Medical Paradigm Research Articles

ON TESTING CONDITIONAL QUALITATIVE TREATMENT EFFECTS.

Precision medicine is an emerging medical paradigm that focuses on finding the most effective treatment strategy tailored for individual patients. In the literature, most of the existing works focused on estimating the optimal treatment regime. However, there has been less attention devoted to hypothesis testing regarding the optimal treatment regime. In this paper, we first introduce the notion of conditional qualitative treatment effects (CQTE) of a set of variables given another set of variables and provide a class of equivalent representations for the null hypothesis of no CQTE. The proposed definition of CQTE does not assume any parametric form for the optimal treatment rule and plays an important role for assessing the incremental value of a set of new variables in optimal treatment decision making conditional on an existing set of prescriptive variables. We then propose novel testing procedures for no CQTE based on kernel estimation of the conditional contrast functions. We show that our test statistics have asymptotically correct size and non-negligible power against some nonstandard local alternatives. The empirical performance of the proposed tests are evaluated by simulations and an application to an AIDS data set.

Personal recovery of young adults with severe anorexia nervosa during adolescence: a case series.

Despite the emergence of a growing qualitative literature about the personal recovery process in mental disorders, this topic remains little understood in anorexia nervosa (AN), especially severe AN during adolescence. This cases series is a first step that aims to understand recovery after severe AN among adolescents in France, from a first-person perspective. This cases series applied the interpretative phenomenological analysis (IPA) method to data collected in semi-structured face-to-face interviews about the recovery process of five young women who had been hospitalized with severe AN 10years earlier during adolescence. A model of recovery in four stages (corseted, vulnerable, plastic, and playful) crossing seven dimensions (struggle and path of initiation; work on oneself; self-determination and help; body; family; connectedness; and timeline) emerged from the analysis. New features of the AN personal recovery process were characterized: bodily well-being and pleasure of body; stigmatization; the role of the group; relation to time; and importance of narratives. We suggest a new shape to model the AN recovery process, one that suggests several tipping points. Recruitment must now be widened to different AN contexts. The personal recovery paradigm may provide a new approach to care, complementary to medical paradigm. No. NCT03712384. Our study was purely observational, without assignment of medical intervention. As a consequence, this clinical trial was registered retrospectively. LevelV, descriptive study.

The problem of predisposition to diseases: classic approaches and modern technologies

The article is devoted to urgent pediatric problem of comparing traditional and innovative approaches to the study of predisposition to diseases. It is noted that in the era of the formation of personalized pediatrics, along with the introduction of the latest diagnostic and therapeutic technologies, it is important to take into account the classic achievements, including those associated with the ideology of diathesis developed in the Russian pediatrics – concepts of hereditary predispositions. The article contains data on changing classification of diathesis. Within the framework of the 4P medical paradigm and, first of all, personalized medicine, the authors discuss molecular genetic and other high-tech potential methods of the disease risk assessment. Based on the concept of the space-time bioecological continuum of transitional health states, in particular, using the example of the atopic march, the authors consider the approaches to multi-level research, adaptation mechanisms and their breakdowns, and possible development of appropriate prognostic biomarkers. Using the example of biophenotypes of bronchial asthma and variants of manifestations of disenergetic states, the authors pay their attention to the importance of identifying the individual characteristics of pathological processes in children. The authors have concluded that the main task of personalized pediatrics is the development of methodology used for designing a personal health management program based on the principles of a new strategy for diagnosing, monitoring and controlling individual (including genomic) health, with the formation of a genetic passports for each child.

Thinking outside the box: a more efficient diagnostic approach in metastatic colorectal cancer

Thinking outside the box: a more efficient diagnostic approach in metastatic colorectal cancer

Le trouble dysphorique prémenstruel : trouble mental ou difficulté d’adaptation ?

