Everyday Patient Care Research Articles

Positive Wrongdoings: Reading Doctors' Narratives on Ordinary Ethics

The ethics of everyday life, morality of ordinary, is 'place' in which medical ethics is enacted (. . .) The case studies filling ethics textbooks do not typically address moral dynam- ics of everyday care of patients. Extraordinary decisions are not routine. An ethics of is also required. 1 Doctors' narratives about their experiences of the morality of ordinary hit on major questions that have troubled ethicists in contemporary philosophy and ethical literary criticism in last two decades and that deeply concern medical educators and practicing physicians in their endeavor to foster medical professionalism in day-by-day care of patients. How can one accommodate moral ideals, understood here as duties of medical professionalism, with emotional messiness of living and harried everyday real- ity of medical practitioners? Who has moral authority in clinical setting? Indeed, what do we mean when we talk about caregivers' moral authority and responsibilities? How can doctors best balance principles of beneficence and patient autonomy in their relationships with patients? And what images of good doctor does medical education conjure and hope to instill in minds and hearts of young students and residents? In their narrated accounts of ethical engagements, doctors whose autobiographical stories I shall analyze in this essay place their moral choices in concrete, dense contexts that invoke what Martha Nussbaum calls the indeterminacy, sheer difficulty of actual hu- man deliberation. 2 Because their narratives are more complex and more closely resemble lived experience of practicing physicians than usually terse cases in bioethics textbooks, those narratives

Neoadjuvant chemotherapy for breast cancer: a surgeon’s checklist

Understanding and translating results from the highly regulated and uniform environment of therapeutic trials to everyday patient care are one of the most challenging aspects of maintaining a clinical breast cancer practice. Careful interpretation of study results is of utmost importance when determining whether or not to adopt a new therapy or treatment sequence. Randomized clinical trials investigating neoadjuvant chemotherapy approaches to breast cancer management deserve special attention from surgeons and all members of the multidisciplinary team to obtain the best result and focus patient goals and expectations. Each patient for whom neoadjuvant chemotherapy is contemplated should undergo a careful physical exam focused on clinical tumor size, tumor mobility, or fixation with respect to skin and chest wall, axillary lymph node status, and a thorough exam of the contralateral breast. As with any newly diagnosed breast cancer, imaging is intended to characterize the index cancer, detect multifocal and multicentric disease in the ipsilateral breast, and screen the contralateral breast for abnormalities. Diagnostic mammography and ultrasound are the primary modalities for determining tumor size, identifying subclinical breast lesions, and evaluating the axillary lymph nodes. In some scenarios, magnetic resonance imaging may play a role in determining tumor extent and monitoring response to therapy. While the precise timing of axillary nodal staging in the setting of neoadjuvant chemotherapy remains controversial, it is clear that nodal status helps to define the role of chemotherapy and postmastectomy radiotherapy. Evaluation for distant metastatic disease should be performed based on clinical stage and patient symptoms. After thorough clinical evaluation, the multidisciplinary team should ask the following questions before proceeding with neoadjuvant chemotherapy:

Diuretics and diabetes incidence—an appeal against the reluctance to prescribe a medication that is safe and proven

The publication of the scientific report of the Institute for Quality and Efficiency in Health Care (IQWiG) in Germany on the 'Comparative evaluation of the benefits and harms of different antihypertensive drug classes [diuretics, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium-channel blockers and angiotensin II (AT-II) blockers] as first-choice therapy for patients with essential hypertension' raised an enormous public debate, particularly as diabetes incidence was not judged to be a patient-relevant outcome. In this assessment, the overall view of the patient-relevant results was that diuretics can be used as first-line antihypertensive treatment. Diabetes incidence is highest with diuretics, but minimal differences in fasting plasma glucose of approximately 0.28 mmol/l are magnified by the transformation of continuous blood glucose values into categorical data: with the establishment of thresholds, the diagnosis of diabetes depends on being above a certain blood glucose value. The protective cardiovascular effects of diuretics do not seem to be reduced in hypertensive patients who develop new-onset diabetes during treatment. Since blood pressure control is often worse, detection, treatment and control should be urgently improved. The debate on antihypertensive agents is mainly of scientific interest and has only minor clinical relevance for everyday patient care.

