Choice Of Physicians Research Articles

Freedom of choice of specialist physicians is important to Swiss residents - A cross-sectional study

To assess how important the possibility to choose specialist physicians is for Swiss residents and to determine which variables are associated with this opinion. This cross-sectional study used data from the 2007 Swiss population-based health survey and included 13,642 non-institutionalised adults who responded to the telephone and paper questionnaires. The dependent variable included answers to the question "How important is it for you to be able to choose the specialist you would like to visit?" Independent variables included socio-demographics, health and past year healthcare use measures. Crude and adjusted logistic regressions for the importance of being able to choose specialist physicians were performed, accounting for the survey design. 45% of participants found it very important to be able to choose the specialist physician they wanted to visit. The answers "rather important", "rather not important" and "not important" were reported by 28%, 20% and 7% of respondents. Women, individuals in middle/high executive position, those with an ordinary insurance scheme, those reporting ≥2 chronic conditions or poorer subjective health, or those who had had ≥2 outpatient visits in the preceding year were more likely to find this choice very important. In 2007, almost half of all Swiss residents found it very important to be able to choose his/her specialist physician. The further development of physician networks or other chronic disease management initiatives in Switzerland, towards integrated care, need to pay attention to the freedom of choice of specialist physicians that Swiss residents value. Future surveys should provide information on access and consultations with specialist physicians.

Reasons for Choice of Referral Physician Among Primary Care and Specialist Physicians

Specialty referral patterns can affect health care costs as well as clinical outcomes. For a given clinical problem, referring physicians usually have a choice of several physicians to whom they can refer. Once the decision to refer is made, the choice of individual physician may have important downstream effects. To examine the reasons why primary care and specialist physicians choose certain specific colleagues to refer to and how those reasons differ by specialty. Cross-sectional Web-based survey supplemented with analysis of administrative claims data. A total of 616 physicians in office-based patient care specialties who were members of an academic physicians' organization and treated Medicare patients in 2006. A total of 386 respondents (63% response rate) were presented with a "roster" of other physicians' names with whom we predicted they had a relationship based on sharing Medicare patients. Among physicians in their "professional network" (consisting of any listed physician with whom respondents acknowledged a professional relationship), respondents reported if they referred to those physicians, and if so, provided up to two reasons why they referred to that particular colleague. Using logistic regression, we examined the likelihood that different specialists would endorse specific reasons for referring to chosen colleagues. Primary care physicians (PCPs) initiated referrals to 66% of their "professional network" colleagues, while medical and surgical specialists initiated referrals to 49% and 52%, respectively (p < 0.001 for both versus PCPs). After adjustment, medical specialists were less likely than PCPs to cite ease of communication with colleagues (RR = 0.69, 95% CI = 0.49-0.91), and medical and surgical specialists were less likely than PCPs to cite "shares my medical record system" as a reason to refer (medical specialist RR = 0.13, 95% CI 0.03-0.40, surgical specialist RR = 0.26, 95% CI = 0.05-0.78). Specialists frequently initiate referrals, bypassing PCPs. In choosing specific physicians to refer to, PCPs are more often concerned with between-physician communication and patient access. Modifying referral practices among doctors may need to account for such patterns of behavior.

Immunogenicity and Reactogenicity of Diphtheria—Tetanus—Acellular Pertussis—Hepatitis B—Inactivated Poliovirus and Haemophilus influenzae Type B Vaccines Administered Concomitantly to Infants as a Three-dose Primary Course

Immunogenicity and reactogenicity of primary vaccination with combined diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliovirus (DTPa-HBV-IPV) vaccine when co-administered with Haemophilus influenzae (Hib) conjugate vaccine were assessed in 60 healthy infants. Infants received HBV vaccine at birth, then DTPa-HBV-IPV and Hib vaccines at age 1.5 months, 3.5 months and 6 months. Blood samples were collected before the first DTPa-HBV-IPV and Hib vaccine doses and 1 month after dose 3. Reactogenicity was assessed using diary cards. One month after primary vaccination, all infants were seroprotected/seropositive against all vaccine antigens evaluated. The poliovirus antigen could not be evaluated. The vaccines were well tolerated. No case of fever > 39.0 °C was reported. No serious adverse events were considered related to vaccination. Primary vaccination with DTPa-HBV-IPV and Hib vaccines was immunogenic and well tolerated. Combined vaccines, such as this pentavalent vaccine, minimize the number of injections and vaccination visits required to complete primary vaccination, and provide choice and flexibility for physicians and vaccine providers.

