Cardiovascular health checks test risk factors for cardiovascular disease. They are offered to improve health: in case of an increased risk, participants receive lifestyle advice and medication. With this review, we investigate what is known about the reasons why people do or do not test for CVD risk factors. To what extent do these reasons relate to health monitoring and/or improvement? And do reasons differ in different contexts in which health checks are offered? We conducted (...) a literature search and included 22 papers in which we identified a broad range of motives. We conclude that people have reasons to test related to health improvement and reasons other than health improvement, practical reasons related to the way health checks are offered play an important role and motives should be understood in the context of the situation in which health checks are offered. Our results are relevant for public health officials and providers of health checks: first, if people undergo testing for reasons unrelated to health, this could explain why participation in health checks does not necessarily lead to health improvement. Second, efforts to improve uptake not necessarily serve justice and may hamper informed consent. (shrink)

Recent research has shown that psychological risk factors play an important role in the pathogenesis of cardiovascular diseases. The so-called coronary prone behaviour pattern predominates, an important part of which is the Type A behaviour pattern. This is characterized by a marked ambition, a constant feeling of being under pressure, due to latent aggression and to a striving to dominate. For cerebrovascular diseases the so-called pressured pattern as a risk factor has been found to be typical which (...) is comparable to the Type A behaviour. Psychological risk factors and their components are not equally important for different vascular diseases. Besides the explanation of the question as to how far psychological processes really are involved in the development of vascular diseases, the research on psychological risk factors serves as a foundation for psychosomatic theories. (shrink)

IntroductionChildhood maltreatment is a developmental risk factor and can negatively influence later psychological functioning, health, and development in the next generation. A comprehensive understanding of the biopsychosocial underpinnings of CM transmission would allow to identify protective factors that could disrupt the intergenerational CM risk cycle. This study examined the consequences of maternal CM and the effects of psychosocial and biological resilience factors on child attachment and stress-regulatory development using a prospective trans-disciplinary approach.MethodsMother-child dyads participated shortly after parturition, after (...) 3 months, and 12 months later. Mothers’ CM experiences were assessed at t0, attachment representation at t1 and psychosocial risk and social support were assessed at t1 and t2. At t2, dyads participated in the Strange Situation Procedure. Children’s attachmen status were classified as organized vs. disorganized, including their level of disorganized behavior, and heart rate and respiratory sinus arrhythmia were recorded as stress response measures of the autonomic nervous system. Maternal caregiving during SSP was assessed using the AMBIANCE scale. Child’s single nucleotide polymorphisms rs2254298 within the oxytocin receptor and rs2740210 of the oxytocin gene were genotyped using DNA isolated from cord blood.ResultsMaternal CM experiences were significantly associated with an unresolved attachment status, higher perceived stress and more psychological symptoms. These negative effects of CM were attenuated by social support. As expected, maternal unresolved attachment and child disorganized attachment were significantly associated. Maternal caregiving did not mediate the relationship between maternal and child attachment but influenced children’s HR and RSA response and disorganized behavior. Moreover, the rs2254298 genotype of the OXTR gene moderated the stress response of children from mothers with CM. Children carrying the rs2740210 risk allele of the OXT gene showed more disorganized behavior independent from maternal CM experiences.ConclusionWe replicated and extended existing CM and attachment models by co-examining maternal attachment, social support, and child genetic susceptibility on child attachment and cardiovascular stress regulation. The findings contribute to an extended understanding of risk and resilience factors and enable professionals to target adequate services to parents and children at risk. (shrink)

Risk is the probability that within a certain time some expected negative event will take place. In medicine risk can be related to a decision or to some intrinsic factors which are associated with the probability of the occurrence of a disease. Decisions can be necessary in the individual life with respect to the question of visiting a physician or performing a certain diagnostic or therapeutic procedure. The introduction of new pharmaceutical or technical products into medical use are (...) another set of decisions which can generate certain risks. Intrinsic or inherent risk factors are a set of variables or signs and symptoms which indicate the presence of a certain probability that some disease or event, e.g., arteriosclerosis or sudden infant death syndrome, may occur. Risk is always related to judgement. In a decision process cost, effectiveness and profit can be used to estimate the magnitude of the risk to be taken. In a similar way the problems in connection with an inherent risk are primarily related to the recognition of the magnitude of risk and to the possibility of prophylactic measures.In our own area of research, the sudden infant death syndrome (SIDS) is an event where only risk factors can be observed. We point at two facts in this context: Highly complex patterns of symptoms like behaviour can better be classified by intuitive Gestalt perception. A medical procedure like induction of labour can itself become a risk factor. (shrink)

