Current Medical Practice Research Articles

High-density Lipoprotein (HDL) Dysfunction and the Future of HDL.

Although High Density Lipoprotein Cholesterol (HDL-C) levels are inversely proportional to cardiovascular risk in many studies, recent pharmacological interventional studies with HDL-C raising strategies did not show a benefit in terms of vascular events. The HDL particle is heterogenous with anti-atherogenic functions and non-vascular effects. Many factors affect HDL components and may either cause compositional changes, post-translational modifications of proteins, or alter lipids and other cargo molecules; generally these factors cause more than one of these changes, resulting in functional differences. Therefore, the role of lipoproteins change in different physical and disease conditions. Mainly, in proteome, Apolipoprotein A1 (Apo-A1), Myeloperoxidase (MPO), Paroxonase (PON) are affected by inflammation or glycation-related factors; and especially esterification or unesterification of lipids, changes in phospholipid or unsaturated lipid content change the HDL function. Measuring the HDL-C level is probably not a good predictor of its cardiovascular benefits, and methods to evaluate HDL functions are required. In current medical practice, it is not simple and feasible to measure different functions of this lipoprotein, but near-future strategies may be developed. Meanwhile, as we learn more about HDL structure and the role of each component, we can develop therapeutic approaches to improve HDL function. Apo-A1-mimetics, reconstituted HDL, nanoparticles and microRNA therapies could be promising as anti-atherosclerotic therapies. They may even provide useful therapies for the treatment of some non-cardiovascular diseases.

Impact of a week-long rehabilitation medicine posting on third-year medical students’ rehabilitation knowledge and attitudes

Rising rates of disability have increased the need for rehabilitation. In Singapore, like many countries, a shortage of Rehabilitation Medicine Physicians exists. Knowledge and awareness of rehabilitation principles, concepts and work are often poor. One reason could be inadequate exposure or teaching during undergraduate medical school. Since 2016, third-year undergraduate medical students from Yong Loo Lin School of Medicine (YLLSoM), Singapore, had been given a mandatory structured one-week Rehabilitation Medicine posting at Tan Tock Seng Hospital, Rehabilitation Medicine Department. This paper aims to study the impact of a week-long rehabilitation medicine posting on third-year medical students’ rehabilitation knowledge and attitudes. The students were administered a Multiple-Choice Questionnaire (MCQ) before commencement and after completion of the week-long rehabilitation medicine program. Correct responses to the questionnaire were only discussed at the completion of the course. The students were posed additional personal response questions following the course. This is a retrospective study of the responses to the MCQ and post-course personal response questions. There were 72 out of 78 completed questionnaires. Only 67% were aware that Rehabilitation Medicine exists as a specialty prior to commencement of the program. After going through the course, 98.6% had improved MCQ scores, with a 23.2% gain in mean score at post-course testing. Following course completion, all the students were in agreement that Rehabilitation Medicine merits recognition as a clinical specialty. And 76.4% would consider Rehabilitation Medicine as a career. Having a structured and standardized Rehabilitation Medicine Posting in undergraduate medical curriculum does improve the knowledge and awareness of the Rehabilitation Medicine discipline amongst the medical students. Given the rising relevance of rehabilitation in current and future medical practice, due consideration should be given to making the topic a significant component in Singapore's undergraduate medical education.

REASSESSING FRONTLINE MEDICAL PRACTITIONERS OF THE BRITISH CIVIL WARS IN THE CONTEXT OF THE SEVENTEENTH-CENTURY MEDICAL WORLD

AbstractMedical provision in Civil War armies has generally suffered a poor reputation. Medical matters have been excluded from assessments of how far Civil War armies confirm evidence of the so-called ‘Military Revolution’, whilst Harold Cook argued that it was not until after the Glorious Revolution that the medical infrastructure of the armed forces was brought in line with continental practices, particularly those of the Dutch army. Despite the recent rehabilitation of early modern practitioners elsewhere, frontline military practitioners continue to be dismissed as uneducated, unskilful and incompetent. This is largely due to the lack of a fresh perspective since C. H. Firth published Cromwell's Army in 1902. This article argues that the English were well aware of current medical practice in European armies and endeavoured to implement similar procedures during the Civil Wars. Indeed, almost all the developments identified by Cook for the later seventeenth century can be found in Civil War armies. Whilst failures may have occurred, most of these can be attributed to administrative and financial miscarriages, rather than ignorance of contemporary medical developments. Moreover, there is little to suggest that medics mobilized for Civil War armies were any less capable than those who practised civilian medicine in this period.