How Do Quality Information and Cost Affect Patient Choice of Provider in a Tiered Network Setting? Results from a Survey

To assess how quality information from multiple sources and financial incentives affect consumer choice of physicians in tiered physician networks. Survey of a stratified random sample of Massachusetts state employees. Respondents were assigned a hypothetical structure with differential copayments for "Tier 1" (preferred) and "Tier 2" (nonpreferred) physicians. Half of respondents were told they needed to select a cardiologist, and half were told they needed to select a dermatologist. Patients were asked whether they would choose a Tier 1 doctor, a Tier 2 doctor, or had no preference in a case where they had no further quality information, a case where a family member or friend recommended a Tier 2 doctor, and a case where their personal physician recommended a Tier 2 doctor. The effects of copayments, recommendations, physician specialty, and patient characteristics on the reported probability of selecting a Tier 1 doctor are analyzed using multinomial logit and logistic regression. Relative to a case where there is no copayment differential between tiers, copayment differences of U.S.$10-U.S.$35 increase the number of respondents indicating they would select a Tier 1 physician by 3.5-11.7 percent. Simulations suggest copayments must exceed U.S.$300 to counteract the recommendation for a lower tiered physician from friends, family, or a referring physician. Sensitivity to the copayments varied with physician specialty. Tiered provider networks with these copayment levels appear to have limited influence on physician choice when contradicted by other trusted sources. Consumers' response likely varies with physician specialty.

Effect of celiprolol on prevention of cardiovascular events in vascular Ehlers-Danlos syndrome: a prospective randomised, open, blinded-endpoints trial

Vascular Ehlers-Danlos syndrome is a rare severe disease that causes arterial dissections and ruptures that can lead to early death. No preventive treatment has yet been validated. Our aim was to assess the ability of celiprolol, a β(1)-adrenoceptor antagonist with a β(2)-adrenoceptor agonist action, to prevent arterial dissections and ruptures in vascular Ehlers-Danlos syndrome. Our study was a multicentre, randomised, open trial with blinded assessment of clinical events in eight centres in France and one in Belgium. Patients with clinical vascular Ehlers-Danlos syndrome were randomly assigned to 5 years of treatment with celiprolol or to no treatment. Randomisation was done from a centralised, previously established list of sealed envelopes with stratification by patients' age (≤32 years or >32 years). 33 patients were positive for mutation of collagen 3A1 (COL3A1). Celiprolol was administered twice daily and uptritrated by 100 mg steps every 6 months to a maximum of 400 mg per day. [DOSAGE ERROR CORRECTED]. The primary endpoints were arterial events (rupture or dissection, fatal or not). This study is registered with ClinicalTrials.gov, number NCT00190411. 53 patients were randomly assigned to celiprolol (25 patients) or control groups (28). Mean duration of follow-up was 47 (SD 5) months, with the trial stopped early for treatment benefit. The primary endpoints were reached by five (20%) in the celiprolol group and by 14 (50%) controls (hazard ratio [HR] 0·36; 95% CI 0·15-0·88; p=0·040). Adverse events were severe fatigue in one patient after starting 100 mg celiprolol and mild fatigue in two patients related to dose uptitration. We suggest that celiprolol might be the treatment of choice for physicians aiming to prevent major complications in patients with vascular Ehlers-Danlos syndrome. Whether patients with similar clinical presentations and no mutation are also protected remains to be established. French Ministry of Health, Programme Hospitalier de Recherche Clinique 2001.

