Abstract

Informed Consent: Considering its Implications

Brian Taylor Slingsby

Informed consent is one of the ethical cornerstones of modern health care and a fundament of clinical medicine. Concerned about possible malpractice claims and regulations, however, clinicians often overlook the process of informed consent and rather focus on the informed consent form and required signature. This is particularly true in Japan where recent revisions to the Medical Care Law have stressed the importance of signed consent forms. Here, I will first discuss informed consent in clinical medicine and how its process of communication can encourage shared decision-making among patient, patient's family and healthcare provider. Second, to better be able to assess how a patient wishes to participate in the process of informed consent, I will delineate the differences among competence / capacity for decision-making, desire to participate in decision-making, and preferences for different styles of decision-making. Third, considerable attention will be given to the role of the family in informed consent and decision-making, and how this family-facilitated approach is not unique to Japan but universal. Lastly, I will consider the recent trends in multicultural patient care and how intracultural differences are often more important to understanding the patient than those that are intercultural.

A Journey to the Heart of Dermatology and Dermatopathology

Helmut Kerl

In this lecture the character and quality of the practice of dermatology and dermatopathology will be illuminated. Modern concepts and principles are provided including the following aspects: Reflections on a modern dermatopathology, the challenge of melanocytic tumors, and lessons from patients. Special emphasis will be placed on modern concepts of cutaneous lymphomas. Today, cutaneous lymphomas are classified as a fully recognized and well-defined group of extranodal lymphomas according to the criteria of the World Health Organization and the European Organization for Research and Treatment of Cancer classification. Better understanding of the mechanisms of their pathogenesis including especially immunophenotypic and molecular features will hopefully stimulate investigative research and provide further improvement of diagnosis and treatment.

Posterior Vertebral Column Resection (VCR) for Severe Pediatric and Adult Spinal Deformity:
Indications, Results, and Complications of 43 Consecutive Cases

Lawrence G. Lenke, Brenda Sides, Linda Koester, Marsha Hensley, and Kathy Blanke

The ability to treat severe pediatric and adult spinal deformity through an all-posterior VCR has obviated the need for a circumferential approach in primary and revision cases. We examined the indications, correction rates, and complications of these challenging procedures. Between 2002 and 2006, 43 (30 pediatric / 13 adult) consecutive patients of which 23 were primary and 20 were revision cases underwent a posterior-only VCR for severe scoliosis (S) (n=7, mean 102°, range 63-150); global kyphosis (GK) (n=12, mean 92°, range 81-134°); angular kyphosis (AK) (n=10, mean 77°, range 43-135°); or kyphoscoliosis (K+S) (n=14, mean total 198°, range 149-275°) by a single surgeon. Patients underwent a 1-level (n=24), 2-level (n=15), or 3-level (n=4) VCR utilizing pedicle screws, anteriorly positioned cages (n=31), and intraoperative spinal cord monitoring (NMEPs & SSEPs). 39/43 (90%) were performed at L1 or cephalad in spinal cord territory; the remainder were in the upper cauda equina (L2 and / or L3). Major curve correction: Group S=73° (72%), Group GK=46° (50%), Group AK=55° (71%), and Group K+S=a combined 115° (58%). 7 patients (18%) lost NMEP data during correction with data returning to baseline following prompt surgical intervention. Following surgery, all patients were at their baseline (n=40) or showed improved spinal cord function (n=3), while no one worsened. Postoperatively, 2 patients had nerve root palsies, which spontaneously resolved at 6 months / 2 weeks respectively. Thus far no one has required revision surgery for any neurologic, wound, instrumentation, or fusion complication. Intraoperative SCM (especially motor-evoked potentials) is mandatory to prevent spinal cord-related neurologic complications in this safe but challenging technique.

The Role of COUP-TFII in Reproduction

Dong-Kee Lee, Isao Kurihara, Ming-Jer Tsai and Sophia Y. Tsai

The Chicken Ovalbumin Upstream Promoter Transcription Factor II (COUP-TFII, NR2F2) is a member of the orphan nuclear receptor of the steroid/thyroid hormone receptor superfamily. Genetic ablation of COUP-TFII results in early embryonic lethality due to cardiac and vascular development defects. Expression of COUP-TFII persists throughout postnatal life in various tissues including the female reproductive tract. COUP-TFII ^+/- females show significantly reduced fecundity, irregular estrus cycles, reduced decidual response and delayed puberty. To analyze the physiological function of COUP-TFII in the uterus, we used PR-Cre to conditionally ablate COUP-TFII in the uterus.
PR^+/cre; COUP-TFII^F/F mutant mice are infertile and exhibit defects in both embryo attachment and uterine decidualization; phenotypes resemble those of conditional ablation of Indian Hedgehog (Ihh) in the uterus. We further uncover a novel genetic pathway in which epithelial progesterone-induced Ihh regulates stromal COUP-TFII. COUP-TFII in turn controls BMP2 to regulate decidualization. In addition, COUP-TFII regulates stromal progesterone receptor expression. Progesterone receptor and COUP-TFII together suppress epithelial ER activity to provide proper window of receptivity. Taken together, stromal-derived COUP-TFII is an essential mediator of this complex cross-communication pathway in uterus.