. 

Advantages

• Protects the youth and those with addictive tendencies from misuse and abuse 
• Limits the risks of health risks associated with marijuana use such as metabolic syndrome, acute myocardial infarction, and coronary artery disease in patients with cardiovascular disease
• Continues to offer marijuana for medicinal use for those with chronic diseases associated with pain

Disadvantages

• Relies on physician compliance. Past examples show that physicians have easily bypassed this system for financial gains
• Dispensaries lose business
• Government experiences loss in tax revenue
• Illegal sources of marijuana continues to appeal to young adults

2. National legalization and regulation of marijuana for recreational use accompanied by public health education. In the Netherlands, marijuana is legalized for sale to adults in limited quantities. The city also implements strong education and public health measures by offering free drug testing, syringe exchange program, and methadone treatment. In doing so, individuals are offered better protection and services by the government in the event of drug misuse. Data also shows that with lenient policies and strong public health measures deters young adults from using recreational drugs as the appeal is lost. Statistics show that young adults in the Netherlands are less likely to have ever smoked marijuana compared to those in the United States.

Advantages

• Reduces likelihood of individuals obtaining marijuana from an illegal source
• Increased regulation decreases availability of synthetic or tainted marijuana products
• Stimulates economic gains through dispensaries
• Creates jobs
• Raises tax revenues for government
• Releases individuals who are incarcerated in states with stricter marijuana laws 

Disadvantages

• Relies on compliance by public
• Poses risks to pregnant and young adult population if misused 
• Complex legal terrain for those already incarcerated for the sale and use of marijuana
• Increases federal spending on regulation infrastructure and public health measures

3. National legalization of recreational sale of marijuana with limitations on the quantity and type of marijuana sold to each individual. For example, the state of Connecticut legalized the retail sale of cannabis by licensed establishments in 2021. However, individuals may not gift purchased cannabis products. Possession is also limited to adults over the age of 21 and to 1.5 ounces of cannabis.

Advantages

• Minimizes misuse and abuse of cannabis products
• Continues to promote small businesses and dispensaries 
• Generates jobs
• Protects individuals who present with health risks (ex. Young population, pregnant women)
• Reduces likelihood of marijuana-related crimes

Disadvantages

• Expensive process to develop database to track sales of each individual
• Limits economic momentum of marijuana businesses

Policy Recommendation : As the legalization of marijuana grows among the United States, reform is needed for a uniform and standardized policy to ensure safety of use by the general public. From the start, there was emphasis to limit the use of marijuana for medicinal use only. However, this policy presented with conflict as physician and patients easily bypassed screening regulations for personal gains. Stricter screening procedures may curb this problem, but does not provide effective measures unless implemented with strong law enforcement and legal consequences. It also did not solve the issue of the illegal distribution of marijuana. Alternatively, the government may consider to fully legalize marijuana for recreational use by the public. Public health measures may offer some buffer to ensure that cannabis products are used responsibly. As there are substantial studies to show the health risks to pregnant women and young adults, a stricter policy should be considered to better protect the public. This leaves the best option of having recreational marijuana legalized at a federal level, but with strong limitations on the quantity and types of products sold. This policy would work similarly to that of the restrictions placed on alcohol. In doing so, individuals at higher risks are better protected. The limitation of sales also reduces the likelihood of misuse and abuse as cannabis is still a psychoactive substance. 

References 

Governor Lamont Signs Bill Legalizing and Safely Regulating Adult-Use Cannabis. CT.gov. https://portal.ct.gov/office-of-the-governor/news/press-releases/2021/06-2021/governor-lamont-signs-bill-legalizing-and-safely-regulating-adult-use-cannabis. Accessed July 17, 2021. 

Map of Marijuana Legality by State. DISA Global Solutions. https://disa.com/map-of-marijuana-legality-by-state. Published June 14, 2021. Accessed July 17, 2021. 

Marijuana Legalization and Regulation. Drug Policy Alliance. https://drugpolicy.org/issues/marijuana-legalization-and-regulation. Accessed July 17, 2021. 

Marijuana Tax Revenue in States that Regulate Marijuana for Adult Use. Marijuana Policy Project. https://www.mpp.org/issues/legalization/marijuana-tax-revenue-states-regulate-marijuana-adult-use/. Accessed July 17, 2021. 

Pacula RL, Smart R. Medical Marijuana and Marijuana Legalization. Annual review of clinical psychology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6358421/. Published May 8, 2017. Accessed July 17, 2021. 

Page RL, Allen LA. Medical Marijuana, Recreational Cannabis, and Cardiovascular Health: A Scientific Statement From the American Heart Association. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000883. Published August 5, 2020. Accessed July 17, 2021.

Zha C. High Economy: Impacts of Marijuana Legalization on the US Economy. The Economics Review. https://theeconreview.com/2020/12/18/high-economy-impacts-of-marijuana-legalization-on-the-us-economy/. Published June 8, 2021. Accessed July 17, 2021. 

Clinical Question: Does the use of straight catheters as opposed to indwelling urinary catheters reduce the likelihood of infection in female patients over 40 years old?

PICO Question

P – post-operative patients

I – straight catheter
C – indwelling catheter
O – urinary tract infectio

Terms Used

• Indwelling catheter in post-op total hip replacement female patients

• Foley catheter in post-op total hip replacement female patients

• Foley catheter infection in female post-op patients over 40

Databases Searched

Pubmed: Search criteria produced 103 results that provided both tangential and specific applications to the clinical question.

Cochrane: Search criteria produced 7 results with minimal relevancy.

Trip Database: Search criteria produced 62 results which were narrowed down to 4 after filtering for randomized control studies

Articles Chosen for Inclusion (please copy and paste the abstract with link):

1. Effect of a hospital-associated urinary tract infection reduction policy on general surgery patients [Harris et. al, 2018]a. Harris SK, Mitchell EL, Lasarev MR, Attia F, Hunter JG, Sheppard BC. Effect of a hospital-associated urinary tract infection reduction policy on general surgery patients. Am J Surg. 2018 Apr;215(4):658-662. doi: 10.1016/j.amjsurg.2017.11.025. Epub 2017 Dec 14. PMID: 29275909.

2. Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis [Zhang et. al, 2015]a. Brosnahan J, Jull A, Tracy C. Types of urethral catheters for management of short-term voiding problems in hospitalised adults. Cochrane Database Syst Rev.2004;(1):CD004013. doi: 10.1002/14651858.CD004013.pub2. Update in: Cochrane Database Syst Rev. 2008;(2):CD004013. PMID: 14974052.

3. Overuse of the indwelling urinary tract catheter in hospitalized medical patients [Jain et. al, 1995]
a. Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995 Jul10;155(13):1425-9. PMID: 7794092.

4. The Effect of Bladder Catheterization Technique on Postoperative Urinary Tract Infections After Primary Total Hip Arthroplasty [Garbarino et al., 2020]a. Zhang W, Liu A, Hu D, Xue D, Li C, Zhang K, Ma H, Yan S, Pan Z. Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. PLoS One. 2015 Jul 6;10(7):e0130636. doi: 10.1371/journal.pone.0130636. PMID: 26146830; PMCID: PMC4492963.

5. Treatment of urinary complications after total joint replacement in elderly females. [Carpiniello et. al, 1988] a. Carpiniello VL, Cendron M, Altman HG, Malloy TR, Booth R. Treatment of urinary complications after total joint replacement in elderly females. Urology. 1988 Sep;32(3):186-8. doi: 10.1016/0090-4295(88)90381-0. PMID: 3413910.

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
Harris et. al (2017)	Retrospective Cohort Study	General surgery patients from 2006-2015	Frequency of hospital-associated UTIs in surgery patients after recommendations for reducing indwelling catheter days.	Females had significantly higher risk of HA-UTIs While number of straight catherterizations increased, there was no significant change in HA-UTIs	–  Hospital policy only looked to reduce indwelling catheter days, did not account for provider education of placement and best infection prevention practices. –  Did not account for initial indwelling catheter days of patients with CA-UTI after policy implementation

Zhang et al. (2015)	Meta Analysis	1771 post total joint othoplasty patients	compare the rates of UTI and POUR in patients undergoing total joint arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization.	No significant difference in the rates of UTIs between foley and intermittent catheters Lower rate of POUR in the foley group vs the intermittent group	–  No precise definition of POUR even amongst urologists –  Because only 9 RCTs were used, it became impossible to stratify according to surgical site. –  Unable to identify whether the two groups were comparable with respect to the use of opiates and antibiotics because most authors did not report sufficient data in this regard.
Garbarino et al. (2020)	Retrospective Cohort Study	7306 THA patients across 15 hospitals between Nov 28, 2016 – April 1, 2019	Incidence of infection in various post operative bladder catheterizations.	A significantly higher risk of developing UTI’s was seen in patients with both indwelling and intermittent catheters. A lower risk was seen in the use of indwelling alone and an even lower risk was associated with intermittent catheterization.	–  Since the patient data was collected via EMR, patients who sought external follow up were usually lost. However, most infections were seen during the initial stay and this lowers the risk of missed data. –  The study was also unable to gather the exact duration of urinary bladder catheterization –  Sample was collected based on billing codes which may have been erroneously added (coding error within 15 different institutions)
Jain P. Parada (1995)	Prospective Cohort Study	202 ICU patients	Infection vs. No Infection after use of indwelling catheter	– Continued catheterization was found to be unjustified in 47% of patients ( causing complication).	– Results recorded by human observer → human error is a possibility – No parameters on gender or age Limited to one hospital setting → may skew results based on procedures performed in the hospital and demographic of community
Carpiniello, et. al (1988)	Randomized control study	77 patients undergoing total joint replacement	Incidence of urinary tract infection and retention and for 24 hours postoperatively had a reduced incidence of infection as opposed to patients who received straight catheterization in the recovery room alone	-Patients who received an indwelling Foley catheters preoperatively –  Limited to patients receiving spinal anesthesia only, not general anesthesia –  Patients were given prophylactic antibiotics for 3 days post-op which were not controlled. They were given either clindamycin or cefazolin	–  Small sample size of 77 patients –  Study was performed in 1988, over 20 years ago

Conclusion(s):

In postoperative patients, indwelling catheters demonstrated to increase the risk of infection, especially in female patients. They were found to be used to monitor urine output for longer than necessary that further exacerbated complications with use of foley catheters. Greater prophylactic antibiotic use was also tied to foley catheter use. In contrast, intermittent or straight catheters demonstrated a lower association with risk of infection and is the recommended treatment option.

Clinical Bottom Line:

• The category of research question was risk of infection.
• 5 studies were critically appraised.
• 1 prospective, 1 retrospective, 1 randomized controlled trial, 1 meta-analysis, 1 cohort study
• 4 out of the 5 articles showed the indwelling catheters presented with the risk of infection

A Proposal for Collaboration Between News Media Outlets and The National Public Health Emergency Management Team

In the past eighteen months, Covid-19 has proven to be a momentous force that altered the course of history. As the pandemic spread across the world at an alarming rate, health measures were inevitably imperfect. To exacerbate the crisis, the United States emerged with a fragmented and disorganized response. This was largely due to an ongoing presidential election that created political rivalries in the approach to combating Covid. In retrospect, news media should have aligned with health agencies, such as the CDC and WHO, instead of political parties to  ameliorate this conflict. As head of the Public Health Emergency Management Team, I would foster stronger relationships with news agencies so that a unified scientifically-backed plan could be broadcasted to the general public, generating less confusion and a response that is easier to follow. 

To better understand the divisive U.S. response to Covid, we must also explore the relationship between the presidential administration and news channels. The association between Fox News and president Trump at the time became notorious during this period as there was a clear political alignment. This alliance demonstrated detrimental effects as a polarizing perspective of the pandemic was presented on a global level that divided the public’s understanding of what was happening. This collaboration may be largely attributed to Fox News’ long history in leaning towards the Republican Party and its supporters. Up to 2020, thirty-seven percent of Fox viewers were above the age of sixty-five and eight-seven percent of viewers of identified as white. Two-Thirds of Republicans also cited Fox News as their trusted news outlet (Gramlich, 2020). As news medias survive off of viewership and ratings, they are likely to cater stories towards the demographic of their audience. This may have contributed to how the Trump  administration continued to receive extensive airtime and influence over Fox News. However, this also damaged public health efforts as information was politically aligned and not scientifically based. For this reason, the Public Healthy Emergency Management Team may find investing in relationships with news agencies to be a crucial tool in advocating for public health. Media and technology play crucial roles in everyday communication and has inevitably become an important source of public health information (Strazewski, 2020). In times of emergency, media must be used to reach the masses. Although a public health team may have the latest updates and best plan to combat a global health crisis, it is useless if these ideas are not heard by the public.