Premenstrual dysphoric disorder (PMDD) is characterized by thymic (irritability, depressed mood, anxiety), physical (breast swelling, muscle pain), and behavioural (decreased interest, lethargy) cyclical symptoms that appear approximately one week before menstruation and begin to decrease after the luteal phase. Diagnosis considers the degree to which these symptoms have altered social or professional functioning during the year preceding consultation. DSM-III (Diagnostic and Statistical Manual of Mental Disorders) and DSM-IV working groups have successively decided not to attribute an official disorder status to PMDD, apprehending its possible negative impact (e.g., potential increase in prejudice against women through pathologization of natural female functioning and a risk of misuse). Since its inclusion in the DSM-5 (the latest edition of the American Psychiatric Association's DSM) in 2013, it has achieved official status of mental disorder. It is also expected to be included in the 11th revision of the International Classification of Diseases (ICD-11) according to the beta draft of the World Health Organisation. The current paper challenges the validity and relevance of PMDD inclusion in diagnostic textbooks through an argument from both sides on this issue. Criticism about PMDD largely comes from feminist groups, worried about the implications of including the diagnosis and its associated treatments, which are firmly rooted within the medical paradigm. The scientific community, however, is divided, and while some welcome the DSM-5 work group initiative, others are less enthusiastic. The DSM-5 work group identified sufficient empirical support to justify inclusion of PMDD in the Depressive disorders category. Their decision was based on an examination of the four requirements necessary for including any disorder in diagnostic textbooks, that is: (a) a clear distinction of PMDD from other disorders, (b) the presence of antecedent validators (environment and cultural consideration), (c) concomitant factors (biomarkers) and (d) predictive validator (PDMM's stability over time and drug treatment response). The current paper reviews these requirements. A first consideration leading to the inclusion of PMDD in DSM-5 is that it could clearly be distinguished from other mood disorders by the concordance between the premenstrual phase and the symptoms’ onset. Indeed, the symptoms begin at the luteal phase and tend to disappear when menstruation ends. However, a meta-analysis reveals some issues in how symptoms ratings have been used in PMDD's studies. Furthermore, it appears that PMDD present high comorbidity with other disorders. A majority (73%) of PMDD cases are combined with another mental disorder (anxiety disorder, mood disorder, etc.). Secondly, PMDD work group advocates the importance of heritability, compared to what they describe as a very modest impact of environmental issues on symptoms’ onset. That said, some studies highlight the association between PMDD and various life events and suggest that PMDD is a culture-bound phenomenon. Women who met PMDD criteria would have had experienced significantly more physical and sexual abuse, interpersonal problems, and mistreatment at work than women who did not meet the diagnostic criteria. In addition, women in Western Europe and North America appear to be at greater risk of having PMDD. Third, although no biological markers have systematically been associated with PMDD, notable differences on some gene of women with PMDD have recently been identified. However, biological markers that are characteristic of women with PMDD could be the result of traumatic antecedents rather than the unique cause of this psychological distress. Finally, the work group claims that some predictive factors, which predict the PMDD symptoms’ and response to drug therapy, tend to confirm its existence. The fact that symptoms reappear at each cycle would demonstrate the disorder's periodicity and stability. Furthermore, the effectiveness of medications (Selective Serotonin Reuptake Inhibitors- SSRI) in treating this disorder has been a significant factor in the decision of its inclusion in the DSM-5. Nevertheless, the central role played by treatment response in PDMM validation has been challenged by some researchers. Scientific literature review urges to be careful regarding PMDD's place in the diagnostic textbook. Indeed, additional studies concerning discrimination of PMDD from other disorders, life event's role, intercultural issues, and biological correlates are warranted to confirm its validity. To conclude, the arguments raised in the current paper are not intended to invalidate the existence of women's premenstrual symptoms or emotional distress that some women may experience, but rather to debate on the legitimacy of PMDD's inclusion as a “disorder” in psychiatric textbooks and diagnostic manuals.

A History of Anglican Exorcism: Deliverance and Demonology in Church Ritual

A History of Anglican Exorcism: Deliverance and Demonology in Church Ritual

Evidence for personalised medicine: mechanisms, correlation, and new kinds of black box.

