Course Of Medical Practice Research Articles

Application of logical modeling for the analysis and classification of medical data for the purpose of diagnosis.

The subject of the research is a logical approach to data analysis and the development of software tools capable of identifying hidden patterns, even with a limited amount of data. The input data consists of indicators of the diagnosis of patients, their diagnoses and the experience of doctors obtained in the course of medical practice. The research method is the development of software tools based on systems of multivalued predicate logic for the analysis of patient data. This approach considers the source data as a set of general rules, among which it is possible to distinguish those rules that are sufficient to explain all the observed data. These rules, in turn, are generative for the area under consideration and help to better understand the nature of the objects under study. The novelty of the study lies in the use of multivalued logic to analyze a limited amount of medical data of patients in order to determine the most likely diagnosis with a given accuracy. The proposed approach makes it possible to detect hidden patterns in the symptoms and results of patient examinations, classify them and identify unique signs of various forms of gastritis. Unlike neural networks, logical analysis is transparent and does not require training on large amounts of data. The conclusions of the study show the possibility of such an approach for diagnosis with a lack of information, as well as the offer of alternatives if the required accuracy of diagnosis is not achieved.

Modern challenges of medical education and their reflection in the curriculum

Medical education in the 21st century is at a crossroads. Faced with the challenges posed by science and technology, as well as social change, the curriculum is increasingly out of step with the new needs for teaching and medical practice. The road to major curriculum reform is challenging due to a variety of factors, including deep-rooted values, natural resistance to change, and the accreditation process. In fact, even the very understanding of what it means to be a professional is changing, which has a profound impact on the future role of the physician in society and the relationship that develops in the course of medical practice between physician and patient. In this article, the author considers the problems facing medical education in the modern era. To solve these problems, the author recommends paying special attention to the 21st century medical education curriculum – knowledge acquisition and storage, cooperation with and management of artificial intelligence applications, a deep understanding of probabilistic reasoning, and the development of empathy and compassion in accordance with ethical norms and standards. Given these needs, it is essential, in the author's opinion, to undertake a significant reform of the curricula and, at the same time, strives to introduce such changes that will help prepare practitioners in the rapidly changing 21st century. The author of the article suggests the first steps that a higher education institution can take to solve the problems considered in this study.

Perceptions of education quality and influence of language barrier: graduation survey of international medical students at four universities in China

BackgroundAs the number of Asian and African students studying medicine in China increases, it is imperative to evaluate the educational experiences of these international medical students (IMSs). This study was intended to investigate opinions of China-educated IMSs towards the medical curriculum and the impact of Chinese language capability on their clinical studies.MethodsA self-administered questionnaire was circulated to the final-year IMSs during the graduation time from May 2019 to July 2019 in 4 universities in China. The questionnaire asked IMSs to assess the quality of medical education and provide a self-evaluation of their Chinese language capability. One-way Analysis of Variance (ANOVA) was used to determine whether IMSs’ Chinese language capability was associated with their clinical experiences and clinical competence.ResultsOverall, we received 209 valid responses, of which 76.1% were satisfied with the quality of medical education. Genetics, physics, and mathematics were perceived as the least relevant basic courses for medical practice, and 21.5% of student reported that community-oriented medicine was a neglected subject. Notably, 58.9% of students had positive views about discussions on ethical topics during their clerkships, and 71.3% believed they had acquired sufficient clinical skills to begin a residency program. Chinese speaking skills and communication initiatives were found to be critical factors in influencing students’ clinical experiences and competence.ConclusionThis study presents the perceptions of China-educated IMSs towards medical curriculum from various aspects. Results show that language influences the education experiences of IMSs. Collectively, these results indicate that the curriculum for IMSs in China should be more problem-based and community-engaged to improve IMSs’ learning experiences and preparation for community deployment. Furthermore, training curriculum for the oral Chinese should be improved to equip IMSs with sufficient language competence to enable them to efficiently carry out clinical clerkship and rotations. Our findings provide evidence for benchmarking medical curricular codifications tailored for Asian and African students.

