Thin, R N
Work loads in venereal disease--sexually transmitted disease (STD)--genitourinary medicine (GUM) clinics have risen greatly in recent years. The increase in viral infections which are more difficult and time consuming to manage than those caused by bacteria and the higher expectations and demands of patients have combined to increase workloads more than the case figures indicate. This prompted the Department of Health and Social Security in 1988 to set up a survey of clinics in England with the following terms of reference: "To examine current and forecast workloads on GUM clinics, taking account of AIDS and other STDs, and to recommend any action which may need to be taken on manpower (including nursing manpower), training, resources and accommodation". The team concluded that the GUM service was ill equipped to meet the demands for its services, and made 36 recommendations. The priority recommendations included: the need to provide more resources; government ministers should give a lead in developing the service; all health districts should provide care for STD and HIV infection; all new patients should be seen on the day of presentation or failing that on the next occasion the clinic was open. Other recommendations included: location of all GUM clinics in the general outpatient department of general hospitals; accommodation of the same standard as other outpatient departments; review of the distribution of clinics; review of staffing levels and roles; and coordination of care of HIV infection. Many of these recommendations have already led to action including a lead from government ministers and provision of more funds. Many of the problems and recommendations will apply in other countries. PMID:2613217
Carne, C; Foley, E; Rowen, D; Kell, P; Maw, R
Objectives: This study was conducted to examine the variation in clinical practice in genitourinary medicine clinics in the United Kingdom in early 2002. Methods: Questionnaires were sent to all 234 consultants in charge of genitourinary medicine clinics in the United Kingdom in March-May 2002. The questions concerned clinical practice in respect of asymptomatic patients presenting for an infection screen, and practice in respect of some specific sexually transmitted and other genitourinary infections. Results: The test for infection least likely to be offered to heterosexuals is an HIV test (71% and 70% of clinics routinely offer this to male and female heterosexuals respectively). The practice of permitting "low risk" patients to telephone for their HIV results now extends to 24% of clinics. 34% of clinics do not require patients with non-specific urethritis to attend for follow up. 41% of clinics routinely ask patients treated for Chlamydia trachomatis to return for a follow up chlamydia detection test. 25% of clinics routinely offer two tests of cure to all patients with gonorrhoea. 6% of clinics do not routinely offer syphilis serology to heterosexuals. Other significant variations in clinical practice were documented. Conclusions: Overall, our findings indicate the need for further evidence to guide clinical practice and a wider knowledge and debate of national guidelines. PMID:12794212
Carne, C A; Foley, E; Rowen, D; Kell, P; Maw, R
This study was conducted to examine the variation in clinical practice in genitourinary medicine clinics in the United Kingdom in early 2002. Questionnaires were sent to all 234 consultants in charge of genitourinary medicine clinics in the United Kingdom in March-May 2002. The questions concerned clinical practice in respect of asymptomatic patients presenting for an infection screen, and practice in respect of some specific sexually transmitted and other genitourinary infections. The test for infection least likely to be offered to heterosexuals is an HIV test (71% and 70% of clinics routinely offer this to male and female heterosexuals respectively). The practice of permitting "low risk" patients to telephone for their HIV results now extends to 24% of clinics. 34% of clinics do not require patients with non-specific urethritis to attend for follow up. 41% of clinics routinely ask patients treated for Chlamydia trachomatis to return for a follow up chlamydia detection test. 25% of clinics routinely offer two tests of cure to all patients with gonorrhoea. 6% of clinics do not routinely offer syphilis serology to heterosexuals. Other significant variations in clinical practice were documented. Overall, our findings indicate the need for further evidence to guide clinical practice and a wider knowledge and debate of national guidelines.
A total of 113 individuals (101 women, 12 men) who had experienced sexual assault (SA) attended the genitourinary medicine clinic. Of the 60 patients who were seen at a dedicated clinic for victims of SA, the median age was lower, a greater number had reported to the police and the interval between assault and attendance was shorter, compared with the 53 who attended the routine walk-in service. However, the majority of the men attended routine clinics. Drug-facilitated rape was reported in 20%, excess alcohol in 10% and the use of violence in 20% cases. Overall, the prevalence of sexually transmitted infections was the same as the total clinic population.
Carlin, E M; Russell, J M; Sibley, K; Boag, F C
To evaluate an integrated family planning clinic (FPC) established by genitourinary medicine (GUM) staff held within a GUM women-only clinic (WOC). A retrospective case note review of women attending the FPC during the first year January-December 1992. One hundred and thirteen women, aged 13-41 years, attended the FPC; 45 were new attenders, six had previously tested antibody positive for the human immunodeficiency virus (HIV), seven were intravenous drug users; 54% had a history of sexually transmitted disease (STD); 17.7% were using no contraception; 32.7% had previous termination of pregnancy (TOP) with 70 TOPs in total. Within three months of FPC attendance 89 (78.8%) women had genital STD screening performed; syphilis, HIV and hepatitis B serology, together with cervical cytology were performed in 77, 18, 13 and 62 women respectively. Infections identified were similar to those identified in the GUM clinic but the prevalence of Chlamydia trachomatis in diagnosed infections was commoner in FPC attenders and epidemiological treatment commoner in GUM attenders. No high grade cytology abnormalities were detected. No positive syphilis or new HIV positive results were identified; five women were found to be hepatitis B surface antibody positive. Contraception was changed in 60.8%. Most frequently supplied was the combined oral contraceptive pill (COCP). At the first FPC attendance six women required post coital contraception (PCC) and five were already pregnant, three suspected it, two were unaware. During the year three women conceived; two used COCP, but were non compliant; one used a diaphragm with unclear compliance. Seven of the eight pregnancies were terminated. Over the following year, 1992-93, contraception was supplied to 42 women; four required PCC; two intentional pregnancies occurred. Only one of the TOP women returned. An integrated FPC provides co-ordinated sexual health care. Pregnancy, TOP and FPC re-attendance rates together with improvement
Catchpole, M; Connor, N; Brady, A; Kinghorn, G; Mercey, D; Band, B; Thin, N
To investigate how attenders with sexually transmitted disease (STD) differ from the general population with respect to sexual behaviour, and to identify which attenders at genitourinary medicine (GUM) clinics are at particular behavioural risk for acquiring STD. Multicentre cross sectional survey. Two genitourinary medicine clinics, one in London and one in Sheffield 20,516 patients attending the two clinics over an 18 month period. Behavioural and demographic characteristics and clinical diagnoses were recorded for each patient. 8862 patients, in whom 12,506 diagnoses were made, were seen in the Sheffield clinic, and 11,654 patients, in whom 20,243 diagnoses were made, were seen in the London clinic. When compared with the reported results from a general population survey, there were higher proportions of clinic attenders reporting two or more sexual partners in the preceding 12 months (p < 0.001), and a higher proportion of males reporting homosexual contact (13% compared with 1%, p < 0.001). Only age and number of sexual partners in the past 12 months were significantly associated with acute STDs for each sex in each clinic. Acute STDs tended to occur with greater frequency in the younger age groups, peaking among 16-19 year olds, particularly among females. The results have confirmed that patients with STDs exhibit higher risk sexual behaviour than the general population, and have highlighted the problem of continuing high risk behaviour among younger attenders, particularly younger homosexual men. This study has demonstrated that among GUM clinic attenders age and number of sexual partners are key risk factors for the acquisition of an acute STD. The results of this survey also indicate, however, that half of the females and more than one quarter of males with acute STDs reported only one sexual partner in the past 12 months, suggesting that health education messages should point out that it is not only those who have multiple recent sexual partners, or who
Carlin, E M; Russell, J M; Sibley, K; Boag, F C
OBJECTIVE--To evaluate an integrated family planning clinic (FPC) established by genitourinary medicine (GUM) staff held within a GUM women-only clinic (WOC). DESIGN--A retrospective case note review of women attending the FPC during the first year January-December 1992. RESULTS--One hundred and thirteen women, aged 13-41 years, attended the FPC; 45 were new attenders, six had previously tested antibody positive for the human immunodeficiency virus (HIV), seven were intravenous drug users; 54% had a history of sexually transmitted disease (STD); 17.7% were using no contraception; 32.7% had previous termination of pregnancy (TOP) with 70 TOPs in total. Within three months of FPC attendance 89 (78.8%) women had genital STD screening performed; syphilis, HIV and hepatitis B serology, together with cervical cytology were performed in 77, 18, 13 and 62 women respectively. Infections identified were similar to those identified in the GUM clinic but the prevalence of Chlamydia trachomatis in diagnosed infections was commoner in FPC attenders and epidemiological treatment commoner in GUM attenders. No high grade cytology abnormalities were detected. No positive syphilis or new HIV positive results were identified; five women were found to be hepatitis B surface antibody positive. Contraception was changed in 60.8%. Most frequently supplied was the combined oral contraceptive pill (COCP). At the first FPC attendance six women required post coital contraception (PCC) and five were already pregnant, three suspected it, two were unaware. During the year three women conceived; two used COCP, but were non compliant; one used a diaphragm with unclear compliance. Seven of the eight pregnancies were terminated. Over the following year, 1992-93, contraception was supplied to 42 women; four required PCC; two intentional pregnancies occurred. Only one of the TOP women returned. CONCLUSION--An integrated FPC provides co-ordinated sexual health care. Pregnancy, TOP and FPC re
A retrospective case note review of 212 individuals (190 women) attending a city-centre Genitourinary Medicine clinic between 1/4/2002 and 31/3/2004 following an acute sexual assault. Direct referral by the Forensic Medical Examiner to the dedicated weekly clinic for victims of sexual assault facilitated the attendance of 55/113 attending the dedicated clinic. The 99 individuals who did not disclose a recent assault as the reason for attendance were seen at routine clinics. One third of individuals attending the dedicated clinic were less than 16 years old, reflecting the facilitated referral pathway. Those attending the dedicated clinic were more likely to be offered the extended service outlined in the departmental protocol. Twenty four sexually transmitted infections were detected in 23 (11%) individuals but 23/24 could have been acquired during other recent consensual sexual activity. Overall, the assailant was known to the victim in 53% cases, there was an allegation of violence associated with the assault in 20%, suspicion of a drug facilitated ('spiked drink') assault in 24% and admission of alcohol intoxication in 11% cases. The 22/212 (10%) who were male were more likely to present to a routine clinic.
McClean, H; Carne, C A; Sullivan, A K; Menon-Johansson, A; Gokhale, R; Sethi, G; Mammen-Tobin, A G; Daniels, D
A national audit of screening of asymptomatic patients seen in UK genitourinary medicine clinics in 2009 was conducted against the national guidelines. Data were aggregated by regions and clinics in regions, allowing practice to be compared within and between regions, as well as to national averages and against national guidelines. The case-notes of 4428 patients were audited. Performance was over 80% against the national guidelines for screening of asymptomatic heterosexual men, men who have sex with men (MSM) and women for chlamydial, gonorrhoeal, syphilis and HIV infections. However, the recommended method of endocervical culture for gonorrhoea was performed in only 65% of women, with a further one-quarter being screened with endocervical or vulvovaginal nucleic acid amplification tests (NAATs). Although significant NAAT use for gonorrhoea was seen in all groups, testing for gonorrhoea by culture is still recommended as a first-line test on invasive samples. Over 80% of MSM, who were not known to be immune, were screened for hepatitis B. Urethral microscopy was performed in 22% of heterosexual men and 17% of MSM, and cervical microscopy in 12% of women.
Carne, Christopher A; Chilcott, Sian; Palmer, Christopher; Green, Oliver; Bridge, Simeon; Walsh, Richard; Gramy-Mason, Anna; O'Donovan, Maria
To conduct a case-control study of abnormalities in the semen of genitourinary (GU) medicine clinic attendees compared with general practice (GP) controls and in patients with asymptomatic and symptomatic non-specific urethritis (NSU) before and after the urethritis resolves. Rates of semen abnormalities were compared between the different groups (19 with symptomatic and 27 with asymptomatic NSU, seven with symptomatic non-NSU and 64 clinic controls) and between clinic attendees and 417 patients attending GP for the first investigation of possible infertility. Those with symptomatic or asymptomatic NSU gave repeat semen samples on resolution of the NSU. The study included 117 clinic volunteers. They were shown to have statistically significantly worse total sperm counts (p=0.002), volume of semen (p<0.001) and percentage of abnormal forms (p<0.04) compared with 417 GP controls. Compared with the rest of the clinic volunteers, asymptomatic NSU patients had statistically significantly lower total sperm counts (p<0.02). Asymptomatic NSU patients had statistically significantly lower total sperm counts compared with symptomatic NSU patients (p<0.02). Compared with GP controls, clinic controls had statistically significantly inferior total sperm counts (p=0.009) and semen volume (p<0.001). GU clinic attendees are more likely to have abnormalities of semen than patients attending GP for the first check for possible infertility. A high rate of abnormal semen findings are found in patients with and without NSU but the highest rate occurred in those with asymptomatic NSU. Is asymptomatic NSU therefore pathogenic and does it require treatment like symptomatic NSU?
Scoular, Anne; Abu-Rajab, Kirsty; Winter, Andy; Connell, Judith; Hart, Graham
We conducted a matched case-control study to investigate social factors associated with gonorrhoea acquisition among genitourinary (GU) medicine clinic attendees, designed to inform appropriate prevention strategies. Detailed social and behavioural data were elicited using a self-completed questionnaire. The effect sizes of these characteristics were quantified using univariate and multivariable conditional logistic regression in 53 cases and 106 matched controls. Homo-bisexual orientation was the strongest independent predictor of gonorrhoea acquisition (Adjusted odds ratio 31.1 (95% confidence intervals, 3.09-312.92). Other independent predictors were not currently being in a relationship and concordant residential characteristics. Three principal implications for sexual health policy were identified; social marketing approaches to gonorrhoea prevention should focus on gay men and individuals not in established relationships; gonorrhoea prevention should be more closely integrated with wider social inclusion policies; finally, more proactive, systematic and theory-based approaches should capitalize on opportunities for sexual health promotion in GU medicine clinic settings.
Carne, C A; McClean, H; Sullivan, A K; Menon-Johansson, A; Gokhale, R; Sethi, G; Mammen-Tobin, A G; Daniels, D
Of clinics responding to the audit, 99 and 97% have policies that are compliant with the British Association for Sexual Health and HIV National Guidelines for testing of asymptomatic men and women for HIV and syphilis, respectively. All clinics offer men, and all but one clinic offer women, screening for chlamydial infection with nucleic acid amplification tests (NAATs), as recommended by the guidelines. However, for gonorrhoea screening one-third of clinics offer men urine or urethral NAATs, and one quarter of clinics offer women endocervical, vulvovaginal or urinary NAATs, and not endocervical culture, and these practices are not compliant with the guidelines. Eight clinics did not specify whether they routinely offer testing for gonorrhoea in women. One-third of clinics routinely perform rectal and oropharyngeal screening for gonorrhoea in men who have sex with men (MSM), but fewer screen for chlamydia, regardless of sexual history which is stated as a determinant of offering screening at these anatomical sites. Finally, one-fifth of clinics offer urethral microscopy to asymptomatic heterosexual men and MSM, and about one half of clinics offer urethral culture for detection of gonorrhoea in asymptomatic women, even though these practices are not compliant with the guidelines.
Hughes, G.; Andrews, N.; Catchpole, M.; Goldman, M.; Forsyth-Benson, D.; Bond, M.; Myers, A.
Objectives: To determine important risk factors associated with cases of gonorrhoea in England, and whether any particular risk groups were associated with the substantial rise in numbers of cases seen between 1994 and 1996. Design: Two retrospective cross sectional surveys. Setting: 70 randomly selected genitourinary medicine (GUM) clinics in England. Subjects: 10% of all gonorrhoea patients attending GUM clinics in England in 1994 (847 patients) and 1996 (1146 patients). Main outcome measures: For risk factors in 1996 (study 1), unadjusted rates per 100 000 population aged 14–70 and relative rates (RR) with 95% confidence intervals (CIs). For the change in risk factors between 1994 and 1996 (study 2), adjusted odds ratios (ORs) with 95% CIs, derived from logistic regression analyses of data on patients in 1996, with patients in 1994 as the comparison group. Results: The incidence of gonorrhoea in 1996 was higher in homosexual males (812 per 100 000; RR=30.2, CI= 25.2 to 36.0) compared with heterosexual males (27 per 100 000); in black Caribbeans (467 per 100 000; 21.4, 17.9 to 25.5) and black Africans (235 per 100 000; 10.8, 7.5 to 15. 5) compared with white people (22 per 100 000); and in previous GUM clinic attenders (433 per 100 000; 37.93, 35.46 to 40.56) compared with those who had not attended previously (11 per 100 000). However, most patients were either white or heterosexual. Heterosexual patients in 1996 were significantly more likely to have reduced sensitivity to penicillin (2.55, 1.20 to 5.41) than those in 1994. Male homo/bisexual patients in 1996 were significantly more likely to be from the north west (3.77, 1.45 to 9.80) and to have either reduced sensitivity (2.63, 1.03 to 6.73) or complete resistance (1.98, 1.03 to 3.78) to penicillin, compared with those in 1994. Conclusions: Homo/bisexual men and the black Caribbean population in England experience a disproportionate burden of gonococcal infections, however, the bulk of diagnoses are in
Jalal, H; Stephen, H; Bibby, D F; Sonnex, C; Carne, C A
High-risk subtypes of human papillomavirus (HPV) are the main causative agents of cervical cancer, for which Chlamydia trachomatis (CT) may sometimes be a co-factor. Vaccines have been developed against some subtypes of human papillomavirus and a vaccine against CT is in development. The objective of this study was to determine the prevalence of the subtypes of HPV and CT in genitourinary (GU) medicine clinic attenders. In total, 1000 consecutive patients attending the GU clinic participated in this anonymized point-prevalence study. Urethral swabs from 437 men and urethral plus cervical swabs as a single specimen from 563 women were tested for the subtypes of both organisms. Nested major outer membrane protein (MOMP) polymerase chain reaction detected CT chromosomal DNA in 44/437 (10%) of the men and 73/563 (13%) of the women. Genotypes E, F, and D were the most common. In all, 55/437 (13%) of men and 244/563 (43%) of women were infected with at least one high-risk HPV type. In conclusion, the new HPV vaccines, Gardasil and Cervarix, would have protected against 58% and 45%, respectively, of the high-risk subtypes found in women in this population. The rate of high-risk HPV infection (43%) found in women in this study raises concern.
Le Polain de Waroux, Olivier; Hughes, Gwenda; Maguire, Helen; Crook, Paul D
We analysed factors associated with travelling to non-local genitourinary medicine clinics for gonorrhoea care in London. We used surveillance data on London residents attending genitourinary medicine clinics in 2009-10 and calculated distances between patients' areas of residence and both the nearest genitourinary medicine clinic and the clinic attended. Non-local clinics were attended by 5408 (46.7%) patients. Men having sex with men attended non-local services more than heterosexuals (OR 3.83, p < 0.001). Among heterosexual men, black Africans and black Caribbeans were more likely, and South Asians less likely, to attend non-local services compared to whites (OR [95%CI] 1.33 [1.04-1.72], 1.36 [1.11-1.67] and 0.46 [0.31-0.70] respectively). Similar associations, although not statistically significant, were found in women. People were more likely to attend local services if their local clinic provided walk-in and young people's services, weekend consultations and long opening hours. These findings could help design services meeting local population needs and facilitate prompt and equitable access to care.
Evans, B A; McCormack, S M; Bond, R A; MacRae, K D; Thorp, R W
During the six months immediately after a public information campaign about the acquired immune deficiency syndrome 1115 women who attended a genitourinary medicine clinic in west London were tested for antibodies to the human immunodeficiency virus (HIV). Three women (0.27%) were positive, and all three were regular sexual partners of men with high risk lifestyles--two intravenous drug users and one bisexual. A consecutive series of 647 women from the cohort was tested for antibodies for hepatitis B core antigen: 27 were positive, of whom six had been born in the United Kingdom and were not known to have been at risk. The two women who were seropositive for HIV who completed a questionnaire on their sexual behaviour before they were tested reported both anal and oral receipt of semen and were in the upper fifth percentile for lifetime sexual partners. More than half (53%) of 424 women who reported that they had non-regular sexual partners never used a condom. It is concluded that heterosexual women in London are at a low risk of becoming infected with HIV.
Das, Satyajit; Huengsberg, Mia
The victims of sexual assault may attend GUM clinic without any referral from any other agency. The management of these cases need special care. We audited the management of females who were known to us as victims of sexual assault. In 15 months, 68 females attended our clinic. All were screened for sexually transmitted infections (STI). Emergency contraception was offered to only 38.4% at risk cases, and formal counselling support was offered to only 25% cases. Further care is necessary to improve counselling support and offering emergency contraception to the victims of sexual assault.
Evans, B. A.; Kell, P. D.; Bond, R. A.; MacRae, K. D.
OBJECTIVES: To compare variables of sexual behaviour and incidence of genital infections among women of different racial origins and lifestyles. DESIGN: A prospective cross sectional study of sexual behaviour reported by a standardised self administered questionnaire in new patients who presented for screening and diagnosis. SETTING: A genitourinary medicine clinic in west London. SUBJECTS: 1084 consecutive women newly attending in 1992. MAIN OUTCOME MEASURES: Variables relating to sociodemographic status, sexual lifestyle, condom use, sexually transmitted diseases, and other genital infections stratified by racial origin. RESULTS: There were 948 evaluable women, of whom 932 (98.3%) were heterosexual and 16 (1.7%) were lesbian. Previous heterosexual intercourse was reported by 69% of lesbian women and their most frequent diagnosis was bacterial vaginosis (38%). The majority of heterosexual women were white (78%) and 16% were black. The black women were more likely to be teenagers (18% cf 8%; p = 0.0004) or students (28% cf 15%; p = 0.0008), and to have had an earlier coitarche (48% cf 38% before aged 17; p < 0.004). They also had a higher proportion of pregnancies (58% cf 38%; p < 0.00001) and births (38% cf 20%; p < 0.00001). The white women showed significantly more sexual partners during the preceding year (p = 0.004) and in total (p < 0.00001) and more reported non-regular partners (48% cf 35%; p = 0.004) with whom they were more likely to use condoms (p = 0.009). However, the black women were more likely to have gonorrhoea (7% cf 2% p < 0.0003), chlamydial infection (12% cf 5% p < 0.002), trichomoniasis (10% cf 2% p < 0.00001), or to sexual contacts of men with non-gonococcal urethritis (19% cf 12% p < 0.02). They were less likely to have genital warts (3% cf 12% p = 0.002). Logistic regression showed that all these variables were independently associated with the black women. The Asian women (2%), none of whom had a sexually transmitted disease, had commenced
Savage, E J; Mohammed, H; Leong, G; Duffell, S; Hughes, G
A new electronic surveillance system for sexually transmitted infections (STIs) was introduced in England in 2009. The genitourinary medicine clinic activity dataset (GUMCAD) is a mandatory, disaggregated, pseudo-anonymised data return submitted by all STI clinics across England. The dataset includes information on all STI diagnoses made and services provided alongside demographic characteristics for every patient attendance at a clinic. The new system enables the timely analysis and publication of routine STI data, detailed analyses of risk groups and longitudinal analyses of clinic attendees. The system offers flexibility so new codes can be introduced to help monitor outbreaks or unusual STI activity. From January 2009 to December 2013 inclusive, over twenty-five million records from a total of 6,668,648 patients of STI clinics have been submitted. This article describes the successful implementation of this new surveillance system and the types of epidemiological outputs and analyses that GUMCAD enables. The challenges faced are discussed and forthcoming developments in STI surveillance in England are described.
Alawattegama, A B; Rajamanoharan, S; Maw, R; Carne, C A
A questionnaire was circulated to all lead genitourinary (GU) medicine physicians in the UK in November 2003 to obtain data on access, waiting times and triaging. Of the 143 responders, 92.3% departments had limited access to some or all GU medicine clinics. Where access was limited, 5.3% had no identifiable process in place to see urgent patients. The mean waiting times in clinics with an open appointment system only for a routine female and male appointment were 2.9 weeks and 2.8 weeks (range 2 days-10 weeks), respectively, and for an urgent appointment, two days (range same day-14 days), for both sexes. The survey has raised concerns that a number of departments did not consider as urgent for prioritizing, patients with documented untreated gonorrhoea, syphilis, or HIV, or contacts of patients with these conditions. This survey has highlighted a need for the national specialist society to provide guidance on prioritizing patients where access is limited.
Tittle, Victoria; Bull, Lauren; Boag, Fiona
This audit aimed to review clinical standards for Trichomonas vaginalis against British Association of Sexual Health and HIV (BASHH) guidelines. Case notes for patients who had a positive microscopy or culture result were reviewed retrospectively. There was a 0.23% positivity rate for T. vaginalis (n = 84 cases); 96% were female with an average age of 33 years, with proportionally more patients seen in the African/Caribbean population, despite the number of cases being comparable between white (n = 36) and African/Caribbean (n = 34) groups. Seventy percent of patients had both microscopy- and culture-positive results for T. vaginalis. Contact tracing occurred in 87% of patients; 56% of these patients confirmed at least one contact had been treated in the last month. Overall, our data demonstrated a lower positivity rate than expected. Wet microscopy and liquid medium cultures were both important in identifying the infection, but more needs to be done to ensure partner notification has been documented and contacts have been treated.
Hughes, G; Catchpole, M; Rogers, P A; Brady, A R; Kinghorn, G; Mercey, D; Thin, N
To compare the risk factors for four common sexually transmitted infections (STIs) in attenders at three large urban genitourinary medicine (GUM) clinics in England. Clinical, demographic, and behavioural data on attenders at two clinics in London and one in Sheffield were collected. Risk factors associated with first episodes of genital warts and genital herpes simplex virus (HSV), and uncomplicated gonorrhoea and chlamydia were investigated using the presence of each of these STIs as the outcome variable in separate multiple logistic regression analyses. Using data on the first attendance of the 18,238 patients attending the clinics in 1996, the risk of a gonorrhoea or chlamydia diagnosis was strongly associated with teenagers compared with those aged over 34, with black Caribbeans and black Africans compared with whites, and increased with the number of sexual partners. The risk of genital warts or HSV diagnosis was lowest in black Caribbeans and black Africans compared with whites and was not associated with the number of sexual partners. While genital warts were associated with younger age, odds ratios were much lower compared with those for the bacterial infections. Genital HSV diagnoses were not associated with age. This study of GUM clinic attenders suggests a reduction in the incidence of bacterial STIs may be achievable through targeted sexual health promotion focusing particularly on black ethnic minorities, teenagers, and those with multiple sexual partnerships. Viral STIs were less clearly associated with population subgroups and a broader population based approach to sexual health promotion may be more effective in controlling these infections.
Ward, D J; Rowe, B; Pattison, H; Taylor, R S; Radcliffe, K W
Are behavioural interventions effective in reducing the rate of sexually transmitted infections (STIs) among genitourinary medicine (GUM) clinic patients? Systematic review and meta-analysis of published articles. Medline, CINAHL, Embase, PsychINFO, Applied Social Sciences Index and Abstracts, Cochrane Library Controlled Clinical Trials Register, National Research Register (1966 to January 2004). Randomised controlled trials of behavioural interventions in sexual health clinic patients were included if they reported change to STI rates or self reported sexual behaviour. Trial quality was assessed using the Jadad score and results pooled using random effects meta-analyses where outcomes were consistent across studies. 14 trials were included; 12 based in the United States. Experimental interventions were heterogeneous and most control interventions were more structured than typical UK care. Eight trials reported data on laboratory confirmed infections, of which four observed a greater reduction in their intervention groups (in two cases this result was statistically significant, p < 0.05). Seven trials reported consistent condom use, of which six observed a greater increase among their intervention subjects. Results for other measures of sexual behaviour were inconsistent. Success in reducing STIs was related to trial quality, use of social cognition models, and formative research in the target population. However, effectiveness was not related to intervention format or length. While results were heterogeneous, several trials observed reductions in STI rates. The most effective interventions were developed through extensive formative research. These findings should encourage further research in the United Kingdom where new approaches to preventing STIs are urgently required.
Swarbrick, C; Foley, E; Sanmani, L; Patel, R
Patients who do not attend (DNA) clinic appointments are wasteful of resources and may also pose a potential public health risk through the onward transmission of untreated sexually transmitted infections (STIs). This service evaluation was performed to assess the demographics of DNAs, patient reasons for non-attendance and follows up data to determine the health outcomes of non-attendance. The genitourinary (GU) medicine clinic DNA rate between October 2008 and March 2009 was 6% (383/6961). Of the 383 patients who DNA'd their appointment successful telephone contact was made in 182 (48%) of them. Of these 40% of patients reported that they had forgotten they held an appointment; no patients reported that clinic opening hours prevented their attendance. Telephone contact increased GU medicine clinic attendance by 9% (35/383), but led to a greater number of subsequent DNAs; 43/75 (63%) of patients who accepted a further appointment DNA'd that appointment. Sending a SMS text message to patients who DNA notifying them of the time of walk-in services might be the most effective way of recapturing these patients without compromising future clinic appointment slots.
Clarke, J; Christodoulides, H; Taylor, Y
To attempt to assess demand for access to sexual health services in a community where a "closed" appointment system operates in the local genitourinary medicine (GUM) clinic. A large GUM clinic serving a provincial city in England. Appointments for new episodes are available only 1 or 2 days ahead. Service user complaints about repeated difficulty in getting through to book a visit prompted a review of all methods of access. A prospective review of all calls received in the departmental telephone booking service was performed. Temporary extra staff manned a cascade sequence of telephone lines and recorded all calls and caller characteristics such as age and declaration of symptoms. All attempts to book an appointment in person, by written referral, or by telephone in a period of 5 working days were also logged. This total demand was compared with the actual capacity and maximum theoretical capacity of the clinic during the same time period. 626 appointments would be required in the working week to accommodate all patients within 48 hours of requesting to be seen. 84% of all calls requested a new appointment, and 77% all new appointment requests were by phone. There were 181 new appointments available; 72% of those requesting an appointment could not be seen. The clinic was working at 103% capacity. To accommodate demand at this quiet time of the academic year, the GUM service would need to increase capacity by 3-4-fold. Closed appointment systems in GUM services may produce an apparent "improvement" in waiting times to 48 hours, but many callers are not able to book an appointment at all. Demand for GUM services outstrips capacity to an extent that internal efficiency savings cannot hope to address.
Adlington, R; Browne, R
An audit of all patients presenting to an inner city sexual health clinic post-sexual assault over a four-year period was undertaken to evaluate the overall management of these patients. Sixty-five cases were identified; 22.6% had a pre-existing vulnerability factor and 21.0% a sexually transmitted infection (STI). Recommendations from the audit included: to offer non-invasive methods of testing for STIs to patients presenting at less than one week, improve documentation by completing the specific clinic template and ensure all patients are offered emotional support when they first attend.
Hegazi, Aseel; Daley, Natalie; Williams, Elizabeth; McLeod, Felicity; Rafiezadeh, Saba; Prime, Katia
Young people attending genitourinary medicine services are at high risk of unplanned pregnancy. We performed a retrospective cohort study to identify characteristics of pregnant teenagers accessing an inner London genitourinary medicine service. There were 481 pregnancies in 458 teenagers with 54 previous pregnancies and 46 previous terminations of pregnancy. The under-18 and under-16 teenage pregnancy rates were 92.1 and 85.8 per 1000 age-matched clinic attendees, respectively. Median age was 17.1 years. 'Black Other' teenagers ('Black British', 'Mixed White-Black Caribbean' and 'Mixed White-Black African') were over-represented, compared to our clinic population, while those of White ethnicity were under-represented. Few pregnancies (1.5%) were planned with the majority (64%) intending terminations of pregnancy. Most teenagers did not use consistent contraception. Two-thirds of patients had attended genitourinary medicine services in the past and sexually transmitted infection prevalence at presentation was high. Effectively targeting the sexual and reproductive health needs of teenage genitourinary medicine clinic attendees may have a significant impact on reducing sexually transmitted infections, unplanned pregnancy and terminations of pregnancy in this group.
Ahmed-Jushuf, I; Griffiths, V
Rates of sexually transmitted infections have continued to rise in recent years throughout the UK. Poor access to genitourinary medicine clinics has been highlighted as a major factor contributing to this increase. Despite a lack of investment in sexual health services, capacity for new patients has almost doubled over the past decade. However, a significant amount of unreleased capacity is still available within the service. This 'Six Sigma' study group was formed in 2003 to explore whether capacity could be enhanced by further reducing the ratio of follow-up to new-case patient visits. Following implementation of recommended changes, the mean follow-up to new-case ratio reduced from 0.82 (range 0.29-1.69) to 0.62 (range: 0.19-1.40). Crucially, this increase in capacity was achieved without adversely affecting quality of care. The Six Sigma group have developed the tools to release capacity in a controlled and validated way and are keen to help other clinics achieve similar results.
Newell, A; Herbert, E; Vigus, J; Grieg, A; Rodgers, M E
The management and outcome of all cases of gonorrhoea which presented to a south London genitourinary medicine clinic during 1999 were assessed and compared with published national guidelines. The incidence of penicillin resistance was calculated, as was the rate of co-infection with chlamydia and trichomonas. Information regarding demographic data, microscopy, culture results, test of cure, antibiotic use, sensitivity and health adviser contact was examined. A total of 257 cases of gonorrhoea were diagnosed in 238 patients. Heterosexual men constituted 52.9% of cases, 6.6% were in homosexual men and 40.5% in women. Direct microscopy was positive in 88.8% of men and in 40.5% of women. In women, the rate of gonorrhoea co-infection with chlamydia was 34.7% and with trichomonas was 11.5%. In men the rate of chlamydia co-infection was only 3.3%, however, we do not believe this to be an accurate figure as we are unable to routinely screen all men for chlamydia due to financial restrictions. Amoxicillin with probenecid were the most commonly used antibiotics in line with local guidelines. Penicillin resistance was demonstrated in 4.6% of infected cases. Health advisers saw 73.2% of patients.
Rogers, D J; Roberts, R E
Whenever a child is seen in a genitourinary clinic the possibility that the child is the victim of child sexual abuse must be considered. This article considers the definition and postulated prevalence of child sexual abuse in England and Wales. A proposed management plan is then detailed with a review of the significance of the medical findings. Finally consideration is given to the ethical dilemmas which such cases pose. Images PMID:7750955
Ratliff, T.L.; Catalona, W.J.
This book contains 12 chapters. Some of the chapter titles are: Isoenzymes in Prostate Cancer; Growth Facgors in Urology; Methods of Detecting Prostatic Tumors; Oncogenes and Genitourinary Neoplasia; BCG Immunotherapy for Superficial Bladder Cancer; and the Role of Flow Cytometry in Urologic Oncology.
An early evaluation of clinical and economic costs and benefits of implementing point of care NAAT tests for Chlamydia trachomatis and Neisseria gonorrhoea in genitourinary medicine clinics in England.
Turner, Katherine M E; Round, Jeff; Horner, Patrick; Macleod, John; Goldenberg, Simon; Deol, Arminder; Adams, Elisabeth J
To estimate the costs and benefits of clinical pathways incorporating a point of care (POC) nucleic acid amplification test (NAAT) for chlamydia and gonorrhoea in genitourinary medicine (GUM) clinics compared with standard off-site laboratory testing. We simulated 1.2 million GUM clinic attendees in England. A simulation in Microsoft Excel was developed to compare existing standard pathways of management for chlamydia and gonorrhoea with a POC NAAT. We conducted scenario analyses to evaluate the robustness of the model findings. The primary outcome was the incremental cost-effectiveness ratio. Secondary outcomes included the number of inappropriate treatments, complications and transmissions averted. The baseline cost of using the point of POC NAAT was £103.9 million compared with £115.6 million for standard care. The POC NAAT was also associated with a small increase of 46 quality adjusted life years, making the new test both more effective and cheaper. Over 95 000 inappropriate treatments might be avoided by using a POC NAAT. Patients receive diagnosis and treatment on the same day as testing, which may also prevent 189 cases of pelvic inflammatory disease and 17 561 onward transmissions annually. Replacing standard laboratory tests for chlamydia and gonorrhoea with a POC test could be cost saving and patients would benefit from more accurate diagnosis and less unnecessary treatment. Overtreatment currently accounts for about a tenth of the reported treatments for chlamydia and gonorrhoea and POC NAATs would effectively eliminate the need for presumptive treatment.
Lee, J D; Carlin, E M; Robinson, A
Workforce planning is an inexact science. Specialty and Associate Specialist (SAS) doctors are rarely included in workforce analyses. Past studies have shown that SAS doctors are significant contributors to the work in genitourinary (GU) medicine clinics. This survey confirms the large amount of clinical work undertaken by SAS doctors. It appears that 51% of SAS doctors in GU plan to retire in the next 15 years and it is uncertain what effect the 2008 SAS contract will have on SAS recruitment. This information should be taken into consideration in future GUM workforce planning.
Djuretic, T; Catchpole, M; Bingham, J S; Robinson, A; Hughes, G; Kinghorn, G
Recent increases in the incidence of sexually transmitted disease (STD) in the UK have given rise to concerns over the ability of genitourinary medicine (GUM) services to cope with increased demands. We conducted a postal survey to assess the capacity of GUM clinics to meet patient demand for both routine and emergency consultations. A questionnaire was sent to all lead GUM physicians in the UK. The response rate was 80%. In some clinics, patients had to wait for up to 28 days for routine appointments. Urgent appointment patients were seen within 24 h by only 54% of clinics and some had to wait for at least one week (5% of clinics). Prolonged waiting times were reported nationwide in addition to widely expressed concerns about the increasing workload. Additional resources should be made available to GUM services if the population's sexual health is to be improved.
Detailed molecular epidemiology of Chlamydia trachomatis in the population of Southampton attending the genitourinary medicine clinic in 2012-13 reveals the presence of long established genotypes and transitory sexual networks.
Labiran, Clare; Rowen, David; Clarke, Ian Nicholas; Marsh, Peter
Chlamydia trachomatis is the most common sexually transmitted infection (STI) in England. Our objective was to perform a detailed survey of the molecular epidemiology of C. trachomatis in the population of Southampton UK attending the genitourinary medicine clinic (GUM) to seek evidence of sexual network activity. Our hypothesis was that certain genotypes can be associated with specific demographic determinants. 380 positive samples were collected from 375 C. trachomatis positive GUM attendees out of the 3118 who consented to be part of the survey. 302 of the positive samples were fully genotyped. All six of the predominant genotypes possessed ompA locus type E. One ward of Southampton known to contain a large proportion of students had a different profile of genotypes compared to other areas of the city. Some genotypes appeared embedded in the city population whilst others appeared transient. Predominant circulating genotypes remain stable within a city population whereas others are sporadic. Sexual networks could be inferred but not conclusively identified using the data from this survey.
Clarke, J; Christodoulides, H; Taylor, Y
Aim To attempt to assess demand for access to sexual health services in a community where a “closed” appointment system operates in the local genitourinary medicine (GUM) clinic. Setting A large GUM clinic serving a provincial city in England. Appointments for new episodes are available only 1 or 2 days ahead. Service user complaints about repeated difficulty in getting through to book a visit prompted a review of all methods of access. Methods A prospective review of all calls received in the departmental telephone booking service was performed. Temporary extra staff manned a cascade sequence of telephone lines and recorded all calls and caller characteristics such as age and declaration of symptoms. All attempts to book an appointment in person, by written referral, or by telephone in a period of 5 working days were also logged. This total demand was compared with the actual capacity and maximum theoretical capacity of the clinic during the same time period. Results 626 appointments would be required in the working week to accommodate all patients within 48 hours of requesting to be seen. 84% of all calls requested a new appointment, and 77% all new appointment requests were by phone. There were 181 new appointments available; 72% of those requesting an appointment could not be seen. The clinic was working at 103% capacity. To accommodate demand at this quiet time of the academic year, the GUM service would need to increase capacity by 3–4‐fold. Conclusions Closed appointment systems in GUM services may produce an apparent “improvement” in waiting times to 48 hours, but many callers are not able to book an appointment at all. Demand for GUM services outstrips capacity to an extent that internal efficiency savings cannot hope to address. PMID:16461602
Sourial, Michael W.; Brimo, Fadi; Horn, Ruth; Andonian, Sero
Introduction: Although tuberculosis (TB) is the most common cause of mortality from infectious diseases worldwide, genitourinary TB in North America is rare. We review 3 cases of genitourinary TB diagnosed within the last 5 years. Cases: The first case is that of a 76-year-old African-Canadian woman who was referred for percutaneous nephrolithotomy of right lower pole renal stones. Although renal TB was suspected, her initial urinary TB culture was negative. On follow-up imaging, she developed bilateral ureteral thickening and ureteroscopic biopsy confirmed necrotizing granulomata. Repeat urine cultures were positive for M. tuberculosis. The second case is a 73-year-old Italian-Canadian woman who was referred for ureteroscopic biopsy of left thickened ureter to rule out urothelial carcinoma. Initial urine TB cultures were negative, despite biopsies confirming granulomatous inflammation. She was closely followed with urine cytologies and TB cultures. Repeat urine culture was positive for M. tuberculosis. Both patients were treated with a course of anti-tuberculous agents and indwelling ureteral stents to relieve ureteral obstruction. The third case is a 70-year-old Cree woman who was referred for percutaneous nephrolithotomy of a left “staghorn stone” in an atrophic left kidney. Thirty years earlier she had been treated for pulmonary TB in addition to ileocystoplasty for a “thimble” bladder. A computed tomography scan showed autonephrectomized left kidney. Her urine TB cultures were negative. She was placed on prophylactic antibiotics for her recurrent bacterial urinary tract infections. Conclusion: Genitourinary TB may present in various subtle ways, and the astute clinician must have a high index of suspicion for this disease in patients with atypical clinical and radiologic findings. In addition, TB urine cultures should be repeated when there is high index of suspicion. PMID:26279721
Kellock, D J; Bingwa, E; Carlin, E M
Access to genitourinary (GU) medicine services is crucial for the effective control of infection and it is well recognized that improved access to GU medicine will be required in order to meet a 48-hour access target. The object of this study was to evaluate whether access to our GU medicine service would be improved and the observed default rates decreased by the introduction of a partial closed booking system for new patients. The system was run in parallel to our standard appointment service and triage system. Data were collected for the first six months that the new system was operational, with additional data collection over the corresponding calendar periods of the subsequent two years. Approximately 26% of new patient appointments were booked through the partial closed booking system in the time periods specified. New patient appointment default rates fell from 26.8-30.5% in the standard appointment system to 7.5-9.5% in the partial closed booking system (P < 0.0001). This study supports the importance of clinics adapting and providing a range of appointment system strategies as this may improve their clients' access to GU medicine services.
Incidence and reinfection rates of genital chlamydial infection among women aged 16–24 years attending general practice, family planning and genitourinary medicine clinics in England: a prospective cohort study by the Chlamydia Recall Study Advisory Group
LaMontagne, D Scott; Baster, Kathleen; Emmett, Lynsey; Nichols, Tom; Randall, Sarah; McLean, Louise; Meredith, Paula; Harindra, Veerakathy; Tobin, Jean M; Underhill, Gillian S; Hewitt, W Graham; Hopwood, Jennifer; Gleave, Toni; Ghosh, Ajit K; Mallinson, Harry; Davies, Alisha R; Hughes, Gwenda; Fenton, Kevin A
Background In England, screening for genital chlamydial infection has begun; however, screening frequency for women is not yet determined. Aim To measure chlamydia incidence and reinfection rates among young women to suggest screening intervals. Methods An 18‐month prospective cohort study of women aged 16–24 years recruited from general practices, family planning clinics and genitourinary medicine (GUM) clinics: baseline‐negative women followed for incidence and baseline‐positive women for reinfection; urine tested every 6 months via nucleic acid amplification; and behavioural data collected. Extra test and questionnaire completed 3 months after initial positive test. Factors associated with infection and reinfection investigated using Cox regression stratified by healthcare setting of recruitment. Results Chlamydia incidence was mean (95% CI) 4.9 (2.7 to 8.8) per 100 person‐years (py) among women recruited from general practices, 6.4 (4.2 to 9.8) from family planning clinics and 10.6 (7.4 to 15.2) from GUM clinics. Incidence was associated with young age, history of chlamydial infection and acquisition of new sexual partners. If recently acquiring new partners, condom use at last sexual intercourse was independently associated with lower incidence. Chlamydia reinfection was mean (95% CI) 29.9 (19.7 to 45.4) per 100/person‐year from general practices, 22.3 (15.6 to 31.8) from family planning clinics and 21.1 (14.3 to 30.9) from GUM clinics. Factors independently associated with higher reinfection rates were acquisition of new partners and failure to treat all partners. Conclusions Sexual behaviours determined incidence and reinfection, regardless of healthcare setting. Our results suggest annual screening of women aged 16–24 years who are chlamydia negative, or sooner if partner change occurs. Rescreening chlamydia‐positive women within 6 months of baseline infection may be sensible, especially if partner change occurs or all partners are
Nyatsanza, Farai; Trivedy, Anisha; Brook, Gary
Starting July 2013, all patients attending a sexual health clinic who reported risk of extra-genital infection were offered self-taken extra-genital swabs. The study aim was to assess the detection rate of extra-genital infection since self-taken swabs were introduced. We compared patients diagnosed with chlamydia and gonorrhoea in six-month periods before (February-July 2012) and after (February-July 2014) the introduction of self-taken extra-genital swabs. There were 408 (98 gonorrhoea, 310 chlamydia) detected infections in the 2012 period and 404 (121 gonorrhoea, 283 chlamydia) in 2014. The rate of extra-genital chlamydia/gonorrhoea increased fourfold from 18/408, 4.4% to 77/404 19% (P < 0.0001). The rise was seen in both rectal (8/408, 2% vs. 40/404, 9.9%, P < 0.0001) and pharyngeal infection (10/408, 2.5% vs. 48/404, 11.8% P < 0.0001). Significant rises were seen in men who have sex with men in rectal (5/408, 1.2% vs. 28/404, 6.9% P = 0.001) and pharyngeal infection (10/408, 2.5% vs. 20/404, 5%, P = 0.02) and for women in rectal (3/408, 0.7% vs. 12/404, 3% P = 0.03) and pharyngeal infection (0/408, 0% vs. 20/404, 5%, P < 0.0001). In 100 consecutive patients having extra-genital swabs in each study period, self-swabbing rose from 0% (0/100) to 89% (89/100) P < 0.0001. The introduction of routine self-taken extra-genital swabs has led to a large rise in detected extra-genital chlamydia and/or gonorrhoea infection in men who have sex with men and women.
Laverty, Susan; Pugh, R Nicholas; Joseph, A T
The House of Commons Health Select Committee recently described a national crisis in sexual health. Alarmed by dramatic increases in the rates of sexually transmitted infections (STIs) and appalled by over-stretched, under-resourced genitourinary (GU) medicine services, the committee has called for urgent action. The increasing rates of STIs locally, a significant cluster of syphilis cases, and an over-burdened GU medicine service prompted Walsall primary care trust to undertake an evaluation of local service provision. The results were used to inform the development of GU medicine services locally and Walsall's sexual health strategy. This paper reports the results of the evaluation and the implications for service development. The Walsall GU medicine service was evaluated using three approaches, based on standards for GU medicine service provision identified from the literature. Routine data were used to analyse trends in STIs and service activity, including access times. These data further informed the evaluation process. Local stakeholder views on GU medicine service provision were sought using semi-structured interviews. Most standards relating to the provision of core services, including those for the management of patients with HIV infection, were met. High levels of patient satisfaction were reported. However, under-staffing, inadequate clinic facilities, and limited joint working with other agencies were highlighted as key concerns. Tackling sexual health inequalities and improving the sexual health of the population requires investment in resources and manpower, improved partnership working, and configuring services around the needs of patients. In addition, and perhaps most importantly, it will require a shift in how both health professionals and the public perceive and utilize sexual health services.
Russell, J M; Cracknell, M; Barton, S E; Catalan, J
OBJECTIVE--To determine the variation in management of genital herpes by genitourinary physicians, and whether their duration of experience or gender influence their clinical management. METHODS--A postal questionnaire was sent to UK consultant genitourinary physicians with detailed questions about management of primary and recurrent herpes. The gender and duration of genitourinary medicine experience of the physicians were also recorded. RESULTS--One hundred and eighty two questionnaires were sent, 112 (62%) returned. Eighty-one (72%) physicians treat all patients with primary genital herpes, but physicians with more than 20 years experience were significantly (p < 0.05) more likely to treat only "severe" primary attacks. Most experienced physicians were also most likely (p < 0.05) to prescribe topical acyclovir. Prescription of suppressive acyclovir was also influenced by the experience of the physician, the least experienced physicians being more likely to prescribe to patients who were HIV antibody positive or to those entering new relationships, whereas the more experienced prescribed to those patients who were particularly anxious (p < 0.05 for each of these). Male physicians were significantly more likely to agree with the proposition that men cope better with genital herpes (54%) than female physicians (24%, p < 0.01). CONCLUSION--The response to the questionnaire illustrates that management of genital herpes is influenced by the duration of the physicians clinical experience. Gender of the physician may have an indirect role to play as we have shown that physicians differ in their perception of how the sexes cope with genital herpes. PMID:8509090
Buti, Sebastiano; Ciccarese, Chiara; Iacovelli, Roberto; Bersanelli, Melissa; Scarpelli, Marina; Lopez-Beltran, Antonio; Cheng, Liang; Montironi, Rodolfo; Tortora, Giampaolo; Massari, Francesco
The American Society of Clinical Oncology Genitourinary Cancers Symposium, Moscone West Building, San Francisco, CA, USA, 7-9 January 2016 The American Society of Clinical Oncology (ASCO) Genitourinary Cancers Symposium, held in San Francisco (CA, USA), from 7 to 9 January 2016, focused on 'patient-centric care: translating research to results'. Every year, this meeting is a must for anyone studying genitourinary tumors to keep abreast of the most recent innovations in this field, exchange views on behaviors customarily adopted in daily clinical practice, and discuss future topics of scientific research. This two-part report highlights the key themes presented at the 2016 ASCO Genitourinary Cancers Symposium, with part 1 reporting the main novelties of kidney cancer and part 2 discussing the most relevant issues which have emerged for bladder and prostate tumors.
Jaleel, H.; Narouz, N.; Wade, A. A.; Allan, P. S.
Penile intraepithelial neoplasia (PIN) is a clinically well known condition. However, its diagnosis is often difficult. We present four cases of PIN, seen in our department. Various histological patterns ranging from PIN I to PIN III were noted in these cases. PMID:10754953
Ahmed-Jushuf, I; Griffiths, V
Significant increases in genitourinary (GU) medicine clinic workloads throughout the UK have resulted in an unmet demand for appointments, and increased waiting times. In order to meet the government target of a 48-hour maximum waiting time for all patients, many clinics are modernising current practices to increase capacity and improve access to services. The 'Six Sigma' study group of 12 GU medicine clinics which was formed in 2003 to investigate means of enhancing capacity of GU medicine services, has demonstrated that there is a significant amount of unreleased capacity within UK clinics. In this article, the Six Sigma group present potential actions which other GU medicine clinics in the UK may be able to apply and thereby release additional capacity. Example case studies from the Six Sigma study are also presented, illustrating the applicability of this model throughout the UK. The findings of the Six Sigma project offer GU medicine clinics across the UK the opportunity to increase capacity, without adversely affecting quality of care.
Kapoor, Rakesh; Ansari, M. S.; Mandhani, Anil; Gulia, Anil
Objective: We herein describe the various modes of presentation in genitourinary tuberculosis (GUTB) and a simple diagnostic approach to it. Materials and Methods: We made a literature search through Medline database and various other peer-reviewed online journals to study the various modes of presentation in GUTB. We reviewed over 100 articles published in the last 10 years (1998 -- 2007), which were tracked through the key words like GUTB and extrapulmonary tuberculosis. Results: GUTB has varied presentation and the most common way of presentation is in the form of irritative voiding symptoms, which are found in more than 50% of the patients. The usual frequency of organ involvement is: kidney, bladder, fallopian tube, and scrotum. The usual tests used to diagnose GUTB are the demonstration of mycobacterium in urine or body fluid and radiographic examination. Intravenous urography (IVU) has been considered to be one of the most useful tests for the anatomical as well as the functional details of kidneys and ureters. In cases of renal failure, MRI can be used. Newer examinations such as radiometric liquid culture systems (i.e., BACTEC®, Becton Dickinson, USA) and polymerase chain reaction (PCR) give rapid results and are highly sensitive in the identification of mycobacterium. Conclusion: GUTB can involve any part of the genitourinary system and presentation may vary from vague urinary symptoms to chronic kidney disease. Newer tests like radiometric liquid culture systems and polymerase chain reaction give rapid results and carry high diagnostic value. PMID:19468477
Hawkes, S; Hart, G J; Bletsoe, E; Shergold, C; Johnson, A M
OBJECTIVE--To investigate the travel history of clients presenting at a genitourinary medicine (GUM) clinic in order to assess the contribution made by sexual partnerships abroad to STD transmission in the UK. SUBJECTS--386 old and new clients who attended during a 3-month period and who had travelled abroad in the 3 months preceding their visit. METHODS--All participating clients self-completed a confidential questionnaire, the results of which were then linked to their clinical diagnosis (if any). RESULTS--25% of participants reported a new sexual partner during their most recent trip abroad. In comparison to those not reporting a new partner, they were more likely to be male, travelling alone, to have visited the clinic previously and to have no regular sexual partner. Two-thirds reported never or inconsistently using condoms with these new partners. A total of 11.6% of the STDs diagnosed in the study participants may have been acquired abroad. CONCLUSION--We have found a high rate of new sexual relationships reported by attendees at our GUM clinic, and a low rate of reported condom use. With high HIV incidence rates in many tourist regions, the need for further studies to establish the true extent of imported STDs in the UK is a priority, and primary prevention campaigns to inform travellers are of paramount importance. PMID:8566971
Hugen, Cory M.; Zainfeld, Daniel E.; Goldkorn, Amir
Precision medicine with molecularly directed therapeutics is rapidly expanding in all subspecialties of oncology. Molecular analysis and treatment monitoring require tumor tissue, but resections or biopsies are not always feasible due to tumor location, patient safety, and cost. Circulating tumor cells (CTCs) offer a safe, low-cost, and repeatable tissue source as an alternative to invasive biopsies. “Liquid biopsies” can be collected from a peripheral blood draw and analyzed to isolate, enumerate, and molecularly characterize CTCs. While there is deserved excitement surrounding new CTC technologies, studies are ongoing to determine whether these cells can provide reliable and accurate information about molecular drivers of cancer progression and inform treatment decisions. This review focuses on the current status of CTCs in genitourinary (GU) cancer. We will review currently used methodologies to isolate and detect CTCs, their use as predictive biomarkers, and highlight emerging research and applications of CTC analysis in GU malignancies. PMID:28191452
Udager, Aaron M; Alva, Ajjai; Mehra, Rohit
The idea that detailed knowledge of molecular oncogenesis will drive diagnostic, prognostic, and therapeutic clinical decision making in an increasingly multidisciplinary practice of oncologic care has been anticipated for many years. With the recent rapid advancement in our understanding of the molecular underpinnings of genitourinary malignancies, this concept is now starting to take shape in the fields of prostate, kidney, bladder, testicular, and penile cancer. Such breakthroughs necessitate the development of robust clinical-grade assays that can be quickly made available for patients to facilitate diagnosis in challenging cases, risk-stratify patients for subsequent clinical management, select the appropriate targeted therapy from among increasingly diverse and numerous options, and enroll patients in advanced clinical trials. This rapid translation of basic and clinical cancer research requires a streamlined, multidisciplinary approach to clinical assay development, termed here the molecular diagnostics service line laboratory. In this review, we summarize the current state and explore the future of molecular diagnostics in genitourinary oncology to conceptualize a genitourinary service line laboratory at a tertiary clinical institution.
Hunter, Jennifer M; Young, Hugh; Harris, A B
Ureaplasma urealyticum was detected in the cervix of 49·9% and in the urine of 47·7% of women attending a department of genitourinary medicine. Isolation of U urealyticum was not related to diagnosis, nor was there any association between the presence of the organism and any symptoms or signs of genital tract disease. Fewer organisms were detected in the cervix of women who had a concurrent infection with Chlamydia trachomatis than in women who had not. A pathological role for U urealyticum has not been established. PMID:7296255
Buti, Sebastiano; Ciccarese, Chiara; Iacovelli, Roberto; Bersanelli, Melissa; Scarpelli, Marina; Lopez-Beltran, Antonio; Cheng, Liang; Montironi, Rodolfo; Tortora, Giampaolo; Massari, Francesco
The American Society of Clinical Oncology Genitourinary Cancers Symposium, Moscone West Building, San Francisco, CA, USA, 7-9 January 2016 The American Society of Clinical Oncology (ASCO) Genitourinary Cancers Symposium, held in San Francisco (CA, USA), from 7 to 9 January 2016, focused on 'patient-centric care: translating research to results'. Every year, this meeting is a must for anyone studying genitourinary tumors to keep abreast of the most recent innovations in this field, exchange views on behaviors customarily adopted in daily clinical practice and discuss future topics of scientific research. This two-part report highlights the key themes presented at the 2016 ASCO Genitourinary Cancers Symposium, with part 1 reporting the main novelties of kidney cancer and part 2 discussing the most relevant issues which have emerged for bladder and prostate tumors.
French, Rebecca S; Mercer, Catherine H; Robinson, Angela J; Gerressu, Makeda; Rogstad, Karen E
Little evidence is available on the extent to which one-stop shops address users' sexual health needs and the extent to which they identify additional needs users may not have identified. As part of the One-Stop Shop Evaluation, a questionnaire was designed to compare the reasons for users' visits and the reported outcomes of visits at a one-stop shop with the experiences of users in separate genitourinary medicine (GUM) and contraceptive clinics. The difference in the proportions of those attending the one-stop shop and those attending the control sites services for a sexually transmitted infection (STI)-related reason who were diagnosed with an STI was minimal, but those attending for an STI-related reason in the one-stop shop were more likely to receive an additional contraceptive outcome. Women attending for a contraceptive-related reason at the one-stop shop were more likely to have an STI screen than those attending the control sites for the same reason, but there was little difference in the proportions amongst this group receiving an STI diagnosis or receiving treatment. When focusing on women attending for a pregnancy-related reason, one-stop shop users were more likely to have received contraceptive advice or supplies. It was not possible in our evaluation to determine the relative effectiveness of the one-stop shop in comparison to the traditional GUM and contraceptive clinics in improving sexual health status, however the one-stop shop was more likely to address additional sexual health needs that service users may not have previously identified.
McClean, H L; Reid, M; Scoular, A
OBJECTIVE--To assess health professionals' views of genitourinary medicine (GUM) services in a large UK city and to determine potential intervention measures for change. METHODS--A postal questionnaire was sent to 205 service providers in a range of sexual health services in Glasgow, including GUM specialist doctors, nurses and health advisers. The questionnaire included structured questions about organisation and use of GUM services, assessment of profile and stigma, and asked about factors most likely to influence future service development. RESULTS--128 questionnaires were returned from areas throughout the city. Non-GUM health professionals had poor factual knowledge about the organisation of GUM services. GUM had a poor profile compared with other sexual health services and stigma was thought to exist about the service. Most non-GUM service providers continue traditionally to regard GUM mainly as a referral centre for a few specific sexually transmitted infections and not as a centre for holistic sexual health care. Genital chlamydial infection and pelvic inflammatory disease were considered low priority for GUM referral by some groups of service providers. These views contrasted with those working in the speciality. There was generally poor professional contact between GUM and other service providers involved in sexual health. Most indicated that greater levels of information and publicity, increased professional contact, and a broader range of services within GUM were important for future service development. CONCLUSIONS--The response to the questionnaire strongly indicates that there is poor awareness of and consequently suboptimal use of the full range of services offered by GUM. Potential interventions to address this need include increased cross-speciality collaboration and targeting of specific groups of service providers involved in sexual health care. Important groups include hospital-based specialists and voluntary agencies as well as general
Choon, S E; Sapiah, W; Ismail, Z; Balan, V
A study was conducted in the Dermatology cum Genitourinary Clinic, Hospital Sultanah Aminah Johor Bahru to determine a local population's knowledge of HIV and their sexual behaviour in relation to it. A total of 231 men and 217 women were interviewed. The sexual culture seen is one of relatively late age of first sexual intercourse, low level of partner change and low level of condom use. Men reported a higher involvement in risk behaviour. Nearly all the respondents (95.8%) have heard of HIV/AIDS but had incorrect perceptions of its mode of transmission and its associations with risk groups. This study enable us to gain background information about our patients sexual behaviour and HIV knowledge. There is a need to continue HIV education to improve our public's HIV knowledge and the results of this study provides a baseline against which future educational interventions can be gauged.