Pharmacogenomics and perioperative medicine: implications for modern clinical practice

To the Editor, We read with interest the editorial by Kim et al. accompanying the 53-year-old publication by Werner Kalow that was reproduced from the Journal archives for the December 2008 issue. The brief introduction that the authors presented regarding the impact of pharmacogenomics on the everyday care of patients is well worth reading. As implications for modern clinical practice are emphasized and clinicians are encouraged to ‘‘embrace the partnership between genetics and anesthesiology,’’ we believe the authors should provide a specification of their comments regarding the cytochrome P-450 enzyme system CYP2D6. Comparable to codeine, tramadol is a prodrug metabolized by hepatic cytochrome CYP2D6. Its M1-metabolite (?)-O-demethyltramadol possesses analgesic properties, and its affinity to l-opioid receptors is approximately 200 times greater than the parent compound. Thus, it is largely responsible for opioid receptor mediated analgesia, whereas (?)-tramadol and (-)-tramadol inhibit re-uptake of neurotransmitters, serotonin and noradrenaline. CYP2D6, a highly polymorphic enzyme, is deficient in about 7–10% of Caucasians. Extensive metabolizers displaying two functional alleles present normal enzyme activity and are able to metabolize tramadol sufficiently. In previous studies, extensive metabolizers attained adequate analgesia using tramadol, in contrast to poor metabolizers (PM) presenting two mutant alleles with deficient enzyme activity. These PMs are characterized by deficient hydroxylation of several classes of commonly used drugs, e.g., b-blockers, antiarrhythmics, tramadol, and codeine. Patients with the PM genotype were found to be twice more likely to require additional rescue medication than patients with at least one wild-type allele. Several studies have confirmed that, compared to those genotypes carrying at least one wild-type allele, subjects carrying the PM genotype experience reduced analgesic efficacy resulting in an increased non-response rate. Thus, the statement that ‘‘PMs may be overdosed by tramadol’’ may be misleading. Conversely, ultra-rapid CYP2D6 metabolism with an increased production of the active M1-metabolite anticipates adverse events and may result in life threatening side effects such as respiratory depression due to opioid overdose. This may occur with both prodrugs, i.e., codeine and tramadol. Several case reports regarding codeine poisoning associated with CYP2D6 gene duplication demonstrate the pharmacogenetic impact on drug safety and patient outcome. In addition to cases of respiratory depression associated with codeine, a further case has been reported regarding an ultra-rapid metabolizer receiving tramadol via patient-controlled analgesia. In this case, concomitant renal impairment resulting in decreased metabolite clearance enhanced opioid toxicity. Overall, it is possible for CYP2D6 gene duplications to induce an exaggerated response to codeine and tramadol. This risk is particularly increased in patients of Ethiopian and Saudi Arabian descent due to a high prevalence of the ultra-rapid metabolizer genotype (up to 29%). In conclusion, there are no ‘‘opposite effects between codeine and tramadol’’; essentially, there are comparable effects. However, in contrast to codeine, which does not U. M. Stamer, MD (&) University of Bonn, Bonn, Germany e-mail: ulrike.stamer@ukb.uni-bonn.de

Radiogenomics: Creating a link between molecular diagnostics and diagnostic imaging

Studies employing high-throughput biological techniques have recently contributed to an improved characterization of human cancers, allowing for novel sub-classification, better diagnostic accuracy, and more precise prognostication. However, requirement of surgical procurement of tissue among other things limits the clinical application of such methods in everyday patient care. Radiographic imaging is routine in clinical practice but is currently histopathology based. The use of routine radiographic imaging provides a potential platform for linking specific imaging traits with specific gene expression patterns that inform the underlying cellular pathophysiology; imaging features could then serve as molecular surrogates that contribute to the diagnosis, prognosis, and likely gene-expression-associated treatment response of various forms of human cancer. This review focuses on high-throughput methods such as microarray analysis of gene expression, their role in cancer research, and in particular, on novel methods of associating gene expression patterns with radiographic imaging phenotypes, known as “radiogenomics.” These findings underline a potential future role of both diagnostic and interventional radiologists in genetic assessment of cancer patients with radiographic imaging studies.