Personalised medicine (PM) has been discussed as a medical paradigm shift that will improve health while reducing inefficiency and waste. At the same time, it raises new practical, regulatory, and ethical challenges. In this paper, we examine PM strategies epistemologically in order to develop capacities to address these challenges, focusing on a recently proposed strategy for developing patient-specific models from induced pluripotent stem cells (iPSCs) so as to make individualised treatment predictions. We compare this strategy to two main PM strategies-stratified medicine and computational models. Drawing on epistemological work in the philosophy of medicine, we explain why these two methods, while powerful, are neither truly personalised nor, epistemologically speaking, novel strategies. Both are forms of correlational black box. We then argue that the iPSC models would count as a new kind of black box. They would not rely entirely on mechanistic knowledge, and they would utilise correlational evidence in a different way from other strategies-a way that would enable personalised predictions. In arguing that the iPSC models would present a novel method of gaining evidence for clinical practice, we provide an epistemic analysis that can help to inform the practical, regulatory, and ethical challenges of developing an iPSC system.

Perspectives in Radiomics for Personalized Medicine and Theranostics.

Radiomics handles imaging biomarker from high-throughput feature extraction through complex pattern recognition that is difficult for human to process. Recent medical paradigms are rapidly changing to personalized medicine, including molecular targeted therapy, immunotherapy, and theranostics, and the importance of biomarkers for these is growing day by day. Even though biopsy continues to gold standard for tumor assessment in personalized medicine, imaging is expected to complement biopsy because it allows whole tumor evaluation, whole body evaluation, and non-invasive and repetitive evaluation. Radiomics is known as a useful method to get imaging biomarkers related to intratumor heterogeneity in molecular targeted therapy as well as one-size-fits-all therapy. It is also expected to be useful in new paradigms such as immunotherapy and somatostatin receptor (SSTR) or prostate-specific membrane antigen (PSMA)-targeted theranostics. Radiomics research should move to multimodality (CT, MR, PET, etc.), multicenter, and prospective studies from current single modality, single institution, and retrospective studies. Image-quality harmonization, intertumor heterogeneity, and integrative analysis of information from different scales are thought to be important keywords in future radiomics research. It is clear that radiomics will play an important role in personalized medicine.

The Sanford Lorraine Cross Award for medical innovation: Advancing a rigorous and repeatable method for recognizing translational research leaders who today are bringing emerging transformative innovations to patients

The Sanford Lorraine Cross Award identifies the most successful application of translational research that ultimately expedited the development of a treatment or cure of a disease.

Historicizing the Theorization of Race: A Nineteenth-Century Story

In this essay, I bring together Victorian studies and race studies in an effort to overturn what has come to be the most familiar form of racial analysis in contemporary culture: the notion that race is "constructed," that it operates by aligning visible marks of difference with a shifting—and hence contingent—series of meanings and associations. I argue that the very concept of an arbitrary, constructed racial sign might itself have a history. Rather than presuming that skin functions as the default sign of racial difference and then tracing a given set of meanings that might be appended to that sign, I open my analysis by noting that in the final quarter of the eighteenth century, skin suddenly came to be privileged as the primary sign of racial identity. Immanuel Kant has long been identified as the first prominent European thinker to single out skin color in this way, and, as a consequence, I examine his essay on the topic, "On the Use of Teleological Principles for Philosophy" (1788). Read in the context of his late essay on the relationship between philosophy and medicine in The Conflict of the Faculties, Kant's emphasis on skin color suddenly becomes legible in the light of shifting medical paradigms of the human body. Racial constructionism's rhetoric of otherness obscures the degree to which perceiving race involves, for better or for worse, experiencing individuals' likeness to one another rather than their difference. Kant's racial skin turns likeness from an idea that must be discovered over time to something legible instantly.

Isolation and Molecular Characterization of Progenitor Cells from Human Umbilical Cord.

Mesenchymal stem cells (MSCs) are multipotent precursor cells which have been isolated from different vascularized tissue sources. Due to their paracrine function of secreting trophic and immunomodulatory molecules, MSCs are successfully used in cell-based transplantations and provide an alternative medical paradigm for treating a variety of devastating disorders. Umbilical cord is a medical waste with a large, readily available donor pool. Since umbilical cord is a fetal tissue, MSCs derived from it are considered more primitive with proliferative and differentiation advantages over adult MSCs. We define here a simple, efficient, and reproducible protocol to isolate MSCs from WJ of human umbilical cord using a nonenzymatic procedure. Under the optimized culture conditions, the WJ-MSCs undergo robust proliferation, can be expanded up to 15-20 passages and express the characteristic MSC surface antigens. They can be differentiated into mesodermal lineages in vitro.