Gazzaneo, Ilanna Fragoso Peixoto; de Queiroz, Camila Maia Costa; Goes, Larissa Clara Vieira; Lessa, Victor José Correia; de Omena, Reinaldo Luna; do Nascimento, Diogo Lucas Lima; Petroli, Reginaldo José; Zanotti, Susane Vasconcelos; Monlleó, Isabella Lopes
Abstract Objective: To describe the profile of patients with genitourinary abnormalities treated at a tertiary hospital genetics service. Methods: Cross-sectional study of 1068 medical records of patients treated between April/2008 and August/2014. A total of 115 cases suggestive of genitourinary anomalies were selected, regardless of age. A standardized clinical protocol was used, as well as karyotype, hormone levels and genitourinary ultrasound for basic evaluation. Laparoscopy, gonadal biopsy and molecular studies were performed in specific cases. Patients with genitourinary malformations were classified as genitourinary anomalies (GUA), whereas the others, as Disorders of Sex Differentiation (DSD). Chi-square, Fisher and Kruskal–Wallis tests were used for statistical analysis and comparison between groups. Results: 80 subjects met the inclusion criteria, 91% with DSD and 9% with isolated/syndromic GUA. The age was younger in the GUA group (p<0.02), but these groups did not differ regarding external and internal genitalia, as well as karyotype. Karyotype 46,XY was verified in 55% and chromosomal aberrations in 17.5% of cases. Ambiguous genitalia occurred in 45%, predominantly in 46,XX patients (p<0.006). Disorders of Gonadal Differentiation accounted for 25% and congenital adrenal hyperplasia, for 17.5% of the sample. Consanguinity occurred in 16%, recurrence in 12%, lack of birth certificate in 20% and interrupted follow-up in 31% of cases. Conclusions: Patients with DSD predominated. Ambiguous genitalia and abnormal sexual differentiation were more frequent among infants and prepubertal individuals. Congenital adrenal hyperplasia was the most prevalent nosology. Younger patients were more common in the GUA group. Abandonment and lower frequency of birth certificate occurred in patients with ambiguous or malformed genitalia. These characteristics corroborate the literature and show the biopsychosocial impact of genitourinary anomalies. PMID:26522823
Pearce, J; Fernando, I
We undertook a retrospective case note review of our monthly multi-specialty penile dermatoses clinic (which includes clinicians from Genitourinary medicine, Dermatology and Urology), to examine conditions presenting to the service, and compare clinical management and outcomes with other similar services in the UK. Over the 3-year study period, 226 patients were reviewed over 240 individual episodes. Lichenoid conditions were the most common category of genital pathologies seen (n = 60, 24%), but non-specific balanitis was the most common individual diagnosis (n = 55, 22%). Other common conditions seen included eczema and psoriasis (n = 28, 11%), Zoon/plasma cell balanitis (n = 26, 10%), malignancy/pre-malignant change (n = 25, 10%) and infective conditions (n = 24, 9%). The clinic had a biopsy rate of 10%; the most common indication was for confirmation of a clinical suspicion of malignancy/pre-malignancy. There was a high clinical-to-histological correlation in the biopsies of 79%. The most common treatment prescribed was topical corticosteroids and the clinic had a high discharge rate of 93%, the majority of patients discharged back to General Practice. © The Author(s) 2014.
Tuberculosis (TB) is a deadly infectious disease. Pulmonary TB cases have decreased; yet, extrapulmonary cases such as genitourinary TB have not (Centers for Disease Control and Prevention, 2005). Health care awareness of the clinical features of genitourinary TB is necessary to effectively treat patients with this disease.
Al-Ghorab, M M; Smith, D R
Schistosomiasis is a chronic granulomatous disease endemic in the Middle East and Africa, which undermines the function of the genitourinary tract to a serious degree. It is amenable to medical treatment in the early stages but therapy usually is negated by frequent reinfestations. Patients who have complications in the chronic stage of the disease require the level of judicious handling that always taxes the ingenuity and skill of the urologic surgeon.
Goldberg, D; Cameron, S; Sharp, G; Burns, S; Scott, G; Molyneaux, P; Scoular, A; Downie, A; Taylor, A
Our objective is to gauge the prevalence of hepatitis C virus (HCV) antibodies among a population at risk of contracting sexually transmitted infections (STIs) and, thus, the efficiency with which the virus is transmitted sexually. The investigators undertook an unlinked anonymous HCV antibody testing study of residual syphilis serology specimens taken from attenders of genitourinary clinics in Glasgow, Edinburgh and Aberdeen during 1996/97. The results were linked to non-identifying risk information. Anti-HCV prevalences among non-injecting heterosexual men and women, and non-injecting homosexual/bisexual males ranged between 0 and 1.2%; the only exception to this was a 7.7% (4/52) prevalence among homosexual/bisexual males in Aberdeen. The overall anti-HCV prevalence for homosexual/bisexual males was 0.6% (4/668), for heterosexual males 0.8% (32/4135), for heterosexual females 0.3% (10/3035) and for injecting drug users 49% (72/148). Only 3 (all female) of the 46 non-injectors who were antibody positive were non-UK nationals or had lived abroad. HCV antibody positive injectors were less likely to have an acute STI and more likely to know their HCV status than non-injectors; no differences in these parameters were found between positive and negative non-injectors on anonymous HCV antibody testing. Our findings are in keeping with the prevailing view that HCV can be acquired through sexual intercourse but, for most people, the probability of this occurring is extremely low. Interventions to prevent the spread of HCV should be targeted mainly at injecting drug user (IDU) populations.
Higgins, Martin; Chen, Eric Zhong; Gebbie, Ailsa E; Fernando, Imali; Milne, Dona; Cochrane, Rosemary
UK policy documents advocate integrated approaches to sexual health service provision to ensure that everyone can access high-quality treatment. However, there is relatively little evidence to demonstrate any resultant benefits. The family planning and genitourinary medicine services in Lothian have been fully integrated and most care is now delivered from a purpose-built sexual health centre. We wished to study the views of staff on integrated sexual and reproductive care. Staff completed anonymous questionnaires before and after integration, looking at four main aspects: the patient pathway, specific patient groups, their own professional status, and their working environment. The surveys used a mixture of five-point Likert-type scales and open-ended questions. Over 50% of staff completed the surveys on each occasion. Six months after the new building opened, staff attitudes about the integrated service were mixed. Staff reported more stress and less opportunity for specialisation but there was no change in their sense of professional status or development. There were concerns about how well the integrated service met the needs of specific patient groups, notably women. These concerns co-existed with a verdict that overall service quality was no worse following integration. Staff views should form an important part of service redesign and integration projects. Although the results from the Lothian surveys suggest a perceived worsening of some aspects of the service, further evaluation is needed to unpick the different problems that have appeared under the catch-all term of 'integration'. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Wise, Gilbert J; Marella, Venkata K
By the 1980s, the availability of antituberculosis chemotherapy reduced the incidence and prevalence of tuberculosis. Changing patterns of population emigration and the development of large pools of immune-compromised individuals reversed the downward trend of tuberculosis. The incidence of genitourinary tuberculosis has remained constant. The manifestations of GU TB can be variable and cause a variety of clinical patterns that mimic other diseases. Adrenal insufficiency, renal disease, obstructive uropathy, and chronic cystitis are not uncommon with TB. The patient with TB may have genital disease that simulates STD or scrotal tumors. Infertility can be caused by GU tuberculosis. Awareness of environmental factors and patient history should alert the urologist to the wide array of clinical findings in the genitourinary system that can be caused by tuberculosis.
Obisesan, Oluranti J.; Olowe, Olugbenga A.; Taiwo, Samuel S.
The management of genitourinary candidiasis (GC) is fraught with challenges, especially, in an era of increasing antifungal resistance. This descriptive cross-sectional study conducted between May 2013 and January 2014 determined the prevalence and characteristics of GC and the species of Candida among 369 attendees of a Sexually Transmitted Disease (STD) clinic of Ladoke Akintola University Teaching Hospital, Osogbo, Nigeria. Appropriate urogenital specimen collected from each attendee was examined by microscopy and culture for Candida, with preliminary species identification by CHROMAgar Candida and confirmation by Analytical Profile Index (API) 20C AUX. The age range of attendees was 1-80 years, mean age was 36.32 ± 11.34 years, and male to female ratio was 1 to 3. The prevalence of genitourinary candidiasis was 47.4%, with 4.9% in males and 42.5% in females (p < 0.0001). The age groups 31–45 and 16–30 have the highest prevalence of 23.3% and 16.8%, respectively. The species of Candida recovered include Candida glabrata 46.9%, Candida albicans 33.7%, Candida dubliniensis 9.7%, Candida tropicalis 5.7%, Candida krusei 1.7%, Candida lusitaniae 1.7%, and Candida utilis 0.6%. This study reported non-C. albicans Candida, especially C. glabrata, as the most frequently isolated species in GC, contrary to previous studies in this environment and elsewhere. PMID:26064140
Obisesan, Oluranti J; Olowe, Olugbenga A; Taiwo, Samuel S
The management of genitourinary candidiasis (GC) is fraught with challenges, especially, in an era of increasing antifungal resistance. This descriptive cross-sectional study conducted between May 2013 and January 2014 determined the prevalence and characteristics of GC and the species of Candida among 369 attendees of a Sexually Transmitted Disease (STD) clinic of Ladoke Akintola University Teaching Hospital, Osogbo, Nigeria. Appropriate urogenital specimen collected from each attendee was examined by microscopy and culture for Candida, with preliminary species identification by CHROMAgar Candida and confirmation by Analytical Profile Index (API) 20C AUX. The age range of attendees was 1-80 years, mean age was 36.32 ± 11.34 years, and male to female ratio was 1 to 3. The prevalence of genitourinary candidiasis was 47.4%, with 4.9% in males and 42.5% in females (p < 0.0001). The age groups 31-45 and 16-30 have the highest prevalence of 23.3% and 16.8%, respectively. The species of Candida recovered include Candida glabrata 46.9%, Candida albicans 33.7%, Candida dubliniensis 9.7%, Candida tropicalis 5.7%, Candida krusei 1.7%, Candida lusitaniae 1.7%, and Candida utilis 0.6%. This study reported non-C. albicans Candida, especially C. glabrata, as the most frequently isolated species in GC, contrary to previous studies in this environment and elsewhere.
Chen, Xiao-He; Huang, Shuwen; Kerr, David
Biomarkers have been used in clinical medicine for decades. With the rise of genomics and other advances in molecular biology, biomarker studies have entered a whole new era and hold promise for early diagnosis and effective treatment of many diseases. A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic responses to a therapeutic intervention (1). They can be classified into five categories based on their application in different disease stages: 1) antecedent biomarkers to identify the risk of developing an illness, 2) screening biomarkers to screen for subclinical disease, 3) diagnostic biomarkers to recognize overt disease, 4) staging biomarkers to categorise disease severity, and 5) prognostic biomarkers to predict future disease course, including recurrence, response to therapy, and monitoring efficacy of therapy (1). Biomarkers can indicate a variety of health or disease characteristics, including the level or type of exposure to an environmental factor, genetic susceptibility, genetic responses to environmental exposures, markers of subclinical or clinical disease, or indicators of response to therapy. This chapter will focus on how these biomarkers have been used in preventive medicine, diagnostics, therapeutics and prognostics, as well as public health and their current status in clinical practice.
Newman, W G
Pharmacogenetics, the study of genetic variation relevant to drug metabolism, is a rapidly evolving area of medicine. This brief review will consider some of the recent advances where inherited genetic variants have been associated with either drug efficacy or toxicity. Examples of where pharmacogenetic testing has been adopted into clinical practice will be provided as well as a look at its likely development over the next decade. Finally, the large increase in genetic testing of tumour tissue samples to predict response to molecularly targeted treatments in cancer will be considered.
Baisden, Denise L.; Billica, Roger (Technical Monitor)
The practice of space medicine is diverse. It includes routine preventive medical care of astronauts and pilots, the development of inflight medical capability and training of flight crews as well as the preflight, inflight, and postflight medical assessment and monitoring. The Johnson Space Center Medical Operations Branch is a leader in the practice of space medicine. The papers presented in this panel will demonstrate some of the unique aspects of space medicine.
Baisden, Denise L.; Billica, Roger (Technical Monitor)
The practice of space medicine is diverse. It includes routine preventive medical care of astronauts and pilots, the development of inflight medical capability and training of flight crews as well as the preflight, inflight, and postflight medical assessment and monitoring. The Johnson Space Center Medical Operations Branch is a leader in the practice of space medicine. The papers presented in this panel will demonstrate some of the unique aspects of space medicine.
Purnell, Stephanie; Sidana, Abhinav; Maruf, Mahir; Grant, Campbell; Agarwal, Piyush K
Extra-adrenal paragangliomas (PGLs) are infrequent, benign, and neuroendocrine tumors arising from chromaffin cells of the autonomic nervous system. Most PGLs are sporadic, but up to 32% are associated with inherited syndromes such as neurofibromatosis type 1, von Hippel-Lindau disease, and familial PGL. Although most PGLs develop above the umbilicus, they have been reported in the genitourinary (GU) tract. Owing to the paucity of literature on the rates of GU PGL, the objective of our study is to describe the demographic, pathologic, and clinical characteristics of GU PGL, and compare them to non-GU sites of PGL using the surveillance, epidemiology, and end results (SEER) database. The SEER 18 database was used to identify all cases of PGL from 2000 to 2012. Demographic, pathologic, and clinical characteristics were described using chi-square and t-test for categorical and continuous variables, respectively. The Kaplan-Meier method was used to compare overall survival (OS) between GU and non-GU PGL. Statistical significance was defined as P<0.05. All analyses were performed using excel and SAS/Stat version 9.4. A total of 299 cases of PGL were retrieved from SEER, and 20 (6.7%) of the total PGL arose from the GU tract. The mean age at diagnosis was higher in non-GU than GU PGL (50.4±17.2 vs. 40.8±15.6, P = 0.026). Furthermore, 75% of GU PGLs developed in the bladder, followed by the kidneys/renal pelvis, and spermatic cord (20%). Non-GU PGL developed most frequently within the endocrine system (43%). PGL, overall, was more common in men than in women, and it was more common in whites than all other races. Although 55.5% of GU PGLs were organ confined, only 22.2% of non-GU PGLs were localized at diagnosis. All cases of PGL were treated with surgery. There were 2 cause-specific deaths in the GU PGL groups between 2000 and 2012. The 5-year OS was 93.3% for GU PGL vs. 65.5% in non-GU PGL (P = 0.062). GU PGL remains rare with low incidence (6.7% of all PGL cases) in
Ferreira, Arthur Sá; Lopes, Agnaldo José
Chinese medicine practitioners apply the differentiation reasoning for decision-making. The wide scope of Chinese medicine intervention provides coverage of methods and techniques with applications to primary, secondary and tertiary levels of prevention. The rapid evolution of mathematical and computational techniques allowed the implementation of several models for pattern differentiation that were tested for several physiologic systems. Concurrently, it is argued that pattern differentiation might improve the efficacy of either traditional or conventional medical interventions. This article reviewed the influence of pattern differentiation into clinical practice organized by medical field: general pattern differentiation; genitourinary (recurrent cystitis); cardiovascular (coronary heart disease; arterial hypertension; angina pectoris); neurology (stroke); surgery; metabolic (diabetes mellitus); hepatic (cirrhosis); gastrointestinal (chronic superficial gastritis); orthopedic (low back pain; rheumatoid arthritis; cervical spondylosis; elbow arthritis); oncology (gastric mucosal dysplasia; lung cancer); gynecologic and obstetric manifestations (nausea and vomiting). The reviewed studies presented achievements that have contributed to the integration of Chinese medicine and evidence-based medicine in the treatment of many mild and severe diseases. Target diseases considered as major public health problems were also investigated and the results are promising regarding the possibility to treat guided by pattern differentiation.
Proctor, Ashley; Bianchi, Matt T.
The basic treatment goals of pharmacological therapies in sleep medicine are to improve waking function by either improving sleep or by increasing energy during wakefulness. Stimulants to improve waking function include amphetamine derivatives, modafinil, and caffeine. Sleep aids encompass several classes, from benzodiazepine hypnotics to over-the-counter antihistamines. Other medications used in sleep medicine include those initially used in other disorders, such as epilepsy, Parkinson's disease, and psychiatric disorders. As these medications are prescribed or encountered by providers in diverse fields of medicine, it is important to recognize the distribution of adverse effects, drug interaction profiles, metabolism, and cytochrome substrate activity. In this paper, we review the pharmacological armamentarium in the field of sleep medicine to provide a framework for risk-benefit considerations in clinical practice. PMID:23213564
Diabetes is known to increase the risk of infection and the commonest amongst them are the ones involving the genitourinary tract. The infections in a diabetic patient are unique in that they are recurrent, more severe, requiring hospitalization, and also have higher mortality than nondiabetics. Some infections are exclusively found in diabetics like the emphysematous pyelonephritis while others have their natural history complicated due to hyperglycemia. Asymptomatic bacteriuria may lead to albuminuria and urinary tract infection and may need to be treated in diabetics. Not just this certain organisms have a predilection for the genitourinary tract of the diabetic patient. All of the above makes the diabetic patient vulnerable to infections and therefore early diagnosis and appropriate treatment is mandatory. PMID:24251228
Sacco, E; Marangi, F; Pinto, F; D'Addessi, A; Racioppi, M; Gulino, G; Volpe, A; Gardi, M; Bassi, P F
Statistical data referring to sports-related traumas of the urinary tract are quite scarce; nevertheless, it is possible to draw general data on the relationship between sports and urological traumas. Literature review of peer-reviewed articles published by May 2009. Urological traumas account for about 10% of all traumas, and about 13% of them is sports-related. Genitourinary traumas are among the most common cause of abdominal injuries in sports. Blunt injuries are more common than penetrating ones and renal injuries are by far the most common, followed by testicular injuries; ureters, bladder and penis injuries are much more infrequent. Considering chronic microtraumas, injuries of bulbar urethra are also common in sports that involve riding. Overall, the incidence of genitourinary trauma due to sports is low. Renal traumas in sports injuries usually consist of grade I-II lesions and usually do not require surgical treatment. Cycling is the sporting activity most commonly associated with genitourinary injuries, followed by winter sports, horse riding and contact/collision sports. Literature data suggest that significant injuries are rare also in athletes with only one testicle or kidney. General preventive measures against sport-related injuries, along with the use of protective cups for male external genitalia, are generally sufficient to reduce the incidence of urogenital trauma. Overall, studies show that urogenital injuries are uncommon in team and individual sports, and that most of them are low-grade injuries. Participation in sports that involve the potential for contact or collision needs to be carefully assessed in the athletes with only one testicle or kidney, even though urogenital injuries should not preclude sports participation to an appropriately informed and counseled patient. Further research is needed to acquire more knowledge on genitourinary injuries according to age, sports type and technical skill.
Selected topics in the contemporary clinical medicine are reflected. The main fields of interest and characteristic features unifying theory and praxis are outlined; specificities of clinical thinking and decision making, and conception of clinical medicine as a scientific discipline are presented. Author deals with assurances, various forms of irresolution in clinical medicine and with problems resulting from the scientific progress.
Yuvaraja, T. B.; Waigankar, Santosh; Bakshi, Ganesh; Prakash, Gagan
Tumors of the genitourinary system are one of the most common tumors encountered in clinical practice. The associated morbidity and mortality and the significant proportion of affected middle-age individuals have a major bearing on the death-adjusted life years compared to other malignancies. Genitourinary system tumors encompass a very broad spectrum with regard to age, location, histology, and clinical outcomes. Advances in diagnostic imaging, surgical techniques, radiotherapy equipment, and generation of newer chemotherapeutic and targeted agents over the past few years have helped improving treatment outcome. Several focused groups within India have been working on a range of topics related to genitourinary system tumors, and a significant body of work from India in the recent years is being increasingly recognized throughout the world. The present article summarizes the key published work related to the epidemiology of genitourinary system tumors in the Indian setting. A PubMed search was made for locating and selecting articles relevant to the topic. PMID:27606296
Mileto, Achille; Marin, Daniele
Reignited by innovations in scanner engineering and software design, dual-energy computed tomography (CT) has come back into the clinical radiology arena in the last decade. Possibilities for noninvasive in vivo characterization of genitourinary disease, especially for renal stones and renal masses, have become the pinnacle offerings of dual-energy CT for body imaging in clinical practice. This article renders a state-of-the-art review on clinical applications of dual-energy CT in genitourinary imaging.
Cassese, Mariarita; Zuber, Veronica
Women use more medicines than men because they fall ill more often and suffer more from chronic diseases, but also because women pay more attention to their health and have more consciousness and care about themselves. Although medicines can have different effects on women and men, women still represent a small percentage in the first phases of trials (22%) which are essential to verify drugs dosage, side effects, and safety. Even though women are more present in trials, studies results are not presented with a gender approach. This situation is due to educational, social, ethical and economical factors. The scientific research must increase feminine presence in clinical trials in order to be equal and correct, and all the key stakeholder should be involved in this process. We still have a long way to cover and it doesn't concern only women but also children and old people. The aim is to have a medicine not only illness-focused but patient-focused: a medicine able to take into consideration all the patient characteristics and so to produce a really personalized therapy. What above described is part of the reasons why in 2005 was founded the National Observatory for Women's Health (Osservatorio Nazionale sulla Salute della Donna, ONDa) which promotes a gender health awareness and culture in Italy, at all the levels of the civil and scientific society.
Erdem, H; Elaldi, N; Ak, O; Gulsun, S; Tekin, R; Ulug, M; Duygu, F; Sunnetcioglu, M; Tulek, N; Guler, S; Cag, Y; Kaya, S; Turker, N; Parlak, E; Demirdal, T; Ataman Hatipoglu, C; Avci, A; Bulut, C; Avci, M; Pekok, A; Savasci, U; Kaya, S; Sozen, H; Tasbakan, M; Guven, T; Bolukcu, S; Cesur, S; Sahin-Horasan, E; Kazak, E; Denk, A; Gonen, I; Karagoz, G; Haykir Solay, A; Alici, O; Kader, C; Senturk, G; Tosun, S; Turan, H; Baran, A I; Ozturk-Engin, D; Bozkurt, F; Deveci, O; Inan, A; Kadanali, A; Sayar, M S; Cetin, B; Yemisen, M; Naz, H; Gorenek, L; Agalar, C
This study reviewed the clinical, laboratory, therapeutic and prognostic data on genitourinary involvement of brucellosis in this largest case series reported. This multicentre study pooled adult patients with genitourinary brucellar involvement from 34 centres treated between 2000 and 2013. Diagnosis of the disease was established by conventional methods. Overall 390 patients with genitourinary brucellosis (352 male, 90.2%) were pooled. In male patients, the most frequent involved site was the scrotal area (n=327, 83.8%), as epididymo-orchitis (n=204, 58%), orchitis (n=112, 31.8%) and epididymitis (n=11, 3.1%). In female patients, pyelonephritis (n=33/38, 86.8%) was significantly higher than in male patients (n=11/352, 3.1%; p<0.0001). The mean blood leukocyte count was 7530±3115/mm3. Routine laboratory analysis revealed mild to moderate increases for erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The mean treatment duration and length of hospital stay were significantly higher when there were additional brucellar foci (p<0.05). Surgical operations including orchiectomy and abscess drainage were performed in nine (2.3%) patients. Therapeutic failure was detected in six (1.5%), relapse occurred in four (1%), and persistent infertility related to brucellosis occurred in one patient. A localized scrotal infection in men or pyelonephritis in women in the absence of leucocytosis and with mild to moderate increases in inflammatory markers should signal the possibility of brucellar genitourinary disease.
Choon, S E; Mathew, M; Othman, B S
The demographic characteristics, risk behaviourand prevalence of other sexually transmitted diseases (STDs) were determined in 132 HIV-infected individuals seen in a Dermatology cum Genitourinary Clinic, Hospital Sultanah Aminah Johor Bahru. Sixty-one (46.2%) were Malays, 37.9% Chinese, 10.6% Indians and 5.3% were of other ethnic groups. The male to female ratio was 4.5:1. Most of the patients (82.5%) were between 20 to 40 years-old. Seventy (53.0%) were single, 34.1% were married and 7.5% were divorcees. The majority of them (97.7%) were heterosexual. Fifty seven (53.3%) of our male patients patronised commercial workers. Eighty-one (61.8%) were not intravenous drug users (IVDU). Of the 50 IVDUs, 24 had multiple sexual exposures. Fifty-three (48.2%) of the 109 patients screened for STDs had one or more other STDs. Thirty-four patients (31.9%) reported one STD in the past and 3.6% reported two STDs in the past. Fifty-six patients (42.4%) had developed AIDS. Thirteen had passed away. The main mode of transmission of HIV infection in this population is through heterosexual intercourse and the prevalence of STDs is high. These findings indicate a need to advocate responsible sexual behaviour and to detect as well as treat STDs early to prevent the sexual transmission of HIV.
Mauck, Karen F; Litin, Scott C; Bundrick, John B
At the 2001 annual meeting of the American College of Physicians (ACP), a new and innovative teaching format, the "Clinical Pearls" session, was introduced. Clinical Pearls sessions were designed to teach physicians using clinical cases. The session format involves specialty speakers presenting a number of short cases to a physician audience. Each case is followed by a multiple-choice question, answered by each attendee using an electronic audience-response system. After a summary of the answer distribution is shown, the correct answer is displayed and the speaker discusses important teaching points and clarifies why one answer is most clinically appropriate. Each case presentation ends with 1 or 2 "Clinical Pearls," defined as a practical teaching point, supported by the literature, and generally not well known to most internists. The Clinical Pearls sessions are consistently one the most popular and well attended sessions at the American College of Physicians' national meeting each year. Herein, we present the Clinical Pearls in Perioperative Medicine, presented at the ACP National Meeting in San Francisco, California, April 11-13, 2013.
Developments in biotechnology and genomics are providing a biological basis for the heterogeneity of clinical course and response to treatment that have long been apparent to clinicians. The ability to molecularly characterize human diseases presents new opportunities to develop more effective treatments and new challenges for the design and analysis of clinical trials. In oncology, treatment of broad populations with regimens that benefit a minority of patients is less economically sustainable with expensive molecularly targeted therapeutics. The established molecular heterogeneity of human diseases requires the development of new paradigms for the design and analysis of randomized clinical trials as a reliable basis for predictive medicine. We review prospective designs for the development of new therapeutics and predictive biomarkers to inform their use. We cover designs for a wide range of settings. At one extreme is the development of a new drug with a single candidate biomarker and strong biological evidence that marker negative patients are unlikely to benefit from the new drug. At the other extreme are Phase III clinical trials involving both genome-wide discovery of a predictive classifier and internal validation of that classifier. We have outlined a prediction-based approach to the analysis of randomized clinical trials that both preserves the Type I error and provides a reliable internally validated basis for predicting which patients are most likely or unlikely to benefit from the new regimen.
Kadhiravan, Tamilarasu; Sharma, Surendra K
Antimycobacterial chemotherapy is the mainstay of treatment for the majority of patients with genitourinary tuberculosis (GUTB). A large body of evidence from clinical trials suggests that short-course chemotherapy regimens, employing four drugs including rifampicin and pyrazinamide, achieve cure in most of the patients with tuberculosis (TB) and are associated with the lowest rates of relapse. Standard six-month regimens are adequate for the treatment of GUTB. Directly observed treatment, short-course (DOTS) is the internationally recommended comprehensive strategy to control TB, and directly observed treatment is just one of its five elements. DOTS cures not only the individual with TB but also reduces the incidence of TB as well as the prevalence of primary drug-resistance in the community. Corticosteroids have no proven role in the management of patients with GUTB. Errors in prescribing anti-TB drugs are common in clinical practice. Standardized treatment regimens at correct doses and assured completion of treatment have made DOTS the present-day standard of care for the management of all forms of TB including GUTB.
Mazzucchelli, Roberta; Gasparrini, Silvia; Galosi, Andrea B; Massari, Francesco; Raspollini, Maria Rosaria; Scarpelli, Marina; Lopez-Beltran, Antonio; Cheng, Liang; Montironi, Rodolfo
Recent insights and emerging strategies for individualized therapeutic approaches in patients with genitourinary (GU) cancers are based on patient's genomic and cancer's molecular profiles. This depends on the significant advances made in molecular biology technologies, such as next-generation sequencing and whole-exome sequencing. The rise of such novel techniques has grayly increased our knowledge on cancer cell biology and development, thus allowing to identify complex abnormalities at the genomic level. These findings have paved the way toward what is called precision medicine, thus providing healthcare from an individual perspective in patients with GU tumors.
Rodriguez-de-Velasquez, A; Yoder, I C; Velasquez, P A; Papanicolaou, N
Diabetes mellitus is a common multisystemic disease with serious effects on the genitourinary system. In the radiology literature, little attention has been paid to developing an integral approach to imaging of the genitourinary tract in diabetes. The long-term effects of diabetes on the genitourinary system include diabetic nephropathy, papillary necrosis, renal artery stenosis, diabetic cystopathy, and vas deferens calcification. Diabetes-associated urinary tract infections include renal and perirenal abscesses, gas-forming infections such as emphysematous pyelonephritis and emphysematous cystitis, fungal infections, and xanthogranulomatous pyelonephritis. Diabetes-associated genital infections include Fournier gangrene and postmenopausal tubo-ovarian abscess. In a diabetic with fever of unknown origin or in the event of a persistent infection in a diabetic with clinical deterioration despite use of antibiotics, radiologic studies can demonstrate the presence of genitourinary complications. Finally, radiologists should be aware of the risk of contrast material-induced nephropathy in diabetics.
Simpson, Melanie A.; Lokeshwar, Vinata B.
Genitourinary cancers are the most frequently diagnosed cancers in men and the fifth most common in women. Management of disease through accurate and cost effective early diagnostic markers, as well as identification of valid prognostic indicators, has contributed significantly to improved treatment outcomes. In this review, we will discuss the function, regulation and clinical utility of hyaluronan (HA), genes encoding its metabolic enzymes and receptors that mediate its cellular effects. Specific HA synthase (HAS) and hyaluronidase (HAase) genes encode the enzymes that produce HA polymers and oligosaccharides, respectively. Differential effects of these enzymes in progression of genitourinary tumors are determined by the relative balance between HAS and HAase levels, as well as the distribution of receptors. The genes are regulated in a complex fashion at the transcriptional and post-translational levels, but also by epigenetic events, alternative mRNA splicing, and subcellular localization. Importantly, the major tumor-derived HAase enzyme, HYAL-1, either alone or together with HA, is an accurate diagnostic and prognostic marker for genitourinary tumors. PMID:18508614
Horne, R. D.
Graduate training in clinical veterinary medicine is discussed. The options available to the student and problems that must be dealt with are presented, along with the requirements to accomplish a finely structured program that satisfies the needs of both the trainee and clinical veterinary medicine. (Author/MLW)
Horne, R. D.
Graduate training in clinical veterinary medicine is discussed. The options available to the student and problems that must be dealt with are presented, along with the requirements to accomplish a finely structured program that satisfies the needs of both the trainee and clinical veterinary medicine. (Author/MLW)
Naumova, Anna V; Modo, Michel; Moore, Anna; Murry, Charles E; Frank, Joseph A
In regenerative medicine, clinical imaging is indispensable for characterizing damaged tissue and for measuring the safety and efficacy of therapy. However, the ability to track the fate and function of transplanted cells with current technologies is limited. Exogenous contrast labels such as nanoparticles give a strong signal in the short term but are unreliable long term. Genetically encoded labels are good both short- and long-term in animals, but in the human setting they raise regulatory issues related to the safety of genomic integration and potential immunogenicity of reporter proteins. Imaging studies in brain, heart and islets share a common set of challenges, including developing novel labeling approaches to improve detection thresholds and early delineation of toxicity and function. Key areas for future research include addressing safety concerns associated with genetic labels and developing methods to follow cell survival, differentiation and integration with host tissue. Imaging may bridge the gap between cell therapies and health outcomes by elucidating mechanisms of action through longitudinal monitoring. PMID:25093889
Gostomzyk, J G; Simoes, E; Mittelstaedt, G V
The economic transformation of health care systems, which is supported by both the economic and the political sector, is in demand of constant humane correction. Legal regulations of social systems securing health corresponding to the code of social law are guard rails for a responsible use of limited resources and are subject to constant development. All doctors caring for patients should be in a position to reflect the real life context of their patients as both causal and modifying influence for health and disease from a social medical perspective, apart from their specific medical field of expertise.Accordingly 3 parts of sub-specialization training are suggested: clinical tasks of social medicine as detailed in the code of social law, clinical social medicine in health care according to the 5(th) book of the code of social law and social medicine in clinical social medicine/participation. Higher level-of-care hospitals, as well as rehabilitation clinics, should offer sub-specialization in social medicine without interruption of employment contracts. Corresponding criteria for the regulation on further education should be formulated by the German Society of Social Medicine and Prevention (DGSMP) as the competent scientific association and presented to the committee on further education of the Federal Medical Association. This aims at strengthening social medicine in clinical care.
Dénes, Francisco Tibor; Duarte, Ricardo Jordão; Cristófani, Lílian Maria; Lopes, Roberto Iglesias
Tumors of the kidney, bladder, prostate, testis, and adrenal represent a large part of the adult urologic practice, but are relatively infrequent in children. The natural history and management of these tumors in the pediatric age is different from that of the adults. As result of the successful work of several clinical trial groups in recent decades, there has been a significant improvement in their cure rates. The aim of this article is to review their most significant clinical aspects, as well as to present an update in their management. PMID:24400293
In this retrospective study of the outcome of treatment of 245 patients (87 females and 158 males) with a diagnosis of Neisseria gonorrhoeae infection seen between 1996 and 2002, 81% (95% confidence interval (CI) 74%-86.8%) of the males and 88.5% (95% CI 79.9%-94.3%) of the females attended for a test of cure. At initial presentation, 93% (95% CI 87.9%-96.5%) and 94.3% (95% CI 89.5%-97.4%) of males respectively, had symptoms and signs of gonococcal infection compared with 48.3% (95% CI 37.4%-59.2%) and 44.8% (95% CI 34.1%-55.9%) of females, and this difference was statistically significant (P = 0.005). Initial diagnosis at first visit was made by Gram-stained smear in 88.6% (95% CI 82.6%-93.1%) of males and 32.2% (95% CI 22.6%-43.1%) of females, a statistically significant difference P = 0.001. There were 12 (4.9%) cases of reinfection that rebooked to attend after failing to attend for their test of cure in two females and 10 males. There were two (0.8%) treatment failures amongst the 245 episodes in two males who still had symptoms when they returned for their test of cure. One male had a ciprofloxacin-resistant strain (CRNG) acquired locally and the other one had a betalactamase-producing CRNG/penicillinase-producing N. gonorrhoeae (PPNG) isolate acquired abroad in South America. These patients would have sought to return, as they still had signs and symptoms of gonococcal infection, and they would have been recalled following receipt of the antimicrobial susceptibility report. Post-gonococcal urethritis occurred in 36.3% (95% CI 27.8%-45.4%) of the males who attended for their test of cure, 74.8% (95% CI 67.2%-81.5%) received anti-chlamydial therapy with their standard treatment. In men who received anti-chlamydial therapy the odds ratio of having post-gonococcal urethritis was 0.42 (95% CI 0.17-1.06), P = 0.04. Co-infection with Chlamydia trachomatis was more likely to occur amongst females (43.9%), odds ratio 3.97 (95% CI 2.07-7.67), P < 0.001 than males (16.5%). We have now discontinued routine attendance for a test of cure and encourage our patients to telephone for their results with recall only of patients whose antimicrobial susceptibility indicate inappropriate first line therapy or who are still symptomatic.
Hartley, A; Foster, R; Brook, M G; Cassell, J A; Mercer, C H; Coyne, K; Hughes, G; Crook, P
With minimal information on sexual health provision during mass-gathering events, our aim was to describe the use of sexual health, contraceptive, sex worker and sexual assault services during the London 2012 Olympics. We analysed data from five sources. One contraceptive service provider reported a 10% increase in attendance during the main Games, while emergency contraception prescriptions rose during the main Olympics, compared to the week before, but were similar or lower than at the beginning and end of the summer period. A health telephone advice line reported a 16% fall in sexual health-related calls during the main Olympics, but a 33% increase subsequently. London sexual assault referral centres reported that 1.8% of sexual assaults were Olympics-linked. A service for sex workers reported that 16% started working in the sex industry and 7% moved to London to work during the Olympics. Fifty-eight per cent and 45% of sex workers reported fewer clients and an increase in police crack-downs, respectively. Our results show a change in activity across these services during the 2012 summer, which may be associated with the Olympics. Our data are a guide to other services when anticipating changes in service activity and planning staffing for mass-gathering events. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
Irby, David; Rakestraw, Philip
Medical students have been rating clinical teaching in an obstetrics and gynecology clerkship at the University of Washington using an assessment form designed to reflect six factors of clinical teaching effectiveness. High interrater reliability and the utility of the data for faculty development and advancement are discussed. (Author/JMD)
Scott, Stuart A.
Clinical genetic testing has grown substantially over the past 30 years as the causative mutations for Mendelian diseases have been identified, particularly aided in part by the recent advances in molecular-based technologies. Importantly, the adoption of new tests and testing strategies (e.g., diagnostic confirmation, prenatal testing, and population-based carrier screening) has often been met with caution and careful consideration before clinical implementation, which facilitates the appropriate use of new genetic tests. Although the field of pharmacogenetics was established in the 1950s, clinical testing for constitutional pharmacogenetic variants implicated in interindividual drug response variability has only recently become available to help clinicians guide pharmacotherapy, in part due to US Food and Drug Administration-mediated product insert revisions that include pharmacogenetic information for selected drugs. However, despite pharmacogenetic associations with adverse outcomes, physician uptake of clinical pharmacogenetic testing has been slow. Compared with testing for Mendelian diseases, pharmacogenetic testing for certain indications can have a lower positive predictive value, which is one reason for underutilization. A number of other barriers remain with implementing clinical pharmacogenetics, including clinical utility, professional education, and regulatory and reimbursement issues, among others. This review presents some of the current opportunities and challenges with implementing clinical pharmacogenetic testing. PMID:22095251
McGeady, James B.; Breyer, Benjamin N.
Synopsis This article reviews recent publications evaluating the current epidemiology of urologic trauma. It begins by providing a brief explanation of databases that have been recently used to study this patient population, then proceeds to discuss each genitourinary organ individually, discussing the most relevant and up to date information published for each one. The conclusion of the article briefly discusses possible future research and development areas pertaining to the topic. PMID:23905930
With the advent of the human genome project, we have never known so much about the uniqueness of individuals. Personalized medicine is poised to use this genetic and genomic information along with the impact of environment and clinical presentation to provide healthcare from an individual perspective. This offers the opportunity to improve our ability to diagnose and predict disease, provide earlier intervention, identify new treatment regimens, and address the safety and efficacy of drug use. The impact of personalized medicine to our current model of healthcare delivery is tremendous, and although strides have been made, there are still challenges and barriers to overcome before personalized medicine can be fully implemented. Advanced practice nurses may not be fully aware of the personalized medicine initiative or may not be well versed on genetic and genomic content, which is a key concept of personalized medicine. The role of advanced practice nurses is an integral part of the healthcare system, and as such, they are poised to be key providers and contributors to personalized medicine. The personalized medicine initiative is discussed along with examples of genetic and genomic information that lend to our understanding, diagnosis, and treatment of disease, as well as the role and responsibilities of advanced practice nurses. Resources for personalized medicine and genetic and genomic content are provided.
Song, Joseph B; Tanagho, Youssef S; Haseebuddin, Mohammed; Benway, Brian M; Desai, Alana C; Bhayani, Sam B; Figenshau, Robert S
Retrieval of foreign bodies from the genitourinary system, most commonly inserted for sexual satisfaction or as a result of a psychiatric illness, can pose a significant surgical challenge. Due to their breadth of size, shape, and location within the genitourinary system, endoscopic management can be difficult. Here, we review the management of four cases of foreign object insertion into the genitourinary system and their outcomes and management. PMID:24082848
Pinho, João Renato Rebello; Sitnik, Roberta; Mangueira, Cristóvão Luis Pitangueira
Personalized medicine is the use of biomarkers, most of them molecular markers, for detection of specific genetic traits to guide various approaches for preventing and treating different conditions. The identification of several genes related to heredity, oncology and infectious diseases lead to the detection of genetic polymorphisms that are involved not only in different clinical progression of these diseases but also in variations in treatment response. Currently, it is possible to detect these polymorphisms using several methodologies: detection of single nucleotide polymorphisms using polymerase chain reaction methods; nucleic acid microarray detection; and nucleic acid sequencing with automatized DNA sequencers using Sanger-derived methods and new generation sequencing. Personalized medicine assays are directed towards detecting genetic variations that alter interactions of drugs with targets or the metabolic pathways of drugs (upstream and downstream) and can be utilized for the selection of drug formulations and detect different immunogenicities of the drug. Personalized medicine applications have already been described in different areas of Medicine and allow specific treatment approaches to be applied to each patient and pathology according to the results of these assays. The application of such a protocol demands an increasing interaction between the clinical laboratory and the clinical staff. For its implementation, a coordinated team composed of basic researchers and physicians highly specialized in their areas supported by a highly specialized team of clinical analysts particularly trained in molecular biology assays is necessary. PMID:25295459
Creditor, Morton C.
Describes briefly the objectives, problem-oriented educational process, 4-phase curriculum, and resources of a new 3-year School of Clinical Medicine, part of a decentralized and regionalized scheme of medical education designed to improve geographic distribution of graduates, increase incentive to enter primary care specialties, and assure…
Rohena-Quinquilla, Iván R; Lattin, Grant E; Wolfman, Darcy
The genitourinary (GU) system is commonly affected by disseminated lymphoma. Rarely, lymphoma can originate from and remain localized to one of the GU organs and thus presents as primary extranodal disease. Up to 40% of lymphomas present as extranodal disease, with only 3% having the GU system as the primary site of involvement. This article describes and correlates the radiologic and pathologic features of extranodal lymphomatous disease affecting the GU system with specific focus on the kidneys, adrenal glands, testicles, and ovaries. Lymphoma of the uterine body and cervix, external female genitalia, urinary bladder, and prostate gland is briefly discussed. Copyright © 2016 Elsevier Inc. All rights reserved.
Ventegodt, Søren; Solheim, Elin; Saunte, Mads E; Morad, Mohammed; Kandel, Isack; Merrick, Joav
We believe that the consciousness-based/holistic medical toolbox has a serious additional offer to cancer patients and, as a consequence, designed a treatment for the patient with metastasized cancer. From a holistic perspective, cancer can be understood as a simple disturbance of the cells, arising from the tissue holding on to a trauma with strong emotional content. This is called "a blockage", where the function of the cells is allocated from their original function in the tissue to a function of holding emotions. We hope to be able not only to improve the quality of life, but also to improve survival and in some cases even induce spontaneous remission of the metastasized cancer. This paper describes how work with a patient with metastasized cancer can be done in the holistic clinical practice in 14 days on an individual basis, helping the patient to recover her human character, purpose of life, coherence, and will to live, thus improving quality of life and possibly also survival time. The holistic therapeutic work includes (1) teaching existential theory, (2) working with life perspective and philosophy of life, (3) helping the patient to acknowledge the state of the disease and the feelings connected to it, and finally (4) getting the patient into the holistic state of healing: (a) feeling old repressed emotions, (b) understanding why she got sick from a holistic point of view, and finally (c) letting go of the negative beliefs and decisions that made her sick according to the holistic theory of nongenetic diseases. The theory of the human character, the quality of life theories, the holistic theory of cancer, the holistic process theory of healing, the theory of (Antonovsky) coherence, and the life mission theory are the most important theories for the patient to find hope and mobilize the will to fight the cancer and survive. The patient went through the following phases: (1) finding the purpose of life and hidden resources; (2) confronting denial; (3
Regitz-Zagrosek, Vera; Seeland, Ute
Sex and gender differences in frequent diseases are more widespread than one may assume. In addition, they have significant yet frequently underestimated consequences on the daily practice of medicine, on outcomes and effects of therapies. Gender medicine is a novel medical discipline that takes into account the effects of sex and gender on the health of women and men. The major goal is to improve health and health care for both, for women as well as for men. We give in this chapter an overview on sex and gender differences in a number of clinical areas, in cardiovascular diseases, pulmonary diseases, gastroenterology and hepatology, in nephrology, autoimmune diseases, endocrinology, hematology, neurology. We discuss the preferential use of male animals in drug development, the underrepresentation of women in early and cardiovascular clinical trials, sex and gender differences in pharmacology, in pharmacokinetics and pharmacodynamics, in management and drug use. Most guidelines do not include even well-known sex and gender differences. European guidelines for the management of cardiovascular diseases in pregnancy have only recently been published. Personalized medicine cannot replace gender-based medicine. Large databases reveal that gender remains an independent risk factor after ethnicity, age, comorbidities, and scored risk factors have been taken into account. Some genetic variants carry a different risk in women and men. The sociocultural dimension of gender integrating lifestyle, environment, stress, and other variables cannot be replaced by a sum of biological parameters. Because of this prominent role of gender, clinical care algorithms must include gender-based assessment.
Cunnington, Marianne; Kortsalioudaki, Christini; Heath, Paul
The aim is to describe and quantify the association between genitourinary tract infections and preterm birth. Recent studies confirm the importance of identifying and treating both asymptomatic and symptomatic bacteriuria in pregnancy, which is reflected in current antenatal screening guidelines. These guidelines do not recommend routine screening for other asymptomatic lower genital infections (bacterial vaginosis, trichomonas and gonorrhoea) reflecting inconsistent study results, which may reflect differences in study design, size, diagnostics and the timing of screening in pregnancy. Screening for group B Streptococcus (GBS) late in pregnancy is recognized to reduce neonatal disease, but there is a striking lack of robust studies, specifically randomized controlled trials (RCTs), considering the effect of GBS screening earlier in pregnancy on adverse pregnancy outcomes. The potential for screening and treatment of genitourinary tract infections in pregnancy to reduce preterm birth rates has been demonstrated in some RCTs. Current guidelines do not reflect these data because of inconsistencies across the body of evidence. There is a need for robust RCTs to confirm or refute earlier data, to inform the optimal timing for screening in pregnancy and to better quantify the contribution of individual infections to the burden of preterm birth.
Recktenwald, Kathy; Hunsaker, Donna M; Corey, Tracey S; Weakley-Jones, Barbara
Clinical forensic medicine (CFM) is "the application of appropriate forensic practices and principles, heretofore reserved for use by the pathologist at autopsy, to living patients in a clinical setting." "Living forensic" patients include survivors of trauma and potentially catastrophic experiences resulting in injury. CFM arose from "clinically" affirming that not all abuse or assault victims sustain fatal injuries. Appropriate medical documentation and interpretation of physical findings may aid law enforcement and/or social services in the legal evaluation of a case or situation. Additionally, timely collection of pertinent evidence may be performed as the case necessitates.
The mission of our department is to contribute to diagnostic improvement in medicine in order to promote better outcomes. We have clinical expertise in internal medicine including primary care medicine, hematology, allergy, rheumatology, and nephrology. We also have expertise in clinical laboratory medicine and hospital infection control. Specific areas of academic interest include immune-mediated hematological diseases, allergic diseases, autoimmune diseases, and chronic kidney disease. Immune recovery following hematopoietic stem cell transplantation and the immunopathophysiology of bone marrow failure syndrome have been our main topics of interest, and we have been applying our knowledge of T-cell receptor diversity to these areas in order to explore the mechanisms of immunodeficiency and autoimmunity in hematological disorders. We have found that the peripheral expansion of mature T cells in grafts plays an important role in immune reconstitution after stem cell transplantation in humans, and have also found altered T-cell repertoires in immune-mediated chronic acquired pure red cell aplasia. Thus, quantitative and qualitative analyses of immune receptors could be a promising method for assessing immunocompetence and exploring the pathophysiology of autoimmune diseases. Research and development of novel approaches in this field should be intensively conducted.
The 18th century is an important turning point not only in human history, but also in medical history. G. B. Morgagni was an Italian who founded the organic pathology in the 18th century, which was a bridge between basic medicine and clinical medicine of western medicine. H. Boerhaave called for "paying attention to the development of clinical medicine", and under this situation, western clinical medicine was attached importance and developed again in the 18th century. However, at the same time, the mechanical materialism was also infiltrated into western clinical medicine.
Jones, Jeffrey A.; Sargsyan, Ashot; Pietryzk, Robert; Sams, C.; Stepaniak, Phillip; Whitson, P.
Genitourinary medical events have shown to be an issue for both short duration and long duration spaceflight, and are anticipated to also be a potential issue for future exploration missions as well. This is based on actual historical pre-, in- and post-flight medical events, as well as assessment of what future flight challenges lay ahead. For this study, retrospective record review, as well as prospective studies of ultrasound and contingency management procedure development, and oral urinary stone prophylaxis were conducted. Results showed that the incidence of prior urinary calculi in- and post-flight was a risk driver for development of on-orbit countermeasures, as well as diagnostic and therapeutic methods for a possible in-flight calculus contingency. Oral potassium citrate and bisphosphonate preparations show promise for prophylaxis in spaceflight risk reduction. We conclude that a properly developed approach of selection, monitoring, and preventive medicine with effective countermeasures, along with early imaging diagnosis and minimally-invasive contingency intervention, should prevent issues such as urinary calculi from having a significant mission impact for exploration-class spaceflight.
Masukume, Gwinyai; Zumla, Alimuddin
Medicine is traditionally known as an 'art', and not an exact 'science'. Medical images of clinical signs and pathology were communicated through 'metaphors' in the 19th and early 20th centuries to make recognition easier in anticipation of the clinical counterpart when encountered in medical practice. They have served as teaching aids, enhancing memory retention for medical students, nurses and doctors and have withstood the test of time. Standard medical textbooks contain metaphors that have become entrenched in teaching, learning and examining in medical schools and hospitals worldwide. The continued use of metaphors has given rise to an ongoing debate, particularly in Africa, due to the usage of inappropriate or unfamiliar metaphors which are not locally or culturally relevant. Despite this, medical analogies will no doubt continue to be useful for medical education, clinical practice and 'aide memoirs' for examinations, and bring light humour, for a long time to come.
This book gives a topical account of the applications and implications of DNA technology in clinical medicine. Starting with a description of the anatomy of the gene and the techniques used in molecular biology, it goes on to describe the uses of these methods in hormone bioassays, tumor diagnosis, virology and the pre-natal detection and diagnosis of genetic disease. In addition, it examines the commercial exploitation of bioengineering and the ethical issues that arise through the use of this technology. Technical detail is kept to a minimum.
Mattana, Joseph; Kerpen, Howard; Lee, Clifton; Multz, Alan; Pekmezaris, Renee; Napolitano, Barbara; Walia, Rajni; Steinberg, Harry
While experiential learning is a desirable goal of residency education, little is known regarding the actual clinical experience of internal medicine residents during their training. We modified an electronic patient handoff tool to include a system for resident entry of a primary diagnosis for each of their patients. Using the International Classification of Diseases, Ninth Revision (ICD-9) system, we created two methods to select the code: 1) an organ system-based dropdown list containing frequently used codes; and 2) a search option for the complete ICD-9 database. The codes were then grouped using ICD-9 categorization. A total of 7562 resident-patient diagnostic encounters were studied. A wide spectrum of clinical conditions was observed, with symptoms and ill-defined conditions, circulatory disorders, respiratory disorders, neoplasms, genitourinary disorders, digestive disorders, diseases of the blood/blood forming organs, endocrinologic/nutritional/metabolic/immune disorders, and disorders of the skin and subcutaneous tissue accounting for about 86% of resident clinical experience. Symptoms and ill-defined conditions were noted to represent a sizable portion of resident clinical experience. Within this category, the most common conditions were fever; abdominal pain; and chest pain, unspecified. Analysis of resident-selected ICD-9 codes might serve as a method to attempt to define resident clinical experience, and may be useful in the development of innovative experiential learning-based residency curricula. This might also be used to assess gaps in experiential learning at the program or resident level, and may serve to identify topics that require additional teaching supplementation. Copyright © 2011 Society of Hospital Medicine.
Cofield, Stacey; Conwit, Robin; Barsan, William; Quinn, James
The emergency medicine and pre-hospital environments are unlike any other clinical environments and require special consideration to allow the successful implementation of clinical trials. This article reviews the specific issues involved in Emergency Medicine Clinical Trials (EMCT), and provides strategies from emergency medicine and non-emergency medicine trials to maximize recruitment and retention. While the evidence supporting some of these strategies is deficient, addressing recruitment and retention issues with specific strategies will help researchers deal with these issues in their funding applications and in turn develop the necessary infrastructure to participate in emergency medicine clinical trials. PMID:21040112
Smith, James F; Wayment, Robert O; Cartwright, Patrick C; Snow, Brent W; Opitz, John M
The FG syndrome, also known as Opitz-Kaveggia syndrome, is an X-linked disorder characterized by developmental delay, congenital hypotonia, characteristic facial appearance, relative macrocephaly and anomalies affecting the genitourinary, gastrointestinal and musculoskeletal systems. Genitourinary abnormalities in the FG syndrome include cryptorchidism, hypospadias, inguinal hernia, hydrocele and occasional anomalies of renal or ureteral development. To our knowledge no previous study has systematically evaluated the genitourinary aspects of the disorder. We describe the genitourinary anomalies seen in children with the FG syndrome. This report may help elucidate the pathogenic mechanisms responsible for the disorder. Also, we provide a simple checklist for urologists that will help guide referrals for genetics and other specialty consultations. We retrospectively reviewed 228 patients with the FG syndrome to identify the frequency of characteristic historical and physical findings. These patients were diagnosed on the basis of a firsthand history and physical examination, or by a careful outside evaluation including detailed records and photographs. Of the patients 90% were male. The overall incidence of any genitourinary anomaly was 48.5% in boys, 13.6% in girls and 44.7% overall. In boys the most common abnormalities were cryptorchidism (24%), hypospadias (14%) and hernia or hydrocele (13%). The FG syndrome is a disorder with a greater prevalence than previously thought, yet is rarely suspected by urologists. The manifestations may be complex. Identification of patients with syndromal genitourinary anomalies by urologists will enhance the quality of care based on referral of patients for additional evaluation.
Burnett, A L
It is apparent that evolving concepts of the regulatory basis for functions in the pelvis must take into account the role exerted by nitric oxide. A recently characterized messenger molecule, nitric oxide has been associated with numerous physiologic processes. Intense investigations of this molecule have extended its importance to several genitourinary functions. Penile erection, micturition, peristalsis of the male excurrent duct system, contractile properties of the prostate, and lumbosacral spinal cord neurotransmission are all functions that may transpire under some degree of control by nitric oxide. Impotence, urinary obstruction, or ejaculatory problems, in turn, may represent alterations of nitric oxide production or action. The strategic manipulation of nitric oxide or its mechanism of action, possibly by pharmacologic means, may restore or produce desired functional effects. These possibilities, therefore, suggest that the advancing knowledge of nitric oxide in the genitourinary tract may be of enormous clinical value in the future.
Being a member of the Flight Medicine Clinic (FMC) Staff is a great experience. I joined the FMC staff 2 years ago when I became part of the Kelsey-Seybold team. The FMC staff consists of Flight Surgeons, Family Clinic Physician, Nursing staff, Wellness Coordinator and Support staff. We serve as the Primary Care Physicians for the astronauts and their families and provide annual physicals for the retired astronauts. We have approximately 800 patients in the FMC. As the Family Clinic Physician, I care for the astronaut spouses and children and provide annual physicals for the retired astronauts. Since we have a small patient population, we have the opportunity to spend increased personal time with our patients, which I enjoy. We have a pretty healthy patient population, who are very interested in their overall health and preventive care. In preparation for a shuttle launch, our nursing staff assists the flight surgeons with the astronaut physical exams, which occur 10 days prior to launch and again 3 days after their return. We also provide Primary Contact physicals for the families and guests, who will be in close contact with shuttle crew members. During these physicals, we provide education, emphasizing the importance of preventing the spread of communicable diseases to shuttle crew members. Being a part of the Space Medicine Program is an honor. To know that you contribute in some way to our nation s Space Program is very special. (This article was prepared by Dr. Trela Landry, M.D. for inclusion in a Kelsey-Seybold newsletter on 25 OCT 2006.)
Immunotherapy has traditionally been a critical component of the cancer treatment armamentarium in genitourinary (GU) cancers. It has an established role in the management of carefully selected patients with metastatic renal cell carcinoma (RCC) [e.g., high dose interleukin-2 (IL-2)] and non-muscle invasive bladder cancer (NMIBC) [e.g., intravesical Bacillus Calmette-Guérin (BCG)]. In 2010, the sipuleucel-T vaccine was approved by the FDA for the management of metastatic castration-resistant prostate cancer (mCRPC), based on a phase III trial showing overall survival (OS) benefit compared to placebo. The immune checkpoint inhibitor nivolumab (anti-PD-1) recently received FDA approval for the management of patients with advanced RCC patients previously treated with anti-angiogenic therapy, based on OS benefit compared to everolimus. Recently, large clinical trials demonstrated meaningful clinical benefit, including durable responses, as well as a good tolerability/safety profile with the use of immune checkpoint inhibitors in advanced RCC and chemotherapy-resistant advanced urothelial carcinoma (UC), while FDA just approved atezolizumab for platinum-treated advanced UC. Numerous interesting trials in different cancers are ongoing. Several combinations of immune checkpoint blockade with chemotherapeutics, vaccines, targeted tyrosine kinase inhibitors & monoclonal antibodies, epigenetic modifiers, anti-angiogenic agents, tumor microenvironment & myeloid cell targeting therapies, metabolic modification strategies, radiation, and others, are being tested in clinical trials. Comprehensive understanding of the factors underlying antitumor immune responses in physiologically relevant animal models and humans will refine further the clinical benefit of immunotherapy. Discovery and validation of appropriate molecular biomarkers via coordinated translational research efforts, rational clinical trial designs with suitable endpoints and well-defined eligibility criteria
Stewart, William C; Adams, Michelle P; Stewart, Jeanette A; Nelson, Lindsay A
The purpose was to evaluate faith-based studies within the medical literature to determine whether there are ways to help physicians understand how religion affects patients’ lives and diseases. We reviewed articles that assessed the influence of religious practices on medicine as a primary or secondary variable in clinical practice. This review evaluated 49 articles and found that religious faith is important to many patients, particularly those with serious disease, and patients depend on it as a positive coping mechanism. The findings of this review can suggest that patients frequently practice religion and interact with God about their disease state. This spiritual interaction may benefit the patient by providing comfort, increasing knowledge about their disease, greater treatment adherence, and quality of life. The results of prayer on specific disease states appear inconsistent with cardiovascular disease but stronger in other disease states.
Randomized clinical trial (RCT) can fail to demonstrate the richness of individual patient characteristics. Given the unpredictable nature of medicine, a patient may present in an unusual way, have a strange new pathology, or react to a medical intervention in a manner not seen before. The publication of these novelties as case reports is a fundamental way of conveying medical knowledge. Throughout history there have been famous case studies that shaped the way we view health and disease. Case reports can have the following functions: (I) descriptions of new diseases; (II) study of mechanisms; (III) discovery new therapies; (IV) recognition of side effects; and (V) education. Before submitting a case report, it is worthwhile to refer to the Case Report Check Sheet described by Green and Johnson . PMID:25525572
female genitourinary, sexual , and reproductive func- tion. J Orthop Trauma 1997; 11(2): 73–81. MILITARY MEDICINE, Vol. 180, March Supplement 2015 67...energy pelvic ring injury. J Orthop Trauma 2012; 26(5): 296–301. 14. Vallier HA, Cureton BA, Schubeck D: Pelvic ring injury is associ- ated with sexual
Madea, Burkhard; Saukko, Pekka; Musshoff, Frank
In the last years the research output of forensic medicine has sometimes been regarded as insufficient and as of poor quality, especially when parameters as impact factors and external funding were taken into account. However, forensic medicine has different tasks compared to clinical medicine. The main difference between basic subjects, clinical and forensic medicine is not a lack of scientific efficiency in forensic medicine but is a result of the questions asked, the available methods and specific aims. In contrast to natural-scientific research, forensic science has furthermore important intersections with arts and socio-scientific disciplines. Etiologic and pathogenetic research is of only limited relevance in forensic medicine. Thus, forensic medicine is excluded from these research fields, which are mainly supported by external funding. In forensic medicine research mainly means applied research regarding findings, the probative value and reconstruction as well as examination at different points of intersection between medicine and law. Clinical types of research such as controlled randomised, prospective cross-sectional, cohort or case-control studies can only rarely be applied in forensic medicine due to the area specific research fields (e.g. thantatology, violent death, vitality, traffic medicine, analytical toxicology, hemogenetics and stain analysis). The types of studies which are successfully established in forensic medicine are comparison of methods, sensitivity studies, validation of methods, kinetic examinations etc. Tasks of research in forensic medicine and study types, which may be applied will be addressed.
Upshur, Ross E G
Probability claims are ubiquitous in clinical medicine, yet exactly how clinical events relate to interpretations of probability has been not been well explored. This brief essay examines the major interpretations of probability and how these interpretations may account for the probabilistic nature of clinical events. It is argued that there are significant problems with the unquestioned application of interpretation of probability to clinical events. The essay concludes by suggesting other avenues to understand uncertainty in clinical medicine.
Raditic, Donna M; Bartges, Joseph W
Integrative medicine is the combined use of complementary and alternative medicine with conventional or traditional Western medicine systems. The demand for integrative veterinary medicine is growing, but evidence-based research on its efficacy is limited. In veterinary clinical oncology, such research could be translated to human medicine, because veterinary patients with spontaneous tumors are valuable translational models for human cancers. An overview of specific herbs, botanics, dietary supplements, and acupuncture evaluated in dogs, in vitro canine cells, and other relevant species both in vivo and in vitro is presented for their potential use as integrative therapies in veterinary clinical oncology.