Human Genetics of Obesity and Type 2 Diabetes Mellitus: Past, Present, and Future.

Type 2 diabetes mellitus (T2D) and obesity already represent 2 of the most prominent risk factors for cardiovascular disease, and are destined to increase in importance given the global changes in lifestyle. Ten years have passed since the first round of genome-wide association studies for T2D and obesity. During this decade, we have witnessed remarkable developments in human genetics. We have graduated from the despair of candidate gene-based studies that generated few consistently replicated genotype-phenotype associations, to the excitement of an exponential harvest of loci robustly associated with medical outcomes through ever larger genome-wide association study meta-analyses. As well as discovering hundreds of loci, genome-wide association studies have provided transformative insights into the genetic architecture of T2D and other complex traits, highlighting the extent of polygenicity and the tiny effect sizes of many common risk alleles. Genome-wide association studies have also provided a critical starting point for discovering new biology relevant to these traits. Expectations are high that these discoveries will foster development of more effective strategies for intervention, through optimization of precision medicine approaches. In this article, we review current knowledge and provide suggestions for the next steps in genetic research for T2D and obesity. We focus on four areas relevant to precision medicine: genetic architecture, pharmacogenetics and other gene-environment interactions, mechanistic inference, and drug development. As we describe, the genetic architecture of complex traits has major implications for the prospects of precision medicine, rendering some anticipated approaches decidedly unrealistic. We highlight obstacles to the translation of human genetic findings into mechanism inference but are optimistic that, as these are overcome, there is untapped potential for novel drugs and more effective strategies for treating and preventing T2D and obesity.

Su1441 INITIAL EXPERIENCE OF EUS-GUIDED BILIARY DRAINAGE IN A GENERAL HOSPITAL IN JAPAN

Over the past decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an effective alternative biliary drainage method after unsuccessful ERCP. EUS-BD is an efficient technique, but is associated with significant morbidity that makes it a challenging procedure to introduce to general hospitals. The aim of this study is to investigate the initial treatment outcomes of EUS-BD in a general hospital. Retrospective analyses of all consecutive patients with biliary obstruction who underwent EUS-BD after failed ERCP in our institution between January 2011 and November 2017. The technical success, clinical success, and adverse events rates were evaluated. During the study period, a total of 6035 ERCP procedures were attempted, and EUS-BD was performed in 31 of 6035 procedures (0.5 %). The mean age was 75.8 years old, 18 patients were men and 13 patients were women. The etiologies of bile duct obstruction were malignant in 27 patients (87%) and benign in four patients (13%). Reasons for failed ERCP included duodenal stenosis caused by tumor invasion in 13 patients (41.9%), failed deep biliary cannulation in 11 patients (35.5%), and surgically altered anatomy in 7 patients (22.6%). The technical and clinical success rates for EUS-BD were 90.3% (28/31) and 96.4% (27/28), respectively. Adverse event rate was 25% (7/28). EUS-BD consists of EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided antegrade stenting (EUS-AG), and EUS-guided rendezvous technique (EUS-RV). Biliary drainage could be achieved from two different approach routes: the extrahepatic bile duct access or the intrahepatic bile duct access. For the intrahepatic bile duct access group, there were 26 patients. 23 patients underwent HGS (including AG) and three patients underwent RV. The technical and clinical success rates were 88.4% (23/26), and 95.6% (22/23) respectively. The adverse event rate was 26% (6/23). The adverse events were two cases of stent migration, three cases of stent occlusion, and one case of mediastinitis in HGS (including AG). As for the extrahepatic bile duct access group, there were five patients. Four patients underwent CDS and one patient underwent RV. The technical and clinical success rates were 100% (5/5) and 100% (5/5) respectively. The adverse event rate was 20% (1/5). The adverse event was one case of bile peritonitis in RV. Given the potential serious adverse events associated to the with the procedure, EUS-BD is yet to be widely used in current medical practice in general hospitals. However, even though our institution is not a high volume nor an academic institution, the results of EUS-BD was relatively acceptable. Due to the limitations of the number of patients, further study is needed.