A Medical Paradigm Shift and Cooperation between Korea and China in the Medical Service Industry

A Medical Paradigm Shift and Cooperation between Korea and China in the Medical Service Industry

The Role of Chinese Medicine in Health Maintenance and Disease Prevention: Application of Constitution Theory.

Traditional Chinese medicine (TCM) has guided health maintenance and disease treatment for thousands of years and has been widely used in many countries around the world. TCM regards each individual as unique so all corresponding therapeutic and preventive approaches in TCM are personalized. Personalized medicine, also referred to as precision medicine, is an emerging medical paradigm that points toward a new direction for future medical development. TCM constitution studies the holistic body condition, which is affected by both inborn and acquired factors. Body constitution lays the foundation for disease diagnosis, prevention and treatment. Different constitution types predispose individuals to different disease susceptibilities. Examining an individual's unique body constitution can promote effective health management and benefit the application of personalized medicine significantly. This review will introduce and discuss the application of the TCM constitution for health maintenance and disease prevention. In last decade, a number of modern techniques have been employed in the constitution research to evaluate the health status of individuals. The TCM constitution reflects the current status and future trends of human health in four aspects, i.e., individual differences, life processes, psychological condition and adaptability to natural and social environments. This TCM constitution theory has already been applied in the Chinese public health management at different levels with promising outcome. The constitution theory and practice provide a new approach for health maintenance and disease prevention.

Herbal Products and Conventional Drugs – an Uneasy Alliance

This review examines the interaction between herbal remedies and conventional (orthodox) drugs. There has been a substantial increase in the consumption of herbal remedies in recent times for various reasons. They are often combined with one another, and are often used simultaneously with conventional drugs that are taken for a wide range of disorders, both acute and chronic. The probability of a real and substantial interaction between the therapeutic agents originating from different medical paradigms is likewise expanding. Whilst most of the herbdrug interactions are undoubtedly minor, benign, and harmless, there are reports of more serious interactions. Possible reasons for specific herb-drug interactions are examined, particularly from the pharmacokinetic and pharmacodynamic perspectives
 Bangladesh Journal of Medical Science Vol.18(1) 2019 p.24-29

Social reintegration and rehabilitation of obstetric fistula patients before and after repair in Sub-Saharan Africa: A systematic review

Aims: To review how social reintegration and rehabilitation processes are being executed among obstetric patients in Sub-Saharan Africa and highlight projects and programs involved.
 Methods: This is a systematic review involving a search of relevant literature from PubMed, Google scholar, PsychINFO, African Journals Online, Australian Journals Online, and open access journal of international organizations such as WHO, UNFPA, USAID, Engender Health, Fistula Foundation, and Fistula Care Plus published between 1978 to date. Of the 46 articles identified, 25 were suitable for achievement of this study’s purpose.
 Results: Sub-Saharan African countries have recognized the overall burden of obstetric fistula and have devised strategies for its’ holistic management. Most countries have National Obstetric Fistula Strategic Frameworks which emphasize multi-sectoral and multidisciplinary approaches other than medical paradigm. Extraordinary among others are: Nigeria, Uganda, Tanzania and Guinea while some countries such as Benin Republic, Chad, Malawi, Mali, and Zambia lack support the at policy level, and have inadequate community outreach programmes. Social reintegration and rehabilitation have been done through the identification of individual patient’s need/s. Upon discharge from hospital, they are counseled, given soap, clothes, transportation fund and are referred to community based projects for elementary education and skills development. Projects and programmes aiming to combat obstetric fistula and restore patients’ self-worth and dignity are: Lamaneh Suisse, and Delta Survie in Mali, Dimol in Niger, Medecins Sans Frontieres (MSF) in Burundi, FORWARD in Nigeria and Sierra Leone, Handicap International in Benin Republic, Women For Africa in Ghana and Liberia, TERREWODE and CoRSU both in Uganda, Hamlin Fistula Ethiopia in Ethiopia, and Safe Motherhood Initiative, Fistula Foundation, Fistula Care Plus, Engender Health, UNFPA, AMREF for Health, WHO and others which cut across the region.
 Conclusions: Most Sub-Saharan countries have registered progress in assuring effective social reintegration and rehabilitation of obstetric fistula patients although some are still grappling with the issue due to lack of political commitment and inadequate outreach programmes. There is scanty information regarding reintegration and rehabilitation before obstetric fistula repair and yet it would hasten physical and mental wellbeing of the patients as they await repair.

