Realities Of Medical Practice Research Articles

Treatment and outcome analysis of patients with ruptured distal anterior cerebral artery aneurysms: a multicenter real-world study.

To reveal the safety and efficacy of clipping and coiling in patients with ruptured distal anterior cerebral artery aneurysms (DACAA) and to calculate the risk factors affecting the two-year survival rate in follow-up patients. A retrospective study was conducted on the data of 140 patients (21 were lost to follow-up) with DACAA rupture who were treated by neurosurgery at 12 medical centers over a 2-year period, from January 2017 to December 2020. Univariate analysis was used to examine factors contributing to poor patient prognosis and to compare the prognosis of coiling and clipping treatments. Survival analysis was employed to compare survival rates between coiling and clipping, and risk factors affecting patient survival were analyzed using multivariate Cox regression analysis. Out of 140 patients with ruptured DACAA, 80 (57.1%) were male, and 60 (42.9%) were female. A total of 111 (79.3%) patients were classified under Hunt-Hess scale grades I-III, while 95 (67.9%) were graded I-III according to the WFNs classification. Among them, 63 (45%) were treated with clipping, and 77 (55%) underwent coiling. Within 2 years of discharge from the hospital, 31 (59.6%) patients who underwent clipping and 54 (80.6%) who underwent coiling had a good prognosis. Multivariate Cox regression analysis revealed that only WFNs classification (I-III) was a protective factor influencing the 2-year survival of patients with ruptured DACAA. In the reality of medical practice, neurosurgeons are more likely to choose clipping as the treatment for cases with WFNs classification than or equal to III. There was no difference between clipping and coiling in the two-year prognosis at discharge. High priority should be given to DACAA cases with WFNs grading (I-III), as better outcomes can be achieved. The sample size will continue to be enlarged in the future to obtain more accurate findings. Abstracts for reviews, technical notes, and historical vignettes do not need to be separated into sections. They should begin with a clear statement of the paper's purpose followed by appropriate details that support the authors' conclusion(s).

Professional identity struggle and ideology: A qualitative study of residents' experiences.

To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. The role of ideology in medical socialisation may offer insight into these tensions experienced by medical learners. Ideology is the system of ideas and representations that dominates the minds of individuals or social groups and calls individuals into certain ways of being and acting in the world. In this study, we use the concept of ideology to explore residents' experiences with identity struggle during residency. We conducted a qualitative exploration of residents in three specialties at three academic institutions in the United States. Participants engaged in a 1.5-hour session involving a rich picture drawing and one-on-one interview. Interview transcripts were coded and analysed iteratively, with developing themes compared concurrently to newly collected data. We met regularly to develop a theoretical framework to explain findings. We identified three ways that ideology contributed to residents' identity struggle. First was the intensity of work and perceived expectations of perfectionism. Second were tensions between the developing professional identity and pre-existing personal identities. Many residents perceived messages regarding the subjugation of personal identities, including the feeling that being more than physicians was impossible. Third were instances where the imagined professional identity clashed with the reality of medical practice. Many residents described how their ideals misaligned with normative professional ideals, constraining their ability to align their practice and ideals. This study uncovers an ideology that shapes residents' developing professional identity-an ideology that creates struggle as it calls them in impossible, competing or even contradictory ways. As we uncover the hidden ideology of medicine, learners, educators and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements.

Who judges medical practice?

Lawsuits due to patient perception of inappropriate medical actions are a growing reality in medical practice, which entails widespread concern in the medical community. Lawsuits often entail additional circumstances beyond the primary concern of preventing or sanctioning acts of medical negligence. CETREMI proposes various recommendations aimed at legal and medical professionals to improve this circumstance and avoid harming the doctor-patient relationship.

Augmented Reality in Medical Practice: From Spine Surgery to Remote Assistance.