Therapeutic Conduct in Soft-Tissue Tumors Diagnosed in the Pregnant Patient

Abstract Introduction. Soft tissue tumors are a rare pathology encountered in the pregnant patient. Considering the patient’s potential vital risk, the concomitant evolution of pregnancy and the possible infertility acquired after treatment, the therapeutic conduct of these tumors is a challenge to current medical practice. Material and method. The paper aims to present certain cases of soft-tissue tumors diagnosed in pregnant women as well as a retrospective analysis of literature. Results. The diagnosis of certainty was significantly delayed in the case of pregnant patients. The treatment plan was complex and had to take into account the type and the location of the primary tumor, growth rate, associated symptom, age of pregnancy, as well as minimize the fetal toxic effects. Conclusions. The identification of a soft-tissue tumor during pregnancy is associated with limited diagnostic methods. A multidisciplinary team should establish the therapeutic approach for softtissue tumors diagnosed in the pregnant patient. The therapeutic approach should be individualized in each case in order to achieve a balance between tumor treatment, pregnancy outcome, and subsequent reproductive capacity of the patient.

Comparative accuracy assessment of the Gustilo and Tscherne classification systems as predictors of infection in open fractures

ObjectiveThe aim of this study is to analyze the accuracy of the two classification systems for open fractures most commonly used in current medical practice, Gustilo and Tscherne, as predictors of infection. MethodsA retrospective observational study was performed, including 121 patients suffering from open fracture of the appendicular skeleton treated at an emergency hospital. The fractures were classified according to Gustilo and Tscherne systems during the initial treatment, and ratings were subsequently confirmed or rectified during hospitalization. Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated according to each classification adopted. ResultsThe results of this study demonstrated that both classifications of Gustilo and Tscherne are associated with the clinical outcome of infection in open fractures. The Gustilo classification achieved sensitivity of 76.7%, specificity of 53.8%, and accuracy of 59.5%. Tscherne's classification had a sensitivity of 56.7%, specificity 82.4%, and accuracy of 76.1%. ConclusionThe Tscherne system showed better accuracy, including specificity as a predictor of infection in open fractures, when compared with the Gustilo system.

Fortune and hindsight: gene patents' muted effect on medical practice.

Physicians have long worried about gene patents' potential to restrict their medical practices. Fortune and hindsight have proven these worries exaggerated both in the UK and elsewhere. Neither current nor future medical practices appear to be impinged by gene patents, although they may be subject to future intellectual property disputes. Qualitative and quantitative (survey) studies of gene patents' effects on medical practice; recent developments in patent law. Traditional gene patents do not appear to have restricted medical practice in the UK, although their effect elsewhere has been more nuanced. Whether patents will restrict the spread of newer medical technologies is unresolved. Continuing survey data on practitioners' views concerning patents' role in the distribution of newer technologies would be beneficial.

Delivery systems of current biologicals for the treatment of chronic cutaneous wounds and severe burns.

While wound therapy remains a clinical challenge in current medical practice, much effort has focused on developing biological therapeutic approaches. This paper presents a comprehensive review of delivery systems for current biologicals for the treatment of chronic wounds and severe burns. The biologicals discussed here include proteins such as growth factors and gene modifying molecules, which may be delivered to wounds free, encapsulated, or released from living systems (cells, skin grafts or skin equivalents) or biomaterials. Advances in biomaterial science and technologies have enabled the synthesis of delivery systems such as scaffolds, hydrogels and nanoparticles, designed to not only allow spatially and temporally controlled release of biologicals, but to also emulate the natural extracellular matrix microenvironment. These technologies represent an attractive field for regenerative wound therapy, by offering more personalised and effective treatments.

The view of experts on initiatives to be undertaken to promote equity in the access to orphan drugs and specialised care for rare diseases in Spain: A Delphi consensus

ObjectivesTo reach a consensus amongst experts on the most feasible actions to be undertaken to facilitate patient access to specialised care and orphan drugs (OD) in the public health sector in Spain. MethodsTwo Delphi rounds were completed. The questionnaire was based on a literature review and 2 focus groups. Agreement was sought on the desire (D) and prognosis (P) for the implementation within the next 5 years, on a 5-point Likert scale. Consensus was reached when ≥75% participants chose agreement (1–2) or disagreement options (4–5). Results82 experts on rare disease (RD) participated. Agreement on the D and P was reached in 66.07% statements: OD pricing review [absence of clinical effectiveness (D:85.37%; P:85.90%), target population increase (D:79.27%; P:91.03%)]; reference team definition of referral protocols and clinical practice guidelines (D: 97.56%; P: 89.74%); and a unified, usable, etiology-based registry (D:97.56%; P:84.62%). D and P assessment diverged in 32.14% items: creation of a specific funding system for OD (D: 97.56%; P: 60.25%); and a network of medical teams to coordinate the care of RD patients (D: 99%; P: 62%). ConclusionsThe results have shown the need to promote dialogue between stakeholders, introduce European recommendation to national and regional Spanish policies and set up priorities and undertake actions to drive relevant changes in current medical practice in managing RD patients.