Trafficking and persistence of fetal microchimeric cells (fMCs) and circulating extracellular vesicles (EVs) have been observed in animals and humans, but their consequences in the maternal body and their mechanistic contributions to maternal physiology and pathophysiology are not yet fully defined. Fetal cells and EVs may help remodel maternal organs after pregnancy‐associated changes, but the cell types and EV cargos reaching the mother in preterm pregnancies after exposure to various risk factors can be distinct from term pregnancies. As preterm (...) delivery‐associated maternal complications are rising, revisiting this topic and formulating scientific questions for future research to reduce the risk of maternal morbidities are timely. Epidemiological studies report maternal cardiovascular risk as one of the major complications after preterm delivery. This paper suggests a potential link between fMCs and circulating EVs and adverse maternal cardiovascular outcomes post‐pregnancies, the underlying mechanisms, consequences, and methods for and how this link might be assessed. (shrink)

Three negative affective dispositions—anger, anxiety, and depression—are hypothesized to increase physical disease risk and have been the subject of epidemiological studies. However, the overlap among the major negative affective dispositions, and the superordinate construct of trait negative affectivity are only beginning to be tested. Presented here is a narrative review of recent prospective studies that simultaneously tested anger, anxiety, depression, and trait NA as risk factors for cardiac outcomes. Anxiety and depression emerged as independent risk factors for (...) premature heart disease in population studies of persons nominally healthy at baseline, and for recurrence/mortality among patients with existing heart disease. General trait NA also was a cardiac risk factor in population samples. (shrink)

Many formerly incarcerated people have civil legal needs that can imperil their successful re-entry to society and, consequently, their health. We categorize these needs and assess their association with cardiovascular disease risk factors in a sample of recently released people. We find that having legal needs related to debt, public benefits, housing, or healthcare access is associated with psychosocial stress, but not uncontrolled high blood pressure or high cholesterol, in the first three months after release.

Cardiovascular disease (CVD) and sustained high blood glucose as prediabetes are an established comorbidity. People's experience in reconciling these long‐term conditions requires deeper appreciation if nurses are to more effectively support person‐centred care for people who have them. Our analysis explores the initial experience of people admitted to hospital with CVD who then find they also have sustained high blood glucose. Our methodology is informed by the philosophy of Gadamer and applies interpretive description to develop an interpretation of participant (...) experiences. The major theme emerging from participant interviews was the ‘invisible disequilibrium’ characterised by three subthemes: ‘losing equilibrium’, ‘becoming embattled’ and ‘evolving illness’. This study examines CVD and prediabetes in conjunction with the Gadamerian notion of the ‘whole’, as being in a social and emotional world in which illness is also a component part. We explore how participants lived within an ‘invisible disequilibrium’, with prediabetes frequently remaining unnoticed, while CVD was manifest. To identify multiple conditions and support effective intervention to manage them as part of person‐centric care, nursing practice should explore the ‘whole’ of the person's experience, value people’s knowledge as potential indicators of complex illness, thereby reducing the risk of accelerating complex illness. (shrink)

The advances in treatment of HIV and the introduction of polymerase chain reaction assay for the virus now make it acceptable for HIV discordant couples where the male partner is seropositive to attempt to conceive through artificial insemination by husband (AIH) or via in vitro fertilisation. With undetectable viral load and washed sperm, there is minimal risk of transmission of HIV to the female partner, children, other patients, or staff. We describe the development of a programme of AIH for (...) HIV discordant couples and the reasoning behind offering such a programme. (shrink)

Despite recent advances in the research related to air pollution and associated adverse cardiovascular events, the combined effects of air pollution, climate change, and SARS‐CoV‐2 infection on cardiovascular health need to be researched further. This Commentary addresses their impacts on cardiovascular health in the approximately 25 million people with a severe form of inherited hypercholesterolemia, called familial hypercholesterolemia (FH). The arterial endothelium in these individuals is potentially under multiple attacks caused by particles of both endogenous and exogenous (...) origin. Thus, they have a lifelong highly elevated level of circulating low density lipoprotein (LDL) cholesterol which drives premature atherosclerosis. The high levels of LDL particles, often associated with an elevated level of circulating lipoprotein(a) particles, are both capable of inducing and maintaining endothelial dysfunction. Such pre‐existing endothelial dysfunction can be exacerbated by exposure to SARS‐CoV‐2 viral particles, by exposure to fine particulate matter generated by climate change‐associated wildfires, and by dehydration during deadly heatwaves linked to the globally rising temperatures. The external factors can severely worsen the pre‐existing endothelial dysfunction, and thereby significantly increase the risk of a cardiovascular event in the exposed FH patients. (shrink)

