Personal Medical File Research Articles

Urogenital Tuberculosis and Delayed Diagnosis: A Qualitative Study.

To identify the causes of delayed diagnosis of urogenital tuberculosis (UGT) through a qualitative study of patients with contracted bladder due to UGT. Eight patients diagnosed with contracted bladder due to UGT were evaluated. Data were obtained using face-to-face in-depth interviews and supplemented with medical records analysis and personal medical files. The identification of situations of diagnosis delay was coded by 2 urologists after data analyses. Codes were divided into 3 categories related to its causes: (1) health system; (2) disease factors; and (3) medical factors. The 8 interviews produced 220 minutes of audio and 1.3 GB of scanned documents. The most frequent categories were "Medical factors," followed by "Disease factors" and "Health system." The codes "No clinical-laboratory-radiological suspicion" and "No clinical suspicion" were the most frequent, both belonging to "Medical factors." Clinically, tuberculosis simulates other pathologies and lacks specific tests with adequate sensitivity. The low representation of "Health system" codes indicates that access to public and private health services does not influence delayed diagnosis. The lack of clinical and radiological suspicion and the lack of knowledge of UGT features are the main reasons for diagnosis delay. The causes of delayed diagnosis in our sample were related to "Medical factors," followed by "Disease factors." Better understanding UGT features is an important topic in continuous medical education.

Outcome of inflammatory breast cancer in Moroccan patients: clinical, molecular and pathological characteristics of 219 cases from the National Oncology Institute (INO)

BackgroundUsually misdiagnosed, Inflammatory Breast Cancer (IBC) is the most aggressive form of non-metastatic breast cancer. This orphan disease is more frequent in North Africa. Despite intensive treatment, the survival rate remains very low.MethodsWe have retrospectively studied all breast cancer cases diagnosed at the National Oncology Institute (INO), Rabat between 2005 and 2010. We have collected 219 cases of women with metastatic and non-metastatic IBC. Data have been obtained from patients’ personal medical files over a follow-up period of 5 years. We have described IBC’s clinicopathological features and analyzed its clinical outcome using SPSS software. HR (hazard Ratio) was calculated using Cox regression analysis.ResultsThe frequency of IBC cases is 4.05%. The majority of our patients (65.3%) were under 50 years old. The most prevalent molecular subtype was Luminal A (38.7%) followed by Luminal B HER2+ (27.9%) and Triple negative (21.6%).During the follow-up period, 72 patients (32.9%) had recurrence and 40 patients (18.3%) died. The 3-year OS (Overall Survival) and EFS (Event Free Survival) of non-metastatic patients were 70.4 and 46.5% respectively, while in the metastatic disease, the 3-year OS was only 41.9%. In non-metastatic women, we observed a higher rate of EFS associated to Selective estrogen receptor modulation treatment (p = 0.01), and a lower rate EFS in triple negative breast cancer patients (p = 0.02). In univariate analysis, we found that EFS rate is lower in patients presenting Triple Negative tumors when compared to other molecular subtypes (HR: 3.54; 95%CI: 1.13–11.05; p = 0.02). We also found that Selective estrogen receptor modulation treatment is associated with higher EFS rate (HR: 0.48; 95%CI: 0.07–0.59; p = 0.01).ConclusionsIBC in Morocco shows similar characteristics to those in North African countries; however, survival rates are still the highest when compared with neighboring countries. Collaborative studies with prospective aspects are warranted to establish the epidemiological profile and understand the high frequencies of IBC in North Africa. More studies on molecular markers are also needed to improve IBC patients’ management and eventually their survival rate.

