Challenges Of Medical Care Research Articles

Befragung von Hausärzt*innen zur Versorgung von Patienten unter oralen Tyrosinkinaseinhibitoren

IntroductionOral tyrosine kinase inhibitor (TKI) therapies are becoming increasingly more important in the treatment of malignant diseases. Monitoring with focus on adherence, side effects and interactions poses new challenges for medical care. The role and capabilities of family doctors in the care of TKI patients are yet unclear and should be uncovered in a nationwide survey. MethodsFrom April to July 2016, 3,000 family doctors in Germany were asked to complete a written questionnaire regarding their capabilities for co-supervision of TKI patients. ResultsThe response rate was 18% (n=553). The peak age was between 50 and 60 years. 81% were specialists in general medicine, 14% specialists in internal medicine and 5% general practitioners. 98% cared for no or less than 10 TKI patients per quarter. Knowledge of side effects and interaction potential of TKIs was low in over 90%. 83% preferred monitoring by the treating oncologist and 93% felt uncertain about treatment monitoring. The control of adherence was of little importance in 66%. The number of treated TKI patients had a significant impact on knowledge and opportunities for treatment monitoring. There was a significant correlation between knowledge about TKIs and confidence in treatment monitoring. In general, younger doctors tended to be more confident in treatment monitoring, and specialists in internal medicine tended to have more knowledge than specialists in general medicine general practitioners and general practitioners. DiscussionCurrently, the low number of TKI patients, little knowledge about TKI, and the desire for specialist care are limiting the possibilities of co-caring for TKI patients by family doctors. ConclusionAlthough family doctors are generally motivated to care for tumor patients, routine treatment controls of TKI patients conducted by family doctors seem hardly possible at the moment and should currently remain with the specialist.

Increasing Rural Recruitment and Retention through Rural Exposure during Undergraduate Training: An Integrative Review.

Objectives: Ensuring nationwide access to medical care challenges health systems worldwide. Rural exposure during undergraduate medical training is promising as a means for overcoming the shortage of physicians outside urban areas, but the effectiveness is widely unknown. This integrative review assesses the effects of rural placements during undergraduate medical training on graduates’ likelihood to take up rural practice. Methods: The paper presents the results of a longitudinal review of the literature published in PubMed, Embase, Google Scholar and elsewhere on the measurable effects of rural placements and internships during medical training on the number of graduates in rural practice. Results: The combined database and hand search identified 38 suitable primary studies with rather heterogeneous interventions, endpoints and results, mostly cross-sectional and control studies. The analysis of the existing evidence exhibited predominantly positive but rather weak correlations between rural placements during undergraduate medical training and later rural practice. Beyond the initial scope, the review underpinned rural upbringing to be the strongest predictor for rural practice. Conclusions: This review confirms that rural exposure during undergraduate medical training to contributes to recruitment and retention in nonurban settings. It can play a role within a broader strategy for overcoming the shortage of rural practitioners. Rural placements during medical education turned out to be particularly effective for rural-entry students. Given the increasing funding being directed towards medical schools to produce graduates that will work rurally, more robust high-quality research is needed.

