Internal Medicine Doctors Research Articles

Dermatological adverse effects of heart medicine. A retrospective study of patients in a dermatological ward in Gdansk between years 2004-2013 and review of the literature.

Introduction. A wide range of medications are used in cardiology. The treated population is often elderly with polypharmacy. The treatment sometimes comes with adverse effects and these patients can be met in all hospital wards. Material and methods. We analyzed medical charts of all patients admitted to Department of Dermatology, Allergology and Venereology at Medical University of Gdansk in the years 2004–2013. The aim was to investigate the demographics as well as skin manifestations, abnormalities in laboratory results and treatment. Results. Twenty-nine cases were found with hypersensitivity reactions manifested on the skin due to different drugs used in cardiology. The manifestations were diverse. Most presented as urticaria with or without accompanying angioedema (11), pemphigoid changes (9) and non-urticarial maculopapular exanthema (6). One patient presented with Stevens-Johnson syndrome (SJS) and 2 patients were diagnosed with vasculitis. The causative drugs were angiotensin converting enzyme inhibitors, loop-diuretics, calcium channel inhibitors, metoprolol, statins, acetylsalicylic acid, ticlopidine, molsidomine, doxazosin and enoxaparin. In our study we present three reactions not yet described in literature; bullous pemphigoid after torasemide and quinalapril and SJS after enalapril. The treatment of all patients consisted of discontinuation of suspected drug and in all except one medical therapy was required. In the patients with urticaria, anaphylaxis and maculopapular exanthema, oral glucocorticosteroids and oral antihistamines were given with good effect. The diagnosis of pemphigoid resulted in additional immunosuppressive treatment with adjuvant drugs. All patients recovered within a week without any sequelae. Conclusions. Quick diagnosis of the hypersensitivity reaction and identification of the culprit drug is crucial for the patient. It is important to have a good communication between internal medicine doctors and dermatologist to succeed in treatment of the dermatological pathology and to plan further cardiological treatment. Although cardiological drugs are commonly used we could find a few hypersensitivity reactions due to this group of medications, compared to all patients admitted due to adverse drug reactions during the time studied.

Cardiovascular safety of type 2 diabetes medications: Review of existing literature and clinical implications.

Type 2 diabetes mellitus (T2DM), cardiovascular disease (CVD) and the cardiovascular effect of antidiabetic drugs are today critical medical issues, with the prevalence of T2DM in particular showing a steep increase worldwide, mainly due to unhealthy lifestyle habits. T2DM in association with obesity and other cardiovascular risk factors, results in the development of CVD, the leading cause of morbidity and mortality in patients with T2DM. Thus, treatment of T2DM is an individualized and complex challenge in which targeting cardiovascular risk factors is an important component in the decision making. Given the cardiovascular adverse events associated with rosiglitazone, both the Food and Drug Administration and the European Medicines Agency currently require the demonstration of cardiovascular safety of new antidiabetic drugs. Consequently, clinical trials to guarantee their cardiovascular safety are now obligatory. This review aims to summarize the available evidence on the cardiovascular effects and safety of the major drugs used in T2DM treatment and also to provide an overview of upcoming and ongoing clinical trials in this field. Our belief is that this review will be of substantial assistance to all medical doctors who are treating diabetic patients, namely primary care physicians, internal medicine doctors, endocrinologists, diabetologists and less well experienced personnel such as young doctors in training.

Physical Examination Has Been Paid Less Attention to Compared to Diagnostic Imaging: from a Bibliometric Analysis of PubMed

Physical examination is still needed in this modern era in spite of the recent development of advanced imaging modalities. However, not only clinicians but also researchers (including clinical researchers) seem to pay less attention to physical examination as a research topic. A PubMed search revealed that instead of an increasing percentage of diagnostic imaging articles, there were decreasing percentages of physical examination articles, especially in Japan. We should reconsider physical examinations as an important research topic, which might be especially interesting for general internal medicine doctors.

