Current Medical Environment Research Articles

Updated Practice Guideline for Somatostatin Receptor Scintigraphy

In the current medical environment, policy makers, accreditation agencies, and third-party payers are increasingly looking for standardization of medical practice. One way of making medical practice more uniform is the acceptance of standards and guidelines. The SNM has been developing practice

Electronic Hand-Drafting and Picture Management System

The Department of Health of Executive Yuan in Taiwan (R.O.C.) is implementing a five-stage project entitled Electronic Medical Record (EMR) converting all health records from written to electronic form. Traditionally, physicians record patients' symptoms, related examinations, and suggested treatments on paper medical records. Currently when implementing the EMR, all text files and image files in the Hospital Information System (HIS) and Picture Archiving and Communication Systems (PACS) are kept separate. The current medical system environment is unable to combine text files, hand-drafted files, and photographs in the same system, so it is difficult to support physicians with the recording of medical data. Furthermore, in surgical and other related departments, physicians need immediate access to medical records in order to understand the details of a patient's condition. In order to address these problems, the Department of Health has implemented an EMR project, with the primary goal of building an electronic hand-drafting and picture management system (HDP system) that can be used by medical personnel to record medical information in a convenient way. This system can simultaneously edit text files, hand-drafted files, and image files and then integrate these data into Portable Document Format (PDF) files. In addition, the output is designed to fit a variety of formats in order to meet various laws and regulations. By combining the HDP system with HIS and PACS, the applicability can be enhanced to fit various scenarios and can assist the medical industry in moving into the final phase of EMR.

Treating Cervical Dysplasia: Why Does It Matter?

The cone biopsy described in the case series discussed by Mulhem et al[1][1] touches on several key issues in cervical cancer prevention and within the scope of practice of family physicians. In the current medical environment health care reform to bolster primary care to reduce health care costs

Where Is It? The Utility of Biopsy-Site Photography

With wrong-site surgery being one of the major causes of medical lawsuits in the United States, tools to confirm location are essential. A previous survey of 300 Mohs surgeons revealed that 14% of malpractice cases were due to wrong-site surgery. In dermatologic surgery, photography is helpful in precisely locating biopsy sites. We present a case series of 34 biopsy-proven cutaneous head and neck malignancies performed in our university-based dermatology clinic, comparing the reliability of patient and blinded dermatologist identification with that of biopsy-site photography. Of 34 biopsy sites, the patient and the blinded dermatologist incorrectly identified four (12%). The patient alone incorrectly identified an additional six biopsy sites, resulting in a total of 10 (29%) cases incorrectly identified by the patient. There were no instances in which the patient correctly identified the biopsy site and the blinded dermatologist incorrectly identified it. In our current medical environment, in which more than 90% of health care is delivered in a clinic setting, wrong-site surgery is certainly underreported. In adopting a zero-tolerance policy for wrong-site surgeries, biopsy-site photography saves time, money, and potential frustration, hopefully eliminating the number of excisions performed on the wrong site.

Intravitreal bevacizumab (Avastin) for age-related macular degeneration: a critical analysis of literature

The current medical environment demands that quality health care is delivered at an affordable cost through the use of objective, unbiased clinical data. This study was undertaken to review the current literature on bevacizumab for age-related macular degeneration and its value in determining best clinical practice. Randomised controlled trials (RCTs) and observational studies that met the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria were identified from the current literature for further analysis. Data concerning treatment dosing regimens, response to treatment, complications, and factors influencing outcome and safety were extracted and compiled into a database. As of January 2009, there were 5 RCTs that compared the outcomes of bevacizumab to other treatment options and 50 studies that met the STROBE criteria with similar visual and anatomical outcomes between RCTs and observational studies. Although the doses and dosing frequencies varied between the studies, the mean gain in vision at 3 months was +7.76+/-5.4 ETDRS letters (range +2 to +14.4); an effect that was maintained at 6 months in studies with longer follow-up. Predominantly classic lesions were the most responsive of all lesion subtypes. The complication profiles/rates were similar to those reported with other anti-vascular endothelial agents. There is sufficient scientific and statistical evidence to advocate the effective use of OCT-guided administration of intravitreal bevacizumab for neovascular AMD. This is reflected in our study outcome measures that are comparable to findings published from recent well-conducted RCTs on intravitreal ranibizumab at the same time point.