Intraoperative computed tomography and automated registration for image-guided cranial surgery

Two key problems for the use of navigation systems in image-guided surgery are accurate patient-to-image registration and the fact that with ongoing surgery the patient's anatomy is altered while the image data remains unchanged. A system for intraoperative CT imaging and fully automated registration of this image addresses both problems. It had been evaluated successfully in phantom studies. In this clinical study, we assessed the impact of the system on intraoperative workflow and registration accuracy in everyday patient care. In ten patients who underwent image-guided surgery, CT image data were acquired intraoperatively and were automatically registered in the navigation system. Registration accuracy and surgical outcome were assessed clinically. In six of these patients, a maxillary splint with markers had been inserted to cross-check registration accuracy. The target registration error of these markers was measured. In all cases, registration accuracy was clinically sufficient and the surgical task could be performed successfully. In those cases where a maxillary template with target markers was attached for additional control of the registration accuracy, the target registration error was always better than 2 mm. Automated registration reduced the intraoperative registration time considerably and partially compensated for the time needed to perform the image data acquisition. Intraoperative CT imaging and automated registration successfully address the two key problems of image-guided surgery. The method is robust and accurate and proved its usability in everyday patient care.

Orthotopic liver transplantation and what to do during follow-up: recommendations for the practitioner

Improvements in surgical technique and the introduction of several new immunosuppressive medications mean that outcome after orthotopic liver transplantation (OLT) has improved continuously over the past 15 years. Given the increasing longevity of patients after OLT, the recognition and prevention of long-term complications after transplantation have become ever more important. With respect to graft function, physicians responsible for the everyday care of patients following transplantation should be particularly aware of the risk of late and chronic rejection episodes and of recurrence of the underlying liver disease. The major challenge of post-transplant care is, however, how best to prevent and manage the long-term adverse effects caused by the immunosuppressive medications prescribed. Screening investigations for early diagnosis of malignancy, strict control of cardiovascular risk factors, preservation of renal function, and prevention of infections are, therefore, fundamental. This Review suggests guidelines for the management of OLT recipients to improve long-term survival, overall outcome and health-related quality of life.

Central Venous Catheter Complications during Home Parenteral Nutrition: A Prospective Pilot Study of 481 Patients with More than 30,000 Catheter Days

Background: Home parenteral nutrition (HPN) has been shown to delay deterioration in cancer patients with malnutrition. Its risk-benefit ratio, however, is determined by the threat of central venous catheter (CVC) complications. Only few prospective studies on this subject exist, most of them based on small samples. The objective of this study was to provide reliable estimates of incidence rates of CVC complications in everyday HPN patient care in Germany. Patients and Methods: Aiming for a large prospective cohort study, we cooperated with a service provider caring for HPN patients nationwide. Between July 1 and November 30, 2006, all consecutive adult patients with more than 10 infusion days and no previous history of HPN were recruited. Follow-up ended on January 31, 2007. Data were collected in a standardised way by the provider’s staff. To prevent underreporting, we used computer-assisted telephone interviews with medical caregivers as a provider-independent data source. Results: 481 patients met the inclusion criteria, contributing a total of 31,337 catheter days. 52 patients experienced a total of 63 CVC complications, resulting in an incidence rate of 2.01 CVC complications per 1,000 catheter days including 1.02 CVC infections per 1,000 catheter days. Conclusion: HPN administration can be safely performed with a relatively low rate of CVC complications.

Entwicklung, Implementierung und Evaluation eines «Curriculums Naturheilverfahren» an der Universität Heidelberg

Hintergrund: Mit der 9. Revision der Ärztlichen Approbationsordnung (ÄAppO) wurde 2003 der Querschnittsbereich «Rehabilitation, Physikalische Medizin, Naturheilverfahren» (QB 12) als verbindlicher Bestandteil der Lehre in das Medizinstudium eingeführt. Der vorliegende Artikel beschreibt die Entwicklung eines Lehrkonzeptes für Naturheilverfahren (NHV), dessen Implementierung in den QB 12 und dessen Evaluation. Methodik: Entsprechend dem 6-stufigen Modell von Kern zur Curriculumsentwicklung werden dargestellt: Bedarf, Interesse/Vorkenntnisse Studierende, Lernziele, Entwicklung Lehrveranstaltungen, Implementierung sowie Evaluation. Zur Überprüfung von Interesse/Vorkenntnissen der Studierenden wurde ein Fragebogen konzipiert. Die Evaluation der Lehrveranstaltungen erfolgt über Schulnoten sowie eine modifizierte Form des HILVE-I. Ergebnisse: Basierend auf den Kriterien «Evidenz» und «Verbreitung in der Versorgung» wurden von den beteiligten Dozenten eine Auswahl naturheilkundlicher Methoden für die Lehre getroffen und Lernziele für die Domänen Wissen, Fertigkeiten und Haltungen formuliert. Auf dieser Basis wurden Lehrveranstaltungen zu klassischen NHV, Akupunktur/Traditionelle Chinesische Medizin und Neuraltherapie konzipiert und in den QB 12 integriert. Die regelmäßig durchgeführten Evaluationen zeigen eine konstant gute Beurteilung der Lehrveranstaltungen. Bei der 2006/2007 durchgeführten Umfrage nach Vorkenntnissen/Interesse an NHV gaben 69% der 219 befragten Studierenden Interesse an NHV an, 27% der Studierenden hatten bereits eigene Erfahrungen mit NHV gemacht. Diskussion: Die insgesamt guten Evaluationsergebnisse weisen auf eine erfolgreiche Entwicklung und Implementierung des «Curriculums Naturheilverfahren» an der Universität Heidelberg hin. Hierdurch wird einerseits der Auftrag der ÄAppO erfüllt und andererseits wird man mit der Verankerung naturheilkundlicher Lehrinhalte in den QB 12 der weiten Verbreitung dieser Methoden in der Versorgung gerecht.

