Doctor's Discretion Research Articles

Інтенсифікація антигіпертензивної терапії у хворих із неконтрольованою артеріальною гіпертензією та надлишковою масою тіла/ожирінням за даними українського дослідження SATISFACTION

Мета дослідження – визначити профіль пацієнтів із артеріальною гіпертензією (АГ) і надлишковою масою тіла (індекс маси тіла (ІМТ) 25–29,9 кг/м2) або ожирінням (ІМТ ≥ 30 кг/м2), які не досягають офісного артеріального тиску (АТ) < 140/90 мм рт. ст. при застосуванні терапії антигіпертензивними препаратами.Матеріали і методи. До багатоцентрового відкритого обсерваційного епідеміологічного дослідження 185 лікарями загальної практики/терапевтами послідовно на прийомі залучено 1798 хворих з АГ, офісним АТ > 140/90 мм рт. ст. та надлишковою масою тіла/ожирінням. Проведено опитування за стандартним опитувальником, загальноклінічне обстеження, виміряно ІМТ, окружність талії (ОТ), надані рекомендації щодо фізичної активності та харчування, здійснена корекція антигіпертензивної терапії на розсуд лікаря. На другому візиті через 1 міс проведено кон­троль АТ, оцінено ефективність призначеної терапії, зміни маси тіла, ІМТ та ОТ, прихильність до терапії. Третій візит, ще через 1 міс, відбувався в телефонному режимі.Результати та обговорення. Середній вік хворих становив (59,06±11,38) року, жінок було 1203 (66,9 %). Надлишкову масу тіла відзначено у 33,4 % випадків, ожиріння – у 66,6 % випадків. Середня маса тіла становила (92,06±14,03) кг, ІМТ – (32,38±4,55) кг/м2, ОТ у чоловіків – (104,92±12,74) см, у жінок – (99,32±12,74) см, тобто домінував абдомінальний тип ожиріння. Сімейний анамнез серцево-судинних захворювань відзначено у 60,7 % осіб, при цьому ніколи не курили 63,6 %. Цукровий діабет або порушення толерантності до глюкози зафіксовано у 11,06 %. Рівень систолічного АТ (САТ) становив (163,15±12,21) мм рт. ст., діастолічного (ДАТ) – (95,62±7,78) мм рт. ст., частота скорочень серця (ЧСС) – (78,16±8,98) за 1 хв, тобто спостерігалася переважно тяжка АГ. На момент залучення в дослідження один антигіпертензивний препарат приймали 38,4 % хворих, два – 47,8 %, три та більше – 13,8 % (переважно модулятори ренін-ангіотензин-альдостеронової системи в комбінації з антагоністами кальцію та гідрохлоротіазидом, більше половини – у формі окремих препаратів). Початкова прихильність до лікування (кількість позитивних відповідей) становила 3,33 бала та була низькою у 73,9 % хворих і тільки у 4,0 % – високою. Лікарями на першому візиті було змінено антигіпертензивну терапію: 84,43 % пацієнтів було рекомендовано оригінальну фіксовану комбінацію периндоприлу й індапаміду в дозуванні 10/2,5 мг; 14,07 % пацієнтів – у дозуванні 5/1,25 мг; 0,95 % пацієнтів – у дозуванні 2,5/0,625 мг; 0,56 % пацієнтів призначено іншу антигіпертензивну терапію. Через 1 міс лікування САТ знизився на (27,12±13,7) мм рт. ст., ДАТ – на (13,32±9,08) мм рт. ст., ЧСС – на (5,2±8,16) за 1 хв (усі р<0,001), що привело до контролю АГ у 74,9 % осіб та поліпшення прихильності до лікування (р<0,05). Подальше лікування впродовж місяця привело до подальшого зниження АТ. Середній САТ через 2 міс становив (130,29±11,58) мм рт. ст., ДАТ – (79,37±6,69) мм рт. ст., знизившись від початкового рівня на (32,87±12,21) та (16,26±8,93) мм рт. ст. відповідно (р<0,0001). Усі зміни АТ мали дозозалежний характер (доза оригінальної фіксованої комбінації периндоприлу й індапаміду) і були максимальними при застосуванні комбінації з дозуванням 10/2,5 мг. Від характеру попереднього лікування, віку обстежених ефективність лікування та прихильність не залежали. Контролю АТ було досягнуто у 93,09 % пацієнтів, прихильність до лікування поліпшилася у 71 %.Висновки. Терапія оригінальною фіксованою комбінацією периндоприлу й індапаміду переважно в максимальних дозах (10/2,5 мг) у попередньо лікованих хворих з АГ і надлишковою масою тіла/ожирінням є ефективною, дозволяє досягти контролю АТ упродовж 2 міс терапії у 93 % хворих незалежно від віку, а також значно поліпшити прихильність до терапії.