PF739 SICKLE CELL DISEASE IN GERMANY IS HETEROGENEOUS AND RESULTS IN SEVERE MORBIDITY: ANALYSES FROM A NATIONAL REGISTRY

Background:Sickle Cell Disease (SCD) in Germany exclusively affects immigrants and their descendants. Its increasing prevalence results in challenges for medical care for these patients.Aims:The registry aims at describing the epidemiology, clinical course and treatment of patients with SCD in Germany.Methods:To date, 367 patients have been included in the registry by 36 mainly pediatric institutions. At initial registration, basic data including date of birth, date and circumstances of diagnosis, genotype, country of origin, blood type and complications in the patient's history are reported. Annual follow‐ups document details on complications, laboratory parameters and treatment. Data of 327 patients were analyzed for this abstract.Results:Genotypes of registry patients were homozygous SCD in 75% of patients, HbSC disease in 12%, HbS/β0thal in 6% and HbS/β+thal in 7%. The main regions of origin were sub‐Saharan Africa (in total 69% of patients, including Ghana 19%, Nigeria 19%, Togo 9%) and the Middle East (in total 21%, including Lebanon 6%, Turkey 5%, Syria 4%). Although pilot projects for newborn screening for SCD were in place in some of the centers, only 35% of patients were diagnosed during their first year of life, 85% before the age of six. SCD was diagnosed on the occasion of presenting symptoms in 60% of patients. The mean age at registration was 12 years (median 10), with 10% of patients being older than 21 years at registration. The most frequent complications in the patients’ prior history were pain crises with hospitalization (67% of patients), acute chest syndrome (32%), splenic sequestration (15%), aplastic crisis (10%), stroke (4%) and sepsis (4%).During the first year of observation, 47% of the registry patients were hospitalized, 11% required treatment on an intensive care unit. Red blood cell transfusions were given to 27% of patients. 96% of patients with homozygous SCD or with HbS/β0thal at an age of 2 years or older were prescribed hydroxycarbamide, 76% of these patients under the age of 18 were annually examined by transcranial Doppler ultrasound (TCD).Summary/Conclusion:Patients with SCD in Germany are genetically and ethnically highly heterogeneous and suffer from severe morbidity. The diagnosis is frequently made too late because of the lack of a routine newborn screening for SCD. While the high rate of hydroxycarbamide prescription indicates good care at the institutions that contribute to the registry, the insufficient proportion of patients receiving routine TCD checks indicates an incomplete availability of the diagnostic infrastructure required for the optimal care of this challenging group of patients.

Annotated Guidance and Recommendations for the Role and Actions of Emergency Medical Services Systems in the Current Opioid and Drug-Related Epidemics.

The U.S. and worldwide death toll from opioids and other drugs has accelerated, rivaling all other causes of premature death. Emergency medical services (EMS) now has an evolving role in providing solutions. EMS medical directors from the majority of the largest U.S. cities and global counterparts met to share/compile an inventory of best practices derived from their respective high-volume experiences in jurisdictions with >114 million residents combined. In turn, they created a consensus guideline document for the purposes of information-sharing among themselves and other interested parties. The group concluded that EMS personnel have evolving training needs with respect to new medical care challenges, but they also recommended that agencies have a special place within the collective of those hoping to provide solutions to the public health crisis of addiction and drug-related epidemics. In addition to intervening in real-time overdose events, it was recommended that they partner with other key stakeholders to develop mechanisms to end the repetitive cycle of emergency rescue followed by an almost immediate return to addictive behaviors. EMS providers should be trained to optimally communicate, refer, and direct the affected individuals to appropriate resources that will provide viable and evidence-based pathways directed toward long-term recovery. Beyond a need to update acute medical rescue practices and improved assessment techniques, EMS providers should also learn to optimally communicate, encourage, and even participate in facilitating management continuity for the affected individuals by identifying and using the appropriate resources that will provide viable, evidence-based pathways toward sustained recovery.

Мультиморбідність як клінічна проблема

Multimorbidity is defined as two or more chronic conditions in the same individual. It is associated with significant impacts on quality of life, poor functional status, enhancement of the challenges of medical care and cost implications, unnecessary hospitalizations, increases the terms of hospital stay, and affects the evaluation of the interventions effectiveness. The article reviews the prevalence of multimorbidity, combinations of conditions in people with multimorbidity, especially, in patients with cardiovascular diseases. This review also identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities as presented in WHO manual, Guiding principles for the care of older adults with multimorbidity of the American Geriatrics Society and NICE clinical guidelines (NG56). The paper outlined key problems posed by current healthcare organization and experienced by patients with multimorbidity – the need for the development of accurate and reliable methods of comorbidity assessment and evidence-based outcome measurement criteria and tools.