Background: While performing surgeries in the OR, surgeons and assistants often need to access several information regarding surgical planning and/or procedures related to the surgery itself, or the accessory equipment to perform certain operations. The accessibility of this information often relies on the physical presence of technical and medical specialists in the OR, which is increasingly difficult due to the number of limitations imposed by the COVID emergency to avoid overcrowded environments or external personnel. Here, we analyze several scenarios where we equipped OR personnel with augmented reality (AR) glasses, allowing a remote specialist to guide OR operations through voice and ad-hoc visuals, superimposed to the field of view of the operator wearing them.Methods: This study is a preliminary case series of prospective collected data about the use of AR-assistance in spine surgery from January to July 2020. The technology has been used on a cohort of 12 patients affected by degenerative lumbar spine disease with lumbar sciatica co-morbidities. Surgeons and OR specialists were equipped with AR devices, customized with P2P videoconference commercial apps, or customized holographic apps. The devices were tested during surgeries for lumbar arthrodesis in a multicenter experience involving author's Institutions.Findings: A total number of 12 lumbar arthrodesis have been performed while using the described AR technology, with application spanning from telementoring (3), teaching (2), surgical planning superimposition and interaction with the hologram using a custom application for Microsoft hololens (1). Surgeons wearing the AR goggles reported a positive feedback as for the ergonomy, wearability and comfort during the procedure; being able to visualize a 3D reconstruction during surgery was perceived as a straightforward benefit, allowing to speed-up procedures, thus limiting post-operational complications. The possibility of remotely interacting with a specialist on the glasses was a potent added value during COVID emergency, due to limited access of non-resident personnel in the OR.Interpretation: By allowing surgeons to overlay digital medical content on actual surroundings, augmented reality surgery can be exploited easily in multiple scenarios by adapting commercially available or custom-made apps to several use cases. The possibility to observe directly the operatory theater through the eyes of the surgeon might be a game-changer, giving the chance to unexperienced surgeons to be virtually at the site of the operation, or allowing a remote experienced operator to guide wisely the unexperienced surgeon during a procedure.

SHOULD WE BE AFRAID OF MEDICAL MALPRACTICE COMPLAINTS? THE DOCTORS’ PERSPECTIVE

Background. Medical malpractice litigation is a well-known increasing phenomenon all over the world, although precise data are not always available. The reasons for submitting complaints against the doctors may vary from one country to another, from one culture to another, from the view of the patients and the view of physicians, although some of them are universal. The aim of this study was to analyze the risk of malpractice complaints and the reasons lying beneath through the eyes of physicians who were involved in complaints filed by patients. Material and method. The authors performed a qualitative research and the data were collected using a semi-structured interview. The target population was represented by doctors from different specialties, who were involved in complaints from patients on any of the three components of medical liability: civil, criminal, disciplinary. The analysis of the collected data was done inductively, identifying common themes. Results. The general opinion of the participants was that the malpractice risk follows an upward trend, and the factors that contribute to this are related both to patients (e.g. external influences, financial motivations) and medical practice (e.g. medical communication, overwork of the medical staff). Conclusions. Malpractice complaints are an increasing reality in medical practice in Romania, and the data are of particular importance for sounding the alarm in the directions in which measures should be taken to limit the continued growth in the number of complaints and open up new opportunities for research on this topic.

Use of Virtual Reality in Medical Practice in Russia

In the article is represented an analysis of the different areas of using virtual reality technologies (VR) in medicine in the Russian Federation. Virtual reality gives a chance for creating multi-tiered systems such as VR-based operating rooms. VR allows organizing the medical operations with a high accuracy of steering. VR technology is also used in the education process of young doctors. Most often VR is known to be an auxiliary method in such areas as neurorehabilitation. More than that, VR can influence re-storing of body movements after lessons. In the conclusion it is stressed that VR technologies need to be studied and made a detailed description.

Extended Reality in Medical Practice

Advances in display technology and computing have led to new devices capable of overlaying digital information onto the physical world or incorporating aspects of the physical world into virtual scenes. These combinations of digital and physical environments are referred to as extended realities. Extended reality (XR) devices offer many advantages for medical applications including realistic 3D visualization and touch-free interfaces that can be used in sterile environments. This review introduces extended reality and describes how it can be applied to medical practice. The 3D displays of extended reality devices are valuable in situations where spatial information such as patient anatomy and medical instrument position is important. Applications that take advantage of these 3D capabilities include teaching and pre-operative planning. The utility of extended reality during interventional procedures has been demonstrated with through 3D visualizations of patient anatomy, scar visualization, and real-time catheter tracking with touch-free software control. Extended reality devices have been applied to education, pre-procedural planning, and cardiac interventions. These devices excel in settings where traditional devices are difficult to use, such as in the cardiac catheterization lab. New applications of extended reality in cardiology will continue to emerge as the technology improves.