Ninety Years of Supporting the Practice of Pathology and Laboratory Medicine: Archives Celebrates Milestone Anniversary

This month, January 2016, we celebrate the 90th anniversary of the Archives of Pathology & Laboratory Medicine. First published in January 1926 as a specialty journal of the American Medical Association, the ARCHIVES is one of the oldest continuously published pathology journals in the United States. The ARCHIVES’ first editor (1926–1950), Ludvig Hektoen, MD, of Chicago, a founder of immunopathology, was chair of the Department of Pathology at the University of Chicago and director of the John McCormick Institute of Infectious Disease. Among the discoveries in immunopathology attributed to Dr Hektoen are homologous erythrocyte hemagglutination during blood transfusions, the principles of the accelerated response following a booster shot (specific anamnestic reaction), and the use of adjuvants to augment the immune response. Dr Hektoen was an advisor to the American Medical Association, and editor of the Journal of Infectious Diseases (published since 1904), the Proceedings of the Institute of Medicine of Chicago, and the Transactions of the Chicago Pathological Society. His original editorial board consisted of 3 anatomic pathologists, an experimental pathologist whose research was in avitaminosis, and an internal medicine doctor who had once been a pathologist. The second editor (1950–1954), Granville Bennett, MD, was famous in bone and joint pathology and was chair of the Department of Pathology at Tulane University. Subsequently, he became the first full-time appointed chair of the Department of Pathology at the University of Illinois College of Medicine and later dean of the University of Illinois College of Medicine. The third editor (1954–1963), Paul Cannon, MD, was chair of the Department of Pathology at the University of Chicago. He was an expert on protein deprivation and its effects on the immune system. During and after World War II, his work with the US military on protein malnutrition led to many medical advances in plasmapheresis, stomach tube feeding, and intravenous feeding. The US military also enlisted his help in the development of the K ration. The fourth editor (1964–1973), D. Murray Angevine, MD, was an expert in immunity with a focus on rheumatoid arthritis and vasculitis. He was chair of the Department of Pathology at the University of Wisconsin and later scientific director of the Armed Forces Institute of Pathology, leader of what was the largest pathology group in the world at that time. The fifth editor (1974–1983), Kenneth Brinkhous, MD, was chair of the Department of Pathology at the University of North Carolina at Chapel Hill. Dr Brinkhous developed the partial thromboplastin test, developed the first effective treatment for hemophilia (factor VIII), and was the first scientist to receive 50 years of continuous research funding from the US National Institutes of Health. The sixth editor (1984–1997), William W. McLendon, MD, was chair of both the Department of Hospital Laboratories and the Division of Laboratory Medicine at the University of North Carolina School of Medicine. It was under his leadership that the Department of Pathology and Laboratory Medicine was formed at the University of North Carolina in 1995. The clinical laboratories there are named after him, the William W. McLendon Clinical Laboratories. Two important events occurred during Dr McLendon’s tenure. In 1984, the ARCHIVES became a joint publication of the American Medical Association and the College of American Pathologists (CAP), making ARCHIVES a member benefit for CAP members, which gave the ARCHIVES the greatest circulation of any peer-reviewed pathology journal in the world, a title which it continues to hold currently. It was in 1995 that the ARCHIVES became the official journal of the CAP. The seventh editor (1998–2003), Kenneth D. McClatchey, was a DDS as well as an MD, with a master’s degree in oral pathology. He was famous in both surgical pathology (head and neck pathology) and clinical pathology (microbiology). After serving as associate chair, vice chair, and director of laboratories at the University of Michigan, he became chair of the Pathology Department at Loyola University Medical Center, Maywood, Illinois. Dr McClatchey served on the CAP Board of Governors from 1986 to 1992. When Dr McClatchey died rather suddenly and unexpectedly at age 61, ARCHIVES Associate Editor Gregorio Chejfec, MD, took over as acting editor in January 2004. Dr Accepted for publication September 18, 2015. From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas. The author has no relevant financial interest in the products or companies described in this article. doi: 10.5858/arpa.2015-0393-ED Reprints: Philip T. Cagle, MD, Department of Pathology and Genomic Medicine, Houston Methodist Hospital, 6565 Fannin St, Main Building, Room 227, Houston, TX 77030 (e-mail: pcagle@ HoustonMethodist.org).