Mathematical Analysis of the Probability of Spontaneous Mutations in HIV-1 Genome and Their Role in the Emergence of Resistance to Anti-Retroviral Therapy

$\textbf{Background:}$ High mutability of HIV is the driving force of antiretroviral drug resistance, which represents a medical care challenge. $\textbf{Method and Model Equation:}$ To detect the mutability of each gene in the HIV-1 genome; a mathematical analysis of HIV-1 genome is performed, depending on a linear relation wherein the probability of spontaneous mutations emergence is directly proportional to the ratio of the gene length to the whole genome length. \begin{equation*} {P_g}{S_i} =\frac{g}{G} \end{equation*} $\textbf{Results:}$ $\textbf{tat}$, $\textbf{vpr}$ and $\textbf{vpu}$ are the least mutant genes in HIV-1 genome. Protease $\textbf{PROT}$ gene is the least mutant gene component of the polymerases $\textbf{pol}$. $\textbf{Conclusion:}$ $\textbf{tat}$, $\textbf{vpr}$ and $\textbf{vpu}$ are the best candidates for HIV-1 recombinant subunit vaccines or as a part of $\textit{prime and boost}$ vaccine combinations. Also; the protease inhibitor-based regime represents a high genetic barrier for HIV to overcome.

DISTURBANCES OF CARDIOVASCULAR SYSTEM IN PERSONS WITH CHRONIC SPINAL CORD INJURY DURING EXERCISE AND PARTICIPATION IN PARALYMPIC SPORTS

Spinal cord injury (SCI) is a devastating condition that affects mostly young and active individuals but also impacts their family members and results in significant challenges for medical care and social integration. In addition to obvious motor impairment (tetraplegia/paraplegia), these individuals also suffer from a variety of less obvious but devastating autonomic nervous system dysfunctions that negatively impact their health and affect various aspects of daily living. Physical training and sports are essential components of rehabilitation and leaser activities for people with disabilities. Number of individuals with SCI who run an active lifestyle is increasing. Physical activity puts an additional stress on various organs and body systems. The presented manuscript describes in detail cardiovascular dysfunctions in physically active individuals with a SCI, including those engaged in Paralympic sports: low resting blood pressure, orthostatic hypotension, arrhythmias, and the phenomenon of «autonomic dysreflexia». We also address issues related to self-induced episodes of autonomic dysreflexia in order to improve athletic performance ― a phenomenon known as «boosting». Boosting may improve sports performance in short term but is associated with the risk of serious cardiovascular disorders and even sudden death. This practice is considered as anti-doping rule violation by the International Paralympic Committee and thus prohibited. Understanding of the changes occurring in the body of a physically active individual after SCI is necessary for general practitioners, neurologists, rehabilitation specialists, sports medicine physicians, as well as for specialists of adapted physical education and sports.

障害児(者)と家族における医療的ケアに関する研究動向と課題の文献検討

障害児(者)と家族における医療的ケアに関する研究動向と課題の文献検討

Gastrointestinal and nutritional problems inneurologically impaired children.

The current increasing survival of children with severe central nervous system damage has created a major challenge for medical care. Gastrointestinal and nutritional problems in neurologically impaired children have been recently recognized as an integral part of their disease, often leading to growth failure and worsened quality of life for both children and caregivers. Nutritional support is essential for the optimal care of these children. Undernourished handicapped children might not respond properly to intercurrent diseases and suffer unnecessarily. On the other hand, restoring a normal nutritional status results in a better quality of life in many. The easiest and least invasive method to increase energy intake is to improve oral intake. However, oral intake can be maintained as long as there isno risk of aspiration, the child is growing well and the time required to feed the child remains within acceptable limits. When oral intake is unsafe, insufficient or too time consuming, enteral nutrition should be initiated. Damage to the developing central nervous system may result in significant dysfunction in the gastrointestinal tract and is reflected in impairment in oral-motor function, rumination, gastro-oesophageal reflux (GER), with or without aspiration, delayed gastric emptying and constipation. These problems can all potentially contribute to feeding difficulty in disabled children, carrying further challenging long-term management issues.

Evolutionary evidence on suitability of SecD as a target for development of antibacterial agents against Staphylococcus aureus.