Bioimpedance analysis is safe in patients with implanted cardiac electronic devices

There is an increase in the number of patients worldwide with cardiac implantable electronic devices (CIEDs). Current medical practice guidelines warn against performing bioimpedance analysis (BIA) in this group of patients in order to avoid any electromagnetic interference. These recommendations restrict using the BIA in patients undergoing heart failure or with nutrition disorders in whom BIA could be of major interest in detecting peripheral congestion and to help guide treatment. The present study was conducted to evaluate whether BIA caused electromagnetic interference in patients having CIEDs. Patient enrollment was conducted during routine face-to-face consultations for scheduled CIEDs interrogations. Device battery voltage, lead impedance, pacing thresholds and device electrograms were recorded before and after each BIA measurement to detect any electromagnetic interference or oversensing. A total of 200 patients were enrolled. During BIA, no significant changes in battery voltage, lead impedance or pacing thresholds were detected, nor were there any inappropriate over- or undersensing observed in intracardiac electrograms. Furthermore, 6- and 12-month follow-up did not reveal any changes in CIEDs. This study shows no interference in patients equipped with CIEDs and suggests that BIA can be securely performed in these patients. Trial registered under the identifier NCT03045822.

A VISUAL RESOLUTION OF CARDIOTOXICITY: DIGOXIN INDUCED BIDIRECTIONAL VENTRICULAR TACHYCARDIA

The use of digoxin is declining in current medical practice. As a result, digoxin toxicity is becoming increasingly rare, with an increasingly unfamiliar presentation. A 78-year-old African-American woman presented with complaints of epigastric and substernal chest discomfort, nausea and vomiting.

6 minutes.

At present, there is a trend towards reducing the duration of office visits. In some regions of Spain, it has been set at 6 minutes per patient. This impacts on several levels: literally, many times it is impossible to complete the medical act; at an emotional level, because there is little possibility to establish an adequate doctor-patient relationship; and symbolically, for considering that the main aspects of humane health care are expendable. This takes place in a society that tends to see health care as a merchandise subject to market rules that gives priority to the immediate over the important. Patients, physicians, and managing authorities are participants of this change which negatively affects current medical practice. The increase in unnecessary additional testing, avoidable treatments, the costs of iatrogenesis, a lower treatment adherence, and unnecessary reconsultations are proven consequences. In the field of pediatrics, this increases the risk of losing screening opportunities in critical areas.

Unilateral hypertrophy of the palatine tonsil – a continuous diagnostic and therapeutic challenge

The palatine tonsil is a lymphatic structure, part of the pharyngeal ring described by Waldayer. Anatomically, we can discover the palatine tonsils into the palatine fossa of the oro-pharynx, but sometimes in current medical practice we encounter a bilateral hypertrophy of the tonsils which can get very close to one another. Unilateral hypertrophy of the palatine tonsil is not so common in practice and has a wide etiology. The authors try to make an up-to-date of the causes of unilateral hypertrophy, focusing on the different therapeutic modalities on each specific pathology.

Autonomy and Intervention in Medical Practice

Autonomy and intervention are two terms of Political philosophy, and they have always been essentially located polar opposites of each other. But in medical practice, it is problematic to stress alone that either side. We should get rid of abstract liberal individual right thinking and reconsider the relationship between the patients and the physicians in all kinds of real situations. Only if we truly worship and praise for the life, including more moral and humanistic concern in abstract right discourse, the more elastic the ethical decision model will be aroused in current medical practice.

Therapeutical Aspects Regarding Pancreatic Pseudocysts.