Влияние факторов социального окружения на представления пациентов об эффективности психотерапевтической помощи

One of the most important factors, influencing the development on concept of confidence in
 psychotherapy is social environment.
 The analysis of expectations of Russian patients towards psychotherapy (this construct with a certain limitations
 can be assimilated to concept of confidence in psychotherapy) requires taking into account social environment
 factor, including social-demographic situation in the Russian Federation. According to the results of a
 survey of the Public Opinion Foundation (POF) including 1500 individuals aged 18+ years (dated November 2014), the use of psychotherapeutic and psychological services decreased since 2006 by 20% (!) and today constitutes
 less than 20%. According to participant’s opinion, the accessibility of psychotherapeutic service slightly
 increased (by 5%). During the same time period the number of respondents who are certain that reference to psychologists
 or psychotherapists is worthless increased by 8%. At the same time, according to national statistical
 investigations, more than 30% of population has psychiatric conditions requiring medical help or consultation of
 a psychiatrist, or, more often, a psychotherapist or clinical psychologist. Consequently, there is a decrease of
 confidence in psychotherapy among potential service consumers in our country, which is to no small degree associated
 with concern of disapproval of psychotherapeutic help by reference group (friends, colleagues, family
 members etc.). In other words, psychotherapeutic or psychological help will be associated with shame and insecurity.
 The reason for such an attitude of population to psychotherapeutic treatment are likely distorted perception,
 associated with lack of information, apprehensive attitude towards psychiatric treatment (which is closely
 related in the public consciousness to psychotherapy). The attitude of internists and health officials towards psychotherapy
 may play an important role in the discrediting psychotherapy. One gets the impression that nowadays
 at the present stage of development of psychotherapy in our country, educational function of psychotherapist
 becomes of paramount significance. It should be aimed both at the development of knowledge on the efficacy of
 psychotherapeutic methods and at the necessity of engagement of psychotherapists and psychologists in diagnostics
 and treatment alongside with internal medicine doctors, and also at the promotion of credibility of psychotherapy
 among the potential users of psychotherapeutic services.

Doing more does not mean doing better: the FADOI contribution to the Slow Medicine program for a sustainable and wise healthcare system

Consistently with its own vision on the necessity to implement a sustainable and frugal medicine, in 2013 the Italian Federation of Associations of Hospital Doctors in Internal Medicine (FADOI) decided to adhere to the Slow Medicine program entitled <em>Doing more does not mean doing better</em>, launched in Italy in late 2012, following the Choosing Wisely® campaign of the American Board of Internal Medicine (ABIM) Foundation started in the USA in 2010. According to the program, FADOI has now produced a list of ten evidence-based recommendations of the <em>do not</em> type, regarding different practices whose benefits for the patients are questionable at least, if not harmful at worst. The list was obtained from a questionnaire submitted to 1175 FADOI members, containing a purposely selected choice of 32 pertinent recommendations already published by Choosing Wisely®, and reflects the qualified opinion of a large number of Italian internists. These recommendations are now endorsed by the FADOI, as a contribution to the discussion among doctors, health professionals, nurses, patients and citizens about what is worth choosing in medicine; they are also meant to promote a shared decision making process in the clinical practice.

Medical teleconsultation to general practitioners reduces the medical error vulnerability of internal medicine patients

Backgrounde-Health strategies are supposed to improve the performance of national health systems. Medical teleconsultation (MT) is an important component of such e-Health strategies. ObjectivesThe outcome of MT was evaluated with regard to the impact on the medical error vulnerability (MEV) of internal medicine patients. MethodsA team of internal medicine doctors plus a network of forty specialists was set-up in one health district belonging to a unified and universal national health system of a country of Western Europe, in order to provide free-of-charge MT to support general practitioners in solving internal medicine cases. In this observational study, the case series of 2013 is reviewed. Resultsa) Only 21% of the MT fell short to the general practitioner's expectations about the case solving focus; b) throughout the medical care process of the patient, 49% of the cases met with one or more of the five MEVs, namely: 1) clinical test mishandling; 2) inaccurate differential diagnosis; 3) inadequate information flow between health providers at different levels of care (transition care); 4) poor coordination between health providers; and 5) poor reconciliation of medications or hazardous therapies. c) MT canceled or prevented MEVs in 56% and mitigate MEVs in 15% of the cases; d) MT canceled or prevented 85% of MEV caused by poor information exchange in transition care, therefore improving patient referral and counter-referral. ConclusionsMT reduces MEV and therefore, whenever implemented to a large extent, may improve the quality of health care delivery and the performance of national health systems.

Analysis of provider specialties in the treatment of patients with clinically diagnosed back and joint problems.

