Problem In Management Of Patients Research Articles

Patient Management Problem-Preferred Responses

Following are the preferred responses for the Patient Management Problem in this CONTINUUM issue. The case, questions, and answer options are repeated, and the preferred response appears in bold print, followed by an explanation and a reference with which you may seek more specific information. You are encouraged to review the responses and explanations carefully to evaluate your general understanding of the material. The comment and references included with each question are intended to encourage independent study.

Patient Management Problem-Preferred Responses

Following are the preferred responses for the Patient Management Problem in this CONTINUUM issue. The case, questions, and answer options are repeated, and the preferred response appears in bold print, followed by an explanation and a reference with which you may seek more specific information. You are encouraged to review the responses and explanations carefully to evaluate your general understanding of the material. The comment and references included with each question are intended to encourage independent study.

Behavior Assessment of Children in Dental Settings: A Retrospective Study

ABSTRACTIn children, dental anxiety and fear of dental treatment have been recognized as a source of problems in patient management for many years, which can affect the quality of care.Aims : The aim of the study was to assess the behavior of children during their dental visit and to determine the effect of behavior management techniques on children.Materials and Methods : A retrospective study was done by analyzing the records of 328 children to assess their behavior during dental visits. Behavior assessment was done using Frankl’s behavior rating scale. All children were exposed to live modeling and tell-show-do behavior management technique.Statistical analysis : The analysis was carried out using SPSS version 10. The comparison between visits was carried out by applying Friedman test.Results and conclusion : Children showed improvement in their behavior with every subsequent visits. Proper assessment of children’s behavior helps the dentist to execute a required treatment plan in the most appropriate manner. Techniques like live modeling and tell-show-do are very effective in modifying a child’s behavior.

A survey of cardiologists, diabetologists, gynecologists and ophthalmologists practicing in Osaka on the medical consultation behaviors of myotonic dystrophy patients

An anonymous postal survey of cardiologists, diabetologists, gynecologists, and ophthalmologists in Osaka was performed to assess the medical care-seeking behaviors of and problems associated with the medical management of patients with myotonic dystrophy (DM). The questionnaires were sent to 927 cardiologists, 357 diabetologists, 882 gynecologists, and 915 ophthalmologists. Of these, 172 cardiologists, 85 diabetologists, 220 gynecologists, and 154 ophthalmologists responded. More than 30% of responders had provided care to DM patients, and approximately 10% had experience diagnosing DM patients. These facts suggest that DM patients receive medical care from various specialists due to complications involving multiple systems and some of them visit other specialists prior to neurologists. Some patients were diagnosed after perinatal or perioperative difficulties. Therefore, it seems important to improve the ability of physicians to identify DM patients. Because specialists with experience diagnosing DM paid more attention to the characteristic features of DM, such as grip myotonia and hatchet face, a simple screening test may be useful for detecting DM. Some responders pointed out the negative attitude of DM patients toward medical care and the lack of neurologists for consultation as problems in the medical management of DM patients. Cooperation among neurologists and other specialists and education of DM patients are important to improve the medical management of DM patients.

Tissue proteomics of the human mammary gland: Towards an abridged definition of the molecular phenotypes underlying epithelial normalcy

Our limited understanding of the biological impact of the whole spectrum of early breast lesions together with a lack of accurate molecular-based risk criteria for the diagnosis and assignment of prognostic significance to biopsy findings presents an important problem in the clinical management of patients harboring precancerous breast lesions. As a result, there is a need to identify biomarkers that can better determine the outcome of early breast lesions by identifying subpopulations of cells in breast premalignant disease that are at high-risk of progression to invasive disease. A first step towards achieving this goal will be to define the molecular phenotypes of the various cell types and precursors – generated by the stem cell hierarchy – that are present in normal and benign conditions of the breast. To date there have been very few systematic proteomic studies aimed at characterizing the phenotypes of the different cell subpopulations present in normal human mammary tissue, partly due to the formidable heterogeneity of mammary tissue, but also due to limitations of the current proteomic technologies. Work in our laboratories has attempted to address in a systematic fashion some of these limitations and here we present our efforts to search for biomarkers using normal fresh tissue from non-neoplastic breast samples. From the data generated by the 2D gel-based proteomic profiling we were able to compile a protein database of normal human breast epithelial tissue that was used to support the biomarker discovery program. We review and present new data on the putative cell-progenitor marker cytokeratin 15 (CK15), and describe a novel marker, dihydropyriminidase-related protein 3 (DRP3) that in combination with CK15 and other well known proteins were used to define molecular phenotypes of normal human breast epithelial cells and their progenitors in resting acini, lactating alveoli, and large collecting ducts of the nipple. Preliminary results are also presented concerning DRP3 positive usual ductal hyperplasias (UDHs) and on single cell layer columnar cells (CCCs). At least two bona fide biomarkers of undifferentiated ERα/PgR negative luminal cells emerged from these studies, CK15 and c-KIT, which in combination with transformation markers may lead to the establishment of a protein signature able to identify breast precancerous at risk of progressing to invasive disease.