Staphylococcus aureus causes many infections and its drug resistance is a worrying challenge for medical care. The SecD subunit of Sec secretion system in methicillin-resistant S.aureus is an attractive target because SecD dysfunction leads to the death of bacteria and SecD as a target is more efficient than SecA and SecF. Evolution could have made SecD to become insensitive to antibacterial agents although the drugs directly against SecD have yet to develop. So far, no detailed information on SecD evolution has been available, thus 2686 SecD sequences with full taxonomic information from kingdom to species were analyzed. First, the variance of pairwise p-distance was evaluated for each taxonomic group. Second, the variance was further partitioned into intergroup and intragroup variances for quantification of horizontal and vertical gene transfer. Third, phylogenetic tree was built to trace the evolutionary pathway. The results showed that overall evolution of SecDs appears to have undergone horizontal and vertical gene transfer. Only 0.5% horizontal transfers were found between any two SecDs in S.aureus, 6.8% and 8.8% horizontal transfers were found between any two Staphylococcus SecDs from different and the same species, and only one SecD from S.aureus was located far away from its sister cluster. Thus, statistic and evolutionary analyses demonstrate that the SecDs from staphylococcus species have a small chance of mutating, and provide taxonomic evidence to use the SecD as a potential target for new generation of antibacterial agents against S.aureus.

Ileal transposition in surgical treatment for type 2 diabetes mellitus

High prevalence and insufficient efficacy of medical treatment in type 2 diabetes mellitus (T2DM) poses a major challenge for medical care. Generally, only 30% of patients reach therapeutic goals, while remission occurs only in the minority of patients. In the obese (BMI>35 kg/m2), bariatric surgery provides an alternative to pharmacological treatment of T2DM, boosting remission/compensation rate up to 76.8%. A few recent clinical studies explored the anti-diabetic effect of ileal transposition (IT). This type of surgery targets restoration of incretin balance by proximal transposition of ileal segment. In this review, we discuss the salutary mechanisms of IT in T2DM based on the analysis of the pioneering clinical trials.

Top ten inpatient palliative medicine billing and coding mistakes (and how to fix them this week).

Palliative care (PC) has undergone incredible growth in the last 10 years, having gained subspecialty status and penetration into 85% of hospitals over 300 beds. The comprehensive services provided by multiple members of the PC team combined with low reimbursement for nonprocedural medical care challenges all PC teams to operate with financial sustainability. Accurately and compliantly documenting and coding services provided to patients can help to maximize PC programs' revenues and limit operating subsidies received from health care systems or hospice programs. In this article we share common billing and coding mistakes made by our programs and colleagues while providing inpatient, consultative palliative care. Each mistake is explained and paired with a straightforward fix to enable compliant, efficient practice. This will allow clinicians to more accurately communicate to payers the complex care provided to inpatients by the PC team. This fuller picture of the complexity of care provided can increase reimbursements received by your PC program from payers. Understanding how to accurately document, code, and receive appropriate reimbursement will allow our field to continue to grow, broadening the reach of PC nationally to improve quality of life for all patients and families in need.

Survival Efficacy of the PEGylated G-CSFs Maxy-G34 and Neulasta in a Mouse Model of Lethal H-ARS, and Residual Bone Marrow Damage in Treated Survivors

