Medical Condition Of Patient Research Articles

A Mortality Study for ICU Patients using Bursty Medical Events.

The study of patients in Intensive Care Units (ICUs) is a crucial task in critical care research which has significant implications both in identifying clinical risk factors and defining institutional guidances. The mortality study of ICU patients is of particular interest because it provides useful indications to healthcare institutions for improving patients experience, internal policies, and procedures (e.g. allocation of resources). To this end, many research works have been focused on the length of stay (LOS) for ICU patients as a feature for studying the mortality. In this work, we propose a novel mortality study based on the notion of burstiness, where the temporal information of patients longitudinal data is taken into consideration. The burstiness of temporal data is a popular measure in network analysis and time-series anomaly detection, where high values of burstiness indicate presence of rapidly occurring events in short time periods (i.e. burst). Our intuition is that these bursts may relate to possible complications in the patient's medical condition and hence provide indications on the mortality. Compared to the LOS, the burstiness parameter captures the temporality of the medical events providing information about the overall dynamic of the patients condition. To the best of our knowledge, we are the first to apply the burstiness measure in the clinical research domain. Our preliminary results on a real dataset show that patients with high values of burstiness tend to have higher mortality rate compared to patients with more regular medical events. Overall, our study shows promising results and provides useful insights for developing predictive models on temporal data and advancing modern critical care medicine.

Problems of precision hepatic surgery in nowadays

With the era of precision hepatic surgery coming, the hepatic surgery has been promoted to brand-new level, which would be more accurate and meticulous. However, all those advances, such as super-thin computed tomography scan, three-dimensional imaging and the technology of three-dimensional printing, have not promoted the clinic results for patients overtly. The optimal curative effect could be attained, if there is a perfect combination of operators′ experience and those advanced imaging. For two issues, the time of vascular inflow occlusion and residual hepatic volume, operators could flexiblely use of clinic existing researches with surgical team and instruments according to the medical condition of patients. Precision hepatic surgery could be promoted to a higher level through constantly clinical research and innovations. Key words: Liver diseases; Precision hepatic surgery; Vascular inflow occlusion; Residual hepatic volume

The role of informal caregivers at the end of life: providing support through Advance Care Planning

In the palliative phase of a person's illness, the needs of the patient and informal caregivers are paramount. Caregivers often look to palliative care practitioners for support, guidance and emotional comfort. This article reviews the role of the informal caregiver at the end of life, summarising their concerns and needs. The paper also highlights caregiver difficulties in making the coping transition when the patient's medical condition becomes advanced and they require end-of-life care. The focus of the review is placed on discussions about Advanced Care Planning (ACP). ACP is a complex legal, ethical and practical issue that can enable caregivers to consider future strategies and enable them to provide high quality care at the end of life. The paper looks at some of the ethical and legal issues associated with this sensitive end-of-life issue.

Prescription Pattern Analysis of Nonsteroidal Anti-inflammatory Drugs in the Northeastern Iranian Population.

Objective:Inappropriate nonsteroidal anti-inflammatory drugs (NSAIDs) therapy is a common cause of actual and potential adverse effects, such as bleeding and gastrointestinal ulceration, which exacerbates the patient's medical condition and might even be life threatening. We aimed to evaluate and analyze the prescription pattern of NSAIDs in Northeastern Iranian population and also provide suggestions for a more rational prescription behavior for such drugs.Methods:In this cross-sectional retrospective study, pattern of 1-year prescriptions was inspected based on 9.3 million prescriptions from two insurance companies. Type of NSAIDs, all dispensed doses and the number of NSAIDs ordered per prescription, and the route of administration for each patient were extracted from the databases. The prescription pattern of NSAIDs was analyzed seasonally.Findings:Out of 9,303,585 prescriptions, 19.3% contained at least one NSAID. Diclofenac was the most commonly prescribed NSAID (49.21%). At least two NSAIDs were simultaneously prescribed in 7% of prescriptions. General practitioners prescribed NSAIDs more frequently (67%) than specialists. Orthopedic surgeons and internists more frequently prescribed NSAIDs in comparison with other physicians (6% and 4%, respectively). Gastroprotective agents (GPAs) were coprescribed to only 7.62% of prescriptions.Conclusion:The frequency of NSAIDs prescription was relatively high in Northeast of Iran. A significant number of prescriptions were associated with irrational prescribing in both coadministration of NSAIDs and GPAs and NSAIDs combination. A strategy must be developed and implemented for prescribing and rational use of medications, e.g., continuing medical education regarding the potential risks of NSAIDs, importance of their appropriate and rational use, and necessity of appropriate prescription writing regarding both content and indication.