TREATMENT OF WILMS TUMOR: A Report from the Turkish Pediatric Oncology Group (TPOG)

Aim: To standardize diagnosis and treatment of childhood Wilms tumor (WT) in Turkey. Methods and patients: Between 1998 and 2006, WT patients were registered from 19 centers. Patients <16 years with unilateral WT whose treatment started in first postoperative 3 weeks were included. Treatments were stage I favorable (FH) and unfavorable histology (UH) patients, VCR + Act-D; stage IIA FH, VCR + Act-D; stage IIB FH, VCR + Act-D + radiotherapy (RT); stage III–IV FH, VCR + Act-D + adriamycin (ADR) + RT; stages II–IV UH tumors, VCR + Act-D + ADR + etoposide + RT. Results: 165/254 registered cases were eligible (bilateral, 5.9%) [median age 3.0 years; M/F: 0.99; 50/165 cases ≤2 years]. 9.7% cases had UH tumors. Disease stages were stage I 23.6%; IIA 36.4%; IIB 5.5%; III 22.4%; IV 12.1%. Cases >2 years had significantly more advanced disease. 1/11 cases with recurrent disease died; 2/165 had progressive disease, 2/165 had secondary cancers, and all 4 died. In all cases 4-year OS and EFS were 92.8 and 86.5%, respectively. Both OS and EFS were significantly worse in stage IV. Conclusions: Despite problems in patient management and follow-up, treatment results were encouraging in this first national experience with a multicentric study in pediatric oncology. Revisions and modifications are planned to further improve results and minimize short- and long-term side effects.

Treatment of Wilms Tumor: A Report from the Turkish Pediatric Oncology Group (TPOG)

Aim To standardize diagnosis and treatment of childhood Wilms tumor (WT) in Turkey. Methods & Patients Between 1998 and 2006, WT patients were registered from 19 centers. Patients Results 165/254 registered cases were eligible (bilateral, 5.9%) [median age 3.0 years; M/F:0.99; 50/165 cases £2 years]. 9.7% cases had UH tumors. Disease stages were: stage I 23.6%; IIA 36.4%; IIB 5.5%; III 22.4%; IV 12.1%. Cases >2 years had significantly more advanced disease. 1/11 cases with recurrent disease died; 2/165 had progressive disease, 2/165 had secondary cancers and all four died. In all cases four-year OS and EFS were 92.8% and 86.5%, respectively. Both OS and EFS were significantly worse in stage IV. Conclusions Despite problems in patient management and follow-up, treatment results were encouraging in this first national experience with a multicentric study in pediatric oncology. Revisions and modifications are planned to further improve results and minimize short and long term side effects.

Post-earthquake problem in management of patients with diabetes mellitus: A comment

A hot issue in the present day is the big Haiti earthquake. Basically, there are several problems in public health and medicine in post-earthquake scenario. In this specific brief article, the author hereby briefly discusses on post-earthquake problem in management of patients with diabetes mellitus.

Unique Thrombopoietic Activity of Novel PKC Agonist Ingenol 3,20 Dibenzoate.