Tackling patient safety

It cannot be said that in today’s NHS that we have an engrained patient safety culture where patient safety is at the forefront of every nurse’s and doctor’s mind – it is not. Many nurses will not know of the Seven Steps to Patient Safety from the National Patient Safety Agency (NPSA, 2004), nor will many doctors. Their attention is focused on the everyday care of patients in often resource-challenged circumstances, while chief executives are largely focused on the delivery of targets and mergers. There are exceptions to this but patient safety initiatives have had to compete with the reality of an NHS in an almost constant state of reform for many years, and there is a limit to how many balls people can juggle at once.

The Lowering of Vascular Atherosclerotic Risk (LOVAR) Program: An Approach to Modifying Cerebral, Cardiac, and Peripheral Vascular Disease

More than 1 million US citizens die of cerebral, cardiac, and peripheral vascular disease (collectively, CVD) each year. Basic science and clinical outcome research aimed at reducing the burden of this illness is widespread, but the knowledge gleaned from controlled trials has not fully translated into everyday clinical practice and care of patients with CVD and their inherent risk factors. The Lowering of Vascular Atherosclerotic Risk (LOVAR) program was a 5-year observational study that evaluated the feasibility of a high-intensity multidisciplinary program of risk factor reduction in a population with known symptoms of CVD. The population comprised patients with documented clinically symptomatic cerebral, cardiac, or peripheral vascular disease and at least two modifiable risk factors for stroke, myocardial infarction, or peripheral vascular occlusive disease. Final outcomes were evaluated by comparing primary and secondary end points and quality of life. A total of 271 patients were enrolled in the intervention group, and 242 were enrolled in the standard care group (control). At 3 years, significant improvements in several risk factors were seen in the intervention group, with no significant improvements for the control group. The rate of patient retention was 95% at 3 years, and overall rates of physician and patient satisfaction were high. We believe that the Lowering of Vascular Atherosclerotic Risk program is generalizable to a sufficiently motivated population targeted as high risk for vascular disease.

The incredible shrinking world of DNA microarrays.

The efficacy of microarrays in examining gene expression, gene and genome structure, protein-DNA interactions, whole-genome similarities and differences, microRNA expression, methylation (and more) is no longer in question. It is a fast-developing, cutting edge technology that has grown up along with massive sequence databases and is likely to become part of everyday patient care. Many advances have recently expanded the power and utility of microarrays; among them is our development of a new array tiling technique that dramatically increases the scope of coverage of an oligonucleotide tiling array without substantially increasing its cost.

Breast Cancer Gene Expression Profiling: Clinical Trial and Practice Implications

The advent of high-throughput array-based technology and the sequencing of the human genome has provided the opportunity to begin comprehensive molecular and genetic profiling of cancers. Such efforts have, in a limited time, given us new insights into breast cancer biology and confirmed that the disease is considerably more heterogeneous than can be predicted by traditional histopathological methods. The estrogen receptor has been found to be the most dominant factor influencing the molecular composition of breast cancer and, in addition, novel subgroups of breast cancer with differing clinical outcomes have been observed. These may have substantial management implications for breast cancer patients and facilitate individualized rather than empirical oncological prescription. Furthermore, new methods of prognostic classification have been developed using array technology. The challenges ahead lie in refining the use of the technology, proper validation of discoveries, and the large-scale collaborative efforts necessary for the incorporation of genomic knowledge into the design and conduct of clinical trials. This will lead, ultimately, to the application of user-friendly tools derived from this technology to everyday patient care.

