[The XXI century patient]

We are experiencing a social change in health that is unprecedented in the history of humanity. Modern sociology attempts to explain this change using concepts of reflexive modernisation, liquid life or society, or the end of history. This social change results in a new model of patient who is better informed and has greater expectations with respect to healthcare and health. More information does not mean better understanding and more responsibility with respect to health. For this to occur, it is necessary to increase the social and individual conscience of people as health agents and as responsible users. The University of the Patients emerges as a project directed towards increasing the health and civic literacy of the population and from the need to adapt the health systems to the new needs generated by a new model of user.

[Organization of oncogynaecological help and care: time for change? Summarising our and foreign experience]

With this study we try to put on discussion the organization of the oncogynaecological help and care, as we try to summarise our and foreign experience in this field. Always in a discussion can be born good ideas and consensus is reached especially in such field as the oncogynaecology. The theme of the organization of the oncogynaecological help and care, the possibilities for change into better expertise and the attitude to the subspeciality of oncogynaecology are even more important now when Bulgaria will be accepted in the european family of countries in 2007.

Dialysis Patients and Cardiovascular Problems: Can Technology Help Solve the Complex Equation?

Patients with end-stage kidney disease undergoing chronic hemodialysis (HD) present higher mortality rates compared with the general population. Once patients are on HD, the risk of cardiovascular death is approximately 30 times higher than in the general population and remains 10-20 times higher after stratification for age, gender, and the presence of diabetes. About half the deaths of patients on dialysis are attributed to cardiovascular causes including coronary heart disease, cerebrovascular disease, peripheral vascular disease, and heart failure. The cardiovascular burden of the HD patient arises from three different sources: risks inherent to the patient and the uremic syndrome, traditional risk factors, and risk factors related to the dialysis therapy. Based on these considerations and the fact that several aspects of the dialysis procedure can either add to the cardiovascular burden or modify the existing burden, new technologies should be directed towards the approach of a potential 'cardioprotective dialysis therapy'; such an approach may be facilitated by the application of new techniques and advanced dialysis machines. Created to make dialysis easy and safe, new machines feature several options that make patient monitoring and online hemodiafiltration therapy routine procedures. These and other features will possibly make dialysis better tolerated and more efficient in protecting patients from undesirable or potentially fatal cardiovascular events.

Influence of socio-economic deprivation on outcomes for patients diagnosed with gastric cancer

OBJECTIVE

Socio-economic deprivation has an influence on the outcome for patients diagnosed with breast, colorectal and bronchial cancer, but there are few data on its association with gastric cancer. The aim of this study was to determine the influence of socio-economic deprivation on outcomes for patients with gastric cancer.

MATERIAL AND METHODS

Three hundred and thirty consecutive patients with gastric adenocarcinoma presenting to a single hospital between 1 October 1995 and 30 June 2004 were studied prospectively and deprivation scores calculated using the National Assembly for Wales Indices of Multiple Deprivation. The patients were subdivided into quintiles for analysis.

RESULTS

Inhabitants of the most deprived areas (quintile 5) were younger at presentation (median 70 years versus 74 years, p=0.007), and experienced longer delays in diagnosis (18 weeks versus 9 weeks, p=0.02) when compared with patients from the least deprived areas (quintile 1). Operative mortality was 3-fold higher for patients from the most deprived areas when compared with patients from less deprived areas (15% versus 5%, p=0.03). There was no correlation between stage of disease and socio-economic deprivation. For patients undergoing potentially curative surgery, the 5-year survival for patients from the most deprived areas was 32%, compared with 66% for patients from the least deprived areas (p=0.03).

CONCLUSIONS

Socio-economic deprivation was associated with younger age at diagnosis, longer diagnostic delay, greater operative mortality and a shorter duration of survival following R0 gastrectomy. These poorer outcomes were not explained by the stage of disease at diagnosis.

Modernising Medical Careers: is it good for patients?

Postgraduate medical education and training is about to be overhauled in a way that will make the Calman reforms of specialist training seem modest in comparison. August 2005 sees the launch of a new structure and curriculum for the first 2 years, called the foundation programme.

Epidemiology of restless legs syndrome in French adults: A nationwide survey: The INSTANT Study

OBJECTIVE

To evaluate the prevalence, characteristics, and treatment of restless legs syndrome (RLS) in France.

METHODS

In this population-based survey, face-to-face home interviews were conducted among a random sample of 10,263 French adults. A French translation of the four features defined by the International RLS Study Group in 1995 was used to assess the prevalence of symptoms consistent with a diagnosis of RLS. Data on severity of symptoms and their management were also collected.