HESTER: A Phase II Study Evaluating Efficacy and Safety of Tisagenlecleucel Reinfusion in Pediatric and Young Adult Patients with Acute Lymphoblastic Leukemia Experiencing Loss of B-Cell Aplasia

Background: Tisagenlecleucel is an anti-CD19 chimeric antigen receptor (CAR)-T cell therapy approved for pediatric and young adult patients with relapsed/refractory (r/r) B-cell acute lymphoblastic leukemia (B-ALL) and adult patients with r/r diffuse large B-cell lymphoma. The ELIANA trial showed efficacy (81% overall remission rate [ORR]; 60% complete remission [CR]) and safety of tisagenlecleucel in r/r B-ALL (Maude et al. N Engl J Med. 2018). In the ELIANA trial, sustained remissions were associated with B-cell aplasia, an expected on-target effect of tisagenlecleucel and a pharmacodynamic marker for tisagenlecleucel persistence. In some patients who demonstrated short CAR-T cell persistence, reinfusion with 1 or more additional doses of tisagenlecleucel has restored B-cell aplasia and produced a 60% CR rate in patients who were reinfused with humanized CD19-targeted CAR-T cell therapy (Maude et al. J Clin Oncol. 2016). This prolongs the period of tisagenlecleucel activity and immunosurveillance and may therefore prolong durable remission. We introduce a trial in progress investigating the efficacy and safety of tisagenlecleucel reinfusion in pediatric and young adult patients with B-ALL experiencing a loss of B-cell aplasia. Study Design and Methods: HESTER (NCT04225676) is a phase II, open-label, multicenter trial to determine the efficacy and safety of tisagenlecleucel reinfusion in pediatric and young adult patients with B-ALL experiencing loss of B-cell aplasia. Eligible patients must be ≤25 years of age with a confirmed diagnosis of CD19(+) leukemia. Patients must have been previously infused with commercial tisagenlecleucel and have at least 1 additional dose of commercial tisagenlecleucel prescribed to them in the course of medical practice. Commercial tisagenlecleucel must be given for reinfusion within 9 months of the initial manufacturing date. Patients must have loss of B-cell aplasia defined as peripheral blood (PB) absolute B lymphocyte count ≥50/μL or PB B lymphocyte ≥10% of the total lymphocytes; patients are not required to be minimal residual disease negative (MRD)(-). Karnofsky (age ≥16 years) or Lansky (age <16 years) performance status must be ≥50 at screening. Patients treated with prior gene/adoptive T-cell therapy other than tisagenlecleucel and patients with active central nervous system involvement by malignancy are excluded. The primary efficacy endpoint is the proportion of patients who reestablish B-cell aplasia within 12 months of reinfusion as measured by circulating B lymphocytes (<50/μL) and presence of tisagenlecleucel cells by quantitative polymerase chain reaction (qPCR) in the PB. Secondary outcomes include the ORR (CR + CR with incomplete blood count recovery) during the 12 months post reinfusion, event-free survival, overall survival, MRD status, and safety; immunogenicity and tisagenlecleucel persistence (by qPCR) are exploratory endpoints. Subgroup analysis of efficacy outcomes will include patients with a loss of B-cell aplasia within 9 months of first infusion who are MRD(+) at time of enrollment, as well as patients with very early (<3 mo), early (≤3 to <6 mo), and later (≥6 mo) loss of B-cell aplasia following first infusion. Safety will be assessed throughout the trial. For the primary analysis, a minimum of 10% of patients reestablishing B-cell aplasia within 12 months after reinfusion is expected with an estimated true rate of 25%. All secondary and exploratory variables will be summarized descriptively. Estimated enrollment is about 54 patients in the United States. Clinical Trial Information: NCT04225676 Disclosures Boyer: Thunder Biotech Inc: Consultancy. Grupp:Servier: Research Funding; Cellectis: Other; Roche: Consultancy; Adaptimmune: Other: SAB; Jazz: Other: SSC; TCR2: Other: SAB; GlaxoSmithKline: Consultancy; CRISPR Therapeutics/Vertex Pharmaceuticals: Other; Juno/BMS: Other; Janssen/JnJ: Consultancy; Humanigen: Consultancy; CBMG: Consultancy; Kite/Gilead: Research Funding; Allogene: Other; Novartis: Consultancy, Other: SSC, Research Funding. Hermiston:Novartis: Membership on an entity's Board of Directors or advisory committees; Sobi: Membership on an entity's Board of Directors or advisory committees. Kovacs:Novartis: Current Employment. Magley:Novartis: Current Employment. Myers:Novartis: Consultancy, Honoraria, Other: ELIANA trial Steering Committee, Speakers Bureau. Phillips:Novartis: Membership on an entity's Board of Directors or advisory committees. Pulsipher:Bellicum: Honoraria; Mesoblast: Honoraria; Miltenyi: Honoraria, Research Funding; Adaptive: Research Funding; Novartis: Honoraria; Jasper: Honoraria. Purkayastha:Novartis: Current Employment. Willert:Novartis: Current Employment.