Self-employment, specialty choice, and geographical distribution of physicians in Japan: A comparison with the United States

Geographic and specialty maldistributions of physicians are political concerns in Japan. This study examined the associations of physician employment status with the number and geographic distribution of the physicians in each specialty in Japan, in comparison with the US. The number of physicians per unit population, proportion of clinic (Japan) or office (US) based physicians, and Gini coefficient of physicians against population were calculated in each of 20 specialties in Japan, and 21 specialties in the US. The geographic unit of Gini coefficient was municipality in Japan, and county in the US. Correlations among these three variables were also examined. The lower the proportion of clinic-based physicians was, the lower the number of physicians and the higher the Gini coefficient were in Japanese specialties, while there was no association between office-based rate and Gini coefficient in the US specialties. In radiology, anaesthesiology, emergency medicine, and pathology, Japanese clinic-based rates were less than one-tenth, and the numbers of physicians per unit population were less than half of the US values, and the Gini coefficients were substantially higher than the US values. Difficulty in being self-employed created low numbers in some specialties, and highly urban-biased distributions of these specialists in Japan.

Hurdles in successful treatment of cancer pain caused by primary healthcare

Background: The aim of this study is to envisage the hurdles set by physicians in primary healthcare that can cause, or contribute to unsatisfactory cancer pain management. Methods: The study has been carried out as a prospective open non-randomized one (based on a questionnaire). It comprised 283 physicians in primary healthcare from 21 institutions of primary healthcare in Serbia. The choice of physicians was done at random, and the completion of questionnaires was voluntary. The questionnaire comprised 12 questions. Among other issues the questions covered the most important characteristics of the analgesics in their opinion, the individual doses of drugs they most often prescribe, maximum daily doses of these drugs they prescribe (tramadol, fentanyl TD, hydromorphone, methadone, IR morphine); whether they introduce opioids and/or increase the dose autonomously or only upon a specialist?s recommendation; and what is preventing them to successfully treat cancer pain; what side effects they fear and others. Results: Tramadol was favored in the previous year (82.3%), in the last month the physicians prescribed NSAID as therapy in 63.4% of the cases, tramadol was given to 13.60%; fentanyl TD to 13.40%; hydromorphone to 2.7%; IR morphine to 3.80%. Efficiency was marked by 89.80% of physicians as the most important characteristic, tolerability by 82.3%, and duration of effects by 77.4%. Tramadol is most often the choice of therapy in their daily practice although they said it to be less efficient, less tolerable, with shorter analgesic effect, less user friendly, and more expensive compared to fentanyl TD and the other opioids. They said the side effects they fear the most were respiratory depression and sedation. 23.70% of the physicians in the primary healthcare introduce and/or increase the dose of opioids (34.6%) into the therapy autonomously, and 76.30% of them introduce these drugs and/or increase the dose (65.4%) only upon a specialist?s recommendation. Conclusion: Barriers have a great influence on successful treatment of cancer pain. There is a burning need for further education which has to encompass raising awareness of the current guidelines and recommendations in the cancer pain therapy, their acquisition and utilization in everyday practice through interactive workshops with case studies because there is still an alarming lack of knowledge, level of prejudice and apparent opiophobia.

House Passes Major Expansion of Access to Health Insurance

House Passes Major Expansion of Access to Health Insurance

Ipratropium Bromide for Acute Asthma Exacerbations in the Emergency Setting

Since the 1970s, when inhaled anticholinergic agents were first introduced as adjunct therapies for the immediate treatment of pediatric asthma exacerbations, several trials have shown varying degrees of benefit from their use as bronchodilators in combination with inhaled short-acting beta-adrenergic agonists and systemic corticosteroids. Although other anticholinergics exist, ipratropium bromide (IB) specifically has emerged as the overwhelming choice of pulmonologists and emergency physicians because of its limited systemic absorption from the lungs when given as an inhaled preparation. However, although the varying trials, predominantly in the emergency department setting, have typically shown a trend toward improved outcomes, none has set forth clear dosing protocol recommendations for use by practicing physicians. It is our goal in this review of the available literature on the use of IB, as an adjunct to inhaled short-acting beta-adrenergic agonists, to summarize practical, evidence-based recommendations for use in the pediatric emergency department setting for acute asthma exacerbations. We also hope to better delineate the most effective dosing regimen in those patients who might benefit most from the addition of IB and to explore proposed additional benefits it may have as a modulator of cholinergic-induced effects from high-dose beta-agonist therapy and viral triggers.