Integrating standardized patients into bioethics education for freshman nursing students

Background & Aim: Bioethics education nourishes consciousness in bioethics and influences the attitude and perception of death. The purpose of this study was to investigate the effect of bioethics education by employing standardized patients for freshmen nursing students. Methods & Materials: A quasi-experimental single group pretest-posttest design was used to assess the effect of bioethics education employing standardized patients on 33 freshman nursing students’ perception of dignified death and empathy who took the course of bioethics of a university. Results: The perception of dignified death appeared higher in post-education than pre-education, and the subdomain of personal distress under empathy appeared higher in post-education than pre-education. In regard to the replies on the question of “disclosure of diagnosed cancer”, 54.6% of respondents approved, while 90.9% expressed “it should be at the discretion of doctors.” Conclusion: bioethics education employing standardized patients appeared assisting students experiencing changes in perception of a dignified death. It may be useful in applying the teaching module for students with courses in bioethics.

Impact of adherence to board-certified surgeon systems and clinical practice guidelines on colon cancer surgical outcomes in Japan: A questionnaire survey of the National Clinical Database.

AimTo investigate the effectiveness of the institutional medical structure and of the implemented clinical practice guidelines for improving colon cancer surgical outcomes.MethodsWe conducted a web‐based questionnaire survey among departments registered at the National Clinical Database in Japan from October 2014 to January 2015 to assess the association between quality indicators (QIs), including structure and process indicators (clinical practice guideline adherence), and the risk‐adjusted odds ratio for operative mortality (AOR) after right hemicolectomy for colorectal cancer during the study period.ResultsAmong the 2064 departments registering at least one colorectal surgery during the study period, we obtained responses from 814 departments (39.4%). Our analysis on data from 22 816 patients with right hemicolectomy demonstrated that three structural QIs (certification of training hospitals by the Japanese Society of Gastroenterological Surgery and the presences of board‐certified gastroenterological and colorectal surgeons) were associated with significantly lower AOR (P < .001, P = .02, and P = .05, respectively). The “performed at the doctor's discretion” answer was associated with poorer short‐term outcomes in six process QIs than other answers.ConclusionThe board certification system for gastroenterological and colorectal surgeons and the adherence to the clinical guidelines improve the operative mortality after right hemicolectomy. It is desired to clarify the most suitable QIs to reduce the operative mortality after colorectal surgery.

Bereavement care in Japanese pediatrics: Pediatrician awareness in practice.