Social Reintegration and Rehabilitation of Obstetric Fistula Patients Before and After Repair in Sub-Saharan Africa: A Systematic Review

Aims: Social reintegration and rehabilitation of obstetric fistula patients before and after repair enhance their overall status, which may be unattainable even with a successful repair. Nonetheless, there is little traceable documentation about it even with supportive programs and projects, the thrust of this study.
 Methods: This is a systematic review involving a search of relevant literature from PubMed, Google scholar, PsychINFO, African Journals Online, Australian Journals Online, and open access journals of international organizations such as WHO, UNFPA, USAID, Engender Health, Fistula Foundation and Fistula Care Plus published between 1978 to date. Of the 46 articles identified, 25 were suitable for achievement of this study’s purpose.
 Results:Sub-Saharan African countries have recognized the overall burden of obstetric fistula and have devised strategies for its holistic management. Most countries have National Obstetric Fistula Strategic Frameworks which emphasize multi-sectoral and multidisciplinary approaches other than medical paradigms. Social reintegration and rehabilitation have been done through the identification of individual patient’s need/s. Projects and programs aiming to combat obstetric fistula and restore patients’ self-worth and dignity are: Lamaneh Suisse, and Delta Survie in Mali, Dimol in Niger, Medecins Sans Frontieres (MSF) in Burundi, FORWARD in Nigeria and Sierra Leone, Handicap International in Benin Republic, Women For Africa in Ghana and Liberia, TERREWODE and CoRSU both in Uganda, Hamlin Fistula Ethiopia in Ethiopia, and others which cut across the region.
 Conclusions: Effective social reintegration and rehabilitation strategies are still inadequate in Sub-Saharan Africa due to lack of political commitment and inadequate outreach programs.
 Keywords: obstetric fistula, recto-vaginal fistula, rehabilitation, social reintegration, vesico-vaginal fistula.

Are we on the cusp of a fourth research paradigm? Predicting the future for a new approach to methods-use in medical and health services research

BackgroundThe dominant medical and health research paradigm continues to be quantitative. While the authors sense a sea-change in opinion about mixed-method research, underpinned by two decades of highly-cited publications in medical journals, much of the medical literature still widely favours the Randomised Control Trial.Main bodyThis debate article examines whether it is the beginning of the end of the dominant quantitative paradigm and the interest this holds for researchers and clinicians at the forefront of care delivery. It examines the Third Research Paradigm, signifying the importance of mixed-methods, and discusses the power of the patient voice and person-focused research activity. The authors discern the coming of age of a Fourth Research Paradigm integrating mixed-methods with data collected ‘on the hoof’. Within this new paradigm, the article explores the power of available, real time, and emergent data – from smart phones, wearable devices, and social media, as well as more creative approaches to data collection. The Fourth Research Paradigm will require the support of multi-disciplinary teams, moving through the world alongside their research subjects. The impact of a Fourth Research Paradigm on the health researcher is assessed, as the researcher’s gaze moves away from considerations of methodological superiority to re-considerations of their role in the brave new world of research multiplicity.ConclusionThe Fourth Research Paradigm offers extensive opportunities to tell more complete research stories in real-time settings. It concentrates on contextual notions of everyday happenings within the ever-changing world of healthcare delivery. There will be challenges ahead, not least the management of large, complex datasets and adaptive study designs. But rigorous planning will enable unique insights into the relationships played out in the world of the patient and healthcare provider. Better care and new delivery models are likely to result, but how this will manifest is not yet clear.

Expectations of rural community-based medical education: a case study from Thailand.