Physicians-in-training are not prepared to prescribe medical marijuana

BackgroundWhile medical marijuana use is legal in more than half of U.S. states, evidence is limited about the preparation of physicians-in-training to prescribe medical marijuana. We asked whether current medical school and graduate medical educational training prepare physicians to prescribe medical marijuana. MethodsWe conducted a national survey of U.S. medical school curriculum deans, a similar survey of residents and fellows at Washington University in St. Louis, and a query of the Association of American Medical Colleges (AAMC) Curriculum Inventory database for keywords associated with medical marijuana. ResultsSurveys were obtained from 101 curriculum deans, and 258 residents and fellows. 145 schools were included in the curriculum search. The majority of deans (66.7%) reported that their graduates were not at all prepared to prescribe medical marijuana, and 25.0% reported that their graduates were not at all prepared to answer questions about medical marijuana. The vast majority of residents and fellows (89.5%) felt not at all prepared to prescribe medical marijuana, while 35.3% felt not at all prepared to answer questions, and 84.9% reported receiving no education in medical school or residency on medical marijuana. Finally, only 9% of medical school curriculums document in the AAMC Curriculum Inventory database content on medical marijuana. ConclusionsOur study highlights a fundamental mismatch between the state-level legalization of medical marijuana and the lack of preparation of physicians-in-training to prescribe it. With even more states on the cusp of legalizing medical marijuana, physician training should adapt to encompass this new reality of medical practice.

Use of Mechanical Insufflation-Exsufflation Devices for Airway Clearance in Subjects With Neuromuscular Disease.

The aim of this systematic review is to examine the benefit/risk ratio of the use of mechanical insufflation-exsufflation (MI-E) devices for airway clearance in patients with neuromuscular diseases. A search was conducted for relevant studies in MEDLINE, the Cochrane Library, and the Health Technology Assessment Database using the main key words: cough, airway clearance, in-exsufflation. The search limits were studies published in English and French between 1970 and 2014 (literature watch until December 2015). The methodological quality of the studies was assessed using (1) the Cochrane Collaboration's risk of bias tool for randomized controlled trials and (2) the Institute of Health Economics' 20-item checklist for comparative and observational studies. Data were extracted into an evidence table according to (1) study design, (2) population characteristics (including age and type of diseases) and intervention (MI-E associated or not with other interventions), (3) outcome measures, and (4) key findings. Twelve studies met the inclusion criteria (4 randomized controlled trials, 3 comparative studies, and 5 observational studies). The quality of the selected studies was poor. None of the studies reported survival outcome. All studies evaluated change of pulmonary function parameters, such as peak expiratory flow. This review underlines the lack of robust data on mechanical medical devices used for airway clearance. The current scientific evidence does not support the use of MI-E for cough augmentation in patients with neuromuscular diseases, but health-care professionals are faced with the reality of medical practice and the absence of alternatives. Most European and American guidelines recommend the use of MI-E despite low-level evidence. However, even if performing comparative trials in a specific population is difficult, the medical device industry should provide reliable data to assist health-care professionals, providers, and payers in the decision-making process. This is the only way to ensure the best treatment for patients.

Choice of injury scoring system in low- and middle-income countries: Lessons from Mumbai.