Although several studies have compared patient outcomes by provider specialty in the treatment of back and joint pain, little is known about the cost-effectiveness of improving patient outcomes across specialties. This study uses a large-scale, nationally representative database to evaluate the cost-effectiveness of being treated by specific provider specialists for back and joint pain in the United States. The 2002-2012 Medical Expenditure Panel Surveys were used to examine patients diagnosed with back and/or joint problems seeking treatment from doctors (internal medicine, family/general, osteopathic medicine, orthopaedics, rheumatology, neurology) or other providers (chiropractor, physical therapist, acupuncturist, massage therapist). A total of 16,546 respondents aged 18 to 85 and clinically diagnosed with back/joint pain were examined. Self-reported measures of physical and mental health and general quality of life (measured by the EuroQol-5D) were compared with average total costs of treatment across medical providers. Total annual treatment costs per person ranged from $397 for family/general doctors to $1205 for rheumatologists. Cost-effectiveness analysis suggests that osteopathic, family/general, internal medicine doctors and chiropractors and massage therapists were more cost-effective than other specialties in improving physical function to back pain patients. For mental health measures, family/general and orthopaedic doctors and physical therapists were more cost-effective compared with other specialties. Similar to results on physical function, family/general, osteopathic and internal medicine doctors dominated other specialties. However, only massage therapy was cost-effective among non-doctor providers in improving quality of life measures. Patients seeking care for back and joint-related health problems face a wide range of treatments, costs and outcomes depending on which specialist provider they see. This study provides important insight on the relationship between health care costs and patients' perceived physical and mental health status from receiving treatment for diagnosed back/joint problems.

The development of online doctor reviews in China: an analysis of the largest online doctor review website in China.

BackgroundSince the time of Web 2.0, more and more consumers have used online doctor reviews to rate their doctors or to look for a doctor. This phenomenon has received health care researchers’ attention worldwide, and many studies have been conducted on online doctor reviews in the United States and Europe. But no study has yet been done in China. Also, in China, without a mature primary care physician recommendation system, more and more Chinese consumers seek online doctor reviews to look for a good doctor for their health care concerns.ObjectiveThis study sought to examine the online doctor review practice in China, including addressing the following questions: (1) How many doctors and specialty areas are available for online review? (2) How many online reviews are there on those doctors? (3) What specialty area doctors are more likely to be reviewed or receive more reviews? (4) Are those reviews positive or negative?MethodsThis study explores an empirical dataset from Good Doctor website, haodf.com—the earliest and largest online doctor review and online health care community website in China—from 2006 to 2014, to examine the stated research questions by using descriptive statistics, binary logistic regression, and multivariate linear regression.ResultsThe dataset from the Good Doctor website contained 314,624 doctors across China and among them, 112,873 doctors received 731,543 quantitative reviews and 772,979 qualitative reviews as of April 11, 2014. On average, 37% of the doctors had been reviewed on the Good Doctor website. Gynecology-obstetrics-pediatrics doctors were most likely to be reviewed, with an odds ratio (OR) of 1.497 (95% CI 1.461-1.535), and internal medicine doctors were less likely to be reviewed, with an OR of 0.94 (95% CI 0.921-0.960), relative to the combined small specialty areas. Both traditional Chinese medicine doctors and surgeons were more likely to be reviewed than the combined small specialty areas, with an OR of 1.483 (95% CI 1.442-1.525) and an OR of 1.366 (95% CI 1.337-1.395), respectively. Quantitatively, traditional Chinese medicine doctors (P<.001) and gynecology-obstetrics-pediatrics doctors (P<.001) received more reviews than the combined small specialty areas. But internal medicine doctors received fewer reviews than the combined small specialty areas (P<.001). Also, the majority of quantitative reviews were positive—about 88% were positive for the doctors' treatment effect measure and 91% were positive for the bedside manner measure. This was the case for the four major specialty areas, which had the most number of doctors—internal medicine, gynecology-obstetrics-pediatrics, surgery, and traditional Chinese medicine.ConclusionsLike consumers in the United States and Europe, Chinese consumers have started to use online doctor reviews. Similar to previous research on other countries’ online doctor reviews, the online reviews in China covered almost every medical specialty, and most of the reviews were positive even though all of the reviewing procedures and the final available information were anonymous. The average number of reviews per rated doctor received in this dataset was 6, which was higher than that for doctors in the United States or Germany, probably because this dataset covered a longer time period than did the US or German dataset. But this number is still very small compared to any doctor’s real patient population, and it cannot represent the reality of that population. Also, since all the data used for analysis were from one single website, the data might be biased and might not be a representative national sample of China.