Webb, David J
Clinical pharmacologists are the only medical specialists whose training focuses specifically on the safe, effective and cost-effective use of medicines, underpinned by an understanding of drug discovery, drug regulation, pharmacology, translational medicine and the performance of clinical trials. This unique perspective has allowed them to provide expertise and leadership in medicines regulation, medicines policy, health technology assessment and drug pricing. Clinical pharmacologists assisted in the creation of the Committee on Safety of Medicines (now the Commission on Human Medicines), the Yellow Card Scheme, the National Institute of Health and Clinical Excellence (NICE) and related organizations in Scotland and Wales, and contributed to clinical guidelines (through the Scottish Intercollegiate Guidelines Network) and the British National Formulary. Their research work has contributed substantially, through translational medicine and therapeutics, to the development of new medicines and, as a result, creation of health and wealth in the UK. Their work in medicines policy has served to protect patients from harms associated with the use of medicines. A reduction in the number of able junior doctors attracted to a career in clinical pharmacology, a reduction in the number of training posts, and an ageing population of academic trainers, puts the future of the specialty, and its contribution to patient safety and UK wealth creation, at substantial risk. Urgent measures are needed to convince the NHS and government that these essential skills should be protected and nurtured. PMID:22360620
Palacios, S; Mejía, A; Neyro, J L
The vagina, vulva, vestibule, labia majora/minora, and bladder trigone have a high concentration of estrogen receptors; therefore, they are a sensitive biological indicator of serum levels of these hormones in women. The estrogen loss in postmenopausal women produces a dysfunction called genitourinary syndrome of menopause. The principal therapeutic goal in the genitourinary syndrome of menopause is to relieve symptoms. Treatment options, as well as local and systemic hormonal treatment are changes in lifestyle and non-hormonal treatments mainly based on the use of moisturizers and lubricants. New treatments that have recently appeared are ospemifeme, the first selective hormone receptor modulator for dyspareunia and vulvovaginal atrophy treatment, and the use of vaginal laser. This review has been written with the intention of giving recommendations on the prevention and treatment of genitourinary syndrome of menopause.
de Lima, M M; Tobias-Machado, M
Genitourinary cancers are significant causes of morbidity and mortality around the world. The present review summarises the current literature on suicide and its risk factors among patients with genitourinary cancers. The review was based on relevant articles published in MEDLINE, ProQuest, PsycINFO, Science Direct and Scopus databases. Patients with prostate cancer represented the most important risk group for suicide, among patients with urogenital cancers. Other risk factors are male gender, older age, white race, advanced disease, living alone and co-existing psychological comorbidities. Findings from the review call for a greater caregiver awareness on psychosocial morbidity and suicidality among genitourinary cancer patients pre- and post-treatment and their early identification, adoption of risk-reduction strategies and prompt referral for expert mental health care.
Payne, L; Lawrence, D; Soni, S; Llewellyn, C; Dean, G
The number of confirmed cases of gonorrhoea increased by one-third in England from 2013 to 2014 and the incidence increased by 32% in men who have sex with men (MSM). In our clinic, annual incidence increased by 28.8% (2013) and re-infection (second infection within one-year of initial infection) rose from 6.7% as a proportion of total infections (2009) to 19.4% (2013). The aim of this study was to explore reasons for repeat gonorrhoea infections among MSM. We interviewed 16 MSM about knowledge and awareness of gonorrhoea, antibiotic resistance and attitudes towards safe sex. We used qualitative methods to investigate the potential causes for the rise in gonorrhoea re-infection. Mobile applications were used to meet casual sex partners and arrange impromptu group-sex parties with partner anonymity making contact tracing difficult. The use of recreational drugs was widespread. It was suggested that new technologies could also be used to increase awareness of STI trends and services for at-risk individuals. Participants were concerned about global antibiotic resistance, but felt that behaviour would not change unless there was local evidence of this. Despite knowing gonorrhoea prevalence was high, participants felt their behaviour was unlikely to change and frequently felt resigned to repeat infections. The use of geosocial networking applications to arrange sexual encounters may be contributing to a rise in STIs, as well as recreational drugs, alcohol and sex parties. Networking applications could increase awareness and advertise testing opportunities. In some cases, risk-taking behaviours are unlikely to change, and for these men, regular sexual health screens should be encouraged to detect and treat infections earlier and reduce onward spread.
Baerg, Richard H.
Contemporary clinical educational programs at five colleges of podiatric medicine are reviewed. Both classroom contact hours and clinical experience are examined and compared among institutions. Course offerings in podiatric medicine, radiology, surgery, othopedics, community health, etc., are listed by college. (MLW)
Tuteur, Peter G.
The Introduction to Clinical Medicine course developed at Washington University School of Medicine (St. Louis) early in 1973 is described, which, in part, was the product of a revision of two previous courses: clinical diagnosis and physical diagnosis. The new course stresses techniques of bedside data collection, communication of data, and data…
Baerg, Richard H.
Contemporary clinical educational programs at five colleges of podiatric medicine are reviewed. Both classroom contact hours and clinical experience are examined and compared among institutions. Course offerings in podiatric medicine, radiology, surgery, othopedics, community health, etc., are listed by college. (MLW)
Pang, Ran; Wang, Shihan; Tian, Lin; Lee, Mark C; Do, Alexander; Cutshall, Susanne M; Li, Guangxi; Bauer, Brent A; Thomley, Barbara S; Chon, Tony Y
Complementary and alternative medicine (CAM) has gained acceptance throughout the industrialized world. The present study was performed to provide information about the use of CAM at Mayo Clinic, an academic medical center in Northern Midwest of the US. We retrospectively reviewed the electronic medical records of 2680 patients visiting the CAM program at Mayo Clinic, Rochester, between 1 July 2006 and 31 March 2011. Services provided included acupuncture, massage, integrative medical consultations and executive stress management training. Data including age, gender, race, diagnosis and the number of treatment/consultation sessions were collected to describe the use of CAM in our institute over the last several years. It was found that the mean (standard deviation) age of patient was 52.6 (15.5) years. Of those, 73.1% were female and 26.9% were male. Most patients were white. The number of patients referred to CAM increased significantly from 2007 to 2010. The three most common diagnostic categories were back pain (12.9%), psychological disorders (11.8%), and joint pain (9.6%). Back pain was the most common diagnosis for patients receiving acupuncture, and fibromyalgia was the most common for patients receiving massage therapy. Psychological disorders (i.e., stress) were the major diagnosis referred to both integrative medical consults and executive stress management training. These results suggest that the diseases related to pain and psychological disorders are the main fields of CAM use. It also shows the increasing trend of the use of CAM at an academic medical center in the US.
Shebel, Haytham M; Elsayes, Khaled M; Abou El Atta, Heba M; Elguindy, Yehia M; El-Diasty, Tarek A
Genitourinary schistosomiasis is produced by Schistosoma haematobium, a species of fluke that is endemic to Africa and the Middle East, and causes substantial morbidity and mortality in those regions. It also may be seen elsewhere, as a result of travel or immigration. S haematobium, one of the five fluke species that account for most human cases of schistosomiasis, is the only species that infects the genitourinary system, where it may lead to a wide spectrum of clinical symptoms and signs. In the early stages, it primarily involves the bladder and ureters; later, the kidneys and genital organs are involved. It rarely infects the colon or lungs. A definitive diagnosis of genitourinary schistosomiasis is based on findings of parasite ova at microscopic urinalysis. Clinical manifestations and radiologic imaging features also may be suggestive of the disease, even at an early stage: Hematuria, dysuria, and hemospermia, early clinical signs of an established S haematobium infection, appear within 3 months after infection. At imaging, fine ureteral calcifications that appear as a line or parallel lines on abdominopelvic radiographs and as a circular pattern on axial images from computed tomography (CT) are considered pathognomonic of early-stage schistosomiasis. Ureteritis, pyelitis, and cystitis cystica, conditions that are characterized by air bubble-like filling defects representing ova deposited in the ureter, kidney, and bladder, respectively, may be seen at intravenous urography, intravenous ureteropyelography, and CT urography. Coarse calcification, fibrosis, and strictures are signs of chronic or late-stage schistosomiasis. Such changes may be especially severe in the bladder, creating a predisposition to squamous cell carcinoma. Genital involvement, which occurs more often in men than in women, predominantly affects the prostate and seminal vesicles.
Saensiriphan, Sarun; Rungmuenporn, Lerdsak; Phiromnak, Pimpawee; Yingyeun, Siriporn; Klayjunteuk, Supawadee; Pengsakul, Theerakamol
Genitourinary amoebiasis is a rare form of kidney and urinary tract infection caused by Entamoeba histolytica. Here, we describe the first case of unusual infection caused by E. histolytica in Bueng Kan province, northeast, Thailand. A 63-year-old female patient was diagnosed as acute pyelonephritis. E. histotolytica trophozoites were accidentally found in urine collected from a catheter.
Benor, Dan E
A study published in this issue (Lotan et at.) reveals distressing data on the percentage of 4th year students, after their first clerkship, that regret their choice of medicine as a career and contemplate a non-clinical vocational path. This phenomenon, entitled "eluding clinical medicine", is analyzed in terms of early professional socialization of the students toward sciences and their difficulty to tolerate ambiguity and uncertainty, so typical to clinical medicine. Also discussed is the student's incapability to integrate acquired knowledge across disciplines and to interweave it into clinical reality. Rectification of this escape from clinical medicine" may require modification of the pattern of the students' professional socialization during their first years of studies by such measures as early clinical exposure, interdisciplinary integration and practice in decision-making and problem-solving throughout the so-called "preclinical phase". The alarming findings presented in the above-mentioned study call for immediate response.
Herman, James M.; And Others
A study assessed (1) the validity of the Bowman Gray School of Medicine evaluation instrument regarding the occurrence of halo effects and (2) possible relationships between the faculty's evaluations of the residents and the residents' cognitive knowledge and productivity. (MLW)
Herman, James M.; And Others
A study assessed (1) the validity of the Bowman Gray School of Medicine evaluation instrument regarding the occurrence of halo effects and (2) possible relationships between the faculty's evaluations of the residents and the residents' cognitive knowledge and productivity. (MLW)
Dong, Ling; Wang, Wanheng; Li, Alvin; Kansal, Rina; Chen, Yuhan; Chen, Hong; Li, Xinmin
Rapid adoption of next generation sequencing (NGS) in genomic medicine has been driven by low cost, high throughput sequencing and rapid advances in our understanding of the genetic bases of human diseases. Today, the NGS method has dominated sequencing space in genomic research, and quickly entered clinical practice. Because unique features of NGS perfectly meet the clinical reality (need to do more with less), the NGS technology is becoming a driving force to realize the dream of precision medicine. This article describes the strengths of NGS, NGS panels used in precision medicine, current applications of NGS in cytology, and its challenges and future directions for routine clinical use. PMID:27006629
Individual practitioners and health care systems/organizations increasingly understand the rationale for collaborative medicine. An absence of collaboration can compromise the quality and safety of patient care. But having a rationale to provide collaborative medicine without also having a rational clinical strategy can be equally compromising to the quality and safety of patient care. Reasonable evidentiary criteria must be used to determine whether specific therapies merit inclusion or exclusion in a collaborative medicine model. Ranking therapies hierarchically on the basis of their risk-benefit ratio simplifies matching of therapies with the needs of the patient. A unifying taxonomy that categorizes all therapies (complementary/alternative and conventional) on the basis of how we think they work (presumed mechanisms of action) facilitates development of a clinical strategy for collaborative medicine. On the basis of these principles, a rational clinical strategy for collaborative medicine is described to help optimize the quality and safety of patient care.
Charon, R; Banks, J T; Connelly, J E; Hawkins, A H; Hunter, K M; Jones, A H; Montello, M; Poirer, S
Introduced to U.S. medical schools in 1972, the field of literature and medicine contributes methods and texts that help physicians develop skills in the human dimensions of medical practice. Five broad goals are met by including the study of literature in medical education: 1) Literary accounts of illness can teach physicians concrete and powerful lessons about the lives of sick people; 2) great works of fiction about medicine enable physicians to recognize the power and implications of what they do; 3) through the study of narrative, the physician can better understand patients' stories of sickness and his or her own personal stake in medical practice; 4) literary study contributes to physicians' expertise in narrative ethics; and 5) literary theory offers new perspectives on the work and the genres of medicine. Particular texts and methods have been found to be well suited to the fulfillment of each of these goals. Chosen from the traditional literary canon and from among the works of contemporary and culturally diverse writers, novels, short stories, poetry, and drama can convey both the concrete particularity and the metaphorical richness of the predicaments of sick people and the challenges and rewards offered to their physicians. In more than 20 years of teaching literature to medical students and physicians, practitioners of literature and medicine have clarified its conceptual frameworks and have identified the means by which its studies strengthen the human competencies of doctoring, which are a central feature of the art of medicine.
Rahn, David D.; Carberry, Cassandra; Sanses, Tatiana V.; Mamik, Mamta M.; Ward, Renée M.; Meriwether, Kate V.; Olivera, Cedric K.; Abed, Husam; Balk, Ethan M.; Murphy, Miles
OBJECTIVE To comprehensively review and critically assess the literature on vaginal estrogen and its alternatives for women with genitourinary syndrome of menopause and to provide clinical practice guidelines. DATA SOURCES MEDLINE and Cochrane databases were searched from inception to April 2013. We included randomized controlled trials and prospective comparative studies. Interventions and comparators included all commercially available vaginal estrogen products. Placebo, no treatment, systemic estrogen (all routes), and nonhormonal moisturizers and lubricants were included as comparators. METHODS OF STUDY SELECTION We double-screened 1,805 abstracts, identifying 44 eligible studies. Discrepancies were adjudicated by a third reviewer. Studies were individually and collectively assessed for methodologic quality and strength of evidence. TABULATION, INTEGRATION, AND RESULTS Studies were extracted for participant, intervention, comparator, and outcomes data, including patient-reported atrophy symptoms (eg, vaginal dryness, dyspareunia, dysuria, urgency, frequency, recurrent urinary tract infection (UTI), and urinary incontinence), objective signs of atrophy, urodynamic measures, endometrial effects, serum estradiol changes, and adverse events. Compared with placebo, vaginal estrogens improved dryness, dyspareunia, urinary urgency, frequency, and stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). Urinary tract infection rates decreased. The various estrogen preparations had similar efficacy and safety; serum estradiol levels remained within postmenopausal norms for all except high-dose conjugated equine estrogen cream. Endometrial hyperplasia and adenocarcinoma were extremely rare among those receiving vaginal estrogen. Comparing vaginal estrogen with nonhormonal moisturizers, patients with two or more symptoms of vulvovaginal atrophy were substantially more improved using vaginal estrogens, but those with one or minor complaints had similar
Fu, Shufei; Zhang, Junhua; Gao, Xiumei; Xia, Ye; Ferrelli, Rita; Fauci, Alice; Guerra, Ranieri; Hu, Limin
Background Chinese medicines have been used for chronic heart failure (CHF) for thousands of years; however, the status of traditional Chinese medicines (TCMs) used for CHF has not been reported. This review was carried out in the framework of a joint Sino-Italian Laboratory. Objective To investigate the baseline of clinical practice of TCMs for CHF, and to provide valuable information for research and clinical practice. Methods The authors included articles about the use of TCMs for the treatment of CHF by searching the Chinese Journal Full-text Database (1994 to November 2007). Results In all, 1029 papers were included, with 239 herbs retrieved from these. The most commonly used herbs included Huangqi (Radix Astragali), Fuling (Poria), Danshen (Radix Salviae Miltiorrhiae), Fuzi (Radix Aconiti Lateralis Preparata) and Tinglizi (Semen Lepidii). Modern Chinese patent medicines (produced by pharmaceutical companies) and traditional prescriptions (comprising several herbs) are the application forms of these drugs. Shenmai, Shengmai and Astragalus injections were the most commonly used Chinese patent medicines. Some classic prescriptions (including Zhenwu decoction, Shengmai powder and Lingguizhugan decoction) were also frequently used. The effectiveness and safety of the TCMs were both satisfactory, and the traditional Chinese medicine and western medicine therapy could significantly improve the clinical effectiveness and reduce some of the adverse reactions from western medicines used alone. Conclusion The authors have acquired overall information about the clinical application of TCMs for CHF. Modern pharmacology has provided limited evidence for the rationality of this clinical use. Further research is needed to provide more evidence. PMID:27325938
Saylor, Philip J.; Armstrong, Andrew J.; Fizazi, Karim; Freedland, Stephen; Saad, Fred; Smith, Matthew R.; Tombal, Bertrand; Pienta, Kenneth
Bone metastases are a common feature of advanced genitourinary malignancies and a prominent cause of morbidity and mortality. Clinical manifestations can include pain, hypercalcemia, pathologic fractures, and spinal cord compression. Optimal systemic therapy for the skeletal component of these cancers often features a combination of disease-specific therapy and bone-targeted therapy. Some agents such as the radiopharmaceutical radium-223 blur the line between those two categories. Osteoclast inhibition is a validated strategy in the management of selected patients with bone metastases and can best be accomplished with one of two agents. Zoledronic acid is the most potent available bisphosphonate and is approved for the prevention of skeletal events due to solid tumors metastatic to bone. Denosumab is a fully human monoclonal antibody that binds and inactivates receptor activator of nuclear factor-kappa-B ligand and is approved for the same indication. Radiopharmaceuticals represent a distinct strategy. Beta-emitters such as strontium-89 and samarium-153 can be effective for the palliation of pain due to bone metastases, but their use is often limited by bone marrow suppression. The alpha-emitting radiopharmaceutical radium-223 has recently been shown to improve overall survival and prevent skeletal events in selected men with castration-resistant prostate cancer metastatic to bone. Multiple ongoing clinical trials are designed to examine the potential for therapeutic inhibition of additional targets such as Src and hepatocyte growth factor (MET). This review discusses the incidence, pathophysiology, and management of bone metastases in the most prevalent genitourinary malignancies. PMID:23201471
World Health Organization aims to develop safe, effective and practical traditional medicine. Traditional Chinese medicine (TCM) and other complementary and alternative medicine are being recognized in the whole world nowadays. However, the definite effect of Chinese medicine is still in need of scientific research proof. Placebo control is of equal importance to active control and blank control in clinical trial of TCM. This article briefly reviewed the importance of placebo control and commented on its present situation in clinical trial of TCM. This article also brought up the preliminary proposals of placebo application in TCM clinical trial. We should emphasize scientific placebo preparation and good design of placebo-controlled trial, which are directed by International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use. A good clinical trial project will avoid unnecessary wastes and provide safe and effective treatment for people.
Irby, David M.
Using information drawn from a study of six distinguished clinical medical teachers, six domains of knowledge essential to quality clinical teaching were identified and incorporated in a model: knowledge of clinical medicine, patients, the context of teaching rounds, learners, general principles of teaching and learning, and case-based teaching…
Shen, Steven S; Truong, Luan D; Ro, Jae Y; Ayala, Alberto G
Frozen section diagnosis provides critical information for immediate surgical management decision making. Over the last several years, there have been some significant advances in treatment of genitourinary cancer, particularly with regard to surgical techniques. These changes in turn impact the type and frequency of intraoperative frozen section requests. In this review, we describe the main indications and diagnostic challenges of frozen section diagnosis during surgeries of each genitourinary organ system including prostate, kidney, bladder, testis, and penis. The pitfalls and approaches to different diagnostic situations are discussed. It is also stressed that pathologists must not only be familiar with the histological diagnosis, but also understand the limitations of frozen section diagnosis and communicate with urologists during the intraoperative treatment decision making process.
DNA methylation is a common mechanism of inactivation of tumour-suppressor and other cancer genes in neoplastic cells. The advantages of gene methylation as a target for the detection and diagnosis of cancer in biopsy specimens and non-invasive body fluids such as urine or blood has led to many studies of application in genitourinary cancer. Here, we consider the background, promise and status, challenges and future directions of gene methylation and its clinical utility for the early detection of genitourinary cancer. The challenges of, and strategies for, advancing gene-methylation-based detection are relevant to all types of cancer.
Heron, Neil; Malliaropoulos, Nikolaos G.
Summary I undertook the 2012 ECOSEP travelling fellowship, sponsored by Bauerfeind, between May and August 2012, which involved visiting 5 European sport medicine centres and spending approximately one week in each centre. The 5 centres included: National Track and Field Centre, SEGAS, Thessaloniki, Greece; Professional School in Sport & Exercise Medicine, University of Barcelona, Spain; Sport Medicine Frankfurt Institute, Germany; Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna, Italy, and Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, England. Throughout the fellowship, the clinical cases which were routinely encountered were documented. The following sections detail my experiences throughout the fellowship, the sports of the athletes and the injuries which were treated at each of the sport medicine centres during the fellowship visit and the different forms of management employed. PMID:23738305
Ito, Wataru; Chihara, Junichi
Education in laboratory medicine is important. However, many medical students and doctors cannot understand this importance. This problem may be caused by the unclear character of laboratory medicine in research as well as hospital work, resulting in a lack of staff in the Department of Laboratory Medicine. One of the characters of laboratory medicine is its all-inclusive actions unrestrained by medical specialty. Thus, we tell medical students that the staff of laboratory medicine are suitable members of the infection control team (ICT) and nutrition support team (NST) in lectures. Moreover, we also teach allergy, immunology, infection, and sex-specific medicine, which are some subjects the topics of research. Many students in Akita University recognize that the staff of the Department of Laboratory Medicine are specialists of infection and allergy. On the other hand, young doctors can also receive postgraduate clinical training and conduct research not restricted to allergy and infection. We have a policy whereby the Department of Laboratory Medicine always opens its door widely to everyone including students and doctors. Nine staff joined the Department of Laboratory Medicine of Akita University about ten years, and now, can fully provide students with medical education. To solve some problems regarding education in laboratory medicine, we should promote our roles in medical education as well as in hospitals, and increase the number of staff.
Predicting who will suffer from diseases in the future is basically mathematical work. Current computer technology will accelerate the progress of preventive medicine. In this respect, there are two useful tools for the research. First, long-term archiving of health-care information is valuable in a retrospective study, such as, determination of diagnostic criteria for the prediction. Health-care information here includes past history, laboratory data, and dietary habits. Using such criteria, potential patients can be discriminated from truly healthy persons. Second, prediction is successfully carried out on the basis of mathematical equations which represent the relationship between disease status and health-care information. In conclusion, technology for database management and mathematical modelling is essential for the basic study in preventive medicine.
Di Sanzo, Mariantonia; Fineschi, Vittorio; Borro, Marina; La Russa, Raffaele; Santurro, Alessandro; Scopetti, Matteo; Simmaco, Maurizio; Frati, Paola
The personalized medicine is an emergent and rapidly developing method of clinical practice that uses new technologies to provide decisions in regard to the prediction, prevention, diagnosis and treatment of disease. The continue evolution of technology and the developments in molecular diagnostics and genomic analysis increased the possibility of an even more understanding and interpretation of the human genome and exome, allowing a "personalized" approach to clinical care, so that the concepts of "Systems Medicine" and "System Biology" are increasingly actual. The purpose of this study is to evaluate the personalized medicine about its indications and benefits, actual clinical applications and future perspectives as well as its issues and health care implications. It was made a careful review of the scientific literature on this field that highlighted the applicability and usefulness of this new medical approach as well as the fact that personalized medicine strategy is even more increasing in numerous fields of applications.
Lipp, Allyson; Shaw, Chris; Gill, Paul
Genitourinary investigations are performed on a large proportion of middle-aged and older men and the majority undergo investigations for prostate issues. The effects that genitourinary disease can have on men depend on the type of problem, investigations required and treatment including impotence, gynaecomastia and urinary incontinence that have lasting devastating physical, social and psychological effects. The aim was to explore older men's experience and views of intimate and intrusive genitourinary investigations and specifically to develop hypotheses and theories concerning gender and sexuality issues in intimate genitourinary investigations. Written informed consent was obtained for this qualitative study. Data were collected through one-off, semi-structured interviews involving 15 men in the first year following patient's last urological procedure. Initially, multiple themes were identified and when analysed further concepts were repeatedly present. As the urological investigations were limited to men, gender and sexuality became prominent issues in the data. On analysis, the term parasexuality appeared to explain the dynamic of the situation. Parasexuality is a modified form of sexuality which is channelled and limited to maintain propriety. This was not expressed as sexuality in its overt, explicit sense, but instead a type of covert sexuality where professional boundaries are maintained but nonetheless undercurrents remain. This managed version of sexuality created a common currency by which interactions between staff and patients could take place safely. Feeding into parasexuality were gender role stereotypes and for some of the participants this reflected their own experience, context, historical and cultural norms. Intimate contact in the form of exposure and handling of the participants' genitalia during the investigations particularly challenged the boundaries of parasexuality. In order to remain parasexual, many of the participants suppressed their
Havas, S; Rixey, S; Sherwin, R; Zimmerman, S I; Anderson, S
Lifestyle risk factors play a major role in the etiology of premature mortality, morbidity, and disability in the United States. Numerous professional groups as well as the Surgeon General of the Public Health Service have recommended that increased attention be devoted to training medical students and physicians to improve their knowledge and skills in health promotion and disease prevention. Such training is critical for attaining many of the "Healthy People 2000" objectives. For a variety of reasons, however, most medical schools have had difficulty in successfully integrating preventive medicine into their clinical curriculums. This article describes the critical elements that allowed the faculty at the University of Maryland School of Medicine to accomplish this goal through its fourth year clinical preventive medicine course. The strategies employed in this course may serve as a model for other institutions to achieve the integration of preventive medicine into their clinical curriculums. PMID:8497571
Milburn, J M; Merritt, C R
A variety of cystic abdominal masses not related to the genitourinary tract may be encountered in the pediatric population. Ultrasound is the most informative imaging modality in the workup of these masses which include lymphangiomas, duplication cysts, enteric cysts, mesothelial cysts, pseudocysts, choledochal cysts, and gastrointestinal teratomas. The clinical and sonographic characteristics of these lesions are presented.
Fischer, T; Brothers, K B; Erdmann, P; Langanke, M
Systems medicine is the name for an assemblage of scientific strategies and practices that include bioinformatics approaches to human biology (especially systems biology); "big data" statistical analysis; and medical informatics tools. Whereas personalized and precision medicine involve similar analytical methods applied to genomic and medical record data, systems medicine draws on these as well as other sources of data. Given this distinction, the clinical translation of systems medicine poses a number of important ethical and epistemological challenges for researchers working to generate systems medicine knowledge and clinicians working to apply it. This article focuses on three key challenges: First, we will discuss the conflicts in decision-making that can arise when healthcare providers committed to principles of experimental medicine or evidence-based medicine encounter individualized recommendations derived from computer algorithms. We will explore in particular whether controlled experiments, such as comparative effectiveness trials, should mediate the translation of systems medicine, or if instead individualized findings generated through "big data" approaches can be applied directly in clinical decision-making. Second, we will examine the case of the Riyadh Intensive Care Program Mortality Prediction Algorithm, pejoratively referred to as the "death computer," to demonstrate the ethical challenges that can arise when big-data-driven scoring systems are applied in clinical contexts. We argue that the uncritical use of predictive clinical algorithms, including those envisioned for systems medicine, challenge basic understandings of the doctor-patient relationship. Third, we will build on the recent discourse on secondary findings in genomics and imaging to draw attention to the important implications of secondary findings derived from the joint analysis of data from diverse sources, including data recorded by patients in an attempt to realize their
Qi, Guan D; We, Ding A; Chung, Leung P; Fai, Cheng K
One of the important components in randomized Controlled Trial (RCT) is blinding. The gold standard of clinical trials is to achieve a double blind design. However, only a small number of randomized controlled trials in traditional Chinese medicine have been reported, most of them are of poor quality in methodology including placebo preparation and verification. The purpose of the article is to review the validity of placebo used in blinded clinical trials for Chinese herbal medicine (CHM) in recent years and related patents. We searched the Wanfang Database (total of 827 Chinese journals of medicine and/or pharmacy, from 1999 to 2005) and 598 full-length articles related to placebo clinical trials were found. 77 placebo blinded clinical trials for Chinese medicine were extracted by manual search from the 598 articles. After reviewing the 77 full-length articles, we found that nearly half of the clinical trials did not pay attention to the physical quality of the testing drug and placebo and whether they were of comparable physical quality. The rest provided very limited placebo information so that blinding assurance could not be assumed. Only 2 articles (2.6%) specifically validated the comparability between the testing drug and the placebo. Researchers in Chinese medicine commonly ignored the quality of the placebo in comparison to the test drug. This may be causing bias in the clinical trials. Quality specifications and evaluation of the placebo should deserve special attention to reduce bias in randomized controlled trials in TCM study.
Davis, F D
In terms of Aristotle's intellectual virtues, the process of clinical reasoning and the discipline of clinical medicine are often construed as techne (art), as episteme (science), or as an amalgam or composite of techne and episteme. Although dimensions of process and discipline are appropriately described in these terms, I argue that phronesis (practical reasoning) provides the most compelling paradigm, particularly of the rationality of the physician's knowing and doing in the clinical encounter with the patient. I anchor this argument, moreover, in Pellegrino's philosophy of medicine as a healing relationship, oriented to the end of a right and good healing action for the individual patient.
Morozov, V G; Khavinson, V Kh
Available are the results of experimental and clinical study of a new class of peptide bioregulators--cytomedines. Mechanism of action of these substances is considered. Cytomedines-based drugs can be used for prevention and treatment of age pathology and premature aging. A new trend in clinical medicine--bioregulation therapy--is grounded.
Background Although Adolescent Medicine is a pediatric subspecialty, it addresses many issues that differ from other aspects of pediatrics clinical training. The aim of this study was to explore the general experiences of pediatric residents during their rotations in Adolescent Medicine. Methods Qualitative methods were applied. Semi-structured individual interviews were conducted with pediatric residents who had completed a rotation in Adolescent Medicine. Emergent themes were identified. Results Three key themes emerged: gaining exposure, taking on a professional role, and achieving self-awareness. Subcategories were also identified. There was particular emphasis on the multidisciplinary team and the biopsychosocial approach to adolescent health care. Conclusions The experiences in Adolescent Medicine reflected residents' learning, notably gains in the "non-expert" as well as "medical expert" physician competencies. Future studies should explore how the interprofessional nature of an Adolescent Medicine team and the patient populations themselves contribute to this learning. PMID:21122143
Albuhairan, Fadia; Leslie, Karen; Goldberg, Eudice
Although Adolescent Medicine is a pediatric subspecialty, it addresses many issues that differ from other aspects of pediatrics clinical training. The aim of this study was to explore the general experiences of pediatric residents during their rotations in Adolescent Medicine. Qualitative methods were applied. Semi-structured individual interviews were conducted with pediatric residents who had completed a rotation in Adolescent Medicine. Emergent themes were identified. Three key themes emerged: gaining exposure, taking on a professional role, and achieving self-awareness. Subcategories were also identified. There was particular emphasis on the multidisciplinary team and the biopsychosocial approach to adolescent health care. The experiences in Adolescent Medicine reflected residents' learning, notably gains in the "non-expert" as well as "medical expert" physician competencies. Future studies should explore how the interprofessional nature of an Adolescent Medicine team and the patient populations themselves contribute to this learning.
Muttarak, M; ChiangMai, W N; Lojanapiwat, B
The prevalence of pulmonary and extrapulmonary tuberculosis (TB) has been increasing over the past decade, due to the rising number of people with acquired immunodeficiency syndrome and the development of drug-resistant strains of Mycobacterium tuberculosis. The genitourinary tract is the most common site of extrapulmonary TB. Diagnosis is often difficult because TB has a variety of clinical and radiological findings. It can mimic numerous other disease entities. A high level of clinical suspicion and familiarity with various radiological manifestations of TB allow early diagnosis and timely initiation of proper management. This pictorial essay illustrates the spectrum of imaging features of TB affecting the kidney, ureter, bladder, and the female and male genital tracts.
Zhang, Yue; Guo, Shu-Li; Han, Li-Na; Li, Tie-Ling
Objective: To review theories and technologies of big data mining and their application in clinical medicine. Data Sources: Literatures published in English or Chinese regarding theories and technologies of big data mining and the concrete applications of data mining technology in clinical medicine were obtained from PubMed and Chinese Hospital Knowledge Database from 1975 to 2015. Study Selection: Original articles regarding big data mining theory/technology and big data mining's application in the medical field were selected. Results: This review characterized the basic theories and technologies of big data mining including fuzzy theory, rough set theory, cloud theory, Dempster–Shafer theory, artificial neural network, genetic algorithm, inductive learning theory, Bayesian network, decision tree, pattern recognition, high-performance computing, and statistical analysis. The application of big data mining in clinical medicine was analyzed in the fields of disease risk assessment, clinical decision support, prediction of disease development, guidance of rational use of drugs, medical management, and evidence-based medicine. Conclusion: Big data mining has the potential to play an important role in clinical medicine. PMID:26960378
Zhang, Yue; Guo, Shu-Li; Han, Li-Na; Li, Tie-Ling
To review theories and technologies of big data mining and their application in clinical medicine. Literatures published in English or Chinese regarding theories and technologies of big data mining and the concrete applications of data mining technology in clinical medicine were obtained from PubMed and Chinese Hospital Knowledge Database from 1975 to 2015. Original articles regarding big data mining theory/technology and big data mining's application in the medical field were selected. This review characterized the basic theories and technologies of big data mining including fuzzy theory, rough set theory, cloud theory, Dempster-Shafer theory, artificial neural network, genetic algorithm, inductive learning theory, Bayesian network, decision tree, pattern recognition, high-performance computing, and statistical analysis. The application of big data mining in clinical medicine was analyzed in the fields of disease risk assessment, clinical decision support, prediction of disease development, guidance of rational use of drugs, medical management, and evidence-based medicine. Big data mining has the potential to play an important role in clinical medicine.
Messinger-Rapport, Barbara J; Gammack, Julie K; Thomas, David R; Morley, John E
This is the seventh article in the series of Clinical Updates on Nursing Home Care. The topics covered are antiresorptive drugs, hip fracture, hypertension, orthostatic hypotension, depression, undernutrition, anorexia, cachexia, sarcopenia, exercise, pain, and behavioral and psychological symptoms of dementia.
This is a collection of four papers describing aspects of past and future use of nuclear magnetic resonance as a clinical diagnostic tool. The four papers are entitled (1) What Does NMR Offer that Nuclear Medicine Does Not by Jerry W. Froelich, (2) Oncological Imaging: Now, Future and Impact Jerry W. Froelich, (3) Magnetic Resonance Spectroscopy/Spectroscopic Imaging and Nuclear Medicine: Past, Present and Future by H. Cecil Charles, and (4) MR Cardiology: Now, Future and Impact by Robert J. Herfkens.
This is a collection of four papers describing aspects of past and future use of nuclear magnetic resonance as a clinical diagnostic tool. The four papers are entitled (1) What Does NMR Offer that Nuclear Medicine Does Not? by Jerry W. Froelich, (2) Oncological Imaging: Now, Future and Impact Jerry W. Froelich, (3) Magnetic Resonance Spectroscopy/Spectroscopic Imaging and Nuclear Medicine: Past, Present and Future by H. Cecil Charles, and (4) MR Cardiology: Now, Future and Impact by Robert J. Herfkens.
Medicine is another area where big data is being used. The link between clinical treatment and outcome is the key step when applying big data in medicine. In the era of big data, it is critical to collect complete outcome data. Patient follow-up, comprehensive integration of data resources, quality control and standardized data management are the predominant approaches to avoid missing data and data island. Therefore, establishment of systemic patients follow-up protocol and prospective data management strategy are the important aspects of big data in medicine.
Siegfried, Nandi; Johnson, Quinton
Abstract An electronic survey was used to assess the training needs of clinical and public health researchers who have been involved, and/or plan to become involved, in clinical trials of herbal medicines in Africa. Over 90 researchers were contacted through pre-existing networks, of whom 58 (64%) responded, from 35 institutions in 14 African countries. Over half (57%) had already been involved in a clinical trial of an herbal medicine, and gave information about a total of 23 trials that have already been completed. Of these, only five had been published, and only one had resulted in a licensed product. Fifty-four (54) of the researchers were planning to conduct a clinical trial of an herbal medicine in the future, and gave information about 54 possible trials. Respondents outlined the following most commonly encountered difficulties when conducting clinical trials: resource constraints (including lack of funding, equipment, staff, and infrastructure); social acceptance of the clinical trial (including difficulty recruiting enough patients, poor rapport with traditional healers, and willingness of biomedical staff to be involved); herbal medicine supply (including insufficient cultivation, production, and quality control); lack of trained staff; and logistical issues in conducting trials. The topics in which researchers were least confident were Intellectual Property Rights issues, statistical issues, and issues related to Good Clinical Practice guidelines. PMID:22784350
Özlük, Yasemin; Kılıçaslan, Işın
The endocrine system and genitourinary tract unite in various syndromes. Genitourinary malignancies may cause paraneoplastic endocrine syndromes by secreting hormonal substances. These entities include Cushing`s syndrome, hypercalcemia, hyperglycemia, polycythemia, hypertension, and inappropriate ADH or HCG production. The most important syndromic scenarios that links these two systems are hereditary renal cancer syndromes with specific genotype/phenotype correlation. There are also some very rare entities in which endocrine and genitourinary systems are involved such as Carney complex, congenital adrenal hyperplasia and Beckwith-Wiedemann syndrome. We will review all the syndromes regarding manifestations present in endocrine and genitourinary organs.
Doctors in any department should have at least minimum knowledge of Kampo medicines. However, doctors who specialize in neurology often have inadequate knowledge of Kampo medicines. The efficacy of Kampo medicines in treating intractable diseases such as neurodegenerative diseases is not adequately understood and needs to be investigated in the future. On the other hand, Kampo medicines are often effective for treating common symptoms such as headache, dysesthesia, pain, and vertigo, encountered in daily medical practice. Because many patients suffer from these symptoms, the impact of these symptoms on our society is not small, even though the causes of these symptoms are not crucial. Having the skill to prescribe even a dozen or so Kampo medicines (for example, goshuyuto, goreisan, goshajinkigan, sokeikakketsuto) increases the treatment options and may be very beneficial in daily medical practice. In this article, I provide instructions on the use of representative Kampo medicines and present some case reports to elucidate their use. Amassing and sharing clinical experiences regarding the use of Kampo medicines would strengthen the medical evidences of Kampo medicines.
Yang, Zhiyin; Su, Zhonghua; Ji, Feng; Zhu, Min; Bai, Bo
Behavior modification, as the core of clinical behavioral medicine, is often used in clinical settings. We seek to summarize behavior modification techniques that are commonly used in clinical practice of behavioral medicine in China and discuss possible biobehavioral mechanisms. We reviewed common behavior modification techniques in clinical settings in China, and we reviewed studies that explored possible biobehavioral mechanisms. Commonly used clinical approaches of behavior modification in China include behavior therapy, cognitive therapy, cognitive-behavioral therapy, health education, behavior management, behavioral relaxation training, stress management intervention, desensitization therapy, biofeedback therapy, and music therapy. These techniques have been applied in the clinical treatment of a variety of diseases, such as chronic diseases, psychosomatic diseases, and psychological disorders. The biobehavioral mechanisms of these techniques involve the autonomic nervous system, neuroendocrine system, neurobiochemistry, and neuroplasticity. Behavior modification techniques are commonly used in the treatment of a variety of somatic and psychological disorders in China. Multiple biobehavioral mechanisms are involved in successful behavior modification.
Ma, Li; Liu, Baoyan; Xie, Qi; Mao, Shusong; Cui, Zhiwei
This study proposes the ontological reconstruction of the current clinical terminology of traditional Chinese medicine (TCM). It also provides an overview of preliminary work related to the said reconstruction, including the ontology-based analysis of TCM clinical terminology. We conclude that the ontological reconstruction of TCM clinical terminology provides a proper translation from the idealized organizational model to real-world implementation and to a formalized, shared, and knowledge-based framework.
Farrugia, G; Weinshilboum, RM
The Mayo Clinic Center for Individualized Medicine (CIM) is designed to discover and integrate the latest in genomic, molecular, and clinical science into personalized care for patients across a multiple-site academic medical center. Despite a highly integrated structure, fully electronic medical record, and strong administrative support, achievement of this goal has had challenges. This article will describe the activities of the CIM, with emphasis on the strategy being used to clinically implement genomics. PMID:23588321
Minsker, Stanislav; Zhao, Ying-Qi; Cheng, Guang
Individualized treatment rules (ITRs) tailor treatments according to individual patient characteristics. They can significantly improve patient care and are thus becoming increasingly popular. The data collected during randomized clinical trials are often used to estimate the optimal ITRs. However, these trials are generally expensive to run, and, moreover, they are not designed to efficiently estimate ITRs. In this article, we propose a cost-effective estimation method from an active learning perspective. In particular, our method recruits only the “most informative” patients (in terms of learning the optimal ITRs) from an ongoing clinical trial. Simulation studies and real-data examples show that our active clinical trial method significantly improves on competing methods. We derive risk bounds and show that they support these observed empirical advantages. Supplementary materials for this article are available online. PMID:28018014
As 21st century health care moves from a disease-based approach to a more patient-centric system that can address biochemical individuality to improve health and function, clinical decision making becomes more complex. Accentuating the problem is the lack of a clear standard for this more complex functional medicine approach. While there is relatively broad agreement in Western medicine for what constitutes competent assessment of disease and identification of related treatment approaches, the complex functional medicine model posits multiple and individualized diagnostic and therapeutic approaches, most or many of which have reasonable underlying science and principles, but which have not been rigorously tested in a research or clinical setting. This has led to non-rigorous thinking and sometimes to uncritical acceptance of both poorly documented diagnostic procedures and ineffective therapies, resulting in less than optimal clinical care. PMID:24278827
Pizzorno, Joseph E
As 21st century health care moves from a disease-based approach to a more patient-centric system that can address biochemical individuality to improve health and function, clinical decision making becomes more complex. Accentuating the problem is the lack of a clear standard for this more complex functional medicine approach. While there is relatively broad agreement in Western medicine for what constitutes competent assessment of disease and identification of related treatment approaches, the complex functional medicine model posits multiple and individualized diagnostic and therapeutic approaches, most or many of which have reasonable underlying science and principles, but which have not been rigorously tested in a research or clinical setting. This has led to non-rigorous thinking and sometimes to uncritical acceptance of both poorly documented diagnostic procedures and ineffective therapies, resulting in less than optimal clinical care.
Messinger-Rapport, Barbara J; Cruz-Oliver, Dulce M; Thomas, David R; Morley, John E
This article is the sixth in the series of clinical updates on nursing home care. The topics covered are management of hypertension, antidepressant medications in people with dementia, peripheral arterial disease, probiotics in prevention, and treatment of Clostridium difficile-associated diarrhea, frailty, and falls.
Ribera Pascuet, Esteban; Curran, Adria
Standard antiretroviral therapy (ART) consists of a combination of three active drugs. The selection of these drugs varies considerably according to the clinical scenario. The "gold standard" in patients initiating ART is tenofovir (TDF)/emtricitabine (FTC)/efavirenz. TDF/FTC is also considered a combination of choice when, for various reasons, ART is initiated with a boosted protease inhibitor. Abacavir and lamivudine (ABC/3TC) is also considered a combination of choice in most clinical practice guidelines. HLA-B*5701 determination minimizes the possibility of hypersensitivity of ABC and is a positive datum for the use of ABC/3TC. However, negative findings from the data collection on Adverse Events of Anti-HIV drugs (DAD) and ACTG5202 studies on this combination should be bourne in mind. TDF can also be a good choice for substituting another nucleoside analogue to avoid or reverse certain toxicities in patients with good virological control. Substituting thymidine analogues for TDF improves lipid profile and produces partial recuperation of subcutaneous fat. Because of the profile of resistance to TDF, this drug continues to be active in most patients with one, or even several, therapeutic failures. TDF plays and especially important role in patients coinfected with hepatotrophic viruses. In summary, TDF is a widely used drug in clinical practice due to its excellent combination of effectiveness, durability and tolerability, in addition to its ease of administration in a single daily dose, whether in its individual formation (Viread), or associated with FTC (Truvada), or with FTC and efavirenz (Atripla).
Kim, Sollip; Yun, Yeo Min; Chae, Hyo Jin; Cho, Hyun Jung; Ji, Misuk; Kim, In Suk; Wee, Kyung A; Lee, Woochang; Song, Sang Hoon; Woo, Hye In; Lee, Soo Youn; Chun, Sail
Pharmacogenetic testing for clinical applications is steadily increasing. Correct and adequate use of pharmacogenetic tests is important to reduce unnecessary medical costs and adverse patient outcomes. This document contains recommended pharmacogenetic testing guidelines for clinical application, interpretation, and result reporting through a literature review and evidence-based expert opinions for the clinical pharmacogenetic testing covered by public medical insurance in Korea. This document aims to improve the utility of pharmacogenetic testing in routine clinical settings.
Kim, Sollip; Yun, Yeo-Min; Chae, Hyo-Jin; Cho, Hyun-Jung; Ji, Misuk; Kim, In-Suk; Wee, Kyung-A; Lee, Woochang; Song, Sang Hoon; Woo, Hye In
Pharmacogenetic testing for clinical applications is steadily increasing. Correct and adequate use of pharmacogenetic tests is important to reduce unnecessary medical costs and adverse patient outcomes. This document contains recommended pharmacogenetic testing guidelines for clinical application, interpretation, and result reporting through a literature review and evidence-based expert opinions for the clinical pharmacogenetic testing covered by public medical insurance in Korea. This document aims to improve the utility of pharmacogenetic testing in routine clinical settings. PMID:28029011
Bellazzi, Riccardo; Zupan, Blaz
The widespread availability of new computational methods and tools for data analysis and predictive modeling requires medical informatics researchers and practitioners to systematically select the most appropriate strategy to cope with clinical prediction problems. In particular, the collection of methods known as 'data mining' offers methodological and technical solutions to deal with the analysis of medical data and construction of prediction models. A large variety of these methods requires general and simple guidelines that may help practitioners in the appropriate selection of data mining tools, construction and validation of predictive models, along with the dissemination of predictive models within clinical environments. The goal of this review is to discuss the extent and role of the research area of predictive data mining and to propose a framework to cope with the problems of constructing, assessing and exploiting data mining models in clinical medicine. We review the recent relevant work published in the area of predictive data mining in clinical medicine, highlighting critical issues and summarizing the approaches in a set of learned lessons. The paper provides a comprehensive review of the state of the art of predictive data mining in clinical medicine and gives guidelines to carry out data mining studies in this field. Predictive data mining is becoming an essential instrument for researchers and clinical practitioners in medicine. Understanding the main issues underlying these methods and the application of agreed and standardized procedures is mandatory for their deployment and the dissemination of results. Thanks to the integration of molecular and clinical data taking place within genomic medicine, the area has recently not only gained a fresh impulse but also a new set of complex problems it needs to address.
Flight, Laura; Julious, Steven A; Goodacre, Steve
Adaptive design clinical trials use preplanned interim analyses to determine whether studies should be stopped or modified before recruitment is complete. Emergency medicine trials are well suited to these designs as many have a short time to primary outcome relative to the length of recruitment. We hypothesised that the majority of published emergency medicine trials have the potential to use a simple adaptive trial design. We reviewed clinical trials published in three emergency medicine journals between January 2003 and December 2013. We determined the proportion that used an adaptive design as well as the proportion that could have used a simple adaptive design based on the time to primary outcome and length of recruitment. Only 19 of 188 trials included in the review were considered to have used an adaptive trial design. A total of 154/165 trials that were fixed in design had the potential to use an adaptive design. Currently, there seems to be limited uptake in the use of adaptive trial designs in emergency medicine despite their potential benefits to save time and resources. Failing to take advantage of adaptive designs could be costly to patients and research. It is recommended that where practical and logistical considerations allow, adaptive designs should be used for all emergency medicine clinical trials. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
Surolia, Ira; Gulley, James; Madan, Ravi A
Despite a recent increase in US FDA-approved treatments, genitourinary malignancies remain a source of significant morbidity and mortality. One focus of research is the use of therapeutic cancer vaccines in these diseases, and a significant body of clinical trial experience now exists for refining vaccine strategies to enhance antitumor efficacy and develop immune-based combination regimens. In recent years, clinical data from multiple trials in genitourinary malignancies have enhanced our understanding of the potential for immunotherapy in these cancers. There are also emerging clinical strategies that combine cancer vaccines with chemotherapy, radiation, androgen-deprivation therapy and immune checkpoint inhibitors. This review is based on a search of relevant literature for data presented over the past 5 years from clinical trials of cancer vaccines in prostate, bladder and renal carcinomas. In the coming years, clinical trials informed by decades of preclinical data and emerging clinical data will help to define the role of immunotherapy in genitourinary malignancies. Combination strategies that capitalize on the immune properties of standard treatments will bring greater clinical benefits, and immune-based combinations will likely be moved to the neoadjuvant setting, where they may have optimal clinical impact.
Tebo, Anne E; Detrick, Barbara; Hamilton, Robert G; Khanolkar, Aaruni; O'Gorman, Maurice R G; Schmitz, John L; Abraham, Roshini S
Clinical laboratory immunology affects practically every aspect of medicine. Accordingly, appropriately trained, board-certified clinical laboratory immunologists are key contributors to the diagnosis and management of patients with various immune-mediated conditions. This review highlights the availability of postdoctoral level training programs for clinical laboratory immunology and identifies possible career tracks. Fundamental elements for doctoral level clinical laboratory immunologists are identified and the critical components of diagnostic immunology training as well as career opportunities in and out of academia are described. Relative to other disciplines in laboratory medicine, little emphasis has been given to clinical laboratory immunology in medical, graduate, and postgraduate training. Formal postgraduate fellowship programs and board certification examinations are available, yet there remains a significant lack of awareness in the medical education community about the value and necessity of training in this field. It is anticipated that sharing this knowledge will increase awareness of the discipline of clinical laboratory immunology at the postdoctoral level with implications for the practice of laboratory medicine. Copyright© by the American Society for Clinical Pathology.
Delaney, Susan K; Hultner, Michael L; Jacob, Howard J; Ledbetter, David H; McCarthy, Jeanette J; Ball, Michael; Beckman, Kenneth B; Belmont, John W; Bloss, Cinnamon S; Christman, Michael F; Cosgrove, Andy; Damiani, Stephen A; Danis, Timothy; Delledonne, Massimo; Dougherty, Michael J; Dudley, Joel T; Faucett, W Andrew; Friedman, Jennifer R; Haase, David H; Hays, Tom S; Heilsberg, Stu; Huber, Jeff; Kaminsky, Leah; Ledbetter, Nikki; Lee, Warren H; Levin, Elissa; Libiger, Ondrej; Linderman, Michael; Love, Richard L; Magnus, David C; Martland, AnneMarie; McClure, Susan L; Megill, Scott E; Messier, Helen; Nussbaum, Robert L; Palaniappan, Latha; Patay, Bradley A; Popovich, Bradley W; Quackenbush, John; Savant, Mark J; Su, Michael M; Terry, Sharon F; Tucker, Steven; Wong, William T; Green, Robert C
Precision or personalized medicine through clinical genome and exome sequencing has been described by some as a revolution that could transform healthcare delivery, yet it is currently used in only a small fraction of patients, principally for the diagnosis of suspected Mendelian conditions and for targeting cancer treatments. Given the burden of illness in our society, it is of interest to ask how clinical genome and exome sequencing can be constructively integrated more broadly into the routine practice of medicine for the betterment of public health. In November 2014, 46 experts from academia, industry, policy and patient advocacy gathered in a conference sponsored by Illumina, Inc. to discuss this question, share viewpoints and propose recommendations. This perspective summarizes that work and identifies some of the obstacles and opportunities that must be considered in translating advances in genomics more widely into the practice of medicine.
Delaney, Susan K.; Hultner, Michael L.; Jacob, Howard J.; Ledbetter, David H.; McCarthy, Jeanette J.; Ball, Michael; Beckman, Kenneth B.; Belmont, John W.; Bloss, Cinnamon S.; Christman, Michael F.; Cosgrove, Andy; Damiani, Stephen A.; Danis, Timothy; Delledonne, Massimo; Dougherty, Michael J.; Dudley, Joel T.; Faucett, W. Andrew; Friedman, Jennifer R.; Haase, David H.; Hays, Tom S.; Heilsberg, Stu; Huber, Jeff; Kaminsky, Leah; Ledbetter, Nikki; Lee, Warren H.; Levin, Elissa; Libiger, Ondrej; Linderman, Michael; Love, Richard L.; Magnus, David C.; Martland, AnneMarie; McClure, Susan L.; Megill, Scott E.; Messier, Helen; Nussbaum, Robert L.; Palaniappan, Latha; Patay, Bradley A.; Popovich, Bradley W.; Quackenbush, John; Savant, Mark J.; Su, Michael M.; Terry, Sharon F.; Tucker, Steven; Wong, William T.; Green, Robert C.
ABSTRACT Precision or personalized medicine through clinical genome and exome sequencing has been described by some as a revolution that could transform healthcare delivery, yet it is currently used in only a small fraction of patients, principally for the diagnosis of suspected Mendelian conditions and for targeting cancer treatments. Given the burden of illness in our society, it is of interest to ask how clinical genome and exome sequencing can be constructively integrated more broadly into the routine practice of medicine for the betterment of public health. In November 2014, 46 experts from academia, industry, policy and patient advocacy gathered in a conference sponsored by Illumina, Inc. to discuss this question, share viewpoints and propose recommendations. This perspective summarizes that work and identifies some of the obstacles and opportunities that must be considered in translating advances in genomics more widely into the practice of medicine. PMID:26810587
Many studies analyse the diagnostic process, diagnostic errors and diagnostic excellence but few provide a broad, yet practical view of this complex and highly context-dependent challenge. A personal, experience- and research-based selection of the principles of data collection, processing and clinical reasoning found to be most useful in achieving an efficient, timely and patient-centered diagnosis. Twenty-four principles were identified and each one is presented followed by a brief commentary. No single strategy can provide a solution for all diagnostic problems. However, the 24 principles have proven validity and can be applied for solving diagnostic problems in varied settings and as a scaffold in teaching diagnosis at all levels of medical education. © The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: firstname.lastname@example.org.
Texas Univ., Austin. Extension Instruction and Materials Center.
The materials in this packet are for a course designed to provide individualized classroom study for a specific area of clinical rotation--sports medicine. The instructor's manual describes the learning objectives together with a list of reference materials that should be provided for completion of the student worksheets, and lists suggested…
Texas Univ., Austin. Extension Instruction and Materials Center.
The materials in this packet are for a course designed to provide individualized classroom study for a specific area of clinical rotation--sports medicine. The instructor's manual describes the learning objectives together with a list of reference materials that should be provided for completion of the student worksheets, and lists suggested…
Bailey, Sean M.; Mally, Pradeep V.
Global tissue perfusion and oxygenation are important indicators of physiologic function in humans. The monitoring of splanchnic oximetry through the use of near-infrared spectroscopy (NIRS) is an emerging method used to assess tissue oxygenation status. Splanchnic tissue oxygenation (SrS) is thought to be potentially of high value in critically ill patients because gastrointestinal organs can often be the first to suffer ischemic injury. During conditions of hypovolemia, cardiac dysfunction, or decreased oxygen-carrying capacity, blood flow is diverted toward vital organs, such as the brain and the heart at the expense of the splanchnic circulation. While monitoring SrS has great potential benefit, there are limitations to the technology and techniques. SrS has been found to have a relatively high degree of variability that can potentially make it difficult to interpret. In addition, because splanchnic organs only lie near the skin surface in children and infants, and energy from currently available sensors only penetrates a few centimeters deep, it can be difficult to use clinically in a noninvasive manner in adults. Research thus far is showing that splanchnic oximetry holds great promise in the ability to monitor patient oxygenation status and detect disease states in humans, especially in pediatric populations.
Isotope scanning using technetium 99m pertechnetate has fallen into disuse since the advent of x-ray computerized tomography. Regional brain blood flow studies have been pursued on a research basis. Increased regional blood flow during focal seizure activity has been demonstrated and is of use in localizing such foci. Cisternography as a predictive tool in normal pressure hydrocephalus is falling into disuse. Positron tomographic scanning is a potent research tool that can demonstrate both regional glycolysis and blood flow. Unfortunately, it is extremely expensive and complex to apply in a clinical setting. With support from the National Institutes of Health, seven extramural centers have been funded to develop positron tomographic capabilities, and they will greatly advance our knowledge of stroke pathophysiology, seizure disorders, brain tumors, and various degenerative diseases. Nuclear magnetic resonance imaging is a potentially valuable tool since it creates tomographic images representing the distribution of brain water. No tissue ionization is produced, and images comparable to second-generation computerized tomographic scans are already being produced in humans.
Until recently the common opinion was that medicine was substantially a natural science. In recent years, this has completely changed because two non-naturalistic disciplines have become part of the physician's activity; ethics and economy. These new disciplines have evidenced many problems to which doctors did not pay much attention before; however, they had an impact on the clinician's sensibility. At present, clinical medicine represents a complex knowledge as well as an activity: it is both a "historical" and a "technological" science characterized by a specific goal, the recovery or maintenance of health, and by a series of values.
The use of assistive technology and telemedicine is likely to continue to shape our medical practice in the future, notably in the field of sleep medicine, especially within developed countries. Currently, the number of people suffering from obstructive sleep apnea syndrome (OSAS) is increasing. Telemedicine (TM) can be used in a variety of ways in sleep medicine: telediagnostics, teleconsultation, teletherapy and telemonitoring of patients being treated with positive pressure devices. In this review, we aim to summarize the recent scientific progresses of these techniques and their potential clinical applications and give consideration to the remaining problems related to TM application. PMID:27983582
Chong, S. K.; Oberholzer, V. G.
Panax ginseng occupies an important place among the tonic remedies of Oriental medicine. Pharmacological investigations show that crude ginsenosides can increase non-specific resistance of an organism to various untoward influences. The effects of purified derived derivatives have only recently become better studied in immunological and cell growth studies in animals and in man. This has now provided some evidence to suggest that ginseng is a drug that contains many derivatives with different pharmacological properties, which could be useful in clinical medicine. PMID:3076665
Smoller, Jordan W; Karlson, Elizabeth W; Green, Robert C; Kathiresan, Sekar; MacArthur, Daniel G; Talkowski, Michael E; Murphy, Shawn N; Weiss, Scott T
The integration of electronic medical records (EMRs) and genomic research has become a major component of efforts to advance personalized and precision medicine. The Electronic Medical Records and Genomics (eMERGE) network, initiated in 2007, is an NIH-funded consortium devoted to genomic discovery and implementation research by leveraging biorepositories linked to EMRs. In its most recent phase, eMERGE III, the network is focused on facilitating implementation of genomic medicine by detecting and disclosing rare pathogenic variants in clinically relevant genes. Partners Personalized Medicine (PPM) is a center dedicated to translating personalized medicine into clinical practice within Partners HealthCare. One component of the PPM is the Partners Healthcare Biobank, a biorepository comprising broadly consented DNA samples linked to the Partners longitudinal EMR. In 2015, PPM joined the eMERGE Phase III network. Here we describe the elements of the eMERGE clinical center at PPM, including plans for genomic discovery using EMR phenotypes, evaluation of rare variant penetrance and pleiotropy, and a novel randomized trial of the impact of returning genetic results to patients and clinicians.
Genome editing based on site-directed nucleases facilitated efficient and versatile genetic modifications in human cells. However, recent reports, demonstrating CRISPR/Cas9-mediated genome editing in human embryos have raised profound concerns worldwide. This commentary explores the clinical justification and feasibility of reproductive medicine using germline genome editing. Despite the perceived utility of reproductive medicine for treating intractable infertility, it is difficult to justify germline genome editing from the perspective of the prospective child. As suggested by the UK legalization regarding mitochondrial donation, the prevention of genetic disease in offspring by genome editing might be acceptable in limited cases of serious or life-threatening conditions, where no alternative medicine is available. Nonetheless, the mosaicism underlying human embryos as well as the off-target effect by artificial nucleases will likely hamper preimplantation genetic diagnosis prior to embryo transfer. Such considerations suggest that this type of reproductive medicine should not be developed toward a clinical application. However, the clinical uncertainties underscore the need for embryology that can address fundamental questions regarding germline aneuploidy and mosaicism using genome editing. Copyright © 2016 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
Yoshida, Hiroshi; Koshiba, Masahiro
The Japanese Society of Laboratory Medicine has been running its own Medical Safety Committee, and holding a symposium on medical safety during the annual meeting every year. The activities based on a team approach to medicine play a critical role in the development of medical safety culture and the driving forward of medical safety in clinical practice. The best medical practice involves cooperation among information-sharing medical staff from a variety of professions, providing medical care based on medical safety, which patients hope for. It is hoped that the present symposium on medical safety can help drive medical safety into the future.
Advances in genomic medicine have the potential to change the way we treat human disease, but translating these advances into reality for improving healthcare outcomes depends essentially on our ability to discover disease- and/or drug-associated clinically actionable genetic mutations. Integration and manipulation of diverse genomic data and comprehensive electronic health records (EHRs) on a big data infrastructure can provide an efficient and effective way to identify clinically actionable genetic variants for personalized treatments and reduce healthcare costs. We review bioinformatics processing of next-generation sequencing (NGS) data, bioinformatics infrastructures for implementing precision medicine, and bioinformatics approaches for identifying clinically actionable genetic variants using high-throughput NGS data and EHRs. PMID:27195526
Bi, Ying-fei; Mao, Jing-yuan
In recent years, Delphi method has been widely applied in traditional Chinese medicine (TCM) clinical research. This article analyzed the present application situation of Delphi method in TCM clinical research, and discussed some problems presented in the choice of evaluation method, classification of observation indexes and selection of survey items. On the basis of present application of Delphi method, the author analyzed the method on questionnaire making, selection of experts, evaluation of observation indexes and selection of survey items. Furthermore, the author summarized the steps of application of Delphi method in TCM clinical research.
Fine art is good medicine. It comforts, elevates the spirit, and affirms life and hope. Art in the healthcare setting, combined with outstanding care and service, creates an environment that encourages healing and supports the work of medical professionals. As one of the world’s great medical centers, Cleveland Clinic has always included the arts in its healing environment. The four founders and subsequent leadership encouraged artistic and musical expression by employees. Distinguished artworks have long hung on the walls. In 1983, an Aesthetics Committee was officially formed at Cleveland Clinic to address issues of art and design in Cleveland Clinic facilities. PMID:24282686
De Freitas, Julian; Haque, Omar S; Gopal, Abilash A; Bursztajn, Harold J
A long-debated question in the philosophy of health, and contingent disciplines, is the extent to which wise clinical practice ("clinical wisdom") is, or could be, compatible with empirically validated medicine ("evidence-based medicine"--EBM). Here we respond to Baum-Baicker and Sisti, who not only suggest that these two types of knowledge are divided due to their differing sources, but also that EBM can sometimes even hurt wise clinical practice. We argue that the distinction between EBM and clinical wisdom is poorly defined, unsupported by the methodology employed, and ultimately incorrect; crucial differences exist, we argue, not in the source of a particular piece of clinical knowledge, but in its dependability. In light of this subtle but fundamental revision, we explain how clinical wisdom and EBM are--by necessity--complementary, rather than in conflict. We elaborate on how recognizing this relationship can have far-reaching implications for the domains of clinical practice, medical education, and health policy.