Of course, the maintenance of relationships requires a give and take balance. As head of the emergency response team, I would propose that a public health correspondent be an on-air consultant for major news channels during a health crisis with a designated time slot each night. In doing so, there will be a consistent message broadcasted to the public by a verified source from a national healthy agency. In return, the public health management team can allow exclusive access and content for news media. For example, the public health team can refer a greater number of physicians, hospitals, and medical research facilities that are willing to be filmed and interviewed. This way, both sides are satisfied to enter a mutually beneficial relationship where public health officials receive a platform and news agencies gain a larger margin of content. 

Cooperation between public health officials and news agencies will also reduce fragmented news reporting. As seen during Covid, divisive media coverage resulted in a confused and combative response by the general public. Every action aimed to fight the pandemic was met with opposition, leading to ineffective measures and a high rate of transmission. A prime example is the debate over the use of masks. On April 3, 2021, the Centers for Disease Control and Protection recommended that Americans wear face coverings as a public health measure (Jingnan, 2020). On April 27, 2021, Fox News refuted the benefits of wearing a mask, deeming that “there’s no scientific justification for any of it,” and that it jeopardized America’s freedoms (Tucker, 2021). As Fox News is one of the most-watched cable news channels with 2.16 million viewers, its message is a powerful one that poses a strong source of conflict if it opposes that of the national center for disease control (Watson, 2021). 

As a result of the mixed-attitude towards wearing masks, the United States emerged as a country that had a low compliance in wearing masks. Although there is still debate over the efficacy of wearing masks, a comparison between mask-mandated countries and non-mandated mask countries sheds light on its impact. Take for example the country of Singapore. Singapore emerged as one of the strictest countries where use of masks was mandated by the government. There were 7, 825 cases of Covid out of a million. In comparison, the United States experienced 9, 811 cases of Covid out of a million with its more lenient attitude towards the use of masks (“Which Countries”, 2021). When we scale these findings to the United States population of 328 million citizens, over six hundred thousand cases could have been spared with a unified response in wearing masks. This could have saved thousands of lives and, at the very least, eased the burden on our hospital systems. The use of masks illustrates the power that lies with media coverage and the information it spreads. The media directly impacts public perception and influences the actions individuals will take during a global health crisis. If there were stronger ties between the CDC, public health emergency management team, and news outlet, a coordinated message could have been broadcasted for greater cooperation among the general public.

With talks about collaboration between media and national agencies, we must also address the issue of free speech. As a country founded on the basis of freedom, a national broadcasting message may appear to be authoritarian. However, it should be emphasized that during a worldwide public health crisis where lives are lost at an alarming rate, a unified emergency response is absolutely crucial to mobilize a coordinated plan of action. There must be some form of order that individuals can follow so that effective action may be implemented. Furthermore, the presence of a public health correspondent on air provides a consistent message while still allowing room for debate and expression of opinions. 

In hindsight, we can observe how impactful news outlets are in spreading messages to the mass public. We were also grossly unprepared for the rate at which unverified news spread and its damaging consequences on public cooperation. Moving forward, the Public Health Emergency Management team may find it beneficial to maintain contacts with news outlets so that verified public health updates are broadcasted to the public. This would generate less divergence and confusion to the public’s understanding of the health crisis so that a unified plan of action may be followed. Ultimately, the priority is to provide the most updated and scientifically-based information on public health to the country’s citizens so that goals in combating a pandemic and saving lives may be achieved.

References

1. Tucker C. We should start asking people to stop wearing masks outside, it makes us uncomfortable. Fox News. https://www.foxnews.com/opinion/tucker-carlson-we-should-start-asking-people-to-stop-wearing-masks-outside-it-makes-us-uncomfortable. Published April 27, 2021. Accessed July 12, 2021. 

2. Demographics of Social Media Users and Adoption in the United States. Pew Research Center: Internet, Science & Tech. https://www.pewresearch.org/internet/fact-sheet/social-media/. Published April 26, 2021. Accessed July 12, 2021.

3. Gramlich J. 5 facts about Fox News. Pew Research Center. https://www.pewresearch.org/fact-tank/2020/04/08/five-facts-about-fox-news/. Published August 18, 2020. Accessed July 12, 2021. 

4. Jingnan H. Why There Are So Many Different Guidelines For Face Masks For The Public. NPR. https://www.npr.org/sections/goatsandsoda/2020/04/10/829890635/why-there-so-many-different-guidelines-for-face-masks-for-the-public. Published April 10, 2020. Accessed July 12, 2021. 

5. Strazewski L. How news media is filling public health role during COVID-19. American Medical Association. https://www.ama-assn.org/delivering-care/public-health/how-news-media-filling-public-health-role-during-covid-19. Published September 16, 2020. Accessed July 12, 2021. 

6. Watson A. U.S. most-watched news network 2020. Statista. https://www.statista.com/statistics/373814/cable-news-network-viewership-usa/. Published June 7, 2021. Accessed July 12, 2021. 

7. Which Countries Are Requiring Face Masks? Council on Foreign Relations. https://www.cfr.org/in-brief/which-countries-are-requiring-face-masks. Accessed July 12, 2021. 

Bio Ethics – Group Essay

The Ethical Complications to Surrogacy and How PA’s Can Facilitate it.

By: Mosammat Alam, Lingqiao Chen, Daniel Crosby, Tiffany Liang, and Sophia Lobo HPPA 514: Biomedical Ethics
Prof. Bridget McGarry
July 14, 2021

Introduction

Surrogacy has become a popular option for the LGBTQ community and families facing infertility or other conception related issues. While it provides a solution to many, the key issues arise from the lack of centralized guidelines that dictate these practices and the role of the physician in moderating these situations. Oftentimes, problems arise when individuals involved either break their contract or come across an issue not previously addressed in their contracts. The laws for surrogacy vary by state, with many having little to no guidelines to monitor these procedures. New York, for instance, has legalized and set specific guidelines on gestational surrogacy as recently as February 2021 (“The Child-Parent Security Act: Gestational Surrogacy”). What we propose is a more centralized system to facilitate surrogate practices, based on medical collaboration with legal protocols to guide the interest of the intended parents, surrogate, and fetus.