A child's death affects not only family members but also the health-care professionals involved in patient care. The education system for bereavement care in Japan, however, is not set up in a systematic way, and the care provided is based on the individual experience of the health-care professional. The aim of this study was to investigate pediatrician awareness of and actual circumstances involved in bereavement care in Japan. A qualitative descriptive study was conducted at four facilities in Japan. Data collected using semi-structured interviews of 11 pediatricians were assessed using inductive qualitative analysis. Pediatrician recognition of the elements of bereavement care was categorized as follows: (i) developing relationships with families before a child's death is important in bereavement care; (ii) after the child dies, family involvement is left to the doctor's discretion; (iii) coping with a child's death myself through past experience is essential; (iv) doctors involved in a child's death also experience mental burden; and (v) a system for the family's bereavement care must be established. Two categories were established according to actual circumstances involved in bereavement care: (i) attention must be given to the emotions of the families who lost a child; and (ii) doctor involvement with bereaved families depends on doctor awareness and expertise. Japanese pediatricians provided bereavement care to families who lost their children in a non-systematic manner. This is necessitates improvement of the self-care of health-care professionals with regard to grief by improving bereavement care-related education. Additionally, health-care professionals must be trained, and a national-level provision system must be established to provide high-quality bereavement care to families who lose a child.

Procedimento de registro dos parâmetros intervenientes na logística reversa em uma farmácia hospitalar

Os estabelecimentos assistenciais à Saúde são de extrema relevância para a economia nacional e para a qualidade de vida da população. Considerando-se a alta demanda de recursos e o baixo investimento no setor da saúde, este se apresenta altamente atrativo aos estudos de melhorias de operações, pois há registros de elevados índices de desperdício, acarretando aumento dos custos operacionais. Nesta pesquisa, aplicada em uma unidade hospitalar situada na Região Oeste do Paraná, Brasil, visa-se identificar o que motiva o retorno dos medicamentos na farmácia hospitalar, sistematizando um procedimento para registro dos parâmetros de devolução desses medicamentos. Verificou-se que o hospital apresenta um processo de logística padronizado, contudo, não implantado em todos os seus setores. Observou-se que o principal motivo de devolução de medicamentos para os dois blocos em estudo foi “A critério médico/Se necessário”. Sendo necessária a mensuração e identificação dos motivos de devoluções em fluxo contínuo, para a melhora do processo logístico interno do hospital.

Clinical efficacy of a traditional Japanese (kampo) medicine for burning mouth syndrome

AbstractAimAt Hokkaido University Hospital, selective serotonin re‐uptake inhibitors (SSRI) or serotonin and norepinephrine re‐uptake inhibitors (SNRI) are the first‐line medications for burning mouth syndrome (BMS). Occasionally, when standard SSRI/SNRI are deemed inappropriate because of certain side‐effects, treatment incompatibility, age concerns, or doctor discretion, a kampo medicine called rikkosan can be used. The purpose of this study was to evaluate the effectiveness of rikkosan for BMS.MethodsThis retrospective study included 48 patients (four men, 44 women; mean age, 70 years) who were diagnosed with BMS in the present department between 2006 and 2014. Only patients who received rikkosan (7.5 g/day) for &gt;4 weeks were included. Patients who were taking other medicines for BMS were excluded. Pain was assessed using a visual analog scale.ResultsImprovement was seen in 54% of patients (26/48).ConclusionRikkosan is an effective alternative treatment for BMS.

Rethinking Managerial Reporting

Rethinking Managerial Reporting

Pomalidomide (CC4047) Plus Low-Dose Dexamethasone (Pom/dex) Is Highly Effective Therapy in Relapsed Multiple Myeloma