PP.05.18] TREATMENT OF “BULGARIAN HYPERTENSIVE PATIENT” – GUIDELINES VERSUS REAL LIFE PRACTICE

Objective: To investigate how far real situation of evaluation and treatment of outpatients with arterial hypertension coincides with the requirements of the contemporary guideline of ESC/ESH. Design and method: Snapshot study, including 600 consecutive outpatients for 1 year (2015): 265 women (44%) and 335 men (56%). Age - from 18 to 70 years. All of them were referred for evaluation to cardiology practice, according to protocol of Bulgarian National Health Insurance Fund (NHIF) for treatment and follow up of patients with arterial hypertension by GP‘s. The main source of information about their status and therapy was the personal medical file. Results: I. Investigations (laboratory and instrumental techniques): No one patient had evaluation of microalbuminuria as marker of early cardiovascular damage; 8% of patients had carotid ultrasound; 15% of patients had serum uric acid; 18% of patients had fasting plasma glucose above 5,8 mmol/L without further tests to determine presence/absence of diabetes; only 38% of patients had blood pressure below 140/90 mm Hg; 80% of patients had lipid profile; 80% of patients had echocardiography II. Cardiovascular risk evaluation: 80% did not have cardiovascular risk evaluation. III. Lifestyle changes: 50 patients used step-counters and only 10 of them performed on the average over 6000 steps daily. IV. Pharmacological therapy: over 50% patients were treated with a combination of Beta-blocker and Diuretic as first choice without precise indications; approximately 50% of patients used fixed combinations – mainly ACEI/Diuretic and ARB/Diuretic, very often not as a first choice. Conclusions: 1. The control of blood pressure in hypertensive patients is insufficient in spite of recommendations of NHIF. 2. Cardiovascular risk evaluation has not become integral part of routine care in outpatient settings. 3. Evaluation of glucose tolerance as first step of diagnosis of Diabetes mellitus is often neglected. 4. The role of uric acid is neglected in the assessment of cardiovascular risk. 5. Beta-blockers combined with diuretics are still leading as first choice of medicines to treat arterial hypertension.6. General practitioners prefer to use expensive and sophisticated methods as echocardiography rather than cheap and also informative tests as microalbuminuria.

The patient perspective on the effects of medical record accessibility: a systematic review

Background: Health care is shifting from a paternalistic to a participatory model, with increasing patient involvement. Medical record accessibility to patients may contribute significantly to patient comanagement.Objectives: To systematically review the literature on the patient perspective of effects of personal medical record accessibility on the individual patient, patient–physician relationship and quality of medical care.Methods: Screening of PubMed, Web of Science, Cinahl, and Cochrane Library on the keywords ‘medical record’, ‘patient record’, ‘communication’, ‘patient participation’, ‘doctor–patient relationship’, ‘physician–patient relationship’ between 1 January 2002 and 31 January 2016; systematic review after assessment for methodological quality.Results: Out of 557 papers screened, only 12 studies qualified for the systematic review. Only a minority of patients spontaneously request access to their medical file, in contrast to frequent awareness of this patient right and the fact that patients in general have a positive view on open visit notes. The majority of those who have actually consulted their file are positive about this experience. Access to personal files improves adequacy and efficiency of communication between physician and patient, in turn facilitating decision-making and self-management. Increased documentation through patient involvement and feedback on the medical file reduces medical errors, in turn increasing satisfaction and quality of care. Information improvement through personal medical file accessibility increased reassurance and a sense of involvement and responsibility.Conclusion: From the patient perspective medical record accessibility contributes to co-management of personal health care.

Self-management skills in adolescents with chronic rheumatic disease: A cross-sectional survey

BackgroundFor adolescents with a diagnosis of lifelong chronic illness, mastery of self-management skills is a critical component of the transition to adult care. This study aims to examine self-reported medication adherence and self-care skills among adolescents with chronic rheumatic disease.MethodsCross-sectional survey of 52 adolescent patients in the Pediatric Rheumatology Clinic at UCSF. Outcome measures were self-reported medication adherence, medication regimen knowledge and independence in health care tasks. Predictors of self-management included age, disease perception, self-care agency, demographics and self-reported health status. Bivariate associations were assessed using the Student's t-test, Wilcoxon rank sum test and Fisher exact test as appropriate. Independence in self-management tasks were compared between subjects age 13-16 and 17-20 using the chi-squared test.ResultsSubjects were age 13-20 years (mean 15.9); 79% were female. Diagnoses included juvenile idiopathic arthritis (44%), lupus (35%), and other rheumatic conditions (21%). Mean disease duration was 5.3 years (SD 4.0). Fifty four percent reported perfect adherence to medications, 40% reported 1-2 missed doses per week, and 6% reported missing 3 or more doses. The most common reason for missing medications was forgetfulness. Among health care tasks, there was an age-related increase in ability to fill prescriptions, schedule appointments, arrange transportation, ask questions of doctors, manage insurance, and recognize symptoms of illness. Ability to take medications as directed, keep a calendar of appointments, and maintain a personal medical file did not improve with age.ConclusionsThis study suggests that adolescents with chronic rheumatic disease may need additional support to achieve independence in self-management.