Nayar, Suresh K; Dein, Eric J; Spiker, Andrea M; Bernard, Johnathan A; Zikria, Bashir A
Orthopedic sports medicine continues to evolve, owing much of its clinical management and practice to rigorous academic research. In this review, we identify and describe the top 100 cited articles in clinical sports medicine and recognize the authors and institutions driving the research. We collected articles (excluding basic science, animal, and cadaveric studies) from the 25 highest-impact sports medicine journals and analyzed them by number of citations, journal, publication date, institution, country, topic, and author. Mean number of citations was 408 (range, 229-1629). The articles were published in 7 journals, most in the 1980s to 2000s, and represented 15 countries. Thirty topics were addressed, with a heavy emphasis on anterior cruciate ligament injury and reconstruction, knee rating systems, rotator cuff reconstruction, and chondrocyte transplantation. The 3 most cited articles, by Insall and colleagues, Constant and Murley, and Tegner and Lysholm, addressed a knee, a shoulder, and another knee rating system, respectively. Several authors contributed multiple articles. The Hospital for Special Surgery and the University of Bern contributed the most articles (5 each). This study provides a comprehensive list of the past century's major academic contributions to sports medicine. Residents and fellows may use this list to guide their scholarly investigations.
Ventegodt, Søren; Andersen, Niels Jørgen; Kandel, Isack; Merrick, Joav
This paper identifies five formal errors in non-drug medicine including most types of complementary and alternative medicine (CAM). These are based on five central principles of healing from the curriculum of the EU master in complementary, psychosocial and integrated health sciences (EU-MSc-CAM) from the Interuniversity College in Graz, Austria. An error is defined, as a therapeutic intervention that judged from established scientific knowledge should have been done differently. We found formal errors regarding: 1) The principle of salutogenesis, 2) The principle of similarity, 3) The principle that healing happens in surplus of resources, 4) The principle of using as little force as possible (primum non nocere), 5) The Hering's law of cure (you will get well in the opposite order of the way you got ill). From the primary errors secondary errors can be identified: A) Focusing on the patient's consciousness instead of the patient's unconscious, B) Wasting time on taking anamnesis and giving diagnoses, C) To ignore that the therapy does not help, D) Not to refer a patient that you know cannot be helped by you, E) Not to observe that a close relationship does not develop between therapist and patient, F) To work on a patient that you are not competent to help, G) Not to support the development of the patient into an independent person, H) Not letting go of the patient. None of the errors caused harm to the patient but slowed down healing. The presented list of errors is ideal for training and supervision.
Cánovas Ivorra, Jose Antonio; Tramoyeres Galván, Alfredo; Sánchez Ballester, Francisco; de la Torre Abril, Luis; Ordoño Domínguez, Felipe; Navalón Verdejo, Pedro; Ramada Benlloch, Francisco; López Alcina, Emilio; Pérez Albacete, Mariano; Zaragoza Orts, Julio
Professor Rafael Molla Rodrigo is considered by some the author who contributed with his scientific work and solid technique to consolidate Urology as a speciality in Valencia. Such importance is also perceived in a national level, as demonstrated by the fact that he belonged to the first board of the Spanish Association of Urology and contributed to its foundation in the two-year period 1910--1911, from his position of head of the department of Surgical Therapy and Operations at the Central University. Genitourinary tuberculosis is one of the most outstanding chapters of his extensive works. We reviewed all his works, selecting all original articles about genitourinary tuberculosis. Original articles have been obtained from the journals Revista de Higiene y Tuberculosis, La Medicina Valenciana, Revista Valenciana de Ciencias Médicas y Policínica, and from his two most important books, Clinical Lessons In Urology and Clinical Lessons in Urology and Genitourinary Surgery. Throughout his work he analyzes features of relevance about this disease, such as diagnosis, about which he emphasizes the clinical and bacteriological difficulties, and treatment, which was only feasible by precocious nephrectomy. He dedicates a great part of his work to the study of this pathology and defends a precocious diagnosis in order to perform the only treatment that had demonstrated efficacy. He also exposes the symptoms and variety of clinical presentations, as well as diagnosis through separate kidney catheterization with the aim to determine unilateral involvement.
Tabarrai, Malihe; Qaraaty, Marzie; Aliasl, Jale
Traditional medicine is one of the medical schools, which has been considered in recent years. Achieving reliable and valid research in ITM is very important to introduce this line of medicine into the healthcare organizations. The aim of this study was to investigate clinical research issues in ITM. This study is a qualitative research. We formed an expert panel and, after identifying the content, the study findings were divided into two main categories. Challenges of clinical research studies are divided into two major categories in ITM, the problems of clinical trial processes and the difficulties in publishing research results. Lack of standard data collection instruments and questionnaires, limited sample size, lack of study models designed for distemperament treatment, unawareness, and non-compliance of ethics committees in facilities approved by WHO for clinical research of TM, and even rigidity beyond conventional medicine studies are some of the previously mentioned issues. Some difficulties in the publication of research results include lack of specialized journals especially at high academic levels, lack of familiarity with editorial board and difficulty in publishing the results of studies that are designed with combined products. A few proposals for these problems include: Conducting codification questionnaire workshops (approved by a thesis assistant with a subject of research tools)Introducing appropriate methods of multi-intervention research in ITMCreating the database of similarly performed research available for researchersDesigning multicenter researchCollaborations between academic centersLinking two or more thesis assistants or research projects in the form of a joint proposal with larger sample sizesEstablishing joint meeting between researchers, the heads of TM research centers and ethics committeesDedicated TM journal. Considering a history of several thousand years, the Iranian traditional medicine is a great venue for students. To
Myskja, A; Lindbaek, M
Music has been an element in medical practice throughout history. There is growing interest in music as a therapeutic tool. Since there is no generally accepted standard for how, when and where music should be applied within a medical framework, this literature study endeavours to present an overview of central areas of application of music in medicine. It further attempts to find tentative conclusions that may be drawn from existing clinical research on the efficacy of music as a medical tool. Traditionally, music has been linked to the treatment of mental illness, and has been used successfully to treat anxiety and depression and improve function in schizophrenia and autism. In clinical medicine several studies have shown analgetic and anxiolytic properties that have been used in intensive care units, both in diagnostic procedures like gastroscopy and in larger operations, in preoperative as well as postoperative phases, reducing the need for medication in several studies. The combination of music with guided imagery and deep relaxation has shown reduction of symptoms and increased well-being in chronic pain syndromes, whether from cancer or rheumatic origin. Music has been used as support in pregnancy and gestation, in internal medicine, oncology, paediatrics and other related fields. The use of music with geriatric patients could prove to be especially fruitful, both in its receptive and its active aspect. Studies have shown that music can improve function and alleviate symptoms in stroke rehabilitation, Parkinson's disease, Alzheimer's disease and other forms of dementia. The role of music in medicine is primarily supportive and palliative. The supportive role of music has a natural field of application in palliative medicine and terminal care. Music is well tolerated, inexpensive, with good compliance and few side effects.
Ren, Jun; Li, Xun; Sun, Jin; Han, Mei; Yang, Guo-Yan; Li, Wen-Yuan; Robinson, Nicola; Lewith, George; Liu, Jian-Ping
Background Evidence-based medicine promotes and relies on the use of evidence in developing clinical practice guidelines (CPGs). The Chinese healthcare system includes both traditional Chinese medicine (TCM) and Western medicine, which are expected to be equally reflected in Chinese CPGs. Objective To evaluate the inclusion of TCM-related information in Western medicine CPGs developed in China and the adoption of high level evidence. Methods All CPGs were identified from the China Guideline Clearinghouse (CGC), which is the main Chinese organisation maintaining the guidelines issued by the Ministry of Health of China, the Chinese Medical Association and the Chinese Medical Doctors’ Association. TCM-related contents were extracted from all the CPGs identified. Extracted information comprised the institution issuing the guideline, date of issue, disease, recommendations relating to TCM, evidence level of the recommended content and references supporting the recommendations. Results A total of 604 CPGs were identified, only a small number of which (74/604; 12%) recommended TCM therapy and only five guidelines (7%) had applied evidence grading. The 74 CPGs involved 13 disease systems according to the International Classification of Diseases 10th edition. TCM was mainly recommended in the treatment part of the guidelines (73/74, 99%), and more than half of the recommendations (43/74, 58%) were related to Chinese herbal medicine (single herbs or herbal treatment based on syndrome differentiation). Conclusions Few Chinese Western medicine CPGs recommend TCM therapies and very few provide evidence grading for the TCM recommendation. We suggest that future guideline development should be based on systematic searches for evidence to support CPG recommendations and involve a multidisciplinary approach including TCM expertise. PMID:26041487
Li, Lan; Yu, Fei; Shi, Dongquan; Shi, Jianping; Tian, Zongjun; Yang, Jiquan; Wang, Xingsong; Jiang, Qing
The present review discusses the application of virtual reality (VR) technology in clinical medicine, especially in surgical training, pain management and therapeutic treatment of mental illness. We introduce the common types of VR simulators and their operational principles in aforementioned fields. The clinical effects are also discussed. In almost every study that dealt with VR simulators, researchers have arrived at the same conclusion that both doctors and patients could benefit from this novel technology. Moreover, advantages and disadvantages of the utilization of VR technology in each field were discussed, and the future research directions were proposed.
Yasuhara, Takao; Agari, Takashi; Kameda, Masahiro; Kondo, Akihiko; Kuramoto, Satoshi; Jing, Meng; Sasaki, Tatsuya; Toyoshima, Atsuhiko; Sasada, Susumu; Sato, Kenichiro; Shinko, Aiko; Wakamori, Takaaki; Okuma, Yu; Miyoshi, Yasuyuki; Tajiri, Naoki; Borlongan, Cesario V.; Date, Isao
Epilepsy is a chronic neurological disorder, which presents with various forms of seizures. Traditional treatments, including medication using antiepileptic drugs, remain the treatment of choice for epilepsy. Recent development in surgical techniques and approaches has improved treatment outcomes. However, several epileptic patients still suffer from intractable seizures despite the advent of the multimodality of therapies. In this article, we initially provide an overview of clinical presentation of epilepsy then describe clinically relevant animal models of epilepsy. Subsequently, we discuss the concepts of regenerative medicine including cell therapy, neuroprotective agents, and electrical stimulation, which are reviewed within the context of our data. PMID:24287913
Li, Lan; Yu, Fei; Shi, Dongquan; Shi, Jianping; Tian, Zongjun; Yang, Jiquan; Wang, Xingsong; Jiang, Qing
The present review discusses the application of virtual reality (VR) technology in clinical medicine, especially in surgical training, pain management and therapeutic treatment of mental illness. We introduce the common types of VR simulators and their operational principles in aforementioned fields. The clinical effects are also discussed. In almost every study that dealt with VR simulators, researchers have arrived at the same conclusion that both doctors and patients could benefit from this novel technology. Moreover, advantages and disadvantages of the utilization of VR technology in each field were discussed, and the future research directions were proposed. PMID:28979666
The article deals with the becoming of clinical medicine in chronologic scope from 1800 to middle 1870s. The major scientific achievements related to the application of practical medicine such methods as clinical anatomical comparison, laboratory experiment, chemical analysis, physical, instrumental, functional, laboratory diagnostics are discussed.
Brawley, Stephen; Fairbanks, Keith; Nguyen, William; Blivin, Steve; Frantz, Earl
A transition from traditional problem-based clinics to the Sports Medicine and Reconditioning Team (SMART) clinic model was completed by January 2009 at Marine Corps Base Camp Lejeune. The SMART clinic model allows for more patients to be seen and enhances coordinated care between providers. The objective of this research is to show the advantages of implementing a training room team approach for the care of musculoskeletal injuries in active duty members by comparing the number of patients seen, the number of limited duty (LIMDU) periods, the number of physical evaluation boards (PEBs), and the percentage of orthopedic referrals. Electronic medical records for patients seen at sports medicine clinics between January 1, 2007 and December 31, 2010 were reviewed. Naval Hospital Camp Lejeune provided a database of patients placed on LIMDU and PEB from 2007 through 2010. Fifty-eight and twenty-four percent more encounters occurred in 2009 and 2010, respectively, than that in 2007. The percentage of LIMDU referred for PEB in 2010 was reduced to 9% compared to that in 2007. In conclusion, the SMART clinic model allows for more patients to be seen and a reduction in the percentage of patients recommended for PEB from LIMDU.
Ledru, S; Meda, N; Fofana, M; Soula, G; Bazié, A J; Chiron, J P
Genitourinary infections have a major impact upon public health, especially in Africa. This paper describes findings from a study conducted to describe the etiology of such infections in Bobo-Dioulasso, to establish the sensitivity of Neisseria gonorrhoeae to antibiotics, and to provide epidemiologic and biologic evidence to optimize the treatment of genitourinary infections. The findings are based upon clinical and biologic diagnoses among 223 women with genitourinary infections. Study found the following etiologies: trichomoniasis in 27.8%, chlamydia in 26.9%, bacterial vaginosis in 19.7%, candidiasis in 16.6%, and Neisseria gonorrhoeae infection in 10.9%. HIV antibodies were present in 42% of patients. The authors recommend spectinomycin or ceftriaxone for the treatment of gonorrhea in Bobo-Dioulasso. Moreover, that the prevalence of Chlamydia trachomatis is higher than that of Neisseria gonorrhoeae should be taken into account when managing STDs in this setting.
Hammad, Fayez T; Eid, Hani O; Hefny, Ashraf F; Abu-Zidan, Fikri M
Background: The epidemiology of genitourinary (GU) organ injury following general trauma is not well-studied especially in the Middle East. Patients and Methods: All patients with GU injuries from the Trauma Registry of Al-Ain Hospital were studied. The registry data was prospectively collected from March 2003 to March 2006. Results: Out of 2573 patients in the registry, 22 had GU injuries (incidence: 0.9%, 2.0 per 100,000 inhabitants per year). Road traffic collision was the most frequent mechanism of injury (50% of all cases). 41% of injuries were renal. In 73% of patients, GU injuries were associated with other organ injuries, the most frequent of which were injuries to the other abdominal and pelvic organs (94%). The mean Injury Severity Score, mean total hospital stay, the percentage of patients who required intensive care unit (ICU) admission were higher in patients with GU injuries compared to non-GU patients (17.1 vs. 5.5 (P 0.001), 15.4 vs. 9.2 days (P 0.040) and 43% vs. 8%, (P 0.0001), respectively. Conclusions: The incidence of trauma-related GU injuries in the current study appears to be comparable to those reported from the West. Patients with GU organ injuries tend to have more severe trauma compared to other patients. Road traffic collision was the most common mechanism of injury and the kidney was the most frequently injured organ. PMID:21887022
Abbara, Aula; Davidson, Robert N
Genitourinary tuberculosis (GUTB) is the second most common form of extrapulmonary tuberculosis, with more than 90% of cases occurring in developing countries. Postmortem studies--from before anti-TB therapy was available--have provided insight into the prevalence and natural history of the disease. In GUTB, the kidneys are the most common sites of infection and are infected through hematogenous spread of the bacilli, which then spread through the renal and genital tract. Diagnosis of TB is often delayed owing to the nonspecific nature of its presentation; therefore, a high degree of suspicion should be exercised and a systematic approach should be taken during investigation. Appropriate culture samples should be obtained to tailor treatment. Standard treatment should be administered for 6 months; quadruple therapy for 2 months and dual therapy for 4 months. However, additional drugs and prolonged treatment are required if drug resistance occurs. Although the role of surgery in GUTB has decreased since the advent of anti-TB therapy, it can still have a role as an adjunct to drug treatment. Today, the challenges of GUTB and other forms of TB include increasing rates of drug-resistant cases and co-infection with HIV.
Parulkar, B G; Lamontagne, D P; Vickers, M A
Improved manufacturing techniques and stronger materials have significantly reduced but not eliminated the incidence of hydraulic leakage in the inflatable genitourinary devices. This study was designed to test the efficacy of pressure dissipation and volume loss as potential tests for the detection of site-specific hydraulic leakage in the inflatable penile prosthesis (IPP) and the artificial sphincter (AS) and compare their efficacy with the current standard--the ohmmeter technique. Five IPPs and ASs were dismantled to achieve five reservoirs and cuff-pump assemblies. Each component was inspected visually and then tested for volume, pressure, and electrical resistance over 5 minutes. Next a needle puncture was deliberately made in these components, and the experiment was repeated. The in vivo pseudocapsule was simulated by an elastic covering, made from antiembolic hose. The techniques of pressure, volume, and ohmmeter testing were not able to detect current leakage in all the components, with the pseudocapsule in place. None of the currently available tests qualify for the label of "gold standard" in accurately detecting hydraulic leakage. We currently recommend testing the device's integrity by visual inspection in vivo, starting with the reservoirs. If a leakage is detected, the reservoir alone is replaced. If no leakage is found, we recommend that the entire unit be removed and replaced. If the malfunctioning device is more than 2 years old, we suggest that it be entirely replaced.
Husmann, D A; Rathburn, S R; Driscoll, D J
Prior reviews regarding genitourinary manifestations of Klippel-Trenaunay syndrome used data acquired from diverse specialty specific articles to define the incidence and sequelae of its genitourinary manifestations. We believe that this resulted in erroneous conclusions regarding the urological complications of Klippel-Trenaunay syndrome. Data on genitourinary manifestations in patients with Klippel-Trenaunay syndrome treated at 1 institution from 1970 through 2005 were acquired. Of 218 patients with Klippel-Trenaunay syndrome 30% (66 of 218) had genitourinary involvement, including 7% (15) with cutaneous genital abnormalities, 7% (15) with visceral genitourinary involvement and 16% (36) with each type. Intermittent bleeding from cutaneous genital abnormalities developed in 65% of patients (33 of 51). Conservative treatment with compression and/or cauterization was attempted in all 33 patients and it was successful in 64% (21 of 33). Intractable hemorrhage resulted in excision of the cutaneous bleeding site in 36% of cases (12 of 33). A total of 39 hospitalizations for gross hematuria occurred in 9% of the patients (19 of 218). Hematuria developed from the bladder in 11 cases, the urethra in 4 and the kidney in 4. Conservative therapy resolved gross hematuria in 21% of the patients (4 of 19). Refractory hematuria was successfully treated with cauterization in 37% of the patients (7 of 19) and by angiographic embolization in 10% (2 of 19). Intractable gross hematuria resulted in open surgical excision of the bleeding site in 32% of the patients (6 of 19). The incidence of genitourinary manifestations of Klippel-Trenaunay syndrome is 30%, which is triple the previously reported incidence of 9%. Unlike prior reports stating that the genitourinary abnormalities rarely caused problems, 52% of the patients (34 of 66) with Klippel-Trenaunay syndrome who had urological manifestations eventually required interventional therapy for genitourinary complications.
Ventegodt, Søren; Merrick, Joav
Holistic medicine seems to be efficient in the treatment of chronic pain in internal organs, especially when the pain has no known cause. It is quite surprising that while chronic pain can be one of the toughest challenges in the biomedical clinic, it is often one of the simplest things to alleviate in the holistic clinic. These pains are regarded as being caused by repressed emotions and are explained as psychosomatic reactions. Using holistic medicine, the patients can often be cured of their suffering when they assume responsibility for the repressed feelings. The holistic process theory of healing states that the return to the natural (pain free) state of being is possible whenever the person obtains the resources needed for existential healing. This shift is explained by the related quality of life and life mission theories. The resources needed are "holding" or genuine care in the dimensions of awareness, respect, care, acknowledgment, and acceptance with support and processing in the dimensions of feeling, understanding, and letting go of negative attitudes and beliefs. The preconditions for the holistic healing to take place are "love" and trust. Obtaining the full trust of the patient, therefore, seems to be the biggest challenge of holistic medicine, especially when dealing with a patient in pain.
Kravet, Steven J.; Christmas, Colleen; Durso, Samuel; Parson, Gregory; Burkhart, Kathleen; Wright, Scott
Background Role modeling is an integral component of medical education. The literature suggests that being a clinically excellent academic physician and serving as a role model for trainees are integrally related. Purpose To explore the relationship between being considered clinically excellent and being considered an effective role model. Methods Two independent surveys were administered to clinically active faculty (asked to name clinically excellent colleagues) and internal medicine residents (asked to name faculty role models). We compared frequency counts of clinically excellent faculty mentioned and frequency counts of role models mentioned by respondents. Spearman correlations and odds ratios with 95% confidence intervals were used to assess the relationship between the responses. Results A total of 39 of 66 faculty (59%) and 45 of 50 residents (90%) responded. There were 31 faculty members judged to be clinically excellent and 67 faculty identified as role models. Thirty faculty members appeared on both lists. There was a moderately high correlation between these groups (Spearman correlation coefficient = 0.54, P < .001). Faculty members who were among those named as clinically excellent by their peers were more likely to be named 3 or more times as a role model by trainees (odds ratio, 24.6; confidence interval, 2.9–207). Conclusions This study tested and confirmed the correlation between clinical excellence and role modeling, illustrating the value of these faculty members at teaching hospitals. PMID:23205192
Zhang, Junhua; Zhang, Boli
With the advent of big data era, our thinking, technology and methodology are being transformed. Data-intensive scientific discovery based on big data, named "The Fourth Paradigm," has become a new paradigm of scientific research. Along with the development and application of the Internet information technology in the field of healthcare, individual health records, clinical data of diagnosis and treatment, and genomic data have been accumulated dramatically, which generates big data in medical field for clinical research and assessment. With the support of big data, the defects and weakness may be overcome in the methodology of the conventional clinical evaluation based on sampling. Our research target shifts from the "causality inference" to "correlativity analysis." This not only facilitates the evaluation of individualized treatment, disease prediction, prevention and prognosis, but also is suitable for the practice of preventive healthcare and symptom pattern differentiation for treatment in terms of traditional Chinese medicine (TCM), and for the post-marketing evaluation of Chinese patent medicines. To conduct clinical studies involved in big data in TCM domain, top level design is needed and should be performed orderly. The fundamental construction and innovation studies should be strengthened in the sections of data platform creation, data analysis technology and big-data professionals fostering and training.
The use of complementary and alternative medicine (CAM) has become a core component of the daily challenges faced when treating cancer patients. PHY906 is a formulation of four herbal compounds traditionally used to treat nausea, vomiting, cramping, and diarrhea. Diarrhea is one of the major side effects of the cancer drug irinotecan. In this issue of Science Translational Medicine, Lam and colleagues report that administration of PHY906 with irinotecan in a mouse model of colon cancer resulted in a synergistic reduction in tumor burden, maintenance of body weight, and stem cell regeneration in the intestinal mucosa. Yet when considering CAM use in the treatment of cancer patients, one must take into account reproducibility of preclinical findings in clinical practice, quality assurance of herbal products, and potential toxicities associated with alternative therapies.
Glurich, Ingrid; Acharya, Amit; Shukla, Sanjay K.; Nycz, Greg R; Brilliant, Murray H.
Periodontal disease and diabetes, two diseases that have achieved epidemic status, share a bi-directional relationship driven by micro-inflammatory processes. The present review frames the current understanding of the pathological processes that appear to link these diseases and advances the hypothesis that reversal of the epidemic is possible through application of interdisciplinary intervention and advancement of oral-systemic personalized medicine. An overview of how Marshfield Clinic’s unique clinical, informatics and bio-repository resources and infrastructures are being aligned to advance oral-systemic personalized medicine is presented as an interventional model with the potential to reverse the epidemic trends seen for these two chronic diseases over the past several decades. The overall vision is to engineer a transformational shift in paradigm from ‘personalized medicine’ to ‘personalized health’. PMID:22458294
Blake, G H; DeHart, R L
The individual educational and intervention emphasis of clinical preventive medicine programs is successful in reducing an employee's risk for disease and injury. Although some studies note that decreased risk is found predominantly in those with low initial risk, a critical mass of healthful lifestyles may spread to non-participants in the organization, the halo effect. Thus, the more employees there are modeling a health lifestyle, the greater likelihood others will follow. Preventive medicine programs offer intangible advantages to the employer. Such programs demonstrate an attitude of caring for the employee which has an influence on the public. Happier employees tend to increase their level of socialization within a company. The ultimate effect is decreased employee risk, improved productivity, reduced absenteeism, and improved health at reduced cost.
Gender medicine studies sex- and gender-based differences in the development and prevention of diseases, the awareness and presentation of symptoms, and the effectiveness of therapy. Gender medicine is part of personalized medicine, considering differences in biological and psychosocial factors individually. There are differences in genes, chromosomes, hormones, and metabolism as well as differences in culture, environment, and society. Lifelong interactions between physical and psychosocial factors will influence the health and ill-health of men and women in different ways. Epigenetic modifications provide evidence of the impact of environment and lifestyle during vulnerable phases on biological processes, effecting future generations. Maternal lifestyle and environmental factors during pregnancy can impact the health of offspring in later life already in utero in a sex-specific way. Pain, stress, and coping styles differ between men and women. Women experience more dramatic physical changes during their lifetime, which are associated with specific burdens and psychosocial alterations. Women with multiple roles and responsibilities suffering from stress develop depression more frequently. However, men are often not diagnosed and treated appropriately in cases of depression or osteoporosis, diseases that are typically considered "female." There are prominent differences between men and women in medicine regarding the immune system, inflammation, and noncommunicable diseases such as obesity, type 2 diabetes, hypertension, and cardiovascular disease. Women experience more often autoimmune diseases and suffer more frequently from (chronic) pain, neurodegenerative changes, and functional disabilities. Men have shorter life expectancy but relatively more healthy years of life, which is in greater part ascribed to psychosocial determinants. State-of-the-art clinical medicine comprises individual risk factors based on sex- and gender-sensitive health programs in order to
Annesley, Thomas M.; Cooks, Robert G.; Herold, David A.; Hoofnagle, Andrew N.
Each year the journal Clinical Chemistry publishes a January special issue on a topic that is relevant to the laboratory medicine community. In January 2016 the topic is mass spectrometry, and the issue is entitled “Clinical Mass Spectrometry: Achieving Prominence in Laboratory Medicine”. One popular feature in our issues is a Q&A on a topic, clearly in this case mass spectrometry. The journal is assembling a panel of 5-6 experts from various areas of mass spectrometry ranging from instrument manufacturing to practicing clinical chemists. Dick Smith is one of the scientist requested to participate in this special issue Q&A on Mass Spectrometry. The Q&A Transcript is attached
Allen, D. G.
Echocardiography is the accepted term for the study of cardiac ultrasound. Although a relatively new tool for the study of the heart in man it has already found wide acceptance in the area of cardiac research and in the study of clinical cardiac disease. Animals had often been used in the early experiments with cardiac ultrasound, but only recently has echocardiography been used as a research and clinical tool in veterinary medicine. In this report echocardiography is used in the research of anesthetic effects on ventricular function and clinically in the diagnosis of congestive cardiomyopathy in a cat, ventricular septal defect in a calf, and pericardial effusion in a dog. Echocardiography is now an important adjunct to the field of veterinary cardiology. ImagesFigure 7.Figure 8.Figure 9.Figure 10. PMID:17422196
Schelke, Matthew W; Hackett, Katherine; Chen, Jaclyn L; Shih, Chiashin; Shum, Jessica; Montgomery, Mary E; Chiang, Gloria C; Berkowitz, Cara; Seifan, Alon; Krikorian, Robert; Isaacson, Richard Scott
Alzheimer's disease (AD) is a major source of morbidity and mortality, with the disease burden expected to rise as the population ages. No disease-modifying agent is currently available, but recent research suggests that nutritional and lifestyle modifications can delay or prevent the onset of AD. However, preventive nutritional interventions are not universally applicable and depend on the clinical profile of the individual patient. This article reviews existing nutritional modalities for AD prevention that act through improvement of insulin resistance, correction of dyslipidemia, and reduction of oxidative stress, and discusses how they may be modified on the basis of individual biomarkers, genetics, and behavior. In addition, we report preliminary results of clinical application of these personalized interventions at the first AD prevention clinic in the United States. The use of these personalized interventions represents an important application of precision medicine techniques for the prevention of AD that can be adopted by clinicians across disciplines. © 2016 New York Academy of Sciences.
Graham, Michael M
The Clinical Trials Network of the Society of Nuclear Medicine was formed to provide quality assurance of both imaging and radiopharmaceutical manufacturing in clinical trials. The intention is to register and qualify a large number (>200) of sites, both in the United States and internationally, to be able to do the positron emission tomography imaging part of clinical trials. Initially, the types of trials to be supported include evaluation of novel radiopharmaceuticals and trials that use approved or experimental radiopharmaceuticals for early assessment of tumor response to novel chemotherapy agents. The Clinical Trials Network is organized into 7 committees that provide overall oversight and strategic guidance, database management, site qualification and monitoring, scanner validation, clinical site orientation, technologist education, trial design, and a manufacturer's registry. At the end of the first year, more than 200 potential clinical trial sites and more than 125 manufacturing sites have expressed interest in participating. The qualification process is well underway. Funding is being provided by 3 large pharmaceutical companies. An investigational new drug application has been obtained for F-18 fluorothymidine that is held by Society of Nuclear Medicine to allow simplification of data management during multisite trials with F-18 fluorothymidine. A second investigational new drug application is in preparation for F-18 fluoromisonidazole. A supply of oncology chest phantoms has been manufactured and have been shipped to numerous sites for scanner validation. Educational materials are being developed for the physicians, technologists, and research coordinators at the sites. This is an important initiative that is likely to help significantly expand the role of molecular imaging and will help bring the right treatment to the right patient at the right time. Copyright 2010 Elsevier Inc. All rights reserved.
Buscemi, Dolores; Kumar, Ashwani; Nugent, Rebecca; Nugent, Kenneth
Epidemiological studies have demonstrated an association between short sleep times and obesity as defined by body mass index (BMI). We wanted to determine whether this association occurs in patients with chronic medical diagnoses since the number of confounding factors is likely higher in patients than the general population. Two hundred patients attending internal medicine clinics completed a survey regarding sleep habits, lifestyle characteristics, and medical diagnoses. An independent surveyor collected the information on the questionnaires and reviewed the medical records. Height and weight were measured by clinic personnel. Data were analyzed with multivariate logistic regression. Subjects with short sleep times (< 7 hours) had an increased likelihood of obesity as defined by a BMI > or = 30 kg/m2 when compared to the reference group of (8, 9] hours (odds ratio 2.93; 95% confidence interval, 1.06-8.09). There was a U-shaped relationship between obesity and sleep time in women but not in men. Young age (18 to 49 years), not smoking, drinking alcohol, hypertension, diabetes, and sleep apnea were also associated with obesity in the overall model. This study demonstrates an association between short sleep times and obesity in undifferentiated patients attending an internal medicine clinic using models adjusting for age, lifestyle characteristics, and some medical diagnoses. The U-shaped relationship in women suggests that sleep patterns may have gender specific associations. These observations provide the background for therapeutic trials in weight loss in patients with established medical problems.
Hammer, U; Blaas, V; Büttner, A; Philipp, M
Clinical forensic medicine does not only entail examination of patients after physical violence but also the option of clinical autopsies, e.g. after non-notifiable complications of medical interventions, after fatalities closely following medical interventions or fatalities as a result of injuries when the public prosecutor decides not to order a medicolegal autopsy. Based on this routine the Institute of Forensic Medicine at the University of Rostock offers a training course in topographical anatomy to physicians for further training in interventional and surgical disciplines. At the beginning of autopsies the participants can explore the approaches of interventional puncture techniques as well as surgical techniques and the basic topographical anatomy in small groups of 2-4 persons under the supervision of forensic examiners. The format is essentially oriented to the early further training period but fulfils the requirements for the exploration of complex operative techniques. The course was adapted for physicians and offered separately to students. The explorations are performed manually or by support with autopsy instruments. The courses offer an ideal room for individual, discipline-specific topics and result in a great benefit for all participants. A statistical assessment can only be achieved with a larger number of participants. Making autopsy rooms available for teaching and further training represents an additional feature to the profile of clinical forensic medicine. Lessons in topographical anatomy provide a great benefit for patient safety. It seems to be important to offer the opportunity to address individual interests in a closed meeting to consolidate skills and abilities in a non-judgemental environment. The post-mortem examiners have to ensure that the autopsy is carried out lege artis. Basic ethical principles and all regulations from an accredited scope have to be adhered to.
Crabtree, Benjamin F.; Miller, William L.; Tallia, Alfred F.; Cohen, Deborah J.; DiCicco-Bloom, Barbara; McIlvain, Helen E.; Aita, Virginia A.; Scott, John G.; Gregory, Patrice B.; Stange, Kurt C.; McDaniel, Reuben R.
BACKGROUND This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts. METHODS We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force. RESULTS Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns. CONCLUSIONS Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices’ propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations. PMID:16189059
Buckley, Christopher D
Academic medicine may have been in crisis but it is now starting to flourish again. In the words of Eric Thomas: "Clinical academia has a rosy future if you really celebrate and respect it as an activity, if you ensure a supply of graduates committed to research, if you get the relationship right with the key partners, if you get the best facilities for prosecuting research". It looks as though many of these 'ifs' will now be fulfilled within the reforming agenda of MMC.
Modern healthcare faces the challenges of rising costs, increasing expectations of patients and changing disease patterns. Physicians practise medicine in an era of easy availability and access to a plethora of modern and sometimes expensive diagnostic aids. The powerful utility of clinical skills cannot be underestimated nor lost. The physician has a powerful platform to encourage the rational use of tests, prevent wasteful overutilisation and ensure that tests do not cause more harm than benefit in physical, emotional or financial terms. Diagnostic skills should not be substituted by diagnostic greed. It is possible to do more for the patient rather than to the patient. PMID:27664173
Green, E.D.; Waterston, R.H. )
The recently initiated human genome project is a large international effort to elucidate the genetic architecture of the genomes of man and several model organisms. The initial phases of this endeavor involve the establishment of rough blueprints (maps) of the genetic landscape of these genomes, with the long-term goal of determining their precise nucleotide sequences and identifying the genes. The knowledge gained by these studies will provide a vital tool for the study of many biologic processes and will have a profound impact on clinical medicine.
Laube, Justin G R; Shapiro, Martin F
Health history questionnaires (HHQs) are a set of self-administered questions completed by patients prior to a clinical encounter. Despite widespread use, minimal research has evaluated the content of HHQs used in general internal medicine and family medicine (GIM/FM), integrative medicine, and complementary and alternative medicine (CAM; chiropractic, naturopathic, and Traditional Chinese Medicine [TCM]) clinics. Integrative medicine and CAM claim greater emphasis on well-being than does GIM/FM. This study investigated whether integrative medicine and CAM clinics' HHQs include more well-being content and otherwise differ from GIM/FM HHQs. HHQs were obtained from GIM/FM (n = 9), integrative medicine (n = 11), naturopathic medicine (n = 5), chiropractic (n = 4), and TCM (n = 7) clinics in California. HHQs were coded for presence of medical history (chief complaint, past medical history, social history, family history, surgeries, hospitalizations, medications, allergies, review of systems), health maintenance procedures (immunization, screenings), and well-being components (nutrition, exercise, stress, sleep, spirituality). In HHQs of GIM/FM clinics, the average number of well-being components was 1.4 (standard deviation [SD], 1.4) compared with 4.0 (SD, 1.1) for integrative medicine (p < 0.01), 3.2 (SD, 2.1) for naturopathic medicine (p = 0.04), 2.0 (SD, 1.4) for chiropractic (p = 0.54), and 2.0 (SD, 1.5) for TCM (p = 0.47). In HHQs of GIM/FM clinics, the average number of medical history components was 6.4 (SD, 1.9) compared with 8.3 (SD, 1.2) for integrative medicine (p = 0.01), 9.0 (SD, 0) for naturopathic medicine (p = 0.01), 7.1 (SD, 2.8) for chiropractic (p = 0.58), and 7.1 (SD, 1.7) for TCM (p = 0.41). Integrative and naturopathic medicine HHQs included significantly more well-being and medical history components than did GIM/FM HHQs. Further investigation is warranted to determine the optimal HHQ content to
Gupta, Mona; Upshur, Ross
In this paper, we explore the recent emphasis, in various medical contexts, of the term 'critical' or the notion of 'being critical'. We identify various definitions of being critical and note that they differ strikingly. What are these different uses of the term trying to capture that is important in clinical medicine and medical education? We have analysed these qualities as responsibilist, epistemic virtues. We believe that a virtues approach is best able to make sense of the non-cognitive elements of 'being critical', such as the honesty and courage to question claims in the face of persuasion, authority or social pressure. Medical educators and professional bodies seem to agree that being critical is important and desirable. Yet, it is unclear how this quality can be optimally fostered and balanced with the constraints that act upon individual practitioners in the context of institutional medicine including professional standards and the demands of the doctor-patient relationship. Other constraints such as authoritarianism, intimidation and financial pressures may act against the expression of being critical or even the cultivation of critical thinking. The issue of the constraints on critical thinking and the potential hazards it entails will require further consideration by those who encourage being critical in medicine.
Nelson, Caleb P; Chow, Jeanne S; Rosoklija, Ilina; Ziniel, Sonja; Routh, Jonathan C; Cilento, Bartley G
The impact of diagnostic genitourinary imaging on patients and families is poorly understood. We measured patient and family reaction to commonly performed genitourinary imaging studies using a standardized measurement tool. We surveyed families undergoing genitourinary imaging (renal ultrasound, voiding cystourethrography, radionuclide cystogram, static renal scintigraphy and diuretic renal scintigraphy) using a Likert scaled 11-item survey to assess impact across 4 domains (pain, anxiety, time, satisfaction). Survey scores were analyzed using ANOVA and linear regression. A total of 263 families were surveyed (61 renal ultrasound, 52 voiding cystourethrogram, 55 radionuclide cystogram, 47 mercaptoacetyltriglycine dynamic renal scintigraphy, 48 dimercaptosuccinic acid static renal scintigraphy). Mean patient age was 2.1 years old. Of the patients 45% were male and 77% were white. Patient age, gender and prior genitourinary imaging experience varied by study type. Study type was significantly associated with total and weighted scores on the genitourinary imaging survey (both p <0.0001). Renal ultrasound was scored as better and mercaptoacetyltriglycine dynamic renal scintigraphy was worse than voiding cystourethrogram, radionuclide cystogram and dimercaptosuccinic acid static renal scintigraphy, which did not differ from each other. Other factors associated with worse total scores included patient age 1 to 3 years (p <0.001) and nonwhite race (p = 0.04). Gender, prior testing history, wait time and parent education were not associated with total scores. In the multivariate model renal ultrasound remained the best and mercaptoacetyltriglycine dynamic renal scintigraphy the worst (p <0.0001). In a direct comparison dimercaptosuccinic acid static renal scintigraphy and voiding cystourethrogram total scores did not differ (p = 0.59). There were significant differences among genitourinary imaging studies regarding the patient/family experience, but there was no overall
Block, Norman L.; Kava, Bruce R.
Introduction: Sarcoidosis is a multisystem disease that commonly involves the lungs, but may also present with extrapulmonary manifestations. Genitourinary (GU) tract involvement has been traditionally thought to be rare, but that view may underestimate the true prevalence of the disease due to the often, silent presentation thereof. Methods: The literature pertaining to sarcoidosis from the general systemic point of view, etiology and therapy and with regard to specific organs was reviewed by identifying key words in a PubMed search. That material with special relevance to the Indian experience was emphasized. Results: There are a number of isolated case reports in the literature describing symptomatic and asymptomatic GU tract sarcoidosis. The world literature associated with the generalized syndrome was reviewed and summarized. Specific aspects of GU involvement are presented for each organ of the GU tract. Conclusions: It is critical for the practicing clinician to have a working knowledge of the clinical manifestations of this disease as it involves the GU tract, as well as to be able to distinguish it from tuberculosis and the various malignancies that affect this organ system. PMID:28197023
Dalpiaz, Amanda; Gandhi, Jason; Smith, Noel L.; Dagur, Gautam; Schwamb, Richard; Weissbart, Steven J.; Khan, Sardar Ali
Introduction Appendicitis is a prevailing cause of acute abdomen, but is often difficult to diagnose due to its wide range of symptoms, anatomical variations, and developmental abnormalities. Urological disorders of the genitourinary tract may be closely related to appendicitis due to the close proximity of the appendix to the genitourinary tract. This review provides a summary of the urological complications and simulations of appendicitis. Both typical and urological symptoms of appendicitis are discussed, as well as recommended diagnostic and treatment methods. Methods Medline searches were conducted via PubMed in order to incorporate data from the recent and early literature. Results Urological manifestations of appendicitis affect the adrenal glands, kidney, retroperitoneum, ureter, bladder, prostate, scrotum, and penis. Appendicitis in pregnancy is difficult to diagnose due to variations in appendiceal position and trimester-specific symptoms. Ultrasound, CT, and MRI are used in diagnosis of appendicitis and its complications. Treatment of appendicitis may be done via open appendectomy or laparoscopic appendectomy. In some cases, other surgeries are required to treat urological complications, though surgery may be avoided completely in other cases. Conclusion Clinical presentation and complications of appendicitis vary among patients, especially when the genitourinary tract is involved. Appendicitis may mimic urological disorders and vice versa. Awareness of differential diagnosis and proper diagnostic techniques is important in preventing delayed diagnosis and possible complications. MRI is recommended for diagnosis of pregnant patients. Ultrasound is preferred in patients exhibiting typical symptoms. PMID:28413377
Goldstein, Irwin; Dicks, Brian; Kim, Noel N; Hartzell, Rose
Introduction Vaginal atrophy, which may affect up to 45% of postmenopausal women, is often associated with one or more urinary symptoms, including urgency, increased frequency, nocturia, dysuria, incontinence, and recurrent urinary tract infection. Aims To provide an overview of the current literature regarding cellular and clinical aspects of vaginal atrophy and response to treatment with local vaginal estrogen therapy. Methods PubMed searches through February 2012 were conducted using the terms “vaginal atrophy,” “atrophic vaginitis,” and “vulvovaginal atrophy.” Expert opinion was based on review of the relevant scientific and medical literature. Main Outcome Measure Genitourinary symptoms and treatment of vaginal atrophy from peer-reviewed published literature. Results Typically, a diagnosis of vaginal atrophy is made based on patient-reported symptoms, including genitourinary symptoms, and an examination that reveals signs of the disorder; however, many women are hesitant to report vaginal-related symptoms, primarily because of embarrassment. Conclusions Physicians in various disciplines are encouraged to initiate open discussions about vulvovaginal health with postmenopausal women, including recommended treatment options. Goldstein I, Dicks B, Kim NN, and Hartzell R. Multidisciplinary overview of vaginal atrophy and associated genitourinary symptoms in postmenopausal women. Sex Med 2013;1:44–53. PMID:25356287
Goldstein, Irwin; Dicks, Brian; Kim, Noel N; Hartzell, Rose
Vaginal atrophy, which may affect up to 45% of postmenopausal women, is often associated with one or more urinary symptoms, including urgency, increased frequency, nocturia, dysuria, incontinence, and recurrent urinary tract infection. To provide an overview of the current literature regarding cellular and clinical aspects of vaginal atrophy and response to treatment with local vaginal estrogen therapy. PubMed searches through February 2012 were conducted using the terms "vaginal atrophy," "atrophic vaginitis," and "vulvovaginal atrophy." Expert opinion was based on review of the relevant scientific and medical literature. Genitourinary symptoms and treatment of vaginal atrophy from peer-reviewed published literature. Typically, a diagnosis of vaginal atrophy is made based on patient-reported symptoms, including genitourinary symptoms, and an examination that reveals signs of the disorder; however, many women are hesitant to report vaginal-related symptoms, primarily because of embarrassment. Physicians in various disciplines are encouraged to initiate open discussions about vulvovaginal health with postmenopausal women, including recommended treatment options. Goldstein I, Dicks B, Kim NN, and Hartzell R. Multidisciplinary overview of vaginal atrophy and associated genitourinary symptoms in postmenopausal women. Sex Med 2013;1:44-53.
Cochrane, Zara Risoldi; Gregory, Philip; Wilson, Amy
To compare the quality of natural product clinical trials published in alternative medicine journals versus those published in conventional medicine journals. Systematic search and review of the literature. Randomized controlled trials of natural products were included if they were published in English between 2003 and 2008. Articles were categorized by their journal of publication (alternative medicine versus conventional medicine). Two independent reviewers evaluated study quality using guidelines from the Cochrane Collaboration. The results with respect to the primary outcome (positive or negative) were also assessed. Thirty articles were evaluated, 15 published in alternative medicine journals and 15 in conventional medicine journals. Of articles published in alternative medicine journals, 33.33% (n = 5) were considered low quality, and none were considered high quality. Of articles published in conventional medicine journals, 26.67% (n = 4) were considered low quality and 6.67% (n = 1) were considered high quality. Two thirds of all trials reviewed were of unclear quality, due to inadequate reporting of information relating to the study's methodology. Similar proportions of positive and negative primary outcomes were found in alternative and conventional medicine journals, and low-quality articles were not more likely to report a positive primary outcome (Fisher's exact test, two-tailed p = .287). The quality of natural product randomized controlled trials was similar among alternative and conventional medicine journals. Efforts should be made to improve the reporting of natural product clinical trials for accurate determinations of study quality to be possible.
In the last 20 years or so, functional MRI has matured very rapidly from being an experimental imaging method in the hands of a few labs to being a very widely available and widely used workhorse of cognitive neuroscience and clinical neuroscience research internationally. FMRI studies have had a considerable impact on our understanding of brain system phenotypes of neurological and psychiatric disorders; and some impact already on development of new therapeutics. However, the direct benefit of fMRI to individual patients with brain disorders has so far been minimal. Here I provide a personal perspective on what has already been achieved, and imagine how the further development of fMRI over the medium term might lead to even greater engagement with clinical medicine.
Li, Rui; Weng, Wei-liang; Tian, Yuan-xiang; Li, Qiu-yan; Lu, Fang
Beginning with 4-level quality control measures of clinical research in traditional Chinese medicine (TCM), we elaborated the implementation process and demands of quality control measures of each level, including quality control, monitoring, auditing, and inspection. On the basis of joint inspection experience of 41 projects of the "Prevention and Treatment of Difficult and Complicated Diseases of TCM" plan of the "11th Five-year National Key Technology R&D Program", we analyzed the ensuring effect of 4-level quality control system and joint inspection model, and then pointed out the existing problems in the executing process of quality control system at different levels and joint inspection model. Finally we investigated what should be revised in the quality control system and joint inspection model, thus providing the theoretical support for quality inspection improvement of TCM clinical research.
Genuis, Stephen J.; Lipp, Chris
In a climate of plurality about the concept of what is “good,” one of the most daunting challenges facing contemporary medicine is the provision of medical care within the mosaic of ethical diversity. Juxtaposed with escalating scientific knowledge and clinical prowess has been the concomitant erosion of unity of thought in medical ethics. With innumerable technologies now available in the armamentarium of healthcare, combined with escalating realities of financial constraints, cultural differences, moral divergence, and ideological divides among stakeholders, medical professionals and their patients are increasingly faced with ethical quandaries when making medical decisions. Amidst the plurality of values, ethical collision arises when the values of individual health professionals are dissonant with the expressed requests of patients, the common practice amongst colleagues, or the directives from regulatory and political authorities. In addition, concern is increasing among some medical practitioners due to mounting attempts by certain groups to curtail freedom of independent conscience—by preventing medical professionals from doing what to them is apparently good, or by compelling practitioners to do what they, in conscience, deem to be evil. This paper and the case study presented will explore issues related to freedom of conscience and consider practical approaches to ethical collision in clinical medicine. PMID:24455248
Franconi, G; Manni, L; Aloe, L; Mazzilli, F; Giambalvo Dal Ben, G; Lenzi, A; Fabbri, A
Acupuncture has been used as treatment for infertility for hundreds of years, and recently it has been studied in male and female infertility and in assisted reproductive technologies, although its role in reproductive medicine is still debated. To review studies on acupuncture in reproductive medicine, in experimental and clinical settings. Papers were retrieved on PubMed and Google Scholar and were included in the review if at least the abstract was in English. There is evidence of benefit mainly when acupuncture is performed on the day of embryo transfer (ET) in the live birth rate. Benefit is also evident when acupuncture is performed for female infertility due to polycystic ovary syndrome (PCOS). There is some evidence of sperm quality improvement when acupuncture is performed on males affected by idiopathic infertility. Experimental studies suggest that acupuncture effects are mediated by changes in activity of the autonomic nervous system and stimulation of neuropeptides/neurotransmitters which may be involved in the pathogenesis of infertility. Acupuncture seems to have beneficial effects on live birth rate when performed on the day of ET, and to be useful also in PCOS as well as in male idiopathic infertility, with very low incidence of side effects. However, further studies are necessary to confirm the clinical results and to expand our knowledge of the mechanisms involved.
Pedersen, Inge Kryger; Hansen, Vibeke Holm; Grünenberg, Kristina
Demands for alternative medicine have increased since the 1970s in nations in which western scientific evidence has become the basis for health care. This paradox has been the impetus to examine how trust emerges in clinics of alternative medicine. Alternative practitioners are self-regulated and the clients pay out of their own pockets to attend non-authorised treatments with very limited scientific evidence of their effects. Trust is a key issue in this context. However, only a few studies have dealt with the ways in which alternative practitioners win their clients' trust. Drawing on three qualitative studies and informing the empirical findings with a sociological concept of trust, this article provides new empirical insights on how trust emerges in Danish clinics of acupuncture, reflexology and homeopathy. The analysis demonstrates how trust is situational and emerges through both clients' susceptibility and practitioners' individual skill development and strategies, as well as from objects, place and space. Trust is developed on relational and bodily as well as material grounds. It is argued that the dynamics and elements of trust identified do not only minimalise uncertainties but sometimes convert these uncertainties into productive new ways for clients to address their ailments, life circumstances and perspectives.
[From classification medicine to clinical medicine (the end of the XVIII century--1870s). Communication 2. The first stage of clinical medicine development: introduction of the method of clinico-anatomic correlations].
The first stage of clinical medicine development is analysed which covers the period from early 1800s to middle 1870s. Considered are basic research achievements associated with introduction of the method of clinico-anatomic correlations into practical medicine.
Woolley, Amanda; Kostopoulou, Olga
The clinical literature advises physicians not to trust their intuition. Studies of clinical intuition, however, equate it to early impressions, the first thing that comes to the physician's mind. This study aimed to investigate the validity of this perspective by examining real cases of intuition in family medicine. Eighteen family physicians were interviewed about patient cases in which they believed that they had experienced an intuition. Cases were included if (1) participants were unaware of the basis of their judgment, or (2) participants talked about the basis of their judgment but believed that it was irrational or unsubstantiated. During the interview, case descriptions were systematically probed following the Critical Decision Method. Transcripts were coded for judgments, informational cues, expectancies, goals, and actions and were reordered into chronological accounts of the decision process. The 2 authors independently categorized cases into 3 emerging decision process types. Participants reported 31 cases, 24 of which met inclusion criteria. Three types of decision process emerged: gut feelings, recognitions, and insights (κ = 0.78). In all cases, participants thought that their intuitive judgment was in conflict with a more rational explanation or what other colleagues would do. Automatic, nonanalytical processes in clinical judgment extend beyond first impressions. Rather than admonishing clinicians not to trust their intuition, it should be acknowledged that little is currently known about the different types of intuitive processes and what determines their success or failure. Research on the conditions for accurate clinical intuitions is needed.
Damodaran, Senthilkumar; Berger, Michael F.; Roychowdhury, Sameek
Overview Advances in tumor genome sequencing have enabled discovery of actionable alterations leading to novel therapies. Currently, there are approved targeted therapies across various tumors that can be matched to genomic alterations, such as point mutations, gene amplification, and translocations. Tools to detect these genomic alterations have emerged as a result of decreasing costs and improved throughput enabled by next-generation sequencing (NGS) technologies. NGS has been successfully utilized for developing biomarkers to assess susceptibility, diagnosis, prognosis, and treatment of cancers. However, clinical application presents some potential challenges in terms of tumor specimen acquisition, analysis, privacy, interpretation, and drug development in rare cancer subsets. Although whole-genome sequencing offers the most complete strategy for tumor analysis, its present utility in clinical care is limited. Consequently, targeted gene capture panels are more commonly employed by academic institutions and commercial vendors for clinical grade cancer genomic testing to assess molecular eligibility for matching therapies, whereas whole-exome and transcriptome (RNASeq) sequencing are being utilized for discovery research. This review discusses the strategies, clinical challenges, and opportunities associated with the application of cancer genomic testing for precision cancer medicine. PMID:25993170
Pérez Campos, José Pascual; Aguilar Mejía, Estela; Viniegra Velázquez, Leonardo
The study deals theoretical aspects of evaluation and the importance of consider one as part of a research process. The diverse theoretical trends in the field of education are synthesized in two main tendencies: the participating and passive education perspectives. The influences of these two tendencies in selection the subjects for evaluation are also discussed in order to explore the gammagraphic interpretation aptitude in residents of nuclear medicine. An evaluation instrument developed by us to explore aptitudes result of a long validation process. It consists of 90 questions was applied to the whole sample (19 residents in two IMSS courses) in one single session. We also applied other instrument of multiple choice (90 questions too) within the passive tendency of education (control instrument). Scores obtained by three groups of residents in nuclear medicine in the aptitudes instrument, showed difference in accordance with the respective time of experience: first year obtained the lowest scores (31.5) second year showed intermediate scores (36) 3rd the highest (43) (p = 0.03 between 1st and 3rd). The scores obtained by the control instrument, was not clear difference: the 2nd year of residents was found better (score of 56) than 3rd year residents (score 52.5) The aptitude instrument is better than the control instrument in order to explored, discriminated and estratificated by time of formative experience in medical courses. We believe that the aptitude instrument is capable of detecting learning dependent on the time of clinical experience. Some considerations on the advantages and scope of this instrument, as compared to other current instruments, which are also intended to measure clinical aptitudes, are done. The theoretical superiority of the clinical aptitudes instrument in relation the others are discussed.
Bush, Stephen H; Lao, Michael R; Simmons, Kathy L; Goode, Jeff H; Cunningham, Steve A; Calhoun, Byron C
To apply the Six Sigma tools of Change Acceleration Process and Work-Out and to improve patient access in an outpatient clinic in a hospital-based residency training program. Observational study. Comparison of productivity in an obstetrics and gynecology clinic after implementation of the Six Sigma principles, with a comparable internal medicine clinic as a control group. Productivity from January 1 through December 31, 2005, was assessed in both clinics. After applying the Six Sigma tools to obstetrics and gynecology, outputs from both clinics from January 1 through December 31, 2006, were analyzed. Wait times for new obstetrical visits decreased from 38 to 8 days. The patient time spent in the clinic dropped from 3.2 to 1.5 hours. Initial gynecologic visits increased by 87% (from 453 to 850 per year), return gynecologic visits increased by 66% (from 1392 to 2311 per year), initial obstetrical visits increased by 55% (from 520 to 808 per year), repeat obstetrical visits increased by 45% (from 2239 to 3243 per year), and the mean patient satisfaction scores increased from 5.75 to 8.54 (on a 10-point scale). The gross clinic revenue increased by 73% in the first 6 months of 2006 over that of the previous year. By contrast, internal medicine patient wait times for new patients and for revisits, patient satisfaction scores, total number of clinic visits, and revenues remained unchanged. Application of the Six Sigma principles resulted in a team approach to solving the clinic's productivity issues.
Mulders, Peter F; Abrahamsson, Per-Anders; Bukowski, Ronald M
Bone metastases are common among patients with stage IV genitourinary cancers. Most patients with bone metastases develop at least one debilitating and potentially life-limiting skeletal-related event. These events are associated with increased medical expenses and decreased quality of life. Current guidelines recommend screening for bone metastases in men with high-risk prostate cancer, but guidance for screening and treatment of bone metastases from genitourinary cancers varies by country and setting. Several bisphosphonates have been evaluated in the advanced genitourinary cancer setting. Zoledronic acid has demonstrated efficacy in significantly reducing the risk of skeletal-related events in patients with bone metastases from a broad range of solid tumors including prostate, renal and bladder cancers, and is recommended for preserving bone health.
Kalyesubula, Robert; Wearne, Nicola; Semitala, Fred C; Bowa, Kasonde
With the recent massive scale-up of access to antiretroviral therapy (ART) in resource-limited countries, HIV has become a chronic disease with new challenges. There is mounting evidence of an increased burden of renal and genitourinary diseases among HIV-infected persons caused by direct HIV viral effects and/or indirectly through the development of opportunistic infections, ART medication-related toxicities, and other noncommunicable diseases (NCDs). We review the epidemiology of HIV-associated renal and urogenital diseases, including interactions with kidney-related NCDs such as hypertension, diabetes mellitus, and cardiovascular disease. We also examine the current evidence regarding the impact of HIV infection on the development of urogenital diseases. Highly advisable in sub-Saharan Africa are the establishment of renal disease registries, reviews of existing clinical practice including cost-effectiveness studies, and the adoption and use of HIV-related NCD management, with training for different cadres of health providers. Epidemiological research priorities include prospective studies to evaluate the true prevalence and spectrum of HIV-related renal disease and their progression. Simple diagnostics tools should be evaluated, including urinary dipsticks and point-of-care urea and creatinine tests to screen for kidney injury in primary care settings. Study of urological manifestations of HIV can help determine the extent of disease and outcomes. As patients live longer on ART, the burden of renal and genitourological complications of HIV and of ART can be expected to increase with a commensurate urgency in both discovery and evidence-based improvements in clinical management.
Fields, S A; Toffler, W L; Elliott, D; Chappelle, K
In 1992, the School of Medicine at Oregon Health Sciences University inaugurated a Principles of Clinical Medicine (PCM) course as part of an overall curricular revision. The PCM course, which covers the first and second years of medical school, integrates material from ten separate courses in the previous curriculum. Students learn longitudinally over the two years, rather than "cramming" discrete areas of knowledge and then moving on. Course sessions are related to concurrently taken basic science classes. Meeting two afternoons per week, the PCM course offers preceptorships, health care issues sessions, and patient examination sessions. The PCM course aims to encompass the body of knowledge, skills, and attitudes necessary to become a competent physician. First- and second-year students have more opportunities than previously to interact with patients and practicing physicians in the community. Competition between learning areas, student perceptions of "soft" and "hard" courses, teacher recruitment, and administrative burnout are ongoing difficulties, while faculty recognition and development, administrative commitment and flexibility, and student and faculty feedback all contribute to the success of the course. The PCM course is now the backbone of the first two years of medical school and creates a solid foundation for the third and fourth years.
This article provides primary care providers, including pediatric nurse practitioners, with a framework for completing a genitourinary assessment. Many primary care providers are reluctant to examine the genitalia of their patients. Routine genital examinations increase diagnostic skills, provide a baseline for future examinations, may improve parent and child compliance with the examination, and may reveal previously undiscovered anomalies or trauma. An assessment of the reproductive and urologic systems should begin with obtaining a focused history from the parent from birth to present. Techniques for performing a focused genitourinary examination will be discussed.
Cram, Lorie F; Zapata, Maria-isabel; Toy, Eugene C; Baker, Benton
Genitourinary tract infections are one cause of preterm delivery. Prematurity is one of the leading causes of perinatal mortality in the United States. Uterine contractions may be induced by cytokines and prostaglandins, which are released by microorganisms. Asymptomatic bacteriuria, gonococcal cervicitis and bacterial vaginosis are strongly associated with preterm delivery. The role of Chlamydia trachomatis, Trichomonas vaginalis and Ureaplasma urealyticum is less clear. By adopting a rational approach to the diagnosis and treatment of genitourinary infections, family physicians can substantially decrease a patient's risk of preterm delivery.
Lippi, Giuseppe; Favaloro, Emmanuel J
Hemostasis is a delicate, dynamic and intricate system, in which pro- and anti-coagulant forces cooperate for either maintaining blood fluidity under normal conditions, or else will prompt blood clot generation to limit the bleeding when the integrity of blood vessels is jeopardized. Excessive prevalence of anticoagulant forces leads to hemorrhage, whereas excessive activation of procoagulant forces triggers excessive coagulation and thrombosis. The hemostasis laboratory performs a variety of first, second and third line tests, and plays a pivotal role in diagnostic and monitoring of most hemostasis disturbances. Since the leading targets of Clinical Chemistry and Laboratory Medicine include promotion of progress in fundamental and applied research, along with publication of guidelines and recommendations in laboratory diagnostics, this journal is an ideal source of information on current developments in the laboratory technology of hemostasis, and this article is aimed to celebrate some of the most important and popular articles ever published by the journal in the filed of laboratory hemostasis.
Blaufox, M.D.; Fine, E.; Lee, H.B.; Scharf, S.
The application of radionuclide studies to nephrologic and urologic practice has reached a measurable degree of maturity during the past several years. In spite of this, the utilization of these techniques in many institutions in the United States continues to be far less frequent than one would expect from the clinical advantages. The aim of this editorial is to try to place the role of nuclear medicine in urology and nephrology in perspective. At the present time, in spite of the large number of renal agents that have been developed, there is no practical ideal radiopharmaceutical that can serve as a universal agent. Arbitrarily, one may reduce the chief armamentarium to only four radiopharmaceuticals; technetium-99m DTPA, I-131 OIH (orthoiodohippurate), technetium-99m glucoheptonate and technetium-99m DMSA. These agents are discussed with their relative advantages and disadvantages.