RESULTS

The 12-month prevalence of RLS symptoms in the French adult population was estimated to be 8.5% (95% CI 8.0%, 9.0%), with a higher prevalence (p < 0.001) observed in women (10.8%) than in men (5.8%). Prevalence increases with age until 64 years and decreases thereafter in both sexes. Half of the identified subjects reported symptoms once a week at least. Symptoms were more severe in subjects reporting symptoms once a week at least compared to subjects with less frequent symptoms. In this group, half of the subjects reported a family history, the age at onset was earlier, and severity of symptoms higher. RLS had been previously diagnosed in only 5.3% of the subjects who reported previous medical diagnosis, and recommended RLS drug treatment was received by 3.4% of the 28.7% currently treated subjects.

CONCLUSIONS

Restless legs syndrome (RLS) occurred in 10% of women and 5% of men. RLS prevalence decreases after the age of 64. RLS is often underdiagnosed and few subjects receive recommended RLS drug treatment.

Contemporary issues in the care of patients with chronic obstructive pulmonary disease

OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and is estimated to be responsible for 119,000 deaths in the year 2000 alone. Additionally, COPD places a tremendous burden on the health care system, with estimated annual costs of US 24 billion dollars in 2000, and it is generally expected that costs will continue to rise as more individuals are diagnosed. COPD was responsible for approximately 8 million physician outpatient visits, 1.5 million emergency department visits and 726,000 hospitalizations, also in the year 2000. The objective of this article is to review current, pertinent clinical issues in the management of patients with COPD, with estimates of their relative utility and efficacy.

SUMMARY

COPD is a disease characterized by airflow limitation that is not fully reversible. Patients with COPD may frequently experience symptoms of chronic cough with sputum production, dyspnea, and reduced exercise capacity. They may frequently experience exacerbations characterized by increased symptoms that often require medical intervention. The diagnosis of COPD is usually fairly straightforward and made in a cigarette smoker, with the aforementioned symptoms and airflow obstruction measured by spirometry. Spirometry should be performed in all patients in whom COPD is suspected, as it provides useful prognostic information and may be used to stage the disease. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has provided evidenced-based management guidelines for COPD. GOLD guidelines advocate staging COPD by spirometry and make specific treatment recommendations based on COPD stage. The most important risk factor for the development of COPD is cigarette smoking, and smoking cessation has been shown to reduce all-cause mortality and to alter the natural history of COPD. Smoking cessation strategies that employ both counseling and medications like buproprion and nicotine replacement are most effective, but relapse rates remain high. It has not been shown that medications like bronchodilators or inhaled steroids change the natural history of COPD, nor do they reduce mortality, but they can affect other important outcomes. Long-acting bronchodilators, including beta- 2-adrenergic agonists such as salmeterol and formoterol, and the anticholinergic agent tiotropium, improve lung function and exercise tolerance, reduce symptoms, and modestly reduce exacerbation rates. Long-acting bronchodilators are indicated for all COPD patients with chronic symptoms. Short-acting bronchodilators are indicated for rescue when acute symptoms occur. Inhaled corticosteroids minimally improve lung function, but, importantly, reduce exacerbation rates and are indicated in severe COPD or when exacerbations are frequent. Continuous oxygen therapy has been shown to reduce mortality when severe hypoxemia is present and can improve quality of life when moderate hypoxia is present. Finally, well-designed, multidisciplinary disease management programs and pulmonary rehabilitation can improve important disease outcomes in a cost-effective manner.

CONCLUSION

COPD is a common, preventable disease that affects a significant number of people. It may be managed by utilizing various readily available medical therapies, as well as other nonpharmacologic interventions, such as pulmonary rehabilitation. Proper coordination of care is important in this disease, and efforts should be focused on improving quality of life and reduction of symptoms.

Racial and ethnic variations in office-based medical care for work-related injuries and illnesses

OBJECTIVES

This exploratory study uses nationally representative data to evaluate the extent to which ambulatory care for work-related conditions varies by patients' race and ethnicity.

METHODS

Using the National Ambulatory Medical Care Survey (NAMCS) for 1997 and 1998, we describe medical care for work-related conditions, stratifying by whether the patient self-identified as African-American, white, Hispanic and/or non-Hispanic. Multivariate regression analyses were conducted to evaluate the impact of patient race and ethnicity on care, controlling for age, gender, geographical region and MSA (urban/rural) status.