Differences between Pediatricians and Internists in Advance Care Planning for Adolescents with Cancer

To evaluate differences between pediatricians and internists in the practice of and barriers to advance care planning (ACP) for adolescent patients with cancer. A self-reported questionnaire was administered to assess the practice of ACP, advance directives, and barriers to ACP for adolescent patients with cancer. All 3392 Japanese board-certified hematologists were surveyed, and 600 hematologists (227 pediatricians, 373 internists) who take care of adolescent patients with cancer with decision-making capacity were analyzed. If a patient's prognosis for survival was <3 months, pediatricians were significantly less likely to discuss ACP with their patients than internists, including discussions regarding the patient's medical condition (59% vs 70%), the patient's understanding of his/her medical condition (55% vs 66%), do not attempt resuscitation orders (17% vs 24%), and ventilator treatment if the patient's condition worsened (19% vs 25%). More than 75% of hematologists (both pediatricians and internists) discussed all ACP topics with patients' families. Similarly, with regard to advance directives, pediatricians were less likely than internists to discuss cardiopulmonary resuscitation (24% vs 47%) and the use of ventilators (31% vs 51%), vasopressors (24% vs 42%), and antibiotics (21% vs 31%) with their patients. Both pediatricians and internists discussed these issues more often with patients' families than with patients, especially cardiopulmonary resuscitation (98%) as well as the use of ventilators (98%) and vasopressors (91%). Pediatricians were less likely than internists to discuss ACP and advance directives with patients, and both pediatricians and internists tended to discuss ACP and advance directives more often with patients' families.

Solitary Eosinophilic Granuloma in the Lumbar Spine: Case Report

A case of a 3-year-old patient with osteolytic lesion in the lumbar region is presented. The clinic-radiological suspicion was infection, primary or metastatic tumor of spine. Subsequently, a CT guided biopsy proved an eosinophilic granuloma of bone. Following medical treatment after two month, there was improvement in patient medical status.

Description and Contribution of Brain Magnetic Resonance Imaging in Nontraumatic Critically Ill Children.

The authors aimed to collect all brain magnetic resonance imaging (MRI) performed in critically ill children in the authors' medical pediatric intensive care unit over a 2-year period (2012-2013) to (1) describe the findings and (2) assess its contribution on practical patient care. This is a single-center and retrospective study. All children without traumatic brain injury who underwent a brain MRI during pediatric intensive care unit stays were included. To assess the exam's contribution, the patient's medical condition at the time of the MRI exam was blindly and separately exposed to a pediatric neurologist and a pediatric intensivist. During the study period, 87 patients (7.5%) underwent a brain MRI. Median age was 4 months and 13 children (14.9%) died in pediatric intensive care unit. The most common final diagnosis was postanoxic encephalopathy. Brain MRI was abnormal in 68 patients (78.2%). No serious adverse event occurred during the transport. The neurologist and the intensivist considered brain MRI as indicated during pediatric intensive care unit stay in 65 (74.7%) and 68 patients (78.2%). They deemed that brain MRI had a diagnostic contribution in 76 (87.4%) and 60 (69.0%) patients, respectively. A therapeutic change consecutive to MRI findings occurred in 19 patients (21.8%) and MRI results were associated with a decision to withdraw life-sustaining treatment in 21 patients (24.1%). Brain MRI is one component of neuromonitoring, and this study suggests a substantial diagnostic contribution, although its therapeutic impact appears limited to specific diagnoses.