Influence des facteurs socioculturels dans la prise de décision médicale en cancérologie

Shared decision-making is based on the idea of an enlightened participation of the patient to the therapeutic decision process, especially when the ratio between risks and benefits of treatment options is uncertain. The physician owes to ponder the advantages and the inconveniences of chemotherapy, which can be enlightened by a discussion with the patient. Thus, neither shared decision-making nor decision tools are currently used in France. Our aim is to evaluate the variables that step in the therapeutic choice of French physicians concerning the adjuvant chemotherapy prescription in breast cancer. We focus on the impact of different medical cultures on decision processes and shared decision-making conceptions. A socio-anthropological study is carried out with the participation of six French medical centre. First results show the influence of local specificities, professional groups and individual sociocultural background of physicians.

Single Payer or Individual Tax Credit: Which Reform Proposal Is Best?

Single Payer or Individual Tax Credit: Which Reform Proposal Is Best?

The new generation of family physicians--career motivation, life goals and work-life balance.

The present study aimed to investigate the differences between future family physicians, and physicians aspiring to other medical specialities, in terms of sociodemographic factors and variables concerning personality factors, career motivation, career success, importance of life goals and work-life balance; further, the stability in career choice of family physicians from medical school through to residency was evaluated. Data reported are from four assessments of the Swiss physicians' longitudinal career development study, begun in 2001 (T1). At T4, in 2007, 543 residents (76% of the initial sample at T1) completed a questionnaire concerning their personal and professional goals. The difference between family physicians and specialists was studied by multivariate analyses of covariance adjusted for gender. Of the study sample, 84 (17%) decided on family medicine, 66% of them as early as medical school or at the beginning of residency. Compared to specialists, more family physicians are married and more have children. Their intrinsic and extrinsic career motivation is lower, their extraprofessional concerns are greater and they rate their objective and subjective career success lower. The favoured models of work-family and work-life balance respectively are part-time oriented. Future family physicians, both females and males, are less career-oriented. The results suggest that the waning reputation of family medicine and the uncertain development of this medical discipline in the Swiss healthcare system attract less career-oriented applicants. A well-balanced integration of professional and private life is an essential goal for the new generation of doctors; this applies even more to female doctors and family physicians. Considering this trend, the question arises whether the current number of medical school graduates is sufficient to ensure the population's healthcare provision in the future.

The new generation of family physicians--career motivation, life goals and work-life balance.

The present study aimed to investigate the differences between future family physicians, and physicians aspiring to other medical specialities, in terms of sociodemographic factors and variables concerning personality factors, career motivation, career success, importance of life goals and work-life balance; further, the stability in career choice of family physicians from medical school through to residency was evaluated. Data reported are from four assessments of the Swiss physicians' longitudinal career development study, begun in 2001 (T1). At T4, in 2007, 543 residents (76% of the initial sample at T1) completed a questionnaire concerning their personal and professional goals. The difference between family physicians and specialists was studied by multivariate analyses of covariance adjusted for gender. Of the study sample, 84 (17%) decided on family medicine, 66% of them as early as medical school or at the beginning of residency. Compared to specialists, more family physicians are married and more have children. Their intrinsic and extrinsic career motivation is lower, their extraprofessional concerns are greater and they rate their objective and subjective career success lower. The favoured models of work-family and work-life balance respectively are part-time oriented. Future family physicians, both females and males, are less career-oriented. The results suggest that the waning reputation of family medicine and the uncertain development of this medical discipline in the Swiss healthcare system attract less career-oriented applicants. A well-balanced integration of professional and private life is an essential goal for the new generation of doctors; this applies even more to female doctors and family physicians. Considering this trend, the question arises whether the current number of medical school graduates is sufficient to ensure the population's healthcare provision in the future.