Switching within glaucoma medication class

In the current medical care environment, switching within class is often demanded by cost consideration, medical insurance coverage, or formulary restriction. With many choices of drugs available within a glaucoma medication class, questions exist whether switching within class is beneficial. The purpose of this article is to provide a clinical update on the feasibility of switching among the frequently used drugs within glaucoma medication class. Although efficacies of medications within a therapeutic class are similar and significant differences are generally not observed in clinical trials, response to medication often varies among individual patients in a clinical practice. Such variation may be secondary to differences in drug-receptor interactions, patient's compliance and tolerability to medical treatment, or bioavailability of the medication in individual ocular condition. In addition, switching within class is often necessary to minimize the systemic or local adverse reactions from the active or inactive ingredients of the medication. In addition to keeping up-to-date with the efficacy and safety profiles of drugs within each glaucoma medication class, clinicians should familiarize themselves with the different formulations available, preservative systems used, generics availability and compatibility, and the local insurance formulary restriction to deliver an effective glaucoma management.

The Hippocratic Oath: Revisited

Traditionally, the model of the physician-patient relationship was rooted in the Hippocratic Oath that condoned paternalism. The current emphasis on autonomy and distributive justice has changed the relationship to such extent that one might argue that the Oath has become irrelevant. This article will discuss whether the obligations dictated by the Oath are specifically Western or not, what has changed in the current medical environment and what should replace this traditional Oath?

Monitoring Adherence to Guidelines

In our current medical environment, which is characterized by oversight, accountability, practice guidelines, and documentation, it was inevitable that practice patterns would be monitored to rank compliance with guidelines as an index of the quality of care. It is a small step to a “pay-for-performance” approach, which is well intentioned because it uses data from clinical trials and guideline recommendations to reward physicians who are using treatment strategies known to be effective. Such an approach is aimed at identifying and reforming doctors who do not use “evidence-based” therapy. Article see p 98 In this issue of Circulation: Heart Failure , Fonarow and colleagues1 review the data on >15000 patients with heart failure cared for in 167 outpatient cardiology practices in the United States. The results can be viewed as encouraging or discouraging, depending on your expectations, and as an optimistic step in the right direction to ensure quality care or as a depressing retreat from individualized …

Aprotinin—Are There Lessons Learned?

THIS PAST YEAR HAS BEEN A COMPLICATED ONE FOR aprotinin, an antifibrinolytic serine protease inhibitor used to lessen bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass. Thirteen years after the initial approval of aprotinin by the US Food and Drug Administration, the report by Mangano and colleagues in this issue of JAMA will intensify the debate about the benefits and risks associated with use of this drug. Perhaps more important, this aprotinin story illuminates the larger issue of postmarket safety evaluation surrounding drugs and devices in the current medical environment. In this article, the investigators report 5-year, all-cause mortality data from patients enrolled in an international registry of on-pump coronary artery bypass graft surgery. The authors conclude that use of aprotinin in routine and complex coronary artery bypass graft surgery is associated with an increased risk of late mortality as compared with use of no hemorrhage-sparing agent and with use of aminocaproic acid and tranexamic acid, 2 lysine analog antifibrinolytics that are less expensive and less toxic. The 3876 patients from 62 of 69 centers were observed (87% follow-up rate) for 5 years. The authors used extensive statistical analytical techniques to address bias inherent in observational analyses, and referenced select randomized clinical trial data to support their observational findings. This current study by Mangano et al follows an earlier publication from 2006 addressing the perioperative risk of aprotinin therapy. The same registry was used for both studies and consisted of prospectively collected clinical data (7500 variables/patient) from 69 cardiac surgery sites in North and South America, Europe, and Asia. The earlier study analyzed 4374 patients, nonrandomly enrolled into the same 4 groups (ie, control, aminocaproic acid, tranexamic acid, aprotinin). Propensity-adjusted, multivariable logistic regression analysis demonstrated that as compared with control, aprotinin was associated with increased perioperative risk of death, acute renal failure, myocardial infarction, and stroke/ encephalopathy. The lysine analogs were not associated with any of these adverse outcomes. Importantly, the perioperative observational study findings seemed to conflict with findings from several dozen randomized trials, 2 meta-analyses, a Cochrane Collaboration summary on aprotinin use, and an evaluation by the US Food and Drug Administration. The challenges in translating clinical trial data into the “real world” are well known. Possible reasons that randomized trial results might not be available for assessment of adverse events with pharmacologic therapies include the fact that trials powered for efficacy are often too small to detect adverse events and too short to detect events requiring longer exposure. In addition, there are limited industry incentives to fund trials to quantify adverse events for drugs or devices, and head-to-head comparison of adverse events between different manufacturers may not be available. Moreover, observational-based studies (of the type reported by Mangano et al) might be a model for the future in assessing adverse effects from drugs. A variety of observational data sets exist in cardiovascular disease, including large administrative databases (Medicare, other payer, and hospitalor network-based systems), industry-sponsored postmarket registries, and comprehensive databases and registries from professional organizations (the Society of Thoracic Surgeons, the American College of Cardiology, and the American Heart Association). If observational data sets and analyses specific to those data sets are potential candidates for use in the safety evaluation process for drugs and devices, 4 criteria will need to be met: (1) the data sets must be sources of information that cannot be acquired through other mechanisms; (2) the reason patients receive the drug/device therapy must be determinable; (3) integration of both periprocedural data and long-term data are necessary; and (4) observational database systems will need to be modified and prospectively integrated into the overall process of evaluation for safety and efficacy. All of these criteria impact this aprotinin story. The studies by Mangano et al are important because they have generated new information not otherwise available about aprotinin use. However, it is not clear that the reasons patients received any specific agent (or no agent) are determinable. In the registry used by Mangano et al, the use of