Microsurgery treatment of midline deep brain lesions (clinical analysis of 25 cases)

Objective: To explore experience and methods in the microsurgical treatment of midline deep brain lesions. Methods: The clinical data of patients with midline deep brain lesions were retrospectively analyzed. The clinical manifestation, imaging findings, lesion locations, surgical procedures, pathological diagnosis and follow-up results were summarized and analyzed. All the lesions were located deeply in the brain midline: corpus callosum (n=1), thalamus and basal ganglia (n=6), lateral ventricle (n=4), the third ventricle (n=2), pineal region (n=8), brainstem and fourth ventricle region (n=4). Results: Symptoms of 25 cases improved to varying degrees after operation and all the lesions got gross total removal without perioperative death. Followed by necessary adjuvant radiotherapy and/or chemotherapy, there were no recurrence during the follow-up period. Conclusions: Suitable surgical approaches should be individually chosen according to lesion location, the surrounding neural and vascular anatomy, blood supply, the patient's medical condition and the operator's experience. Localization of minor lesions can be assisted by neuronavigation system. In addition to try to determine the border of the lesion during operation, we emphasize the protection of the surrounding vital neural structures and deep veins. Finally, adjuvant radiotherapy and/or chemotherapy based on histology should be adopted to prevent recurrence.

The Lung Point Sign, not Pathognomonic of a Pneumothorax

Since the development of portable ultrasonography equipment, this technology has provided clinicians the ability to evaluate a variety of lung pathology at the bedside, but we are still learning how to accurately interpret the acquired images. Adequate interpretation and recognition of certain signs is crucial to diagnosing pathological processes. In addition, such signs must be adequately correlated with the patient's medical condition. For instance, the "lung point sign" has been traditionally considered to be pathognomonic for the presence of a pneumothorax, yet such finding may be present in patients with bullous lung disease without a pneumothorax.We present a case of an 83-year-old man with underlying chronic obstructive pulmonary disease. Bedside ultrasonography identified a "lung point sign" initially suggesting a possible pneumothorax. Further evaluation demonstrated absence of pneumothorax, with the patient having a large bulla.To our knowledge, this is the first case reported demonstrating that the "lung point sign" is not always indicative of a pneumothorax. We discuss the importance of both clinical correlation and understanding of the underlying pathophysiology when reviewing ultrasound images to accurately interpret ultrasound findings.

Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database.

The perineal wound following abdominoperineal excision (APR) is associated with a high complication rate. We aimed to evaluate the risk factors for wound complications and examine the effect of flap reconstruction on wound healing. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was searched for patients who underwent APR for rectal adenocarcinoma. They were divided into two groups: primary closure of the perineal wound and flap reconstruction. A logistic regression analysis was performed to identify the risk factors for deep surgical site infection (SSI) and wound dehiscence. A total of 8449 (94%) patients from the database underwent primary closure and 550 (6%) underwent flap reconstruction. Patients who underwent flap reconstruction had a longer operation time, a higher incidence of deep SSI, wound dehiscence, more blood transfusion requirement and a higher rate of return to the operating room (all P<0.001). Risk factors for deep SSI were African American race (OR 1.5, P=0.02), American Society of Anesthesiologists (ASA) classification ≥4 (OR 3.2, P<0.001), body mass index (BMI) ≥35kg/m(2) (OR 1.7, P=0.006), weight loss (OR 2, P<0.001) and closure with a flap (OR 1.9, P<0.001). Risk factors for wound dehiscence included ASA classification ≥4 (OR 2.2, P=0.003), history of smoking (OR 2.2, P<0.001), history of chronic obstructive pulmonary disease (OR 1.7, P=0.03), BMI ≥35kg/m(2) (OR 1.9, P=0.001) and closure with a flap (OR 2.9, P<0.001). Perineal wound complications are related to a patient's race, ASA classification, smoking, obesity and weight loss. Compared with primary closure, closure with a flap was associated with higher odds of wound infection and dehiscence and was not protective of wound complications in the presence of other risk factors. Therefore optimizing the patient's medical condition will lead to a better outcome irrespective of the technique used for perineal wound closure.

The cardiac consult for patients undergoing non-cardiac surgery

### Learning objectives The goal of the preoperative cardiac consultation is to assess the patient’s perioperative risk, to determine the need for additional testing or changes in management and to...