Injury is a major cause of morbidity and mortality in low- and middle-income countries. Effective trauma surveillance is imperative to guide research and quality improvement interventions, so an accurate metric for quantifying injury severity is crucial. The objectives of this study are (1) to assess the feasibility of calculating five injury scoring systems--ISS (injury severity score), RTS (revised trauma score), KTS (Kampala trauma score), MGAP (mechanism, GCS (Glasgow coma score), age, pressure) and GAP (GCS, age, pressure)--with data from a trauma registry in a lower middle-income country and (2) to determine which of these scoring systems most accurately predicts in-hospital mortality in this setting. This is a retrospective analysis of data from an institutional trauma registry in Mumbai, India. Values for each score were calculated when sufficient data were available. Logistic regression was used to compare the correlation between each score and in-hospital mortality. There were sufficient data recorded to calculate ISS in 73% of patients, RTS in 35%, KTS in 35%, MGAP in 88% and GAP in 92%. ISS was the weakest predictor of in-hospital mortality, while RTS, KTS, MGAP and GAP scores all correlated well with in-hospital mortality (area under ROC (receiver operating characteristic) curve 0.69 for ISS, 0.85 for RTS, 0.86 for KTS, 0.84 for MGAP, 0.85 for GAP). Respiratory rate measurements, missing in 63% of patients, were a major barrier to calculating RTS and KTS. Given the realities of medical practice in low- and middle-income countries, it is reasonable to modify the approach to characterising injury severity to favour simplified injury scoring systems that accurately predict in-hospital mortality despite limitations in trauma registry datasets.

Energy-resolved X-ray detectors: the future of diagnostic imaging

Energy-resolved X-ray detectors: the future of diagnostic imaging Danilo Pacella ENEA-Frascati, Rome, Italy Abstract: This paper presents recent progress in the field of X-ray detectors, which could play a role in medical imaging in the near future, with special attention to the new generation of complementary metal-oxide semiconductor (C-MOS) imagers, working in photon counting, that opened the way to the energy-resolved X-ray imaging. A brief description of the detectors used so far in medical imaging (photographic films, imaging plates, flat panel detectors), together with the most relevant imaging quality parameters, shows differences between, and advantages of these new C-MOS imagers. X-ray energy-resolved imaging is very attractive not only for the increase of contrast but even for the capability of detecting the nature and composition of the material or tissue to be investigated. Since the X-ray absorption coefficients of the different parts or organs of the patient (object) are strongly dependent on the X-ray photon energy, this multienergy ("colored") X-ray imaging could increase enormously the probing capabilities. While dual-energy imaging is now a reality in medical practice, multienergy is still in its early stage, but a promising research activity. Based on this new technique of color X-ray imaging, the entire scheme of source–object–detector could be revised in the future, optimizing spectrum and detector to the nature and composition of the target to be investigated. In this view, a transition to a set of monoenergetic X-ray lines, suitably chosen in energy and intensity, could be envisaged, instead of the present continuous spectra. Keywords: X-ray detectors, X-ray medical imaging, C-MOS imagers, dual and multienergy CT

A experiência da Medicina de Família e Comunidade enquanto disciplina no curso de graduação em medicina

Este estudo relata a experiência de implantação da disciplina eletiva de Medicina de Família e Comunidade (MFC) no curso de graduação em medicina, na visão dos discentes da Universidade Federal de Juiz de Fora, Minas Gerais, Brasil. Levando-se em conta a metodologia aplicada, verificou-se que os alunos consideraram os conteúdos práticos mais relevantes em comparação aos teóricos, o que pode ser atribuído ao fato de a prática permitir a crítica, a problematização e a resolução de situações cotidianas, sendo, além disso, um elo entre o jovem estudante de medicina e a realidade da prática médica. Diante da necessidade de aprimorar a abordagem integral à saúde dos indivíduos, considerando seus aspectos biopsicossociais, torna-se necessário que as alterações no currículo médico tenham como eixo norteador os princípios da Atenção Primária à Saúde (APS). Nesse contexto, a Medicina de Família e Comunidade (MFC) é a especialidade chave para a APS, pois estimula a formação de médicos generalistas capacitados a oferecerem cuidado longitudinal e responderem às necessidades em saúde das pessoas.