Intravesical Instillation of Bacille Calmette-Guérin for Superficial Bladder Cancer: Cost-Effectiveness Analysis

Frequent recurrence of superficial bladder cancer is a major problem that impairs patients' quality of life. We studied the current treatment of superficial bladder cancer, including the economic aspects of intravesical instillation. A total of 138 superficial bladder cancers were assessed. The tumor characteristics and treatments were investigated during a mean observation period of 86 months by univariate and multivariate analyses. The costs associated with intravesical instillation of bacille Calmette-Guérin (BCG) and its side effects were subjected to cost-effectiveness analysis. Tumor histologic examination revealed grade 1 in 21 lesions, grade 2 in 60 lesions, grade 3 in 40 lesions, and unclassified in 17 lesions. The pathologic stage was Stage Ta in 85 lesions, T1 in 47 lesions, and Tis in 6 lesions. Univariate and multivariate analyses showed that intravesical instillation of BCG was the most significant factor preventing recurrence, and intravesical chemotherapy had no impact on recurrence. The 5-year recurrence-free survival rate was 78% and 28% for tumors with and without BCG instillation, respectively. The cost-effectiveness ratio of BCG instillation was approximately 3900 dollars/5-yr recurrence-free period. Our results have indicated that BCG is an effective adjuvant therapy after transurethral resection of superficial bladder cancer in the current medical environment.

Disseminated zygomycosis presenting as thyroid abscess in a renal allograft recipient

In the current medical environment, thyroid abscessis a clinical entity that is seldom encountered;however, it was a common condition in the erabefore antibiotics [1,2]. Review of the publishedcauses of thyroid abscess since 1980 demonstratedthat although Gram-positive bacteria (Staphylococcusand Streptococcus species) remain the most commoncauses, there have been a number of cases in theliterature, caused by mycobacteria, Salmonella speciesand anaerobes [2]. Fungal thyroid infections are veryrare and described in immunosuppressed patients.Immunocompromised patients, such as those withleukaemia, lymphoma, autoimmune diseases andorgan-transplant patients on pharmacologicalimmunosuppression, are particularly at risk.Aspergillus is by far the most common cause offungal thyroiditis [3]. However, zygomycoticthyroiditis is rarely reported in the literature. To thebest of our knowledge, there are only four reports inthe literature, of disseminated zygomycosis in whichthyroid was also involved [4–7]. Possibly, ours is a fifthcase in which a live unrelated renal allograft recipient(LURRAT) presented with thyroid abscessantemortem, which was diagnosed at autopsy withdisseminated zygomycosis.