A cross-sectional survey of the Maltese general public on medication wastage.

Medication wastage is a global issue, with key public health implications in terms of safety, the environment and the economy. A recently conducted systematic review of the published literature identified a lack of focus on the views of healthcare professionals and the general public. To explore awareness, attitudes and behaviours relating to medication wastage amongst the general public in Malta. Malta. Survey methodology employing a pre-piloted questionnaire was developed from theoretical frameworks of behaviour. Questionnaire items comprised open, closed and 5-point Likert scales. Medication adherence as a possible factor associated with wastage was measured using the 8-item Morisky Medication Adherence Scale. Random sample of 1920 was obtained from the Maltese electoral register 2013. Ethical approval was obtained. Awareness, attitudes and behaviours relating to medication wastage amongst the general public in Malta. Response rate was 20.4 %. The majority (70.6 %) agreed that they were fully aware of the issue of wastage and 71.9 % disagreed that they had no interest in wastage. The following were significantly related to increased awareness of wastage: older age (p = 0.003), pensioners (p = 0.011), on regular medication (p = 0.021) and obtaining free medication (p = 0.026). Lack of interest in wastage was significantly related to obtaining free medication by government (p = 0.022), with those purchasing medication being significantly more interested (p = 0.028). While 75.1 % of respondents on regular medication self-reported not being fully adherent, there were no associations with awareness (p = 0.100) and interest in wastage (p = 0.385). Unemployed were more likely to report contribution towards wastage (p = 0.010) and the presence of a healthcare professional as family member was significantly related to confidence in ability to reduce wastage (p = 0.009). 46.2 % claimed to have unused medication at home and improvement in patient's medical condition was the main reason for this. More effort is warranted to raise awareness of the public as an initial step in promoting behavioural change in relation to medication wastage.

Students' perception of multiple dental visits for root canal treatment: Questionnaire-based study

Introduction: Root canal treatment (RCT) is a meticulous procedure that requires focus and precision while working in a confined space such as the root canal system of the tooth. Hence, it is a challenging practice for dental students a questionnaire-based study was conducted to evaluate senior dental students' perception toward single- and multiple-visit RCT while considering tooth type and patient cooperation, and to identify the most common reasons for multiple-visit RCT. Materials and Methods: This cross-sectional study included 267 senior year dental students from three universities and one private college in Saudi Arabia. A self-administered questionnaire was distributed between May and October 2014. The questionnaire was divided into four main sections, which evaluated student perception regarding single- and multiple-visit treatment, patient cooperation, and the nontherapeutic reasons for multiple-visits treatment. The collected data were analyzed using SAS 9.3. Results: Two hundred and seventeen questionnaires were returned (response rate, 81%). Dental students perceive multiple-visit RCT for anterior and premolar teeth as a significantly more stressful event than multiple-visit RCT for molars (P < 0.0001; Bowker's test). Tooth type and patient medical status were the highest ranked reasons for multiple-visit RCT. The majority of the responders (90%) considered single-visit RCT for single-rooted teeth a positive practice. Conclusions: Multiple-visit RCT is a stressful event for dental students, especially if the treated tooth was a single-rooted tooth. Dental students are aware of the negative effect of multiple-visit treatment on patient compliance. Clinical training should consider single-visit treatment for single rooted teeth.

Is Platelet-Rich Plasma a Future Therapy in Pain Management?

Platelet-rich plasma (PRP) has the potential to regenerate tissues and decrease pain through the effects of bioactive molecules and growth factors present in alpha granules. Several PRP preparation systems are available with varying end products, doses of growth factors, and bioactive molecules. This article presents the biology of PRP, the preparation of PRP, and the effects PRP-related growth factors have on tissue healing and repair. Based on available evidence-based literature, the success of PRP therapy depends on the method of preparation and composition of PRP, the patient's medical condition, anatomic location of the injection, and the type of tissue injected.

Predictive factors for sorafenib-induced hand-foot skin reaction using ordered logistic regression analysis.