Rosenstock, L.; Cullen, M.; Brodkin, C.; Redlich, C.
Comprehensive and updated throughout, this new edition makes it easy to detect, diagnose, and treat the full spectrum of problems caused by occupational or environmental factors, including physical, chemical, and biologic agents. An international cast of experts offers in-depth, authoritative guidance on clinical problems as well as the legal and regulatory issues impacting the practice of occupational and environmental medicine today. Section 1 is on principles and practice. Section 2 on work sectors and special populations includes a chapter on mining. Section 3 on occupational diseases and injuries includes several chapters of relevance to the coal mining industry, including diseases of the lung and pleura covering silicosis, respiratory diseases of coal miners, and malignancies of the respiratory tract and pleura. Section 4 on hazards in the workplace and the environment includes a chapter on mineral dusts. Section 5 covers policy, regulation and control.
Lugo-Reyes, Saúl Oswaldo; Maldonado-Colín, Guadalupe; Murata, Chiharu
Medicine is one of the fields of knowledge that would most benefit from a closer interaction with Computer studies and Mathematics by optimizing complex, imperfect processes such as differential diagnosis; this is the domain of Machine Learning, a branch of Artificial Intelligence that builds and studies systems capable of learning from a set of training data, in order to optimize classification and prediction processes. In Mexico during the last few years, progress has been made on the implementation of electronic clinical records, so that the National Institutes of Health already have accumulated a wealth of stored data. For those data to become knowledge, they need to be processed and analyzed through complex statistical methods, as it is already being done in other countries, employing: case-based reasoning, artificial neural networks, Bayesian classifiers, multivariate logistic regression, or support vector machines, among other methodologies; to assist the clinical diagnosis of acute appendicitis, breast cancer and chronic liver disease, among a wide array of maladies. In this review we shift through concepts, antecedents, current examples and methodologies of machine learning-assisted clinical diagnosis.
Appreciation of the potential of newly marketed medicines to produce both benefit and harm has increased the role of the clinical pharmacologist. Pharmacoepidemiology applies epidemiological reasoning, methods and knowledge to the study of the uses and effects of drugs in human populations. Pharmacovigilence identifies and then responds to safety issues about marketed drugs. Whilst adverse drug reaction (ADR) reporting systems can identify potential problems with drugs, determination of causation requires population-based studies of adverse events (including information from large clinical trials), which attempt to link unequivocally the adverse outcome to the drug in question. Pharmacovigilance is closely linked to postmarketing surveillance and is important for determining issues such as the long-term effects of drugs, identification of low-frequency ADRs, the effectiveness of drugs for their licensed indications or in new indications and other factors which may modify the efficacy and effectiveness of the drug in question. The related field of drug utilization developed in parallel with the study of adverse drug reactions, in recognition of the dramatic increase in the marketing of new drugs, the wide variations in the patterns and extent of drug prescribing, the growing concern about ADRs and the increasing costs of drugs. With the ever increasing number of recognized adverse effects of drugs, prescribing errors, patients' expectations concerning drug safety and the need for appropriate new drug appraisal, the clinical pharmacologist will play an important role both in the introduction of new drugs and in improving the safe and effective use of established drugs.
Bonham, Vence L; Sellers, Sherrill L; Gallagher, Thomas H; Frank, Danielle; Odunlami, Adebola O; Price, Eboni G; Cooper, Lisa A
Purpose This qualitative study explored black and white general internists’ attitudes about the relevance of race in clinical care; views of the relationships among race, genetics, and disease; and expectations about the future of genetics and health. Methods We conducted 10 racially concordant focus groups of primary care physicians in five metropolitan areas in the United States. Ninety board certified or eligible general internists (50 self-identified white and 40 self-identified black) participated in the study. Analysis included a two-stage independent review and adjudication process. Results Both black and white physicians concluded that the race of the patient is medically relevant, but did not agree upon why race is important in clinical decisions. They were reticent to make connections among race, genetics, and disease and asserted that genetics has a limited role in explaining racial differences in health. However, they were enthusiastic about the future of genomic medicine, believing that the main benefit will be the potential to improve the efficacy of commonly used drugs. Conclusions Understanding the similarities and differences between black and white physicians’ attitudes and beliefs about race, health and genetics is important for the translation of genomics to clinical care. PMID:19265721
Stein, R A
A major biomedical advance from recent years was the finding that gene expression and phenotypic traits may be shaped by potentially reversible and heritable modifications that occur without altering the sequence of the nucleotides, and became known as epigenetic changes. The term 'epigenetics' dates back to the 1940s, when it was first used in context of cellular differentiation decisions that are made during development. Since then, our understanding of epigenetic modifications that govern development and disease expanded considerably. The contribution of epigenetic changes to shaping phenotypes brings at least two major clinically relevant benefits. One of these, stemming from the reversibility of epigenetic changes, involves the possibility to therapeutically revert epigenetic marks to re-establish prior gene expression patterns. The strength and the potential of this strategy are illustrated by the first four epigenetic drugs that were approved in recent years and by the additional candidates that are at various stages in preclinical studies and clinical trials. The second particularity is the finding that epigenetic changes precede the appearance of histopathological modifications. This has the potential to facilitate the emergence of epigenetic biomarkers, some of which already entered the clinical arena, catalysing a major shift in prophylactic and therapeutic strategies, and promising to fill a decades-old gap in preventive medicine.
Casas, Ana I.; Maghzal, Ghassan J.; Seredenina, Tamara; Kaludercic, Nina; Robledinos-Anton, Natalia; Di Lisa, Fabio; Stocker, Roland; Ghezzi, Pietro; Jaquet, Vincent; Cuadrado, Antonio
Abstract Significance: Oxidative stress is suggested to be a disease mechanism common to a wide range of disorders affecting human health. However, so far, the pharmacotherapeutic exploitation of this, for example, based on chemical scavenging of pro-oxidant molecules, has been unsuccessful. Recent Advances: An alternative emerging approach is to target the enzymatic sources of disease-relevant oxidative stress. Several such enzymes and isoforms have been identified and linked to different pathologies. For some targets, the respective pharmacology is quite advanced, that is, up to late-stage clinical development or even on the market; for others, drugs are already in clinical use, although not for indications based on oxidative stress, and repurposing seems to be a viable option. Critical Issues: For all other targets, reliable preclinical validation and drug ability are key factors for any translation into the clinic. In this study, specific pharmacological agents with optimal pharmacokinetic profiles are still lacking. Moreover, these enzymes also serve largely unknown physiological functions and their inhibition may lead to unwanted side effects. Future Directions: The current promising data based on new targets, drugs, and drug repurposing are mainly a result of academic efforts. With the availability of optimized compounds and coordinated efforts from academia and industry scientists, unambiguous validation and translation into proof-of-principle studies seem achievable in the very near future, possibly leading towards a new era of redox medicine. Antioxid. Redox Signal. 23, 1113–1129. PMID:26415051
Manolio, Teri A.; Chisholm, Rex L.; Ozenberger, Brad; Roden, Dan M.; Williams, Marc S.; Wilson, Richard; Bick, David; Bottinger, Erwin P.; Brilliant, Murray H.; Eng, Charis; Frazer, Kelly A.; Korf, Bruce; Ledbetter, David H.; Lupski, James R.; Marsh, Clay; Mrazek, David; Murray, Michael F.; O'Donnell, Peter H.; Rader, Daniel J.; Relling, Mary V.; Shuldiner, Alan R.; Valle, David; Weinshilboum, Richard; Green, Eric D.; Ginsburg, Geoffrey S.
Although the potential for genomics to contribute to clinical care has long been anticipated, the pace of defining the risks and benefits of incorporating genomic findings into medical practice has been relatively slow. Several institutions have recently begun genomic medicine programs, encountering many of the same obstacles and developing the same solutions, often independently. Recognizing that successful early experiences can inform subsequent efforts, the National Human Genome Research Institute brought together a number of these groups to describe their ongoing projects and challenges, identify common infrastructure and research needs, and outline an implementation framework for investigating and introducing similar programs elsewhere. Chief among the challenges were limited evidence and consensus on which genomic variants were medically relevant; lack of reimbursement for genomically driven interventions; and burden to patients and clinicians of assaying, reporting, intervening, and following up genomic findings. Key infrastructure needs included an openly accessible knowledge base capturing sequence variants and their phenotypic associations and a framework for defining and cataloging clinically actionable variants. Multiple institutions are actively engaged in using genomic information in clinical care. Much of this work is being done in isolation and would benefit from more structured collaboration and sharing of best practices. Genet Med 2013:15(4):258–267 PMID:23306799
Ouellet, Jérôme; Boisvert, Leslie; Fischer, Lisa
Abstract Objective To describe the characteristics of patients who presented to outpatient sport and exercise medicine clinics with concussion. Design Retrospective chart review of electronic medical records. Setting Three specialized sport and exercise medicine clinics in London, Ont. Participants A total of 283 patients presenting with concussion. Main outcome measures Data collected included demographic variables (age and sex), sport participation at the time of injury, previous medical history (including history of concussion), Post-Concussion Symptom Scale (PCSS) scores, and return-to-play (RTP) variables (delay and outcome). Results The mean age of patients presenting for care was 17.6 years; 70.9% of patients were younger than 18 years of age (considered pediatric patients); 58.8% of patients were male; and 31.7% of patients had a previous history of concussion. The main sports associated with injury were hockey (40.0%), soccer (12.6%), and football (11.7%). Return to play was granted to 50.9% of patients before the 3-week mark and 80.2% of patients before 8 weeks. Total PCSS scores (maximum score was 132) and neck scores (part of the PCSS, maximum score was 6) were significantly higher in adults compared with pediatric patients (36.2 vs 27.6, P = .02, and 1.8 vs 1.2, P = .02, respectively). A significant difference was seen in RTP, with pediatric patients returning earlier than adults did (P = .04). This difference was not seen when comparing males with females (P = .07). Longer duration of follow-up did not influence RTP outcomes. Previous history of concussion was associated with restriction from contact or collision sports (P < .001). Conclusion Given the age and sex variability found in this study, as well as in previous published reports, it is important to manage each patient individually using current best available practice strategies to optimize long-term outcomes.
Small, Alexander C; Gong, Yixuan; Oh, William K; Hall, Simon J; van Rijn, Cees J M; Galsky, Matthew D
Circulating tumor cells are malignant cells in peripheral blood that originate from primary tumors or metastatic sites. The heterogeneous natural history and propensity for recurrence in prostate, bladder and kidney cancers are well suited for improved individualization of care using circulating tumor cells. The potential clinical applications of circulating tumor cells include early diagnosis, disease prediction and prognosis, and selection of appropriate therapies. The PubMed® and Web of Science® databases were searched using the key words circulating tumor cells, CTC, prostate, kidney, bladder, renal cell carcinoma and transitional cell carcinoma. Relevant articles and references from 1994 to 2011 were reviewed for data on the detection and significance of circulating tumor cells in genitourinary cancer. Technical challenges have previously limited the widespread introduction of circulating tumor cell detection in routine clinical care. Recently novel platforms were introduced to detect these cells that offer the promise of overcoming these limitations. We reviewed the current state of circulating tumor cell capture technologies and their clinical applications for genitourinary cancers. In genitourinary cancer circulating tumor cell enumeration has been useful for prognosis in patients with castration resistant prostate cancer. Soon characterizing individual circulating tumor cells in blood will serve as a noninvasive real-time liquid biopsy to monitor molecular changes in cancer, allowing clinicians to custom tailor treatment strategies. Circulating tumor cells will serve as a treatment response biomarker. Finally, circulating tumor cell detection promises to assist in the early detection of clinically localized cancers, facilitating curative therapy. Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
Peters, Mark J; Argent, Andrew; Festa, Marino; Leteurtre, Stéphane; Piva, Jefferson; Thompson, Ann; Willson, Douglas; Tissières, Pierre; Tucci, Marisa; Lacroix, Jacques
Intensive Care Medicine set us the task of outlining a global clinical research agenda for paediatric intensive care (PIC). In line with the clinical focus of this journal, we have limited this to research that may directly influence patient care. Clinician researchers from PIC research networks of varying degrees of formality from around the world were invited to answer two main questions: (1) What have been the major recent advances in paediatric critical care research? (2) What are the top 10 studies for the next 10 years? (1) Inclusive databases are well established in many countries. These registries allow detailed observational studies and feasibility testing of clinical trial protocols. Recent trials are larger and more valuable, and (2) most common interventions in PIC are not evidenced-based. Clinical studies for the next 10 years should address this deficit, including: ventilation techniques and interfaces; fluid, transfusion and feeding strategies; optimal targets for vital signs; multiple organ failure definitions, mechanisms and treatments; trauma, prevention and treatment; improving safety; comfort of the patient and their family; appropriate care in the face of medical complexity; defining post-PICU outcomes; and improving knowledge generation and adoption, with novel trial design and implementation strategies. The group specifically highlighted the need for research in resource-limited environments wherein mortality remains often tenfold higher than in well-resourced settings. Paediatric intensive care research has never been healthier, but many gaps in knowledge remain. We need to close these urgently. The impact of new knowledge will be greatest in resource-limited environments.
Lu, Peng-fei; Liao, Xing; Xie, Yan-ming; Wang, Zhi-guo
In recent 10 years, clinical trials of Chinese medicine and pharmacy (cMP) at clinicalTrials.gov.(USA) are gradually increasing. In order to analyze features of CMP clinical register, ClinicalTrials.gov register database were comprehensively retrieved in this study. Included clinical trials were input one item after another using EXCEL. A final of 348 CMP clinical trials were included. Results showed that China occupied the first place in CMP clinical register, followed by USA. CMP clinical trials, sponsored mainly by colleges/universities and hospitals, mostly covered interventional studies on evaluating safety/effectiveness of CMP. The proportions of studies, sponsored by mainland China and companies, recruitment trials and multi-center clinical trials in interventional trials were increasing. The proportions of studies sponsored by Hong Kong and Taiwan, research completed trials, unclear research status, phase III clinical trials, and published research trials in interventional trials were decreasing. Published ratios of CMP clinical trials were quite low. There were more missing types and higher proportions in trial register information.
Chang, Kun; Dai, Bo; Kong, Yun-Yi; Qu, Yuan-Yuan; Gan, Hua-Lei; Gu, Wei-Jie; Ye, Ding-Wei; Zhang, Hai-Liang; Zhu, Yao; Shi, Guo-Hai
The predictive factors of prognosis and treatment strategies for small-cell carcinoma (SCC) of the urinary tract are controversial. This study was aimed to investigate the clinical experience and management of patients with SCC of the urinary tract. We collected data of patients who were diagnosed with genitourinary SCC (GSCC) between 2002 and 2013 and were treated in the Fudan University Shanghai Cancer Center. A total of 18 patients were diagnosed with GSCC of which 10 originated from the prostate, seven from the bladder and one from the adrenal gland. The mean follow-up time was 15.5 months and progression-free survival (PFS) was 9.3 months. Primary tumor resection was attempted in 13 of 18 patients (72.2%) in whom radical surgery was performed in six of 14 (42.9%) limited disease patients. Most of the patients (13, 72.2%) received cisplatin-based chemotherapy. Patients who had normal lactic dehydrogenase (LDH) levels showed a significantly higher median PFS and overall survival (OS) compared with patients with high LDH levels (P = 0.030, P= 0.010). Patients with limited disease treated with a radical operation experienced a non-significant (P = 0.211) longer PFS compared with patients who were not treated, but this reached statistical significance after analyzing OS (P = 0.211, P= 0.039). Our patients showed a poor prognosis as reported previously. Serum LDH levels beyond the normal range indicate a poor prognosis. For GSCC patients who are diagnosed with limited disease, radical surgery is strongly recommended along with cisplatin-based chemotherapy.
Jarvis, Margaret; Williams, Jessica; Hurford, Matthew; Lindsay, Dawn; Lincoln, Piper; Giles, Leila; Luongo, Peter; Safarian, Taleen
: Biological drug testing is a tool that provides information about an individual's recent substance use. Like any tool, its value depends on using it correctly; that is, on selecting the right test for the right person at the right time. This document is intended to clarify appropriate clinical use of drug testing in addiction medicine and aid providers in their decisions about drug testing for the identification, diagnosis, treatment, and recovery of patients with, or at risk for, addiction. The RAND Corporation (RAND)/University of California, Los Angeles (UCLA) Appropriateness Method (RAM) process for combining scientific evidence with the collective judgment of experts was used to identify appropriate clinical practices and highlight areas where research is needed. Although consensus panels and expert groups have offered guidance on the use of drug testing for patients with addiction, very few addressed considerations for patients across settings and in different levels of care. This document will focus primarily on patients in addiction treatment and recovery, where drug testing is used to assess patients for a substance use disorder, monitor the effectiveness of a treatment plan, and support recovery. Inasmuch as the scope includes the recognition of addiction, which often occurs in general healthcare settings, selected special populations at risk for addiction visiting these settings are briefly included.
In 1993, the American Association of Electrodiagnostic Medicine formed an Ethics and Peer Review Committee in concert with a renewed initiative by organized medicine to emphasize ethical standards. Guidelines for ethical behavior relating to clinical practice issues in electrodiagnostic medicine were developed to formalize the standards of professional behavior for electrodiagnostic medical consultants and were approved by the AAEM Board of Directors in April 1994. The guidelines are modeled after the Code of Professional Conduct of the American Academy of Neurology and are consistent with the Guidelines in Electrodiagnostic Medicine of the American Association of Electrodiagnostic Medicine and Principles of Medical Ethics as adopted by the American Medical Association. The Guidelines may provide grounds for disciplinary action under Article X of the AAEM Bylaws.
Yamakawa, Jun-Ichi; Moriya, Junji; Takeuchi, Kenji; Nakatou, Mio; Motoo, Yoshiharu; Kobayashi, Junji
The cause of obesity includes genetic and environmental factors, including cytokines derived from adipocytes (adipo-cytokines). Although drug therapy is available for obesity, it is highly risky. Our main focus in this review is on the traditional form of Japanese medicine, Kampo, in the treated of obesity. Two Kampo formulas, that is, bofutsushosan () and boiogito (), are covered by the national health insurance in Japan for the treatment of obesity. Various issues related to their action mechanisms remain unsolved. Considering these, we described the results of basic experiments and presented clinical evidence and case reports on osteoarthritis as examples of clinical application of their two Kampo medicine. Traditional medicine is used not only for treatment but also for prevention. In clinical practice, it is of great importance to prove the efficacy of combinations of traditional medicine and Western medicine and the utility of traditional medicine in the attenuation of adverse effects of Western medicine.
Hanna, Eve; Rémuzat, Cecile; Auquier, Pascal; Toumi, Mondher
Advanced therapy medicinal products (ATMPs) constitute a class of innovative products that encompasses gene therapy, somatic cell therapy, and tissue-engineered products (TEP). There is an increased investment of commercial and non-commercial sponsors in this field and a growing number of ATMPs randomized clinical trials (RCT) and patients enrolled in such trials. RCT generate data to prove the efficacy of a new therapy, but the discontinuation of RCTs wastes scarce resources. Our objective is to identify the number and characteristics of discontinued ATMPs trials in order to evaluate the rate of discontinuation. We searched for ATMPs trials conducted between 1999 to June 2015 using three databases, which are Clinicaltrials.gov, the International Clinical Trials Registry Platform (ICTRP), and the EU Drug Regulating Authorities Clinical Trials (EudraCT). We selected the ATMPs trials after elimination of the duplicates. We identified the disease areas and the sponsors as commercial or non-commercial organizations. We classified ATMPs by type and trial status, that is, ongoing, completed, terminated, discontinued, and prematurely ended. Then, we calculated the rate of discontinuation. Between 1999 and June 2015, 143 withdrawn, terminated, or prematurely ended ATMPs clinical trials were identified. Between 1999 and June 2013, 474 ongoing and completed clinical trials were identified. Therefore, the rate of discontinuation of ATMPs trials is 23.18%, similar to that for non-ATMPs drugs in development. The probability of discontinuation is, respectively, 27.35, 16.28, and 16.34% for cell therapies, gene therapies, and TEP. The highest discontinuation rate is for oncology (43%), followed by cardiology (19.2%). It is almost the same for commercial and non-commercial sponsors; therefore, the discontinuation reason may not be financially driven. No failure risk rate per development phase is available for ATMPs. The discontinuation rate may prove helpful when assessing the
Massof, Robert W
Comparative effectiveness research in rehabilitation medicine requires the development and validation of clinically meaningful and scientifically rigorous measurements of patient states and theories that explain and predict outcomes of intervention. Patient traits are latent (unobservable) variables that can be measured only by inference from observations of surrogate manifest (observable) variables. In the behavioral sciences, latent variables are analogous to intensive physical variables such as temperature and manifest variables are analogous to extensive physical variables such as distance. Although only one variable at a time can be measured, the variable can have a multidimensional structure that must be understood in order to explain disagreements among different measures of the same variable. The use of Rasch theory to measure latent trait variables can be illustrated with a balance scale metaphor that has randomly added variability in the weights of the objects being measured. Knowledge of the distribution of the randomly added variability provides the theoretical structure for estimating measures from ordinal observation scores (e.g., performance measures or rating scales) using statistical inference. In rehabilitation medicine, the latent variable of primary interest is the patient's functional ability. Functional ability can be estimated from observations of surrogate performance measures (e.g., speed and accuracy) or self-report of the difficulty the patient experiences performing specific activities. A theoretical framework borrowed from project management, called the Activity Breakdown Structure (ABS), guides the choice of activities for assessment, based on the patient's value judgments, to make the observations clinically meaningful. In the case of low vision, the functional ability measure estimated from Rasch analysis of activity difficulty ratings was discovered to be a two-dimensional variable. The two visual function dimensions are independent
Counselman, Francis L; Beeson, Michael S; Marco, Catherine A; Adsit, Susan K; Harvey, Anne L; Keehbauch, Julia N
The Model of the Clinical Practice of Emergency Medicine (the EM Model) is a three-dimensional representation of the clinical practice of emergency medicine. It is a product of successful collaboration involving the American Board of Emergency Medicine (ABEM), the American College of Emergency Physicians (ACEP), the Society for Academic Emergency Medicine (SAEM), the Emergency Medicine Residents' Association (EMRA), the Council of Emergency Medicine Residency Directors (CORD), the Residency Review Committee for Emergency Medicine (RRC-EM), and the American Academy of Emergency Medicine (AAEM). In 2017, the most recent update and revision of the EM Model will be published. This document will represent the culmination of nearly 40 years of evolution, from a simple listing of presenting patient complaints, clinical symptoms, and disease states into a three-dimensional representation of the clinical practice of emergency medicine. These dimensions include conditions and components, physician tasks, and patient acuity. In addition, over the years, two other documents have been developed, the Knowledge, Skills, and Abilities (KSAs) and the Emergency Medicine Milestones. Both serve as related and complementary educational and assessment tools. This article will review the development of the EM Model from its inception in 1979 to today. © 2016 by the Society for Academic Emergency Medicine.
Liu, Huan; Xie, Yanming
The clinical literature evaluation of the post-marketing traditional Chinese medicine is a comprehensive evaluation by the comprehensive gain, analysis of the drug, literature of drug efficacy, safety, economy, based on the literature evidence and is part of the evaluation of evidence-based medicine. The literature evaluation in the post-marketing Chinese medicine clinical evaluation is in the foundation and the key position. Through the literature evaluation, it can fully grasp the information, grasp listed drug variety of traditional Chinese medicines second development orientation, make clear further clinical indications, perfect the medicines, etc. This paper discusses the main steps and emphasis of the clinical literature evaluation. Emphasizing security literature evaluation should attach importance to the security of a comprehensive collection drug information. Safety assessment should notice traditional Chinese medicine validity evaluation in improving syndrome, improveing the living quality of patients with special advantage. The economics literature evaluation should pay attention to reliability, sensitivity and practicability of the conclusion.
Anaya, Juan-Manuel; Duarte-Rey, Carolina; Sarmiento-Monroy, Juan C; Bardey, David; Castiblanco, John; Rojas-Villarraga, Adriana
Personalized medicine encompasses a broad and evolving field informed by a patient distinctive information and biomarker profile. Although terminology is evolving and some semantic interpretations exist (e.g., personalized, individualized, precision), in a broad sense personalized medicine can be coined as: "To practice medicine as it once used to be in the past using the current biotechnological tools." A humanized approach to personalized medicine would offer the possibility of exploiting systems biology and its concept of P5 medicine, where predictive factors for developing a disease should be examined within populations in order to establish preventive measures on at-risk individuals, for whom healthcare should be personalized and participatory. Herein, the process of personalized medicine is presented together with the options that can be offered in health care systems with limited resources for diseases like rheumatoid arthritis and type 1 diabetes. Copyright © 2016 Elsevier B.V. All rights reserved.
Choudhary, Gautam Ram; Singh, Shivanshu; Prasad, Seema; Singh, Shrawan Kumar; Bhansali, Anil; Bhadada, Sanjay; Dutta, Pinaki
Introduction Genitourinary and retroperitoneal paragangliomas are infrequent tumors with bizarre presentation. A high index of suspicion is required to make a diagnosis in young hypertensive individuals. Our aim is to study the varied clinical presentations and management of these paragangliomas. Herein, we share our experience of clinical presentation, diagnosis, and management of these paragangliomas. Material and methods Seventeen consecutive patients who underwent surgery for paraganglioma at our institute from August 2009 to July 2014 were included. Demographic, peri-operative, surgical, and follow up data were collected and analyzed. Results Mean age of presentation was 34.8 years with female predominance. The majority of the tumors were located in the retroperitoneum and urinary bladder. Most of them presented with classical symptoms of catecholamine excess and hypertension. Complete surgical resection could be performed in 13 cases. At a median follow up of two years, cases with R0 resection (no microscopic malignant cells) did not show recurrence. Among patients on chemotherapy, one died, another had partial response, and yet another had progressive disease. Conclusions Genitourinary and retroperitoneal paragangliomas are a disease of a young age group with variable clinical features at presentation. Appropriate pre-operative optimization and complete surgical resection provide the best chance of cure. PMID:26855794
Barbieri, Ruggero; Guryev, Victor; Brandsma, Corry-Anke; Suits, Frank; Bischoff, Rainer; Horvatovich, Peter
Proteogenomics is a multi-omics research field that has the aim to efficiently integrate genomics, transcriptomics and proteomics. With this approach it is possible to identify new patient-specific proteoforms that may have implications in disease development, specifically in cancer. Understanding the impact of a large number of mutations detected at the genomics level is needed to assess the effects at the proteome level. Proteogenomics data integration would help in identifying molecular changes that are persistent across multiple molecular layers and enable better interpretation of molecular mechanisms of disease, such as the causal relationship between single nucleotide polymorphisms (SNPs) and the expression of transcripts and translation of proteins compared to mainstream proteomics approaches. Identifying patient-specific protein forms and getting a better picture of molecular mechanisms of disease opens the avenue for precision and personalized medicine. Proteogenomics is, however, a challenging interdisciplinary science that requires the understanding of sample preparation, data acquisition and processing for genomics, transcriptomics and proteomics. This chapter aims to guide the reader through the technology and bioinformatics aspects of these multi-omics approaches, illustrated with proteogenomics applications having clinical or biological relevance.
Freise, K J; Lin, T-L; Fan, T M; Recta, V; Clark, T P
Noninferiority trials are clinical studies designed to demonstrate that an investigational drug is at least as effective as an established treatment within a predetermined margin. They are conducted, in part, because of ethical concerns of administering a placebo to veterinary patients when an established effective treatment exists. The use of noninferiority trial designs has become more common in veterinary medicine with the increasing number of established veterinary therapeutics and the desire to eliminate potential pain or distress in a placebo-controlled study. Selecting the appropriate active control and an a priori noninferiority margin between the investigational and active control drug are unique and critical design factors for noninferiority studies. Without reliable historical knowledge of the disease response in the absence of treatment and of the response to the selected active control drug, proper design and interpretation of a noninferiority trial is not possible. Despite the appeal of conducting noninferiority trials to eliminate ethical concerns of placebo-controlled studies, there are real limitations and possible ethical conundrums associated with noninferiority trials. The consequences of incorrect study conclusions because of poor noninferiority trial design need careful attention. Alternative trial designs to typical noninferiority studies exist, but these too have limitations and must also be carefully considered.
Hess, Søren; Høilund-Carlsen, Poul Flemming; Alavi, Abass
In 1976, 2 major molecular imaging events coincidentally took place: Clinical Nuclear Medicine was first published in June, and in August researchers at the Hospital of the University of Pennsylvania created the first images in humans with F-FDG. FDG was initially developed as part of an evolution set in motion by fundamental research studies with positron-emitting tracers in the 1950s by Michel Ter-Pegossian and coworkers at the Washington University. Today, Clinical Nuclear Medicine is a valued scientific contributor to the molecular imaging community, and FDG PET is considered the backbone of this evolving and exciting discipline.
Alessio, L; Crippa, Michela; Porru, S; Lucchini, R; Placidi, Donatella; Vanoni, O; Torri, D
The daily practice of Occupational Physicians in the mot industrialized countries suggests that the frequency of traditional occupational diseases is progressively lowering, their gravity is decreasing, and the etiological factors are changing. This trend should be quantitatively and qualitatively verified with ad hoc studies. The information is particularly relevant for Academic Institutions where medical students and residents in occupational medicine are trained. To analyse the trends of clinical diagnoses and health surveillance activities conducted in the last 15 years by an Italian Institute of Occupational Health, and to gain information on the most relevant topics to be taught in academic program and to be addressed with future research. Data sources were represented by the computerised registration of a) diagnostic activities and b) health surveillance programs, conducted by the Institute of Occupational Medicine of the University of Brescia, a highly industrialized area in Northern Italy. The observation period was from 1990 to 2005. The health surveillance programs regarded workers pulled from an iron foundry, a veterinary institute, a health departments for the assistance of elderly subjects, a nursery schools and a municipal department for road maintenance. Diagnostic activities were conducted on 9080 subjects, who had been referred for suspected occupational disease. The diagnosis of occupational disease was confirmed for 3759 cases. Multiple diseases were diagnosed in 1554 subjects, yielding the total number of 5721 occupational diseases. The most frequent diagnoses accounted for allergic skin disease (23.4%), followed by pneumoconiosis (20.4%), chronic obstructive pulmonary disease (15.9%), noise hearing loss (7.1%), musculoskeletal disorders (6.9%), respiratory allergies (6.9%), cancer (5.9%), miscellaneous (6.4%). When limited to the last quinquennium, the analysis showed a definite increase of muskuloskeltal disorders, cancer, and, although at a
Simoes, E; Sokolov, A N; Graf, J; Pavlova, M A; Brucker, S Y; Wallwiener, D; Schmahl, F W; Bamberg, M
Advances in biomedicine, especially molecular biology and genetics, gave rise to the concept of personalized medicine targeting the patient's individual characteristics and needs to ensure the best possible therapy and healthcare. This concept, however, can be successfully implemented only if due consideration is given to (psycho-)social factors, as is shown for instance by considerably reduced post-therapy survival rates among cancer patients in regions with lower socioeconomic status, How breast cancer patients, for instance, find their way back to daily life and work after initial treatment at a breast center is substantially determined by multiple factors going beyond pure medical care. These factors critically affect health status and therapy outcomes, but are missing in current research agenda. A profound expertise in social medicine is required to respond in ways tailored to the individual's healthcare needs that go beyond just medical therapy. This expertise comprises, in particular, knowledge of inequality of access to healthcare due to varying health competence that in turn, results in inequality of health outcome and care. Competence in social medicine both in the clinic and outpatient care can help to individually target negative factors that originate from the social environment as well as from deficits in communication and coordination in the healthcare system and have an effect on the health status of patients..This, however, requires institutionalization of (clinical) social medicine and in particular, better opportunities for advanced training in social medicine in clinical departments and outpatient units.
The best clinical decisions are based on both evidence and values in what is known as the 'two-feet principle'. Anecdotally, educationalists find teaching clinicians to become more evidence based is relatively simple in comparison to encouraging them to become more values based. One reason is likely to be the importance of values awareness. As values-based practice is premised on a mutual respect for the diversity of values, clinicians need to develop the skills to ascertain patient values and to get in touch with their own beliefs and preferences in order to understand those at play in any consultation. Only then can shared decision-making processes take place within a shared framework of values. In a research article published in BMC Medicine, Altamirano-Bustamante and colleagues highlight difficulties that clinicians face in getting in touch with their own values. Despite finding that healthcare personnel's core values were honesty and respect, autonomy was initially low ranked by participants. One significant aspect of this work is that this group has demonstrated that the extent to which clinicians value 'autonomy' and 'openness to change' can both be positively influenced by well designed education.
Lin, Ming-Hwai; Chang, Hsiao-Ting; Tu, Chun-Yi; Chen, Tzeng-Ji; Hwang, Shinn-Jang
Patients with a polyherbal prescription are more likely to receive duplicate medications and thus suffer from adverse drug reactions. We conducted a population-based retrospective study to examine the items of Chinese herbal medicine (CHM) per prescription in the ambulatory care of traditional Chinese medicine (TCM) in Taiwan. We retrieved complete TCM ambulatory visit datasets for 2010 from the National Health Insurance database in Taiwan. A total of 59,790 patients who received 313,482 CHM prescriptions were analyzed. Drug prescriptions containing more than five drugs were classified as polyherbal prescriptions; 41.6% of patients were given a polyherbal prescription. There were on average 5.2 ± 2.5 CHMs: 2.3 ± 1.1 compound herbal formula items, and 3.0 ± 2.5 single Chinese herb items in a single prescription. Approximately 4.6% of patients were prescribed 10 CHMs or more. Men had a lower odds ratio (OR) among polyherbal prescriptions (OR = 0.96, 95% confidence interval [CI] 0.92–0.99), and middle-aged patients (35–49 years) had the highest frequency of polyherbal prescription (OR = 1.19, 95% CI = 1.13–1.26). Patients with neoplasm, skin and subcutaneous tissue disease, or genitourinary system disease were more likely to have a polyherbal prescription; OR = 2.20 (1.81–2.67), 1.65 (1.50–1.80), and 1.52 (1.40–1.64), respectively. Polyherbal prescription is widespread in TCM in Taiwan. Potential herb interactions and iatrogenic risks associated with polyherbal prescriptions should be monitored. PMID:26287228
Chandra, Smita; Chandra, Harish; Chauhan, Neena; Gaur, Dushyant Singh; Gupta, Harendra; Pathak, Ved Prakash; Burathoki, Sandeep Kumar
We conducted a retrospective study of genitourinary tuberculosis (TB) among males attending a hospital in the northern Himalayan region of India. Records from 1 January 1997 to 31 December 2009 were reviewed for clinical history, relevant radiological findings laboratory data, histopathology and treatment. Of the 1,113 male urogenital non-neoplastic specimens received at the histopathology laboratory of the hospital, tuberculosis was diagnosed in 25 cases (2.2%). Urinary bladder and prostate were the most common organs involved. Thirty-six percent of cases had a previous history of TB; 12% of cases presented with no symptoms. Ziehl-Neelsen staining was positive in 72% of cases. Cultures were positive for TB in 42.8% of cases and polymerase chain reaction was positive in two cases in which it was performed. Antituberculosis treatment was required for up to 12 months in some cases and surgery was required in 32% of cases. Genitourinary TB in this study had varying presentations. Cases having strong clinical and radiological findings and suggestive histopathology for tuberculosis, even without demonstration of mycobacteria may be considered for TB treatment, particularly in endemic areas. Patients living in more remote areas may have more specific and severe symptoms due to late presentation. Histopathology plays a crucial role in diagnosis due to lack of sophisticated techniques. The emphasis should be on early detection followed by prompt treatment to avoid further complications.
Wang, Xiao-Xia; Jin, Zhong-Zheng; Guo, Gui-Ming; Zhai, Hua-Qiang; Jin, Shi-Yuan
The aim of this study was to develop the data element standard directory of traditional Chinese medicine (TCM) clinical pharmacy information, to provide application standards and models of TCM clinical pharmacy for the electronic medical record (EMR). The developed line of work is as follows: initially establish research through four forms: literature analysis, questionnaires, discussion groups, expert advice. The research range from the Chinese herbal medicine research, herbal origin, harvesting, processing, identification of traits, physical and chemical identification, modern research, character, taste, Indications, clinical application, processing, dispensing medicine, Chinese medicine specifications, usage, dosage, caution, efficacy indications to small packaging applications, drug research, management and other related issues, including traditional Chinese medicine theory, application and hospital management information; according to the general and part 16 content of the national "Health Information Data Element Standards", and the basic method of extracting data element to study and develop the data element of TCM clinical pharmacy information from the defining content. Correspondingly propose the ideas and methods of construction of the "Data Element Standard Directory of TCM Clinical Pharmacy Information", sort out medicine clinical information data element standard catalog, divided into basic categories, clinical application class, management class three parts, and set norms and standards of identifying data elements, definitions, allowable value of traditional Chinese medicine clinical information, and discuss the sources and standards of information collection, leaving the interface, standardized and scientific terminology, docking with the existing standards, maintenance and management program and oter issues.
Liu, Jian-xun; Li, Xin-zhi; Ren, Jian-xun
On the base of reviewing the current literatures concerning the animal models with syndromes of Chinese medicine and investigating thee present state of the syndrome models, the authors have put forward a definition that research of animal models with the syndromes of Chinese medicine should be combined with clinical methods, and commented the potential application. Further it was suggested that clinical methods should be used in the exploration of scientific principles and the progresses on syndromes of Chinese medicine. In addition, intervene and evaluation of Chinese herbal medicine in animal model with integrated diseases and syndromes should be emphasized to establish a platform with special properties of TCM.
Wells, Eden V; Sarigiannis, Amy N; Boulton, Matthew L
To evaluate the utility of a competency mapping process for assessing the integration of clinical and public health skills in a newly developed Community Health Center (CHC) rotation at the University of Michigan School of Public Health Preventive Medicine residency. Learning objectives for the CHC rotation were derived from the Accreditation Council for Graduate Medical Education core clinical preventive medicine competencies. CHC learning objectives were mapped to clinical preventive medicine competencies specific to the specialty of public health and general preventive medicine. Objectives were also mapped to The Council on Linkages Between Academia and Public Health Practice's Tier-2 Core Competencies for Public Health Professionals. CHC learning objectives mapped to all four (100%) of the public health and general preventive medicine clinical preventive medicine competencies. CHC population-level learning objectives mapped to 32 (94%) of 34 competencies for public health professionals. Utilizing competency mapping to assess clinical-public health integration in a new CHC rotation proved to be feasible and useful. Clinical preventive medicine learning objectives for a CHC rotation can also address public health competencies. Copyright © 2012 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
Clinical forensic medicine is a sub-specialty of forensic medicine and is intimately associated with the justice system of a country. Practice of clinical forensic medicine is evolving, but deviates from one jurisdiction to another. Most English-speaking countries practice clinical forensic medicine and forensic pathology separately while most non-English-speaking countries practice forensic medicine which includes clinical forensic medicine and forensic pathology. Unlike the practice of forensic pathology, several countries have informal arrangements to deal with forensic patients and there are no international standards of practice or training in this discipline. Besides, this is rarely a topic of discussion. In the adversarial justice system in Sri Lanka, the designated Government Medical Officers practice both clinical forensic medicine and forensic pathology. Practice of clinical forensic medicine, and its teaching and training in Sri Lanka depicts unique features. However, this system has not undergone a significant revision for many decades. In this communication, the existing legal framework, current procedure of practice, examination for drunkenness, investigations, structure of referrals, reports, subsequent legal procedures, undergraduate, in-service, and postgraduate training are discussed with suggestions for reforms.
Zhou, Xuezhong; Li, Yubing; Peng, Yonghong; Hu, Jingqing; Zhang, Runshun; He, Liyun; Wang, Yinghui; Jiang, Lijie; Yan, Shiyan; Li, Peng; Xie, Qi; Liu, Baoyan
Traditional Chinese medicine (TCM) investigates the clinical diagnosis and treatment regularities in a typical schema of personalized medicine, which means that individualized patients with same diseases would obtain distinct diagnosis and optimal treatment from different TCM physicians. This principle has been recognized and adhered by TCM clinical practitioners for thousands of years. However, the underlying mechanisms of TCM personalized medicine are not fully investigated so far and remained unknown. This paper discusses framework of TCM personalized medicine in classic literatures and in real-world clinical settings, and investigates the underlying mechanisms of TCM personalized medicine from the perspectives of network medicine. Based on 246 well-designed outpatient records on insomnia, by evaluating the personal biases of manifestation observation and preferences of herb prescriptions, we noted significant similarities between each herb prescriptions and symptom similarities between each encounters. To investigate the underlying mechanisms of TCM personalized medicine, we constructed a clinical phenotype network (CPN), in which the clinical phenotype entities like symptoms and diagnoses are presented as nodes and the correlation between these entities as links. This CPN is used to investigate the promiscuous boundary of syndromes and the co-occurrence of symptoms. The small-world topological characteristics are noted in the CPN with high clustering structures, which provide insight on the rationality of TCM personalized diagnosis and treatment. The investigation on this network would help us to gain understanding on the underlying mechanism of TCM personalized medicine and would propose a new perspective for the refinement of the TCM individualized clinical skills.
Charles-Ferdinand University. Important role in the partition of the Czech Medical Faculty from the German one had the foundation of the Czech Medical Society and the Czech Medical Journal in 1862 patronaged by professors Purkynĕ, Eiselt, Grégr and others. That was the platform for the conception of the Czech medical terminology. Partition of faculties was decided by the law, which was accepted at February 28, 1882. The Czech Medical Faculty was opened only at 1883 because Emperor resolved that professors themselves had to decide to either faculty their clinics would belong. Only professor Eiselt with the First clinic of internal medicine, Weiss with the clinic of surgery and Streng with clinic of obstetrics were assigned to the Czech faculty. Till the official opening on October 15, 1882 all other departments and clinics had to be organized. Though Professor Vilem Weiss as the head of the department and dean of the faculty had his opening Czech lecture already on April 28, 1882, due to material and personal reasons the Czech Medical Faculty was opened only one year later than Faculties of law and philosophy. Most of the eminent members of the Medical faculty remained at the German faculty. However, having higher number of students the Czech faculty became larger and was attended by students from the whole Slavonic world.
Stochik, A M; Zatravkin, S N
This communication is devoted to appearance of a qualitatively different methodological approach to problems of practical medicine in 1890s. This approach gave rise to formation of a new style of medical thinking (clinical thinking) and development of clinical medicine.
Barrett, D.M.; O'Sullivan, D.C.; Malizia, A.A.; Reiman, H.M.; Abell-Aleff, P.C. )
Of 26 patients undergoing revision of genitourinary prostheses the surrounding reactive fibrous capsule was biopsied in 25 and the draining lymph nodes also were biopsied in 4. The prostheses included 16 inflatable and 14 flexible penile devices, and 10 artificial urinary sphincters. Tissue was examined by light and transmission electron microscopy. X-ray microanalysis was done on intracellular and extracellular foreign material from each specimen. Silicone was found in 18 of the 25 periprosthetic specimens and in all 4 lymph nodes. Foreign body granulomas were identified in 14 of these 29 specimens. Examination of new and explanted versions of each prosthesis by scanning electron microscopy revealed free particles of silicone or silicates on the surface of most devices. Pitting and microfissuring were seen on a few of the new devices and on nearly all of the used ones. Thus, genitourinary prostheses shed silicone particles that can be found in the fibrous capsule and draining lymph nodes.
Harding, Simon D; Armit, Chris; Armstrong, Jane; Brennan, Jane; Cheng, Ying; Haggarty, Bernard; Houghton, Derek; Lloyd-MacGilp, Sue; Pi, Xingjun; Roochun, Yogmatee; Sharghi, Mehran; Tindal, Christopher; McMahon, Andrew P; Gottesman, Brian; Little, Melissa H; Georgas, Kylie; Aronow, Bruce J; Potter, S Steven; Brunskill, Eric W; Southard-Smith, E Michelle; Mendelsohn, Cathy; Baldock, Richard A; Davies, Jamie A; Davidson, Duncan
The GenitoUrinary Development Molecular Anatomy Project (GUDMAP) is an international consortium working to generate gene expression data and transgenic mice. GUDMAP includes data from large-scale in situ hybridisation screens (wholemount and section) and microarray gene expression data of microdissected, laser-captured and FACS-sorted components of the developing mouse genitourinary (GU) system. These expression data are annotated using a high-resolution anatomy ontology specific to the developing murine GU system. GUDMAP data are freely accessible at www.gudmap.org via easy-to-use interfaces. This curated, high-resolution dataset serves as a powerful resource for biologists, clinicians and bioinformaticians interested in the developing urogenital system. This paper gives examples of how the data have been used to address problems in developmental biology and provides a primer for those wishing to use the database in their own research.
Harding, Simon D.; Armit, Chris; Armstrong, Jane; Brennan, Jane; Cheng, Ying; Haggarty, Bernard; Houghton, Derek; Lloyd-MacGilp, Sue; Pi, Xingjun; Roochun, Yogmatee; Sharghi, Mehran; Tindal, Christopher; McMahon, Andrew P.; Gottesman, Brian; Little, Melissa H.; Georgas, Kylie; Aronow, Bruce J.; Potter, S. Steven; Brunskill, Eric W.; Southard-Smith, E. Michelle; Mendelsohn, Cathy; Baldock, Richard A.; Davies, Jamie A.; Davidson, Duncan
The GenitoUrinary Development Molecular Anatomy Project (GUDMAP) is an international consortium working to generate gene expression data and transgenic mice. GUDMAP includes data from large-scale in situ hybridisation screens (wholemount and section) and microarray gene expression data of microdissected, laser-captured and FACS-sorted components of the developing mouse genitourinary (GU) system. These expression data are annotated using a high-resolution anatomy ontology specific to the developing murine GU system. GUDMAP data are freely accessible at www.gudmap.org via easy-to-use interfaces. This curated, high-resolution dataset serves as a powerful resource for biologists, clinicians and bioinformaticians interested in the developing urogenital system. This paper gives examples of how the data have been used to address problems in developmental biology and provides a primer for those wishing to use the database in their own research. PMID:21652655
Santoni, Matteo; Conti, Alessandro; Piva, Francesco; Massari, Francesco; Ciccarese, Chiara; Burattini, Luciano; Cheng, Liang; Lopez-Beltran, Antonio; Scarpelli, Marina; Santini, Daniele; Tortora, Giampaolo; Cascinu, Stefano; Montironi, Rodolfo
The STAT3 is often dysregulated in genitourinary tumors. In prostate cancer, STAT3 activation correlates with Gleason score and pathological stage and modulates cancer stem cells and epithelial–mesenchymal transition. In addition, STAT3 promotes the progression from carcinoma in situ to invasive bladder cancer and modulates renal cell carcinoma angiogenesis by increasing the expression of HIF1α and VEGF. STAT3 is also involved in the response to tyrosine kinase inhibitors sunitinib and axitinib, in patients with metastatic renal cell carcinoma, and to second-generation androgen receptor inhibitor enzalutamide in patients with advanced prostate cancer. In this review, we describe the role of STAT3 in genitourinary tumors, thus describing its potential for future therapeutic strategies. PMID:28031890
Bałkowiec-Iskra, Ewa; Cessak, Grzegorz; Kuzawińska, Olga; Sejbuk-Rozbicka, Katarzyna; Rokita, Konrad; Mirowska-Guzel, Dagmara
Introduction of generic medicinal products to the market has increased access to modern therapies but also enabled significant reduction in their cost, leading to containment of public expenditures on medicinal products reimbursement. The critical assessment of bioequivalence of any reference medicinal product and its counterpart is based on comparison of their rate and extent of absorption. It is assumed that two medicinal products are bioequivalent when their rate and extent of absorption do not show significant differences when administered at the same dose under similar experimental conditions. Bioequivalent medicinal products are declared to be also therapeutically equivalent and can be used interchangeably. However, despite regulatory declaration, switching from reference to generic drugs is often associated with concerns of healthcare providers about decreased treatment effectiveness or occurrence of adverse drug reactions. The aim of this article is to provide a description of rules that guide registration of generic medicinal products in the European Union and to analyze specific examples from the scientific literature concerning therapeutic equivalence of reference and generic antidepressant and antipsychotic medicinal products.
Lei, Yang; Mayo, Matthew S; Carlson, Susan E; Gajewski, Byron J
Personalized medicine aims to match patient subpopulation to the most beneficial treatment. The purpose of this study is to design a prospective clinical trial in which we hope to achieve the highest level of confirmation in identifying and making treatment recommendations for subgroups, when the risk levels in the control arm can be ordered. This study was motivated by our goal to identify subgroups in a DHA (docosahexaenoic acid) supplementation trial to reduce preterm birth (gestational age<37 weeks) rate. We performed a meta-analysis to obtain informative prior distributions and simulated operating characteristics to ensure that overall Type I error rate was close to 0.05 in designs with three different models: independent, hierarchical, and dynamic linear models. We performed simulations and sensitivity analysis to examine the subgroup power of models and compared results to a chi-square test. We performed simulations under two hypotheses: a large overall treatment effect and a small overall treatment effect. Within each hypothesis, we designed three different subgroup effects scenarios where resulting subgroup rates are linear, flat, or nonlinear. When the resulting subgroup rates are linear or flat, dynamic linear model appeared to be the most powerful method to identify the subgroups with a treatment effect. It also outperformed other methods when resulting subgroup rates are nonlinear and the overall treatment effect is big. When the resulting subgroup rates are nonlinear and the overall treatment effect is small, hierarchical model and chi-square test did better. Compared to independent and hierarchical models, dynamic linear model tends to be relatively robust and powerful when the control arm has ordinal risk subgroups.
Ellis, Demetrius; Lieb, Jessica
We describe 3 children presenting with hematuria, dysuria or kidney stones, and hyperoxaluria believed to be related to ingestion of excessive amounts of almond milk products. Our investigation of the oxalate content of several popular plant-based milk substitutes indicates that almond milk products are a particularly rich source of dietary oxalate. All genitourinary and urinary metabolic disturbances resolved after discontinuation of almond milk ingestion. Therefore, pediatricians should be aware of this potential link.
Towards the end of the 19th century, Europe turned particular attention to the problem of tuberculosis, at that time the most serious social disease. In the majority of cases, pulmonary tuberculosis had a fatal outcome owing to the lack of effective drugs and methods of treatment. Due to poor sanitary conditions, particularly as regards dwellings, pulmonary tuberculosis was able to spread rapidly. Hospital departments were reluctant to admit patients suffering from tuberculosis. It was only after the discoveries of Robert Koch (bacillus tubercle in 1882) that the cause of the disease became understood and methods of treatment began to be developed. A modern sanatorium and hospital with 270 beds was erected in Hohenkrug (today Szczecin-Zdunowo) between 1915 and 1930. Patients could now be treated with modern methods, surgically in most cases. After the Second World War, pulmonary tuberculosis was still an enormous epidemiologic problem. In 1949, the Polish authorities opened a 400-bed sanatoriumin Zdunowo. The methods of treatment were not much different from pre-war practice and it was only the routine introduction of antituberculotic drugs during the fifties of the past century that brought about a radical change in the fight against tuberculosis. The growing numbers of patients with tuberculosis of the genitourinary system led to the opening in 1958 of a 40-bed specialist ward at the Tuberculosis Sanatorium in Zdunowo. It should be emphasized that the Department of Genitourinary Tuberculosis in Szczecin-Zdunowo was a historical necessity and a salvation for thousands of patients from Northern Poland. The Department totally fulfilled its social duties thanks to the commitment of many outstanding persons dedicated to helping the patients. This unit was finally closed in 1987 because the demand for surgical treatment of tuberculosis was declining concurrently with the advent of new and potent antituberculotics and falling number of new cases of genitourinary
Background Medicinal cannabis has recently attracted much media attention in Australia and across the world. With the exception of a few countries, cannabinoids remain illegal–known for their adverse effects rather than their medicinal application and therapeutic benefit. However, there is mounting evidence demonstrating the therapeutic benefits of cannabis in alleviating neuropathic pain, improving multiple sclerosis spasticity, reducing chemotherapy induced nausea and vomiting, and many other chronic conditions. Many are calling for the legalisation of medicinal cannabis including consumers, physicians and politicians. Pharmacists are the gatekeepers of medicines and future administrators/dispensers of cannabis to the public, however very little has been heard about pharmacists’ perspectives. Therefore the aim of this study was to explore pharmacists’ views about medicinal cannabis; its legalisation and supply in pharmacy. Methods Semi-structured interviews with 34 registered pharmacists in Australia were conducted. All interviews were audio-recorded, transcribed ad verbatim and thematically analysed using the NVivo software. Results Emergent themes included stigma, legislation, safety and collaboration. Overall the majority of pharmacists felt national legalisation of a standardised form of cannabis would be suitable, and indicated various factors and strategies to manage its supply. The majority of participants felt that the most suitable setting would be via a community pharmacy setting due to the importance of accessibility for patients. Discussion This study explored views of practicing pharmacists, revealing a number of previously undocumented views and barriers about medicinal cannabis from a supply perspective. There were several ethical and professional issues raised for consideration. These findings highlight the important role that pharmacists hold in the supply of medicinal cannabis. Additionally, this study identified important factors, which
Isaac, Sami; Saini, Bandana; Chaar, Betty B
Medicinal cannabis has recently attracted much media attention in Australia and across the world. With the exception of a few countries, cannabinoids remain illegal-known for their adverse effects rather than their medicinal application and therapeutic benefit. However, there is mounting evidence demonstrating the therapeutic benefits of cannabis in alleviating neuropathic pain, improving multiple sclerosis spasticity, reducing chemotherapy induced nausea and vomiting, and many other chronic conditions. Many are calling for the legalisation of medicinal cannabis including consumers, physicians and politicians. Pharmacists are the gatekeepers of medicines and future administrators/dispensers of cannabis to the public, however very little has been heard about pharmacists' perspectives. Therefore the aim of this study was to explore pharmacists' views about medicinal cannabis; its legalisation and supply in pharmacy. Semi-structured interviews with 34 registered pharmacists in Australia were conducted. All interviews were audio-recorded, transcribed ad verbatim and thematically analysed using the NVivo software. Emergent themes included stigma, legislation, safety and collaboration. Overall the majority of pharmacists felt national legalisation of a standardised form of cannabis would be suitable, and indicated various factors and strategies to manage its supply. The majority of participants felt that the most suitable setting would be via a community pharmacy setting due to the importance of accessibility for patients. This study explored views of practicing pharmacists, revealing a number of previously undocumented views and barriers about medicinal cannabis from a supply perspective. There were several ethical and professional issues raised for consideration. These findings highlight the important role that pharmacists hold in the supply of medicinal cannabis. Additionally, this study identified important factors, which will help shape future policies for the
Zhou, Li; Wang, Kui; Li, Qifu; Nice, Edouard C; Zhang, Haiyuan; Huang, Canhua
Cancer is a common disease that is a leading cause of death worldwide. Currently, early detection and novel therapeutic strategies are urgently needed for more effective management of cancer. Importantly, protein profiling using clinical proteomic strategies, with spectacular sensitivity and precision, offer excellent promise for the identification of potential biomarkers that would direct the development of targeted therapeutic anticancer drugs for precision medicine. In particular, clinical sample sources, including tumor tissues and body fluids (blood, feces, urine and saliva), have been widely investigated using modern high-throughput mass spectrometry-based proteomic approaches combined with bioinformatic analysis, to pursue the possibilities of precision medicine for targeted cancer therapy. Discussed in this review are the current advantages and limitations of clinical proteomics, the available strategies of clinical proteomics for the management of precision medicine, as well as the challenges and future perspectives of clinical proteomics-driven precision medicine for targeted cancer therapy.
30-09-2003 Final Report July 2002 to July 2003 4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER Sports Medicine and Rehabilitation Team Clinic: Comparative 5b...distribution is unlimited 13. SUPPLEMENTARY NOTES 14. ABSTRACT The purpose of this project was to examine the suitabibity of several Sports Medicine...for musculoskeletal injuries or illnesses. 15. SUBJECT TERMS Sport Medicine, Athletic Trainers, Rehabilitation Team, SMART, Musculoskeletal Injuries
Clinical chemistry and laboratory medicine can look back over more than 150 years of eventful history. The subject encompasses all the medicinal disciplines as well as the remaining natural sciences. Clinical chemistry demonstrates how new insights from basic research in biochemical, biological, analytical chemical, engineering, and information technology can be transferred into the daily routine of medicine to improve diagnosis, therapeutic monitoring, and prevention. This Review begins with a presentation of the development of clinical chemistry. Individual steps between the drawing of blood and interpretation of laboratory data are then illustrated; here not only are pitfalls described, but so are quality control systems. The introduction of new methods and trends into medicinal analysis is explored, along with opportunities and problems associated with personalized medicine.
Wells, Eden V; Sarigiannis, Amy N; Boulton, Matthew L
We evaluated the utility of a competency mapping process for assessing the integration of clinical and public health skills in a newly developed Community Health Center (CHC) rotation at the University of Michigan School of Public Health Preventive Medicine residency. Learning objectives for the CHC rotation were derived from the Accreditation Council for Graduate Medical Education core clinical preventive medicine competencies. CHC learning objectives were mapped to clinical preventive medicine competencies specific to the specialty of public health and general preventive medicine. Objectives were also mapped to The Council on Linkages Between Academia and Public Health Practice's tier 2 Core Competencies for Public Health Professionals. CHC learning objectives mapped to all 4 (100%) of the public health and general preventive medicine clinical preventive medicine competencies. CHC population-level learning objectives mapped to 32 (94%) of 34 competencies for public health professionals. Utilizing competency mapping to assess clinical-public health integration in a new CHC rotation proved to be feasible and useful. Clinical preventive medicine learning objectives for a CHC rotation can also address public health competencies.
Tang, Tony Yuqi; Li, Fang-Zhou; Afseth, Janyne
In 2012, USA Food and Drug Administration (FDA) approved 39 new drugs, however, there are only two botanical drugs (one topical and one oral) approved by FDA since the publication of the FDA's industry guidelines for the botanical drug product in June 2004. The approval shows the Western guideline can be used for herbal medicines, authors investigate current regulation on herbal medicine clinical research, identify challenges conducting clinical trials, and seek to produce some guidance for potential investigators and sponsors considering a clinical trial in this area. Key words were formulated for searching on Medline and FDA website to locate relevant regulations for clinical research in herbal medicines to understand current environment for herbal medicine usage and examine the barriers affecting herbal medicine in clinical trials. Authors critically explore case study of the 1st FDA approved botanical drugs, Veregen (sinecatechins), green tea leaves extract, a topical cream for perianal and genital condyloma. In consideration of current regulation environment in USA, based on the findings and analysis through the literature review and Veregen case study, authors produce and propose a Checklist for New Drug Application of Herbal Medicines for potential investigators and sponsors considering in a herbal medicine clinical trial.
Gleicher, Norbert; Kushnir, Vitaly A; Barad, David H
There is almost unanimity that modern medicine should be "evidence based." In this context, lack of prospectively randomized clinical trials (RCTs) is widely lamented in reproductive medicine. Some leading voices, indeed, increasingly suggest that only RCT-based clinical conclusions should be integrated into clinical practice, since lower levels of evidence are inadequate. We have argued that reproductive medicine requires special considerations because, like clinical oncology, fertility treatments (especially in older women) are time dependent. Unlike clinical oncology, reproductive medicine, however, does not receive substantial financial research support from government or industry and, at least in the United States, has, therefore, to be primarily funded via patient revenues. Given a 50% chance of receiving placebo, infertility patients are, understandably, reluctant to fund their own RCTs. We here selectively review this subject, contrasting opposing opinions recently published in the literature by a prominent reproductive scientist and one of the world's leading experts on evidence-based medicine. Placing these recent publications into the evolving context of infertility practice, as also addressed in this journal in recent publications, we conclude that objective reasons explain why relatively few RCTs are performed in reproductive medicine and predict that this will not change in the foreseeable future. Reproductive medicine, therefore, has to find ways to develop satisfactory clinical evidence in other ways, satisfying patients' rights to easy access to potentially beneficial medical treatments with low costs and low risks. The RCTs should be reserved for relatively high risk and/or high cost treatments. © The Author(s) 2015.
[From classificational medicine to clinical medicine (the end of the XVIII century to 1870s). Communication 3. The second stage of clinical medicine development: introduction of methods of laboratory experiment and chemical analysis].
Stochik, A M; Zatravkin, S N
The article concerns the end stage of clinical medicine establishment covering the period from early 1840s to the middle 1870s of the XIX century. Basic scientific achievements related to introduction into practical medicine of the methods of laboratory experiment and chemical analysis are reviewed.
Hippocrates of Kos (460-377 Before Common Era, BCE) is universally recognized as the father of modern medicine, which is based on observation of clinical signs and rational conclusions, and does not rely on religious or magical beliefs. Hippocratic medicine was influenced by the Pythagorean theory that Nature was made of four elements (water, earth, wind and fire), and therefore, in an analogous way, the body consisted of four fluids or 'humors' (black bile, yellow bile, phlegm and blood). The physician had to reinstate the healthy balance of these humors by facilitating the healing work of 'benevolent Nature'. The Hippocratic Oath contains the Pythagorean duties of justice, secrecy, respect for teachers and solidarity with peers. The clinical and ethical basics of medical practice as well as most clinical terms used even today have their origins in Hippocrates. His contribution in clinical medicine is immense. Asclepiades of Bithynia (124-40 BCE) was the first physician who established Greek medicine in Rome. Influenced by the Epicurean philosophy, he adhered to atomic theory, chance and evolution, and did not accept the theory of a 'benevolent Nature'. He suggested that the human body is composed of molecules and void spaces, and that diseases are caused by alteration of form or position of a patient's molecules. Asclepiades favored naturalistic therapeutic methods such as a healthy diet, massage and physical exercise. Above all, he introduced the friendly, sympathetic, pleasing and painless treatment of patients into medical practice, influenced by the teachings of Epicurus on pleasure and friendship. He was the first who made the highly important division of diseases into acute and chronic ones and to perform an elective non-emergency tracheotomy. As the founder of the Methodic School, Asclepiades was the first known physician who spoke about what is known today as molecular medicine.