Standardized Screening Process & Care – A Medicine Centered Approach

The first step to starting the surrogacy process is finding a suitable surrogate mother. Some families already have a personal connection while others may use a surrogacy agency. Currently, surrogacy agencies exist as full or partial-service establishments. A full-service agency is responsible for the screening, matching, delivery, and return-to-home plans with legal and clinical coordinations. A partial-service agency provides only some of these services with less step-by-step guidance (Mello, 2019). The main complication with these varying pathways to finding a surrogate mother is a disjunctive process with no central oversight. There is a lack of protocol in determining if a surrogate mother is suitable for carrying a baby to full-term and delivery. Furthermore, over ten percent of gestational surrogates are not properly informed of the risk of multiple pregnancies and the demands on their body (White, 2017). This presents with the issue of a lack of informed consent by both the surrogate mother and intended parents before proceeding with the contract. For this reason, the medical community can play a crucial role in developing a standardized screening plan for potential surrogacy mothers.

A thorough medical screening process should be implemented before a surrogate mother is cleared to carry a child to minimize health complications and provide concise documentation in case of legal ramifications as seen in Johnson vs. Calvert lawsuit of Orange County. In this case, the couple sued the surrogate mother for concealing pregnancy complications that included several miscarriages and alleged that the agency failed to perform a proper background check of the mother (NeJaime, 2017). There are two sides to this case. First, the agency failed to conduct a thorough background check and standardized screening tests to ensure that the mother was healthy to proceed. Second, the lack of documentation of health status failed to protect the surrogate mother and agency in the event that they are sued on an unfounded basis.

To better protect the legal rights of the surrogate mother, health of the fetus, and expectations of the intended parents, a standardized screening process should consist of a mental health status exam and complete physical exam. A thorough past medical and social history should also be obtained and documented. This would ensure that the mother is in full mental and physical status to proceed with the pregnancy and has the capacity to comply with healthy practices. Ultimately, the medical provider holds the responsibility to ensure that these screening tests are performed. A physician should not perform implantation until the documentation of a completed screening test is provided.

Creating Uniform Federal Guidelines

As surrogacy presents with such intricate and personal matters and inevitable complications, we must turn to laws and regulations to resolve them. Unfortunately, the laws guiding the process are not always clear cut and currently vary among agencies, states, and countries. This makes it even harder to maneuver the various roadblocks that may occur.

In the United States, surrogacy laws are determined at the state level. In “Green Light” states, such as California and Connecticut, surrogacy is permitted for all parents, pre-birth orders are permissible, and the names of both parents are included on the birth certificate. “Yellow Light ” states such as Tennessee and Idaho, allow surrogacy, but present with legal limitations. For example, in Indiana, another yellow light state, surrogacy contracts are not enforceable but some courts have granted pre-birth orders for intended parents, which establish the intended parents as the baby’s legal parents (Trolice, et al., 2019). Lastly, “Red Light” states such as Michigan and Louisiana completely prohibit compensated surrogacy, only allow altruistic surrogacies, and deem anything beyond those limits a criminal offense. For instance, intended parents in Michigan can be fined up to $50,000 and imposed a penalty of up to one year imprisonment. Surrogacy arrangements are so restricted in Louisiana that it is limited to married heterosexual couples (Gonzalez, 2019).

Because the surrogacy industry is still relatively new, many U.S. laws have room for improvement and must keep up with other ongoing advancements in medicine. There are a number of factors and variables that can complicate surrogacy law, so it is extremely important to work with an assisted reproduction attorney in the state where surrogacy is taking place (Radcliff, 2019). Currently, the absence of federal surrogacy laws and competing views can impede transparency and obscure predictability. The establishment of federal regulations with medical committee advice can oversee surrogate agencies, offering clearer and more consistent guidance to the legal and medical terrains of surrogacy.

Rights of the Intended Parents

To further complicate matters, there is a difference between traditional and gestational surrogacy. In traditional surrogacy, the surrogate mother is artificially inseminated with the sperm of the intended father. In gestational surrogacy, a fertilized embryo of the intended parents is implanted in the surrogate mother. The child is not genetically related to the surrogate mother. This is a legally complex process that is carried out based on the contract between the intended parents and the surrogate to define the difference between legal and biological parents.

The contract lists out the roles and responsibilities of each party involved in the surrogate process and outlines the expected behavior of the surrogate during pregnancy. In the event where the surrogate mother violates the agreement, the obstetrician faces the dilemma of whether to disclose the information to the intended parents or not (Daar, 2014). During the course of treatment, the clinician may learn previously unrevealed medical history about the surrogate, the surrogate’s intention to keep the resulting child, or dangerous behaviors like tobacco or alcohol use. Dr. Daar described the dilemma as between “the duty to obtain informed consent and the duty to maintain patient confidentiality.”

First, it is strongly recommended that the surrogate and the intended parents see different clinicians to avoid overlapping patient-physician relationships. This will avoid conflict of interest so that both parties are cared for in their best interests. Next, the use of a written agreement is necessary to resolve any conflict. Disclosure is permitted if the surrogate waived her right to confidentiality. Most surrogate contracts require surrogates to waive certain HIPAA rights to reassure the intended parents that the child is healthy throughout the pregnancy.

If there is a breach in contract, the clinician would ideally encourage the surrogate to discuss the breach with the intended parents. If the surrogate refuses and the agreement does not include a waiver of confidentiality, the clinician should weigh the harm and benefit of revealing the information. The intended parents are genetically related to the fetus and are ultimately responsible for the outcome of the pregnancy. Therefore, protecting the patient’s confidentiality may cause potential harm to the baby as well as the intended parents. Nonconsensual disclosure should be justified to obtain informed consent and to avoid harm.