Hip Fracture--Epidemiology, Management and Liaison Service. Multidisciplinary approach for the treatment of proximal femoral fractures

Multidisciplinary approach for proximal femoral fracture was organized in the hospital. Inter and intra division obstacles were discussed. After general consensus of the team was obtained, manuals and guidelines of the each division were prepared. In addition to this, the electrical chart specific for the proximal femoral fracture was made which enables to eliminate in-hospital reference letters. As the results, all patients were examined by internal medicine doctors at the time of admission. Average interval from the time of admission to surgery became 1.3 days. Closer relationship with psychiatrist made early detection and treatment of delirium possible. After changing the system to check the antiosteoporosis medication at the time of discharge by the ward pharmacist dramatically increased the prescription rate form 39 percent to 95 percent.

Physicians’ Understanding of Patient Autonomy and Choice in Discussions Surrounding the Do-Not-Resuscitate Order (FR415-B)

•Define three criteria necessary for a decision to be autonomous and determine whether these criteria have been fulfilled in the quotations in the presentation.•Describe ideal forms of persuasive communication and contrast that with less desirable communication strategies. Physician paternalism has given way to the primacy of patient autonomy. Challenges occur when patients request potentially nonbeneficial interventions, resulting in ethical conflicts between respecting autonomy and acting with beneficence. To explore physicians’ conceptualization of patient autonomy and choice and how that affects physician communication strategies in conversations where do-not-resuscitate (DNR) status is discussed. Semistructured in-depth interviews were conducted with 29 internal medicine doctors across two sites in the United States who were routinely involved in DNR conversations with patients at the end of life. Participants were purposely sampled by stage of training and medical subspecialty to provide a wide range of perspectives and contribute to understanding emerging patterns and themes. Interviews lasted 60 minutes on average and were audiotaped and transcribed. Transcripts were analyzed and double coded using thematic analysis with an interpretive approach. Experienced doctors at all sites generally felt comfortable engaging in shared decision making and, when clinically appropriate, making more paternalistic recommendations against resuscitation. However, residents and fellows felt less comfortable restricting choice and felt compelled to offer choice even if the chance of successful resuscitation was negligible, often without explaining the likelihood of survival, its consequences, or in the overall context of goals of care. Inexperienced doctors often interpreted hospital policies promoting autonomy to mean that they should not provide clinical recommendations, even in situations where they feel it would not be in a patient’s best interest to offer resuscitation. This obscures truly autonomous informed decision making by offering choice without providing the tools and knowledge necessary to make the decision.

Xenotransplantation of porcine islet cells as a potential option for the treatment of type 1 diabetes in the future.

Solid organ and cell transplantation, including pancreatic islets constitute the treatment of choice for chronic terminal diseases. However, the clinical use of allogeneic transplantation is limited by the growing shortage of human organs. This has prompted us to initiate a unique multi-center and multi-team effort to promote translational research in xenotransplantation to bring xenotransplantation to the clinical setting. Supported by the German Research Foundation, an interdisciplinary group of surgeons, internal medicine doctors, diabetologists, material sciences experts, immunologists, cell biologists, virologists, veterinarians, and geneticists have established a collaborative research center (CRC) focusing on the biology of xenogeneic cell, tissue, and organ transplantation. A major strength of this consortium is the inclusion of members of the regulatory bodies, including the Paul-Ehrlich Institute (PEI), infection specialists from the Robert Koch Institute and PEI, veterinarians from the German Primate Center, and representatives of influential ethical and religious institutions. A major goal of this consortium is to promote islet xenotransplantation, based on the extensive expertise and experience of the existing clinical islet transplantation program. Besides comprehensive approaches to understand and prevent inflammation-mediated islet xenotransplant dysfunction [immediate blood-mediated inflammatory reaction (IBMIR)], we also take advantage of the availability of and experience with islet macroencapsulation, with the goal to improve graft survival and function. This consortium harbors a unique group of scientists with complementary expertise under a cohesive program aiming at developing new therapeutic approaches for islet replacement and solid organ xenotransplantation.

