Daily Medical Practice Research Articles

Annals for Educators - 3 April 2018.

Annals for Educators - 3 April 2018.

Characterization of the population with severe iron deficiency anemia at risk of requiring intravenous iron supplementation

Iron deficiency anemia is the most frequent cause of anemia world-wide and is a very common disorder in daily medical practice. Heavy menstrual bleeding (menorrhagia) and pregnancy and delivery can cause significant iron loss leading to severe anemia The aim of the present study was to characterize the population requiring intravenous iron and identify whether gynecological and obstetric iron loss are frequent indications for treatment. Material and methodsRestrospective, single center study performed in a tertiary level university hospital from January 2014 to December 2016. ResultsDuring the 3-year study period, there were 4529 treatments with intravenous iron (45.98% in men vs. 54.02% in women). The population group from 10 to 54 years of age made up 19.33% of the total treatments, with 35.93% in men and 64.01% in women (Fisher exact test, p<0.001). Intravenous iron administration for gynecological and obstetric reasons was required in 20.54% and 24.82% of the total population, respectively, representing >45% of the indications for treatment in this population. ConclusionsThe need for intravenous iron is related to anemia refractory to oral treatment or the need for rapid iron recovery. Our results show that women of fertile age are a population at risk of requiring intravenous iron as compared to a male population of the same age. It is mainly due to blood los related to pregnancy, delivery and puerperium as well as heavy menstrual bleeding.

Leveraging healthcare utilization to explore outcomes from musculoskeletal disorders: methodology for defining relevant variables from a health services data repository

BackgroundLarge healthcare databases, with their ability to collect many variables from daily medical practice, greatly enable health services research. These longitudinal databases provide large cohorts and longitudinal time frames, allowing for highly pragmatic assessment of healthcare delivery. The purpose of this paper is to discuss the methodology related to the use of the United States Military Health System Data Repository (MDR) for longitudinal assessment of musculoskeletal clinical outcomes, as well as address challenges of using this data for outcomes research.MethodsThe Military Health System manages care for approximately 10 million beneficiaries worldwide. Multiple data sources pour into the MDR from multiple levels of care (inpatient, outpatient, military or civilian facility, combat theater, etc.) at the individual patient level. To provide meaningful and descriptive coding for longitudinal analysis, specific coding for timing and type of care, procedures, medications, and provider type must be performed. Assumptions often made in clinical trials do not apply to these cohorts, requiring additional steps in data preparation to reduce risk of bias. The MDR has a robust system in place to validate the quality and accuracy of its data, reducing risk of analytic error. Details for making this data suitable for analysis of longitudinal orthopaedic outcomes are provided.ResultsAlthough some limitations exist, proper preparation and understanding of the data can limit bias, and allow for robust and meaningful analyses. There is the potential for strong precision, as well as the ability to collect a wide range of variables in very large groups of patients otherwise not captured in traditional clinical trials. This approach contributes to the improved understanding of the accessibility, quality, and cost of care for those with orthopaedic conditions.ConclusionThe MDR provides a robust pool of longitudinal healthcare data at the person-level. The benefits of using the MDR database appear to outweigh the limitations.

Therapeutic Diet: What We Need to Consider!

ABSTRACT Therapeutic diet is needed so that nutritional factors may not affect individuals in diseases during convalescence and rehabilitation. Different research groups have observed a correlation between diseases and diets with diagnosis, prognosis, clinical outcomes and complications. In spite of considerable progress in healthcare, there is scarce evidence-based research excellence on community-level compliance on dietary advice. We need to change our mindset to find user-friendly dietary guidelines for the improvement in clinical approach and treatment in patients with diverse diseases in daily medical practice.