Frequently appearing as a complication of pancreatitis, pancreatic pseudocysts are rare appearances in current medical practice. Multiple therapeutical options are available, from minimum invasive methods to complex open surgical techniques. The indications of drainage include symptomatic pseudocysts, large pseudocysts along with the development of complications such as hemorrhage, secondary infection, and rupture. Choosing the best drainage technique is often a challenge. Multiple factors need to be considered in managing a pseudoocyst, including its location, dimension and the patient's general state and comorbidities. Thus, a therapeutical algorithm may be of great use in choosing the most feasible technique for the diagnosed lesion that is also patient-adapted.

Fast statistical model-based classification of epileptic EEG signals

This paper presents a supervised classification method to accurately detect epileptic brain activity in real-time from electroencephalography (EEG) data. The proposed method has three main strengths: it has low computational cost, making it suitable for real-time implementation in EEG devices; it performs detection separately for each brain rhythm or EEG spectral band, following the current medical practices; and it can be trained with small datasets, which is key in clinical problems where there is limited annotated data available. This is in sharp contrast with modern approaches based on machine learning techniques, which achieve very high sensitivity and specificity but require large training sets with expert annotations that may not be available. The proposed method proceeds by first separating EEG signals into their five brain rhythms by using a wavelet filter bank. Each brain rhythm signal is then mapped to a low-dimensional manifold by using a generalized Gaussian statistical model; this dimensionality reduction step is computationally straightforward and greatly improves supervised classification performance in problems with little training data available. Finally, this is followed by parallel linear classifications on the statistical manifold to detect if the signals exhibit healthy or abnormal brain activity in each spectral band. The good performance of the proposed method is demonstrated with an application to paediatric neurology using 39 EEG recordings from the Children's Hospital Boston database, where it achieves an average sensitivity of 98%, specificity of 88%, and detection latency of 4s, performing similarly to the best approaches from the literature.

The educational challenge of End-of-Life conversations for our junior doctors

Background: In current medical practice we face an increasing array of possible medical interventions, multi-morbid patients and an ageing population. End-of-life (EOL) conversations are key to navigating this complex landscape and ensuring that our patients receive the care most appropriate for their needs. The Challenges: The emotive nature of this topic is well recognised and uncertainties of diagnosis and prognosis can add to the difficulties of these discussions. Junior doctors face some specific challenges in acquiring and practising the necessary skills for EOL conversations in the workplace. Their educational needs are discussed in this article. Educational approach: The educational needs of junior doctors include provision of appropriate resources and reflection on experiences. A coaching style of supervision, with recognition of their skills and support for experiential learning facilitates ongoing development.

Patient-centered outcomes: a qualitative exploration of patient experience with electroencephalograms in the Emergency Department

The primary objective of this qualitative project was to understand the experience of patients who had first-time seizures and who did, and did not, have electroencephalograms (EEGs) performed in the Emergency Department (ED) as part of their initial evaluation, so as to refine the diagnostic and therapeutic approach to these patients and transform the standard of care for first-time seizures by focusing on outcomes as defined by patient experiences and expectations. In this paper, we show that, regardless of the diagnostic and therapeutic approach patients are given in the ED, patients and caregivers trust that health care providers will perform the standard of care consistent with the current medical practice for first-time seizures. However, performing EEGs in the ED and initiating appropriate anticonvulsant therapy for those patients who are at high risk for future seizures addresses patient needs by offering patients a sense of security and control over their medical condition and expediting appropriate follow up care, as long as clearly stated written diagnostic, treatment, and referral instructions are provided upon discharge.

Breast cancer: The translation of big genomic data to cancer precision medicine.

Cancer is a complex genetic disease that develops from the accumulation of genomic alterations in which germline variations predispose individuals to cancer and somatic alterations initiate and trigger the progression of cancer. For the past 2 decades, genomic research has advanced remarkably, evolving from single‐gene to whole‐genome screening by using genome‐wide association study and next‐generation sequencing that contributes to big genomic data. International collaborative efforts have contributed to curating these data to identify clinically significant alterations that could be used in clinical settings. Focusing on breast cancer, the present review summarizes the identification of genomic alterations with high‐throughput screening as well as the use of genomic information in clinical trials that match cancer patients to therapies, which further leads to cancer precision medicine. Furthermore, cancer screening and monitoring were enhanced greatly by the use of liquid biopsies. With the growing data complexity and size, there is much anticipation in exploiting deep machine learning and artificial intelligence to curate integrative “−omics” data to refine the current medical practice to be applied in the near future.