Predictive factors for sorafenib-induced hand-foot skin reaction (HFSR) using ordered logistic regression analysis were studied. This retrospective analysis evaluated patients admitted to a university hospital in Japan from May 2008 through October 2013. Patients age 20 years or older with relapsed or metastatic renal cell carcinoma, unresectable hepatocellular carcinoma, or gastrointestinal stromal tumor resistant to imatinib and sunitinib were included. Data were manually collected from patients' clinical records and included sex, age, Eastern Cooperative Oncology Group (ECOG) performance status, initial daily dose of sorafenib, duration of sorafenib use, concomitant medications, number of metastases, sites of metastases, physical examination findings, and type of cancer. Laboratory test values related to the patient's medical condition that seemed to influence HFSR or the absorption and pharmacologic effects of sorafenib were also collected. HFSR severity was also assessed. Univariate ordered logistic analysis was performed for HFSR severity outcomes and each candidate independent variable. A multivariate ordered logistic regression model was then constructed using a stepwise forward selection procedure. Data were screened for multicollinearity. Data from 113 patients were evaluated. This analysis identified duration of sorafenib use (odds ratio [OR], 0.0531), use of a proton pump inhibitor (PPI) (OR, 0.351), ECOG performance status (OR, 0.555), C-reactive protein level (OR, 17.74), and male sex (OR, 0.403) as significant factors for the occurrence of HFSR. Multivariate logistic regression analysis revealed that short duration of sorafenib use, avoidance of PPIs, good ECOG performance status, high C-reactive protein level, and female sex were predictive factors for the development of HFSR.

Prophylactic and Therapeutic Antibiotic Patterns of Lebanese Dentists for the Management of Dentoalveolar Abscesses.

General dentists issue approximately 10% of antibiotic prescriptions across the global medical community consummation. The use of antibiotics for the management of dentoalveolar infections should be considered only in the presence of an increased risk of a systemic involvement or to prevent metastatic infections. This study aimed to investigate the prophylactic and therapeutic antibiotic prescription patterns of Lebanese dentists for the management of dentoalveolar abscesses. The aim was to evaluate the influence of the patients' medical condition and clinical signs data on the patterns of antibiotics prescription. Only patients with a dentoalveolar abscess were included in the study. Age, medical history, reason for consultation, clinical signs and symptoms, diagnosis, type of local treatment, and type of antibiotherapy were collected for each patient attending dental clinics in Beirut. The data were analyzed with chi-square test and multivariate regression. Out of the 563 initial patients, 127 were selected for the study and received a local treatment. The patient's medical condition and age did not affect the decision to prescribe antibiotics 36.2% patients with pain and 11.8% patients with swelling were prescribed antibiotics. Pain and swelling contributed to a higher level of antibiotic prescription compared to other signs and symptoms. Antibiotics were prescribed inappropriately to 51.76 and 38.10% among patients with an acute or chronic dentoalveolar abscess respectively. The main prescribed antibiotic was amoxicillin. This study showed that dentists often did not follow the current prophylactic and therapeutic antibiotic prescription guidelines. Antibiotics prescriptions in dentistry will be more pertinent, leading to a decrease in inadequacy of prescriptions, microbial resistance, and the development of multiresistant germs against antibiotics.

Approaches to treatment 2: Comparison of American Association of Clinical Endocrinologists (AACE) and American Diabetes Association (ADA) type 2 diabetes treatment guidelines