Abstract 3622Poster Board III-558Despite recent advances in our understanding of megakaryocytic growth and platelet production, thrombocytopenia remains a difficult problem in the clinical management of patients with hematologic malignancies. Thrombopoietin (TPO) is the major cytokine involved in the normal production of platelets. However, the use of TPO has been relatively unsuccessful for the treatment of these patients and platelet transfusions remain the primary treatment for thrombocytopenia despite their significant cost and relatively short-lived responses. Thus, there remains an important clinical need for the development of novel approaches to generate platelets. Despite numerous reports on protein kinase C (PKC) agonists as promoters of megakaryocytic differentiation in leukemic cell lines and primary cells, little is known about their in vitro effects on primary CD34-selected progenitors or when administered in vivo. In the present study, we examine that effects of the novel PKC isoform agonist ingenol 3,20 dibenzoate (IDB) on megakaryocyte differentiation from CD34+ cells cultured in TPO and stem cell factor (SCF) or erythropoietin/SCF and its effects on platelet production in BALB/c mice. IDB potently stimulates early megakaryopoiesis and redirects the specificity of EPO to favor megakaryopoiesis over erythropoiesis. In contrast, broad spectrum PKC agonists such as phorbol myristate acetate, mezerein, and indolactam V fail to promote megakaryopoiesis. In vitro, IDB stimulates early expression of the promegakaryopoietic transcription factors egr1 and fli-1 and downregulates the proerythropoietic factors KLF1 and c-myb. Induction of the early megakaryocytic marker, CD9, was observed within the first 24 hrs of treatment with IDB and CD9 induction was blocked by the PKC inhibitor bisindolylmaleimide, which inhibits both novel and conventional PKC isoforms. In contrast, an inhibitor of conventional PKC isoforms, Gö6976, failed to block CD9 induction. In vivo, single intraperitoneal injections of IDB selectively increased platelet counts in BALB/c mice by 50% (plt= 630,000 vs. 985,000/μl; p<.005) at day 7 without affecting hemoglobin (Hgb) concentration or white counts (WBC). Mice treated with low dose radiation (2-4 Gy) had a transient drop in both platelet and WBC counts. Pretreatment with IDB 3 hrs prior to irradiation increased the platelet counts without improving WBC. More severe radiation exposure (6-8 Gy) causes pancytopenia. IDB treatment 3 hrs prior to 6 Gy irradiation significantly reduced the thrombocytopenia (plt=192,000 vs 594,000/μl; p<0.005) and anemia (hemoglobin=11.9 vs. 13.5gm/dl); p<0.005) without affecting the drop in WBC (WBC=1,200 vs. 1,300/μl; p=NS) at 14 days following irradiation. For mice treated with 8 Gy radiation, IDB pretreatment resulted in similar improvements in platelet counts (plt=111,000 vs. 443,000/μl; p<0.005) and hemoglobin (hgb=8.2 vs. 12.7 gm/dl; p<0.005) at 21 days following irradiation. The mitigation of thrombocytopenia is accompanied by marked increases in the megakaryocyte content in both the spleens and bone marrows of IDB-treated mice. Most importantly, IDB mitigated radiation-induced thrombocytopenia, even when administered 24 hrs after irradiation (plt=80,000 vs. 241,000/μl at 14 days following 6 Gy irradiation; p<0.01). Finally, IDB improved the survival of lethally irradiated mice. Our data suggest that the novel PKC isoform agonist IDB promotes the early differentiation of megakaryocytes from hematopoietic progenitors at the resulting in a significant improvement in platelet recovery following irradiation. IDB also improved Hgb levels following higher radiation doses. This may be due to improved hemostasis secondary to increased platelet numbers; however, an additional radioprotective effect on erythroid precursors cannot be excluded. These results strongly support our hypothesis that the novel PKC agonist IDB may be useful for the treatment of radiation and possibly drug-induced thrombocytopenia. Disclosures:No relevant conflicts of interest to declare.

Endocrine cells in atresic chick embryo intestine: histochemical and immunohistochemical study

Intestinal motility disorders are an important problem in the postoperative management of patients with intestinal atresia. Intestinal motility could be initiated by luminal factors that activate intrinsic and extrinsic primary afferent nerves involved in the peristaltic reflex. Endocrine cells act as a key point, because they transfer information regarding the intestinal contents and intraluminal pressure to nerve fibers lying in close proximity to the basolateral surface of the epithelium. In chick embryo, experimental intestinal atresia is associated with disorders in the development of the enteric nervous system, related to the severity of intestinal dilation. Our aim was to investigate the distribution pattern of endocrine cells in the developing endocrine system of chick embryo small intestine with experimentally-induced atresia on day 12 and on day 16. Changes in enteroendocrine population were examined in gut specimens (excised proximal and distal to the atresia) from experimental embryos 19 days old and in control sham-operated chick embryos at the same age. Sections from proximal and distal bowel and control bowel were stained with Grimelius silver stain, a valuable histochemical method for detecting the argyrophil and argentophilic cells, and with an immunohistochemical procedure for detecting serotonin and neurotensin immunoreactive cells. In chick embryo proximal bowel, intestinal dilation differed in the various embryos. We found significantly higher enteroendocrine cell counts in proximal bowel than in distal and control bowel. The differences depended on the precociousness of surgery and the severity of dilation. Considering the major contribution of enteroendocrine cells to the peristaltic reflex, our data may help to explain the pathogenesis of motility disorders related to intestinal atresia.