Rights of the Surrogate

A written legal contract between the surrogate mother and intended parents becomes especially imperative if disagreements should arise on the decision for abortion. Difficult as these scenarios may be for traditional biological parents, the potential for conflict increases in cases of surrogacy. From the perspective of the surrogate mother, she has to go through many lifestyle changes in caring for her fetus, such as avoiding certain fish, tobacco and alcohol as well as modifying her daily activities. After nine months of this, she then has to emotionally detach herself from the child after delivery. While all this may be previously agreed upon, it does not account for everything. And none of this strips the surrogate of certain basic rights, such as the autonomous right to her body and her own gametal development.

As many intended parents will have a financial interest in achieving a pregnancy on the first attempt, the process of multiple embryo implantation is common in order to increase the odds of just that. Multiple implantations introduce greater chances of a multiple fetus pregnancy, resulting in potential conflicts between surrogate and parents. Multiple gestation comes with increased risks for both the fetuses and the mother carrying them. Additionally, if the surrogate happens to carry twins or triplets, the parents may insist on what is called “fetal reduction,” the process of terminating one or more fetuses with the intention of increasing the odds of a viable pregnancy. With this comes the risk of psychological distress to the surrogate as well as the potential for a complete termination of pregnancy (Tanderup et al., 2015).

In a high-profile case of 2016, surrogate Melissa Cook refused the requests of the commissioning parents to abort one of her triplets. The surrogate mother decided she wished to deliver and seek custody of that triplet, defying the authority of the future parents (as per the contract) along with their concerns over the risks of carrying all three to term (O’Reilly, 2016). With stipulations of binding contracts involved, financial and legal concerns may complicate the counseling of patients who are weighing options in an already stressful situation. Ultimately, the risks of carrying multiple gestations and the surrogate mother’s autonomous rights to her body must be evaluated before coming to a definitive conclusion. Another case that arose in 2017 speaks of a California-based surrogate mother who did not “have sexual intercourse from the first day of her menstrual cycle before the embryo transfer until the date that pregnancy has been confirmed by the IVF Physician” still went on to conceive a second child in a process of superfetation (NeJaime, 2017). In such rare cases, having the definite and autonomous right to one’s body through the different states helps streamline the custody battle and process. Allen should have had full right to conduct her life as planned despite entering a surrogacy contract.

As a medical provider in situations such as this, our consideration of a patient’s autonomy, goal of beneficence toward that patient, and respect for the legally documented wishes of the parents are all in play. The aim of informed consent is not so clear when a medical decision, traditionally made by one party, has been fractured into two. The health of a patient can take primacy over contractual disagreements, however, efforts should be made to establish this consent with the patient as well as to communicate effectively all of the risks and benefits to both parties so that decisions can be made sensibly and amicably. In instances of surrogacy, our ability to communicate clearly and consistently among multiple parties is crucial.

Rights of the Fetus

In all the debate about surrogate mother and the intended parents rights, one important factor we seem to overlook is the rights of the fetus or resulting child. As someone who is unable to speak their mind at the time the contracts are drafted, the fetus is both vulnerable and dependent on the decisions of a proxy (Rafique and DeCherney, 2014). Under normal circumstances that proxy would be the intended parents who have a vested emotional and psychological interest in the wellbeing of the child. However, multiple cases have arisen that put that proxy status in question and beg the need for a third party proxy. This third party proxy may be taken on by a physician so that the health and safety of the surrogate mother and fetus are prioritized.

As previously stated, abortion or pregnancy reduction procedures are often common in gestational surrogates where multiple implantations may overburden the parents. We know that in entering a surrogacy agreement, both parties want to produce a healthy and viable child. Then if the health of the child or the surrogate mother is not a contention, can abortion or reduction still be an ethical option? What if the intended parents change their minds half way through the pregnancy and wish to abort?

Furthermore, in a normal pregnancy the mother’s health is paramount, fetal health is therefore dependent on the mother who has a shared interest. In case of gestational surrogacy, the surrogate has no gametal involvement or interest in the resulting child, creating a paradigm of two separate patients that the obstetrician must cater to (Horner and Burcher, 2021). A third proxy physician may step in to conclude that although the surrogate mother does not have genetic ties to the child, the health of her body ensures the survival of the child.

With multiparity fetuses normally detected between 11-14 weeks of gestation (Bora, et al 2008), the decision to abort or reduce comes after significant emotional involvement of both parties in the contract. At such a time, a third party proxy or physician could be a valuable resource in addressing: the need for a fetal health advocate, a council for the surrogate and guide the intended parents decision.

Conclusion

Surrogacy is a delicate, yet complex topic that requires a significant amount of time to discuss and prepare for. Emotional, financial, medical, ethical and legal aspects contribute to the decision and continue to play a role throughout the journey and beyond. With so many moving parts, the need for standardized legal and medical guidance is important in ensuring a smooth transition and optimal care for all parties involved. A standardized system that can address the autonomy and nonmaleficence nature of care given to the surrogate, the justifiable right of all intended parents to surrogacy, and the dual role of beneficence in caring for both surrogate and fetus. It is because of this that we support a more physician-involved central guide to advocate for the ethical health rights of all parties involved in the surrogacy process.

References:

Bora SA, Papageorghiou AT, Bottomley C, Kirk E, Bourne T. (2008). Reliability of transvaginal ultrasonography at 7-9 weeks’ gestation in the determination of chorionicity and amnionicity in twin pregnancies. Ultrasound Obstet Gynecol. 32(5):618-21

F., S., Alvarez, N., & Trolice , M. (2019, October 18). Surrogacy in the USA – Is It Legal in All 50 States? https://babygest.com/en/united-states/#surrogacy-laws-by-state

Gonzalez, A. (2019, June 12). Commercial Surrogacy in the United States. law.georgetown.edu. https://www.law.georgetown.edu/gender-journal/wp-content/uploads/sites/20/2019/11/Aliia_Surrogacy-6.pdf.
Horner C, Burcher P. (2021) A surrogate’s secrets are(n’t) safe with me: patient confidentiality in the care of a gestational surrogate. Journal of Medical Ethics. 47:213-217

Judith Daar (2014). “Physician Duties in the Face of Deceitful Gamete Donors, Disobedient Surrogate Mothers, and Divorcing Parents.” AMA Journal of Ethics, vol. 16, no. 1, 2014, pp. 43–48.