Needles, picks and an intern named Laing: exploring the psychiatric spaces of Army life

This paper delves into the world of medical and Army psychiatric practice in Britain during the 1950s, in order to reveal the importance of thinking geographically about the life and work of Scottish psychiatrist and psychotherapist Ronald David Laing (1927–1989). The paper first discusses the previous biographical literature produced on Laing and his own autobiography, arguing that by viewing Laing’s life and work through a geographical lens certain underexplored spaces, sites and places emerge. The following sections will detail Laing’s time spent as an intern in the West of Scotland Neurological Unit at Killearn, where he first endured the harsh working realities of medical practice and where critical debates in 1950s mental health care were playing out in a microcosm. These included the controversial treatment of lobotomy and the brewing tensions between neurology and psychiatry. As Laing’s career took a military turn and he was posted to work within the insulin coma unit of the Royal Victoria Military Hospital in Netley, it is possible to highlight the development of Laing’s thoughts on the treatment of psychiatric patients in the hands of the Army, and how he attempted to come to terms with these practices in his own unique way. Using the experimental practice of insulin coma therapy as an example, this paper seeks to demonstrate how the space of treatment itself was active in shaping Laing’s future engagements with his psychiatric patients.

Electronic teaching files and continuing professional development in radiology

Education in diagnostic radiology employs medical images extensively, and case-based teaching files of actual patients are useful to illustrate pertinent teaching points. In the era of digital radiology, there is great potential to use the ready source of patient material from Picture Archive and Communication Systems (PACS) and initiatives such as Medical Imaging Resource Center (MIRC) on the World Wide Web for teaching and for Continuing Professional Development (CPD). As mandatory CPD becomes the reality in medical practice, computerised solutions that support the creation of electronic teaching files in the midst of busy clinical workflow would be very valuable. This paper will explore the features of image-based CPD, the various ways in which medical images can be used for self directed learning and the challenges that face the radiology profession.

Sentinel lymph node mapping and biopsy for breast cancer: a review of the literature relative to 4791 procedures.

The status of axillary nodes is the most important prognostic factor in breast cancer to select patient subgroups for adjuvant chemotherapy; the current standard of care for surgical management of invasive breast cancer is complete removal of the tumor by either mastectomy or lumpectomy followed by axillary lymph node dissection (ALND). The recent introduction of intraoperative lymphatic mapping and sentinel lymph node biopsy (SLND) represents a major new opportunity for appropriate and less invasive surgical management of many tumors. There is an almost uniformly enthusiasm concerning the potential of this technique in breast carcinoma management, shown by published data. A peculiar attention to the so-called "sentinel node debate" in breast cancer surgery is a constant in the last years issues of the major medical journals. Even patients have become more aware about medical enthusiasm and their request of concise information on the topic and the possibilities of this approach is an increasing reality in medical practice. The aim of this paper is to review recent literature to offer an overview about the main controversial methodological aspects and a wide analysis of reported results. The most significative international literature papers from Medline were retrieved from 1993 to September 1999, and 4782 procedures were analysed. This extensive review of the literature has confirmed accuracy, feasibility and reliability of the SN detecting technique in axillary mapping. Provided a good proficiency in SN localisation and pathological evaluation, human resources and efforts should be mainly focused on its clinical validation as an alternative to ALND instead of on further phase I-lI clinical studies.

Reflections on Informed Consent: 40 Years After its Birth

Dr. Jay Katz a physician and law professor at Yale University invites fellow physicians to set aside their dislike of informed consent and consider both its origins and possible future in the field of medicine. He notes that informed consent with its initial pronouncements on patient roles in medical decision- making surfaced in 1957 in US Supreme Court case entitled Salgo vs. Leland Stanford Jr. University Board of Trustees. The notion was expanded by Natanson vs. Kline in 1960 and by Cantenbury vs. Spence in 1972. Informed consent was not designed to serve as a medical blueprint for interactions between physicians and patients says Katz but rather to push physicians to articulate medical standards of disclosure that would better conform to basic legal principles. However the medical profession did not do this and the task of fashioning a doctrine responsive to both the realities of medical practice and the requirements of law remains to be done. Thus Katz advocates a reexamination of the unitary scope of the informed-consent doctrine in light of the diversity of medical practices. He argues that: disclosures may have to be limited to the most essential parts; that the fullest disclosures should be enforced and shared decision making should be an absolute requirement for acute disorders; that the pace of disclosure may have to be slower for conditions in which the prognosis is dire and a fatal outcome is likely; and informed consent could be dispensed with if the patient agrees for relatively minor time-limited disorders.

Medical ethics research between theory and practice.