The study of the autonomic nervous system (ANS) function has shown to provide useful indicators for risk stratification and early detection on a variety of cardiovascular pathologies. However, data gathered during different tests of the ANS are difficult to analyse, mainly due to the complex mechanisms involved in the autonomic regulation of the cardiovascular system (CVS). Although model-based analysis of ANS data has been already proposed as a way to cope with this complexity, only a few models (...) coupling the main elements involved have been presented in the literature. In this paper, a new model of the CVS, representing the ventricles, the circulatory system and the regulation of the CVS activity by the ANS, is presented. The models of the vascular system and the ventricular activity have been developed using the Bond Graph formalism, as it proposes a unified representation for all energetic domains, facilitating the integration of mechanic and hydraulic phenomena. In order to take into account the electro-mechanical behaviour of both ventricles, an electrophysiologic model of the cardiac action potential, represented by a set of ordinary differential equations, has been integrated. The short-term ANS regulation of heart rate, cardiac contractility and peripheral vasoconstriction is represented by means of continuous transfer functions. These models, represented in different continuous formalisms, are coupled by using a multi-formalism simulation library. Results are presented for two different autonomic tests, namely the Tilt Test and the Valsalva Manoeuvre, by comparing real and simulated signals. (shrink)

The use of composite outcomes is becoming widespread in clinical trials. By combining individual outcome measures into a composite, researchers claim a composite can increase statistical precision and trial efficiency, expediting the trial by reducing sample size and cost, and consequently enabling researchers to answer questions that could not otherwise be answered. Another rationale given for using a composite is that it provides a measure of the net effect of the intervention that is more patient-relevant than any single outcome measure. (...) Critics, on the other hand, argue that the use of composites threatens the scientific objectivity of the trial by introducing new risks, and that in practice components are inconsistently defined, unreasonably combined, and inadequately reported. Philosophical scrutiny can help shed light in these disagreements and disentangle ethical and epistemological issues of composites in clinical trials. I examine common use of composites in cardiovascular trials, and show how composite results can be problematic, even misleading, if the proper range of scientific decisions and their consequences are ignored when judging the composite. Philosophies of science that are principled on normative versions of the argument from inductive risk can help explicate issues with composites. I conclude by suggesting ways of remedying composite issues in clinical trials. (shrink)

Epidemiological evidence supports a health‐promoting effect of the Mediterranean Diet (MedDiet), especially in the prevention of cardiovascular diseases. These cardiovascular benefits have been attributed to a number of components of the MedDiet such as monounsaturated fatty acids, antioxidant vitamins and phytochemicals. However, the underlying mechanisms remain unknown. Likewise, little is known about the genes that define inter‐individual variation in response to the MedDiet, although the TCF7L2 gene is emerging as an illustrative candidate for determining relative risk of (...) cardiovascular events in response to the MedDiet. Moreover, omics technologies are providing evidence supporting potential mechanisms, some of them implicating epigenetics (i.e. microRNAs, methylation), and certain data suggest that some traditional foods could contribute via microRNAs possibly acting as exogenous regulators of gene expression. Future research should aim at increasing and consolidating the nutrigenetic and nutrigenomic knowledge of the MedDiet in order to provide sound, personalized and optimized nutritional recommendations. (shrink)

The study of the autonomic nervous system (ANS) function has shown to provide useful indicators for risk stratification and early detection on a variety of cardiovascular pathologies. However, data gathered during different tests of the ANS are difficult to analyse, mainly due to the complex mechanisms involved in the autonomic regulation of the cardiovascular system (CVS). Although model-based analysis of ANS data has been already proposed as a way to cope with this complexity, only a few models (...) coupling the main elements involved have been presented in the literature. In this paper, a new model of the CVS, representing the ventricles, the circulatory system and the regulation of the CVS activity by the ANS, is presented. The models of the vascular system and the ventricular activity have been developed using the Bond Graph formalism, as it proposes a unified representation for all energetic domains, facilitating the integration of mechanic and hydraulic phenomena. In order to take into account the electro-mechanical behaviour of both ventricles, an electrophysiologic model of the cardiac action potential, represented by a set of ordinary differential equations, has been integrated. The short-term ANS regulation of heart rate, cardiac contractility and peripheral vasoconstriction is represented by means of continuous transfer functions. These models, represented in different continuous formalisms, are coupled by using a multi-formalism simulation library. Results are presented for two different autonomic tests, namely the Tilt Test and the Valsalva Manoeuvre, by comparing real and simulated signals. (shrink)