In an effort to expand the worldwide pool of available medical countermeasures (MCM) against radiation, the PEGylated G-CSF (PEG-G-CSF) molecules Neulasta and Maxy-G34, a novel PEG-G-CSF designed for increased half-life and enhanced activity compared to Neulasta, were examined in a murine model of the Hematopoietic Syndrome of the Acute Radiation Syndrome (H-ARS), along with the lead MCM for licensure and stockpiling, G-CSF. Both PEG-G-CSFs were shown to retain significant survival efficacy when administered as a single dose 24 h post-exposure, compared to the 16 daily doses of G-CSF required for survival efficacy. Furthermore, 0.1 mg kg of either PEG-G-CSF affected survival of lethally-irradiated mice that was similar to a 10-fold higher dose. The one dose/low dose administration schedules are attractive attributes of radiation MCM given the logistical challenges of medical care in a mass casualty event. Maxy-G34-treated mice that survived H-ARS were examined for residual bone marrow damage (RBMD) up to 9 mo post-exposure. Despite differences in Sca-1 expression and cell cycle position in some hematopoietic progenitor phenotypes, Maxy-G34-treated mice exhibited the same degree of hematopoietic stem cell (HSC) insufficiency as vehicle-treated H-ARS survivors in competitive transplantation assays of 150 purified Sca-1+cKit+lin-CD150+cells. These data suggest that Maxy-G34, at the dose, schedule, and time frame examined, did not mitigate RBMD but significantly increased survival from H-ARS at one-tenth the dose previously tested, providing strong support for advanced development of Maxy-G34, as well as Neulasta, as MCM against radiation.

Health care experiences of U.S. Retirees living in Mexico and Panama: a qualitative study

BackgroundRetirement migration from northern countries to southern countries is increasing in both Europe and North America, and retiree experiences will impact future migration and health services utilization. We therefore sought to describe the healthcare experiences and perceptions of retired U.S. citizens currently living in Mexico and Panama.Methods46 retired U.S. citizens (23 per country) who had been hospitalized (61%) or had a chronic health condition (78%) in two regions per country with large communities of retired U.S. citizens were identified. Detailed semi-structured interviews were conducted to explore experiences with, attitudes toward, and costs of healthcare. Interviews were analyzed using quantitative and qualitative methods.ResultsRespondents averaged 68–70 years old, were well educated, had few physical dependencies, and had moderate incomes. They praised physician services as more personalized than in the U.S. and home care as inexpensive and widely available, expressed favorable opinions regarding outpatient and dental care, gave mixed ratings on hospital services, and expressed concerns about emergency services. Numerous concerns about health insurance were expressed, including the unavailability of Medicare and reductions in Tricare. Payment concerns and lack of data on local health providers made deciding where to obtain services challenging.ConclusionsRetirees living abroad report dilemmas regarding healthcare choices, insurance availability, and quality of care. As this population segment grows, pressure will increase for policy and business solutions to existing medical care challenges.

Opportunities for diabetes research using the Norwegian Cardiovascular Disease Registry

While Norway has many outstanding health registries that are used as a foundation for surveillance, quality control and epidemiologic research, it was recognized that a knowledge gap existed regarding the prevalence, incidence, and quality of health care delivery for cardiovascular diseases (CVD) which remains the primary cause of death in the country. Given broad agreement for the need for a registry by patient organizations, research environments and health authorities, the Norwegian Parliament decided to establish the Norwegian Cardiovascular Disease Registry (NCVDR) in March 2010 and then adopted new regulations in December 2011 which established the NCVDR. The registry consists of a core registry housed and maintained by the Norwegian Institute of Public Health (NIPH) that is supplemented with information from the medical quality registries housed and maintained by the hospital trusts. Given the burden of CVD among patients with diabetes and the unique challenges of medical care for CVD patients with diabetes, the registries also provides a new opportunity to advance diabetes research in Norway.

難聴児の療育と支援に関わる問題点の検討

難聴児の療育と支援に関わる問題点の検討

MRSA eradication in dermatologic outpatients - theory and practice

The dissemination of methicillin resistant staphylococcus aureus (MRSA) is an increasing challenge in medical care. Apart from hospital acquired MRSA, there has also been an increase in community acquired and livestock associated MRSA. While the risks of MRSA (e. g. wound infections) and consequences (e. g. rejection of patients) are well known, there are little data on the effectiveness of eradication procedures. 32 patients with proven MRSA colonization were monitored during eradication for the following aspects: (1) localization of MRSA (swabs from hairline, anterior nares, throat, axillae, groins, perineum, and wounds, if present), (2) presence of eradication-impairing factors, (3) length of time needed for eradication, (4) cost of eradication, (5) molecular fingerprint and risk assessment (spa-types). We describe the successful eradication of MRSA in all 32 patients. Most positive nasal swabs were obtained from the anterior nares and the throat and only rarely from the hairline or axillae. The greater the number of positive swabs, the more time was needed for eradication. In most patients (37.5%), eradication with topical antiseptics was successful. The average time for eradication was 12.97 (± 7.6) days. Twelve patients required systemic antibiotic therapy. Treatment costs associated with the use of systemic antibiotics were significantly higher. The most frequent spa types were t032 and t003. We report successful MRSA eradication in outpatients. Systemic antibiotics are unnecessary in the majority of patients. A combined anti-MRSA strategy for inpatients and outpatients is recommended.