Regulatory Challenges of Brain Delivered Therapies: A Combination Product Perspective

Delivery of therapeutic agents directly to the central nervous system can be critical to address a number of diseases. Intraventricular administration of drugs has been used for over 50 years. Despite a substantial number of drugs routinely administered to the central nervous system in the course of medical practice, very few medical devices are appropriately cleared in the US for this route of administration. This review explores the regulatory challenges, the supplementary testing and more stringent acceptance criteria required for combination products and medical devices intended for CNS therapies. A case study of the recent Brineura® combination product approval is also presented.

Altruism: Should it be Included as an Attribute of Medical Professionalism?

ProblemAltruism is often included in classical and modern definitions of medical professionalism and some feel that medicine is a vocation where altruism is a pre-requisite. However since the 1970s there have been changes in society affecting the way all professions are viewed. Some high profile medical malpractice cases mean the public no longer perceives the medical profession as infallible. Following the Harold Shipman case, medical educators began to argue that retaining the concept of altruism did a disservice to the medical profession where “it is the claim of altruism that allows the medical profession to claim moral superiority”.1 ApproachThe historical course of medical professionalism was examined looking at changes in the way the profession viewed itself and how doctors were regarded by the public. It drew on the socio-cultural changes of the latter half of the twentieth century as well as the rise in medical malpractice cases to show how these have influenced professional values. Changes to the medical profession following the case of Harold Shipman were highlighted with the current usage of the term altruism by members of the profession. OutcomesArguments both for and against retaining altruism in the definition of medical professionalism were discussed. Ethicists argued that following the moral code of beneficence in the course of medical practice, it was not possible to be altruistic and many feel that receiving a fee for services can never allow for true altruism. There is an argument that working without consideration for one׳s own well-being may lead to an increase in burn-out in the medical profession. Next stepsFor many, the future of the medical profession lies in abandoning altruism as part of its defining qualities and adopting a new ethical definition of professionalism that fits with the complexities of modern society

David Antony Long

The death of David Antony Long at the age of 98 severs one of the last direct links with the era that followed the discovery of penicillin by Alexander Fleming...

Manslaughter and the doctor - conviction and sentence.