The main object of criticism of present-day medical ethics is the standard view of the relationship between theory and practice. Medical ethics is more than the application of moral theories and principles, and health care is more than the domain of application of moral theories. Moral theories and principles are necessarily abstract, and therefore fail to take account of the sometimes idiosyncratic reality of clinical work and the actual experiences of practitioners. Suggestions to remedy the illness of contemporary medical ethics focus on re-establishing the connection between the internal and external morality of medicine. This article discusses the question how to develop a theoretical perspective on medical ethical issues that connects philosophical reflection with the everyday realities of medical practice. Four steps in a comprehensive approach of medical ethics research are distinguished: (1) examine health care contexts in order to obtain a better understanding of the internal morality of these practices; this requires empirical research; (2) analyze and interpret the external morality governing health care practices; sociological study of prevalent values, norms, and attitudes concerning medical-ethical issues is required; (3) creation of new theoretical perspectives on health care practices; Jensen's theory of healthcare practices will be useful here; (4) develop a new conception of bioethics that illuminates and clarifies the complex interaction between the internal and external morality of health care practices. Hermeneutical ethics can be helpful for integrating the experiences disclosed in the empirical ethical studies, as well as utilizing the insights gained from describing the value-contexts of health care practices. For a critical and normative perspective, hermeneutical ethics has to examine and explain the moral experiences uncovered, in order to understand what they tell us.

EEG is a useful predictor of seizure recurrence following withdrawal of anticonvulsant medication in children

Neurologists, like other mortals, are not clairvoyant. Attempting to predict future clinical events is nonetheless an inescapable reality of medical practice. So too is basing current management decisions on such predictions. A salient example is whether to discontinue anticonvulsant medication in an epileptic child whose seizures have been controlled for a prolonged period. In weighing the risk of seizure recurrence that attends drug withdrawal against the likelihood of neurologic and other systemic toxicity with drug continuation, a variety of factors may need to be considered. These frequently include seizure type, etiology, age of onset, and duration of epilepsy prior to treatment (1). Whether EEG findings assist in this decision-making process remains controversial, with some investigators (2-6) but not others (7-10) contending that it is a useful predictor of seizure recurrence. Comparing these studies is difficult because of the varying methodologies employed by the investigators. For example, the subjects may be selected from a variety of sources: epilepsy referral centers, neurology clinics, and less often from general medical practices. Also, although almost all of the major studies rely on EEGs obtained using standard recording techniques, the number and timing of recordings differ. For example, whereas data are commonly derived from EEGs taken just prior to drug withdrawal, some authors have gone further by comparing these results with those obtained prior to and following the institution of drug treatment. Still others continue periodic EEG monitoring during and following completion of the weaning process. In addition, methods of scoring EEG results range in complexity from the

A survey of Cleveland Clinic training-program alumni. Implications for evaluation of graduate medical education.

The graduate of a medical training program is in a unique position to evaluate that program in comparison with the realities of medical practice. A survey of alumni of the Cleveland Clinic's graduate training programs was conducted in September 1986. The alumni's perceptions of the quality of their programs and the educational services provided by the Division of Education are discussed in relation to the educational administrative structure and evaluation process at The Cleveland Clinic Foundation. The need for such evaluation methods, as well as additional techniques to provide a comprehensive evaluation system in graduate medical education, is emphasized.

W. H. R. Rivers Prize Essay (1986): Western Minds, Foreign Bodies

In this essay I discuss the limited gain and potential harm of health development programs that are directed by the assumptions of Western ideologies surrounding the sickness domain. By contrast with the realities of medical practice in the West and the Third World, three aspects of the cultural model of biomedicine are examined: (1) the implicit assumption that biomedicine is a body of widely shared knowledge that directs sickness behavior, and that this knowledge and the institutions in which it is applied are objectively and intrinsically related to each other; (2) the belief in the effectiveness of biomedical techniques; and (3) the implicit model of the ideal rational patient. I argue that the effectiveness of health development projects is lessened if they are planned on the basis of this orthodox biomedical orientation. Furthermore, I suggest that the practice of viewing Third World health development in terms of biomedical ideology inhibits consideration of the influences of both the political and physical environments on the distribution of sickness. Health planners are advised not only to implement culturally appropriate projects but also to promote awareness of important influences on health that biomedical discourse helps obscure from consideration.