The study of the autonomic nervous system (ANS) function has shown to provide useful indicators for risk stratification and early detection on a variety of cardiovascular pathologies. However, data gathered during different tests of the ANS are difficult to analyse, mainly due to the complex mechanisms involved in the autonomic regulation of the cardiovascular system (CVS). Although model-based analysis of ANS data has been already proposed as a way to cope with this complexity, only a few models (...) coupling the main elements involved have been presented in the literature. In this paper, a new model of the CVS, representing the ventricles, the circulatory system and the regulation of the CVS activity by the ANS, is presented. The models of the vascular system and the ventricular activity have been developed using the Bond Graph formalism, as it proposes a unified representation for all energetic domains, facilitating the integration of mechanic and hydraulic phenomena. In order to take into account the electro-mechanical behaviour of both ventricles, an electrophysiologic model of the cardiac action potential, represented by a set of ordinary differential equations, has been integrated. The short-term ANS regulation of heart rate, cardiac contractility and peripheral vasoconstriction is represented by means of continuous transfer functions. These models, represented in different continuous formalisms, are coupled by using a multi-formalism simulation library. Results are presented for two different autonomic tests, namely the Tilt Test and the Valsalva Manoeuvre, by comparing real and simulated signals. (shrink)

Cardiovascular disease is a major complication of type 2 diabetes mellitus. In addition to traditional risk factors, psychological determinants play an important role in CVD risk. This study applied Deep Neural Network to develop a CVD risk prediction model and explored the bio-psycho-social contributors to the CVD risk among patients with T2DM. From 2017 to 2020, 834 patients with T2DM were recruited from the Department of Endocrinology, Affiliated Hospital of Harbin Medical University, China. In this (...) cross-sectional study, the patients' bio-psycho-social information was collected through clinical examinations and questionnaires. The dataset was randomly split into a 75% train set and a 25% test set. DNN was implemented at the best performance on the train set and applied on the test set. The receiver operating characteristic curve analysis was used to evaluate the model performance. Of participants, 272 were diagnosed with CVD. The developed ensemble model for CVD risk achieved an area under curve score of 0.91, accuracy of 87.50%, sensitivity of 88.06%, and specificity of 87.23%. Among patients with T2DM, the top five predictors in the CVD risk model were body mass index, anxiety, depression, total cholesterol, and systolic blood pressure. In summary, machine learning models can provide an automated identification mechanism for patients at CVD risk. Integrated treatment measures should be taken in health management, including clinical care, mental health improvement, and health behavior promotion. (shrink)

YOUNG L, and WHARF HIGGINS J.Nursing Inquiry2010;17: 346–358 Using participatory research to challenge the status quo for women’s cardiovascular healthCardiovascular health research has been dominated by medical and patriarchal paradigms, minimizing a broader perspective of causes of disease. Socioeconomic status as a risk for cardiovascular disease is well established by research, yet these findings have had little influence. Participatory research (PR) that frames mixed method research has potential to bring contextualized clinically relevant findings into program planning and (...) policy‐making arenas toward developing meaningful health and social policies relevant to primary prevention. In this article we provide an overview of a PR program that included two quantitative and one qualitative studies and then we discuss lessons learned. The PR process we found was empowering for lone mothers, and transformative for lone mothers and researchers. Further, PR as an approach to research opened spaces in practice and policy‐making arenas to raise upstream issues relevant to the health of low income lone mothers. We conclude that while PR is an effective approach to social determinants research, as a time‐intensive endeavor, and one that does not easily align with research tradition, researchers must consider the strengths and drawbacks of PR when planning to implement such an approach. (shrink)