Mello L. Everything You Need to Know About Surrogacy Agencies. Circle Surrogacy. https://www.circlesurrogacy.com/blog/circle-surrogacy/everything-to-know-surrogacy-age ncies/. Published May 22, 2020. Accessed July 6, 2021.

NeJaime D. The Nature of Parenthood. 2017;126(8). https://www.yalelawjournal.org/article/the-nature-of-parenthood. Accessed July 5, 2021.

O’Reilly, K. (2016, February 18). When Parents and Surrogates Disagree on Abortion. The Atlantic. https://www.theatlantic.com/health/archive/2016/02/surrogacy-contract-melissa-cook/463323/

Radcliffe, S. (2019, April 55). Lawsuit Filed by Surrogate Mother Raises New Legal, Moral … healthline.com.https://www.healthline.com/health-news/lawsuit-filed-by-surrogate-mother -raises-new-legal-moral-issues-012016.

Rafique, S, and DeCherney, A.H. (2014) Physician Responsibility when a Surrogate Mother Breaks her Contract. AMA Journal of Ethics. Virtual Mentor. 16(1):10-16.

Tanderup, M., Reddy, S., Patel, T., & Nielsen, B. B. (2015). Reproductive Ethics in Commercial Surrogacy: Decision-Making in IVF Clinics in New Delhi, India. Journal of Bioethical Inquiry, 12(3), 491–501. https://doi.org/10.1007/s11673-015-9642-8

The Child-Parent Security Act: Gestational Surrogacy. New York State Department of Health. (2021, March). https://health.ny.gov/community/pregnancy/surrogacy/.

White PM. (2017) “One for Sorrow, Two for Joy?”: American embryo transfer guideline recommendations, practices, and outcomes for gestational surrogate patients. J Assist Reprod Genet. 34(4):431-443.

The Ethical Dilemma of Using Artificial Intelligence In Medicine

With the evolution of modern technology, the emergence of artificial intelligence in medical care is inevitable. Although this advancement in technology presents innovation in diagnoses and treatment, it also proposes several drawbacks in the ethics of using data driven machinery for patient care. The article, “Artificial Intelligence in Medicine : Today and Tomorrow” from Frontiers in Medicine takes a deeper dive in the benefits and detrimental aspects of artificial intelligence in medicine (Briganti, 2020). Although artificial intelligence (AI) offers a faster approach in detecting disease and with greater accuracy than the human eye, it poses a strong threat to medical ethics if used improperly. Using ideas of autonomy, beneficence, non-maleficence, and confidentiality, this paper explores why artificial intelligence may be implemented to facilitate medical evaluations, but should not replace providers in making medical decisions.

AI has been generating enthusiasm among the medical community as it embodies the 4P model of medicine (Predictive, Preventative, Personalized, Participatory) to provide greater beneficence in patient care. AI has the potential to produce greater accuracy in screening and predict future diagnoses at an earlier stage. As a result, AI affords more time for a provider to take necessary preventative measures in patient management. AI can also create a more personalized and participatory experience for patients by delivering convenient and fast medical care. One such example is Kardia. FDA-approved in 2014, Kardia was one of the first applications of AI in medicine and acts as a smartphone application that detects early onset of atrial fibrillation. Patients must purchase the mobile sensor and then pay for a monthly service subscription. Patients are then able to make regular EKG recordings that providers can easily review on their end (Pearson, 2018). Patients experience greater autonomy as they have more control over how frequently they partake in a medical evaluation. Patients are able to conveniently receive EKG recordings without having to go to a clinic. They can simply login to their phone and make a recording at anytime and anyplace. Beneficence is also clearly demonstrated by the Kardia app as patients receive more frequent EKG readings. Early detection of atrial fibrillation becomes more likely and patients can take the necessary steps to prevent heart failure.

Unfortunately, autonomy may also be jeopardized with an over reliance on medical technology to make final medical judgements. In 2018, IDx-DR became the first FDA-authorized AI technology that can make a diagnosis without human interpretation. IDx-DR analyzes images from a retinal camera to diagnosis diabetic retinopathy. Although IDx-DR demonstrates 87% sensitivity and 90% specificity, it runs the risk of missing diagnoses and generating unnecessary referrals due to false-positive readings (Savoy, 2020). AI is ultimately limited by its computerized algorithm and the competency of the user itself. AI works by building upon data and patterns. If the wrong pattern is learned, an inappropriate diagnosis is made. For example, if IDx-DR picks up that a specific image of the eye indicates diabetic retinopathy, it develops the pattern that all such images points to diabetic retinopathy. Detrimental outcomes may be placed into effect if medicine were to depend only on AI decisions without taking into account of exceptions and a holistic view of bodily functions. For this reason, AI must be used with caution as its beneficence may be compromised with improper use and programming.

The “Artificial Intelligence in Medicine : Today and Tomorrow” article also states how AI was found to replicate racial, gender, and socioeconomic status bias during trials (Briganti, 2020). If a sample population presents with any skew, AI builds off of that data and amplifies the bias (Rigby, 2019). This becomes especially problematic as the goal of medicine is to treat patients as individuals with minimal partial judgement. AI pushes the ethical boundaries of non-maleficence as it is a mechanical system that does not have the logical capabilities to remove prejudice. It may develop the wrong algorithm and wrong medical conclusions for a target population. AI does not embody the humanistic experiences, empathy, or reasoning for it to ethically produce definitive judgements on the course of human life. For this reason, it would be dangerous to sacrifice provider autonomy by solely relying on AI to determine the final outcomes in patient management.

Another shortcoming to AI is that it may breach patient confidentiality. Kardia highlights this risk as it is linked to a third party software system. Patient information can easily be hacked or accessed outside of the realms of health care (Gattadahalli, 2020). As smartphones increasingly use facial recognition to unlock functions, security is especially fragile in accessing patient history. Already, the world of health care is struggling to keep up with patient confidentiality with the use of smartphones and telemedicine. AI increases security risks by involving developers outside the medical field in the gathering of patient information.