A conviction for manslaughter is a professional disaster for the doctor, likely to herald the end of his career in medicine, and a possible prison sentence. A finding of civil negligence is bad enough; a verdict of criminal negligence is truly tragic. There are not many prosecutions for doctor manslaughter, because jurors respect doctors, recognise the inherent risks in medicine and are reluctant to convict. However, prosecutions are now more common than before, especially since 1990 or thereabouts (‘‘Doctors charged with manslaughter in the course of medical practice 1795–2005, a literature review’’, RE Ferner and SE McDowell, J R Soc Med 2006 June 99(6) 309–314 – mistakes, slips and violations). A fatal medical mishap may arise in almost any situation, though some areas of practice are more vulnerable than others, such as obstetrics and gynaecology and anaesthetics. The examples from practice are legion: Wrong diagnosis. Failure to refer the patient to hospital. Wrong drug prescribed or administered. Not listening to the patient, or to members of the medical team. Delay in attending to the patient. Failure to check symptoms. Failure to obtain a scan, or quickly enough, or misreading the scan. A one-off lamentable incident. A series of failures, systematic lapses. The standard to be applied is the expected or accepted practice normally exercised by a reasonably competent doctor, following the guidance from the GMC and the Royal Colleges, and the law set down by the judges. This standard is inherently and inevitably somewhat vague and uncertain, as so much depends upon the particular factual circumstances of each case. A mistake or error of judgment will not suffice. The test is gross negligence, more than ordinary negligence, beyond mere inadvertence. The doctor was reckless in his attention to the patient. His conduct was thoroughly reprehensible, very bad. Jurors feel shocked, even outraged. R v Adomako [1995] 1 AC 171. A locum anaesthetist was involved in a detached retina operation. He failed to notice for over 4min that a tube had become dislodged, thus depriving the patient of oxygen. The chest was not moving, the patient was turning blue and the dials on the machine stopped. The patient suffered a cardiac arrest and died. Even when the machine alarm went off, it did not occur to the doctor that there had been a disconnection. The doctor was in breach of his duty of care, namely to exercise reasonable professional skill. Manslaughter. R v Adomako [1995] 1 AC 171, 181–182. Two junior doctors were responsible for the postoperative care of the patient recovering from knee surgery. The patient began to show classic symptoms of serious illness, namely temperature, pulse and blood pressure, and the nurses expressed concern, yet the doctors did nothing and did not refer to the consultant. The patient developed infection of the wound, which went undiagnosed, and died from toxic shock syndrome. Manslaughter. R v Misra and Srivastava [2005] 1 Cr App R 328, [2004] EWCA Crim 2375. After a routine knee operation which went off satisfactorily, the patient was transferred to a consultant surgeon because he complained of abdominal pain. A perforated bowel, a potentially life-threatening condition, was suspected, but the doctor, a colorectal surgeon, ignored the patient for 24 h, did not prescribe antibiotics and delayed in obtaining and examining a scan. The risks grew over time, and the patient died. By multiple failures, the doctor had not measured up to accepted and expected standards. Manslaughter. R v Sellu, Central Criminal Court, 5 November 2013. The patient had fluid overload and low blood pressure and did not respond to antibiotics. The doctor failed to investigate abdominal pain, failed to detect a blocked urethra, failed to ascertain renal failure from tests, failed to detect sepsis and failed to drain the infection. He failed to care properly for the patient. The patient died from pulmonary oedema. The records were poor, and, worse, the doctor tampered with them. Manslaughter. R v Garg [2012] EWCA Crim 2520, (2013) 2 Cr App R (S) 30.

A Classification Algorithm of Abdominal Ultrasound Images in Medical Practice for Secondary Uses

A classification algorithm for abdominal organs in ultrasonic test images based on the operator’s knowledge is proposed. This is in order to use the medical images included in medical charts for secondary uses, e.g., medical data analysis. It makes a correlation between target organs in test images and search unit information on the body mark region. In the central region of abdominal images, target organs are uniquely determined through recognition of the liver region and in consideration of the location of the diaphragm. A classification experiment, done using 600,000 real test images taken at the Kochi Medical School Hospital from 2004 to 2008, was carried out to evaluate the performance of the proposed system in terms of accuracy rate of detection of the body mark region and diaphragm region. The proposed algorithm constitutes an essential classification system for the secondary use of a large database of ultrasound images taken in the course of medical practice.

New insights into the pathophysiology and treatment of chronic itch in patients with end‐stage renal disease, chronic liver disease, and lymphoma

Chronic itch associated with systemic diseases continues to be one of the most bothersome dermatological symptoms accompanying end-stage renal disease (ESRD), chronic liver diseases, and lymphoma. The International Forum for the Study of Itch has recently issued a consensus paper on different types of chronic pruritus, including pruritus in systemic diseases that can present with or without secondary skin changes.1Various types of itch have been described based on the origin of the itch, which could be skin-related, neuropathic, systemic, or psychogenic.2 At any given time patients with these systemic diseases may have more than one origin, for example, patients with end-stage renal disease (ESRD) could have neuropathic itch due to nerve fibers damage, as well as itch associated with skin inflammation such as perforating folliculitis. Itch adversely affects quality of life of patients, leading to sleep deprivation and depression that further augment itch. Chronic itch associated with systemic diseases range from mild to intractable, which is defined as a chronic itch state in which the cause cannot be removed or treated, and no relief or cure has been found in the generally accepted course of medical practice.3 In the last decade, there are significant advances in our understanding of specific itch neuronal pathways, mediators and relevant receptors, opening the field for development of new antipruritic strategies. The purpose of this review is to highlight the new findings related to the pathophysiological mechanisms and the treatment of itch associated with the most common systemic diseases including ESRD, chronic liver disease and lymphoma.