Main skin diseases of the elderly

Due to the increasing life expectancy, the geriatric der­ma­tology has become more important and more common in the daily medical practice. A correct diagnosis and a proper management can reduce the morbidity and improve the quality of life. With age, the structure and functions of the skin are continuously changing. The factors which promote the aging of the skin are divided into two categories: in­trin­sical and extrinsical factors. The intrinsical factors are re­presented by the physiological processes of the aging of the skin, which are genetically determined, like wrinkles and loss of elasticity. Sun exposure, smoking, stress and other environmental factors are parts of the extrinsical group. The pathology of the elderly can be divided into four large groups: inflammatory dermatoses, skin infections, vascular pathologies and neoplasms. The main inflammatory der­ma­toses, which are most likely to be found in the elderly, are: asteatotic eczema, contact dermatitis, nummular ec­zema and drug eruptions. The skin infections which are most commonly found in older patients have various etiologies, for example bacterian (Staphylococcus aureus) fungal (Trichophyton rubrum, Candida albicans etc.) or viral (herpes zoster). These infections need a specific treatment, always taking into consideration the other comorbidities of the patients and the eventual drug interactions. With age, the density of the blood vessels and the cutaneous blood flow are decreasing. Due to the loss of elasticity and the impairment of the immune response, the aged skin is more susceptible to different agressions and has a delayed response to them. As a result, the most common vascular pathologies of the elderly are: senile purpura, stasis dermatitis, ulcers, bedsores and chronic venous insuf­ficiency. Of high importance are also the neoplasms of the elderly. The benign neoplasms are: solar lentigos, actinic keratoses (these two types of lesions suggest an increased sun exposure throughout the entire life and indicate a high risk of developing a malignant neoplasm), seborrheic keratoses, angiomas and fibroepithelial polyps. The most common malignant tumors found at older ages are: basal cell carcinoma, scuamous cell carcinoma and melanoma, all of them being related to increased sun exposure. In conclusion, the spectrum of pathologies of the elderly is very broad, and their treatment requires an important amount of attention, because the patients usualy associate multiple comorbidities and present a high risk of complications.

Child Maltreatment : “Awareness” and “Denial” in daily medical practice

Child Maltreatment : “Awareness” and “Denial” in daily medical practice

Development of a ring light camera system for easy photography of the oral cavity and pharynx in daily medical practice

Development of a ring light camera system for easy photography of the oral cavity and pharynx in daily medical practice

Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines 2016 for the Clinical Practice of Hereditary Colorectal Cancer (Translated Version).

Hereditary colorectal cancer accounts for less than 5% of all colorectal cancer cases. Some of the unique characteristics that are commonly encountered in cases of hereditary colorectal cancer include early age at onset, synchronous/metachronous occurrence of the cancer, and association with multiple cancers in other organs, necessitating different management from sporadic colorectal cancer. While the diagnosis of familial adenomatous polyposis might be easy because usually 100 or more adenomas that develop in the colonic mucosa are in this condition, Lynch syndrome, which is the most commonly associated disease with hereditary colorectal cancer, is often missed in daily medical practice because of its relatively poorly defined clinical characteristics. In addition, the disease concept and diagnostic criteria for Lynch syndrome, which was once called hereditary non‐polyposis colorectal cancer, have changed over time with continual research, thereby possibly creating confusion in clinical practice. Under these circumstances, the JSCCR Guideline Committee has developed the “JSCCR Guidelines 2016 for the Clinical Practice of Hereditary Colorectal Cancer (HCRC)," to allow delivery of appropriate medical care in daily practice to patients with familial adenomatous polyposis, Lynch syndrome, or other related diseases. The JSCCR Guidelines 2016 for HCRC were prepared by consensus reached among members of the JSCCR Guideline Committee, based on a careful review of the evidence retrieved from literature searches, and considering the medical health insurance system and actual clinical practice settings in Japan. Herein, we present the English version of the JSCCR Guidelines 2016 for HCRC.

Primary Health Care Physicians' Knowledge, Attitude and Practice towards Evidence-Based Medicine in Tabuk City, KSA

Background: Evidence-based medicine (EBM) is an essential component of modern medical practice and crucial for patient safety and high-quality health care services. Objectives: This study was conducted to assess the knowledge, attitude and practice towards evidence-based medicine and the barriers against its application in daily medical practice. Subjects and Methods: This is a cross-sectional survey using a self-administered validated questionnaire among 68 primary health care physicians in Tabuk city, Kingdom of Saudi Arabia during the period from December 2016 to June 2017. Validated questionnaire was used to collect data from the respondents. The Statistical Package for Social Sciences (SPSS) was used for data analysis. P-value of <0.05 was considered as significant. Result: There are 62.2% male participants, the age of the majority were from 30 to 50 years (73.5%) and (72.1%) did not have board qualification, the primary literature review and summaries were the popular methods for EBM. The knowledge and attitude were suboptimal; some did not even access Medline. The unavailability of time and internet access were the most frequent barriers reported. Only a minority received formal EBM training. Conclusion: The knowledge and attitude regarding EBM were suboptimal among the primary health care physicians, the time factors, unavailability of the internet and the lack of letters, access to journals, and guidelines were the principal barriers to EBM incorporation in the clinical practice.