Pavlovskiĭ, L N
The article presents information on academician N.D.Strazheshko- the founder of one of key native therapeutic schools with its new, original features. In the article was shown an important contribution of the scientist to the study of significant questions related to internal medicine and his role in the development of current clinical medicine.
Emanuel', Iu V; Trofimov, V I; Filippova, N A; Emanuel', V L
The article considers the actual issues of teaching laboratory medicine to students of medical faculty and to physicians getting trained in different programs of postgraduate education. The major models of interaction between clinical physicians and specialists of laboratory diagnostic are considered. The proposed model of teaching of laboratory medicine is developed in collaboration with clinical chairs and is based on the principle of "clinical laboratory council of physicians". The analysis of clinical cases of specific patients and clinical analytical critiques are in the basement of the given system. The algorithm of considering one of situation tasks used in teaching is presented as example.
Sarigiannis, Amy N.; Boulton, Matthew L.
Objectives. We evaluated the utility of a competency mapping process for assessing the integration of clinical and public health skills in a newly developed Community Health Center (CHC) rotation at the University of Michigan School of Public Health Preventive Medicine residency. Methods. Learning objectives for the CHC rotation were derived from the Accreditation Council for Graduate Medical Education core clinical preventive medicine competencies. CHC learning objectives were mapped to clinical preventive medicine competencies specific to the specialty of public health and general preventive medicine. Objectives were also mapped to The Council on Linkages Between Academia and Public Health Practice’s tier 2 Core Competencies for Public Health Professionals. Results. CHC learning objectives mapped to all 4 (100%) of the public health and general preventive medicine clinical preventive medicine competencies. CHC population-level learning objectives mapped to 32 (94%) of 34 competencies for public health professionals. Conclusions. Utilizing competency mapping to assess clinical–public health integration in a new CHC rotation proved to be feasible and useful. Clinical preventive medicine learning objectives for a CHC rotation can also address public health competencies. PMID:22690972
Chin-Yee, Benjamin H; Upshur, Ross E G
The aim of this article is to create a space for historical thinking in medical practice. To this end, we draw on the ideas of R.G. Collingwood (1889-1943), the renowned British philosopher of history, and explore the implications of his philosophy for clinical medicine. We show how Collingwood's philosophy provides a compelling argument for the re-centring of medical practice around the patient history as a means of restoring to the clinical encounter the human meaning that is too often lost in modern medicine. Furthermore, we examine how Collingwood's historical thinking offers a patient-centred epistemology and a more pluralistic concept of evidence that includes the qualitative, narrative evidence necessary for human understanding. We suggest that clinical medicine can benefit from Collingwood's historical thinking, and, more generally, illustrates how a philosophy of medicine that draws on diverse sources from the humanities offers a richer, more empathetic clinical practice.
Wendland, Claire L
At an understaffed and underresourced urban African training hospital, Malawian medical students learn to be doctors while foreign medical students, visiting Malawi as clinical tourists on short-term electives, learn about “global health.” Scientific ideas circulate fast there; clinical tourists circulate readily from outside to Malawi but not the reverse; medical technologies circulate slowly, erratically, and sometimes not at all. Medicine's uneven globalization is on full display. I extend scholarship on moral imaginations and medical imaginaries to propose that students map these wards variously as places in which—or from which—they seek a better medicine. Clinical tourists, enacting their own moral maps, also become representatives of medicine “out there”: points on the maps of others. Ethnographic data show that for Malawians, clinical tourists are colleagues, foils against whom they construct ideas about a superior and distinctly Malawian medicine and visions of possible alternative futures for themselves.
Chen, De-Dao; Meng, Xian-Hua; Zhang, Ying-Shan; Chen, Gen-Ping; Huang, Yu-Lan
"Shengdeng" is its Tibetan transliteration referring to many medicines. Tibetan doctors and pharmacists in different areas use different drugs in formulation and clinical application, which are easily confused. In order to grasp the formula and clinical application accurately, we conduct a literature survey on history and current state of botanical origin and clinical application of "Shengdeng", making clear the application of various herbs named "Shengdeng" and providing reference to all Tibetan researchers and clinical workers in formulation and clinical application.
Liu, Fang; Ma, Rong; Liao, Xing; Chai, Shi-Wei
Discussion on assessment and intervention models to promote the rational use of medicines of Chinese medicine injection effect. Using systematic prescription assessment and intervention work mode, formed expert group guide established assessment standard, developed the prescription audit specification, and extracted all Chinese medicine injection prescription of outpatient 2010 first quarter (in front of intervention) and 2011 first quarter (behind intervention), respectively for 2 543 and 3 122. The percent of the non-indication of medication in front of intervention outpatient fell from 3.44% to behind intervention of 2.66% (P<0.05), the percent of contraindicated medication in front of intervention outpatient fell from 2. 14% to behind intervention of 1.33% (P<0.05), the incidence of adverse reactions in front of intervention outpatient fell from 1.01% to behind intervention of 0.29% (P<0.05). The modes of prescription assessment and intervention have obvious results for the promotion of rational use of traditional Chinese medicine injections.
O'Rourke, Alan; Booth, Andrew; Ford, Nigel
Discusses evidence-based medicine (EBM) and the need for systematic use of databases like MEDLINE with more sophisticated search strategies to optimize the retrieval of relevant papers. Describes an empirical study of hospital libraries that examined requests for information and search strategies using both structured and unstructured forms.…
O'Rourke, Alan; Booth, Andrew; Ford, Nigel
Discusses evidence-based medicine (EBM) and the need for systematic use of databases like MEDLINE with more sophisticated search strategies to optimize the retrieval of relevant papers. Describes an empirical study of hospital libraries that examined requests for information and search strategies using both structured and unstructured forms.…
Lagman, Ruth L; Walsh, Declan; LeGrand, Susan B; Davis, Mellar P
The medical care of individuals with advanced disease is complex and has historically been fragmented and suboptimal. Palliative medicine attempts to address these needs. The Harry R. Horvitz Center for Palliative Medicine at the Cleveland Clinic is an established comprehensive integrated program. Structured and seamless clinical operations are important to ensure the best delivery of high-quality medical care and continuity for those affected by life-limiting illness.
Smith, Donald F; Hagstrom, Melena R
This paper provides a 50-year overview of research and clinical advances in AAVMC member colleges in four representative fields of veterinary medicine: oncology, vaccine development, production medicine, and public health. Though emphasis is on the progress since the mid-1960s, the salient background and associated personnel in each field are also identified to the extent that their description informs more recent events. Advances in board certification and post-graduate clinical and research educational opportunities are also described.
García Arenillas, Mar; Haj-Ali Saflo, Okba; Sáenz de Tejada, Marta
The new European Union directives affecting clinical trials of medicines introduced important changes for Spain, leading to the publication of a Royal Decree regulating the conduct of clinical trials that went into effect in January 2016. The decree sets out the principles for complying with the EU directives, regulates the work of institutional review boards (IRBs) or ethics committees that review research proposals, introduces means to facilitate clinical research, and clarifies the role of the Spanish register of clinical trials, among other topics. This paper discusses the main changes that have been introduced, especially those intended to facilitate research, such as the new concepts of low intervention trial and noncommercial clinical research. These concepts may be particularly useful for clinical trials designed by emergency medicine physicians. We also comment on changes affecting vulnerable populations and the documents that must be presented to both the researchers' IRB and the Spanish Agency for Medicines and Health Care Products.
Christensen, Alan J; Nezu, Arthur M
This issue represents the 4th Journal of Consulting and Clinical Psychology special issue on behavioral medicine and clinical health psychology over the past 4 decades. Recent developments in health care policy, as well as in the maturation of the science, make a special issue in this area particularly timely. This collection includes state of the clinical science reviews, reports of clinical trials, and articles addressing theory and methods in behavioral medicine and clinical health psychology. A multilevel, ecological perspective that considers multiple levels of influences (e.g., cultural influences on behavior-health linkages, individual differences) is salient throughout many of the articles. Our hope is that this sampling of this broad field, and coverage of some key issues and areas, will play a role in stimulating the next 10 years of research, practice, and policy implementation in behavioral medicine and clinical health psychology.
Francis, C. K.
The medical profession will face many challenges in the new millennium. As medicine looks forward to advances in molecular genetics and the prospect of unprecedented understanding of the causes and cures of human disease, clinicians, scientists and bioethicists may benefit from reflection upon the origins of the medical ethos and its relevance to postmodern medicine. Past distortions of the medical ethos, such as Nazism and the Tuskegee Syphilis Study, as well as more recent experience with the ethical challenges of employer-based market driven managed care, provide important lessons as medicine contemplates the future. Racial and ethnic disparities in health status and access to care serve as a reminders that the racial doctrines that fostered the horrors of the Holocaust and the Tuskegee Syphilis Study have not been completely removed from contemporary thinking. Inequalities in health status based on race and ethnicity, as well as socioeconomic status, attest to the inescapable reality of racism in America. When viewed against a background of historical distortions and disregard for the traditional tenets of the medical ethos, persistent racial and ethnic disparities and health and the prospect of genetic engineering raise the specter of discrimination because of genotype, a postmodern version of "racist medicine" or of a "new eugenics." There is a need to balance medicine's devotion to the wellbeing of the patient and the primacy of the patient-physician relationship against with the need to meet the health care needs of society. The challenge facing the medical profession in the new millennium is to establish an equilibrium between the responsibility to assure quality health care for the individual patient while affecting societal changes to achieve "health for all." PMID:11405593
Engebretsen, Eivind; Heggen, Kristin; Wieringa, Sietse; Greenhalgh, Trisha
The evidence-based practice and evidence-based medicine (EBM) movements have promoted standardization through guideline development methodologies based on systematic reviews and meta-analyses of best available research. EBM has challenged clinicians to question their reliance on practical reasoning and clinical judgement. In this paper, we argue that the protagonists of EBM position their mission as reducing uncertainty through the use of standardized methods for knowledge evaluation and use. With this drive towards uniformity, standardization and control comes a suspicion towards intuition, creativity and uncertainty as integral parts of medical practice. We question the appropriateness of attempts to standardize professional practice through a discussion of the importance of uncertainty. Greenhalgh's taxonomy of uncertainty is used to inform an analysis of the clinical reasoning occurring in a potentially life threatening emergency situation with a young patient. The case analysis is further developed by the use of the Canadian philosopher Bernard Lonergan's theory about understanding and objective knowing. According to Lonergan it is not by getting rid of or even by reducing uncertainty, but by attending systematically to it and by relating to it in a self-conscious way, that objective knowledge can be obtained. The paper concludes that uncertainty is not a regrettable and unavoidable aspect of decision making but a productive component of clinical reasoning.
Patel, Himanshu; Gurumurthy, Parthasarathi
Background This study was conducted to explore the role of clinical pharmacists in providing medicine and therapeutic information service in oncology care setting. Methods It was a prospective study conducted for a period of three years after implementation of medicine and therapeutic information service as an integral part of oncology pharmacy services. The medicine and therapeutic information queries were received during ward rounds, at ambulatory care and via telephone by clinical pharmacists. All the medicine and therapeutic information requests were reviewed and answered to the concerned requester(s). Answered medicine and therapeutic information requests were electronically documented in the hospital drug information database and analyzed further. Results A total of 484 medicine and therapeutic information requests were received by clinical pharmacists during period of August 2013 to June 2016. Majority of medicine and therapeutic information queries were requested by radiation oncologists (27.2%) followed by medical oncologists (26.4%), general physicians (14.04%), resident medical officers (11.7%), ambulatory care nurses (8.6%), in-patient nurses (5.1%) and patients and care takers (6.6%). Majority of the medicine and therapeutic information queries were asked for the purpose of improving patient care (48.3%) followed by to update knowledge (30.9%) and training sessions to nurses (6.6%). The most common categories of medicine and therapeutic information were adverse drug reactions and its management (21.4%) followed by dosage adjustments of chemotherapy and biologicals (15.5%), supportive care related (14.6%), contraindications (14%), drug-drug interactions (11.9%), management of co-morbidities (7.8%), chemotherapy selection in special populations (4.5%). Conclusion The provision of medicine and therapeutic information was found to be useful in providing medicine information to improve patient care and to update knowledge of health care professionals at the
Cavagnaro, Joy; Silva Lima, Beatriz
The utility of animal models of disease for assessing the safety of novel therapeutic modalities has become an increasingly important topic of discussion as research and development efforts focus on improving the predictive value of animal studies to support accelerated clinical development. Medicines are approved for marketing based upon a determination that their benefits outweigh foreseeable risks in specific indications, specific populations, and at specific dosages and regimens. No medicine is 100% safe. A medicine is less safe if the actual risks are greater than the predicted risks. The purpose of preclinical safety assessment is to understand the potential risks to aid clinical decision-making. Ideally preclinical studies should identify potential adverse effects and design clinical studies that will minimize their occurrence. Most regulatory documents delineate the utilization of conventional "normal" animal species to evaluate the safety risk of new medicines (i.e., new chemical entities and new biological entities). Animal models of human disease are commonly utilized to gain insight into the pathogenesis of disease and to evaluate efficacy but less frequently utilized in preclinical safety assessment. An understanding of the limitations of the animal disease models together with a better understanding of the disease and how toxicity may be impacted by the disease condition should allow for a better prediction of risk in the intended patient population. Importantly, regulatory authorities are becoming more willing to accept and even recommend data from experimental animal disease models that combine efficacy and safety to support clinical development. Copyright © 2015 Elsevier B.V. All rights reserved.
Tams, Carl G; Euliano, Neil R
Clinical decision support systems are vital for advances in improving patient therapeutic care. We share lessons learned from creating two respiratory clinical decisions support systems for ventilating patients in a critical care setting.
Lavien, Garjae; Zaid, Uwais; Peterson, Andrew C
Genitourinary prosthetics are used for correction of functional deficits and to improve the quality of lives of affected patients. General surgeons must evaluate patients scheduled for nonurologic surgery with urologic devices that can impact their perioperative management. Lack of recognition of these prosthetics preoperatively can lead to unnecessary morbidity for the patient and have legal implications for the surgeon. Close consultation with a urologist may avoid common complications associated with these devices and allows for surgical assistance when operative misadventures do occur. This article reviews 3 common urologic prosthetics: testicular prosthesis, artificial urinary sphincter, and penile prosthesis.
Chawla, Arun; Chawla, Kiran; Thomas, Joseph
Genitourinary histoplasmosis is very rare and to our knowledge only four cases of epididymal histoplasmosis and nine cases of prostatic histoplasmosis have been reported in literature. We hereby report a case of a middle-aged male, who presented three years after renal transplant, with complaints of fever, pain, and swelling in the scrotum. Imaging disclosed an enlarged right epididymis with prostatic and retrotrigonal abscess, suggesting tuberculosis infection. However, histopathology of the epididymal biopsy revealed histoplasmosis, and the drained pus on culture confirmed infection with Histoplasma capsulatum. PMID:23204674
Lucini, Daniela; Cesana, Giovanna; Vigo, Chiara; Malacarne, Mara; Pagani, Massimo
Chronic non-communicable diseases represent the major drivers of disease burden, being responsible for the majority of health care cost and deaths. Almost half of premature deaths is due to behaviors amenable to change. Accordingly, addressing behavior might represent a strategic change in the health delivery system. Improving lifestyle requires a specific strategy embedding the active collaboration of individuals with a multilevel team-oriented medical practice. With the present study we sought to assess whether the implementation of cognitive-behavioral strategies, following the principles of lifestyle medicine in an outpatient clinic provides better results in weight reduction as compared to simpler strategies as presently executed in General Practitioners' offices. This is an observational study on 173 subjects (age 53.1 ± 11.5), comparing three different groups of preventive practice: a personalized lifestyle medicine, combining cognitive behavioral strategies with patient tailored prescription of exercise and nutrition (Group A); a semi-structured approach with generic counseling (Group B); and an unstructured advice (Group C). At the end of the intervention period (17-20 months), group A showed an average weight loss of 5.4 ± 5.1 kg, which was significantly (p<0.001)more than observed in group B (2.8 ± 5.1 kg) and group C (1.2 ± 4.8 kg). Likewise BMI and waist were progressively more reduced from A to C. It is possible to implement preventive cognitive-behavioral lifestyle strategies in outpatient internal medicine clinics. This methodology appears more efficacious in inducing weight reduction after more than a year as compared to usual family medicine approaches. Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Johnson, Julie A; Elsey, Amanda R; Clare-Salzler, Michael J; Nessl, David; Conlon, Michael; Nelson, David R
The University of Florida and Shands Hospital recently launched a genomic medicine program focused on the clinical implementation of pharmacogenetics called the Personalized Medicine Program. We focus on a preemptive, chip-based genotyping approach that is cost effective, while providing experience that will be useful as genomic medicine moves towards genome sequence data for patients becoming available. The Personalized Medicine Program includes a regulatory body that is responsible for ensuring that evidence-based examples are moved to clinical implementation, and relies on clinical decision support tools to provide healthcare providers with guidance on use of the genetic information. The pilot implementation was with CYP2C19-clopidogrel and future plans include expansion to additional pharmacogenetic examples, along with aiding in implementation in other health systems across Florida. PMID:23651020
Cardinal-Fernández, Pablo; Nin, Nicolás; Ruíz-Cabello, Jesús; Lorente, José A
Most respiratory diseases are considered complex diseases as their susceptibility and outcomes are determined by the interaction between host-dependent factors (genetic factors, comorbidities, etc.) and environmental factors (exposure to microorganisms or allergens, treatments received, etc.) The reductionist approach in the study of diseases has been of fundamental importance for the understanding of the different components of a system. Systems biology or systems medicine is a complementary approach aimed at analyzing the interactions between the different components within one organizational level (genome, transcriptome, proteome), and then between the different levels. Systems medicine is currently used for the interpretation and understanding of the pathogenesis and pathophysiology of different diseases, biomarker discovery, design of innovative therapeutic targets, and the drawing up of computational models for different biological processes. In this review we discuss the most relevant concepts of the theory underlying systems medicine, as well as its applications in the various biological processes in humans. Copyright © 2013 SEPAR. Published by Elsevier Espana. All rights reserved.
Simoes, E; Gostomzyk, J G; Schmahl, F W; Bamberg, M; Brucker, S Y; Wallwiener, D
Social medicine is concerned--in the midst of a constantly changing society--with the social and economic conditions that influence health, disease and medical care. A comprehensive medical care therefore requires medical doctors who, beyond the biomedical issues, realize diseases in the context of the social needs of the individual person and systematically include these in their prevention, treatment and rehabilitation concepts.The system of social security, particularly the health care system, depends on medical doctors' expertise in helping patients for the appropriate use of services from the system of social security. According to the German professional education regulations for doctors the additional specialization in "social medicine" also includes the competence for "assessment of the nature and extent of health disorders and their classification in the framework of social security systems". This judgment is one part of the tasks of the Medical Services belonging to the various branches of the social security system. It is also provided in practice by medical doctors with competence in social medicine working in acute care facilities.
Jefferys, Benjamin R.; Nwankwo, Iheanyi; Neri, Elias; Chang, David C. W.; Shamardin, Lev; Hänold, Stefanie; Graf, Norbert; Forgó, Nikolaus; Coveney, Peter
Personalized medicine relies in part upon comprehensive data on patient treatment and outcomes, both for analysis leading to improved models that provide the basis for enhanced treatment, and for direct use in clinical decision-making. A data warehouse is an information technology for combining and standardizing multiple databases. Data warehousing of clinical data is constrained by many legal and ethical considerations, owing to the sensitive nature of the data being stored. We describe an unconstrained clinical data warehousing architecture, some of the legal constraints that have led us to reconsider this architecture, and the legal and technical solutions to these constraints developed for the clinical data warehouse in the personalized medicine project p-medicine. We also propose some changes to the legal constraints that will further enable clinical research. PMID:24427531
To determine the number of interventions made by pharmacy students at an urban family medicine clinic and the acceptance rate of these recommendations by the healthcare providers. The secondary objective was to investigate the cost avoidance value of the interventions. A prospective, unblinded study was conducted to determine the number and cost avoidance value of clinical interventions made by pharmacy students completing advanced pharmacy practice experiences (APPEs) in an urban family medicine clinic. Eighteen students completed this experience in the 8 months studied. Of the 718 interventions performed, 77% were accepted by physicians, including 58% of the 200 interventions that required immediate action. Projected avoidance was estimated at $61,855. The clinical interventions by pharmacy students were generally well received by healthcare providers and resulted in significant cost savings. Pharmacy students can play an important role in a family medicine clinic.
Jefferys, Benjamin R; Nwankwo, Iheanyi; Neri, Elias; Chang, David C W; Shamardin, Lev; Hänold, Stefanie; Graf, Norbert; Forgó, Nikolaus; Coveney, Peter
Personalized medicine relies in part upon comprehensive data on patient treatment and outcomes, both for analysis leading to improved models that provide the basis for enhanced treatment, and for direct use in clinical decision-making. A data warehouse is an information technology for combining and standardizing multiple databases. Data warehousing of clinical data is constrained by many legal and ethical considerations, owing to the sensitive nature of the data being stored. We describe an unconstrained clinical data warehousing architecture, some of the legal constraints that have led us to reconsider this architecture, and the legal and technical solutions to these constraints developed for the clinical data warehouse in the personalized medicine project p-medicine. We also propose some changes to the legal constraints that will further enable clinical research.
Booth, Laurence; Roberts, Jane L.; Cruickshanks, Nichola; Conley, Adam; Durrant, David E.; Das, Anindita; Fisher, Paul B.; Kukreja, Rakesh C.; Grant, Steven; Poklepovic, Andrew
The present studies determined whether clinically relevant phosphodiesterase 5 (PDE5) inhibitors interacted with clinically relevant chemotherapies to kill gastrointestinal/genitourinary cancer cells. In bladder cancer cells, regardless of H-RAS mutational status, at clinically achievable doses, PDE5 inhibitors interacted in a greater than additive fashion with doxorubicin/mitomycin C/gemcitabine/cisplatin/paclitaxel to cause cell death. In pancreatic tumor cells expressing mutant active K-RAS, PDE5 inhibitors interacted in a greater than additive fashion with doxorubicin/gemcitabine/paclitaxel to cause cell death. The most potent PDE5 inhibitor was sildenafil. Knock down of PDE5 expression recapitulated the combination effects of PDE5 inhibitor drugs with chemotherapy drugs. Expression of cellular FLICE-like inhibitory protein-short did not significantly inhibit chemotherapy lethality but did significantly reduce enhanced killing in combination with sildenafil. Overexpression of B-cell lymphoma–extra large suppressed individual and combination drug toxicities. Knock down of CD95 or Fas-associated death domain protein suppressed drug combination toxicity. Combination toxicity was also abolished by necrostatin or receptor interacting protein 1 knock down. Treatment with PDE5 inhibitors and chemotherapy drugs promoted autophagy, which was maximal at ∼24 hour posttreatment, and 3-methyl adenine or knock down of Beclin1 suppressed drug combination lethality by ∼50%. PDE5 inhibitors enhanced and prolonged the induction of DNA damage as judged by Comet assays and γhistone 2AX (γH2AX) and checkpoint kinase 2 (CHK2) phosphorylation. Knock down of ataxia telangiectasia mutated suppressed γH2AX and CHK2 phosphorylation and enhanced drug combination lethality. Collectively our data demonstrate that the combination of PDE5 inhibitors with standard of care chemotherapy agents for gastrointestinal/genitourinary cancers represents a novel modality. PMID:24353313
Klimas, J; McNeil, R; Ahamad, K; Mead, A; Rieb, L; Cullen, W; Wood, E; Small, W
Despite a large evidence-base upon which to base clinical practice, most health systems have not combined the training of healthcare providers in addiction medicine and research. As such, addiction care is often lacking, or not based on evidence or best practices. We undertook a qualitative study to assess the experiences of physicians who completed a clinician-scientist training programme in addiction medicine within a hospital setting. We interviewed physicians from the St. Paul's Hospital Goldcorp Addiction Medicine Fellowship and learners from the hospital's academic Addiction Medicine Consult Team in Vancouver, Canada (N = 26). They included psychiatrists, internal medicine and family medicine physicians, faculty, mentors, medical students and residents. All received both addiction medicine and research training. Drawing on Kirkpatrick's model of evaluating training programmes, we analysed the interviews thematically using qualitative data analysis software (Nvivo 10). We identified five themes relating to learning experience that were influential: (i) attitude, (ii) knowledge, (iii) skill, (iv) behaviour and (v) patient outcome. The presence of a supportive learning environment, flexibility in time lines, highly structured rotations, and clear guidance regarding development of research products facilitated clinician-scientist training. Competing priorities, including clinical and family responsibilities, hindered training. Combined training in addiction medicine and research is feasible and acceptable for current doctors and physicians in training. However, there are important barriers to overcome and improved understanding of the experience of addiction physicians in the clinician-scientist track is required to improve curricula and research productivity.
Chadha, Rajiv; Khan, Niyaz Ahmed; Shah, Shalu; Pant, Nitin; Gupta, Amit; Choudhury, Subhasis Roy; Debnath, Pinaki Ranjan; Puri, Archana
Aims: To discuss the assessment and management of genitourinary (GU) tract abnormalities in 21 girls with Types I-III congenital pouch colon (CPC), studied over a period of 10 years. Materials and Methods: Assessment included clinical and radiological assessment, examination under anesthesia (EUA), endoscopy of the lower GU tract, and evaluation of the surgical findings, operative procedures for the GU anomalies, and the results of management. Results: Initial examination of the external genitalia showed a “clover-leaf” appearance (n = 6) and a single perineal opening (n = 6). In 9 patients, the openings of the urethra and double vagina were seen, of which a vestibular fistula was seen in 5 and an anterior perineal fistula in 1. Seventeen patients (81%) had urinary incontinence (UI) - partial in 10, and complete in 7. Renal function tests, X-ray sacrum, and abdominal US were normal in all patients. Micturating cystourethrogram (n = 9) showed a wide, bladder neck incompetence (BNI) with reduced bladder capacity in seven patients. EUA and endoscopy revealed a septate vagina in all patients and the urethral opening at a “high” position (n = 14) or at a relatively normal or “low” position (n = 7). In 8 patients, the intervaginal septum was thick and fleshy. Endoscopy showed a short, wide urethra, an open incompetent bladder neck, poorly developed trigone, and reduced bladder capacity in the patients with UI. The fistula from the colonic pouch opened in the proximal urethra (n = 4), high in the vestibule (n = 3), low in the vestibule (n = 8), perineum just posterior to the vestibule (n = 1), and undetermined (n = 5). Vaginoscopy (n = 8) showed normal cervices in all and cervical mucus in 4 patients. The subtypes of CPC were Type I CPC (n = 4), Type II CPC (n = 16), and Type III CPC (n = 1). All 21 patients had uterus didelphys. In four patients with UI, during tubular colorraphy, a segment of the colonic pouch was preserved for later bladder augmentation if
Chadha, Rajiv; Khan, Niyaz Ahmed; Shah, Shalu; Pant, Nitin; Gupta, Amit; Choudhury, Subhasis Roy; Debnath, Pinaki Ranjan; Puri, Archana
To discuss the assessment and management of genitourinary (GU) tract abnormalities in 21 girls with Types I-III congenital pouch colon (CPC), studied over a period of 10 years. Assessment included clinical and radiological assessment, examination under anesthesia (EUA), endoscopy of the lower GU tract, and evaluation of the surgical findings, operative procedures for the GU anomalies, and the results of management. Initial examination of the external genitalia showed a "clover-leaf" appearance (n = 6) and a single perineal opening (n = 6). In 9 patients, the openings of the urethra and double vagina were seen, of which a vestibular fistula was seen in 5 and an anterior perineal fistula in 1. Seventeen patients (81%) had urinary incontinence (UI) - partial in 10, and complete in 7. Renal function tests, X-ray sacrum, and abdominal US were normal in all patients. Micturating cystourethrogram (n = 9) showed a wide, bladder neck incompetence (BNI) with reduced bladder capacity in seven patients. EUA and endoscopy revealed a septate vagina in all patients and the urethral opening at a "high" position (n = 14) or at a relatively normal or "low" position (n = 7). In 8 patients, the intervaginal septum was thick and fleshy. Endoscopy showed a short, wide urethra, an open incompetent bladder neck, poorly developed trigone, and reduced bladder capacity in the patients with UI. The fistula from the colonic pouch opened in the proximal urethra (n = 4), high in the vestibule (n = 3), low in the vestibule (n = 8), perineum just posterior to the vestibule (n = 1), and undetermined (n = 5). Vaginoscopy (n = 8) showed normal cervices in all and cervical mucus in 4 patients. The subtypes of CPC were Type I CPC (n = 4), Type II CPC (n = 16), and Type III CPC (n = 1). All 21 patients had uterus didelphys. In four patients with UI, during tubular colorraphy, a segment of the colonic pouch was preserved for later bladder augmentation if required. A Young-Dees bladder-neck repair (BNR
Henry, Stephen G
Most clinicians take for granted a simple, reductionist understanding of medical knowledge that is at odds with how they actually practice medicine; routine medical decisions incorporate more complicated kinds of information than most standard accounts of medical reasoning suggest. A better understanding of the structure and function of knowledge in medicine can lead to practical improvements in clinical medicine. This understanding requires some familiarity with epistemology, the study of knowledge and its structure, in medicine. Michael Polanyi's theory of tacit knowing is advanced as the basis for developing a more accurate understanding of medical knowledge. Tacit knowing, which explores the taken-for-granted background knowledge that underlies all human knowing, is explained in detail with a focus on its relevance for clinical medicine. The implications of recognizing tacit knowing in medicine and medical decisions are discussed. These include the ability to explain the importance of the clinical encounter in medical practice, mechanisms for analysing patient and doctor as persons, and the need for humility given the uncertainty that the tacit dimension injects into all medical decisions. This more robust medical epistemology allows clinicians to better articulate the nature and importance of patient-centred care, to avoid pitfalls inherent in reductionist approaches to medical knowledge, and to think more clearly about the relationships between medicine and health care at the individual and population levels.
Yamakawa, Jun-ichi; Moriya, Junji; Takeuchi, Kenji; Nakatou, Mio; Motoo, Yoshiharu; Kobayashi, Junji
The cause of obesity includes genetic and environmental factors, including cytokines derived from adipocytes (adipo-cytokines). Although drug therapy is available for obesity, it is highly risky. Our main focus in this review is on the traditional form of Japanese medicine, Kampo, in the treated of obesity. Two Kampo formulas, that is, bofutsushosan (防風通聖散) and boiogito (防己黄耆湯), are covered by the national health insurance in Japan for the treatment of obesity. Various issues related to their action mechanisms remain unsolved. Considering these, we described the results of basic experiments and presented clinical evidence and case reports on osteoarthritis as examples of clinical application of their two Kampo medicine. Traditional medicine is used not only for treatment but also for prevention. In clinical practice, it is of great importance to prove the efficacy of combinations of traditional medicine and Western medicine and the utility of traditional medicine in the attenuation of adverse effects of Western medicine. PMID:23662155
Liamis, George; Tsimihodimos, Vasilis; Doumas, Michalis; Spyrou, Athanasia; Bairaktari, Eleni; Elisaf, Moses
Hypernatraemia is a frequent electrolyte disorder in hospitalized patients that has been mainly studied in an entire hospital population. The aim of this study was to determine the incidence, clinical characteristics, concomitant electrolyte abnormalities and outcome of hypernatraemia in an internal medicine clinic. Also, we sought to identify differences between patients who were admitted with hypernatraemia and those who developed hypernatraemia during hospitalization. We prospectively studied patients who either on admission to our internal medicine clinic or during their hospitalization were found to have hypernatraemia (sodium concentration greater than 148 meq/l, 148 mmol/l). One hundred and thirteen patients out of 9158 patients at risk had hypernatraemia (incidence 1.2%). Of those, fifty patients had hypernatraemia on admission, whereas 63 had hospital-acquired hypernatraemia. Patients who developed hypernatraemia before hospital admission had a much lower mortality rate than patients with hospital-acquired hypernatraemia (28% vs 47.6%, P=0.03), despite the fact that they had a higher peak serum sodium concentration (160.4+/-9.9 vs 154.4+/-2.4 meq/l, P=0.000). Furthermore, they did not differ in either age or the frequency of concomitant electrolyte abnormalities in comparison with patients who developed hypernatraemia during hospitalization. There were two main subgroups of patients with hospital-acquired hypernatraemia. A total of 26 Patients (41%) exhibited a biochemical profile consistent with extracellular volume depletion, whereas 32 patients (51%) with euvolaemia. On the contrary, the majority of patients (82%) who were hypernatraemic on admission had hypovolaemic hypernatraemia. The construction of the receiver operating characteristics (ROC) plots revealed that the urea to creatinine ratio was the best predictor of the extracellular volume status. Indeed, a urea to creatinine value of 57 could differentiate between the groups with euvolaemic or
Roper, Nitin; Stensland, Kristian D; Hendricks, Ryan; Galsky, Matthew D
Advances in tumor biology and multiplex genomic analysis have ushered in the era of precision cancer medicine. Little is currently known, however, about the landscape of prospective "precision cancer medicine" clinical trials in the U.S. We identified all adult interventional cancer trials registered on ClinicalTrials.gov between September 2005 and May 2013. Trials were classified as "precision cancer medicine" if a genomic alteration in a predefined set of 88 genes was required for enrollment. Baseline characteristics were ascertained for each trial. Of the initial 18,797 trials identified, 9094 (48%) were eligible for inclusion: 684 (8%) were classified as precision cancer medicine trials and 8410 (92%) were non-precision cancer medicine trials. Compared with non-precision cancer medicine trials, precision cancer medicine trials were significantly more likely to be phase II [RR 1.19 (1.10-1.29), p<0.001], multi-center [RR 1.18 (1.11-1.26), p<0.001], open-label [RR 1.04 (1.02-1.07), p=0.005] and involve breast [RR 4.03 (3.49-4.52), p<0.001], colorectal [RR 1.62 (1.22-2.14), p=0.002] and skin [RR 1.98 (1.55-2.54), p<0.001] cancers. Precision medicine trials required 38 unique genomic alterations for enrollment. The proportion of precision cancer medicine trials compared to the total number of trials increased from 3% in 2006 to 16% in 2013. The proportion of adult cancer clinical trials in the U.S. requiring a genomic alteration for enrollment has increased substantially over the past several years. However, such trials still represent a small minority of studies performed within the cancer clinical trials enterprise and include a small subset of putatively "actionable" alterations. Copyright © 2015 Elsevier Ltd. All rights reserved.
Kampo-medicine has become popular in Japanese medical practice combined with western medicine. For example, Daikenchu-To for intestinal obstruction after surgical operation, Shakuyakukanzo-To and Goshajinki-Gan for anti-cancer agents-induced neuropathy, and Yokkan-San for behavioral psychological symptoms of dementia are alternatively used in addition to conventional treatments in Japan. However, combined use of Kampo-medicine and western medicine may cause unexpected adverse events including undesirable drug-drug interactions because Kampo-medicine was not originally developed to be used with western medicine. Although adverse effects of Kampo-medicine are rare compared with those of western medicine, severe events such as liver dysfunction and interstitial pneumonia have been reported in increasing trends. Medical staff including pharmacists, therefore, should be aware of the onset of adverse events before the patients' symptoms become severe. Several adverse effects are caused by chemical constituents such as glycyrrhizin in licorice for pseudoaldosteronism and geniposide in Gardeniae fructus for mesenteric phlebosclerosis. To understand the adverse effects of Kampo-medicine, pharmacists should learn trends in current medication as well as pharmacology and toxicology of the chemical constituents in pharmacognosy. These issues should also be addressed in educational materials for students of clinical pharmacy and pharmacy practice.
del Mundo, Winfred F B; Shepherd, William C; Marose, Thomas D
There has been an increasing awareness of the use of alternative medicine and its effect on health care in the United States. However, no previous study has looked at its use among primary care patients in a rural setting. We conducted this study to determine the patterns of use of alternative medicine in this population. A questionnaire was distributed to 750 adult patients in a family practice clinic in northern Pennsylvania. Our response rate was 88% (664/750). Forty-seven percent of patients reported using at least one form of alternative medicine during the past year The most-common types used were chiropractic (used by 17.2% of respondents), relaxation techniques (16.9%), herbal medicine (16.9%), and massage (14.2%). The patients surveyed used alternative medicine more for its benefits than because of dissatisfaction with conventional medicine. Only 51% of patients told their physician about their use of alternative medicine. A significant number of rural family practice patients are using alternative medicine. To better address their patients' needs, primary care physicians should routinely ask patients about their use of alternative medicine and advise them accordingly.
The general status of clinical approach regarding the applications of clinical methodology has been reviewed under the spectacles of author's points. Also the subject of MANAHPARIKSANA has been critically analysed through the lenses of CARAKA and CAKRAPANIDATTA and its utility in present day clinical practices has been underlined. An appeal has been projected to the fellow Ayur-dists to shed of prejudices and hypocritical practices with an information and promise from our side to join hands PMID:22556949
Venkatesh, Arjun K; Savage, Dan; Sandefur, Benjamin; Bernard, Kenneth R; Rothenberg, Craig; Schuur, Jeremiah D
Over 25 years, emergency medicine in the United States has amassed a large evidence base that has been systematically assessed and interpreted through ACEP Clinical Policies. While not previously studied in emergency medicine, prior work has shown that nearly half of all recommendations in medical specialty practice guidelines may be based on limited or inconclusive evidence. We sought to describe the proportion of clinical practice guideline recommendations in Emergency Medicine that are based upon expert opinion and low level evidence. Systematic review of clinical practice guidelines (Clinical Policies) published by the American College of Emergency Physicians from January 1990 to January 2016. Standardized data were abstracted from each Clinical Policy including the number and level of recommendations as well as the reported class of evidence. Primary outcomes were the proportion of Level C equivalent recommendations and Class III equivalent evidence. The primary analysis was limited to current Clinical Policies, while secondary analysis included all Clinical Policies. A total of 54 Clinical Policies including 421 recommendations and 2801 cited references, with an average of 7.8 recommendations and 52 references per guideline were included. Of 19 current Clinical Policies, 13 of 141 (9.2%) recommendations were Level A, 57 (40.4%) Level B, and 71 (50.4%) Level C. Of 845 references in current Clinical Policies, 67 (7.9%) were Class I, 272 (32.3%) Class II, and 506 (59.9%) Class III equivalent. Among all Clinical Policies, 200 (47.5%) recommendations were Level C equivalent, and 1371 (48.9%) of references were Class III equivalent. Emergency medicine clinical practice guidelines are largely based on lower classes of evidence and a majority of recommendations are expert opinion based. Emergency medicine appears to suffer from an evidence gap that should be prioritized in the national research agenda and considered by policymakers prior to developing future quality
... better. In the United States, the Food and Drug Administration is in charge of assuring the safety ... prescription and over-the-counter medicines. Even safe drugs can cause unwanted side effects or interactions with ...
Tan, Susanna K; Relman, David A; Pinsky, Benjamin A
Advances in DNA sequencing technology have provided an unprecedented opportunity to study the human virome. Transplant recipients and other immunocompromised hosts are at particular risk for developing virus-related pathology; thus, the impact of the virome on health and disease may be even more relevant in this population. Here, we discuss technical considerations in studying the human virome, the current literature on the virome in transplant recipients, and near-future applications of sequence-based findings that can further our understanding of viruses in transplantation medicine. Copyright © 2017 American Society for Microbiology.
Bellmunt, Joaquim; Calvo, Emiliano; Castellano, Daniel; Climent, Miguel Angel; Esteban, Emilio; García del Muro, Xavier; González-Larriba, José Luis; Maroto, Pablo; Trigo, José Manuel
For almost the last two decades, interleukin-2 and interferon-alpha have been the only systemic treatment options available for metastatic renal cell carcinoma. However, in recent years, five new targeted therapies namely sunitinib, sorafenib, temsirolimus, everolimus and bevacizumab have demonstrated clinical activity in these patients. With the availability of new targeted agents that are active in this disease, there is a need to continuously update the treatment algorithm of the disease. Due to the important advances obtained, the Spanish Oncology Genitourinary Group (SOGUG) has considered it would be useful to review the current status of the disease, including the genetic and molecular biology factors involved, the current predicting models for development of metastases as well as the role of surgery, radiotherapy and systemic therapies in the early- or late management of the disease. Based on this previous work, a treatment algorithm was developed.
Hammerschlag, Richard; Calabrese, Carlo; Mist, Scott; Aickin, Mikel; Sutherland, Elizabeth; Leben, Joseph; DeBAR, Lynn; Elder, Charles; Dworkin, Samuel F.
Abstract Objectives To assess the feasibility and acceptability of studying whole systems of Traditional Chinese Medicine (TCM) and Naturopathic medicine (NM) in the treatment of temporomandibular disorders (TMD), and to determine whether there is indication to support further research. Design A pilot study using a randomized controlled clinical trial design of whole system TCM and NM versus state-of-the-art specialty care (SC). Setting/location Kaiser Permanente Northwest (KPNW), and practitioner offices in Portland, Oregon. Subjects One hundred and sixty (160) women 25–55 years of age attending a KPNW TMD specialty clinic. Interventions Whole system TCM and NM, and KPNW TMD clinic SC; the intervention protocols were designed to model the individually tailored type of community care offered in alternative medicine practices in Portland and in the KPNW TMD clinic, using protocols that enhanced similarities among practitioners within each system and permitted full descriptions of the treatments provided. Outcome measures TMD was ascertained using the Research Diagnostic Criteria/TMD; outcomes were self-reported worst and average facial pain and interference with activities (scaled 0–10 where 10 is worst). Results Of 948 consecutive eligible patients, 160 were randomized to one of three arms; 128 provided endpoint data. TCM and NM demonstrated significantly greater in-treatment reductions for worst facial pain compared to SC (adjusted regression analysis; higher negative values indicate greater improvement, = −1.11 ± 0.43, p = 0.010 and −1.02 ± 0.45, p = 0.025 for TCM and NM, respectively, compared to SC) and at 3 months post-treatment (−1.07 ± 0.51, p = 0.037 and −1.27 ± 0.54, p = 0.019 for TCM and NM versus SC, respectively). Additionally, TCM provided significantly greater decreases in average pain than SC; NM provided significantly greater decreases than SC or TCM in TMD-related psychosocial interference
Kang, Yoon; Bardes, Charles L.; Gerber, Linda M.; Storey-Johnson, Carol
Purpose: To assess the feasibility of Direct Observation of Clinical Skills (DOCS), a program for formative assessment of students’ clinical skills during a medicine clerkship and to determine relationships between DOCS measures and other clinical performance measures. Method: From August, 2004 through June, 2005, Medicine Clerks assigned to the primary on-campus clinical site were asked to participate in the pilot phase of the DOCS program. Students were asked to complete at least one DOCS exercise focused on interviewing, physical examination, or oral case presentation. Results: Of the 79 students who rotated on the Medicine Clerkship during the pilot period, 79% (n = 62) participated in DOCS, and 163 forms were submitted for evaluation. Seventy-seven percent (77%) of the clinical observations occurred while on-call or during daily rounds. Seventy-three (73%) of observations were completed in 30 minutes or less. In 89% of encounters students received at least 5 minutes of verbal feedback. Satisfaction ratings from both students and observers were “moderately satisfied” or better. Global ratings from DOCS physical exam and case presentation sections were strongly correlated with both faculty ratings of clinical performance and final clerkship grade. DOCS measures were not statistically related to clerkship written examination scores. Conclusions: These data support the feasibility of the DOCS session for formative assessment of student interviewing, physical examination, and oral case presentation skills during a medicine clerkship. Observer ratings from DOCS physical examination and case presentation sections were found to be predictors of final clerkship grade. PMID:20165523
Technological developments in the field of communications have widened access to research evidence and, as a result, scientific epistemology is in the ascendancy in the area of medical knowledge. This has been the subject of vigorous debate within the medical profession itself, with many opposing the increasing weight given to research evidence at the expense of expert opinion. Medicine has a professional culture which identifies knowledge with particular individuals - a 'person culture'. Much of the authority of physicians derives from the presumption that medical professionals have privileged access to medical knowledge. Scientific epistemology, on the other hand, identifies knowledge with a process of investigation. The esoteric knowledge to which expert individuals claim privileged access has no currency in this process. Because of this, the rise of scientific epistemology in medicine partially undermines the profession's authority. Access to scientific research evidence can be used to undermine the individual authority of professional experts. Illustrative examples are given of the nature of debate within a 'person culture' and of ways in which research evidence has been used to challenge the authority of physicians.
Bagri, Anita S.; Zaw, Khin M.; Milanez, Marcos N.; Palacios, Juan J.; Qadri, Syeda S.; Bliss, Linda A.; Roos, Bernard A.; Ruiz, Jorge G.
A total of 8 geriatric medicine fellows participated in an objective structured clinical examination (OSCE) assessing communication skills and clinical reasoning in common geriatric syndromes. To determine their perceptions about the experience, we conducted surveys and semistructured interviews. We analyzed the survey data using descriptive…
Bagri, Anita S.; Zaw, Khin M.; Milanez, Marcos N.; Palacios, Juan J.; Qadri, Syeda S.; Bliss, Linda A.; Roos, Bernard A.; Ruiz, Jorge G.
A total of 8 geriatric medicine fellows participated in an objective structured clinical examination (OSCE) assessing communication skills and clinical reasoning in common geriatric syndromes. To determine their perceptions about the experience, we conducted surveys and semistructured interviews. We analyzed the survey data using descriptive…
Whitley, Heather P.
Purpose: To quantify the monetary value of medications provided to rural Alabamians through provision of pharmaceutical manufacturer-sponsored prescription assistance programs (PAPs) provided by a clinical pharmacist in a private Black Belt family medicine clinic during 2007 and 2008. Methods: Patients struggling to afford prescription medications…
Rohrer, James E; Angstman, Kurt B; Garrison, Gregory M; Maxson, Julie A; Furst, Joseph W
The purpose of this study was to compare continuity of care for family medicine patients using retail medicine clinics to continuity for patients not using retail clinics. Retail medicine clinics have become popular in some markets. However, their impact on continuity of care has not been studied. Electronic medical records of adult primary care patients seen in a large group practice in Minnesota in 2011 were analyzed for this study. Two randomly chosen groups of patients were selected (N = 400): those using 1 of 3 retail walk-in clinics staffed by nurse practitioners in addition to standard office care and a comparison group that only used standard office care. Continuity was measured as the percentage of visits that involved the primary care provider. We also compared patients who made zero visits to their primary care providers with those who made some visits to their primary care providers. Continuity of care was lower for patients who used retail clinics than for patients who did not use retail clinics (0.17 vs 0.44, mean difference 0.27). The percentage of patients who made zero visits to their primary care providers was 54.5 for users of retail clinics versus 31.0 for those who did not use retail clinics. Continuity of care should be monitored as retail medicine continues to expand.
Yeung, Rebecca; Wong, Kam-Hung; Yuen, Kwok-Keung; Wong, Ka-Yan; Yau, Yvonne; Lo, Sing-Hung; Liu, Rico
The importance of early integration of palliative care (PC) into oncology treatment is increasingly being recognized. However, there is no consensus on what is the optimal way of integration. This article describes a unique model in Hong Kong where clinical oncology and palliative medicine (PM) is integrated through the development of PM as a subspecialty under clinical oncology.
Whitley, Heather P.
Purpose: To quantify the monetary value of medications provided to rural Alabamians through provision of pharmaceutical manufacturer-sponsored prescription assistance programs (PAPs) provided by a clinical pharmacist in a private Black Belt family medicine clinic during 2007 and 2008. Methods: Patients struggling to afford prescription medications…
Jiang, Jun-jie; Xie, Yan-ming
In order to ensure the authenticity and accuracy of traditional Chinese medicine injection safety monitoring data, Chinese medicine injection safety monitoring quality control indicators, including the monitoring center, monitoring personnel, hardware conditions, monitoring progress and the number of patients into the group, original documents and archives management, electronic data, adverse events, quality management were constructed. Its application in the creation of major new drugs technology major projects, 10 kinds of traditional Chinese medicine injections clinical safety monitoring quality control work, found the missing case surveillance, not reported adverse events, only reported adverse reactions, electronic data reporting lag, lack of level of efforts to control the problem, and corrected, the traditional Chinese medicine injection safety monitoring of quality control and quality assurance, and subsequent Chinese medicine safety monitoring quality control to provide the reference.
Stoller, James K
The Cleveland Clinic is a large healthcare system based in Cleveland, Ohio (USA) with an extensive American (throughout Northeast Ohio; Weston, Florida; and Las Vegas, Nevada) and global presence (in Abu Dhabi, UAE; and with training alumni in >70 countries). Cleveland Clinic was founded in 1921 as a distinctive medical model with a tripartite mission of "better care of the sick, investigation of their problems, and more teaching of those who serve" which has been vibrantly maintained. Distinctive aspects of the Clinic include its being a closed staff, salaried, group practice which is physician-led and which features 1-year faculty appointments and a vigorous annual review process for all physicians and leaders. Regarding its tripartite mission, the Clinic has demonstrated longstanding clinical excellence, e.g., with consistent ranking as first in cardiovascular care in U.S. News and World Report and top-10 rankings in at least 12 other specialties. A longstanding tradition of research has contributed landmark discoveries, including performance of the first coronary revascularization procedure, the first intra-coronary angiogram, the world's third face transplant, ongoing development of a breast cancer vaccine, etc. Regarding education, the Clinic serves many educational audiences excellently through its Education Institute. These audiences include medical students, graduate medical trainees, faculty physicians, nurses, and allied health providers (both within the Cleveland Clinic and from other institutions worldwide), and patients. The Education Institute also includes the Cleveland Clinic Academy, which offers training in leadership competencies to physicians, nurses, and healthcare administrators both within the Cleveland Clinic and to visitors from abroad (through the Executive Visitors Program and the Samson Global Leadership Academy for Healthcare Executives). The latter program is an intensive 2-week residential leadership development course for emerging
Xie, Yanming; Wang, Yanping; Tian, Feng; Wang, Yongyan
As information on safety and effectiveness is not comprehensive, gained from the researches for listing approval of Chinese medicine, it is very necessary to conduct post-marketing clinical re-evaluation of Chinese medicine. Effectiveness, safety and economic evaluation are three main aspects of post-marketing clinical re-evaluation. In this paper, the difference and relations between the post-marketing clinical re-evaluation and the phase IV clinical trials were discussed, and the basic requests and suggestions were proposed, according to the domestic and foreign relevant regulations and experts' suggestions, and discussed the requirements of the phase IV clinical trials on indications, design methods, inclusion and exclusion criteria, sample size, etc.
Ozeki, Mitsuru; Shioya, Kana; Furuta, Koh
Recent advances in pharmacology and molecular sciences made it possible to develop drugs for patients with various maladies. Frustration has existed concerning the delayed provision of these drugs for routine practices in the clinical field. To correct this problem, the importance of clinical trials is increasing. Although there exists a strong demand for participation of clinical laboratories in clinical trials, an awkward attitude in clinical laboratories frustrates those performing clinical trials. We are attempting to correct this problem by introducing our experience with harmonization procedures directed toward clinical trials in laboratory medicine in general. First we described the current status of clinical trials in our hospital. Then we will show personnel in need for clinical trials. Finally we describe in detail our clinical trial procedures. We focus particularly on three aspects of participation in clinical trials: pre-analytical, analytical, and post analytical. Additionally we describe the problems and perspectives in clinical trials by giving special reference to the clinical laboratories in general through discussion with various personnel and specialists. Our goal in the field of laboratory medicine is to benefit patients through the establishment of a harmony between clinical trials and clinical laboratories.
Haji, Darsim L; Royse, Alistair; Royse, Colin F
There is increased realisation of the emerging role of point-of-care transthoracic echocardiography (TTE) as 'ultrasound-assisted examination', given the low sensitivity of clinical examination for cardiovascular pathologies and the time-critical nature of these pathologies. There is evidence that point-of-care TTE provides higher accuracy in patient assessment and management, with potential prognostic impact by assessing the severity of cardiac dysfunction and response to treatment. Point-of-care TTE is increasingly used by non-cardiologists, as a diagnostic, screening or monitoring tool. The literature shows that TTE identifies new clinical findings, and conversely can accurately rule out clinically important pathologies. Recent reports have examined more advanced ultrasound devices and patients in the critical care settings of emergency medicine, intensive care and anaesthesia. The diagnostic capability of new portable devices is improving rapidly and outdating its predecessors, thereby improving confidence in echocardiography findings.
Paul, Anna; Cramer, Holger; Lauche, Romy; Altner, Nils; Langhorst, Jost; Dobos, Gustav J
Cancer diagnosis and treatment are often associated with physical and psychosocial impairments. Many cancer patients request complementary and alternative therapies such as mind-body medicine. The department of internal and integrative medicine at the Essen-Mitte Clinics offer a mind-body medicine day care clinic for cancer patients that is based on the Mindfulness-Based Stress Reduction Program and the mind-body medicine cancer program of the Harvard Mind/Body Medical Institute. The program encompasses mindfulness training, yoga, mindful exercise, nutrition, naturopathic self-help strategies, and cognitive restructuring. Two patients who had participated in the day care clinic program are presented here. One patient presented with anxiety and depression after recently diagnosed breast cancer and the other with psychological impairments as a result of multiple nevi excision after malignant melanoma surgery. Both patients improved in terms of anxiety and further psychological symptoms. The Essen-Mitte Clinics mind-body medicine day care clinic appears to alleviate psychological consequences of cancer and its treatment. Further studies and randomized controlled trials are necessary to confirm these results.
Williams, Bryan L. Barr, Dana B.; Wright, J. Michael; Buckley, Brian; Magsumbol, Melina S.
Biomonitoring has become a fundamental tool in both exposure science and clinical medicine. Despite significant analytical advances, the clinical use of environmental biomarkers remains in its infancy. Clinical use of environmental biomarkers poses some complex scientific and ethical challenges. The purpose of this paper is compare how the clinical and exposure sciences differ with respect to their interpretation and use of biological data. Additionally, the clinical use of environmental biomonitoring data is discussed. A case study is used to illustrate the complexities of conducting biomonitoring research on highly vulnerable populations in a clinical setting.
Williams, Bryan L; Barr, Dana B; Wright, J Michael; Buckley, Brian; Magsumbol, Melina S
Biomonitoring has become a fundamental tool in both exposure science and clinical medicine. Despite significant analytical advances, the clinical use of environmental biomarkers remains in its infancy. Clinical use of environmental biomarkers poses some complex scientific and ethical challenges. The purpose of this paper is compare how the clinical and exposure sciences differ with respect to their interpretation and use of biological data. Additionally, the clinical use of environmental biomonitoring data is discussed. A case study is used to illustrate the complexities of conducting biomonitoring research on highly vulnerable populations in a clinical setting.
Wolff, Margaret; Carney, Michele; Eldridge, Charles; Zaveri, Pavan; Kou, Maybelle
This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the skills beyond clinical training required of pediatric emergency medicine physicians including teaching, leadership, teamwork, and communication.
Fu, Yingkun; Xie, Yanming
In recent years, as the Chinese government and people pay more attention on the post-marketing research of Chinese Medicine, part of traditional Chinese medicine breed has or is about to begin after the listing of post-marketing evaluation study. In the post-marketing evaluation design, sample size calculation plays a decisive role. It not only ensures the accuracy and reliability of post-marketing evaluation. but also assures that the intended trials will have a desired power for correctly detecting a clinically meaningful difference of different medicine under study if such a difference truly exists. Up to now, there is no systemic method of sample size calculation in view of the traditional Chinese medicine. In this paper, according to the basic method of sample size calculation and the characteristic of the traditional Chinese medicine clinical evaluation, the sample size calculation methods of the Chinese medicine efficacy and safety are discussed respectively. We hope the paper would be beneficial to medical researchers, and pharmaceutical scientists who are engaged in the areas of Chinese medicine research.
Li, Xin-Xue; Han, Mei; Wang, Yu-Yi; Liu, Jian-Ping
Patients with gout referring to Chinese herbal medicine are not rare in China, and a great number of clinical trials on herbal medicine have been published. However, there has not been a systematic review to summarize the evidence of Chinese herbal medicine for gout. The aim of this study is to evaluate the evidence for the effectiveness and safety of Chinese herbal medicine for gout. We searched for randomized clinical trials on Chinese herbal medicine for gout till December 2012. Cochrane risk of bias tool was used to assess the methodological quality. RevMan 5.2 was used to synthesize the results. We included 57 trials involving 4,527 gout patients. The quality of trials was generally poor. No trial reported health-related quality of life in patients. There is not enough evidence showing that herbal medicine was statistically more effective than conventional medications in pain relief [mean difference (MD), -0.03; 95% confidence interval (CI), -0.06, 0.00], but herbal medicine combined with conventional medicines may have better effectiveness (MD, -0.33; 95% CI, -0.59, -0.07). Trials that reported function limitation relief found herbal medicine more effective than conventional medications (MD, -0.23; 95% CI, -0.32, -0.15). There was no evidence showing that herbal medicine prevents gout recurrence better. Twenty-five out of 41 trials, involving 23 different herbal prescriptions, found statistical significance in lowering serum uric acid level, and the overall effect from Chinese herbal medicine in inflammation relief is better than conventional therapies in 19 trials with 17 different prescriptions. The current data show that herbal medicine leads to fewer side reactions compared to conventional therapies [risk ratio (RR), 0.11; 95% CI, 0.08 to 0.15]. Chinese herbal medicine may have clinical effectiveness for functional recovery in patients with gout, and lead to a safe control of serum uric acid level and inflammation severity. Due to low quality of trials
Kenney, Daniel; Jenkins, Sarah; Youssef, Paul; Kotagal, Suresh
This article describes the use of complementary and alternative medicines in an outpatient pediatric neurology clinic, and assesses family attitudes toward the efficacy of complementary and alternative medicines versus prescription medications. Complementary and alternative medicine is an important element of the modern health care landscape. There is limited information about whether, and to what extent, families perceive its utility in childhood neurological disorders. Surveys were distributed to 500 consecutive patients at a child neurology clinic in Rochester, Minnesota. Questions pertained to the child's diagnoses, use of complementary and alternative medicines, and the specific complementary and alternative medicine modalities that were used. Opinions were also gathered on the perceived efficacy of complementary and alternative medicines and prescription medications. Data were compared using χ(2) or Fisher exact tests as indicated. A total of 484 surveys were returned, of which 327 were usable. Only 17.4% admitted to use of complementary and alternative medicine to treat neurological problems. However, in follow-up questioning, actually 41.6% of patients recognized that they were using one or more types of complementary and alternative medicines. Disorders associated with a statistically significant increased prevalence of complementary and alternative medicine use were headache (50.8% with headache used complementary and alternative medicine versus 35.7% without headache; P = 0.008, Fisher exact test), chronic fatigue (63.2% vs 38.8%; P = 0.005, Fisher exact test), and sleep disorders (77.1% vs 37.3%; P < 0.0001, Fisher exact test). A large proportion of pediatric neurology patients in our clinic are also using complementary and alternative medicine. Only 38.5% of these recognize themselves as using complementary and alternative medicine, underlining the need to inquire in-depth about its use. Patients who are less satisfied with their prescription
Weng, C; Kahn, M G
To reflect on the notable events and significant developments in Clinical Research Informatics (CRI) in the year of 2015 and discuss near-term trends impacting CRI. We selected key publications that highlight not only important recent advances in CRI but also notable events likely to have significant impact on CRI activities over the next few years or longer, and consulted the discussions in relevant scientific communities and an online living textbook for modern clinical trials. We also related the new concepts with old problems to improve the continuity of CRI research. The highlights in CRI in 2015 include the growing adoption of electronic health records (EHR), the rapid development of regional, national, and global clinical data research networks for using EHR data to integrate scalable clinical research with clinical care and generate robust medical evidence. Data quality, integration, and fusion, data access by researchers, study transparency, results reproducibility, and infrastructure sustainability are persistent challenges. The advances in Big Data Analytics and Internet technologies together with the engagement of citizens in sciences are shaping the global clinical research enterprise, which is getting more open and increasingly stakeholder-centered, where stakeholders include patients, clinicians, researchers, and sponsors.
Ferwana, Mazen; Al Alwan, Ibrahim; Moamary, Mohamed A.; Magzoub, Mohi E.; Tamim, Hani M.