L’élaboration d’un cursus en anesthésie: principes théoriques fondamentaux

Educational theories provide a guiding basis for coherent medical curriculum development and instruction in a similar way that evidence-based medicine provides a rational basis for medical treatment. The purpose of this review is to provide general organizational, theoretical and educational principles for developing or modifying an anesthesia curriculum. This paper draws from the general educational and cognitive psychology literature, the medical educational literature from the period 1996-2006, as well as our experience in renewing the anesthesia clerkship curriculum at McMaster University. Successful curriculum development includes the consideration of stakeholder needs, organizational issues, funding and sustainability, curriculum design, implementation and evaluation. Curriculum design includes the development of curricular goals and objectives, determination of the content and its organization, instructional methods and strategies, and assessment of the learners. Curriculum evaluation is used to judge the curriculum's merit and worth. The findings and recommendations from these evaluations feed back into the curriculum development cycle for further curricular improvements or modifications. The current medical environment requires a responsive and efficacious curriculum that is able to keep up with its rapid pace of change. By providing a discussion of the educational and theoretical principles which underpin coherent curriculum development, this paper advocates a rational, theory-based approach to curriculum development.

The Role of Rapport: Lessons Learned From Conducting Research in a Primary Care Setting

Conducting research in a primary care setting is difficult because of the competing demands primary care offices have to manage in the current medical environment. Every primary care office has its own relationship and reporting structures, norms, and ways of conducting day-to-day affairs. Regardless of the setting, when carrying out qualitative and/or mixed-methods research, researchers must have rapport with the individuals or group of individuals they will be working with to carry out the research. In this article, the authors describe the different approaches that research staff have used to create rapport with practice staff that were not only participants in the study but were also responsible for the delivery and implementation of this effectiveness study.

Medical Malpractice Liability in Clinical Urology: A Survey of Practicing Urologists

The current medical malpractice environment is in crisis. Costs associated with litigation as well as medical malpractice insurance premiums have increased during the last decade. In fact as of March 2004 the American Medical Association has identified 19 states as crisis states. We investigated the way in which the medical malpractice environment has affected urologists and the manner in which they practice medicine. A survey of 31 questions was electronically mailed to the American Urological Association's database of practicing urologists in the United States. Data were gathered on each urologist's malpractice history as well as their clinical practice. A total of 5,919 surveys were mailed and 683 (12%) were returned. Urologists from 47 states responded. The mean medical malpractice premium in 2003 was 30,665 dollars (median 22,500 dollars, range 6,000 dollars to 120,000 dollars). Of responding urologists 63% report being named in a medical malpractice lawsuit a mean of 2.1 times. Mean length of time practicing urology was 19 years. Of the lawsuits 28% involved urological oncology, 12% involved endourology and 10% involved female urology. All other urological specialties individually generated less than 10% of the lawsuits. In only 3.5% of the cases was the patient successful at trial, compared to 13.2% of the cases where the urologist was successful at trial. The case was dropped or dismissed without financial settlement 46.9% of the time. However, 36.3% of the time the case was settled with a pretrial financial settlement. The mean amount awarded to a patient at trial was 213,855 dollars (median 100,000 dollars, range 2,400 dollars to 1,000,000 dollars). When a patient was awarded pain and suffering at trial, the mean amount awarded was 270,000 dollars (median 85,000 dollars, range 30,000 dollars to 900,000 dollars). The mean amount given to the patient as pretrial settlement was 196,706 dollars (median 70,000 dollars, range 1,500 dollars to 5,000,000). The mean time a urologist spent defending their first lawsuit was 21.8 days. Given the current medical malpractice environment, 58% of responding urologists are considering referring difficult cases, 60% are considering limiting the scope of their practice, 26% are considering changing the state in which they practice and 41% are considering leaving the practice of medicine. Our experience has shown that the medical malpractice crisis has had a profound and real effect on the urological community. When the data are stratified according to those urologists who practice in a crisis state, we consistently see a pattern whereby the crisis state urologists are carrying a larger proportion of the malpractice burden. Most concerning is how the malpractice environment has changed the way in which urologists approach their practice. A larger percentage of urologists from crisis states are reporting that they are considering limiting the scope of their practice, moving their practice to a state with a more favorable malpractice environment and considering leaving the practice of urology altogether. Clearly the urologist is not immune from the current malpractice environment.