Evaluation by undergraduate medical students of a role-playing training program on the management of acute states of agitation

ObjectivesAcute states of agitation (ASAs) are frequent in daily medical practice. However, training on real ASAs raises technical and ethical issues, whereas lecture-based teaching hardly addresses some educational objectives, e.g., improving relational skills and team-based coordination. Simulation-based medical education (SBME) is a promising medium to train students on managing ASAs. We have recently implemented a role-playing training module on ASAs. In this scenario, four to five students play the role of the staff, while a trained professional actor plays the agitated patient. A subsequent standardized debriefing is conducted by a senior psychiatrist. A first wave of 219 students participated in a one-session training of this ASA module in June 2015. They completed pre-session and post-session questionnaires aiming to collect “proof-of-concept” data. MethodsThe pre-session questionnaire investigated: previous experience of ASA among students during their clinical training; previous participation in a role-playing SBME; and perceived knowledge of the good practice rules for managing ASAs. The post-session questionnaire investigated among the students if: they thought having been able to appropriately manage the simulated ASA; they found the SBME medium more fitted for training than real situations; they found that the SBME session faithfully reproduced a real ASA; and the session was found useful for transmitting the skills on correct management of ASA. The average level of stress induced by the training was assessed using a numerical rating scale (0–10). ResultsTwo hundred and six of the 219 students completed the pre-session questionnaire (63% females; response rate 96.7%). A hundred and thirty four students played the scenario and completed the post-session questionnaire (65.7% females; response rate 100%). 38.3% of the responders reported having previously experienced a situation of ASA in their practice, and 31.1% deemed to know the good practices rules for managing an ASA. In post-session, 29.9% of the participants considered that they appropriately managed the ASA, 79.9% deemed that the role-playing session faithfully reproduced a real ASA, and 97% deemed that this SBME was more fitted and useful than a real clinical situation to improve their medical skills. Bivariate analyses revealed that the post-session responses and level of stress were not influenced by previous experience on ASA, previous participation in a SBME role-playing session, or thinking to know the rules for managing ASAs. ConclusionSBME role-playing training appears a promising, realistic, and well-accepted method for teaching the management of ASA.

Bleeding in advanced CKD patients on antithrombotic medication – A critical appraisal

Patients with advanced chronic kidney disease (CKD) are at an increased risk of bleeding, especially in the context of the complex therapeutic schemes of coronary artery disease (CAD) (from stable angina to acute coronary syndromes), atrial fibrillation or venous thromboembolism. The bleeding issue increases morbidity and mortality, a serious problem in daily medical practice. However, these patients are largely excluded from major randomized clinical trials, which results in the lack of medical evidence-based foundation for specific recommendations regarding antithrombotic treatment in a high bleeding risk setting. Within this framework, the clinician does not benefit from a clear set of algorithms and measures in the exploration and balancing of bleeding and thrombosis risks. We discuss a diversity of scenarios, encompassing all categories of advanced CKD patients with CAD or/and atrial fibrillation, and with various combinations of drugs, such as antiplatelet therapy or/and oral anticoagulation. Our review highlights the most recent research as well as existing gaps in the recommendations of European Society of Cardiology Guidelines. We evaluate the existence or lack of assessment tools for the bleeding risk, strength, reliability and usefulness of the bleeding risk scores. Also, we identify all the measures recommended after risk evaluation, including specific plans, dose adjustments and particular therapeutic approaches. Finally, we provide with suggestions for improving the management of this patient population.

Hearing-impaired young people – a physician’s guide

Physicians reading this will have a broad range of in-depth knowledge about their own subspecialty. However, in daily medical practice there are topics of which all physicians should have some knowledge. Those who deal with young people should have some knowledge of the needs of the hearing-impaired population within this group of patients. This article is intended to provide an overview of young people with hearing impairment (HIYP), the challenges they face and what we can do to help them. In this paper, we assume that data published regarding hearing-impaired children apply to HIYP from 13 years (the age at which the transition process begins) to 25 years of age (the age at which ‘youth’ according to the World health Organization and the Education Health Care Plan ends).