Spontaneous Vaginal Expulsion of a Filshie Clip

Dear Editor, Laparoscopic sterilisation is a common method of permanent contraception. The Filshie clip system is a safe and effective method of female sterilisation. Being used around the world for more than 20 years, this form of contraception continues to be the method of choice for many physicians and patients due to the ease and simplicity of application and minimal tube damage produced. Nevertheless, failures are known to have happened. The Royal College of Obstetricians and Gynaecologists’ evidence-based guidelines recommended that the Filshie clip failure rate be quoted as 1 in 200.1 One reason for failure is clip migration. We present a case where the migrated Filshie clip was expelled per vaginum. A 32-year-old woman, who has 2 children, appeared at the gynaecology clinic, with a history of having passed a Filshie clip per vaginum the previous night. She had undergone post -partum sterilisation via a mini-laparotomy 5 years ago. The procedure was uncomplicated and the post-operative period was uneventful. Now, 5 years later, during her menstruation, the woman passed out the clip per vaginum. She brought the clip to the clinic; it was still in a locked position. During examination, no defect was found in any of the vaginal fornices; but there was 1 tender spot in the posterior fornix. A hysterosalpingogram was arranged for her. The abdominal cavity was surveyed under fluoroscopy prior to dye injection. Only 1 Filshie clip was noted in the entire abdominal cavity. This was in the right hemipelvis. After Lipoidal injection, there was opacification of both the fallopian tubes but there was no spillage into the peritoneal cavity (Fig. 1). The remaining Filshie clip was noted to be off the tube and in a closed position. The patient was informed of these findings. She elected to do nothing despite counselling that she might be at risk of getting pregnant again. Sterilisation is a common mode of contraception for women who have completed their families. The Filshie clip system has been used for female sterilisation for more than 20 years. Rioux and Yuzpe2 have reported an overall failure rate of 0.27% for interval procedures and 0.9% for post-partum procedures. The Filshie clip, made of titanium, is lined with silicon rubber. After the clip is applied over the fallopian tube, the soft silicone lining is compressed. The part of the tube between the jaws of the clip undergoes avascular necrosis. The silicone then expands to keep the lumen closed. Over time, peritoneal tissue grows over the clip, thereby holding the clip in place. Occasionally, this process of peritoSpontaneous Vaginal Expulsion of a Filshie Clip