Teaching Evidence Based Medicine (EBM) helps medical students to develop their decision making skills based on current best evidence, especially when it is taught in a clinical context. Few medical schools integrate Evidence Based Medicine into undergraduate curriculum, and those who do so, do it at the academic years only as a standalone (classroom) teaching but not at the clinical years. The College of Medicine at King Saud bin Abdulaziz University for Health Sciences was established in January 2004. The college adopted a four-year Problem Based Learning web-based curriculum. The objective of this paper is to present our experience in the integration of the EBM in the clinical phase of the medical curriculum. We teach EBM in 3 steps: first step is teaching EBM concepts and principles, second is teaching the appraisal and search skills, and the last step is teaching it in clinical rotations. Teaching EBM at clinical years consists of 4 student-centered tutorials. In conclusion, EBM may be taught in a systematic, patient centered approach at clinical rounds. This paper could serve as a model of Evidence Based Medicine integration into the clinical phase of a medical curriculum. PMID:22870419
Correale, Jorge; Chiquete, Erwin; Boyko, Alexey; Beran, Roy G; Strauch, Jorge Barahona; Milojevic, Snezana; Frider, Nadina
Both proprietary and nonproprietary medicines are expected to undergo rigorous preapproval testing and both should meet stringent health authority regulatory requirements related to quality to obtain approval. Nonproprietary (also known as copy, or generic) medicines, which base their authorization and use on the proprietary documentation and label, are often viewed as a means to help lower the cost and, thus, increase patient access. If these medicines fail to meet quality standards, such as good manufacturing practice and bioequivalence (in humans), they are then defined as substandard copies and can pose serious risks to patients in terms of safety and efficacy. Potentially noncontrolled or different manufacturing process and excipients in nonproprietary medicines may result in poor batch-to-batch reproducibility (accurate and consistent quantity of each ingredient in each capsule/tablet) and lower quality. Substandard, nonproprietary copies of medicines that are immunomodulatory or immunosuppressive are of concern to patients due to their possible untoward safety and lack of efficacy events. This article reviews the potential risks associated with nonproprietary medicines that do not meet the regulatory requirements of the United States Food and Drug Administration, the European Medicines Agency, or the World Health Organization. The clinical implications for patients are described. This article focuses on nonproprietary medicines for multiple sclerosis, particularly fingolimod, that are not identical to proprietary versions and could thus fail to meet efficacy expectations or have different impact on the safety of patients with multiple sclerosis. PMID:27418809
Su, Chun-Xiang; Wang, Li-Qiong; Grant, Suzanne J; Liu, Jian-Ping
To assess the effectiveness and safety of Chinese herbal medicine for the treatment of cancer-related fatigue. We systematically searched seven electronic databases and two trial registries for randomized clinical trials of Chinese herbal medicine for cancer-related fatigue. Two authors independently extracted data and assessed the methodological quality of the included trials using the Cochrane risk of bias tool. Data were synthesized using RevMan 5.2 software. A total of 10 trials involving 751 participants with cancer-related fatigue were identified and the methodological quality of the included trials was generally poor. Chinese herbal medicine used alone or in combination with chemotherapy or supportive care showed significant relief in cancer-related fatigue compared to placebo, chemotherapy or supportive care based on single trials. Chinese herbal medicine plus chemotherapy or supportive care was superior to chemotherapy or supportive care in improving quality of life. Data from one trial demonstrated Chinese herbal medicine exerted a greater beneficial effect on relieving anxiety but no difference in alleviating depression. Seven trials reported adverse events and no severe adverse effects were found in Chinese herbal medicine groups. The findings from limited number of trials suggest that Chinese herbal medicine seems to be effective and safe in the treatment of cancer-related fatigue. However, the current evidence is insufficient to draw a confirmative conclusion due to the poor methodological quality of included trials. Thus, conducting rigorously designed trials on potential Chinese herbal medicine is warranted. Copyright © 2014 Elsevier Ltd. All rights reserved.
Correale, Jorge; Chiquete, Erwin; Boyko, Alexey; Beran, Roy G; Strauch, Jorge Barahona; Milojevic, Snezana; Frider, Nadina
Both proprietary and nonproprietary medicines are expected to undergo rigorous preapproval testing and both should meet stringent health authority regulatory requirements related to quality to obtain approval. Nonproprietary (also known as copy, or generic) medicines, which base their authorization and use on the proprietary documentation and label, are often viewed as a means to help lower the cost and, thus, increase patient access. If these medicines fail to meet quality standards, such as good manufacturing practice and bioequivalence (in humans), they are then defined as substandard copies and can pose serious risks to patients in terms of safety and efficacy. Potentially noncontrolled or different manufacturing process and excipients in nonproprietary medicines may result in poor batch-to-batch reproducibility (accurate and consistent quantity of each ingredient in each capsule/tablet) and lower quality. Substandard, nonproprietary copies of medicines that are immunomodulatory or immunosuppressive are of concern to patients due to their possible untoward safety and lack of efficacy events. This article reviews the potential risks associated with nonproprietary medicines that do not meet the regulatory requirements of the United States Food and Drug Administration, the European Medicines Agency, or the World Health Organization. The clinical implications for patients are described. This article focuses on nonproprietary medicines for multiple sclerosis, particularly fingolimod, that are not identical to proprietary versions and could thus fail to meet efficacy expectations or have different impact on the safety of patients with multiple sclerosis.
Spitzer, E D; Pierce, G F; McDonald, J M
We describe a laboratory medicine residency training program that includes ongoing interaction with both clinical laboratories and clinical services as well as significant research experience. Laboratory medicine residents serve as on-call consultants in the interpretation of test results, design of testing strategies, and assurance of test quality. The consultative on-call beeper system was evaluated and is presented as an effective method of clinical pathology training that is well accepted by the clinical staff. The research component of the residency program is also described. Together, these components provide training in real-time clinical problem solving and prepare residents for the changing technological environment of the clinical laboratory. At the completion of the residency, the majority of the residents are qualified laboratory subspecialists and are also capable of running an independent research program.
Wardle, Jonathan Lee; Sarris, Jerome
Complementary medicine is forming an increasingly large part of health care in developed countries and is increasingly being formally taught in tertiary academic settings. An exploratory study of naturopathic student perceptions of, use of and attitudes towards teaching resources in naturopathic clinical training and education. Focus groups were conducted with current and recent students of 4-year naturopathic degree programmes in Brisbane and Sydney to ascertain how they interact with clinical teaching materials, and their perceptions and attitudes towards teaching materials in naturopathic education. Naturopathic students have a complex and critical relationship with their learning materials. Although naturopathic practice is often defined by traditional evidence, students want information that both supports and is critical of traditional naturopathic practices, and focuses heavily on evidence-based medicine. Students remain largely ambivalent about new teaching technologies and would prefer that these develop organically as an evolution from printed materials, rather than depart from dramatically and radically from these previously established materials. Findings from this study will assist publishers, librarians and academics develop clinical information sources that appropriately meet student expectations and support their learning requirements. © 2014 The authors. Health Information and Libraries Journal © 2014 Health Libraries Group.
Peleg, Roni; Liberman, Orly; Press, Yan; Shvartzman, Pesach
Pain is one of the most common reasons for seeking medical care. The purpose of this study was to characterize patients visiting the complementary medicine clinic for a pain complaint. This is a cross-sectional study. The study took place at Clalit Health Services (CHS) complementary clinic in Beer-Sheva, Israel. Patients visiting the complementary clinic, aged 18 years old and older, Hebrew speakers, with a main complaint of pain were included. Patients were recruited consecutively on random days of the month during a period of six months. Main outcome measures were: pain levels, location of pain, and interference with daily activities. Once informed consent was signed patients were interviewed using a structured questionnaire by a qualified nurse. The questionnaire included socio-demographic data, and the Brief Pain Inventory (BPI). Three-hundred and ninety-five patients were seen at the complementary medicine clinic during the study period, 201 (50.8%) of them met the inclusion criteria. Of them, 163 (81.1%) agreed to participate in the study and were interviewed. Pain complaints included: 69 patients (46.6%) with back pain, 65 (43.9%) knee pain, and 28 (32.4%) other limbs pain. Eighty-two patients (50.3%) treated their pain with complementary medicine as a supplement for their conventional treatment, and 55 (33.7%) felt disappointed from the conventional medicine experience. Eighty-three patients (50.9%) claimed that complementary medicine can result in better physical strength, or better mental state 51 (31.3%). Thirty-seven patients (22.7%) were hoping that complementary medicine will prevent invasive procedures. Given the high proportion of patients with unsatisfactory pain relief using complementary and alternative medicine (CAM), general practitioners should gain knowledge about CAM and CAM providers should gain training in pain topics to improve communication and counsel patients. More clinical research to evaluate safety and efficiency of CAM for pain is
Low, Wah Yun; Ng, Kwan Hoong; Kabir, M A; Koh, Ai Peng; Sinnasamy, Janaki
Research collaboration is the way forward in order to improve quality and impact of its research findings. International research collaboration has resulted in international co-authorship in scientific communications and publications. This study highlights the collaborating research and authorship trend in clinical medicine in Malaysia from 2001 to 2010. Malaysian-based author affiliation in the Web of Science (Science Citation Index Expanded) and clinical medicine journals (n = 999) and articles (n = 3951) as of 30th Oct 2011 were downloaded. Types of document analyzed were articles and reviews, and impact factors (IF) in the 2010 Journal Citation Report Science Edition were taken to access the quality of the articles. The number of publications in clinical medicine increased from 4.5 % (n = 178) in 2001 to 23.9 % (n = 944) in 2010. The top three contributors in the subject categories are Pharmacology and Pharmacy (13.9 %), General and Internal Medicine (13.6 %) and Tropical Medicine (7.3 %). By journal tier system: Tier 1 (18.7 %, n = 738), Tier 2 (22.5 %, n = 888), Tier 3 (29.6 %, n = 1170), Tier 4 (27.2 %, n = 1074), and journals without IF (2.1 %, n = 81). University of Malaya was the most productive. Local collaborators accounted for 60.3 % and international collaborations 39.7 %. Articles with international collaborations appeared in journals with higher journal IFs than those without international collaboration. They were also cited more significantly than articles without international collaborations. Citations, impact factor and journal tiers were significantly associated with international collaboration in Malaysia's clinical medicine publications. Malaysia has achieved a significant number of ISI publications in clinical medicine participation in international collaboration.
Mittiga, Matthew R; Nagler, Joshua; Eldridge, Charles D; Ishimine, Paul; Zuckerbraun, Noel S; McAneney, Constance M
This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the clinical aspects of fellowship training including the impact of the clinical environment, modalities for teaching and evaluation, and threats and opportunities in clinical education.
Casas-Patiño, Donovan; Rodríguez-Torres, Alejandra; Reséndiz-Rivera, Sergio; Rivera-Villa, Adrián; Trejo-Carvajal, Hugo; Mújica-Terán, Alejandra; Vargas-Badillo, Marie Jezreel
A case of Klippel-Feil syndrome in a female nine years is informed. The patient presented a clinical picture compatible with Klippel-Feil syndrome: short neck with joint movements diminished and low hair implantation. We showed the diagnostics and treatment approach at the primary medicine level, the follow-up until the presence of clinical manifestations of the main clinical problems associated. The liver, cardiovascular, audiology, and muscle-bones are describe and finally some aspects of her physical rehabilitation.
Over the last two years, a special field named the "Medicine for Children" has been intensively developed. It is particularly significant for professionals, parents, but also for politicians and high-level officials of the European Union and its constitutive institutions: the European Health Commission and the European Council. The main idea is to make a drastic change in the attitude toward children, as the most vulnerable members of the society, namely to create the "Medicine for Children" instead of the "Medicine in Children". This short report presents the draft and ideas of the new European legislation on the application of drugs for children, performance of clinical studies in paediatric population and mandatory inclusion into the international network of scientific experts, clinical centres capable of performing studies and the already completed or ongoing clinical study registers.
Shumer, Gregory; Warber, Sara; Motohara, Satoko; Yajima, Ayaka; Plegue, Melissa; Bialko, Matthew; Iida, Tomoko; Sano, Kiyoshi; Amenomori, Masaki; Tsuda, Tsukasa; Fetters, Michael D
There is growing interest in the use of complementary and alternative medicine (CAM) throughout the world, however previous research done in Japan has focused primarily on CAM use in major cities. The purpose of this study was to develop and distribute a Japanese version of the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q) to assess the use of CAM among people who visit rural Japanese family medicine clinics. Using a Japanese version of the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q), a cross-sectional survey was conducted in three rural family medicine clinics. All patients and those accompanying patients who met inclusion criteria were eligible to participate. Data were entered into SPSS Statistics and analyzed for use by age, gender, and location. Of the 519 respondents who participated in the project, 415 participants reported CAM use in the past 12 months (80.0%). When prayer is excluded, the prevalence of CAM use drops to 77.3% in the past year, or 403 respondents. The most common forms of CAM used by respondents were pain relief pads (n = 170, 32.8%), herbal medicines/supplements (n = 167, 32.2%), and massage by self or family (n = 166, 32.0%). Female respondents, individuals with higher levels of education, and those with poorer overall health status were more likely to use CAM than respondents without these characteristics. Only 22.8% of CAM therapies used were reported to physicians by survey participants. These data indicate that CAM use in rural Japan is common. The results are consistent with previous studies that show that Japanese individuals are more interested in forms of CAM such as pain relief pads and massage, than in mind-body forms of CAM like relaxation and meditation. Due to the high utilization of certain CAM practices, and given that most CAM users do not disclose their CAM use to their doctors, we conclude that physicians in rural Japan would benefit by asking about CAM use
Levy, Barcey T; Merchant, Mary L
Educators should document students' clinical skills experience and whether curriculum and other course changes impact this experience. We wanted to determine the factors associated with students' clinical skills experience during their third-year family medicine preceptorship. We conducted an observational study of 1,419 third-year students at the University of Iowa taking a required family medicine preceptorship during 9 academic years: 1994-1995 to 2002-2003. Students rated their level of experience with 57 clinical skills on a 5-point scale. Student ratings were summed to obtain scores for total clinical skills (n=57), procedural skills (n=22), and female-specific skills (n=9). Students who completed their preceptorship in rural areas (as opposed to urban areas or in a residency), prior to the implementation of Centers for Medicare and Medicaid Services regulations, prior to integration with ambulatory internal medicine and community-based primary care, or who rotated during the second half of the academic year reported a higher mean level of experience with clinical skills in univariate and multivariate analyses. Both years of experience as a preceptor and total number of previous students taught were positively associated with students' total clinical skills scores. In addition, several preceptor teaching qualities were significantly and positively associated with overall skills experience: opportunity for clinical procedures, delegation of appropriate responsibility, and preceptor conveyed expectations clearly. Use of a consistent clinical skills checklist allowed us to document important effects of curriculum, legislation, and preceptor teaching qualities on the students' clinical skills experience.
Zheng, Wen-ke; Liu, Zhi; Lei, Xiang; Tian, Ran; Zheng, Rui; Li, Nan; Ren, Jing-tian; Du, Xiao-xi; Shang, Hong-cai
The safety of Chinese patent medicine has become a focus of social. It is necessary to carry out work on post-marketing clinical safety evaluation for Chinese patent medicine. However, there have no criterions to guide the related research, it is urgent to set up a model and method to guide the practice for related research. According to a series of clinical research, we put forward some views, which contained clear and definite the objective and content of clinical safety evaluation, the work flow should be determined, make a list of items for safety evaluation project, and put forward the three level classification of risk control. We set up a model of post-marketing clinical safety evaluation for Chinese patent medicine. Based this model, the list of items can be used for ranking medicine risks, and then take steps for different risks, aims to lower the app:ds:risksrisk level. At last, the medicine can be managed by five steps in sequence. The five steps are, collect risk signal, risk recognition, risk assessment, risk management, and aftereffect assessment. We hope to provide new ideas for the future research.
Bowdin, S C; Hayeems, R Z; Monfared, N; Cohn, R D; Meyn, M S
Our increasing knowledge of how genomic variants affect human health and the falling costs of whole-genome sequencing are driving the development of individualized genomic medicine. This new clinical paradigm uses knowledge of an individual's genomic variants to anticipate, diagnose and manage disease. While individualized genetic medicine offers the promise of transformative change in health care, it forces us to reconsider existing ethical, scientific and clinical paradigms. The potential benefits of pre-symptomatic identification of at-risk individuals, improved diagnostics, individualized therapy, accurate prognosis and avoidance of adverse drug reactions coexist with the potential risks of uninterpretable results, psychological harm, outmoded counseling models and increased health care costs. Here we review the challenges, opportunities and limits of integrating genomic analysis into pediatric clinical practice and describe a model for implementing individualized genomic medicine. Our multidisciplinary team of bioinformaticians, health economists, health services and policy researchers, ethicists, geneticists, genetic counselors and clinicians has designed a 'Genome Clinic' research project that addresses multiple challenges in pediatric genomic medicine--ranging from development of bioinformatics tools for the clinical assessment of genomic variants and the discovery of disease genes to health policy inquiries, assessment of clinical care models, patient preference and the ethics of consent. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Lewis, Richard; Rosen, Rebecca
Close relationships between business managers and clinicians, and purchaser and provider, are valuable in chronic-disease management. Organisations used high-quality clinical information and performance management. Chronic-disease management based on risk-management, proactive case managers and patient education is effective.
Nelson, Caleb P; Johnson, Emilie K; Logvinenko, Tanya; Chow, Jeanne S
The 2011 American Academy of Pediatrics guidelines state that renal and bladder ultrasound (RBUS) should be performed after initial febrile urinary tract infection (UTI) in a young child, with voiding cystourethrogram (VCUG) performed only if RBUS shows abnormalities. We sought to determine test characteristics and predictive values of RBUS for VCUG findings in this setting. We analyzed 3995 clinical encounters from January 1, 2006 to December 31, 2010 during which VCUG and RBUS were performed for history of UTI. Patients who had previous postnatal genitourinary imaging or history of prenatal hydronephrosis were excluded. Sensitivity, specificity, and predictive values of RBUS for VCUG abnormalities were determined. We identified 2259 patients age <60 months who had UTI as the indication for imaging. RBUS was reported as "normal" in 75%. On VCUG, any vesicoureteral reflux (VUR) was identified in 41.7%, VUR grade >II in 20.9%, and VUR grade >III in 2.8%. Sensitivity of RBUS for any abnormal findings on VCUG ranged from 5% (specificity: 97%) to 28% (specificity: 77%). Sensitivity for VUR grade >III ranged from 18% (specificity: 97%) to 55% (specificity: 77%). Among the 1203 children aged 2 to 24 months imaged after a first febrile UTI, positive predictive value of RBUS was 37% to 47% for VUR grade >II (13% to 24% for VUR grade >III); negative predictive value was 72% to 74% for VUR grade >II (95% to 96% for VUR grade >III). RBUS is a poor screening test for genitourinary abnormalities. RBUS and VCUG should be considered complementary as they provide important, but different, information.
Gallagher, Lisa M; Lagman, Ruth; Walsh, Declan; Davis, Mellar P; Legrand, Susan B
This study was to objectively assess the effect of music therapy on patients with advanced disease. Two hundred patients with chronic and/or advanced illnesses were prospectively evaluated. The effects of music therapy on these patients are reported. Visual analog scales, the Happy/Sad Faces Assessment Tool, and a behavior scale recorded pre- and post-music therapy scores on standardized data collection forms. A computerized database was used to collect and analyze the data. Utilizing the Wilcoxon signed rank test and a paired t test, music therapy improved anxiety, body movement, facial expression, mood, pain, shortness of breath, and verbalizations. Sessions with family members were also evaluated, and music therapy improved families' facial expressions, mood, and verbalizations. All improvements were statistically significant (P<0.001). Most patients and families had a positive subjective and objective response to music therapy. Objective data were obtained for a large number of patients with advanced disease. This is a significant addition to the quantitative literature on music therapy in this unique patient population. Our results suggest that music therapy is invaluable in palliative medicine.
Ventegodt, Søren; Kandel, Isack; Neikrug, Shimshon; Merric, Joav
Studies indicate that at least 15% of the female population in western countries has experienced sexual abuse and severe sexual traumas. This paper explains how even serious sexual abuse and trauma can be healed when care and resources encourage the patient to return to the painful life events. When the physician cares and receives the trust of the patient, emotional holding and processing will follow quite naturally. Spontaneous regression seems to be an almost pain-free way of integrating the severe traumas from earlier experiences of rape and incest. This technique is a recommended alternative to classical timeline therapy using therapeutic commands. When traumatized patients distance themselves from their soul (feelings, sexuality, and existential depth), they often lose their energy and enjoyment of life. However, this does not mean that they are lost to life. Although it may seem paradoxical, a severe trauma may be a unique opportunity to regain enjoyment of life. The patient will often be richly rewarded for the extensive work of clearing and sorting out in order to experience a new depth in his or her existence and emotional life, with a new ability to understand life in general and other people in particular. So what may look like a tragedy can be transformed into a unique gift; if the patient gets sufficient support, there is the possibility of healing and learning. Consciousness-based medicine seems to provide severely traumatized patients with the quality of support and care needed for their soul to heal.
Antonucci, R; Atzori, L; Barberini, L; Fanos, V
Metabolomics is a new approach based on the systematic study of the full complement of metabolites in a biological sample. This technology consists of two sequential steps: (1) an experimental technique, based on mass spectrometry or nuclear magnetic resonance (NMR) spectroscopy, designed to profile low molecular weight compounds, and (2) multivariate data analysis. Metabolomic analysis of biofluids or tissues has been successfully used in the fields of physiology, diagnostics, functional genomics, pharmacology, toxicology and nutrition. Recent studies have evaluated how physiological variables or pathological conditions can affect metabolomic profiles of different biofluids in pediatric populations. Little is known about the overall metabolic status of the term and preterm neonate. On the other hand, the management of sick or preterm newborns might be improved if more information on perinatal/neonatal maturational processes and their metabolic background were available. At present, the use of metabolomics in Neonatology is still in the pioneering phase. Meaningful diagnostic information and simple, non-invasive collection techniques make urine a particularly suitable biofluid for metabolomic approach in neonatal medicine. Using NMR-based metabolomic analysis of urine, distinct metabolic patterns have been shown to be associated with different classes of gestational age in a population of preterm and term infants. Together with genomics and proteomics, metabolomics appears to be a promising tool in Neonatology for the monitoring of postnatal metabolic maturation, the identification of biomarkers as early predictors of outcome, the diagnosis and monitoring of various diseases and the "tailored" management of neonatal disorders.
Dong, He; Liu, Chuan; Dai, Chang-Jian
Aiming at the shortage of the Raman spectra of drugs and the current situation of drug testing, we have applied Raman spectroscopic technique to several kinds of medicine, such as antibiotics, antihistamine, hemocoagulase and antiemetics. The spectral properties for the samples with high Raman activity are investigated by observing their Raman spectra to yield the shift, intensity, and line width of the Raman peaks, as well as the line shape of Raman envelope. For those samples with weak Raman activity or complex structures that are hard to be identified, we have also made some tentative measurements or raise some suggestions for future measurement. Comparing the similarities or differences among many Raman spectra of drugs, it is evident that drugs with small molecule have apparent spectral characteristics, by which to recognize them is very feasible, while those with large molecule usually have weak peaks or complex envelope in their spectra, leading to a difficult recognition and uncertain peak positions. This work not only proposes to identify chemical ingredients of drugs by observing and analyzing their Raman spectra, but also provides experimental evidences for medical workers doing so. The present results lay the foundation for establish the database of Raman spectra for drugs, and point out the prospect for rapid identification and detection of drugs, promoting the application of Raman spectroscopy technology on drug detection to a certain extent.
Smith, Carolyn L.; Jarrett, Marcia; Bierer, S. Beth
For several decades, a barrier has existed between research and clinical medicine, making it difficult for aspiring scientists to gain exposure to human pathophysiology and access to clinical/translational research mentors during their graduate training. In 2005, the Howard Hughes Medical Institute announced the Med Into Grad initiative to support graduate programs that integrate clinical knowledge into PhD biomedical training, with the goal of preparing a new cadre of translational researchers to work at the interface of the basic sciences and clinical medicine. Two institutions, Baylor College of Medicine and the Cleveland Clinic/Case Western Reserve University, developed new PhD programs in translational biology and/or molecular medicine. These programs teach the topics and skills that today’s translational researchers must learn as well as expose students to clinical medicine. In this article, the authors compare and contrast the history, implementation, and evaluation of the Translational Biology and Molecular Medicine program at Baylor College of Medicine and the Molecular Medicine program at the Cleveland Clinic/Case Western Reserve University. The authors also demonstrate the feasibility of creating a multidisciplinary graduate program in molecular medicine that integrates pathophysiology and clinical medicine without extending training time. They conclude with a discussion of the similarities in training approaches that exist despite the fact that each program was independently developed and offer observations that emerged during their collaboration that may benefit others who are considering developing similar programs. PMID:23165264
Smith, Carolyn L; Jarrett, Marcia; Bierer, S Beth
For several decades, a barrier has existed between research and clinical medicine, making it difficult for aspiring scientists to gain exposure to human pathophysiology and access to clinical/translational research mentors during their graduate training. In 2005, the Howard Hughes Medical Institute announced the Med Into Grad initiative to support graduate programs that integrate clinical knowledge into PhD biomedical training, with the goal of preparing a new cadre of translational researchers to work at the interface of the basic sciences and clinical medicine. Two institutions, Baylor College of Medicine and the Cleveland Clinic/Case Western Reserve University, developed new PhD programs in translational biology and/or molecular medicine. These programs teach the topics and skills that today's translational researchers must learn and expose students to clinical medicine. In this article, the authors compare and contrast the history, implementation, and evaluation of the Translational Biology and Molecular Medicine program at Baylor College of Medicine and the Molecular Medicine program at the Cleveland Clinic/Case Western Reserve University. The authors also demonstrate the feasibility of creating a multidisciplinary graduate program in molecular medicine that integrates pathophysiology and clinical medicine without extending training time. They conclude with a discussion of the similarities in training approaches that exist despite the fact that each program was independently developed and offer observations that emerged during their collaboration that may benefit others who are considering developing similar programs.
Olson, Janet E.; Ryu, Euijung; Johnson, Kiley J.; Koenig, Barbara A.; Maschke, Karen J.; Morrisette, Jody A.; Liebow, Mark; Takahashi, Paul Y.; Fredericksen, Zachary S.; Sharma, Ruchi G.; Anderson, Kari S.; Hathcock, Matthew A.; Carnahan, Jason A.; Pathak, Jyotishman; Lindor, Noralane M.; Beebe, Timothy J.; Thibodeau, Stephen N.; Cerhan, James R.
OBJECTIVE To report the design and first three years of enrollment of the Mayo Clinic Biobank. PATIENTS AND METHODS Preparations for this Biobank began with a 4-day Deliberative Community Engagement with local residents to obtain community input into the design and governance of the biobank. Recruitment, which began in April 2009, is ongoing with a target goal of 50,000. Any Mayo Clinic patient who is 18+ years, able to consent, and a US resident is eligible to participate. Each participant completes a health history questionnaire, provides a blood sample and allows access to existing tissue specimens and all data from their Mayo Clinic medical record (EMR). A Community Advisory Board provides ongoing advice and guidance on complex decisions. RESULTS After three years of recruitment, 21,736 subjects have enrolled. Participants were 58% female, 95% of European ancestry, and median age of 62 years. Seventy-four percent lived in Minnesota, 42% from Olmsted County where the Mayo Clinic Rochester is located. The five most commonly self-reported conditions were hyperlipidemia (41%), hypertension (38%), osteoarthritis (30%), any cancer (29%), and gastroesophageal reflux disease (26%). Among self-reported cancer patients, the five most common types were non-melanoma skin cancer (14%), prostate cancer (12% in men), breast cancer (4%), melanoma (3%), and cervical cancer (2% in women). Fifty-six percent of participants had at least 15 years of EMR history. To date, over sixty projects and over 69,000 samples have been approved for use. CONCLUSION The Mayo Clinic Biobank has quickly been established as a valuable resource for researchers. PMID:24001487
Corrao, S; Arnone, G; Arnone, S; Baldari, S
Medical ethics is the science of survival. It studies the working out of judgments on right or wrong referred to the human being as a biological entity interacting with the whole ecosystem. Medical ethics in clinical research raises numerous moral and technical issues. Methodological aspects are essential for carrying out the aim of clinical research. Medical ethics documents are inspired by the Nuremberg Code and culminate in the recently updated Helsinki Declaration of 1964. In Italy 2 ministerial decrees in 1997 and 1998 laid the basis for the work of a medical ethics committee. They acknowledge the European Good Clinical Practice Guidelines and set professional needs within ethical committees. In clinical research the use of ionising radiation merits special consideration. In the recent past, serious human rights abuses in radiation experiments of the 1950s and 1960s have been found. As regards research in this field we can refer to the publication of the International Commission on Radiological Protection (ICRP) and to the report of the World Health Organisation (WHO). Legislative decree no. 187 of May 26, 2000, which transposed the 97/43/ EURATOM Directive represents the most comprehensive and recent normative reference to clinical research using ionising radiation. However, law no. 39 of March 1, 2002 is important for the partial modifications of previous decrees (art. 108 of L.D. no. 230 of March 17, 1995 and, art. 4 and attachment III of L.D. no. 187 of May 26). In this paper medical ethics, research, methodological issues and aspects of ionizing radiation are discussed.
Su, C-X; Yan, L-J; Lewith, G; Liu, J-P
Idiopathic sudden sensorineural hearing loss has great impact on quality of life. Many clinical trials using Chinese herbal medicine for idiopathic sudden sensorineural hearing loss have been conducted and reported beneficial results. However, there is no critical appraised evidence on efficacy and safety of Chinese herbal medicine for idiopathic sudden sensorineural hearing loss to inform clinical use. To assess the beneficial effect and safety of Chinese herbal medicine for idiopathic sudden sensorineural hearing loss. Systematic review of randomised clinical trials. Seven electronic databases and two trial registries were searched for all eligible trials from inception to January 2013. Two authors independently selected trials and extracted data. The Cochrane risk of bias tool was utilised to assess the methodological quality of the included trials. revman 5.2 software was applied for data analysis with effect estimate presented as risk ratio and mean difference with its 95% confidence interval. Forty-one randomised clinical trials involving 3560 participants were identified. Five kinds of Chinese herbal medicine were trialed. All trials compared conventional therapies of steroids, vasodilators, anticoagulants, nutritional supplements or hyperbaric oxygen with or without herbal medicine. No trial was identified that compared herbal medicine alone with placebo. No trial was identified that blinded the participants or the observers to their herbal medication. Only one trial adequately reported its method of randomisation. No trial reported the sample size calculated to show an effect. All trials had material other defects giving a high likelihood of bias. Because of the overall poor quality of all 41 trials, it was concluded that there was no level-one evidence to support the use of Chinese herbal medicine, alone or in addition to conventional therapies, to improve the hearing in adults with idiopathic sudden sensorineural hearing loss. Two trials reported adverse
Davies, Jamie A; Little, Melissa H; Aronow, Bruce; Armstrong, Jane; Brennan, Jane; Lloyd-MacGilp, Sue; Armit, Chris; Harding, Simon; Piu, Xinjun; Roochun, Yogmatee; Haggarty, Bernard; Houghton, Derek; Davidson, Duncan; Baldock, Richard
The Genitourinary Development Molecular Atlas Project (GUDMAP) aims to document gene expression across time and space in the developing urogenital system of the mouse, and to provide access to a variety of relevant practical and educational resources. Data come from microarray gene expression profiling (from laser-dissected and FACS-sorted samples) and in situ hybridization at both low (whole-mount) and high (section) resolutions. Data are annotated to a published, high-resolution anatomical ontology and can be accessed using a variety of search interfaces. Here, we explain how to run typical queries on the database, by gene or anatomical location, how to view data, how to perform complex queries, and how to submit data.
Ogunyemi, Ore; Rojas, A; Hematpour, K; Rogers, D; Head, C; Bennett, C
The objective of the present study is to characterize genitourinary tumors (GU) metastatic to the head and neck and to determine long-term prognoses. Using a retrospective chart review of 734 patients treated between January 1995 and May 2005 with an ICD-9 code pertaining to a metastatic head and neck cancer, we found 37 patients with primary GU tumors. There were 24 cases of prostate cancer, 10 cases of renal cell carcinoma, and 4 cases of transitional cell carcinoma. Sixteen of 24 patients (67%) with prostate cancer had a cranial metastasis while 6 of 9 (67%) patients with renal cell carcinoma had cerebral metastasis. We concluded that prolonged survival is possible in prostate cancer patients treated aggressively with radiation and chemotherapy, indicating that early detection and aggressive screening are important in these patients.
Rose, Nicole; Toews, Lorraine; Pang, Daniel S J
Clinical audit is a quality improvement process with the goal of continuously improving quality of patient care as assessed by explicit criteria. In human medicine clinical audit has become an integral and required component of the standard of care. In contrast, in veterinary medicine there appear to have been a limited number of clinical audits published, indicating that while clinical audit is recognised, its adoption in veterinary medicine is still in its infancy. A systematic review was designed to report and evaluate the veterinary literature on clinical audit in companion animal species (dog, cat, horse). A systematic search of English and French articles using Proquest Dissertations and Theses database (February 6, 2014), CAB Abstracts (March 21, 2014 and April 4, 2014), Scopus (March 21, 2014), Web of Science Citation index (March 21, 2014) and OVID Medline (March 21, 2014) was performed. Included articles were those either discussing clinical audit (such as review articles and editorials) or reporting parts of, or complete, audit cycles. The majority of articles describing clinical audit were reviews. From 89 articles identified, twenty-one articles were included and available for review. Twelve articles were reviews of clinical audit in veterinary medicine, five articles included at least one veterinary clinical audit, one thesis was identified, one report was of a veterinary clinical audit website and two articles reported incomplete clinical audits. There was no indication of an increase in the number of published clinical audits since the first report in 1998. However, there was evidence of article misclassification, with studies fulfilling the criteria of clinical audit not appropriately recognised. Quality of study design and reporting of findings varied considerably, with information missing on key components, including duration of study, changes in practice implemented between audits, development of explicit criteria and appropriate statistical
Centeno, Christopher J
The use of stem cells in orthopedics has been researched for many years, with robust animal data that show efficacy in cartilage healing, tendon repair, and intervertebral disk treatment. Early clinical data are also just starting to be published, and these results are encouraging. Safety data in large case series, some that lasted for many years, have also been published. The field of tissue engineering with stem cells in musculoskeletal impairments has the potential to reduce morbidity and improve clinical outcomes. The regulatory environment for this area of medicine is still developing. Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
Wright, William F
By the time of Hippocrates and Galen the notion of fevers and temperature were known. Through ensuing centuries, ancient Greek, Roman, and medieval savants and physicians made additional contributions to the understanding of fever, temperature, and thermometry. By the end of that era, there was a working definition of what constitutes a rationale temperature scale, the distinction between fever as a symptom and fever as a disease, an elaborate classification scheme for temperature, hypotheses as to the causes of fever, and methods for measuring fevers. Based on the definition of fever at that time, the 16th century scientist Galileo promulgated production of thermometric instruments hundreds of years before they were routinely used in the clinical setting. In this work we examine the history of fever and clinical thermometry in the ancient world through the end of the eighteenth century with descriptions of instruments for its measure and human relationship to fever.
Neville, Andrew J.; Zach, Sydney J.; Wang, Xiaofang; Larson, Joshua J.; Judge, Abigail K.; Davis, Lisa A.; Vennerstrom, Jonathan L.
Toxoplasma gondii is an apicomplexan parasite of humans and other mammals, including livestock and companion animals. While chemotherapeutic regimens, including pyrimethamine and sulfadiazine regimens, ameliorate acute or recrudescent disease such as toxoplasmic encephalitis or ocular toxoplasmosis, these drugs are often toxic to the host. Moreover, no approved options are available to treat infected women who are pregnant. Lastly, no drug regimen has shown the ability to eradicate the chronic stage of infection, which is characterized by chemoresistant intracellular cysts that persist for the life of the host. In an effort to promote additional chemotherapeutic options, we now evaluate clinically available drugs that have shown efficacy in disease models but which lack clinical case reports. Ideally, less-toxic treatments for the acute disease can be identified and developed, with an additional goal of cyst clearance from human and animal hosts. PMID:26392504
Franceschetti, Diego; Agazia, Bruno; Zanchin, Giorgio
The figure of Giovanbattista da Monte (1489-1551) is associated with the introduction of clinical teaching at the patient's beside, in 1543, at the San Francesco Hospital of Padua. In the XVI century, teaching was still based on the explanation and comment of the ancient authors and the educational programme was founded on theoretical aspects. The "practical" approach consisted of the treatment "ex cathedra" of diseases according to the various parts of the body, without observing the course of the pathological events with a direct confirmation at the patient's beside.To his merit, Da Monte established the practise of training students to gather the case history, to carry out an objective examination, and to closely examine disease phenomena with lessons at the bedside of the patient. Practical clinical training was thus introduced as the crucial moment in the formation of the physician.
Trinka, Eugen; Krämer, Günter; Graf, Martin
Many antiepileptic drugs (AEDs) are now available as a generic product. This can potentially save the healthcare providers massive costs. Hence, governmental authorities have introduced rules and incentives for clinicians to switch from the original branded AED to a generic product. Clinicians and patients with epilepsy are reluctant to switch. The licensing of generic AEDs is based on the equation that bioavailability means therapeutic equivalence. However, from a clinical standpoint one has to consider several other relevant issues: (1) Do generic AEDs have the same efficacy, safety and quality? (2) Can generic AEDs be used as substitutions for brand AEDs? (3) Can generic products of AEDs be used interchangeably? (4) Does the generic AED manufacturer guarantee the long-term consistency of availability on the market? (4) Do generic AEDs reduce the costs, and--if so--are these costs worth any additional risk to patient's safety? This article reviews the clinical issues related to current bioequivalence, prescribability, and switchability of AEDs.
Castello, Luigi M; Negro, Sophie; Santi, Francesca; Zanotti, Isabella; Vidali, Matteo; Bagnati, Marco; Bellomo, Giorgio; Avanzi, Gian Carlo
Introduction: Two Italian adults arrived at the Emergency Department referring diarrhea, nausea and vomiting for 4 days; weakness, fatigue and visual hallucinations were also complained of. Patients reported the ingestion of some leaves of a plant, which they supposed to be “donkey ears”, a week before. Physical examination showed hypotension and bradycardia and ECG examination disclosed sinus rhythm and repolarization abnormalities (scooping of the ST-T complex) in both patients and a 2:1 AV block in the man. Materials and methods: Digoxin concentration was evaluated twice for each patient (at the admission and after 4 hours) by the automated immunoassay system ADVIA Centaur®. Digitoxin concentration was evaluated by liquid chromatography-mass spectrometry (LC-MS/MS). Results: Despite clinical picture was suggestive of digitalis intoxication, digoxin levels were undetectable. Due to the more severe clinical picture, the male patient was treated with anti-digoxin antibodies (Digifab®) achieving a good clinical improvement and remission of the AV block within two hours. Initial diagnosis was confirmed by LC-MS/MS showing high digitoxin concentrations, but digoxin was undetectable. Patients remained stable and 48 hours later were discharged from the hospital. Conclusion: Whereas digoxin determination frequently relies on monoclonal antibodies which do not cross-react to digitoxin, polyclonal antibodies constituting Digifab® recognize a large spectrum of cardiac glycosides, including digitoxin. This report emphasizes the primary role of the clinical approach to patients in the emergency setting and how an active communication and a continuous sharing of professional experiences between Laboratory and Clinicians ensure an early and correct diagnosis. PMID:23092069
Parsons, Patrick J.; Barbosa, Fernando
Increasing numbers of clinical laboratories are transitioning away from flame and electrothermal AAS methods to those based on ICP-MS. Still, for many laboratories, the choice of instrumentation is based upon (a) the element(s) to be determined, (b) the matrix/matrices to be analyzed, and (c) the expected concentration(s) of the analytes in the matrix. Most clinical laboratories specialize in measuring Se, Zn, Cu, and Al in serum, and/or Pb, Cd, Hg, As, and Cr in blood and/or urine, while other trace elements (e.g., Pt, Au etc.) are measured for therapeutic purposes. Quantitative measurement of elemental species is becoming more widely accepted for nutritional and/or toxicological screening purposes, and ICP-MS interfaced with separation techniques, such as liquid chromatography or capillary electrophoresis, offers the advantage of on-line species determination coupled with very low detection limits. Polyatomic interferences for some key elements such as Se, As, and Cr require instrumentation equipped with dynamic reaction cell or collision cell technologies, or might even necessitate the use of sector field ICP-MS, to assure accurate results. Nonetheless, whatever analytical method is selected for the task, careful consideration must be given both to specimen collection procedures and to the control of pre-analytical variables. Finally, all methods benefit from access to reliable certified reference materials (CRMs). While a variety of reference materials (RMs) are available for trace element measurements in clinical matrices, not all can be classified as CRMs. The major metrological organizations (e.g., NIST, IRMM, NIES) provide a limited number of clinical CRMs, however, secondary reference materials are readily available from commercial organizations and organizers of external quality assessment schemes.
Pinkus, Rosa Lynn
Drawing in part on her experiences as a "humanist-in-residence" on a neurological surgery service, the author discusses how stereotypic views held by and toward physicians and humanists interfere with the teaching of ethics to physicians and, indirectly, to the general public. She traces the development of these stereotypes over the past hundred years and suggests ways that they can be overcome to permit more effective working relationships between physicians and clinical ethicists.
Heckman-Stoddard, Brandy M.; Smith, Judith J.
Objectives To discuss the role of clinical trials in the changing landscape of cancer care resulting in individualized cancer treatment plans including a discussion of several innovative randomized studies designed to evaluate multiple targeted therapies in molecularly defined subsets of individuals. Data Sources Medical and nursing literature, research articles, and clinicaltrials.gov. Conclusion Recent advancements in cancer biomarkers and biomedical technology have begun to transform fundamentals of cancer therapeutics and clinical trials through innovative adaptive trial designs. The goal of these studies is to learn not only if a drug is safe and effective but also how it is best delivered and who will derive the most benefit. Implications for Nursing Practice Implementation of clinical trials in the cancer biomarker era requires knowledge, skills, and expertise related to the use of biomarkers and molecularly defined processes underlying a malignancy, as well as an understanding of associated ethical, legal, and social issues to provide competent, safe, and effective health care and patient communication. PMID:24794084
Sim, Ida; Gorman, Paul; Greenes, Robert A.; Haynes, R. Brian; Kaplan, Bonnie; Lehmann, Harold; Tang, Paul C.
Background: The use of clinical decision support systems to facilitate the practice of evidence-based medicine promises to substantially improve health care quality. Objective: To describe, on the basis of the proceedings of the Evidence and Decision Support track at the 2000 AMIA Spring Symposium, the research and policy challenges for capturing research and practice-based evidence in machine-interpretable repositories, and to present recommendations for accelerating the development and adoption of clinical decision support systems for evidence-based medicine. Results: The recommendations fall into five broad areas—capture literature-based and practice-based evidence in machine-interpretable knowledge bases; develop maintainable technical and methodological foundations for computer-based decision support; evaluate the clinical effects and costs of clinical decision support systems and the ways clinical decision support systems affect and are affected by professional and organizational practices; identify and disseminate best practices for work flow–sensitive implementations of clinical decision support systems; and establish public policies that provide incentives for implementing clinical decision support systems to improve health care quality. Conclusions: Although the promise of clinical decision support system–facilitated evidence-based medicine is strong, substantial work remains to be done to realize the potential benefits. PMID:11687560
Bataller-Sifre, R; Bataller-Alberola, A
Integrative medicine is an ambitious and noble-minded attempt to address the shortcomings of the current public health systems in our Western societies, which is restricted by the limited time available, especially in outpatient clinics. Integrative medicine also does not limit the possibilities of useful therapies that have been tested over the centuries (from China, India, etc.) or of certain resources that do not achieve the level of desired scientific credibility but that present certain therapeutic support in specific cases (homeopathy, acupuncture, etc.) but still require a scientific approach. Finally, the resource of botanical products (phytotherapy) constitutes a wide range of possibilities that universities can (and do) make progress on by providing drug brands for these products through the use of the scientific method and evidence-based medical criteria. This approach will help avoid the irrationality of the daily struggle between conventional scientific medicine (which we apply to the immense majority of patients) and the other diagnostic-therapeutic «guidelines» (natural medicine, alternative medicine, complementary medicine, patient-focused medicine and others). Copyright © 2015. Published by Elsevier España, S.L.U.
Phillips, Erica; Harris, Christina; Lee, Wei Wei; Pincavage, Amber T; Ouchida, Karin; Miller, Rachel K; Chaudhry, Saima; Arora, Vineet M
While there has been increasing emphasis and innovation nationwide in training residents in inpatient handoffs, very little is known about the practice and preparation for year-end clinic handoffs of residency outpatient continuity practices. Thus, the latter remains an identified, yet nationally unaddressed, patient safety concern. The 2014 annual Association of Program Directors in Internal Medicine (APDIM) survey included seven items for assessing the current year-end clinic handoff practices of internal medicine residency programs throughout the country. Nationwide survey. All internal medicine program directors registered with APDIM. Descriptive statistics of programs and tools used to formulate a year-end handoff in the ambulatory setting, methods for evaluating the process, patient safety and quality measures incorporated within the process, and barriers to conducting year-end handoffs. Of the 361 APDIM member programs, 214 (59%) completed the Transitions of Care Year-End Clinic Handoffs section of the survey. Only 34% of respondent programs reported having a year-end ambulatory handoff system, and 4% reported assessing residents for competency in this area. The top three barriers to developing a year-end handoff system were insufficient overlap between graduating and incoming residents, inability to schedule patients with new residents in advance, and time constraints for residents, attendings, and support staff. Most internal medicine programs do not have a year-end clinic handoff system in place. Greater attention to clinic handoffs and resident assessment of this care transition is needed.
Fiore, Robin N; Goodman, Kenneth W
In early 2015 the National Institutes of Health launched a new, national Precision Medicine Initiative with the primary goal of rapidly improving the prevention, diagnosis, and treatment of cancers. The first-stage emphasis on oncology presents unique opportunities for clinical oncology to influence how the ethical challenges of precision medicine are to be articulated and addressed. Thus, a review of recent developments in connection with the Initiative, in particular on core ethics issues in clinical genomics, is a useful starting point. Unique ethical issues arise in precision medicine because of the enormous amounts of data generated by clinical whole-genome or whole-exome sequencing and the extent of current uncertainties with respect to data interpretations and disease associations. Among the most ethically challenging issues for clinicians are complicated informed consent processes, returning results - particularly secondary and incidental findings-and privacy and confidentiality. The first tests of precision medicine ethics in practice will be in clinical oncology, providing a rare opportunity to shape the agenda and integrate practical ethics considerations. These efforts can benefit from pre-existing research ethics analyses and recommendations from clinical and translational genetics research.
This is the summary of my talk about the new concept of education for medical technologists. In Osaka University, the course for laboratory medicine changed from a 3-year to a 4-year training course, and our faculty started a new curriculum of special practice in clinical medicine and biotechnology for first-year undergraduate students from 1997. This special practice in clinical medicine consists of three parts, encompassing learning in the essential divisions of the hospital, bedside learning, and presentation in case conferences. Students visit from time to time to seven divisions, outpatients' clinic, surgical operation room, laboratory for radiological examination, rehabilitation rooms, pharmacy, central storage room for medical records, and the department of medical informatics. The aim of this round practice is to broaden their review of clinical medicine. They also go to the bed side of one patient in the ward for 4 weeks especially for learning about values of laboratory data. They follow up the laboratory data and go with the patient to clinical physiological examinations. Finally, they present their case to all their teachers and class mates in a semi-congress style and are evaluated with scores by the staffs.
Ikegami, F; Sumino, M; Fujii, Y; Akiba, T; Satoh, T
Kampo (Japanese traditional herbal) medicines have been produced by combining multiple crude drugs, almost all of plant origin but with some of animal or mineral origin, and contain a great many substances. Their effect is a combination of the various interactions of the constituent substances, whether they are enhancing, synergistic or suppressive. Kampo medicine has an overall effect that is different from the combined effects of individual crude drugs, and several side effects such as anorexia, slight fever and nausea have been reported in the treatment of certain disorders and disease states with Kampo medicines. Among 210 medical formulations used in Japan, some relevant information on the clinical uses, pharmacology and toxicology of six manufactured Kampo medical formulations, Shosaikoto, Daisaikoto, Saikokeishito, Hochuekkito, Saibokuto and Saireito, containing Bupleurum root are reviewed. Studies of some potential interactions between Kampo medicine and western drugs are also considered.
Oyama, M A; Ellenberg, S S; Shaw, P A
Randomized clinical trials (RCTs) are among the most rigorous ways to determine the causal relationship between an intervention and important clinical outcome. Their use in veterinary medicine has become increasingly common, and as is often the case, with progress comes new challenges. Randomized clinical trials yield important answers, but results from these studies can be unhelpful or even misleading unless the study design and reporting are carried out with care. Herein, we offer some perspective on several emerging challenges associated with RCTs, including use of composite endpoints, the reporting of different forms of risk, analysis in the presence of missing data, and issues of reporting and safety assessment. These topics are explored in the context of previously reported veterinary internal medicine studies as well as through illustrative examples with hypothetical data sets. Moreover, many insights germane to RCTs in veterinary internal medicine can be drawn from the wealth of experience with RCTs in the human medical field. A better understanding of the issues presented here can help improve the design, interpretation, and reporting of veterinary RCTs. Copyright © 2017 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.
Holt, Stephen R; Segar, Nora; Cavallo, Dana A; Tetrault, Jeanette M
Substance use is highly prevalent in the United States, but little time in the curriculum is devoted to training internal medicine residents in addiction medicine. In 2014, the authors developed and launched the Addiction Recovery Clinic (ARC) to address this educational gap while also providing outpatient clinical services to patients with substance use disorders. The ARC is embedded within the residency primary care practice and is staffed by three to four internal medicine residents, two board-certified addiction medicine specialists, one chief resident, and one psychologist. Residents spend one half-day per week for four consecutive weeks at the ARC seeing new and returning patients. Services provided include pharmacological and behavioral treatments for opioid, alcohol, and other substance use disorders, with direct referral to local addiction treatment facilities as needed. Visit numbers, a patient satisfaction survey, and an end-of-rotation resident evaluation were used to assess the ARC. From 2014 to 2015, 611 patient encounters occurred, representing 97 new patients. Sixty-one (63%) patients were seen for opioid use disorder. According to patient satisfaction surveys, 29 (of 31; 94%) patients reported that the ARC probably or definitely helped them to cope with their substance use. Twenty-eight residents completed the end-of-rotation evaluation; all rated the rotation highly. The ARC offers a unique primary-care-based approach to exposing internal medicine residents to the knowledge and skills necessary to diagnose, treat, and prevent unhealthy substance use. Future research will examine other clinical and educational outcomes.
Flegar-Mestrić, Zlata; Nazor, Aida; Perkov, Sonja; Surina, Branka; Siftar, Zoran; Ozvald, Ivan; Vidas, Zeljko
Although transplantation of solid organs has become a more standardized method of treatment, liver transplantation represents an exceptional multidisciplinary clinical procedure requiring understanding of specific pathophysiological changes that occur in the end stage of liver disease. Liver transplantation has been performed at Merkur University Hospital since 1998, with 360 transplantations performed to date. The most common indications are alcohol liver disease, cirrhosis caused by hepatitis B and C virus, hepatocellular carcinoma and cryptogenetic liver cirrhosis. Laboratory tests required for liver transplantation are performed at Department of Clinical Chemistry, Merkur University Hospital, accredited according to ISO 15189 in 2007 for the areas of clinical chemistry, laboratory hematology and coagulation, laboratory immunology-cell immunophenotyping, and molecular diagnosis. The complexity of liver transplant patients requires constant interaction between the anesthesiologist team and clinical laboratory, which has to ensure fast and efficient intraoperative monitoring of biochemical and liver profile: electrolytes and acid-base status, complete blood count, coagulation profile and monitoring of graft function according to the individual patient's health status. Dynamics of intraoperative changes is measured in whole arterial blood samples on a Nova Biomedical Stat Profile Critical Care Xpress mobile acid-base analyzer. Frequent monitoring of ionized calcium and magnesium levels is very important because of citrated blood transfusion and for appropriate therapeutic procedure. During anhepatic stage, there is a progressive increase in lactate level concentration. After reperfusion, a rapid increase in lactate clearance is an excellent indicator of stable graft initial function and its adequate size. During the transplantation procedure, there is usually a biphasic acid-base disturbance characterized by metabolic acidosis and then by metabolic alkalosis. The
Molfetta, Luigi; Caldo, Davide
Severe osteoporosis is characterized by a densitometry T-score lower than 2.5 associated with one or more fragility fractures. Fragility fractures represent a serious social and economic problem; the diagnosis of osteoporosis is an unachieved target by orthopaedic surgeons, despite the chance to detect it in many clinical assets and the availability of effective treatment tools. It is necessary to stick to scientific society guidelines, thus avoiding legal consequences related to the diagnosis, the therapy, the prescription coherence and the correct information due to patients.
Trimble, Michael; Hamilton, Paul
Diagnostic errors are responsible for a significant number of adverse events. Logical reasoning and good decision-making skills are key factors in reducing such errors, but little emphasis has traditionally been placed on how these thought processes occur, and how errors could be minimised. In this article, we explore key cognitive ideas that underpin clinical decision making and suggest that by employing some simple strategies, physicians might be better able to understand how they make decisions and how the process might be optimised.
Ventegodt, Søren; Clausen, Birgitte; Nielsen, May Lyck; Merrick, Joav
According to holistic medical theory, the patient will heal when old painful moments, the traumatic events of life that are often called "gestalts", are integrated in the present "now". The advanced holistic physician's expanded toolbox has many different tools to induce this healing, some that are more dangerous and potentially traumatic than others. The more intense the therapeutic technique, the more emotional energy will be released and contained in the session, but the higher also is the risk for the therapist to lose control of the session and lose the patient to his or her own dark side. To avoid harming the patient must be the highest priority in holistic existential therapy, making sufficient education and training an issue of highest importance. The concept of "stepping up" the therapy by using more and more "dramatic" methods to get access to repressed emotions and events has led us to a "therapeutic staircase" with ten steps: (1) establishing the relationship; (2) establishing intimacy, trust, and confidentiality; (3) giving support and holding; (4) taking the patient into the process of physical, emotional, and mental healing; (5) social healing of being in the family; (6) spiritual healing--returning to the abstract wholeness of the soul; (7) healing the informational layer of the body; (8) healing the three fundamental dimensions of existence: love, power, and sexuality in a direct way using, among other techniques, "controlled violence" and "acupressure through the vagina"; (9) mind-expanding and consciousness-transformative techniques like psychotropic drugs; and (10) techniques transgressing the patient's borders and, therefore, often traumatizing (for instance, the use of force against the will of the patient). We believe that the systematic use of the staircase will greatly improve the power and efficiency of holistic medicine for the patient and we invite a broad cooperation in scientifically testing the efficiency of the advanced holistic
The practice of cardiology continues to evolve along with a better understanding of the pathophysiology of cardiovascular disease and the development of new therapeutic procedures. Consequently, new demands are being made on the in vitro diagnostics industry to improve the performance of existing cardiac markers and to develop novel markers for new cardiac disease indications. Indeed, in the last 20 years there has been a progressive increase in new laboratory tests for markers of cardiac diseases. Several highly sensitive and/or specific assays for the detection of myocardial ischemic damage as well as some immunoassays for cardiac natriuretic hormones, now considered a reliable marker of myocardial function, have become commercially available. In parallel, a growing number of some novel risk factors, which can be assessed and monitored by laboratory methods, have been added to the classical risk factors for cardiovascular disease. Finally, the recent explosion of genetic analysis may soon place at the clinical cardiologist's disposal many laboratory tests for defining the diagnosis at the molecular level, assessing new risk factors, and better targeting the pharmaceutical approaches in patients with cardiovascular disease. In the present article, after a brief description of the analytical tests included in these four groups, each group's impact on clinical cardiology is discussed in detail.
Monach, Paul A
Researchers often decide whether to average multiple results in order to produce more precise data, and clinicians often decide whether to repeat a laboratory test in order to confirm its validity or to follow a trend. Some of the major sources of variation in laboratory tests (analytical imprecision, within-subject biological variation and between-subject variation) and the effects of averaging multiple results from the same sample or from the same person over time are discussed quantitatively in this article. This analysis leads to the surprising conclusion that the strategy of averaging multiple results is only necessary and effective in a limited range of research studies. In clinical practice, it may be important to repeat a test in order to eliminate the possibility of a rare type of error that has nothing to do analytical imprecision or within-subject variation, and for this reason, paradoxically, it may be most important to repeat tests with the highest sensitivity and/or specificity (i.e., ones that are critical for clinical decision-making).
Meissner, Karin; Kohls, Niko; Colloca, Luana
The field of placebo research has made considerable progress in the last years and it has become a major focus of interest. We know now that the placebo effect is a real neurobiological phenomenon and that the brain's 'inner pharmacy' is a critical determinant for the occurrence of psychobiological and behavioural changes relevant to healing processes and well-being. However, harnessing the advantages of placebo effects in healthcare is still a challenge. The first part of the theme issue summarizes and discusses the various kinds of placebo mechanisms across medical fields, thereby not only focusing on two main explanatory models-expectation and conditioning theory-but also taking into account empathy and social learning, emotion and motivation, spirituality and the healing ritual. The second part of the issue focuses on questions related to transferring knowledge from placebo research into clinical practice and discusses implications for the design and interpretation of clinical trials, for the therapeutic settings in daily patient care, and for future translational placebo research.
Researchers often decide whether to average multiple results in order to produce more precise data, and clinicians often decide whether to repeat a laboratory test in order to confirm its validity or to follow a trend. Some of the major sources of variation in laboratory tests (analytical imprecision, within-subject biological variation and between-subject variation) and the effects of averaging multiple results from the same sample or from the same person over time are discussed quantitatively in this article. This analysis leads to the surprising conclusion that the strategy of averaging multiple results is only necessary and effective in a limited range of research studies. In clinical practice, it may be important to repeat a test in order to eliminate the possibility of a rare type of error that has nothing to do analytical imprecision or within-subject variation, and for this reason, paradoxically, it may be most important to repeat tests with the highest sensitivity and/or specificity (i.e., ones that are critical for clinical decision-making). PMID:23075249
Lai, Xiao-xiao; Lin, Hua; Luo, Yi-ni; Wang, Ying-yan; Duan, Xiao-hong; Wang, Lin; Luo, Rui; Chen, Yan-hong
In China, many surveys have shown that most people do not have a correct understanding about cold and administration of anti-cold Chinese patent medicine preparations. The author conducted a systematic summary and analysis on the actual application of anti-cold Chinese patent medicine preparations as well as the warning on safe application of anti-cold Chinese patent medicine preparations in Clinical Medication Information of China Pharmacopoeia, in the expectation of reducing the blind application of anti-cold Chinese patent medicine preparations and providing traditional Chinese medicine pharmacists new ideas in monitoring the safe application of exterior syndrome-relieving Chinese patent medicine preparations.
Pedersen, Aasta; Stinner, Daniel J; McLaughlin, H Cathy; Bailey, James R; Walter, Jack R; Hsu, Joseph R
Pelvic fractures are markers of severe injury and are often associated with lower genitourinary injuries. The purpose of this study was to investigate the incidence of lower genitourinary injuries and complaints associated with pelvic fractures sustained in combat among nonsurvivors and survivors. The Armed Forces Medical Examiner System and The Joint Theater Trauma Registry databases were searched to identify survivors and nonsurvivors who sustained a pelvic fracture in combat in 2008. Survivor and autopsy data consisted of injury mode and mechanism and associated organ and extremity injuries. Pelvic fractures were classified using the Tile system. The database search yielded 91 nonsurvivors and 10 survivors with pelvic fractures. Forty-one patients (40%) sustained 61 genitourinary injuries. The majority of genitourinary injuries in nonsurvivors were associated with Tile C pelvic fractures (70%). Twenty percent of survivors had genitourinary injuries, all of which were associated with Tile A fractures. A higher incidence of genitourinary injuries in patients with combat-related pelvic fractures (60%) was found than that of their civilian counterparts. Of the survivors, 100% of those with genitourinary injuries were being treated for erectile dysfunction at their last follow-up. Continued collaboration between orthopaedic surgeons and urologist is needed to address these concurrent injuries. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.
Paquette, Edmond L
This report details the occurrences of genitourinary trauma experienced during Operation Iraqi Freedom at a United States Army Combat Support Hospital, and determines if wearing body armor decreases the frequency of genitourinary and specifically kidney trauma. The Joint Theater Trauma Registry was used to conduct a retrospective study of 2,712 trauma admissions to a United States Army Combat Support Hospital in Baghdad, Iraq from April 1, 2005 to February 28, 2006. There were 1,216 casualties who were wearing body armor and 1,496 casualties not wearing body armor. Of the 2,712 trauma admissions 76 (2.8%) had 1 or more genitourinary injuries for a total of 98 genitourinary injuries. Of the 29 kidney injuries 2 (6.9%) were explored without any treatment, 7 (24.1%) were observed, 1 (3.4%) was repaired and 19 (65.5%) casualties required nephrectomy. Casualties wearing body armor had a 2.1% rate of genitourinary injury versus 3.4% not wearing body armor (p = 0.037). Casualties wearing body armor had a 0.5% rate of kidney injury compared to 1.4% not wearing body armor (p = 0.017). The percentage of casualties with genitourinary injuries and the distribution of these injuries appear similar to previous conflicts. The percentage of casualties undergoing nephrectomy appears to be greater than that observed in other recent conflicts. There was a significant reduction in overall genitourinary injuries and specifically kidney injuries in those casualties wearing body armor.
Shao, Chia-Ho; Lu, Cheng-Chang; Chen, Tou-Rong; Weng, Jui-Hung; Kao, Pan-Fu; Dong, Shang-Lung; Chou, Ming-Jen
The monitoring of radiation dose around the nuclear medicine site is an important study issue. In this study, TLD-100H radiation dosimeters were used to measure the ambient radiation dose rates around a clinical nuclear medicine site in order to investigate the latent hot zones of radiation exposure. Results of this study showed that the radiation doses measured from all piping and storage systems were comparable to the background dose. A relatively high dose was observed at the single bend point of waste water piping of the PET/CT. Another important finding was the unexpected high dose rates observed at the non-restricted waiting area (NRWA) of SPECT. To conclude, this study provides useful information for further determination of an appropriate dose reduction strategy to achieve the ALARA principle in a clinical nuclear medicine site.