Background: Thalidomide and its analogue lenalidomide have high response rates among patients with newly diagnosed as well as previously treated myeloma. Pomalidomide (CC4047) is the newest immunomodulatory (IMiD) agent that has shown single-agent activity in phase I studies. We report on the first Phase 2 trial of pomalidomide combined with low dose dexamethasone (Pom/dex) in patients with relapsed or refractory multiple myeloma.Methods: 37 patients (21 male and 16 female) were enrolled. Pomalidomide was given orally 2 mg daily on days 1–28 of a 28-day cycle. Dexamethasone was given orally at a dose of 40 mg daily on days 1, 8, 15 and 22 of each cycle. Response was assessed by the International Myeloma Working Group Uniform Response criteria. All patients received aspirin 325 mg daily as prophylaxis against DVT.Results: The median age was 66 years (range, 40 – 88). All patients were evaluable for response and toxicity, and all analysis were done on intent to treat basis. All patients had received prior therapy; 38% had 3 prior regimens; 35% had 2 prior regimens and 27% had one prior regimen. 76% had previous autologous stem cell transplant (ASCT) and 24% had 2 prior ASCT. 62% had previous IMiD therapy. Toxicity was mild and consisted primarily of myelosuppression. Grade 3 neutropenia occurred in 31%; grade 3 thrombocytopenia 3%; grade 3 anemia 3 %. Other grade 3/4 toxicities seen in less than 5% pts included: diarrhea, atrial fibrillation, pneumonia, dehydration and renal insufficiency. 16 % had grade 1/2 neuropathy. No grade 3 neuropathy was seen and there have been no thromboembolic events. Thirty (81%) patients are continuing study treatment. Seven patients have discontinued treatment due to: disease progression (5), died on study (1) and the medical doctor's discretion (1). Twenty three of 37 patients (62%) achieved an objective response to therapy; including 9 (24%) with VGPR; 14 patients (38%) with PR; 6 (16%) with stable disease. Objective responses were seen in 4 of 13 patients (29%) who were refractory to lenalidomide.Conclusions: Pomalidomide plus dexamethasone (Pom/dex) is highly active and well tolerated for treatment of relapsed/refractory multiple myeloma with an objective responserate of 62%, including a 29% response rate among patients who are lenalidomiderefractory.

INTERPRETING THE DISABILITY GROUND OF THE ABORTION ACT

“NOT only would it be a bold and brave judge … who would seek to interfere with the discretion of doctors acting under the Abortion Act 1967, but I think he would really be a foolish judge who would try to do any such thing, unless, possibly, where there is clear bad faith and an obvious attempt to perpetrate a criminal offence.” So said Sir George Baker P. in Paton v. B.P.A.S. and his view has been repeated at apposite judicial moments in subsequent cases. Recently, however, a legal attempt was indeed made to question the discretion of doctors in Jepson v. The Chief Constable of West Mercia Police Constabulary. Reverend Joanna Jepson asked the West Mercia Police to investigate doctors who had authorised an abortion for bilateral cleft lip and palate at 28 weeks under the disability ground of the Abortion Act 1967 (as amended by the Human Fertilisation and Embryology Act 1990). Abortion is legal under that section if two doctors have formed an opinion in good faith that “there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped”.

Disclosure of cancer diagnosis and prognosis: a survey of the general public's attitudes toward doctors and family holding discretionary powers

BackgroundThis study aimed to ask a sample of the general population about their preferences regarding doctors holding discretionary powers in relation to disclosing cancer diagnosis and prognosis.MethodsThe researchers mailed 443 questionnaires to registered voters in a ward of Tokyo which had a socio-demographic profile similar to greater Tokyo's average and received 246 responses (response rate 55.5%). We describe and analysed respondents' attitudes toward doctors and family members holding discretionary powers in relation to cancer diagnoses disclose.ResultsAmongst respondents who wanted full disclosure about the diagnosis without delay, 117 (69.6 %) respondents agreed to follow the doctor's discretion, whilst 111 (66.1 %) respondents agreed to follow the family member's decision. For respondents who preferred to have the diagnosis and prognosis withheld, 59 (26.5 %) agreed to follow the doctor's decision, and 79 (35.3 %) of respondents agreed with following family member's wishes.ConclusionsThe greater proportion of respondents wants or permits disclosure of cancer diagnosis and prognosis. In patients who reveal negative attitudes toward being given a cancer disclosure directly, alternative options exist such as telling the family ahead of the patient or having a discussion of the cancer diagnosis with the patient together with the family. It is recommended that health professionals become more aware about the need to provide patients with their cancer diagnosis and prognosis in a variety of ways.