Clinical incidence and clinical audit

Clinical audit lies at the heart of the clinical governance process and is essential for reviewing and improving the quality of everyday care of patients with common conditions

Current practice patterns for adult perioperative transesophageal echocardiography in the United States.

Current practice patterns for adult perioperative transesophageal echocardiography in the United States.

Observation option toolkit for acute otitis media

The observation option for acute otitis media (AOM) refers to deferring antibiotic treatment of selected children for up to 3 days, during which time management is limited to analgesics and symptomatic relief. With appropriate follow-up complications are not increased, and clinical outcomes compare favorably with routine initial antibiotic therapy. Although used commonly in the Netherlands and certain Scandinavian countries, this approach has not gained wide acceptance in Europe and the United States. This article describes an evidence-based toolkit developed by the New York Region Otitis Project for judicious use of the observation option. The toolkit is not intended to endorse the observation option as a preferred method of management, nor is it intended as a rigid practice guideline to supplant clinician judgement. Rather, it presents busy clinicians with the tools needed to implement the observation option in everyday patient care should they so desire.

Translating heart failure guidelines into clinical practice: clinical science and the art of medicine.

The rapid growth of medical knowledge during the past few decades has created many potential advances in the therapeutics of chronic disease, and cardiovascular disease has been at the center of this phenomenon. Translation of these advances into everyday care of patients with chronic disease continues to be problematic. Guideline development has emerged as a major strategy to improve utilization of new and existing therapeutic modalities of proven benefit. To be effective, practice guidelines must not only clearly delineate which therapies are efficacious, but also consider the many practical aspects necessary for implementation of specific therapeutics in the actual care of patients. In this way, both the art and the science of medicine can be employed to obtain better patient outcomes in cardiovascular diseases long associated with severe mortality, morbidity, and poor quality of life. This review examines the difficulties inherent in translating new advances into standards of care. The recent guideline process for a specific chronic cardiovascular disease, heart failure, is used for illustration of the translation process.

A moral economy of American medicine in the managed-care era.

The moral economy of American medicine has been transformed by contentious innovations in organization, administration, regulation, and finance. In many settings old fee-for-service incentives and disincentives have been replaced by those of "managed care", while in other settings they have been diluted or distorted. In the everyday care of patients, old and new may alternate or interact. These innovations may also be having secondary effects on participation in life-sciences research and the development and employment of new technologies, discouraging collective support for preliminary investigation and delaying adoption of improved goods and services until cost-reducing potential has already been realized. This motivational complexity, particularly in its moral dimensions, is hard to address using standard assumptions and methods. I argue for different assumptions, based on the clinical behavior of individual patients rather than the market behavior of aggregated consumers, and I describe a different method, based on an old idea in political economy. I then present a new way to explain the core obligations of clinicians, researchers, and planners and to interpret the policy problems they must now share.

Developing clinical practice guidelines for heart failure: creative process and practice implications.

The rapid growth of medical knowledge has created many advances in therapeutics related to chronic disease. Translation of these advances into everyday care of patients with chronic disease has proven problematic. Guideline development offers a principal strategy to improve use of new and existing therapeutic modalities of proven benefit. To be effective, practice guidelines must not only deal with which therapies are efficacious but attempt to consider the many practical aspects necessary in the actual care of patients. In this way both the art and science of medicine can be employed to obtain optimal patient outcomes in many chronic diseases that have been associated with severe mortality, morbidity, and poor quality of life. The logical process of guideline development and its use in one specific chronic disease, heart failure, is examined.

Critical review of how nurses research massage therapy: are they using the best methods?

Complementary therapies comprise only a fraction of nursing care, yet it is interesting that their use is being considered by an ever-increasing number of nurses. Within the Rhondda NHS Trust, holistic massage therapy is offered to patients both in hospital and in the community, nurses and occupational therapists successfully combining their massage skills with everyday patient care. During the process of devising a research protocol for implementation within the Trust, certain questions began to emerge to which there were no answers. The attempt to answer them is the origin of this paper, which explores some commonly experienced difficulties with reference to the literature and puts forward merits of adapting current methodology to investigate the benefits of massage therapy.