RESULTS

Compared to white patients, African-American patients were more likely to receive mental health counseling and physical therapy and less likely to see a nurse, after controlling for age, gender, geographical region and MSA status. Hispanic patients were more likely to receive x-rays and need insurer authorization for care and less likely to receive a prescription drug or to see a physician, compared to non-Hispanics.

CONCLUSIONS

This is the nation's first study to describe socially based differences in medical care provided for patients with work-related injuries and illnesses. Identifying areas in which these variations in care exist is a critical first step in ensuring that equitable care is afforded to all injured workers.

New strategies to improve outcomes in the surgical intensive care unit

BACKGROUND

Over the last half-decade, substantial breakthroughs have taken place in terms of routine therapy of critically ill patients. The combination of these strategies has the potential to result in improvement in the overall outcomes for patients in intensive care units.

METHODS

A focused review was undertaken of trials of interventions in critically ill patients with outcome endpoints.

RESULTS

This review discusses recent results related to transfusion avoidance, new drug therapy of sepsis, low tidal volume ventilation, tight glycemic control, early goal-directed resuscitation in sepsis, and the contribution of intensivists to improved outcomes.

CONCLUSIONS

Appropriate incorporation of these strategies into everyday practice will likely result in improvements in the care of critically ill surgical patients.

Progress in pain management: where are we?

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Nordic Myeloma Study Group, the first 15 years: scientific collaboration and improvement of patient care

The accomplishments of the Nordic Myeloma Study Group (NMSG) during its first 15 yr are briefly surveyed, together with a discussion of principles guiding the group's clinical trials and of problems that need to be addressed in coming years. The group has so far carried out 12 clinical trials, comprising more than 2500 patients, spanning from minor phase II to large randomised phase III trials. At the time of writing, two randomised trials are running (comparing two doses of i.v. pamidronate, and melphalan-prednisone (MP) vs. MP-thalidomide to elderly patients). The group has strived for a simple organisation with much responsibility delegated to regional coordinators (Denmark 3, Norway 5, Sweden 5). With regard to trial design, the group has considered it important that studies are based on sound scientific questions, are simple to handle for the participants, population based, investigator initiated, include quality of life and health resources assessment as end-points, and can be used as basis for diverse scientific spin-off projects. Like other clinical trial groups, NMSG faces a number of challenges in coming years. The financial situation for independent investigator-initiated trials is far from satisfactory, especially with regard to the resource-consuming implementation of more stringent good clinical practice rules and ethical committee demands. NMSG has also encountered increasing difficulties in recruiting patients to recent trials, partly because of problems related to participating physicians (lack of support, laborious paper work, insufficient credit for participation). Solutions to these problems have to be found if industry-independent clinical trial groups are to survive.

Evolution of treatment for metastatic spine disease

The management of patients with metastatic disease of the spine should be highly individualized and depends on several factors, including the clinical presentation, duration of symptoms, tu-mor type, anticipated radiosensitivity, tumor lo-cation, extent of extraspinal disease, integrity of the spinal column, and medical fitness and life expectancy of the patient. Early diagnosis and intervention are of paramount importance in improving the likelihood of functional neurologic recovery, with the maintenance of ambulation as the primary goal. Effective management of axial spinal pain involves reconstruction and stabilization of the spinal column. Although the ideal therapy has not been established, a wide range of management options is currently available.

Special Article: Improving Outcomes in CKD and ESRD Patients: Carrying the Torch from Training to Practice

Practicing nephrologists are spending more time caring for end-stage renal disease (ESRD) and chronic kidney disease (CKD) patients. Despite this focus, and considerable advances in the understanding of those aspects of care that impact on clinical outcomes, morbidity, mortality, and quality of life for these patients has not improved substantially over the past decade. One of the possible explanations for this lack of progress is the structure of current nephrology training programs, where ESRD and CKD patient care is not emphasized. To address this issue, we developed a short preceptorship for second-year nephrology fellows, including didactic lectures and workshops. Of 67 participating fellows, 50% were from programs offering 3 or fewer months of exposure to outpatient hemodialysis, and 25% reported no exposure to peritoneal dialysis. Of more concern, 25% reported no "official rounds" with an attending nephrologist on dialysis patients. If nephrologists are to take their appropriate place as leaders of the care delivery team, nephrology fellowships must be restructured with appropriate emphasis placed on the comprehensive care of ESRD and CKD patients.