Alternatives to Ciprofloxacin Use for Enteric Fever, United Kingdom

To the Editor: In cases of typhoid and paratyphoid fever, it is often necessary to commence treatment before the results of laboratory sensitivity tests are available. It is therefore important to be aware of optional drug therapies available because some organisms may be resistant to key antimicrobial drugs. For typhoid and paratyphoid, ciprofloxacin has become the first-line drug of choice since the widespread emergence and spread of strains resistant to chloramphenicol, ampicillin, and trimethoprim (1). The Laboratory of Enteric Pathogens (LEP) of the Health Protection Agency of England and Wales is the reference center for Salmonella enterica serovars Typhi and Paratyphi A for the United Kingdom; as such, this laboratory receives isolates from all cases of infection. Isolates are screened by breakpoint for resistance to antimicrobial drugs at the following levels: chloramphenicol, 8 mg/L; ampicillin, 8 mg/L; trimethoprim, 2 mg/L; ciprofloxacin, 0.125 mg/L (decreased susceptibility); and 1.0 mg/L (high-level resistance), ceftriaxone, 1 mg/L, and cefotaxime, 1 mg/L. The levels for testing for resistance to chloramphenicol, ampicillin, trimethoprim, ceftriaxone, and cefotaxime correspond to internationally accepted therapeutic levels for these antimicrobial agents. In contrast, the levels for ciprofloxacin (0.125 and 1.0 mg/L) have been chosen after observations of treatment failures at levels when used at below the expected recommended serum concentrations (2,3). Since 2005, a proportion of isolates exhibiting decreased susceptibility and high-level resistance to ciprofloxacin have been tested for resistance to azithromycin by Etest (AB Biodisk, Solna, Sweden), using drug-sensitive strains of S. Typhi and S. Paratyphi A as controls. From January 2001 through December 2006, LEP reported 1,215 cases of S. Typhi infection and 1,274 cases of S. Paratyphi A infection. Of these, ≈60% (1,493) reported recent travel abroad; India and Pakistan were the most frequently visited countries (4). Other cases were associated with persons who had a history of such travel, but the numbers involved were difficult to document accurately because of underreporting of foreign travel and other communication problems. For S. Typhi, the occurrence of isolates resistant to ciprofloxacin at 0.125 mg/L increased from 60 (35%) of 170 in 2001 to 169 (70%) of 240 cases in 2006, with 4.8 (2%) of isolates in 2006 resistant at 1.0 mg/L (Table). The corresponding figures for S. Paratyphi A were 58 (25%) of 232 cases in 2001, rising to 84% in 2004, with an incidence of 73% in 2006; 9% of these were resistant to ciprofloxacin at 1.0 mg/L (Table). Moreover, in 2006, 56 isolates of S. Typhi (23% of total) exhibited resistance to chloramphenicol, ampicillin, and trimethoprim, 54 (96%) were also resistant to ciprofloxacin at 0.125 mg/L. When tested for resistance to ceftriaxone and cefotaxime, none of the isolates (either S. Typhi or S. Paratyphi A) were resistant at 1.0 mg/L. Table Incidence of resistance/decreased susceptibility to key antimicrobial agents in isolates of Salmonella enterica serovars Typhi and Paratyphi A, United Kingdom, 2001–2006* Although the levels of resistance to ciprofloxacin were for the most part below that regarded as therapeutic (MIC 0.25–1.0 mg/L), at least 21 treatment failures have been documented since 2005. These findings demonstrate that the efficacy of ciprofloxacin for first-line treatment of enteric fever in the United Kingdom has been seriously jeopardized. In cases of treatment failures, commonly used alternative antimicrobial agents have included third-generation cephalosporins such as ceftriaxone. The macrolide antimicrobial azithromycin is also being increasingly used, particularly for patients with hypersensitivity to penicillins (5). With this in mind, 50 S. Typhi and 40 S. Paratyphi A strains isolated from January 2005 through December 2006, which exhibited resistance to ciprofloxacin at 0.125 mg/L, were tested for resistance to azithromycin by Etest. Results indicated that none of the isolates of S. Typhi exhibited MICs >8 mg/L, which corresponded to the MIC to azithromycin of a drug-sensitive control strain of S. Typhi (range 4–8 mg/L, MIC90 6 mg/L). For S. Paratyphi A, none of the isolates exhibited MICs >12 mg/L, corresponding to that of a drug-sensitive control strain of this serovar (range 6–12 mg/L, MIC90 10 mg/L). Although there are no definitive data on resistance levels for azithromycin in relation to treatment of typhoid and paratyphoid, these findings suggest that resistance to this antimicrobial agent in terms of treatment efficacy has not yet been jeopardized. These results indicate that the availability of effective antimicrobial agents for the treatment of typhoid and paratyphoid infection is becoming increasingly limited for patients in the United Kingdom. Nevertheless, despite the dramatic upsurge in the occurrence of strains with decreased susceptibility, ciprofloxacin still remains the drug of choice for many physicians. It is reassuring that in cases of treatment failure, third-generation cephalosporins such as ceftriaxone and macrolide antimicrobial agents such as azithromycin appear to be viable alternatives.

Choice of a regular physician and health care utilization: principal-agent issues for American veterans

Using US Veterans Health Administration (VA) data, we examined factors that affected patients choice of regular physicians and how the location of regular physicians influenced patients health care use. Appropriate estimation methods were applied to control for the endogeneity of patients choice of regular physicians. Our study showed that VA enrollees with regular VA physicians were more likely to use VA for inpatient care while those with regular nonVA physicians were more likely to use VA for special care such as pharmacy or mental health/substance abuse treatment, both of which can have very limited coverage in nonVA settings.