Endocrine cells in atresic chick embryo intestine: histochemical and immunohistochemical study

Intestinal motility disorders are an important problem in the postoperative management of patients with intestinal atresia. Intestinal motility could be initiated by luminal factors that activate intrinsic and extrinsic primary afferent nerves involved in the peristaltic reflex. Endocrine cells act as a key point, because they transfer information regarding the intestinal contents and intraluminal pressure to nerve fibers lying in close proximity to the basolateral surface of the epithelium. In chick embryo, experimental intestinal atresia is associated with disorders in the development of the enteric nervous system, related to the severity of intestinal dilation. Our aim was to investigate the distribution pattern of endocrine cells in the developing endocrine system of chick embryo small intestine with experimentally-induced atresia on day 12 and on day 16. Changes in enteroendocrine population were examined in gut specimens (excised proximal and distal to the atresia) from experimental embryos 19 days old and in control sham-operated chick embryos at the same age. Sections from proximal and distal bowel and control bowel were stained with Grimelius silver stain, a valuable histochemical method for detecting the argyrophil and argentophilic cells, and with an immunohistochemical procedure for detecting serotonin and neurotensin immunoreactive cells. In chick embryo proximal bowel, intestinal dilation differed in the various embryos. We found significantly higher enteroendocrine cell counts in proximal bowel than in distal and control bowel. The differences depended on the precociousness of surgery and the severity of dilation. Considering the major contribution of enteroendocrine cells to the peristaltic reflex, our data may help to explain the pathogenesis of motility disorders related to intestinal atresia.

Issues in Selecting Methods of Evaluating Clinical Competence in the Health Professions: Implications for Athletic Training Education

Objectives: To examine methods used to evaluate the clinical competence and proficiency of students in medicine and allied health professions. To identify factors that would be valuable to educators in athletic training and other medical and allied health professions in the development and use of clinical assessment methods. Data Sources: We searched EBSCO Academic, InfoTrac, MEDLINE and PubMed for literature from professional journals related to clinical education, assessing clinical competence, clinical competence, clinical proficiency assessment. Data Synthesis: Assessment of competence in the clinical setting is an issue for medicine and allied health education programs, including athletic training. Methods used to assess clinical competence included written, objective tests, checklists, oral examinations, patient management problems, simulated patients, observed clinical situations, the Observed Structured Clinical Exam and observation of students. Each method has its advantages and concerns. Psychometric issues relating to reliability, validity and generalizability arise in the development and implementation of clinical assessment instruments. In addition, there are concerns about how faculty expectations relate to student performance and how novices perform in the clinical setting as compared to experienced practitioners. Conclusions/Recommendations: Although specific outcomes may differ between the medical and allied health professions, athletic training educators can benefit from the lessons learned about methods used to evaluate students in the clinical setting. In an effort to capitalize on the benefits and minimize the problems with the assessment of clinical competence and proficiency, athletic training educators must be aware of the psychometric and outcome-related issues in test development. Attention should be paid to issues of reliability, validity and generalizability when developing tests. Clinical education outcomes must be developed in a manner that addresses the variety of cognitive levels at which clinicians function in professional practice to develop authentic assessments of clinical proficiency.

Audit of litigation against the accident and emergency radiology department

The aims of this study were to reduce and monitor litigation due to failure to diagnose a fracture, to evaluate whether the cases were due to radiological error or other problems in the diagnostic and therapeutic management of patients and to identify organisational, technical or functional changes or guidelines to improve the management of patients with suspected fracture and their expectations. We analysed the litigation database for the period 2004-2006 and extracted all episodes indicating failure to diagnose a fracture at the accident and emergency radiology department of our centre. The radiographs underwent blinded review by two experts, and each case was jointly analysed by a radiologist and a forensic physician to see what led to the compensation claim. We identified 22 events (2004 seven cases; 2005 eight cases; 2006 seven cases). Six cases were unrelated to radiological error. Six were due to imperceptible fractures at the time of the examination. These were accounted for by the presence of a major lesion distracting the examiner's attention from a less important associated lesion in one case, a false negative result in a patient examined on a incompletely radiolucent spinal board and underexposure of the coccyx region in an obese patient. Six cases were related to an interpretation error by the radiologist. In the remaining cases, the lesion being referred to in the compensation claim could either not be established or the case was closed by the insurance company without compensation. Corrective measures were adopted. These included planning the purchase of a higher performance device, drawing up a protocol for imaging patients on spinal boards, reminding radiologists of the need to carefully scrutinise the entire radiogram even after having identified a lesion, and producing an information sheet explaining to patients the possibility of false negative results in cases of imperceptible lesions and inviting them to return to the department if symptoms persist. We believe the clinical and administrative analysis we performed is useful. It reviewed some administrative practices and identified critical features. We identified tools that we trust will reduce litigation.