Genomic Messaging System and DNA Mark-Up Language for Information-Based Personalized Medicine with Clinical and Proteome Research Applications

The convergence of clinical medicine and the Life Sciences, commencing with opportunities in clinical trials and clinically linked medical research, presents many novel challenges. The Genomic Messaging System (GMS) described here was originally developed as a tool for assembling clinical genomic records of individual and collective patients, and was then generalized to become a flexible workflow component that will link clinical records to a variety of computational biology research tools, for research and ultimately for a more personalized, focused, and preventative healthcare system. Prominent among the applications linked are protein science applications, including the rapid automated modeling of patient proteins with their individual structural polymorphisms. In an initial study, GMS formed the basis of a fully automated system for modeling patient proteins with structural polymorphisms as a basis for drug selection and ultimately design on an individual patient basis.

Pharmaceutical care model for patients with type 2 diabetes: integration of the community pharmacist into the diabetes team--a pilot study

OBJECTIVE

To evaluate the feasibility and impact of a structured approach for community pharmacist input as a member of the multidisciplinary team caring for patients with type-2 diabetes and health professional providing advice on medication.

METHODS

Prospective pretest-posttest single group study. Sixty-two patients on oral hypoglycaemic therapy, identified as regular customers of four Scottish (UK) community pharmacies, were recruited. Each patient underwent an initial assessment: review of medical general practice notes/community pharmacy PMR (Patient medication record) system and structured interview. Standardised documentation was completed, a pharmaceutical care plan (PCP) prepared, peer-reviewed and then discussed face-to-face with patients' GPs (general practitioners). A second (final) assessment was conducted 24 to 28 weeks from the initial interview.

MAIN OUTCOME MEASURES

Pharmaceutical care issues (PCIs) throughout study period; change in parameters from initial to final assessment: patient knowledge of oral hypoglycaemic and anti-hypertensive therapy; HbA1c; blood pressure; total cholesterol; medication compliance.

RESULTS

A total of 178 PCIs were identified (mean [range] 2.9 [1-5] per patient) and categorised: drug therapy problems (n = 76); monitoring (n = 21); and patient knowledge (n = 81). Drug therapy problems discussed with the GPs were agreed for 74 (97%) and resolved for 55 (72%) at final assessment. Biological outcome measures were assessed for 59 patients (3 drop-outs). A reduction (P < 0.05) in HbA1 c, blood pressure and total cholesterol was observed over the study period. Patients knowledge was poor for oral hypoglycaemic therapy but improved (initial-51 %, final-72%, P < 0.05).

CONCLUSION

This study demonstrated a feasible pharmaceutical care model for diabetes patients in an European country. The results have shown the pharmacist to be effective and well accepted by GPs and patients.

Personalized psychiatry: a realistic goal

It is becoming increasingly evident that the implementation of true personalized medicine will not come as rapidly and smoothly as initially hoped. In the aftermath of the drafting of the human genome in 2001, the popular and scientific media featured numerous commentaries heralding the approaching arrival of personalized medicine to the clinic, and describing its huge benefits for patients. Media coverage predicted a drastic transformation for the practice of medicine, second to the revolution brought about by the discovery of vaccines and antibiotics. From the perspective of another 3 years, during which substantial new insights were made into the enormous complexity of human genome variation, it seems that true personalized medicine may still be decades away for many aspects of medical treatment. Nonetheless, the prospects for implementation of at least certain elements of personalized medicine for one key discipline, psychiatry, might be relatively close and more realistic. With the correct focus, realization of some benefits of genetic patient profiling for psychiatric pharmacotherapy might be near, and in due course, lead the way for true personalized psychiatry.

Patient safety and medical malpractice: a case study

The system of tort liability for medical malpractice is frequently criticized for poorly performing its theoretical functions of compensating injured patients, deterring negligence, and dispensing corrective justice. Working from an actual malpractice case involving serious injury but no apparent negligence, the authors explore these criticisms from the perspectives of both the plaintiff-patient and the defendant-physician. They then examine the tort system through the lens of patient safety and conclude that the tensions between the system and patient safety initiatives suggest a need to reexamine our attachment to adversarial dispute resolution in health care. They propose targeted reforms that could improve the functioning of the system and create incentives to improve safety and quality.