Strategies to improve drug adherence

The demographic development of increasing numbers of elderly patients with chronic diseases requiring continuous polypharmacy represents a challenge for medical care. At present, 30–40% of all German patients >65 years are prescribed four or more different medications, and this number is expected to increase.1,2 Non-adherence to medical treatments is an increasingly recognized cause of adverse treatment outcomes and increased health care costs,3–5 for example, that caused by preventable admissions for heart failure5–9 or coronary artery disease.10–14 Average estimated rates of adherence may be as low as 50–80%.10,15 A typical study reports that of the prescribed medications after discharge of from hospital, only about one-third were regularly taken, whereas two-thirds went to waste.16 In Germany, the annual costs due to poor compliance in medical therapy are estimated up to 10 billion Euro.17 Drug compliance is defined as the extent to which patients follow medical instructions.17 Today, the term ‘compliance’ is used less frequently because it implies that only the patients is responsible for the medical treatment. The term ‘adherence’ has now replaced ‘compliance’, because it reflects a less paternalistic physician–patient relationship, and includes the responsibility of the caregivers. Adherence has been defined as ‘the active, voluntary, and collaborative involvement of the patient in a mutually acceptable course of behaviour to produce a therapeutic result’.4 Some patients may never start treatment and this type of non-adherence has been named non-acceptance. Medication adherence also includes the concept of persistence taking into account the willingness to take a prescribed medication throughout the overall duration of drug therapy.4 The degree of accordance of therapeutic goals of patient and therapist is defined as ‘concordance’. The definition of ‘concordance’ has changed over time from one which focused …

Polytraumaversorgung auf der Intensivstation

The treatment of severely injured trauma patients (polytrauma) is one of the outstanding challenges in medical care. Early in the initial course the patient's diagnostics have to be scrupulously reevaluated by an interdisciplinary team (tertiary trauma survey) to reduce deleterious sequelae of missed injuries after the initial assessment. Severely injured patients stay in intensive care for an average of 11 days. During this time the patient's therapy has to ensure a high quality evidence-based intensive care treatment and simultaneously has to be tailored to the current individual injuries. Because of the fact that the damage control strategy is gaining increasing acceptance, the intensive care unit plays a pivotal role in the critical time between emergency and elective surgery. Therefore a close cooperation between physicians of the intensive care unit and all surgical disciplines involved is essential to reach the aim of therapeutic efforts. After survival of emergency treatment patients with severe trauma should be reintegrated into social and occupational life as soon as possible.

Perceptions of healthcare and familial communications in the context of Parkinson's Disease and Multiple Sclerosis

One of the most important ethical challenges in medical care is the complex process involved in the communications about treatment with individual patients, their informal (eg families) support people, and their formal (eg health professionals) healthcare providers. It is important to recognize that communication about treatment is not a discrete and isolated event, but one that involves a cascade of relationships within a social context, with each communication and context affecting a later possibility (Slomka 1992). We aimed for equal representation of individuals in the proposed triad (patient with condition, unpaid support, and formal support person) from each of the selected groups resulting in patients with a diagnosis (n=6); key support persons (n=5); and, physicians and healthcare providers (n=5). Interviews were held with 16 individuals as part of the designated triad. A primary aim of this paper is to look at environmental contexts, according to the perceptions of patients and care providers that might influence communication. Main themes are discussed as they occurred in the data, with recommendations for care proposed in the conclusion. The study was funded through an internal grant from the University of Manitoba.