Non???Animal-Based Hyaluronic Acid Fillers: Scientific and Technical Considerations

Recent advances in the technology and biocompatibility of the hyaluronans in all skin types mean that they are becoming the temporary facial filling agents of choice for many aesthetic physicians and surgeons. The hyaluronan products that have been approved for clinical usage by the U.S. Food and Drug Administration and Health Canada were reviewed with respect to their composition, clinical effects and safety profiles, and potential complications. The currently approved accepted standard for the hyaluronan family of fillers of nonanimal bacterial origin includes Restylane and Perlane in the United States and Perlane, Restylane Touch, and SubQ in Canada. Also of nonanimal origin, Juvéderm 24HV, 30, and 30HV were approved by the Food and Drug Administration in June of 2006. Another bacteria-derived hyaluronan filler is Captique; the Hylaform group of hyaluronan fillers is of animal origin and appears to be similar in effect and longevity to Captique. The remarkable biocompatibility of the hyaluronan group of agents in individuals of all skin types, allied with the superior aesthetic result and outstanding longevity of response, promises that patients will continue to demand safe these recent advances in filler technology.

Our Health Care System at the Crossroads: Single Payer or Market Reform?

Our Health Care System at the Crossroads: Single Payer or Market Reform?

Potential drug interactions during a three-decade study period: a cross-sectional study of a prescription register

The thesis aimed to study the developments, in the area of pharmacoinformatics, of the electronic prescribing and dispensing processes of drugs - in medical praxis, follow-up, and research. For hundreds of years, the written prescription has been the method of choice for physicians to communicate decisions on drug therapy and for pharmacists to dispense medication. Successively the prescription has also become a source of information for the patient about how to use the medication to maximize its benefit. Currently, the medical prescription is at a transitional stage between paper and web, and to adapt a traditional process to the new electronic era offers both opportunities and challenges The studies in the thesis have shown that the exposure of prescribed drugs in the general population has increased considerably over three decades. The risk of receiving potentially interacting drugs was also strongly correlated to the concomitant use of multiple drugs, polypharmacy. The pronounced increase in polypharmacy over time constitutes a growing reason for prescribers and pharmacists to be aware of drug interactions. Still, there were relatively few severe potential drug interactions. Recently established national prescription registers should be evaluated for drug interaction vigilance, both clinically and epidemiologically. The Swedish National Pharmacy Register provides prescription dispensing information for the majority of the population. The medication history in the register may be accessed online to improve drug utilization, by registered individuals, prescribers, and pharmacists in a safe and secure way. Lack of widespread secure digital signatures in healthcare may delay general availability. With a relatively high prevalence of dispensed drugs in the population, the National Pharmacy Register seems justified in evaluating individual medication history. With a majority of prescriptions transferred as ePrescriptions, the detected increased risk for prescription errors warrants quality improvement, if the full potential of ePrescriptions is to be fulfilled. The main conclusion of the studies was that ePrescribing with communication of prescribed drug information, storing and retrieving dispensed drug information, offers new opportunities for clinical and scientific