摘要 总的来说,2015年美国糖尿病协会(American Diabetes Association,ADA)1与美国临床内分泌学家协会(American Association of Clinical Endocrinologists,AACE)2推荐的2型糖尿病治疗指南都对当前控制糖尿病高血糖的方法与概念进行了深刻的分析。 ADA的方法是以选择血糖控制目标为起点,在控制血糖目标之前强调要控制HbA1c,建议通常的HbA1c目标应该设定为7%,虽然也指出了对于一名特定的患者来说更高或者更低水平的HbA1c目标也可能是合适的,这主要依赖于患者的医疗条件(疾病病程、预期寿命、合并疾病,特别是强调了血管并发症),并且还依赖于患者的态度、预期的努力程度以及可用的资源,这些因素都是可改变的,除此之外还有药物不良反应的风险,特别是低血糖。二甲双胍是推荐的首选初始用药,间隔3个月后可以增加到2种药物的联合使用,接着是3种药物的联合使用。另外还对6类治疗药物进行了陈述,其中胰岛素被认为具有“最高”效能;胰高血糖素样肽-1(GLP-1)受体激动剂(RA)、噻唑烷二酮类(TZD)以及磺脲类(SU)具有“高”效能;而二肽基肽酶(DPP)-4抑制剂与钠-葡萄糖共转运体(SGLT)-2抑制剂具有“中等”效能1。提到了将后面这两类药物引入推荐指南是“治疗方法的主要变化”1,但是没有推荐联合使用GLP-1 RAs进行治疗,这主要是因为缺乏临床试验证据。特别是明确提到了膀胱癌与吡格列酮并不相关,以及心脏衰竭在理论上与使用DPP-4抑制剂无关1;但假设根据一项新的来源于临床试验的证据这个结论将被修改3。在特定的治疗方案中,为了使治疗费用最小化需要将DPP-4抑制剂、SGLT2抑制剂、GLP-1 RAs以及胰岛素类似物排除在外;为了避免低血糖需要将SU与胰岛素排除在外;而为了避免体重增加还需将TZDs排除在外1。 如果HbA1c> 9%,推荐启用一种基础胰岛素进行治疗,剂量为10个单位或者0.1-0.2 U/kg体重,根据自我监测的空腹血糖每周调整剂量1到2次1。根据ADA临床实践标准定义的空腹血糖推荐目标为130 mg/dL(7.2 mmol/L),餐后峰值(假定为餐后1小时)血糖目标为180 mg/dL(10.0 mmol/L])4。对于使用基础胰岛素治疗后空腹血糖达标但是总体血糖控制却没有达标的患者来说,推荐的治疗方法有3种:(i)加用一种GLP-1 RA;(ii)在进食最多的餐前加用一针速效胰岛素;或者(iii)改成一种每日注射两次的预混胰岛素,而每餐前注射一次速效胰岛素是最终的选择1。 AACE推荐的(治疗策略)2纳入了所有已被批准的降糖药。4组药物的区别如下:(i)主要降低空腹血糖的药物(例如二甲双胍、TZDs与基础胰岛素);(ii)主要降低餐后血糖的药物(例如α-葡萄糖苷酶抑制剂[AGI]、胰淀素类似物普兰林肽、DPP-4抑制剂、格列奈类以及短效和/或速效胰岛素);(iii)具有两种作用的药物(例如GLP-1 RA、SU、SGLT2抑制剂以及混合性胰岛素制剂;(iv)适度有效的药物如胆汁酸螯合剂考来维仑以及一种多巴胺D2受体激动剂溴隐亭的快速吸收剂型(BCR)。AACE的治疗策略聚焦于安全性以及降糖获益:SU、格列奈类与胰岛素的低血糖问题;胰岛素、SU与TZDs的体重增加效应;以及GLP-1 RA与SGLT2抑制剂的体重减少效应2。中度肾功能受损导致二甲双胍的禁忌使用,而重度肾功能受损可导致艾塞那肽的禁忌使用。其他安全性问题包括使用SGLT2抑制剂治疗后的泌尿生殖道感染与血容量下降,以及使用GLP1 RAs治疗后的恶心、呕吐与腹泻。使用二甲双胍、AGI、考来维仑与BCR治疗后也可能出现胃肠道不良反应。心血管问题,特别是心脏衰竭,是引证过的TZDs不良效应;SU有可能会导致心血管不良效应(并且提到了SGLT2抑制剂可导致低密度脂蛋白胆固醇水平升高,虽然它的真实临床影响还尚未明确);而TZDs与SGLT2抑制剂还有潜在的导致骨量丢失的副作用2。 AACE在推荐治疗策略时有一个重要原则,就是要制定个体化的治疗计划,主要是根据基线HbA1c来确定。