Prosecution of Physicians for Prescribing Opioids to Patients

In this issue, Reidenberg and Willis(1) highlight the legal dangers associated with prescribing opioids for patients when federal or state governments believe that such prescribing is outside the "usual course of medical practice." This article expands on the themes identified by the authors and addresses the problems faced by both prescribers and patients when "Big Brother" enters the treatment room and looks over the physician's shoulder.

Doctors Charged with Manslaughter in the Course of Medical Practice, 1795–2005: A Literature Review

To quantify the number of doctors charged with manslaughter in the course of legitimate medical practice and to classify cases, as mistakes, slips (or lapses), and violations, using a recognized classification of human error system. We searched newspaper databases, Medline, Embase, and the Wellcome library catalogue to identify relevant cases from 1795 to December 2005. Medical practice in the United Kingdom. Number of doctors charged with manslaughter in the course of medical practice. We identified 85 doctors charged with manslaughter since 1795. The number of doctors charged was relatively high in the mid-19th century and the inter-war years, and has dramatically increased since 1990. Sixty of the doctors were acquitted, 22 were convicted, and three pleaded guilty. Most doctors were charged as a consequence of mistakes (37) or slips (17), and a minority because of alleged violations (16). The number of doctors prosecuted for manslaughter has risen steeply since 1990, but the proportion of doctors convicted remains low. Prosecution for deliberately violating rules is understandable, but accounts for only a minority of these cases. Unconscious errors--mistakes and slips (or lapses)--are an inescapable consequence of human actions and prosecution of individuals is unlikely to improve patient safety. That requires improvement to the complex systems of health care.

Doctors charged with manslaughter in the course of medical practice, 1795-2005: a literature review

To quantify the number of doctors charged with manslaughter in the course of legitimate medical practice and to classify cases, as mistakes, slips (or lapses), and violations, using a recognized classification of human error system. We searched newspaper databases, Medline, Embase, and the Wellcome library catalogue to identify relevant cases from 1795 to December 2005. Medical practice in the United Kingdom. Number of doctors charged with manslaughter in the course of medical practice. We identified 85 doctors charged with manslaughter since 1795. The number of doctors charged was relatively high in the mid-19th century and the inter-war years, and has dramatically increased since 1990. Sixty of the doctors were acquitted, 22 were convicted, and three pleaded guilty. Most doctors were charged as a consequence of mistakes (37) or slips (17), and a minority because of alleged violations (16). The number of doctors prosecuted for manslaughter has risen steeply since 1990, but the proportion of doctors convicted remains low. Prosecution for deliberately violating rules is understandable, but accounts for only a minority of these cases. Unconscious errors--mistakes and slips (or lapses)--are an inescapable consequence of human actions and prosecution of individuals is unlikely to improve patient safety. That requires improvement to the complex systems of health care.

Patenting Medical Inventions

Medical, dental, nursing, and biomedical personnel often perform critical research that can lead to patents. Similarly, patentable discoveries can be made during the normal course of medical practice, e.g., the development of new biocompatible polymers, improved dental materials, new or modified catheters, new laboratory diagnostic tests, and improved medical devices. Many inventions may not be patented in federal organizations due to the lack of information available on the patenting process. In this article, the financial benefits that can be derived from patenting inventions are discussed, as well as the different types of patents that can be obtained, the conditions for patentability, bars or restrictions to obtaining a patent, the importance of proper record keeping, and the steps to take toward getting an invention patented.

Medical Education and the Dying Patient

Several recent cases illustrate the medical-ethical-legal consequences associated with lack of awareness in caring for and treating the dying patient. We question whether solutions advanced by others are feasible or desirable for use in medical education, and suggest looking to the familiar principles of clinical medicine. These principles can be used to acquaint students and residents with the clinical model of medicine so they can learn the differences between the rights and duties of those occupying the "sick" and "dying" roles. Once these differences have been understood, then the rules for moving patients from one role to another can be gradually acquired in the course of medical practice. The task now is to resuscitate these traditional abilities in the context of our times.

Can ethics be taught in a hospital?