Evaluación de la calidad de registro de historias clínicas en consultorios externos del servicio de medicina interna de la Clínica Centenario Peruano Japonesa, 2010-2011

Core of medical audit is a properly tailored medical history. The medical record includes all medical examinations, studies conducted and treatments applied during the course of the disease. Objectives: To assess medical records registration quality of Internal Medicine doctor’s offices at Clinica Centenario Peruano Japonesa. Design: Descriptive cross-sectional study. Location: Internal Medicine outpatient offices at Clinica Centenario Peruano Japonesa. Material: Clinical records of patients attended in Internal Medicine doctor’s offices. Methods: Three hundred and twenty-three medical records were collected by random sampling and subjected to a 10-items record audit, each rated at 10 points, for a total of 100 points. Items included date and time of care, neatness and legibility suitable record, vital signs, physical examination, diagnosis, plan of work, laboratory findings, complete treatment, and signature and stamp of the physician. Records with total score more than or equal to 80 were rated as ‘acceptable’, and all others as ‘need to improve’. Main outcome measures: ‘Acceptable’ or ‘need to improve’ medical records. Results: Two hundred and six (63.8%) clinical records were rated as ‘acceptable’ and 117 (36.2%) as ‘need to improve’. Items diagnosis and complete treatment presented poor registry more frequently, both in records with acceptable registry (filled in completely in 64.6% and 62.6% respectively) and those with need to improve registry (20.5% and 23.1% respectively). Signature and seal of the attending physician were the best items in both categories (99.5% and 93.2% respectively). Conclusions: More than half of the medical records had an acceptable quality at the Clinica Centenario Peruano Japonesa.

P090: Attitudes to end of life care in emergency and general internal medicine doctors

P090: Attitudes to end of life care in emergency and general internal medicine doctors

SAT0278 The Comparison of Diagnostic Accuracy between Eular/Acr Provisional Classification for PMR and Other Criterion

BackgroundPolymyalgia rheumatica (PMR) is a common rheumatic disorder in the elderly population. General Internal Medicine doctors often encounter these patients. However, the gold standard for the diagnosis of PMR is...

Evaluación y construcción de un perfil de competencias profesionales en medicina interna

Objetivo: caracterizar el perfil de desempeño del médico internista según las competencias profesionales propuestas y establecer las relaciones con el perfil de formación actual en esta especialidad en Colombia. Diseño del estudio: estudio mixto, transversal, durante 11 meses; con consentimiento informado y Comité de Ética. Participantes: directivos, internistas, internistas-docentes, residentes. Intervenciones: entrevistas en profundidad, encuesta y análisis de programas. Encuesta anónima, según el análisis cualitativo de entrevistas. Triangulaciones para validez y confiabilidad por fuentes (literatura, participantes, programas), instrumentos (entrevista, encuesta, rejilla para análisis de programas) y tipo de participantes. Análisis: cualitativo Atlas.ti 5.0, cuantitativo Excel 2007. Resultados: entrevistados 45, encuestados 190 y programas analizados 2, para proponer un perfil de formación por competencias profesionales con enfoque pedagógico socio-constructivista. Este perfil propuesto reconfirma las competencias profesionales de la literatura pero surgieron unasnuevas: 1. Específicas nucleares emergentes, que dan la identidad deontológica o razón de ser del internista, son las capacidades para integrar problemas del paciente, organizar conceptos de subespecialistas, ser experto en enfermedades prevalentes, ser soporte de especialistas médico-quirúrgicos, actuar en diferentes niveles de atención y escenarios. 2. Clínicas clásicas y otras nuevas como enfatizarla promoción de la salud y prevención de la enfermedad. 3. Transversales emergentes: comunicativas, profesionalismo, administrativas, pedagógicas, en investigación. Conclusión: el perfil de formación del residente continúa centrado en objetivos y rotaciones fragmentadas en medicina interna y subespecialidades; se infiere un enfoque empírico en competencias profesionales clínicas y el conocimiento médico, mediante los convenios docencia-servicio; hay carencia del desarrollo formal de competencias transversales y específicas nucleares

The future of internal medicine in the United States and Poland

Abstract Internal medicine physicians are critical to the health of the population. Internal medicine doctors also bring cost savings in health care because they treat many systems in the body and treat the patients in a holistic manner. However, the popularity of the specialty of internal medicine is declining. This is due to the decreased compensation that internal medicine doctors obtain when compared to their colleagues who specialize in other fields. The decline in number of physicians specializing in internal medicine causes a decrease in the health of the population. Governments and policy makers must look for ways to reverse the trend of doctors not specializing in internal medicine