与ADA以及欧洲糖尿病研究协会(European Association for the Study of Diabetes,EASD)不同的是,AACE将药物选择按照以下方案进行了分级。如果HbA1c水平 7.5%并且 9.0%,推荐进行二联治疗或者三联治疗,除非患者出现了高血糖症状,对于这些病例来说需要使用胰岛素联用或不联用其他降糖药进行治疗2。 在AACE治疗方法中推荐的胰岛素使用策略是:HbA1c 8%的启始基础胰岛素剂量分别为0.1-0.2与0.2-0.3 U/kg。推荐每3日根据空腹血糖水平进行基础胰岛素剂量的滴定:>180 mg/dL(10.0 mmol/L)增加20%,140-180 mg/dL(7.8-10.0 mmol/L)增加10%,110-139 mg/dL(6.1-7.8 mmol/L)增加1个单位,而低血糖时如果血糖< 70 mg/dL(3.9 mmol/L)或< 40 mg/dL(2.2 mmol/L)则每日剂量分别要减少20%或40%。再次提到了SUs2,建议如果加用胰岛素治疗就要停用SUs或者减量,并且还认为使用基础胰岛素类似物治疗优于中效胰岛素(NPH)。如果加用基础胰岛素治疗后仍然不能达到血糖控制目标,有2种推荐的治疗方法:(i)加用非胰岛素类的治疗药物,建议加用GLP-1 RA或SGLT2抑制剂或DPP-4抑制剂;或者(ii)加用餐时胰岛素,开始时的每日胰岛素总剂量为0.3-0.5 U/kg/天,使用人胰岛素与预混胰岛素治疗是不太理想的治疗方法。如果餐后2小时的血糖水平超过180 mg/dL(10.0 mmol/L)就要对加用的治疗药物剂量进行滴定。 这些推荐的治疗方法都很复杂,并且ADA与AACE的方法具有许多相似性与差异性(表1)。两者都推荐了3个不同的HbA1c目标,通常来说AACE的方法都更为严格;两者都推荐改变生活方式与治疗药物一样重要;两者都强调了启动药物治疗后同时需要每3个月监测一次HbA1c目标,而这也是强化治疗所需。虽然两者都需要使用自我监测血糖(SMBG)水平来调整胰岛素剂量,但是AACE推荐的血糖治疗目标更低,并且AACE还推荐使用SMBG来判断一名特定患者的治疗方案是否最佳,包括空腹或者餐后血糖都要达标。虽然AACE与ADA/EASD都明确表明治疗必须以患者为中心并且要遵循个体化原则,但是ADA/EASD推荐的治疗方案一直都是使用二甲双胍作为初始治疗药物,然而AACE却是根据基线HbA1c水平进行分层治疗,允许一开始就是二联治疗或者三联治疗,更加强调要将那些不适合一开始就使用二甲双胍治疗的亚组患者识别出来(例如晚期肾病患者;在它的2015年更新部分中5,ADA/EASD提到了如果HbA1c超过9%,需要考虑一开始就使用二联治疗)。AACE推荐的治疗药物包括了所有经美国食品与药品管理局(FDA)批准的降糖药物并且将药物选择进行了排名,然而ADA/EASD指南仅仅罗列了主要的6类药物而没有推荐药物的排名顺序。AACE推荐指南明确聚焦于降低空腹与餐后血糖的差异,列出了更多种类的药物,并且对更多不同的潜在药物不良效应作出了评论;AACE与ADA的优化胰岛素使用方法在某种程度上有些差异。 最后,ADA与AACE的治疗方法代表的都是专家共识,因此具有其局限性,因为对于特定的患者来说其特征具有无数种可能性,缺乏来自随机对照试验的证据证实什么才是最佳的治疗方案。对于一名特定的患者来说,我们还缺乏患者水平的meta分析来帮助我们预测何种药物或者是哪一类药物最为安全或是最为有效,特别是在联合用药时。因此我们在治疗高血糖时应该谨慎用药,小心地根据HbA1c与SMBG来明确高血糖情况,逐步调整治疗药物的种类与剂量,并且还要聚焦于潜在的药物不良效应。有些治疗方法可能还具有额外获益(体重、血压以及血脂),因此对于一名特定的患者来说这些药物可能就会显得更加合适或者更加不合适。也许心血管结果数据将可以最终帮助我们提高药物分层选择的特异性6。ADA与AACE推荐的治疗方法都为我们提供了重要的见解。在未来的岁月里随着新型药物以及新研究结果的问世,我们期待会有进一步的变化。