All ordinary decisions involve some risk. If I go outside for a walk, I may trip and injure myself. But if I don’t go for a walk, I slightly increase my chances of cardiovascular disease. Typically, we disregard most small risks. When, for practical purposes, is it appropriate for one to ignore risk? This issue looms large because many activities performed by those in wealthy societies, such as driving a car, in some way risk contributing to (...) climate harms. Are these activities morally appropriate? -/- In this paper, I first summarize and respond to some arguments that purport to show that it is appropriate to ignore or discount very small risks. I argue that because our rationality is bounded, it is impossible for us to include every small risk in our decision-making process, and so we may reasonably use heuristics to guide many decisions. However, contrary to some thinkers, I argue that this does not violate the spirit of expected value theory; it merely shows that we should adopt a so-called "two-level" view. Our use of heuristics allows for the reasonable ignoring of some risks, and this perhaps explains why one might be inclined to think that individual climate-related risks are negligible. However, virtually all greenhouse-gas emitting activities in fact have some climate risk on the negative side of the ledger, and the use of heuristics does not permit the general ignoring of climate-change-related risk by individuals on grounds of expediency of judgment and decision-making. (shrink)

Des mortalités anormales frappent les ruchers d’Europe et d’autres continents depuis un peu plus de vingt ans. Depuis le début des troubles, des suspicions pèsent sur des insecticides d’un genre nouveau, utilisés en traitement de semences. La législation prescrivant l’évaluation des risques environnementaux de toute substance insecticide dès avant sa mise sur le marché, des apiculteurs sont allés consulter les dossiers portant sur les molécules suspectées, ce qui les a amenés à s’impliquer dans la critique et l’élaboration des règles d’évaluation, (...) et à côtoyer le monde des experts en toxicologie de l’abeille.Beehives across Europe and other continents have been affected by abnormal mortality for the last twenty years. Since these problems first appeared, suspicion has fallen on a new type of insecticide, which is used to treat seeds. The legislation prescribes environmental risk assessments of any insecticide substance before it reaches the market, and beekeepers therefore decided to consult the files concerning the suspect molecules. As a result, they became involved in critically reviewing and developing assessment rules, and thus came to rub shoulders with experts in bee toxicology. (shrink)

Genetic testing has historically been performed in the context of chronic disease and cancer diagnostics. The timelines for these tests are typically measured in days or weeks, rather than in minutes. As such, the concept that genetic information might be generated and then used to alter management in the acute setting has, thus far, not been feasible. However, recent advances in genetic technologies have the potential to allow genetic information to be generated significantly quicker. The m.1555A>G genetic variant is present (...) in one in 500 individuals and predisposes to profound hearing loss following the administration of aminoglycoside antibiotics. These antibiotics are used frequently in cases of neonatal sepsis and it is estimated that approximately 180 neonates in the UK are at risk of antibiotic induced hearing loss each year because of this genetic change. Knowledge of this variant in the acute setting would allow clinicians to prescribe alternative antibiotics. The Pharmacogenetics to Avoid Loss of Hearing study will implement a genetic point of care test for the m.1555A>G variant within two major UK based neonatal intensive care units. This represents the first trial of a genetic POCT aimed at altering management in the acute setting. This round table discussion outlines the novel ethical issues faced in the development of this trial and the legal barriers to implementation. We ask five stakeholders to provide their opinions on this trial and their perspectives on the concept of genetic testing in the acute setting.Trial registration numberISRCTN-13704894. (shrink)

BackgroundExercise is one of the effective ways to improve cognition. Different forms of exercises, such as aerobic exercise, resistance exercise, and coordination exercise, have different effects on the improvement of cognitive impairment. In recent years, exergames based on Non-Immersive Virtual Reality have been widely used in entertainment and have gradually been applied to clinical rehabilitation. However, the mechanism of NIVR-Exergames on improving motor cognition has not been clarified. Therefore, the aim of this study is to find whether NIVR-Exergames result in (...) a better neural response mechanism to improve the area of the cerebral cortex related to motor cognition under functional near-infrared spectroscopy dynamic monitoring in comparison with resistance exercise.MethodsA cross-over study design was adopted in this study, and 15 healthy young subjects were randomly divided into group A and group B according to a computerized digital table method. Task 1 was an NIVR-Exergame task, and Task 2 was resistance band stretching. Group A first performed Task 1, rested for 30 min, and then performed Task 2. Group B had the reverse order. The fNIRS test was synchronized in real time during exercise tasks, and heart rate measurements, blood pressure measurements, and 2-back task synchronization fNIRS tests were performed at baseline, Post-task 1, and Post-task 2. The primary outcomes were beta values from the general linear model in different regions of interest, and the secondary outcomes were heart rate, blood pressure, reaction time of 2-back, and accuracy rate of 2-back.ResultsThe activation differences of Task 1 and Task 2 in the right premotor cortex and the left PMC were statistically significant. There were statistically significant differences in the activation of the right supplementary motor area, left dorsolateral prefrontal cortex, left and right PMC between baseline and Post-task 1. The differences in systolic pressure between the two groups at three time points among women were statistically significant.ConclusionIn this study, we found that NIVR-Exergames combined with motor and challenging cognitive tasks can promote the activation of SMA, PMC and DLPFC in healthy young people compared with resistance exercise alone, providing compelling preliminary evidence of the power for the rehabilitation of motor and cognitive function in patients with central nervous system diseases. (shrink)