In conclusion, AI is a promising development in the medical community that may save countless lives. However, in it its quest to continuously improve modern medicine, the medical community should take caution on an over reliance on AI to make decisions. This would dehumanize the art of medicine, pose risks to patient and provider autonomy in decision-making, and jeopardize patient confidentiality. Ultimately, each patient requires a unique approach based on personal experiences and preferences that cannot be simply determined by a computerized algorithm.

References

1. Briganti G, Le Moine O. Artificial Intelligence in Medicine: Today and Tomorrow. Frontiers. https:// www.frontiersin.org/articles/10.3389/fmed.2020.00027/full. Published January 17, 2020. Accessed June 14, 2021.
2. Gattadahalli S. Health care needs ethics-based governance of artificial intelligence. STAT News. https://www.statnews.com/2020/11/03/artificial-intelligence-health-care-ten-steps-to-ethics-based- governance/. Published November 4, 2020. Accessed June 14, 2021.
3. Peason A. Skeptical Cardiologist: Do Mobile Heart-Monitoring Devices Work? Medical News. https://www.medpagetoday.com/cardiology/arrhythmias/71622. Published March 8, 2018. Accessed June 14, 2021.
4. Rigby MJ. Ethical Dimensions of Using Artificial Intelligence in Health Care. Journal of Ethics | American Medical Association. https://journalofethics.ama-assn.org/article/ethical-dimensions- using-artificial-intelligence-health-care/2019-02. Published February 1, 2019. Accessed June 14, 2021.
5. Savoy M. IDx-DR for Diabetic Retinopathy Screening. American Family Physician. https:// www.aafp.org/afp/2020/0301/p307.html. Published March 1, 2020. Accessed June 14, 2021.

Patient-Centered Interview

** All names & scenarios are fictional for the purpose of learning education. **

** All names & scenarios are fictional for the purpose of learning education. **

HPI: 70 y/o man with h/o hypertension, hyperlipidemia, 40 pack-years smoking history, and brother who died of MI at 60y/o brought in by ambulance to the ED with c/o substernal chest pain.  The pain is described as pressure-like and radiating to the left arm and jaw, accompanied by nausea, diaphoresis, and shortness of breath.  Nitroglycerin was administered sublingually, but only provided temporary relief.  Aspirin was given to the patient to chew in the ambulance. Patient was immediately brought to the cardiology lab and had a balloon angioplasty and stent placement and was transferred to the telemetry unit for monitoring.

S : 70 yo man completed a balloon angioplasty and stent placement yesterday (11/9/2020) due to acute inferior wall MI. 

• Denies pain & shortness of breath
• Reports mild fatigue when walking from room to nursing station
• States present condition is comfortable
• States no adverse effects to sublingual nitroglycerine, aspirin, Morphine drip IV, O2 nasal cannula, & Metoprolol that administered prior to stent placement

O :

HR: 72 bpm

BP: 130/70

R: 24

Temp: 37.4   ͦC

EKG: normal sinus rhythm with no ST elevations and no Q waves

Extremities: peripheral pulses are slightly diminished and 1+

Heart: Regular rate and rhythm, no gallops or murmurs

Lungs: clear

Groin: femoral pulses intact and 2+ .  No hematoma.

A :  Patient is stable with vitals signs within normal range. R/O bleeding. R/O blood clots. R/O heart complications.

P : Continue monitoring the patient for the next 3 days. A nurse will monitor vital signs every 4 hours for the first day and then every eight hours.

Patient is currently taking:

• Aspirin 81 mg orally, once a day
• Plavix 75 mg orally, once a day
• Lopressor 25 mg orally every 12 hours

If stable for 3 days, patient may be discharged. Discuss medication plan for patient to continue after discharge. Follow-up with the patient in 2 weeks or sooner if symptoms of dyspnea, nausea, vomiting, or heart palpitation appear. 

Health Promotion Disease Prevention

**All names and scenarios are fictional for the purpose of learning education.**

Calandra James is a 66 year old recently retired administrator for City Harvest, a group that gathers leftover food from restaurants and distributes it to food banks and soup kitchens.  She is a recovering alcoholic (sober for 8 years) and she now describes her health as basically good, but says that she struggles with what she calls “an addictive nature”.  This has expressed itself in her history of drinking and a past history of smoking (she quit 5 years ago after a total of 40 pack-years), and more recently she has noted that her eating has an addictive aspect as well.  She says that eating is “a giant issue for me”.  She joined Weight Watchers and lost 75 pounds over a year and a half.  However, she has gained back 15 pounds of it over the past year.  She says, “I spend way too much time trying to stave off hunger, trying to keep calories to 1500-1800/day and pushing myself to get in enough exercise to achieve a daily calorie deficit (she takes long brisk walks, rides a bike to do errands, swims at the local beach during the season, and has a set of free weights and resistance bands that she uses at home).  I am trying to focus on healthful eating and respecting my body, but it’s really a struggle.”  

Her family history includes an alcoholic father and brother who are still actively drinking, a mother who had breast cancer at age 52, but has been cancer free since then and is now 88, and a sister who has Type 2 Diabetes.  She has a long-term lesbian partner who lives a few towns away.  She also has 2 adult sons who live several states away.  She says she is looking forward to retirement because she hopes to find a way to relax and stop beating herself up all the time.  

When you talk to her a little more about her eating habits, you learn that she does not really cook much.  She mostly eats salads and prepared foods from the grocery store.  A typical breakfast is scrambled egg whites with whole wheat toast.  Lunch is a yogurt and sliced fruit with peanut butter spread on it.  Snacks are humus and pita chips and or vegetables, and dinner is salad with some sort of protein.  She allows herself two pieces of dark chocolate (80 calories) as dessert most nights.  She says she finds her current diet tolerable, but “joyless”.  

Other Information:

BP 128/74 T 99 P 68, regular R 18

Hgt  5 ft 6 in Wgt 160 lbs Waist circumference 37 in

Immunizations

• Flu IIV or RIV
• Tdap or TD
• RZV Zoster or ZVL live
• Pneumococcal Polysaccharide PPSV23 ¹

Screenings

• Colonoscopy – over 50 years old ²
• Mammogram – mother had breast cancer ³
• HIV – relationship with same-sex partner 
• Hypertension
• Depression – descriptions of joylessness and low-self esteem 
• Low CT for lung cancer – past history of smoking ⁴
• Pap smear – one every 3 years for women 32-65 yo ⁵

Injury Prevention

• Traffic Safety ⁶

Diet

First, I would commend Ms. James for the drastic changes she has made in her diet. She is eating very clean and exerting diligence in portion control. However, she should not be trying to “stave off hunger” in order to manage her weight. Some of her changes may be too extreme.