Investigation of Unethical and Unprofessional Behavior in Korean Residency Training

Phenomenon: Medical ethics and professionalism are fundamental competencies for all physicians, and resident physicians have to develop these competencies during their training. Although Korea has a reputation for having the highest quality medical practice in East Asia, improvements in the technological aspects of care have outpaced the developments in institutional systems and education needed to fulfill social responsibility. Enhancing professionalism education during postgraduate training requires thorough exposition of this situation. Approach: Twenty residents from 17 clinical departments at 1 Korean tertiary university-affiliated hospital were recruited, and in-depth interviews were conducted in person by an interviewer who was a fellow resident with participants. Interviewees recalled and described personal experiences or observations of misbehaviors that had occurred during their residency training. Researchers recorded and transcribed all interviews, and 4 researchers conducted a thematic analysis. Findings: Authors extracted 48 descriptors representing 8 categories of unethical and unprofessional behaviors from the transcripts: (a) substandard practice, (b) violation of work ethics, (c) misconduct related to conflict of interest, (d) dishonesty with patients, (e) violation of patient confidentiality, (f) lack of respect for patients, (g) lack of respect for colleagues, and (h) misconduct in research. Each of the interviewees mentioned between 3 and 18 descriptors. “Not fulfilling basic duties for patient care” was the most frequently mentioned misconduct, followed by “fabricating patient medical status or test results to meet preoperative criteria for anesthesia” and “verbal or physical abuse of junior doctors.” Insights: Residents reported a diverse variety of unethical and unprofessional behaviors throughout their training and described the ethical distress they suffered in the real clinical situations. The results of this study support the notion that reinforcing ethics and professionalism education during postgraduate medical training in a practical and authentic way will help trainees manage the ethical conflicts or dilemmas they will inevitably encounter.

A cloud-based system for automatic glaucoma screening.

In recent years, there has been increasing interest in the use of automatic computer-based systems for the detection of eye diseases including glaucoma. However, these systems are usually standalone software with basic functions only, limiting their usage in a large scale. In this paper, we introduce an online cloud-based system for automatic glaucoma screening through the use of medical image-based pattern classification technologies. It is designed in a hybrid cloud pattern to offer both accessibility and enhanced security. Raw data including patient's medical condition and fundus image, and resultant medical reports are collected and distributed through the public cloud tier. In the private cloud tier, automatic analysis and assessment of colour retinal fundus images are performed. The ubiquitous anywhere access nature of the system through the cloud platform facilitates a more efficient and cost-effective means of glaucoma screening, allowing the disease to be detected earlier and enabling early intervention for more efficient intervention and disease management.

Microbiological quality and safe handling of enteral diets in a hospital in Minas Gerais, Brazil.

Contamination of enteral diets represents a high risk of compromising the patient's medical condition. To assess the microbiological quality and aseptic conditions in the preparation and administration of handmade and industrialized enteral diets offered in a hospital in the Valley of Jequitinhonha, MG, Brazil, we performed a microbiological analysis of 50 samples of diets and 27 samples of surfaces, utensils, and water used in the preparation of the diets. In addition, we assessed the good handling practices of enteral diets according to the requirements specified by the Brazilian legislation. Both kinds of enteral diets showed contamination by coliforms and Pseudomonas spp. No sample was positive for Staphylococcus aureus and Salmonella spp. On the other hand, Listeria spp. was detected in only one sample of handmade diets. Contamination was significantly higher in the handmade preparations (p < 0.05). Nonconformities were detected with respect to good handling practices, which may compromise the diet safety. The results indicate that the sanitary quality of the enteral diets is unsatisfactory, especially handmade diets. Contamination by Pseudomonas spp. is significant because it is often involved in infection episodes. With regard to aseptic practices, it was observed the need of implementing new procedures for handling enteral diets.