The Patient Care Pathway for Type 2 Diabetes Mellitus in Asian Countries: Implications on Target Physician Group for Diabetes Clinical Trials

Introduction: A patient care pathway is the referral pathway from a patient’s first consult with a healthcare provider to the time they receive the most appropriate treatment for their condition. With the increase in diabetes prevalence, clinical trial growth in Asia, and lack of published literature in this area, it is critical to understand the patient care pathway of Type 2 Diabetes Mellitus in the region. Method: Between March and August 2013, a survey investigating the diagnosis and treatment patterns of diabetes and diabetes-related complications was sent to healthcare offices in 11 Asian countries. Survey responses received were analyzed. Results: Eighty-seven healthcare offices were contacted, out of which, 49, returned the surveys. Fifty-seven percent of physicians who responded were endocrinologists, 24% were self- reported diabetologists, and 14% were general practitioners. Internists/general practitioners diagnose majority of type 2 diabetics, and they manage majority of diabetes patients treated only with lifestyle therapy. Internists and endocrinologists manage most patients on oral anti-hyperglycemic agents. Endocrinologists/diabetologists treat a majority of patients on insulin and GLP-1 agonists. Specialists such as cardiologists and nephrologists manage those with more severe complications. Discussion: The diabetes patient care pathway has several suggestions on the target physician group for clinical trials, namely (1) Internal medicine doctors and primary healthcare physicians may be potential investigators or referral sites for clinical trials requiring treatment naive diabetic patients; (2) diabetologists/endocrinologists should be considered for clinical trials needing patients on pharmacologic treatment, whether oral or insulin; (3) internists may play a role in trials that involve patients on oral anti-hyperglycemic agents and on insulin; (4) the severity of diabetic complications impacts the medical specialty of the physician treating patients; and (5) cardiologists and nephrologists are important considerations for studies with cardiovascular or nephrology related outcomes.

Follow-up of patients with systemic lupus erythematosus: What is not found in the guidelines

A series of measures in the management of patients with systemic lupus erythematosus (SLE) which usually are not found in the lupus guidelines are discussed. In the lupus patient who has been well-controlled in the long term, the dose of hydroxychloroquine should be progressively reduced, without decreasing more than approximately 600mg per week. We recommend taking this drug in the morning in patients with insomnia, at night in those with dyspepsia and to separate the intake of the drug from the shower (and the water should be as cool as possible) in those patients with aquagenic pruritus. We do not use prednisone on alternate days and exceptionally divide the dose into ¾ before breakfast and ¼ before dinner. Twenty to 30min should be used per patient in every scheduled visit to assure a good clinical and human practice. We analyzed the follow-up of 112 consecutive patients from our systemic disease unit and found that 71.4% of them had symptoms that were unexplained by lupus and we only referred 8.9% of them to other specialists, probably because of our general training as internal medicine doctors. We suggest that knowing the views of SLE specialists might be of interest since, well-designed studies that would allow to progress in the understanding of this disease could be performed based on their experience.

Seguimiento de los pacientes con lupus eritematoso sistémico: lo que no está en las guías

A series of measures in the management of patients with systemic lupus erythematosus (SLE) which usually are not found in the lupus guidelines are discussed. In the lupus patient who has been well-controlled in the long term, the dose of hydroxychloroquine should be progressively reduced, without decreasing more than approximately 600mg per week. We recommend taking this drug in the morning in patients with insomnia, at night in those with dyspepsia and to separate the intake of the drug from the shower (and the water should be as cool as possible) in those patients with aquagenic pruritus. We do not use prednisone on alternate days and exceptionally divide the dose into ¾ before breakfast and ¼ before dinner. Twenty to 30min should be used per patient in every scheduled visit to assure a good clinical and human practice. We analyzed the follow-up of 112 consecutive patients from our systemic disease unit and found that 71.4% of them had symptoms that were unexplained by lupus and we only referred 8.9% of them to other specialists, probably because of our general training as internal medicine doctors. We suggest that knowing the views of SLE specialists might be of interest since, well-designed studies that would allow to progress in the understanding of this disease could be performed based on their experience.