Use of a hand-held digital cognitive aid in simulated crises: the MAX randomized controlled trial

BackgroundCognitive aids improve the technical performance of individuals and teams dealing with high-stakes crises. Hand-held electronic cognitive aids have rarely been investigated. A randomized controlled trial was conducted to investigate the effects of a smartphone application, named MAX (for Medical Assistance eXpert), on the technical and non-technical performance of anaesthesia residents dealing with simulated crises. MethodsThis single-centre randomized, controlled, unblinded trial was conducted in the simulation centre at Lyon, France. Participants were anaesthesia residents with >1 yr of clinical experience. Each participant had to deal with two different simulated crises with and without the help of a digital cognitive aid. The primary outcome was technical performance, evaluated as adherence to guidelines. Two independent observers remotely assessed performance on video recordings. ResultsFifty-two residents were included between July 2015 and February 2016. Six participants were excluded for technical issues; 46 participants were confronted with a total of 92 high-fidelity simulation scenarios (46 with MAX and 46 without). Mean (sd) age was 27 (1.8) yr and clinical experience 3.2 (1.0) yr. Inter-rater agreement was 0.89 (95% confidence interval 0.85–0.92). Mean technical scores were higher when residents used MAX [82 (11.9) vs 59 (10.8)%; P<0.001]. ConclusionThe use of a hand-held cognitive aid was associated with better technical performance of residents dealing with simulated crises. These findings could help digital cognitive aids to find their way into daily medical practice and improve the quality of health care when dealing with high-stakes crises. Clinical trial registrationNCT02678819.

Protecting personal information: Implications of the Protection of Personal Information (POPI) Act for healthcare professionals.

Careless handling of patient information in daily medical practice can result in Health Professions Council of South Africa sanction, breach of privacy lawsuits and, in extreme cases, serious monetary penalty or even imprisonment. This review will focus on the Protection of Personal Information (POPI) Act (No. 4 of 2013) and the implications thereof for healthcare professionals in daily practice. Recommendations regarding the safeguarding of information are made.

Addiction to work and factors relating to this: a cross-sectional study on doctors in the state of Paraíba.

Addiction to work is one of the new behavioral phenomena present in organizations and it is characterized by excess work and compulsion to work. This phenomenon may give rise to different sicknesses and may affect different professionals, including doctors. Thus, the aims of this study were to analyze the factorial validity and internal consistency of the Dutch Work Addiction Scale (DUWAS); to evaluate the prevalence of addiction to work among doctors in the state of Paraíba; and to investigate factors relating to addiction to work among these doctors. This was an exploratory, descriptive cross-sectional study with a quantitative approach conducted in municipalities in the state of Paraíba. Data were gathered between June and October 2015, by applying a questionnaire containing sociodemographic questions and the Work Addiction Scale. The results showed that the Work Addiction Scale has internal consistency and factorial validity and that, in the population studied, only one factor was pointed out: addiction to work. Most of the doctors were not addicted to work; among the addicts, the addiction was not excessive; and the addiction had a positive correlation with the number of shifts done and a negative correlation with age. Greater attention to this phenomenon is required and further research on this topic is needed in order to elucidate the harm caused by addiction to work in daily medical practice.

Better patient safety: implementing exploration and exploitation learning in daily medical practice

BackgroundCurrent medical daily practice relies on guidelines, protocols and procedures (GPPs), which require exploitation. However, diagnosis, treatment, risk management and process improvements require exploration. Physician are often unable to switch...