No one now doubts that physicians frequently face difficult ethical questions in the course of medical practice. These questions are often of a kind that cannot simply be left to await a time when one has greater leisure. Physicians have to act and take responsibility for their decisions, whichever way they decide. Often the ethical decisions are as crucial as the medical ones. Yet most physicians have received no formal training in ethics and many of them have not thought, talked, or read much about the subject either. It is not uncommon for a physician to describe himself as purely a technician, a kind of advanced plumber who does nothing but respond to requests from people who come to have defective plumbing put right.

The rate of initiation of treatment for hypertension in a community, 1971--1975.

In 1971 persons aged 50-59 in a community were screened for hypertension and those with diastolic BP greater than or equal to 110 mmHg were notified. On reviewing the sample in 1975 the treatment rate had doubled to 22%. Screening in 1971 was followed by an immediate rise in numbers starting treatment, most being notified cases. Thereafter initiation of treatment at a rate of 3-8 cases per 100 persons per year chiefly reflected identification of subjects deemed to need treatment in the ordinary course of medical practice. Of those starting treatment during the four years 25% had stopped it by 1975. The influence of screening and other factors on the rate of initiation of treatment and adherence to it are discussed. With an already high attendance rate at doctors, regular screening of this whole age group seems feasible within the framework of general practice. The high treatment rate found in 1975 underlines the urgent need for the indications currently used for starting treatment to be validated.

Sociology and Medical Problems

The theme I was given by the editorial committee of the JSR was to discuss the future tasks of sociology in the following three domains - social welfare, social pathology and social problems.Firstly, however, I must dare to say a word or two about the way to treat this theme. For, I think it can be no easy job at all to search for the proper subject of sociology in these three domains without any special analyzing viewpoint. Let's take social welfare as an example. My standpoint is that it is one of the most dangerous thoughts that sociology of social welfare can be brought into existence even in the case of lacking in the special analyzing viewpoint. My assertion is based on the following two points.1, The learning subjects of social welfare, social pathology and social problems are the problems of practice in the actual social life. So each sociology of each domains as an academic science will be impossible to be realized, chiefly because the academic subjects always need to have a certain distance from the social practice.2, What I call “the tendency of complimentality” in today's our Japanese sociology is one of the most essential causes of its prosperity. But, at the same time, - here is my emphasis - it has prevented sociology from developing in its proper, ideal course.Therefore, as for me, I fix the medicine and medical problems in the core of my original viewpoint. From this point, I discuss about society, medicine, human beings and so on.Why do the medicine and medical problems stay only in the medical technical application to sufferers? Why so they restricted to the biological ones in the course of medical practice ?If we can make efforts to change these conditions mentioned above, we will be able to expect sociology a great part in searching for the renewed relationship between human beings and the medicine and medical problems.

The United States Public Health Service's Clinical Center for Medical Research.

The interrelationships between clinical medicine and medical research form one of the most intriguing chapters in the history of medicine. They have never been completely separated, or completely together, and the ways in which they have affected each other have varied markedly as medicine has evolved in this country. During recent years, perhaps as a cumulative effect of the general lifting of standards of medical education since the Flexner report, the spirit of inquiry has been widely dispersed among practicing physicians. Indeed, the innumerable studies and observations made in the course of medical practice are an indispensable contribution to the total medical research effort of the nation. At the same time, the scope of laboratory research related to medicine has expanded rapidly as the techniques and viewpoint of the biochemist and biophysicist have been brought to bear not only on disease problems but on the mechanism of normal body function.

An Address on SOME ALARMING SEIZURES

In the course of medical practice we are confronted from time to time by peculiar seizures or nerve storms, which lack conformity with the more familiar descriptions. Some of these seizures cause great alarm to their victims, in that they seem to threaten paralysis, speechlessness, unconsciousness, or even death itself, or because they occasion profound states of instability and prostration. The appearance and sufferings of the patients during these attacks may further alarm relatives or onlookers, and even the medical man, unless he be familiar with the true nature of the seizures or fully alive to the history of the case, may be taken unawares, and feel so dubious about their purport and outcome as to be unable to give a reassuring prognosis. And yet the seizures which I have in mind are all consistent with long life and with good health at other times. Those with the more local effects may simulate or suggest organic disease of the brain ; those causing serious instability may also be wrongly attributed to cerebral vascular disease or cerebral tumour ; those which cause