In modern medicine, health risks are often managed through the collection of health data and subsequent intervention. One of the goals of clinical genetics, for example, is to identify genetic predisposition to disease so that individuals can intervene to prevent potential harms. But recently, some clinicians have suggested that patients should undergo less testing and monitoring in an effort to reduce overdiagnosis and overtreatment. In this paper, I explore how clinicians navigate the tension between identifying real disease risks for their (...) patients with concerns about overdiagnosis and overtreatment. I focus on clinicians ordering genetic testing for inherited cardiovascular diseases. Of the genes determined to be “clinically actionable” by the American College of Medical Genetics and Genomics, half are related to cardiovascular diseases. But, due in part to high levels of uncertainty surrounding cardiovascular genetics, there is still disagreement within the field about how to order and interpret these tests. Based on semi-structured, in-depth interviews with 20 clinicians who order genetic testing for cardiovascular diseases, I find that there is considerable variability in the ways that clinicians determine which types of genetic tests are appropriate for their patients and how they interpret test results. Most importantly, I find that many providers do not presume that more genetic data will lead to better care. Instead, increased genetic data can lead to confusion and inappropriate treatment. This re-valuation of the utility of medical data is crucial for bioethicists to explore, especially as medical fields are sorting through increasing amounts of data. (shrink)

In this response article, we challenge a core assumption that lies at the centre of a round table discussion regarding the Pharmacogenetics to Avoid Loss of Hearing trial. The round table regards a genetic test for a variant that increases the risk of deafness if a carrier is given the antibiotic gentamicin. The idea is that rapid testing can identify neonates at risk, providing an opportunity to prevent giving an antibiotic that might cause deafness. We challenge the assumption (...) that a positive test unequivocally guides antibiotic choice because, aside from the risk of deafness, all antibiotics for neonatal sepsis are equivalent. We argue that this assumption is faulty and has particularly troubling moral consequences. We claim that giving an alternative to gentamicin is potentially providing inferior treatment and thereby may increase the risk of death. Parents and doctors are faced with a terrible choice as a result of positive point-of-care testing : give gold-standard treatment and risk deafness or give second line care and risk death. While we do not indicate an answer to this choice, what we do argue is that such a deep and difficult choice is one that may make parents wish genetic testing was never undertaken, and therefore, contra some authors in the round table, provides a reason to gain specific consent for POCT. (shrink)

In current mental health care psychiatric conditions are defined as compilations of symptoms. These symptom-based disease categories have been severely criticised as contingent and boundless, facilitating the rise to epidemic proportions of such conditions as depression. In this article we look beyond symptoms and stress the role of epidemiology in explaining the current situation. By analysing the parallel development of cardiovascular disease and depression management in Finland, we argue, firstly, that current mental health care shares with the medicine of (...) chronic somatic conditions an attachment to risk factor epidemiology, which accentuates risk and prevention in disease management. However, secondly, due to the symptom-based definitions of psychiatric conditions, depression management cannot differentiate properly between symptoms, signs and risk factors such as, for example, cardiovascular medicine, but treats symptoms as signs or risk factors in contexts of treatment and prevention. Consequently, minor at-risk conditions have become difficult to separate from proper cases of depression. (shrink)

Climate change has substantial impacts on public health and safety, disease risks and the provision of health care, with the poor being particularly disadvantaged. Management of the associated health risks and changing health service requirements requires adequate responses at local levels. Health-care providers are central to these responses. While climate change raises ethical questions about its causes, impacts and social justice, medicine and bioethics typically focus on individual patients and research participants rather than these broader issues. We broaden this focus (...) by examining awareness among health-care providers in the Caribbean region, where geographic and socioeconomic features pose particular vulnerabilities to climate change. In focus groups, Caribbean providers described rises in mosquito-borne, flood-related, heat-related, respiratory and mental illnesses, and attributed these to local impacts of climate change. Their discussions showed that the significance of these impacts differs in different Caribbean nations, raising policy and social justice questions. Bioethics and public health ethics are situated to frame, inform and initiate public and policy dialog about values and scientific evidence associated with climate change. We urge readers to initiate such dialog within their own institutions about the context-dependent nature of the burdens of climate change, and values and policies that permit it to worsen. (shrink)