Thailand has recognised and sought to remedy rural medical workforce shortages. The Collaborative Project to Increase Production of Rural Doctors (CPIRD) has improved rural workforce recruitment through publicly funding medical school places for students with rural backgrounds. However, challenges in rural retention continue. CPIRD is seeking to develop a Thai rural community-based medical education (RCBME) program in the southern region of Thailand to improve preparation for rural practice and rural medical retention rates. Prospective stakeholder consultations will allow the understanding of expectations and concerns of stakeholders required for successful RCBME implementation. This study aims to explore stakeholders' expectations of the Southern Thai RCBME initiative. A qualitative case study comprised a purposive sample of students, clinical educators, policymakers, rural health professionals and local community stakeholders, all likely to be involved in a new RCBME program in Songkhla Province, Thailand. Individual semi-structured interviews were audiotaped, transcribed in Thai and coded using Worley's symbiosis framework. Following this, text and quotes used in the initial analysis were translated into English, discussed and reanalysed for emergent themes across the framework. A total of 21 participants contributed RCBME stakeholder perspectives. They demonstrated expectations and concerns in each of the relationship axes of the symbiosis model including the clinical, institutional, social and personal axes. Three major themes emerged from the data that integrated stakeholder perspectives on the implication of RCBME in Thailand. These themes were a dramatic shift in Thai medical education paradigm, seeing rural practice as a future career, and collaboration to improve education and health in rural services. This study comprehensively describes Thai stakeholder expectations of RCBME and demonstrates that, although some principles of RCBME are universal, context does influence the expectations and capacity of stakeholders to contribute to RCBME. Prospective formal stakeholder engagement is recommended to ensure successful implementation of new educational innovations.

The Medical and Psychosocial Associations of Alopecia: Recognizing Hair Loss as More Than a Cosmetic Concern.

Alopecia encompasses a broad range of hair loss disorders, generally categorized into scarring and non-scarring forms. Depending on the specific pathogenesis of hair loss and geographic location, a number of psychiatric and medical comorbidities, including but not limited to thyroid disease, lupus erythematosus, diabetes mellitus, atopic dermatitis, sinusitis, coronary artery disease, anxiety, depression, and suicidality, have been identified in association with alopecia. In addition to the numerous associated comorbid conditions, patients with alopecia report decreased quality-of-life measures across symptomatic, functional, and global domains. While alopecia can affect patients of all ages, genders, and ethnicities, hair loss may more significantly impact women as hair represents an essential element of femininity, fertility, and female attractiveness in society. Individuals of lower socioeconomic status may also face health disparities in the context of alopecia as a majority of hair loss treatments are considered cosmetic in nature and accordingly are not covered by third-party insurance providers. Although traditionally thought of as a merely aesthetic concern, alopecia encompasses a significant burden of disease with well-defined comorbid associations and genuine psychosocial implications, and thus should be assessed and managed within a proper medical paradigm.

Application of mini-clinical evaluation exercise for assessing the integrated-based learning during physical diagnostic course.

Medical education paradigm has been questioned for the requirements of improving the quality and quantity of medical students. This study was to explore the efficiency of integrated-based learning (IBL) used mini-clinical evaluation exercise (mini-CEX) during physical diagnostics course. One hundred and eleven volunteered students were randomly divided into three groups: lecture-based learning (LBL), case-based learning (CBL), and IBL. Nephrotic syndrome was the teaching content. In the IBL group, students were provided the guideline and additional interpretation from the instructor about the basic knowledge related to disease as vertical integration curriculum. Their performance was evaluated by mini-CEX and theoretical examination, respectively. All subjects have completed the study. The difference of five factors (medical interview, physical examination, clinical judgment, organizational effectiveness, and competence) in mini-CEX between IBL, CBL, and LBL were statistically significant (p <0.05). Sample sizes of below, meets, and above the expectations of mini-CEX in different instructional groups were statistically significant (X2 =17.842, p =0.001). The final exam scores in IBL group and the CBL group were significantly higher than that of LBL group (F =41.553, p =0.000). And the relationship of final exam score only in the IBL group was positive existed with medical interview (R =0.466, p =0.004), physical examination (R =0.328, p =0.048), professional attitude (R =0.366, p =0.026), and communication skill (R =0.412, p =0.011). Therefore, our study revealed the effect of IBL on the medical students' skills. It highlights IBL could improve the physical examination, organizational effectiveness, and competence and the application of basic knowledge. © 2018 International Union of Biochemistry and Molecular Biology, 46(5):417-423, 2018.