Antihypertensive drug treatment: A comparison of usual care with self blood pressure measurement

Blood pressure self-measurement is increasing in most communities and yet its role in the management of hypertension is poorly understood. This study was devised to evaluate the behaviour of doctors in general practice when treating patients with poorly controlled essential hypertension who use self-measurement. Patients, most of whom were already taking antihypertensive medications were commenced on perindopril or indapamide at their doctor's discretion and were randomly allocated to self-measurement (SM) using an OMRON HEM706 oscillometric device or a continuation of their usual care (UC) over an 8-week period. This was an observational study without any specific or set treatment goals for the doctor to follow. Sixty of 62 subjects completed the study and the two groups were equally matched for age, body mass index, gender, and blood pressure (BP). While additional perindopril or indapamide produced a significant fall in BP in both groups over the study period, the systolic pressure remained significantly higher in the SM group (sitting 148 +/- 3 compared with 142 +/- 3; 145 +/- 3 compared with 138 +/- 3 mm Hg respectively; P < 0.05). Twenty-four hour and daytime ambulatory monitor systolic pressures were also significantly higher in the SM group. Differences in diastolic BP were not statistically significant. Furthermore, SM patients were less likely to have their medications increased and more likely to have them reduced or ceased. Doctors and patients found self-measurement convenient and useful. This study suggests that doctors prescribing decisions are influenced by evidence from self-measurement of BP with consequential increases in office BP related to reduced drug use. While self-BP measurement can offer reassurance about adequacy of control when away from a physicians office, our best evidence of understanding target blood pressures comes from large randomised studies using office blood pressures as an end-point. There is an urgent need for further study to provide arbitration between self-measurement and office blood pressures although each measurement must contribute to the management of hypertension.

Research in progress: A report on policies of access to aid as a medical treatment in the U.K.

This paper is the first research report of a comprehensive study of AID as a medical treatment in the U.K. It examines the policies that determine who is able to receive AID when it is administered by doctors in medical clinics. Findings from the survey upon which this report is based indicate that AID treatment is administered under highly discriminatory policies. Women's access to treatment is restricted according to marital status, sexual preference, disability and costs. By operating under restrictive policies, doctor's discretion and medical jurisdiction extends beyond the immediate concerns of the health of patients and into the realm of social control.

TRUST, TRUST, AND PATERNALISM

The emphasis on the necessity for fully informed consent in two new books, Doctors' Dilemmas by M. Phillips and J. Dawson and Whose Body Is It? by C. Faulder, is found to be "lacking in balance" by Brewin. The doctor's discretion in dealing with each patient is considered to be the key to determining priorities between paternalism and communication. Rigid rules, Brewin argues, may not be in the patient's best interest and thus should not be forced on doctors and nurses by "philosophers or experts in ethics."

A Newer Concept of Weaning

intravenous or intramuscular injection, the serum being first warmed to body temperature. In preparing for the administration of serum, the thoughtful nurse will at the same time prepare a hypodermic injection of adrenalin chlorid, m. x, to be ready for emergency use in case the patient presents symptoms of anaphylactic shock. The serum is usually given intravenously, but if given intramuscularly into the buttocks, there may develop within a few hours some local irritation-pain, swelling or redness-which may be relieved to some extent by the application of a hot water bottle, or hot magnesium sulphate compresses. However, these symptoms soon pass with the absorption of the serum. travenous or intramusc lar injection, e serum being first warmed to body perature. preparing for the administration serum, the thoughtful nurse will at The biggest nursing problem incident to serum therapy is the care during serum sickness, five to eight days after begi ning the treatment. The urticaria is usually general, appearing first about the face, neck, and arms, then spreading over the entire body. The patient is extremely uncomfortable, restless and often nauseated. The specific treatment is adrenalin chlorid given at hourly intervals, according to the doctor's discretion, the heart action being carefully watched. Some nursing measures that help are applications of calomine lotion, cool alcohol baths, or cool soda baths. The forcing of fluids is also important and helpful. This condition usually lasts from thirty-six to forty-eight hours. i gest nursing problem incident therapy is the care during sicknes , five to eight days after i g the treatment. The urti-