Recurrent acute otitis media and gastroesophageal reflux disease in children. Is there an association?

Objective To investigate whether there is a relationship between gastroesophageal reflux disease (GERD) and recurrent acute otitis media (RAOM) in infants and children. Possible risk factors are also explored. Material and methods 221 consecutive children who had symptoms and signs associated with GERD and had undergone a prolonged ambulatory 24-h esophageal pH-monitoring. Thirty-four children were excluded from the study due to age, neurological deficits, congenital abnormalities, immunodeficiency syndromes or other chronic systemic disorders. The remaining 187 children (96 boys and 91 girls), aged between 40 days and 33 months (mean age of 18.3 months) were assigned into three groups according to their Reflux Index (RI%). Group A: 49 children (26.2%) without GERD (control group); Group B: 78 children (41.7%) with low to moderate RI; and Group C: 60 children (32.1%) with severe GERD. Parental interviews and personal medical files of the National Health System were used for data collection. However, episodes of acute otitis media were taken into account only if they were diagnosed by a physician. The follow-up period ranged from 6 to 8 years in order to cover the peaks of otitis media incidence in childhood. Results The results revealed that 6 children from Group A (12.24%), 11 from Group B (14.1%) and 19 from Group C (31.67%) presented episodes of RAOM. The difference was statistically significant ( p = 0.01). Furthermore, in children who received anti-reflux treatment, the incidence of RAOM substantially decreased and eventually became approximate to that of the control Group A (12.32%). Logistic regression revealed that the strongest risk factor for recurrent otitis media was severe GERD (odds ratio, 4), then attendance at day-care centres (odds ratio, 3), followed by allergies (odds ratio, 2.7). Conclusions Severe GERD could be implicated in the multifactorial etiology of RAOM in infants and children.

Information médicale : de l’hôpital à la ville. Que perçoit le médecin traitant ?

The communication and circulation of medical information between hospitals and GPs play a central role in the quality of care. Numerous statutes, regulations, and clinical practice guidelines stress the need for such communication. We assessed how it really works. We conducted face-to-face interviews based on a standardized questionnaire with 50 GPs in the districts of Paris and Seine-Saint-Denis, to explore different aspects of their communication with hospitals: the communication channels, and the amount, content, and quality of the information received. It appears that the overall quantity of communication is satisfactory but its quality and content vary according to the reasons for which the GP sent the patient to the hospital. GPs have a deep feeling that hospital staff physicians do not collaborate with them. The proposed personal medical file may help resolve logistic obstacles to the circulation of medical information but it will not bridge the cultural gap that exists between the two pillars of the system of care: the hospital and the GP.

La relation médecin/chirurgien-dentiste doit être améliorée pour une meilleure prise en charge des patients: Enquête au sein d’un réseau de santé

This study had two aims: to assess the nature of the relationship between general practitioners (GPs) and dental surgeons in relation to patient care and to evaluate qualitatively their interest in the changes that health networks and shared patient medical files could bring.Questionnaires were completed by 12 GPs belonging to ASDES, a private practitioner-hospital health network that seeks to promote a partnership between physicians and dental surgeons, and by 13 private dental surgeons in the network catchment area.The GPs and dentists had quite different perceptions of their relationship. Most dentists rated their relationship with GPs as "good" to "excellent" and did not wish to modify it, while GPs rated their relationship with dentists as nonexistent and expressed a desire to change the situation. Some GPs and some dentists supported data exchange by sharing personal medical files through the network.Many obstacles hinder communication between GPs and dentists. There is insufficient coordination between professionals. Health professionals must be made aware of how changes in the health care system (health networks, personal medical files, etc) can help to provide patients with optimal care. Technical innovations in medicine will not be beneficial to patients unless medical education and training begins to include interdisciplinary and holistic approaches to health care and preventive care.