Nuklearmedizinische Abklärung bei vermuteter Infektion einer Hüft- oder Knie-TEP

Komplikationen nach Hüftendoprothesen-Operationen treten mit einer Häufigkeit von ca. 1-2 % nach Erstoperation und ca. 3-5 % nach Revisionsoperation auf und kommen nach Knieendoprothesen-Operationen noch etwas häufiger vor. Dabei kommt der Differenzierung einer aseptischen Lockerung von einer bakteriellen Protheseninfektion besondere Bedeutung zu. Bei einer aseptischen Prothesenlockerung ist üblicherweise ein einzeitiger Prothesenwechsel möglich. Liegt dagegen eine Keimbesiedelung der Prothese vor, sollte zunächst sämtliches Fremdmaterial ausgebaut werden, damit eine Sanierung der Infektion ermöglicht wird. Erst bei einer nachgewiesenen lokalen Keimfreiheit kann schließlich die neue Prothese im Intervall eingesetzt werden. Die Diagnostik und Therapie der schmerzhaften Hüft- oder Knie-TEP ist schwierig, weil Anamnese, klinische Untersuchung, Ergebnisse der Labordiagnostik einschließlich bakteriologischer Untersuchung von Punktionsmaterial und die Ergebnisse radiologischer Untersuchungen oftmals nicht eindeutige Ergebnisse liefern. Im Laufe der Jahre wurden eine Vielzahl von nuklearmedizinischen Untersuchungen vorgestellt, um bei der schmerzhaften Hüft- oder Knie-TEP eine aseptische Prothesenlockerung von einer Prothesenentzündung zu differenzieren. Keine nuklearmedizinische Methode schneidet überragend ab. In der internationalen Literatur wird immer wieder auf die kombinierte Entzündungs- und Knochenmarkdiagnostik mit markierten Leukozyten und 99mTc-Schwefelkolloid als beste Methode bei dieser Fragestellung hingewiesen. In Deutschland ist die Methode in der publizierten Form nicht verfügbar, zudem ist die Methode zeitaufwendig, kostenintensiv und erfordert den direkten Umgang mit Blut. Daher ist zur Abklärung die Entzündungsszintigrafie mit markierten Antikörpern bzw. Antikörperfragmenten für die meisten Nuklearmediziner derzeit die Methode der ersten Wahl, wobei bei semiquantitativer Auswertung eine vergleichbare diagnostische Genauigkeit erreichbar ist. 18F-FDG-PET kann letztendlich nicht sicher zwischen Abriebmaterial, welches eine abakterielle Entzündung hervorruft und einer septischen Entzündung unterscheiden, wenngleich eine Bewertung des Anreicherungsmusters an der Hüfte eine durchaus akzeptable Differenzierung erlaubt. Auch kann ein unauffälliger 18F-FDG-PET-Befund eine Entzündung mit hoher diagnostischer Genauigkeit ausschließen. Am Knie ist eine vergleichbare Bewertung des 18F-FDG-Anreicherungsmusters bisher nicht gelungen, weshalb die Entzündungsszintigrafie mit markierten Antikörpern bzw. Antikörperfragmenten für die meisten Nuklearmediziner auch hier die Methode der ersten Wahl darstellen dürfte. Durchaus enttäuschend ist, dass ein prinzipiell attraktiver Ansatz, mit 99mTc-Ciprofloxacin eine Infektion sicher zu diagnostizieren, nicht zu den erhofften exzellenten Resultaten geführt hat. Es ist festzustellen, dass kein nuklearmedizinisches Verfahren einen direkten Erregernachweis führen kann. Daher ist es erforderlich, die Limitationen der nuklearmedizinischen Diagnostik zu kennen. Um zu einer klinischen Problemlösung zu gelangen, sind vor allem klinische Erfahrung und die zusammenschauende Wertung von Anamnese, klinischen Befunden und Ergebnissen der aufgeführten Untersuchungsmethoden erforderlich. Auch die nicht-nuklearmedizinischen Untersuchungsmethoden sind weit davon entfernt, immer eindeutige und richtige Ergebnisse zu liefern. Die zusammenschauende Wertung macht es jedoch möglich, mit hoher klinischer Treffsicherheit eher die aseptische Prothesenlockerung oder eher die Protheseninfektion zu erkennen. Bei nicht eindeutiger Festlegung soll nicht vergessen werden, dass Verlaufsuntersuchungen die Differenzialdiagnose ermöglichen können. Insbesondere ist es nicht nachzuvollziehen, wenn aus einem überbewerteten Strahlenrisiko oder unbegründeter Strahlenangst medizinisch indizierte nuklearmedizinische Untersuchungen bei den typischerweise älteren Patienten nicht vorgenommen werden. Die reale Einbuße an Lebensqualität und die real existierenden Gefährdungen durch eine nicht ordnungsgemäß funktionierende Hüft- oder Knieendoprothese überwiegen bei weitem gegenüber einem theoretischen, in die Zukunft extrapolierten Strahlenrisiko.