PP.21.05] PREVALENCE OF ASYMMETRICAL BLOOD PRESSURE AND ITS ASSOCIATION WITH CARDIOVASCULAR EVENTS IN UNCONTROLLED HYPERTENSIVE PATIENTS

Objective: Estimate the prevalence of asymmetrical blood pressure (BP) in uncontrolled hypertensive patients in daily community medical practice, and analyze its association with the occurrence of cardiovascular events. Design and method: Observational and descriptive cross sectional study conducted among 68 liberal and hospital cardiologists in the first term of 2016 in Tizi-ouzou and Bejaia areas (Algeria). The investigation focused on hypertensive patients treated with a combination of 2 or 3 antihypertensive drugs at a stable dose for at least 3 months. Uncontrolled hypertension was defined as BP superior or equal to 140 /90 mmHg under treatment. Asymmetrical BP was defined as a between-arm difference in systolic BP superior or equal to 15 mm Hg. Results: uncontrolled patients were included. The mean age of the population was 64 ± 11 years, with 56.4% of men. The proportions of diabetes, Dyslipidemia, persistent smoking, or history of major cardiovascular events were 34.5%, 41.7%, 16.2% and 23.6% respectively. Asymmetrical BP was present in 21.4% of the patients, and in a multiple regression analysis, was significantly associated with subclinical target organ damage [OR: 1.7 (1.3–1.9)], stroke [OR: 1.8 (1.2–2.3) and acute coronary syndrome [OR: 1.7 (1.4–2.5)]. Conclusions: asymmetrical BP is frequent in uncontrolled hypertensive patients and could help to identify patients at high cardiovascular risk.

Risk Factors for Fractures Identified in the Algorithm Developed in 5-Year Follow-Up of Postmenopausal Women From RAC-OST-POL Study

The aim of the study was to establish factors with an impact on fracture risk and to develop an algorithm to predict osteoporotic fracture. A total of 978 postmenopausal women from the epidemiological, population-based RAC-OST-POL study with a mean age of 65.7 ± 7.3 years were enrolled. At baseline, bone mineral density at hip and clinical risk factors for fracture were collected. Afterward, each person was asked annually on fracture incidence in the 5-year follow-up. Finally, data for complete 5-year observation were gathered for the group of 802 patients. During the follow-up, 92 osteoporotic fractures occurred in 78 women. The most common fracture site was the forearm (n = 45). The following baseline factors were found as significant for fracture incidence: femoral neck bone mineral density, prior fractures, steroid use, falls within previous 12 months, and height. Fracture risk was predicted by the following formula: Risk of fracture incidence=11+e−(−9.899+1.077∗STEROIDS+0.681∗PRIORFALLS+0.611∗PRIORFRACTURES−0.483∗FN Tscore+0.042∗HEIGHT). In our current longitudinal study, an algorithm predicting fracture occurrence over a period of 5 years was developed. It may find application in daily medical practice.

Virally vectored vaccine delivery: medical needs, mechanisms, advantages and challenges.

Vaccines represent one of the most successful chapters in the history of medicine. Over the past decades, the advent of recombinant cDNA technology has enabled the biomedical community to genetically engineer viruses for vaccine delivery purposes. As a starting point, this review evaluates the unmet medical needs, which drive scientists and industry to exploit such fundamentally new technology for human vaccination. The author discusses the molecular functioning, production and safety profile of replication-competent and -deficient viral vector systems, representing two fundamentally distinct classes of "genetic vaccines". Building upon this knowledge, he dissects the immunological mechanisms rendering immune responses to viral vectors qualitatively and quantitatively distinct from those elicited by non-live vaccination approaches. These mechanisms comprise (1) the vectors' innate immune recognition by the host cell, (2) potent priming of CD8+ cytotoxic T cells as a result of dendritic cell targeting and endogenous protein synthesis, (3) conformational antigen display for protective antibody induction as well as (4) prolonged availability of substantial quantities of antigen. Deduced from these features, preferential indications for virally vectored vaccines are discussed, taking into consideration specific medical needs as well as risk-benefit assessments of replicating vector systems. The limitations and challenges in virally vectored vaccination must also be given careful consideration. Pre-existing and vaccination-induced anti-vector immunity can interfere with vaccine immunogenicity and prime-boost vaccination, respectively. Additionally, the requirement for eukaryotic production systems imposes technological as well as regulatory hurdles. Existing strategies to overcome these challenges are outlined. With the recent licensure of the first virally vectored vaccine this review seems timely to herald the introduction of virally vectored vaccines into daily medical practice.

医師からみた臨床心理士との役割の作り方とその制度化(日常診療における臨床心理士の役割)(第33回日本心身医学会総会)

医師からみた臨床心理士との役割の作り方とその制度化(日常診療における臨床心理士の役割)(第33回日本心身医学会総会)