Survey of staff attitudes to the smoking ban in a medium secure unit

Aims and methodsThe aim of this survey was to explore staff attitudes to the indoor smoking ban in a medium secure unit and to ascertain if they had experienced any difficulties in imposing the ban in the four months after its introduction. All staff members available on duty who agreed to participate in the survey were interviewed using a semi-structured questionnaire. ResultsThe response rate was 65%. Sixty-four percent of the staff supported the smoking ban. Forty-three percent reported experiencing patient management problems with the majority complaining of increased patient aggression, increased use of staff time in supervising patients smoking. Additionally, supervising staff were still being exposed to passive smoking. Sixty-five percent reported positive effects due to the ban with the majority reporting that patients were sleeping at night due to the smoking area being closed at night. Clinical implicationsA significant proportion of the staff is still opposed to the smoking ban. Changing staff attitudes through educational programmes will be important in ensuring success of a possible future total ban in psychiatric units.

Multiple choice questions. The debate goes on.

The clinical comprehensive examination given to Pahlavi University medical students in their last year was designed to include three types of questions: multiple choice questions (MCQ's) testing factual recall, MCQ's measuring clinical problems solving ability, and simulated patient management problems (PMP's). The scores of the three types of questions were compared with the five-year cumulative class standing and with each other. It was found that the class standing was very highly correlated with MCQ's testing for recall of information. The relation progressively lessened with problem solving MCQ's and PMP's. In the extremes of class standing there was no significant correlation with problem solving MCQ's and a significant but negative correlation with PMP's. Similar results were obtained when recall type MCQ's were compared with problem solving MCQ's and PMP's. It is concluded that the various determinants of class standing (MCQ's, oral exams, 'performance' reports, etc) are probably based on ability for factual recall and that the usual variety of MCQ's are a poor discriminating index of medical competence. It is, however, possible to write MCQ's that are better able to measure the more significant objectives of medical education.

The simulated Patient Management Problem: a technique for evaluating and teaching clinical competence.

The simulated Patient Management Problem: a technique for evaluating and teaching clinical competence.

Computerization of a patient management problems examination to prevent 'retracing'.

During 1973, a 10-patient, linear PMP examination was administered in both written and computerized form to 104 candidates for certification by the American Board of Pediatrics and to 122 individuals in their first month of graduate training in paediatrics. Both groups made significantly more errors of omission (failure to select appropriate actions) and fewer correct diagnoses on the computerized version of the test than on the written version. These results suggest that examinees 'retrace' (use clues from problems near the end of the case to make additional correct decisions on earlier problems) when the test is presented in written form and that computerization prevents this phenomenon. Additional analyses indicated that the reliability of the PMP examination was essentially the same for the written and computerized versions, that both forms distinguished about equally well between first-year residents and candidates, and that both forms had about the same magnitude of correlation with the American Board of Pediatrics oral examination. Finally, correlation between both PMP forms and the American Board of Pediatrics multiple-choice examination suggested that the PMP, in either mode of presentation, measures characteristics that are not tapped by the multiple-choice test. Thus, computerization of the PMP provides a means for controlling a variable (retracing) which may be considered extraneous to the desired measurement, but it does not appear to alter the reliability of the test or to modify its relations with other measures.

3. Computer-assisted teaching of mucopolysaccharidosis by patient management problems

3. Computer-assisted teaching of mucopolysaccharidosis by patient management problems

Patient Management Exercise for Dementia

PATIENT MANAGEMENT PROBLEM: The following patient management problem was chosen to reinforce the facts and issues presented in this course. It emphasizes decisions facing the practicing physician. At each decision point determine how you, as the neurologist, would respond. Then answer the questions provided. The weight or “value” indicates the relative strength or weakness of the response as determined by the faculty. Use these values, as well as the critical comments, to assess your own understanding and handling of the problem. A review of all responses, not merely the ones you select is recommended. Reprinted with permission from Continuum Lifelong Learning Neurol 2007; 13(2):246–255.

Cancer and Thrombosis: Recent Advances

The burden of venous thromboembolism (VTE) is a challenging problem in the medical management of cancer patients. [...]