Shinjo, Keiko; Kondo, Yutaka
Recent studies provide compelling evidence that epigenetic dysregulation is involved in almost every step of tumor development and progression. Differences in tumor behavior, which ultimately reflects clinical outcome, can be explained by variations in gene expression patterns generated by epigenetic mechanisms, such as DNA methylation. Therefore, epigenetic abnormalities are considered potential biomarkers and therapeutic targets. DNA methylation is stable at certain specific loci in cancer cells and predominantly reflects the characteristic clinicopathological features. Thus, it is an ideal biomarker for cancer screening, classification and prognostic purposes. Epigenetic treatment for cancers is based on the pharmacologic targeting of various core transcriptional programs that sustains cancer cell identity. Therefore, targeting aberrant epigenetic modifiers may be effective for multiple processes compared with using a selective inhibitor of aberrant single signaling pathway. This review provides an overview of the epigenetic alterations in human cancers and discusses about novel therapeutic strategies targeting epigenetic alterations.
Whitsett, Carolyn; Vaglio, Stefania; Grazzini, Giuliano
The primary focus of national blood programs is the provision of a safe and adequate blood supply. This goal is dependent on regular voluntary donations and a regulatory infrastructure that establishes and enforces standards for blood safety. Progress in ex vivo expansion of blood cells from cell sources including peripheral blood, cord blood, induced pluripotent stem cells, and human embryonic stem cell lines will likely make alternative transfusion products available for clinical use in the near future. Initially, alloimmunized patients and individuals with rare blood types are most likely to benefit from alternative products. However, in developed nations voluntary blood donations are projected to be inadequate in the future as blood usage by individuals 60 years and older increases. In developing nations economic and political challenges may impede progress in attaining self-sufficiency. Under these circumstances, ex vivo generated red cells may be needed to supplement the general blood supply. PMID:22567025
Agre, Peter; King, Landon S; Yasui, Masato; Guggino, Wm B; Ottersen, Ole Petter; Fujiyoshi, Yoshinori; Engel, Andreas; Nielsen, Søren
The water permeability of biological membranes has been a longstanding problem in physiology, but the proteins responsible for this remained unknown until discovery of the aquaporin 1 (AQP1) water channel protein. AQP1 is selectively permeated by water driven by osmotic gradients. The atomic structure of human AQP1 has recently been defined. Each subunit of the tetramer contains an individual aqueous pore that permits single-file passage of water molecules but interrupts the hydrogen bonding needed for passage of protons. At least 10 mammalian aquaporins have been identified, and these are selectively permeated by water (aquaporins) or water plus glycerol (aquaglyceroporins). The sites of expression coincide closely with the clinical phenotypes – ranging from congenital cataracts to nephrogenic diabetes insipidus. More than 200 members of the aquaporin family have been found in plants, microbials, invertebrates and vertebrates, and their importance to the physiology of these organisms is being uncovered. PMID:12096044
Hatcher, H.; Planalp, R.; Cho, J.; Torti, S. V.
Curcumin is the active ingredient in the traditional herbal remedy and dietary spice turmeric (Curcuma longa). Curcumin has a surprisingly wide range of beneficial properties, including anti-inflammatory, antioxidant, chemopreventive and chemotherapeutic activity. The pleiotropic activities of curcumin derive from its complex chemistry as well as its ability to influence multiple signaling pathways, including survival pathways such as those regulated by NF-κB, Akt, and growth factors; cytoprotective pathways dependent on Nrf2; and metastatic and angiogenic pathways. Curcumin is a free radical scavenger and hydrogen donor, and exhibits both pro- and antioxidant activity. It also binds metals, particularly iron and copper, and can function as an iron chelator. Curcumin is remarkably non-toxic and exhibits limited bioavailability. Curcumin exhibits great promise as a therapeutic agent, and is currently in human clinical trials for a variety of conditions, including multiple myeloma, pancreatic cancer, myelodysplastic syndromes, colon cancer, psoriasis and Alzheimer’s disease. PMID:18324353
Carrasco, G; Pallarés, A; Cabré, L
This article reviews the utility and applicability of available systems in order to calculate general and quality costs in clinical services settings. Review of techniques to calculate costs in Intensive Care Units (ICUs) according to analytical accounting approaches. The methodological development is complemented with the results of its application in the ICU of the Miracle's Hospital showing the structure of costs and the results obtained with this methodology when analyzing the costs of activities related to quality improvement. The effort to implement systems focused to analyze general and quality costs will result in a benefit of those participating in the healthcare system: citizens, professionals, managers, and "financials" since that which is only a legitimate demand today will be a inexcuseable commitment of the healthcare professionals from the society tomorrow.
Lee, M D; King, L S; Agre, P
The aquaporins are a family of membrane channel proteins that serve as selective pores through which water crosses the plasma membranes of many human tissues and cell types. The sites where aquaporins are expressed implicate these proteins in renal water reabsorption, cerebrospinal fluid secretion and reabsorption, generation of pulmonary secretions, aqueous humor secretion and reabsorption, lacrimation, and multiple other physiologic processes. Determination of the aquaporin gene sequences and their chromosomal locations has provided insight into the structure and pathophysiologic roles of these proteins, and primary and secondary involvement of aquaporins is becoming apparent in diverse clinical disorders. Aquaporin-1 (AQP1) is expressed in multiple tissues including red blood cells, and the Colton blood group antigens represent a polymorphism on the AQP1 protein. AQP2 is restricted to renal collecting ducts and has been linked to congenital nephrogenic diabetes insipidus in humans and to lithium-induced nephrogenic diabetes insipidus and fluid retention from congestive heart failure in rat models. Congenital cataracts result from mutations in the mouse gene encoding the lens homolog Aqp0 (Mip). The present understanding of aquaporin physiology is still incomplete; identification of additional members of the aquaporin family will affect future studies of multiple disorders of water distribution throughout the body. In some tissues, the aquaporins may participate in the transepithelial movement of fluid without being rate limiting, so aquaporins may be involved in clinical disorders without being causative. As outlined in this review, our challenge is to identify disease states in which aquaporins are involved, to define the aquaporins' roles mechanistically, and to search for ways to exploit this information therapeutically.
Häuser, Winfried; Hansen, Ernil; Enck, Paul
Nocebo phenomena are common in clinical practice and have recently become a popular topic of research and discussion among basic scientists, clinicians, and ethicists. We selectively searched the PubMed database for articles published up to December 2011 that contained the key words "nocebo" or "nocebo effect." By definition, a nocebo effect is the induction of a symptom perceived as negative by sham treatment and/or by the suggestion of negative expectations. A nocebo response is a negative symptom induced by the patient's own negative expectations and/or by negative suggestions from clinical staff in the absence of any treatment. The underlying mechanisms include learning by Pavlovian conditioning and reaction to expectations induced by verbal information or suggestion. Nocebo responses may come about through unintentional negative suggestion on the part of physicians and nurses. Information about possible complications and negative expectations on the patient's part increases the likelihood of adverse effects. Adverse events under treatment with medications sometimes come about by a nocebo effect. Physicians face an ethical dilemma, as they are required not just to inform patients of the potential complications of treatment, but also to minimize the likelihood of these complications, i.e., to avoid inducing them through the potential nocebo effect of thorough patient information. Possible ways out of the dilemma include emphasizing the fact that the proposed treatment is usually well tolerated, or else getting the patient's permission to inform less than fully about its possible side effects. Communication training in medical school, residency training, and continuing medical education would be desirable so that physicians can better exploit the power of words to patients' benefit, rather than their detriment.
Foran, David J; Chen, Wenjin; Chu, Huiqi; Sadimin, Evita; Loh, Doreen; Riedlinger, Gregory; Goodell, Lauri A; Ganesan, Shridar; Hirshfield, Kim; Rodriguez, Lorna; DiPaola, Robert S
Leading institutions throughout the country have established Precision Medicine programs to support personalized treatment of patients. A cornerstone for these programs is the establishment of enterprise-wide Clinical Data Warehouses. Working shoulder-to-shoulder, a team of physicians, systems biologists, engineers, and scientists at Rutgers Cancer Institute of New Jersey have designed, developed, and implemented the Warehouse with information originating from data sources, including Electronic Medical Records, Clinical Trial Management Systems, Tumor Registries, Biospecimen Repositories, Radiology and Pathology archives, and Next Generation Sequencing services. Innovative solutions were implemented to detect and extract unstructured clinical information that was embedded in paper/text documents, including synoptic pathology reports. Supporting important precision medicine use cases, the growing Warehouse enables physicians to systematically mine and review the molecular, genomic, image-based, and correlated clinical information of patient tumors individually or as part of large cohorts to identify changes and patterns that may influence treatment decisions and potential outcomes. PMID:28469389
Foran, David J; Chen, Wenjin; Chu, Huiqi; Sadimin, Evita; Loh, Doreen; Riedlinger, Gregory; Goodell, Lauri A; Ganesan, Shridar; Hirshfield, Kim; Rodriguez, Lorna; DiPaola, Robert S
Leading institutions throughout the country have established Precision Medicine programs to support personalized treatment of patients. A cornerstone for these programs is the establishment of enterprise-wide Clinical Data Warehouses. Working shoulder-to-shoulder, a team of physicians, systems biologists, engineers, and scientists at Rutgers Cancer Institute of New Jersey have designed, developed, and implemented the Warehouse with information originating from data sources, including Electronic Medical Records, Clinical Trial Management Systems, Tumor Registries, Biospecimen Repositories, Radiology and Pathology archives, and Next Generation Sequencing services. Innovative solutions were implemented to detect and extract unstructured clinical information that was embedded in paper/text documents, including synoptic pathology reports. Supporting important precision medicine use cases, the growing Warehouse enables physicians to systematically mine and review the molecular, genomic, image-based, and correlated clinical information of patient tumors individually or as part of large cohorts to identify changes and patterns that may influence treatment decisions and potential outcomes.
Carroll, Thomas L; Lee, Stella E; Lindsay, Robin; Locandro, Drew; Randolph, Gregory W; Shin, Jennifer J
The assessment of patient-reported outcome measures (PROMs) in the outpatient setting is gaining momentum in clinical and research venues. Implementing this data capture into one's practice, however, is not a one-size-fits-all venture, and it is critical to determine when, how, and where to include these patient-centered assessments. This installment of the "Evidence-Based Medicine in Otolaryngology" series provides insight into the implementation process and experiences with successful incorporation of PROMs into clinical practice. Specifically, 4 differing clinical scenarios and collection techniques are described, including data acquisition protocols, formats for clinician data usage, and applications of PROM results in clinical and research scenarios.
Muzzi, A; Panà, A
Contrary to what has happened so far, hospitals should become a setting which jointly exercise Clinical and Public Health Medicine. The areas of activity that require the presence of multidisciplinary teams and can bring benefits both to the patients and to the community is briefly described.
Handy, Pauline; Sankar, K. Nathan
Objective: To elicit the level of knowledge, training and preferences of men in relation to Testicular Self Examination (TSE). Setting: The Genito Urinary Medicine (GUM) department of a large teaching hospital in the North East of England. The open access clinic serves patients from Newcastle upon Tyne, Northumberland, Gateshead and surrounding…
Handy, Pauline; Sankar, K. Nathan
Objective: To elicit the level of knowledge, training and preferences of men in relation to Testicular Self Examination (TSE). Setting: The Genito Urinary Medicine (GUM) department of a large teaching hospital in the North East of England. The open access clinic serves patients from Newcastle upon Tyne, Northumberland, Gateshead and surrounding…
Willoughby, T. Lee
The validity of an examination of knowledge in the medical sciences was assessed. Scores in clinical medicine categories and total score of the Quarterly Profile Examination were correlated with corresponding scores on the Part II examination of the National Board of Medical Examiners for three different examination dates. (Author/CTM)
Jones, Christopher W; Platts-Mills, Timothy F
In 2005, the International Committee of Medical Journal Editors established clinical trial registration as a requirement for articles submitted to member journals, with the goal of improving the transparency of clinical research. The objective of this study is to characterize the registration of clinical trials published in emergency medicine journals. Randomized trials involving human subjects and published between June 1, 2008, and May 31, 2011 in the 5 emergency medicine journals with the highest impact factors were included. We assessed the clarity of registered primary outcomes, timing of registration relative to patient enrollment, and consistency between registered and published outcomes. Of the 123 trials included, registry entries were identified for 57 (46%). Of the 57 registered studies, 45 (79%) were registered after the initiation of subject enrollment, 9 (16%) had registered outcomes that were unclear, and 26 (46%) had discrepancies between registered and published outcomes. Only 5 studies were registered before patient enrollment with a clear primary outcome that was consistent with the published primary outcome. Annals of Emergency Medicine was the only journal in which the majority of trials were registered. Current compliance with clinical trial registration guidelines is poor among trials published in emergency medicine journals. Copyright © 2012. Published by Mosby, Inc.
el-Guebaly, Nady; Violato, Claudio
The experience of the International Society of Addiction Medicine in setting up the first international certification of clinical knowledge is reported. The steps followed and the results of a psychometric analysis of the tests from the first 65 candidates are reported. Lessons learned in the first 5 years and challenges for the future are…
assistants and primary care nurse practitioners-in primary medicine outpatient clinics. This report, one in a series presenting Rand’s eva !u- ation of the...ACTION Tim BY Mh’CAL PERON ON LADY VISIT (Regular uers of boew; percent) Chanute Pres Fairchild Nellos Response 1976 1977 1976 1977 1976 1977 1976 197
Manolio, Teri A
Increasing knowledge about the influence of genetic variation on human health and growing availability of reliable, cost-effective genetic testing have spurred the implementation of genomic medicine in the clinic. As defined by the National Human Genome Research Institute (NHGRI), genomic medicine uses an individual's genetic information in his or her clinical care, and has begun to be applied effectively in areas such as cancer genomics, pharmacogenomics, and rare and undiagnosed diseases. In 2011 NHGRI published its strategic vision for the future of genomic research, including an ambitious research agenda to facilitate and promote the implementation of genomic medicine. To realize this agenda, NHGRI is consulting and facilitating collaborations with the external research community through a series of "Genomic Medicine Meetings," under the guidance and leadership of the National Advisory Council on Human Genome Research. These meetings have identified and begun to address significant obstacles to implementation, such as lack of evidence of efficacy, limited availability of genomics expertise and testing, lack of standards, and difficulties in integrating genomic results into electronic medical records. The six research and dissemination initiatives comprising NHGRI's genomic research portfolio are designed to speed the evaluation and incorporation, where appropriate, of genomic technologies and findings into routine clinical care. Actual adoption of successful approaches in clinical care will depend upon the willingness, interest, and energy of professional societies, practitioners, patients, and payers to promote their responsible use and share their experiences in doing so.
MENZEL, HERBERT; AND OTHERS
IN 1963 THE NEW YORK ACADEMY OF MEDICINE, WITH THE NEW YORK CITY MUNICIPAL BROADCASTING SYSTEM, INAUGURATED AN EXPERIMENTAL PROGRAM OF WEEKLY ONE-HOUR TELEVISED CLINICAL SCIENCE SEMINARS TO EXPLORE THE ACCEPTABILITY AND EFFECTIVENESS OF OPEN-CIRCUIT TELEVISION AS AN ADDITIONAL MEDIUM OF CONTINUING MEDICAL EDUCATION IN A LARGE METROPOLITAN AREA.…
A Toronto physician has opened a new clinic for male patients, particularly highly stressed executives, who pay to have their physical, mental and nutritional health assessed. The Health Institute for Men, which opened in January, is located close to the Toronto Stock Exchange. It charges $450 for the initial visit, which includes a complete history, mental-assessment exam and thorough physical. The chair of the CMA Board of Directors considers the clinic a sign of growing entrepreneurship within Canadian medicine.
Narayen, Girish; Mandal, Surya Narayan
Hyponatremia is the most common electrolyte abnormality in hospitalized patients. Its treatment is based not only on extracellular fluid volume status of patients but also on its pathogenetic mechanisms. Conventional treatment of hyponatremia like fluid restriction, which is useful in euvolemic and hypervolemic hyponatremia, has very poor patient compliance over long term. Vasopressin receptor antagonists (Vaptans) are a new group of nonpeptide drugs which have been used in various clinical conditions with limited success. Whereas conivaptan is to be administered intravenously, the other vaptans like tolvaptan, lixivaptan, and satavaptan are effective as oral medication. They produce aquaresis by their action on vasopressin type 2 (V2R) receptors in the collecting duct and thus increase solute free water excretion. Vaptans are being used as an alternative to fluid restriction in euvolemic and hypervolemic hyponatremic patients. Efficacy of vaptans is now well accepted for management of correction of hyponatremia over a short period. However, its efficacy in improving the long-term morbidity and mortality in patients with chronic hyponatremia due to cirrhosis and heart failure is yet to be established. Vaptans have not become the mainstay treatment of hyponatremia yet.
Narayen, Girish; Mandal, Surya Narayan
Hyponatremia is the most common electrolyte abnormality in hospitalized patients. Its treatment is based not only on extracellular fluid volume status of patients but also on its pathogenetic mechanisms. Conventional treatment of hyponatremia like fluid restriction, which is useful in euvolemic and hypervolemic hyponatremia, has very poor patient compliance over long term. Vasopressin receptor antagonists (Vaptans) are a new group of nonpeptide drugs which have been used in various clinical conditions with limited success. Whereas conivaptan is to be administered intravenously, the other vaptans like tolvaptan, lixivaptan, and satavaptan are effective as oral medication. They produce aquaresis by their action on vasopressin type 2 (V2R) receptors in the collecting duct and thus increase solute free water excretion. Vaptans are being used as an alternative to fluid restriction in euvolemic and hypervolemic hyponatremic patients. Efficacy of vaptans is now well accepted for management of correction of hyponatremia over a short period. However, its efficacy in improving the long-term morbidity and mortality in patients with chronic hyponatremia due to cirrhosis and heart failure is yet to be established. Vaptans have not become the mainstay treatment of hyponatremia yet. PMID:22470853
Lu, Jonathan T; Muchir, Antoine; Nagy, Peter L; Worman, Howard J
Mutations in the LMNA gene, which encodes A-type nuclear lamins (intermediate filament proteins expressed in most differentiated somatic cells), cause a diverse range of diseases, called laminopathies, that selectively affect different tissues and organ systems. The most prevalent laminopathy is cardiomyopathy with or without different types of skeletal muscular dystrophy. LMNA cardiomyopathy has an aggressive clinical course with higher rates of deadly arrhythmias and heart failure than most other heart diseases. As awareness among physicians increases, and advances in DNA sequencing methods make the genetic diagnosis of LMNA cardiomyopathy more common, cardiologists are being faced with difficult questions regarding patient management. These questions concern the optimal use of intracardiac cardioverter defibrillators to prevent sudden death from arrhythmias, and medical interventions to prevent heart damage and ameliorate heart failure symptoms. Data from a mouse model of LMNA cardiomyopathy suggest that inhibitors of mitogen-activated protein kinase (MAPK) signaling pathways are beneficial in preventing and treating cardiac dysfunction; this basic research discovery needs to be translated to human patients.
Shi, Lin; López Villar, Elena; Chen, Chengshui
Because of the economic growth and changes in lifestyle, metabolic diseases have become a major public health problem, which impose heavy economic burdens on individuals, families and health systems. However, its precise mediators and mechanisms remain to be fully understood. Clinical translational medicine (CTM) is an emerging area comprising multidisciplinary research from basic science to medical applications and as a new tool to improve human health by reducing disease incidence, morbidity and mortality. It can bridge knowledge of metabolic diseases processes, gained by in vitro and experimental animal models, with the disease pathways found in humans, further to identify their susceptibility genes and enable patients to achieve personalized medicament treatment. Thus, we have the reasons to believe that CTM will play even more roles in the development of new diagnostics, therapies, healthcare, and policies and the Sino-American Symposium on Clinical and Translational Medicine (SAS-CTM) will become a more and more important platform for exchanging ideas on clinical and translational research and entails a close collaboration among hospital, academia and industry.
Liu, Tao; Wang, Ning; Zhang, Li; Zhong, Linda
Functional abdominal pain syndrome (FAPS) is one of the less common functional gastrointestinal disorders. Conventional therapy has unsatisfactory response to it so people turn to Chinese medicine for help. Currently, we reviewed the whole picture of Chinese herbal medicine (CHM) clinical and basic application in the treatment of FAPS, especially the traditional Chinese medicine (TCM) syndrome, the single herb, and Chinese medicine formulae, thus to provide a solid base to further develop evidence-based study for this common gastrointestinal complaint in the future. We developed the search strategy and set the inclusion and exclusion criteria for article search. From the included articles, we totally retrieved 586 records according to our searching criteria, of which 16 were duplicate records and 291 were excluded for reasons of irrelevance. The full text of 279 articles was retrieved for detailed assessment, of which 123 were excluded for various reasons. The number one used single herb is Radix Ginseng. The most common syndrome was liver qi depression. The most frequently used classic formula was Si-Mo-Tang. This reflected the true situation of clinical practice of Chinese medicine practitioners and could be further systematically synthesized as key points of the therapeutic research for FAPS.
Liu, Tao; Wang, Ning
Functional abdominal pain syndrome (FAPS) is one of the less common functional gastrointestinal disorders. Conventional therapy has unsatisfactory response to it so people turn to Chinese medicine for help. Currently, we reviewed the whole picture of Chinese herbal medicine (CHM) clinical and basic application in the treatment of FAPS, especially the traditional Chinese medicine (TCM) syndrome, the single herb, and Chinese medicine formulae, thus to provide a solid base to further develop evidence-based study for this common gastrointestinal complaint in the future. We developed the search strategy and set the inclusion and exclusion criteria for article search. From the included articles, we totally retrieved 586 records according to our searching criteria, of which 16 were duplicate records and 291 were excluded for reasons of irrelevance. The full text of 279 articles was retrieved for detailed assessment, of which 123 were excluded for various reasons. The number one used single herb is Radix Ginseng. The most common syndrome was liver qi depression. The most frequently used classic formula was Si-Mo-Tang. This reflected the true situation of clinical practice of Chinese medicine practitioners and could be further systematically synthesized as key points of the therapeutic research for FAPS. PMID:27366194
Nishimura, Nobuhiro; Doi, Norio; Uemura, Tomochika; Taketani, Takeshi; Hayashi, George; Kasai, Takeshi; Kanai, Rie; Yamaguchi, Seiji; Iwamoto, Kikuo; Naora, Kohji
A traditional Chinese herbal medicine, Kampo medicine, maoto, has been widely used in the treatment of febrile symptoms caused by viral infection. This herbal extract granule for oral use, however, is not well accepted by infants or young children due to its unpleasant taste and odor. Therefore, we prepared Kampo medicine, maoto, suppository and investigated the pharmaceutical and clinical efficacy of the suppository. Kampo medicine, maoto, granules were micro-pulverized and homogeneously dispersed into Hosco-H15 to prepare suppositories containing 0.25 to 1.0 g herbal extract by the conventional fusion method. Content of l-ephedrine, an index compound of Kampo medicine, maoto, in the extract granules and suppositories was determined by using a high performance liquid chromatographic method. Physicochemical experiments revealed that the suppository containing 0.5 g herbal extract had the most suitable melting point of 34 degrees C. Contents of l-ephedrine in the suppository were constant, 93-96% of those in the same amount of the extract granules in different three lots. Upper and lower portions of the suppository had the same content of l-ephedrine. The suppository maintained more than 95% of l-ephedrine content through 6 months at 4 degrees C, room temperature and 40 degrees C, although maldistribution of the extract constituent was observed after storage at 40 degrees C. The suppository was administered to 21 pediatric febrile patients at a dose of 1/3 to 2 full pieces depending on their body weight and physical status. Significant reduction (p<0.001) of body temperature from 39.5 to 37.5 degrees C without serious adverse effects was observed in 17 patients who were monitored the clinical effects on the febrile symptoms. In conclusion, Kampo medicine, maoto, suppository was found to satisfy the physicochemical quality and quantity standards as well as to be clinically applicable to neonates, infants and children with viral febrile symptoms without any adverse
Devesa Jordà, F; Pellicer Bataller, J; Ferrando Ginestar, J; Borghol Hariri, A; Bustamante Balén, M; Ortuño Cortés, J; Ferrando Marrades, I; Llobera Bertran, C; Sala Lajo, A; Miñana Morell, M; Nolasco Bonmatí, A; Fresquet Febrer, J L
The consumption of medicinal herbs is one of the most important topics in alternative and complementary medicine. The widespread use of these substances among the general population gives rise to the possibility of therapeutic or toxic effects in patients seeking conventional medical assistance. To determine the frequency of medicinal herb use, the species consumed and the profile of medicinal herb consumers among patients with gastrointestinal disorders, patients attending the gastroenterology outpatient clinic of the Francesc de Borja district hospital (Gandía, Spain) over a 5-month period were interviewed and 539 valid questionnaires were obtained. A total of 34.7% of the interviewees had taken medicinal herbs at some time and 26.9% had used them in the last year. Self-prescription was reported by 67.1%. Medicinal herbs were mainly obtained in the pharmacy or herbalist's (74.7%). The results of medicinal herb therapy were considered good or excellent by 80.3% of the interviewees, average by 18.6% and poor by 1.1%. In the univariate analysis, medicinal herb consumption was positively associated with female sex (p < 0.001), a university education (p < 0.05), consumption of psychotropic drugs (p < 0.005), use of trencar l'enfit (TE, a common practice of magic medicine in Valencia) (p < 0.001), functional gastrointestinal disorders (p < 0.005) and a diagnosis of lower gastrointestinal disorder (p < 0.01). In the multivariate analysis, the variables that remained statistically significant were female sex (p < 0.005), university education (p < 0.01), use of TE and a diagnosis of lower gastrointestinal disorder. Fifty-seven botanical varieties were used. The most frequent varieties were Santolina chamaecyparissus (18.8%), Tilia platyphyllos (6.5%), Thymus vulgaris (6%), Equisetum ramosissimum (4.7%), Mentha pulegium (4.4%) and Valeriana officinalis (4.4%). The results show that consumption of medicinal herbs is frequent among patients attending the gastroenterology
Brailo, Vlaho; Firriolo, Francis John; Tanaka, Takako Imai; Varoni, Elena; Sykes, Rosemary; McCullough, Michael; Hua, Hong; Sklavounou, Alexandra; Jensen, Siri Beier; Lockhart, Peter B; Mattsson, Ulf; Jontell, Mats
To assess the current scope and status of Oral Medicine-specific software (OMSS) utilized to support clinical care, research, and education in Oral Medicine and to propose a strategy for broader implementation of OMSS within the global Oral Medicine community. An invitation letter explaining the objectives was sent to the global Oral Medicine community. Respondents were interviewed to obtain information about different aspects of OMSS functionality. Ten OMSS tools were identified. Four were being used for clinical care, one was being used for research, two were being used for education, and three were multipurpose. Clinical software was being utilized as databases developed to integrate of different type of clinical information. Research software was designed to facilitate multicenter research. Educational software represented interactive, case-orientated technology designed for clinical training in Oral Medicine. Easy access to patient data was the most commonly reported advantage. Difficulty of use and poor integration with other software was the most commonly reported disadvantage. The OMSS presented in this paper demonstrate how information technology (IT) can have an impact on the quality of patient care, research, and education in the field of Oral Medicine. A strategy for broader implementation of OMSS is proposed. Copyright © 2015 Elsevier Inc. All rights reserved.
Jiang, Yue-rong; Chen, Ke-ji
More attentions have been paid to the development of evidence-based clinical practice guidelines (ECPGs) of Chinese medicine (CM). International guideline evaluation instruments such as Appraisal of Guidelines for Research and Evaluation (AGREE I) has been gradually applied in ECPGs quality evaluation of CM. Nowadays, there are some certain methodological defects in partial ECPGs of Chinese medicine, with relatively low applicability and slowly update. It is suggested to establish technical specifications of CM-ECPGs in accordance with the characteristics of CM and international general specification, strengthen the quality evaluation of CM-ECPGs, attach great importance to the regularly update as well as popularization and application of CM-ECPGs.
Sliwa, J A; McPeak, L; Gittler, M; Bodenheimer, C; King, J; Bowen, J
Described as the balance of values on either side of a moral dilemma, ethics and ethical issues are of increasing importance in the changing practice of rehabilitation medicine. Because the substance of ethics and true ethical issues can be difficult to identify, the education of rehabilitation residents in ethics can similarly be challenging. This article discusses topics pertinent to an understanding of clinical ethics in rehabilitation medicine and provides a method of teaching residents through an algorithm of ethical issues, learning objectives, and illustrative cases.
Schaller, Bernhard; Sandu, Nora
In contrast to public health and the resolution to further increase the health care of the whole community in regions worldwide, current clinical medicine has its limits. Further improvement in public health – rather than individual diseases – can only be achieved by integrating new views into treatment. Some years ago, the concept of biopsychosocial medicine was integrated into patient treatment and is now generally accepted. Therefore the author describes here a new dimension to treatment and presents substantial evidence to include ecological health in this already existing concept. The problem of community education is discussed. PMID:22291784
Integrative medicine is becoming an increasingly popular and visible component in oncology care. Thus, the question arises: How can clinicians facilitate, encourage, and integrate the use of complementary and integrative medicines (CIMs) in patients with cancer? The integrative medicine consultation is not easy and involves much more than simply providing reliable information about the proper use of CIM therapies to alleviate symptoms. Some key factors are necessary to allow for a successful consultation for patients and their families and caregivers: physicians must have extensive knowledge of CIM and of cancer care; they must use a sensitive approach in communication with the patient that relies on effective communication skills and experience in listening; and they must have the ability to convey empathy and compassion.
Gallan, Alexander J; Offner, Gwynneth D; Symes, Karen
Vertical integration has been extensively implemented across medical school curricula but has not been widely attempted in the field of biochemistry. We describe a novel curricular innovation in which a near-peer learning model was used to implement vertical integration in our medical school biochemistry course. Senior medical students developed and facilitated a case-based small group session for first year biochemistry students. Students were surveyed before and after the session on their attitudes about biochemistry, as well as the effectiveness of the session. Prior to the session, the students believed biochemistry was more important to understanding the basic science of medicine than it was to understanding clinical medicine or becoming a good physician. The session improved students' attitudes about the importance of biochemistry in clinical medicine, and after the session they now believe that understanding biochemistry is equally important to the basic sciences as clinical medicine. Students would like more sessions and believe the senior student facilitators were knowledgeable and effective teachers. The facilitators believe they improved their teaching skills. This novel combination of near-peer learning and vertical integration in biochemistry provided great benefit to both first year and senior medical students, and can serve as a model for other institutions. © 2016 by The International Union of Biochemistry and Molecular Biology, 44(6):507-516, 2016.
Martín, Patricia Gálvez; Martinez, Adolfina Ruiz; Lara, Visitación Gallardo; Naveros, Beatriz Clares
The development of new drugs using stem cells has become a clinic alternative for the treatment of different diseases such as Alzheimer's, diabetes and myocardial infarction. Similar to conventional medicines, stem cells as new medicinal products for cell therapy are subjected to current legislation concerning their manufacture process. Besides, their legality is determined by the Regulatory Agencies belonging to the Member State of the European Union in which they are being registered. With the evolution of therapy that uses cells as medicines, there is a need to develop the appropriate legislative and regulatory framework capable of ensuring their safety and effectiveness. However, few works have been published regarding the regulations that these products must comply through production and commercialization processes. The present work is focused on the description of key events during clinical development and cell production of stem cells as drugs. Such as the regulations, requirements and directives involved in the production of cell therapy medicinal products, from the clinical design stage to its commercialization in Europe.
Koonrungsesomboon, Nut; Karbwang, Juntra
Cardiovascular disease (CVD) in the ageing is a major public health problem worldwide. The nature of most CVD is subclinical with pathological processes that can span over years. Use of preventive measures could be an appropriate approach to prevailing over CVD in the ageing, and herbal medicine is one of the promising preventive approaches and is currently of interest among medical societies. In the evidence-based era, herbal medicine is, however, often underestimated and approached with skepticism, mainly due to the paucity of scientific evidence. Properly designed clinical trials on herbal medicine for prevention of CVD in a geriatric population are thus of importance and of clinical value. To review ethical issues and discuss considerations when such research is proposed. Four ethical issues, including the scientific validity of research, risk-benefit assessments, subject selection and vulnerability, and informed consent, are structured and extensively discussed in this article. Ethical core considerations of prevention research of CVD on herbal medicine involve particular attention on the scientific validity of research, risk-benefit assessments, subject selection and vulnerability, and informed consent. These issues and considerations are keys, although they must be adapted to an individual research setting in which a clinical study is proposed. Copyright © 2015 Elsevier GmbH. All rights reserved.
Li, Yuanfang; Zhou, Zhiwei
Precision medicine is a new medical concept and medical model, which is based on personalized medicine, rapid progress of genome sequencing technology and cross application of biological information and big data science. Precision medicine improves the diagnosis and treatment of gastric cancer to provide more convenience through more profound analyses of characteristics, pathogenesis and other core issues in gastric cancer. Cancer clinical database is important to promote the development of precision medicine. Therefore, it is necessary to pay close attention to the construction and management of the database. The clinical database of Sun Yat-sen University Cancer Center is composed of medical record database, blood specimen bank, tissue bank and medical imaging database. In order to ensure the good quality of the database, the design and management of the database should follow the strict standard operation procedure(SOP) model. Data sharing is an important way to improve medical research in the era of medical big data. The construction and management of clinical database must also be strengthened and innovated.
Salihefendic, Nizama; Zildzic, Muharem; Masic, Izet; Hadziahmetovic, Zoran; Vasic, Dusko
Emergency medicine is a new academic discipline, as well as a recent independent clinical specialization with the specific principles of practice, education and research. It is also a very important segment of the overall health care and health system. Emergency medicine as a distinct specialty was introduced in the U.S. in 1970. Ten years later and relatively quickly emergency medicine was introduced in the health system in Bosnia and Herzegovina as a specialty with a special education program for specialist and a final exam. Compare the development of emergency medicine in Bosnia and Herzegovina with the trends of development of this discipline in the world as a specialization and an academic discipline. Identify specific problems and possible solutions and learn lessons from other countries. Reviewed are the literature data on the development of emergency medicine in the world, programs of undergraduate and postgraduate teaching, the organizational scheme of emergency centers and residency. This is then compared with data of the current status of emergency medicine as an academic discipline and a recognized specialization, in Bosnia and Herzegovina. There are substantial differences in the development of emergency medicine in the United States, European Union and Bosnia and Herzegovina. Although Bosnia and Herzegovina relatively early recognized specialty of emergency medicine in academia, it failed to mach the academic progress with the practical implementation. A&E departments in the Community Health Centers failed to meet the desired objectives even though they were led by specialists in emergency medicine. The main reason being the lack of space and equipment as well as staff needed to meet set standards of good clinical practice, education and research. Furthermore the Curriculum of undergraduate education and specialization does not match modern concept of educational programs that meet the principles set out in emergency medicine and learning through
Halas, Gayle; Singer, Alexander; Styles, Carol; Katz, Alan
To capture users' experiences with a newly implemented electronic medical record (EMR) in family medicine academic teaching clinics and to explore their perceptions of its use in clinical and teaching processes. Qualitative study using focus group discussions guided by semistructured questions. Three family medicine academic teaching clinics in Winnipeg, Man. Faculty, residents, and support staff. Focus group discussions were audiorecorded and transcribed. Data were analyzed by open coding, followed by development of consensus on a final coding strategy. We used this to independently code the data and analyze them to identify salient events and emergent themes. We developed a conceptual model to reflect and summarize key themes that we identified from participant comments regarding EMR implementation and use in an academic setting. These included training and support, system design, information management, work flow, communication, and continuity. This is the first specific analysis of user experience with a newly implemented EMR in urban family medicine teaching clinics in Canada. The experiences of our participants with EMR implementation were similar to those reported in earlier investigations, but highlight organizational influences and integration strategies. Learning how to use and transitioning to EMRs has implications for clinical learners. This points to the need for further research to gain a more in-depth understanding of the effects of EMRs on the learning environment.
Bacher, Klaus; Thierens, Hubert M
In nuclear medicine, an increasing number of radiolabelled agents are under investigation for future use in diagnostic imaging and for applications in radionuclide therapy. All these studies require large amounts of human data to allow for statistical comparisons with existing and well established diagnostic or therapeutic methodologies. In the framework of a good clinical practice environment, clinical trials should be carried out according to international guidelines and regulations as described in the Declaration of Helsinki. Studies involving ionizing radiation, as is the case in nuclear medicine, require special consideration to comply with the ALARA (as low as reasonably achievable) principle. Special publications of the International Commission of Radiological Protection and the World Health Organization deal with this topic in medical research. From the legislation point of view, the 97/43/EURATOM Directive represents the reference to clinical research using ionizing radiation within the European Union. In order to keep the radiation dose of (healthy) volunteers as low as possible, predictive dosimetry studies based on in-vivo animal biokinetics are essential. On the other hand, patients included in dose-escalation radionuclide therapy trials should be monitored individually with respect to dosimetry of the tumour and the critical organs. In this paper the importance and methodology of contemporary patient dosimetry in diagnostic and therapeutic nuclear medicine research are reviewed. It is concluded that reliable dosimetry is essential in performing scientific clinical studies according to the principle of good clinical practice.
Liu, Xiaoni; Li, Ning
To evaluate clinical treatment regularity of traditional Chinese medicine (TCM) on primary liver cancer and provide inspiration for the clinical use. Traditional Chinese medicine database on primary liver cancer was established to analysis the classification, frequency, dosage of TCM in clinical treatment. Tonic medicine is the most common medication, herbs for heat-clearing, promoting blood circulation for removing blood stasis, eliminating dampness and diuresis and regulating flow of Qi are more common medication, herbs for relieving exterior disorder and digesting are common medication; the first frequency of single herb is Atractglodis Macrocephalae Rhizoma, Poria, Codonopsis Radix. Popular classical prescriptions are Sijunzi Tang, Xiaochaihu Tang, YiguanJian, Xiangsha Liujunzi Tang, Xiaoyao Wan and Gexia Zhuyu Tang, Liuwei Dihuang Tang and Yinchenhao Tang et al. Gallic Gigerii Endothelium Corneum and Ophiopogonis Radix are most commonly drug for poor appetite. Astragali Radix is most commonly drug for fatigue. Corydalis Rhizoma, Toosendan Fructus are most common for liver pain; Pericarpium Arecae, Polyporus, Poria are most common herbs for ascites; Artemisiae Scopariae Herba is common drug for jaundice. Replenishing qi to invigorate the spleen, sparsing liver to regulate the flow of vital energy, clearing heat and promoting diuresis, promoting blood circulation for removing blood stasis, nourishing yin and detoxification are the main principles for treating primary liver cancer. Improving clinical symptoms, signs and quality of life of patients with TCM is the key to clinical treatment.
Halas, Gayle; Singer, Alexander; Styles, Carol; Katz, Alan
Abstract Objective To capture users’ experiences with a newly implemented electronic medical record (EMR) in family medicine academic teaching clinics and to explore their perceptions of its use in clinical and teaching processes. Design Qualitative study using focus group discussions guided by semistructured questions. Setting Three family medicine academic teaching clinics in Winnipeg, Man. Participants Faculty, residents, and support staff. Methods Focus group discussions were audiorecorded and transcribed. Data were analyzed by open coding, followed by development of consensus on a final coding strategy. We used this to independently code the data and analyze them to identify salient events and emergent themes. Main findings We developed a conceptual model to reflect and summarize key themes that we identified from participant comments regarding EMR implementation and use in an academic setting. These included training and support, system design, information management, work flow, communication, and continuity. Conclusion This is the first specific analysis of user experience with a newly implemented EMR in urban family medicine teaching clinics in Canada. The experiences of our participants with EMR implementation were similar to those reported in earlier investigations, but highlight organizational influences and integration strategies. Learning how to use and transitioning to EMRs has implications for clinical learners. This points to the need for further research to gain a more in-depth understanding of the effects of EMRs on the learning environment. PMID:26167563
Parva, Elahe; Boostani, Reza; Ghahramani, Zahra; Paydar, Shahram
Clinical databases can be categorized as big data, include large quantities of information about patients and their medical conditions. Analyzing the quantitative and qualitative clinical data in addition with discovering relationships among huge number of samples using data mining techniques could unveil hidden medical knowledge in terms of correlation and association of apparently independent variables. The aim of this research is using predictive algorithm for prediction of trauma patients on admission to hospital to be able to predict the necessary treatment for patients and provided the necessary measures for the trauma patients who are before entering the critical situation. This study provides a review on data mining in clinical medicine. The relevant, recently-published studies of data mining on medical data with a focus on emergency medicine were investigated to tackle pros and cons of such approaches. The results of this study can be used in prediction of trauma patient’s status at six hours after admission to hospital. PMID:28507995
It has been well established that appropriate physical activity and exercise play an important role in promotion of health and fitness, prevention of disease and treatment and rehabilitation of health conditions. However, practice based on scientific evidence, in respect of the role and effectiveness of exercise interventions in prevention and treatment of diseases, has only been promoted and implemented in the fields of clinical exercise physiology, public health and medicine in recent years. This brief review provides an introduction of the concept of "Exercise is Medicine", the development and evidence-based practice in Clinical Exercise Physiology, and the role and training of Clinical Exercise Physiologist in the health care system of some other countries.
Colburn, Jessica L; Christmas, Colleen
information about the general health of the patient was the most important, followed by education about warning signs and symptoms, and the opportunity to share concerns about the patient. These rankings were consistent with the views of the companions themselves. In this pilot investigation, half of the patients of the internal medicine clinic who brought a companion did so for every visit. These patients relied on their companions to ask questions during the visit and to help remember the physician's instructions. Residents and companions generally agreed on the roles of companions, but almost none of the residents had any formal training in interacting with visit companions.
McMurray, Janet; Zerah, Simone; Hallworth, Michael; Koeller, Ursula; Blaton, Victor; Tzatchev, Kamen; Charilaou, Charis; Racek, Jaroslav; Johnsen, Anders; Tomberg, Karel; Harmoinen, Aimo; Baum, Hannsjörg; Rizos, Demetrios; Kappelmayer, Janos; O'Mullane, John; Nubile, Giuseppe; Pupure, Silvija; Kucinskiene, Zita; Opp, Matthias; Huisman, Wim; Solnica, Bogdan; Reguengo, Henrique; Grigore, Camelia; Spanár, Július; Strakl, Greta; Queralto, Josep; Wallinder, Hans; Schuff-Werner, Peter
In 1997, the European Communities Confederation of Clinical Chemistry and Laboratory Medicine (EC4) set up a Register for European Specialists in Clinical Chemistry and Laboratory Medicine. The operation of the Register is undertaken by a Register Commission (EC4RC). During the last 10 years, more than 2000 specialists in Clinical Chemistry and Laboratory Medicine have joined the Register. In 2007, EC4 merged with the Federation of European Societies of Clinical Chemistry and Laboratory Medicine (FESCC) to form the European Federation of Clinical Chemistry and Laboratory Medicine (EFCC). A Code of Conduct was adopted in 2003 and a revised and updated version, taking account particularly of the guidelines of the Conseil Européen des Professions Libérales (CEPLIS) of which EFCC is a member, is presented in this article. The revised version was approved by the EC4 Register Commission and by the EFCC Executive Board in Paris on 6 November, 2008.
McMurray, Janet; Zérah, Simone; Hallworth, Michael; Schuff-Werner, Peter; Haushofer, Alexander; Szekeres, Thomas; Wallemacq, Pierre; Tzatchev, Kamen; Charilaou, Charis; Racek, Jaroslav; Johnsen, Anders; Tomberg, Karel; Harmoinen, Aimo; Baum, Hannsjörg; Rizos, Demetrios; Kappelmayer, Janos; O'Mullane, John; Nubile, Giuseppe; Pupure, Silvija; Kucinskiene, Zita; Opp, Matthias; Jansen, Rob; Solnica, Bogdan; Reguengo, Henrique; Grigore, Camelia; Spanár, Július; Strakl, Greta; Queralto, Josep; Wallinder, Hans; Wieringa, Gijsbert
In 1997, the European Communities Confederation of Clinical Chemistry and Laboratory Medicine (EC4) set up a Register for European Specialists in Clinical Chemistry and Laboratory Medicine. The operation of the Register is undertaken by a Register Commission (EC4RC). During the last 12 years, more than 2200 specialists in Clinical Chemistry and Laboratory Medicine have joined the Register. In 2007, EC4 merged with the Forum of European Societies of Clinical Chemistry and Laboratory Medicine (FESCC) to form the European Federation of Clinical Chemistry and Laboratory Medicine (EFCC). Two previous Guides to the Register have been published, one in 1997 and another in 2003. The third version of the Guide is presented in this article and is based on the experience gained and development of the profession since the last revision. Registration is valid for 5 years and the procedure and criteria for re-registration are presented as an Appendix at the end of the article.
Todd, Jamie L; White, Kyle R; Chiswell, Karen; Tasneem, Asba; Palmer, Scott M
ClinicalTrials.gov is the largest trial registry in the world. Strengthened registration requirements, including federal mandates in 2007, have increased study representation. A systematic evaluation of all registered studies has been limited by the absence of an aggregate data set and specialty-specific search terms. We leveraged a newly transformed database containing annotated data from ClinicalTrials.gov to define the portfolio of interventional clinical research in pulmonary, critical care, and sleep medicine. Analysis was restricted to studies registered after September 2007 through September 2010 and defined as "interventional" (n = 40,970). A specialty-specific study data set (n = 2,226) was created using disease condition terms provided by data submitters and medical subject heading terms generated by a National Library of Medicine algorithm. Trial characteristics were extracted and summarized using descriptive statistics. Pulmonary, critical care, and sleep medicine trials composed 5.4% of all interventional studies registered over the 3-year period. In contrast, oncology and cardiovascular disease composed 21.9 and 8.4% of trials, respectively. Within pulmonary trials, asthma and chronic obstructive pulmonary disease were the most studied conditions (27.4 and 21.8% of studies, respectively), and measures of lung function or safety were the most frequent primary outcomes. Nearly two-thirds of trials indicated enrollment of 100 patients or fewer, and a majority of studies were phase II or III trials. The single largest funding source (43.5%) was industry, and study characteristics varied by funding source. We applied a novel approach to describe the portfolio of interventional clinical research in pulmonary medicine. Our results indicate a disparity between trial representation and the burden of respiratory disease. Resources should be targeted across the spectrum of pulmonary research to address this discrepancy.
Khongsomboon, Khamphong; Hamamoto, Kazuhiko; Kondo, Shozo
3D reconstruction from ordinary X-ray equipment which is not CT or MRI is required in clinical veterinary medicine. Authors have already proposed a 3D reconstruction technique from X-ray photograph to present bone structure. Although the reconstruction is useful for veterinary medicine, the thechnique has two problems. One is about exposure of X-ray and the other is about data acquisition process. An x-ray equipment which is not special one but can solve the problems is X-ray fluoroscopy. Therefore, in this paper, we propose a method for 3D-reconstruction from X-ray fluoroscopy for clinical veterinary medicine. Fluoroscopy is usually used to observe a movement of organ or to identify a position of organ for surgery by weak X-ray intensity. Since fluoroscopy can output a observed result as movie, the previous two problems which are caused by use of X-ray photograph can be solved. However, a new problem arises due to weak X-ray intensity. Although fluoroscopy can present information of not only bone structure but soft tissues, the contrast is very low and it is very difficult to recognize some soft tissues. It is very useful to be able to observe not only bone structure but soft tissues clearly by ordinary X-ray equipment in the field of clinical veterinary medicine. To solve this problem, this paper proposes a new method to determine opacity in volume rendering process. The opacity is determined according to 3D differential coefficient of 3D reconstruction. This differential volume rendering can present a 3D structure image of multiple organs volumetrically and clearly for clinical veterinary medicine. This paper shows results of simulation and experimental investigation of small dog and evaluation by veterinarians.
Kampo medicines are currently manufactured under strict quality controls. The Ministry of Health, Labour and Welfare of Japan has approved 148 Kampo formulas. There is increasing evidence for the efficacy of Kampo medicines, and some are used clinically for palliative care in Japan. The specific aim of this review is to evaluate the clinical use of Kampo medicines in palliative care in the treatment of cancer. The conclusions are as follows: Juzentaihoto inhibits the progression of liver tumors in a dose-dependent manner and contributes to long-term survival. Hochuekkito has clinical effects on cachexia for genitourinary cancer and improves the QOL and immunological status of weak patients, such as postoperative patients. Daikenchuto increases intestinal motility and decreases the postoperative symptoms of patients with total gastrectomy with jejunal pouch interposition, suppresses postoperative inflammation following surgery for colorectal cancer, and controls radiation-induced enteritis. Rikkunshito contributes to the amelioration of anorectic conditions in cancer cachexia-anorexia syndrome. Goshajinkigan and Shakuyakukanzoto reduce the neurotoxicity of patients with colorectal cancer who undergo oxaliplatin and FOLFOX (5-fluorouracil/folinic acid plus oxaliplatin) therapy. Hangeshashinto has the effect of preventing and alleviating diarrhea induced by CPT-11(irinotecan) and combination therapy with S-1/CPT-11. O’rengedokuto significantly improves mucositis caused by anticancer agents. PMID:24447861
Hart, Curtis W
This article outlines the method utilized by physicians and major figures in the founding of Clinical Pastoral Education, Helen Flanders Dunbar, in her work of 1943, Psychosomatic Diagnosis, and relates it to the currently evolving approach in bioethics known as clinical pragmatism. It assesses Dewey's influence on both Dunbar in psychosomatic medicine and clinical pragmatism in bioethics, and illustrates the breadth of influence of the school of philosophical thought known as pragmatism with which Dewey's name and those of William James and Charles Sanders Pierce are most often identified.
Strom, Brian L; Kelly, Thomas O; Landis, J Richard; Feldman, Harold I
A new model for the conduct of clinical research was established at the University of Pennsylvania (Penn) School of Medicine, now the Perelman School of Medicine, through the development of the interdepartmental Center for Clinical Epidemiology and Biostatistics in 1993 and the basic science Department of Biostatistics and Epidemiology in 1994. The authors describe the development and evolution of these novel structures.Five key objectives were achieved with these structures' creation: (1) Clinical faculty have the opportunity to be identified as both clinicians and epidemiologists, (2) nonclinical faculty have an academic "home," (3) clinical trainees are now educated in population medicine, which promotes its incorporation into their clinical practice, (4) population medicine and clinical medicine have become fully integrated, and (5) better epidemiologic research is conducted, informed by clinical insights.Today's center is the primary home for epidemiology and biostatistics at Penn, linking epidemiology, biostatistics, clinical medicine, and the health sciences. The center's core faculty manage their own research programs, conduct primary research in epidemiology and biostatistics, serve as members of collaborative research teams, manage cores and service centers that support research projects, and lead graduate training programs in epidemiology and biostatistics. The department provides an academic home and structure for faculty, provides primary research in epidemiology and biostatistics, supports the center's mission, and provides training in biostatistics. This organizational approach has wide applicability across schools of medicine in the United States and abroad and has been a model for many.
Zhang, Li; Zhang, Junhua; Chen, Jing; Xing, Dongmei; Wang, Jiaying
Currently, quality issues concerning clinical research of traditional Chinese medicine (TCM) have come into the spotlight. It has been recognized that poorly-devised research methodology largely restricted the development of clinical research in TCM. The choice of appropriate outcome measurements is key to the success of clinical research; however, the current procedure for outcomes selection in clinical research of TCM is problematic due to the underdevelopment of clinical methodology. Under this circumstance, we propose the introduction to the concept of Core Outcome Set (COS) and discuss the feasibility of developing a COS system that caters for clinical studies in TCM, in the hope that the outcome evaluation system could be up to international standards. PMID:24312133
Jubraj, Barry; Barnett, Nina L; Grimes, Lesley; Varia, Sneha; Chater, Angel; Auyeung, Vivian
To critically discuss the need for pharmacists to underpin their consultations with appropriate 'clinical empathy' as part of effective medicines optimisation. Use of literature around empathy, consultation and pharmacy practice to develop a case for greater clinical empathy in pharmacy consultations. Clinical empathy is defined from the literature and applied to pharmacy consultations, with a comparison to empathy in other clinical professions. Historical barriers to the embedding of clinical empathy into pharmacy consultations are also explored. We challenge the pharmacy profession to consider how clinical empathy should underpin consultations with a series of introspective questions and provide some sample questions to support pharmacy consultations. We also make the case for appropriate education and professional development of consultation skills at undergraduate and postgraduate level. We contend that patients' relationships with practitioners are critical, and a lack of empathy can impact the effectiveness of care. © 2016 Royal Pharmaceutical Society.
Yazdy, Mahsa M.; Mitchell, Allen A.; Werler, Martha M.
Genitourinary infections (GUIs) have been associated with increased risk of gastroschisis in 2 studies. Using data collected in the Slone Epidemiology Center Birth Defects Study, we examined the association between GUI and gastroschisis. From 1998 to 2010, mothers of 249 gastroschisis cases and 7,104 controls were interviewed within 6 months of delivery about pregnancy events, including vaginal infections, genital herpes, urinary tract infections (UTIs), and other sexually transmitted diseases (STDs). Women were considered exposed if they reported at least 1 instance of a GUI in the first trimester. Logistic regression models were used to calculate odds ratios and 95% confidence intervals. Women who reported having any GUI had an adjusted odds ratio of 1.8 (95% confidence interval (CI): 1.3, 2.4). The highest risk was seen among women who reported a UTI only (adjusted odds ratio = 2.3, 95% CI: 1.5, 3.5), while the odds ratio for an STD only was slightly elevated (adjusted odds ratio = 1.2, 95% CI: 1.0, 1.5). Among women under 25 years of age, the odds ratio for UTI only was 2.6 (95% CI: 1.7, 4.0), and among older women it was 1.8 (95% CI: 0.6, 5.9). When we considered the joint association of UTIs and young maternal age, a synergistic effect was observed. The results of this study add further evidence that UTIs may increase the risk of gastroschisis. PMID:25073472
King, William W; Young, Melvin E; Fox, M Eugene
A 1-day-old, Toggenburg/Nubian crossbred goat of polled parentage was referred for necropsy because of a large (diameter, 5 cm) bladder-like mass protruding from the perineal midline and difficult urination. Differential diagnoses included cutaneous cyst, ectopic urinary bladder, and urethral diverticulum/dilatation. Several genitourinary aberrations were noted. A second, smaller (diameter, 1 cm), more distal cystic structure was adjacent to an ambiguous prepuce. Testicles were discovered within a constricted, subcutaneous space near the inguinal canals. A rudimentary penis was located dorsal to the penile urethra with no appreciable urethral process. A tiny external urethral orifice was discerned only after liquid was injected into the lumen of the cystic structures, confirming their identity as urethral dilatations. The dilatations were separated by a constricting band of fibrous tissue. No other significant findings were detected. This case illustrates a combination of congenital anomalies including bilateral cryptorchidism with scrotal absence, segmental urethral hypoplasia, and urethral dilatation, most likely associated with the intersex condition seen in polled breeds. The continued production and use of small ruminants as animal models demands the prompt recognition of congenital anomalies. This case also exemplifies the precautions required when breeding goats with polled ancestry.
Luberto, Christina M; Chad-Friedman, Emma; Dossett, Michelle L; Perez, Giselle K; Park, Elyse R
Mind-body interventions can improve vulnerabilities that underlie smoking behavior. The characteristics of smokers who use mind-body medicine have not been explored, preventing the development of targeted interventions. Patients (N = 593) presenting to a mind-body medicine clinic completed self-report measures. Patients were 67 percent never smokers, 27 percent former smokers, and 6 percent current smokers. Current smokers were younger; more likely to be single, unemployed, or on disability; and report greater depression symptoms, greater pain, and lower social support (ps < .05).Current smokers who use mind-body medicine have unique psychosocial needs that should be targeted in mind-body smoking cessation interventions.
Trusheim, Mark R; Berndt, Ernst R
The stratified medicine companion diagnostic (CDx) cut-off decision integrates scientific, clinical, ethical, and commercial considerations, and determines its value to developers, providers, payers, and patients. Competition already sharpens these issues in oncology, and might soon do the same for emerging stratified medicines in autoimmune, cardiovascular, neurodegenerative, respiratory, and other conditions. Of 53 oncology targets with a launched therapeutic, 44 have competing therapeutics. Only 12 of 141 Phase III candidates addressing new targets face no competition. CDx choices might alter competitive positions and reimbursement. Under current diagnostic incentives, payers see novel stratified medicines that improve public health and increase costs, but do not observe companion diagnostics for legacy treatments that would reduce costs. It would be in the interests of payers to rediscover their heritage of direct investment in diagnostic development. Copyright © 2015 Elsevier Ltd. All rights reserved.
Xuan, Nan-Xia; Ying, Song-Min; Li, Wen
Asthma is one of the most common chronic inflammatory disorders, associated with reversible airflow obstruction, airway hyperresponsiveness, and airway remodeling. This disease has a significant impact on individuals, their families, and society. Standardized therapeutics such as inhaled corticosteroid in combination with long acting β2 agonist have been applied for asthma control; however, complementary and alternative medicines, especially herbal medicines, are still widely used all over the world. A growing body of literature suggests that various herbals or related products might be effective in inhibiting asthmatic inflammation. In this review, we summarize recent advances about the mechanistic studies of herbal medicines on allergic airway inflammation in animal models and their potential application into clinic for asthma control. PMID:27478309
Rubin, Ronald P
Alfred Gilman was best known for his co-authorship with Louis Goodman of the seminal textbook on pharmacology The Pharmacological Basis of Therapeutics in 1941. The book made the discipline of pharmacology relevant to clinical medicine by providing a link between the basic medical sciences and the practice of medicine. Gilman was also instrumental in establishing the use of chemotherapy in the treatment of cancer and made important contributions in areas related to renal function, acid-base balance, and diuretics. During the 1960s, he created a first rate department at the newly formed Albert Einstein College of Medicine. A superb lecturer, he commented incisively on issues related to pharmacology, therapeutics, and pathophysiology. Dr Gilman also provided a key link between academia and the pharmaceutical industry by serving as a consultant to several drug firms. The legacy of Alfred Gilman senior was continued by his son, Alfred Goodman Gilman, who became a Nobel Laureate.
This study was designed to investigate the in vitro anticandidal activity of some medicinal plants and Pseudomonas aeruginosa strains against Candida species. The antifungal activity of methanolic extracts of five medicinal plants, namely, Cinnamomum porrectum, Lippia nudiflora, Cestrum nocturnum, Trachyspermum ammi, and Sida carpinifolia were studied. The medicinal characteristics of these plants were compared with commercially used antibiotics. The antimicrobial assay was done by agar well diffusion and the broth dilution method. Among the plants used, T. ammi and C. nocturnum were found to be more potent than the others. Twenty P. aeruginosa strains were isolated from various clinical specimens. The total inhibitions obtained were found to be 47%, 38%, and 36% in blood agar, whereas in Sabouraud dextrose agar (SDA) the inhibitions were 57%, 48%, and 37%, respectively.
Stein, Howard F.
This paper describes an experiment in which Family Medicine residents composed, read, and discussed their poems as a way of bringing to life their often complex relationships with patients. It argues that this approach mobilizes the physicians' own creativity in the service of reflective practice and improved doctor-patient relationships. This…
Tasian, Gregory E.; Bagga, Herman S.; Fisher, Patrick B.; McCulloch, Charles E.; Cinman, Nadya M.; McAninch, Jack W.; Breyer, Benjamin N.
Purpose We describe the epidemiological features of pediatric genitourinary injuries, and determine the products and events that may predict an increased risk of genitourinary injury during childhood. Materials and Methods The National Electronic Injury Surveillance System was queried to identify children 18 years or younger who sustained genitourinary injuries and presented to emergency departments in the United States between 2002 and 2010. Demographics and injury characteristics of these children were analyzed. Analyses were performed with adjustments for sample weighting and the stratified survey design. All data are reported as national estimates along with 95% confidence intervals. Results Based on 10,286 actual cases, an estimated 252,392 children (95% CI 205,579–299,194) sustained genitourinary injuries during the 9-year study period. Children 4 to 7 years old were most frequently injured (36.8% of all injuries), followed by those 8 to 11 years old (20.6%). Girls comprised 55% of the injured children. The yearly incidence of genitourinary injuries was stable across the period studied. The most commonly injured organs were female external genitalia (37.7%), penises (21.6%) and testicles (12%). Genitourinary injuries were most commonly associated with sporting and exercise equipment (35.7%), furniture (15.5%) and clothing items (11.9%). Of the patients 91% were treated at the emergency department and discharged home. Conclusions Genitourinary injuries in children result in approximately 28,000 emergency department visits yearly. Efforts should be made to decrease the risk of genitourinary injuries in children by promoting the use of protective gear and safer product selection for those at greatest risk for injury. PMID:23174237
The Medical University of Plovdiv (MUP) has as its motto 'Committed to humanity". But what does humanity in modern medicine mean? Is it possible to practise a form of medicine that is without humanity? In the current article, it is argued that modern medicine is increasingly being practised in a de-personalised fashion, where the patient is understood not as a unique human individual, a person, but rather as a subject or an object and more in the manner of a complex biological machine. Medicine has, it is contended, become distracted from its duty to care, comfort and console as well as to ameliorate, attenuate and cure and that the rapid development of medicine's scientific knowledge is, paradoxically, principally causative. Signal occurrences in the 'patient as a person' movement are reviewed, together with the emergence of the evidence-based medicine (EBM) and patient-centered care (PCC) movements. The characteristics of a model of medicine evolving in response to medicine's current deficiencies--person-centered healthcare (PCH)--are noted and described. In seeking to apply science with humanism, via clinical judgement, within an ethical framework, it is contended that PCH will prove to be far more responsive to the needs of the individual patient and his/her personal circumstances than current models of practice, so that neither a reductive anatomico-pathological, disease-centric model of illness (EBM), nor an aggressive patient-directed, consumerist form of care (PCC) is allowed continued dominance within modern healthcare systems. In conclusion, it is argued that PCH will enable affordable advances in biomedicine and technology to be delivered to