Advances in neuromodulation and an improved understanding of the anatomy and circuitry of psychopathology have led to a resurgence of interest in surgery for psychiatric disease. Clinical trials exploring deep brain stimulation (DBS), a focally targeted, adjustable and reversible form of neurosurgery, are being developed to address the use of this technology in highly selected patient populations. Psychiatric patients deemed eligible for surgical intervention, such as DBS, typically meet stringent inclusion criteria, including demonstrated severity, chronicity and a failure of conventional (...) therapy. Although a humanitarian device exemption by the US Food and Drug Administration exists for its use in obsessive-compulsive disorder, DBS remains a largely experimental treatment in the psychiatric context, with its use currently limited to clinical trials and investigative studies. The combination of a patient population at the limits of conventional therapy and a novel technology in a new indication poses interesting challenges to the informed consent process as it relates to clinical trial enrollment. These challenges can be divided into those that relate to the patient, their disease and the technology, with each illustrating how traditional conceptualisations of research consent may be inadequate in the surgical psychiatry context. With specific reference to risk analysis, patient autonomy, voluntariness and the duty of the clinician-researcher, this paper will discuss the unique challenges that clinical trials of surgery for refractory psychiatric disease present to the consent process. Recommendations are also made for an ethical approach to clinical trial consent acquisition in this unique patient population. (shrink)

Obesity is characterized by the accumulation of an excessive amount of fat mass in the adipose tissue, subcutaneous, or inside certain organs. The risk does not lie so much in the amount of fat accumulated as in its distribution. Abdominal obesity is an important risk factor for cardiovascular diseases, diabetes, and cancer, having an important role in the so-called metabolic syndrome. Therefore, it is necessary to prevent, detect, and appropriately treat obesity. The diagnosis is based on anthropometric (...) indices that have been associated with adiposity and its distribution. Indices themselves, or a combination of some of them, conform to a big picture with different values to establish risk. Anthropometric indices can be used for risk identification, intervention, or impact evaluation on nutritional status or health; therefore, they will be called anthropometric health indicators. We have found 17 AHIs that can be obtained or estimated from 3D human shapes, being a noninvasive alternative compared to X-ray-based systems, and more accessible than high-cost equipment. A literature review has been conducted to analyze the following information for each indicator: definition; main calculation or obtaining methods used; health aspects associated with the indicator ; criteria to classify the population by means of percentiles or cutoff points, and based on variables such as sex, age, ethnicity, or geographic area, and limitations. (shrink)

Clear-cut cases of decision-making under risk (known probabilities) are unusual in real life. The gambler’s decisions at the roulette table are as close as we can get to this type of decision-making. In contrast, decision-making under uncertainty (unknown probabilities) can be exemplified by a decision whether to enter a jungle that may contain unknown dangers. Life is usually more like an expedition into an unknown jungle than a visit to the casino. Nevertheless, it is common in decision-supporting disciplines to (...) proceed as if reasonably reliable probability estimates were available for all possible outcomes, i.e. as if the prevailing epistemic conditions were analogous to those of gambling at the roulette table. This mistake can be called the tuxedo fallacy . It is argued that traditional engineering practices such as safety factors and multiple safety barriers avoid this fallacy and that they therefore manage uncertainty better than probabilistic risk analysis (PRA). PRA is a useful tool, but it must be supplemented with other methods in order not to limit the analysis to dangers that can be assigned meaningful probability estimates. (shrink)

Clear-cut cases of decision-making under risk (known probabilities) are unusual in real life. The gambler’s decisions at the roulette table are as close as we can get to this type of decision-making. In contrast, decision-making under uncertainty (unknown probabilities) can be exemplified by a decision whether to enter a jungle that may contain unknown dangers. Life is usually more like an expedition into an unknown jungle than a visit to the casino. Nevertheless, it is common in decision-supporting disciplines to (...) proceed as if reasonably reliable probability estimates were available for all possible outcomes, i.e. as if the prevailing epistemic conditions were analogous to those of gambling at the roulette table. This mistake can be called the tuxedo fallacy. It is argued that traditional engineering practices such as safety factors and multiple safety barriers avoid this fallacy and that they therefore manage uncertainty better than probabilistic risk analysis (PRA). PRA is a useful tool, but it must be supplemented with other methods in order not to limit the analysis to dangers that can be assigned meaningful probability estimates. (shrink)