Ms. James’ current BMI is 25.8. As normal BMI ranges from 18.5 – 24.9 for her age range, I would encourage her that she is not far from her weight loss goals and does not need to implement drastic weight loss measures.⁷ In fact, most studies indicate that a maximum weight loss of 9-15% over 52 to 72 weeks is sustainable.⁸ For Ms. James, this would look like 14.4- 24 pound weight loss in the course of the year. I would not want her to lose more than two pounds a month. 

At her age, height, weight, and light activity level, it is estimated that Ms. James can consume 1800 calories to maintain her current weight.⁹ I would warn her not to dip too low below that number as she has been trying to maintain a 1500-1800 calorie diet. Instead, I would recommend that she consume a 1650- 1800 calorie diet. With continued physical activity, she should be able to maintain a stable calorie deficit and achieve a slow, yet sustainable weight loss.

As Ms. James is starting retirement, I would also encourage her to try cooking. It sounds that she is very bored by her diet as she describes a“joyless” attitude towards food. I would emphasize that food plays a very large role in our daily lives and should be enjoyed. With more time in her retirement, she can try cooking and introducing more variety to her meals. There are many cooking videos on YouTube and recipes on the internet. I would suggest adding keywords such as “healthy alternatives”, “lower calorie”, or “plant-based” to her search to find appropriate recipes. Taking time to prepare her food may help her find variety and enjoy the act of eating again. 

Exercise

Again, I would commend Ms. James for taking initiative and implementing changes in her physical activity during her weight loss journey. She builds exercise wonderfully well into her daily activities by taking long walks, biking for errands, and using weights at home. However, I am concerned about her mindset towards exercise. She is motivated to exercise in order to maintain a calorie deficit. I would remind Ms. James that she is allowed to and should enjoy her physical activities, too. They are not intended just for weight loss, but also to promote overall health benefits both physically and mentally. Perhaps she can try to participate in exercise with her partner or a group class. This can create a social aspect to exercise that will make it more enjoyable for her. 

Although she is physically active, most of her exercises are low-impact and low-cardio. I would love to see her engage in physical activity that challenges her at least twice a week so that her heart rate reaches 75-128 bpm.¹⁰ Additionally, Ms. James may incorporate more strengthening exercises as that helps mitigate the onset of osteoporosis. Ms. James is sixty-six years old and is at greater risk of developing osteoporosis as it affects one in three women over the age of fifty. ¹¹

Harm Reduction

Although the National Institute on Drug Abuse states that a maximum alcohol consumption of 4 standard drinks per day for women is acceptable, I would choose to leave this information out for Ms. James.¹² As she struggles with an addictive behavior, is a recovering alcoholic, and has a family history of alcoholism, I do not want to provide an openings that may trigger her addictive behavior. For this reason, I would continue to commend her for staying clear from alcohol and cigarette use and encourage her to keep up these habits. 

Brief Intervention 

In our meeting, I would screen Ms. James for depression. In her own words, she has described her lifestyle with negative terms such as “struggling”, “joyless”, and “beating herself up.” As her sons live states away and her partner lives towns away, I am worried she does not have social and emotional support at home. Her past addiction history and family history of alcoholism also raises concern for me. She may not have the tools for a healthy coping mechanism in the event that something terrible happens. I would utilize the 5 A’s of Brief intervention to ensure that Ms. James is aware of her current emotional and mental status and is more mindful towards her future actions.¹³

Ask – “How do you feel about the quality of your life right now?”

Advise – “If you’re having a bad day, could you tell me how you deal with it? Is there someone you usually talk to?”

Assess – “Have you been experiencing any changes in your sleep patterns, motivation, or mental clarity recently?”

Assist – “You say you are looking forward to retirement in order to finally relax. What do you envision an ideal day to like like in your retirement?”

Arrange – “Would you be open towards trying CBT (Cognitive Behavior Therapy)? I think it could be a great space to help bridge your current lifestyle to a more relaxing one in retirement.” “Do you have any additional questions for me?” 

References

1. Adult Immunization Schedule by Vaccine and Age Group. (2020, February 03). Retrieved November 13, 2020, from https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
2. Recommendation: Colorectal Cancer: Screening: United States Preventive Services Taskforce. (2016, June 15). Retrieved November 10, 2020, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening
3. Recommendation: Breast Cancer: Screening: United States Preventive Services Taskforce. (2016, January 11). Retrieved November 10, 2020, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening
4. Recommendation: Cervical Cancer: Screening: United States Preventive Services Taskforce. (2018, August 21). Retrieved November 10, 2020, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening
5. Draft Recommendation: Lung Cancer: Screening: United States Preventive Services Taskforce. (2020, July 07). Retrieved November 13, 2020, from https://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/lung-cancer-screening-2020
6. Gardner, H. (2007, January 01). Office-Based Counseling for Unintentional Injury Prevention. Retrieved November 13, 2020, from https://pediatrics.aappublications.org/content/119/1/202
7. Calorie Calculator. (n.d.). Retrieved November 13, 2020, from https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/calorie-calculator/itt-20402304
8. Hall, K., & Kahan, S. (2018, January). Maintenance of Lost Weight and Long-Term Management of Obesity. Retrieved November 13, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764193/
9. Calorie Calculator. (n.d.). Retrieved November 13, 2020, from https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/calorie-calculator/itt-20402304
10. Target Heart Rates Chart. (n.d.). Retrieved November 13, 2020, from https://www.heart.org/en/healthy-living/fitness/fitness-basics/target-heart-rates
11. Keen, M. (2020, June 23). Osteoporosis In Females. Retrieved November 13, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK559156/
12. Drinking Levels Defined. (n.d.). Retrieved November 13, 2020, from https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking
13. Brief Interventions. (n.d.). Retrieved November 13, 2020, from https://mdquit.org/cessation-programs/brief-interventions