Investigation of Management Models in Elite Athlete Injuries

This cross-sectional study investigated management models among elite athletes participating in sports including baseball, basketball, soccer, volleyball, tennis, softball, football, handball, track and field, swimming, judo, tae-kwon-do, gymnastics, archery, and weight lifting at the Tsoying National Sport Training Center. Data were collected by questionnaire. Of the 393 athletes investigated, 56% were male and 44% were female, with an average age of 20.9 years and average length of athletic experience of 9.8 years. At the time of the survey, 74.8% had sporting injuries and were being treated with Chinese and/or Western medicine. Among injured athletes, 14.5% chose Western treatment, 8.1% chose Chinese medicine, and 75.4% received combined treatment. There were various reasons for choosing the management model. Most athletes had ordinary self-recognition of sports injury prevention. Their qualified ability for sports injury prevention was 70%. This ability was significantly correlated with age, education, and sports experience. Within Taiwan's current medical and social environment, elite athletes prefer a combination of Eastern and Western treatments for sports injuries. Each of the medical approaches are widely accepted by elite athletes and their coaches. Doctors trained in Western medicine should learn these alternative treatment methods and apply them effectively in athletes, so that a better medical network can be established.

The current medical malpractice environment: An analysis of causes and solutions*1

Nurse practitioners (NPs) and other health care providers are all too familiar with the fact that, since the turn of the last century, premiums for medical malpractice insurance have significantly increased in certain states and disciplines. The current medical malpractice environment has provoked heated political debate at the state and federal levels among interest groups representing health providers, trial lawyers, insurance companies, and consumers. However, few have systematically examined the root causes of increased premium rates and the spectrum of available policy solutions. Thus, the purpose of this paper is to provide stakeholders with an overview of the current medical malpractice environment with some understanding of its causes and highlight various policy options to reform the current medical malpractice situation.

The current medical malpractice environment: An analysis of causes and solutions

Nurse practitioners (NPs) and other health care providers are all too familiar with the fact that, since the turn of the last century, premiums for medical malpractice insurance have significantly increased in certain states and disciplines. The current medical malpractice environment has provoked heated political debate at the state and federal levels among interest groups representing health providers, trial lawyers, insurance companies, and consumers. However, few have systematically examined the root causes of increased premium rates and the spectrum of available policy solutions. Thus, the purpose of this paper is to provide stakeholders with an overview of the current medical malpractice environment with some understanding of its causes and highlight various policy options to reform the current medical malpractice situation.

Decreasing GME training stress to foster residents' professionalism.

The author evaluates current concerns over medical professionalism in residency training. The recent professionalism requirements for residents promulgated by the Accreditation Council for Graduate Medical Education (ACGME) are discussed in relation to the atmosphere of current training. The author first reviews a recent study showing that unprofessional behavior may significantly correlate with burnout, as evaluated by the Maslach Burnout Inventory. Among the elements of that inventory, depersonalization is shown to significantly correspond to unprofessional actions and behavior. Several surveys and studies evaluating residency treatment and stress are reviewed and three sources of training stress are identified: (1) abusive treatment of residents, (2) financial pressures, and (3) pessimism and uncertainty in the medical field. The extent and effects of these stressors are discussed and evaluated in relation to depersonalization, depression, and unprofessional behavior. Each of these pressures is found to correlate with negative effects on residents, such as depersonalization, decreased satisfaction, depression, and burnout. In turn, such effects are found to potentially cause unprofessional behavior among residents. In light of these findings, the author suggests several modifications to the current graduate medical training environment to mitigate such stressors, promote professionalism, and increase morale. Prevention of abusive treatment of residents, alleviation of financial pressure, increased educational opportunities, and role modeling are suggested as beneficial interventions that may foster professionalism and prevent inappropriate behavior. The author indicates that such environmental changes would likely foster professionalism in young physicians more effectively than would ethics seminars or in-class training. Accordingly, the author suggests environmental changes to decrease residency stress as the most effective means of promoting the new ACGME requirements and the ideals of professionalism.