That there is a heritable or familial component of susceptibility to chronic non‐communicable diseases such as type 2 diabetes, obesity and cardiovascular disease is well established, but there is increasing evidence that some elements of such heritability are transmitted non‐genomically and that the processes whereby environmental influences act during early development to shape disease risk in later life can have effects beyond a single generation. Such heritability may operate through epigenetic mechanisms involving regulation of either imprinted or non‐imprinted (...) genes but also through broader mechanisms related to parental physiology or behaviour. We review evidence and potential mechanisms for non‐genomic transgenerational inheritance of ‘lifestyle’ disease and propose that the ‘developmental origins of disease’ phenomenon is a maladaptive consequence of an ancestral mechanism of developmental plasticity that may have had adaptive value in the evolution of generalist species such as Homo sapiens. BioEssays 29: 145–154, 2007. © 2007 Wiley Periodicals, Inc. (shrink)

Excerpt: 1. Introduction This chapter provides insight into the diverse ethical debates on genetics and epigenetics. Much controversy surrounds debates about intervening into the germline genome of human embryos, with catchwords such as genome editing, designer baby, and CRISPR/Cas. The idea that it is possible to design a child according to one’s personal preferences is, however, a quite distorted view of what is actually possible with new gene technologies and gene therapies. These are much more limited than the editing and (...) design metaphors suggest. Such metaphors are therefore highly problematic phrases in the context of new gene technologies, for two reasons. On one hand, to design a child of choice by modifying the genome would require modifying any gene of choice, which is more than can be done with current gene technologies, such as CRISPR/Cas. On the other hand, a modification of genes would need to be enough to create any characteristic of choice in the future child. The latter presupposes the assumption of genetic determinism. Moreover, the CRISPR/Cas technology can not only be used in a potentially therapeutic manner at the germline level. In addition, there is the (more likely) scenario of a future clinical therapeutic use of these new gene technologies for modifying the DNA sequence of other cells of the body (somatic genome editing). There is also the option of modifying the epigenome, that is, the spatial configuration of DNA (epigenome editing) (see table 1). Like genetics and genome editing, epigenetics has been at the center of recent popular scientific and ethical discourse as well as scientific debates. The concept of epigenetics has given rise to very different notions of inheritability and responsibility for health, which, however, are oftentimes based on scientifically controversial basic assumptions. That there continues to be covert genetic determinism in the form of epigenetic determinism (see table 2) in debates about epigenetics has been pointed out in ethical analyses of epigenetics. Neither genetic determinism nor epigenetic determinism has been confirmed scientifically. It is therefore important to recognize the concepts that are discussed (and sometimes harshly criticized) in debates about genome editing and epigenetics—for example, concepts about the causal role of DNA for our own life course. This importance is based on the fact that if we understand such controversial concepts, we will be able to remain critical when evaluating scientific knowledge and ethical arguments about genome editing and epigenetics. This chapter, therefore, explains some of these concepts. For an ethical analysis of epigenetics as well as of genome editing, it is necessary to understand and critically reflect upon the underlying concepts of genetic determinism and other, related -isms. The following section offers a detailed introduction to these -isms (section 2; see also table 2). Section 3 provides an ethical analysis of genome editing and epigenetics based on the explanations in section 2. Section 3 focuses on inheritability and responsibility, justice, safety, the problem of consent, and the effects of genome editing and epigenetics on embryos and future generations. This section does not discuss in detail further points that can be found in ethical debates about epigenetics as well as in ethical debates about genome editing. These points include (among others): • fear that the findings of epigenetics and that the methods of genome editing are misused—this also with respect to eugenics and enhancement; • naturalness—an issue we mention in passing a few times in the following analysis; • a possible connection between the genome/epigenome and the concept of human dignity, and the derived danger of instrumentalization and infringement of autonomy when intervening in the genome or epigenome. Since current discourse about ethical issues associated with genome editing focuses mainly on germline interventions, which are, for instance, interventions into a human embryo’s genome, we mainly focus on germline interventions when comparing the debates on genome editing and on epigenetics in section 3. (shrink)