Building application-related patient identifiers: what solution for a European country?

We propose a method utilizing a derived social security number with the same reliability as the social security number. We show the anonymity techniques classically based on unidirectional hash functions (such as the secure hash algorithm (SHA-2) function that can guarantee the security, quality, and reliability of information if these techniques are applied to the Social Security Number). Hashing produces a strictly anonymous code that is always the same for a given individual, and thus enables patient data to be linked. Different solutions are developed and proposed in this article. Hashing the social security number will make it possible to link the information in the personal medical file to other national health information sources with the aim of completing or validating the personal medical record or conducting epidemiological and clinical research. This data linkage would meet the anonymous data requirements of the European directive on data protection.

Les médecins généralistes face aux réformes

The general practitioners in front of reforms: the reactions of the sample group of liberal physicians of the region PACA This article intends to analyse the opinion of general practioners (GPs) about the two laws of July 2004, relating to the health insurance reform and to public health planning. We used a panel data sample of 528 GPs practising in Provence Alpes Côte d'Azur in order to analyse the determinants of physicians' adherence to the reform, using multinomial logistic regression models. The results show that GPs do not seem to be fully convinced by this reform (45% agree with it, whereas 48% don't): this mistrustful opinion is more marked for young physicians and appears little correlated with their practices. 75% of the GPs are favourable to the Personal Medical File (Dossier Médical Personnel in french) and 76% estimate that they should draw a better attention to the public health dimension of their practice. Two barriers concerning GPs' adherence to the << preferred doctor >> reform (réforme du << médecin traitant >>) seem relevant: the burden of administrative tasks and the disadvantage of young physicians who have not already fixed their own clientele.

Sur les traces de la parole perdue (les enjeux d’un dossier psychiatrique)

The psychiatrie institution is scrutinized through the individual personal medical file which is seen as its mean of expression. The treating personnel, through their institutional position, takes part in this expression (where the word of the patient has no place, where the desire is excluded, the suffering concealed and objectified). Our aim is not to study mental health. It's etiology or its nature but more to enter into the space where it is written and fixated. The reading of a psychotic child's medical file shows how the alienating processes which are closely related to the very form of the psychiatric file are structured.

Privacy and computerized health information in community health centers and district health agencies.

Computers play an important role in health care delivery. Electronic data systems have been extensively applied in health settings to facilitate treatment procedures, to serve as program management aids, and to serve cost-control and billing functions. Underlying this expanding application of computer technology is the issue of privacy as it applies to the collection, storage and retrieval of personal health information. To appreciate the complexity of this issue, one must attend to the use of health data for patient-specific treatment tasks as differentiated from their use in aggregated management, statistical and research tasks. The key factor in this regard is the identification of information that can be linked to a specific person. This article focuses on the basic privacy issues that emerge from the use of computers and how they relate to policy in regard to the use of health information. Differential approaches in the collection and storage of health details must be resolved, including which information should be considered as confidential, who should have access to data banks and what intersystem linkages should be permitted. Salient concerns in regard to patient rights emerge, such as the need for informed consent and the access of individuals to their personal medical files. Essentially, the overriding question is who controls what aspects of health information, to what extent and under what circumstances. Consideration is given to a Canadian model in which small district health centers share computer hardware, while maintaining independent control over their individual management information files. The key to the protection of patient information in this shared system is the absence within the computer banks of any personal information that would allow individual patient identification. Health administrators who maintain such shared computer systems are urged to ensure that maximum awareness and control of specific treatment information should be held by the health practitioner and, as much as is possible, by the service recipient.