Sedation and Analgesia for Diagnostic and Therapeutic Procedures.

Mayo Medical School, Mayo Clinic, Rochester, Minnesota. warner.mary@mayo.edu.Sedation and Analgesia for Diagnostic and Therapeutic Procedures. Edited by Shobha Malviya, Norah Naughton, Kevin Tremper. Humana Press, Totowa, New Jersey, 2003. Pages: 310. ISBN: 0-89603-863-7. Price: $125.The proliferation of diagnostic and therapeutic procedures outside of the traditional operating room environment has brought many challenges to the medical profession. Chief among these is the dilemma of how to provide sedation and analgesia for these varied patients and procedures in a safe environment, often outside of the care of traditional anesthesia providers. Realizing the need for safe and uniform practices, many professional societies have developed guidelines specific for the care of the sedated patient during these procedures. Regulatory agencies have embraced these concepts and have demanded that patients receive the same standard of care, including uniformity of assessments, monitoring, documentation, outcomes measurements, and credentialing and competency of staff, regardless of where or by whom sedation is administered in an institution.In Sedation and Analgesia for Diagnostic and Therapeutic Procedures , the editors have recruited a variety of authors, including physicians, nurses, and scientists, to comprehensively review sedation and analgesia from all realms. The book begins with a short review of the basic physiology of the sedated state, progresses to various clinical guidelines for both the pediatric and adult patient population, and concludes with a very practical section on quality outcomes processes and measurements. Additional chapters included in this very concise and practical review of sedation and analgesia are devoted to pharmacology, assessments, monitoring, and recovery. Tables, graphs, and figures incorporated throughout the book highlight various protocols, regulatory requirements, guidelines, recommended drug dosages, monitoring requirements, and quality measurement tools. All of these will be valuable to a variety of professionals ranging from physicians, to nurses, to hospital administrators as they develop their own sedation and analgesia policies and guidelines.There are some inconsistencies in the book regarding the depth of details on certain subjects and lack of breadth on other matters. For example, an entire chapter is devoted to opioids in the management of acute pediatric pain, but discussion of analgesia for the adult population is noticeably lacking. I found myself searching for an expansion on patient assessments, medication use, and potential complications associated with sedation and analgesia and wishing that less time had been spent on the differences between the pediatric and adult population regarding various guidelines, procedures, and sites. One example of this lack of consistency is the discussion of monitoring for sedation care; approximately 10 pages of a 26-page chapter are devoted to the use of pulse oximetry, whereas all other methods of monitoring are discussed in 7 pages.Overall, editors Malviya, Naughton, and Tremper have produced a valuable, up-to-date, and practical resource for providers who deal with sedation care. Although the book is not intended to provide a thorough, in-depth scientific review of all the mechanisms of the sedated state or the obscure details of the different pharmacologic agents used in sedation and analgesia, it is an excellent reference. In the current medical environment in which sedation practices are increasing exponentially, this book is a very good resource for practitioners to ensure patient safety and high-quality outcomes when administering sedation and analgesia for this vast array of procedural practices. It is a must-read for anyone who is unfamiliar with the current sedation practices and guidelines promulgated by a number of national professional societies. The book contains sufficient information to help everyone ensure compliance with regulatory standards for sedation care.

Thyroid Abscess Due to Acinetobacter calcoaceticus: Case Report and Review of the Causes of and Current Management Strategies for Thyroid Abscesses

Thyroid abscess was a common condition in the era before antibiotics. In the current medical environment, however, it is a clinical entity that is seldom encountered. We report the case of a unique cause of thyroid abscess, the environmental Gram-negative bacterium Acinetobacter calcoaceticus. Review of the published causes of thyroid abscess since 1980 demonstrated that although Gram-positive bacteria (Staphylococcus and Streptococcus species) remain the most common causes, there has been a marked decrease in the number of cases caused by mycobacteria, Salmonella species, and anaerobes when compared with the early part of the 20th century. Patients infected with the human immunodeficiency virus, however, still develop mycobacterial and fungal thyroid infections with some regularity. Reported modes of management of thyroid abscess vary, but drainage remains an integral component of therapy for resolution of the infection.