DNA testing for familial hypercholesterolemia: improving disease recognition and patient care

Cardiovascular disease is the leading cause of death worldwide and, like most chronic diseases, it has major genetic and environmental components. Among patients with coronary heart disease onset before the age of 55, about 5% of cases are attributable to heterozygous familial hypercholesterolemia (FH), a disease following autosomal dominant inheritance. About 50% of individuals with FH die before the age of 60 due to myocardial infarction. The frequency of FH is estimated to be 1 : 500. FH is related to mutations in the low-density lipoprotein (LDL)-cholesterol LDL-receptor gene and apolipoprotein B (apoB) gene. The identification of individuals with FH has been based on lipid levels and segregation of lipid levels within the family. However, phenotypes are overlapping and family history is not always informative. Therefore, a DNA-based genetic test for FH appears to offer the best alternative. The DNA test gives a simple yes/no answer. The FH test is a definitive tool for the identification of affected family members. The approach of targeted family genetic screening to find new patients is faster and more reliable compared with a biochemical form of screening. Early identification and efficient treatment of such patients is important and highly cost effective. There is evidence to suggest that the nature of the LDL-receptor (LDLR) mutation influences the degree of cholesterol lowering achieved by HMG-CoA reductase inhibitors (statins). The observed differences in the LDL-cholesterol (LDL-C) responses to these drugs among the various LDLR gene mutations are not yet completely understood. The relationships shown between LDLR mutation types and lipid levels, and the response of lipid levels to HMG-CoA reductase inhibitor treatment, will have to be investigated within the framework of pharmacogenetic studies. The variables, which are important in determining the overall atherosclerosis risk, are the result of combined activity in a dynamic network of numerous genes and environment. Candidate genes for atherosclerosis need to be further tested and validated. Future research should be directed at determining the significance of such targets, which patients with FH are at particularly high risk of premature cardiovascular disease, and which environmental factors are effective in modulating this risk. Genetics-based diagnostics will complement identification of FH while improving cardiovascular risk prediction, prevention of disease and treatment efficacy.

Evidence-based practice revisited

The evidence-based practice (EBP) movement has gathered considerable momentum both locally and abroad since first promoted a decade ago. This paper presents an updated narrative overview of EBP from the clinical and public health perspectives. First, the origins and definition of EBP and how clinicians should go about incorporating it into routine practice are described. Reasons for adopting the EBP philosophy are outlined and the way to learn the process described. The latter can be summarised as the five A's of EBP--assess, ask, acquire, appraise and apply. Limitations of the approach and misperceptions about its weaknesses are also discussed. Potential solutions are offered and areas for future work in the discipline of EBP are highlighted, with particular reference to Hong Kong's situation and that of elsewhere in Asia.

Guidelines and shared care for asthma and COPD

Shared-care constructions between general practitioners and pulmonary physicians are seemingly attractive for asthma and COPD patients. Thus they have to be implemented in further guidelines. However, anticipation that rapid changes will occur in treatment options towards optimal disease management justifies rapid adjustments in these strategies and requires investigations as to their ultimate benefit in disease outcome.

The future of clinical engineering: the challenge of change

Clinical engineering is at a strategic inflection point. Technical, economic, regulatory, and cultural dynamics are at work shaping the future of healthcare delivery. As the nature of healthcare delivery is transformed by these forces, the types and mix of technology management and support services needed by the industry are changing significantly. Clinical engineering has a relatively short opportunity to adopt a service model that will meet these changing needs. Delay or failure to adopt an effective service model as we pass through the inflection point will result in a diminished role for clinical engineering in healthcare technology management as other technical professionals move in to fill the need. The question is: will clinical engineering rise to the challenge?

The future of clinical engineering: technology that enables improved patient care

Speakers at this year's ACCE Symposium will describe in detail the scope and depth of technological and other factors that are at work changing the healthcare delivery paradigm. Other presenters will explore the impact the changes will likely have on the clinical engineering profession. Still others will outline the steps necessary for clinical engineers to take to effectively prepare for the challenges facing them. The experts agree: clinical engineering is at a critical crossroads. No one who intends to pursue clinical engineering or healthcare technology management over the next 10 years can afford to miss this year's meeting.

Travelling for radiation cancer treatment: Patient perspectives

Radiation treatment for cancer requires patients to receive frequent administrations and attend the treatment facility on a daily basis for several weeks. Travelling for radiation treatment has the potential to add to the distress an individual may be feeling. This study utilized in-depth interviews to capture 118 patients' perspectives about travelling for cancer treatment. Four themes emerged during the analysis of the data: (1) waiting was the most difficult part of the experience; (2) the idea of travelling for treatment was distressing; (3) travelling for treatment was tiring and posed difficulties for patients; and (4) being away from home had both benefits and drawbacks. Given the inevitability of travelling for radiation treatment, and the issues that arises for patients, supportive strategies need to be designed and implemented.