Seltene genetische Stoffwechselstörungen

Rare metabolic diseases are chronic, progressive, present frequently with a life-threatening course and may result in severe handicaps. They demand high diagnostic and therapeutic standards and efforts from physicians and patients. The challenge for society and health systems in dealing with patients affected by one of these diseases is to offer comprehensive service by a multi-professional team of specialists and evidence-based as well as economic (i.e. necessary, sufficient and effective) treatment. Patients and families should be treated in specialized metabolic centres guaranteeing continuous improvement of the scientific and clinical principles of treatment, standardized outcome evaluation, strict quality assurance as well as optimal psychosocial care and counselling. Networking of national and international metabolic centres seems imperative for clinical research in the field of rare metabolic diseases in order to provide adequate sample sizes and to yield substantial results.     

Analyzing the content of physicians' medical practices

For many large physician groups, about 75% of all revenues come from capitation contracts. These groups may reduce the variable expenses of patient care by conducting medical outcome studies. Physician groups will obtain the most benefit for their limited research dollars by focusing outcomes research on prevalent medical conditions. The purpose of this study is to provide a comprehensive analysis of the content of physicians' medical practices. We found that 21 diagnostic clusters defined 70% or more of the episodes treated by primary care physicians. For specialists, no more than eight diagnostic clusters were needed to define the majority of their practices. Outcomes research should initially focus on abdominal pain, acute lower respiratory infections, cataracts, cholelithiasis, congestive heart failure, diabetes mellitus, external abdominal hernias, ischemic heart disease, low back pain, maternity care, menstrual disorders, otitis media, peptic diseases, prostate cancer, psychotic episodes, renal calculi, seizure disorders, and thyroid diseases.     

Screening in Austria: the cases of mammography, PSA testing, and routine use of ultrasound in pregnancy

OBJECTIVE: To study cases of screening in Austria to learn about national strategies to handle the health policy challenge of early detection of widespread diseases and about the outcome of those strategies. The article describes three healthcare interventions (mammography, PSA testing, and routine use of ultrasound in pregnancy) and the instruments of Austrian health policy that are used-with or without explicit intention-to enforce or to control the widespread use of (early) diagnoses. METHODS: Data and information collection on healthcare services, their accessibility, rate of use, expert consensus, and official regulations. For all three case studies, expert interviews were carried out with main actors. RESULTS: Risk-group screening is not a priority in Austrian federal health policy. Although health promotion and prevention is a national task, examinations for early detection of specific diseases (i.e., carcinoma) are left to the health insurance funds, which delegate the decision to offer early diagnoses to their contracted physicians. In this opportunistic screening, general practitioners or specialists are encouraged by their health insurance funds or motivated by professional guidelines to offer certain examinations. CONCLUSIONS: Screening is a coordinated effort to acquire a grasp of a common disease at an early stage in a specified population. To achieve this objective, a culture of coordination and centralization has to be implemented. The collection of data is an essential element in coordination of decentralized medical interventions as much as quality control is an essential task in looking at and comparing the outcome of interventions. In the three case studies, neither of these two essential criteria were met. Evaluations and scientific evidence on the effectiveness of interventions were not used.     

加强医院科技人才队伍建设应处理好几个关系

科技人才队伍建设是一项复杂的系统工程，要把这项工作做好，就要从实际出发，注意处理好以下８个方面的辩证关系：一是处理好挑战与机遇的辩证关系，即正确分析人才队伍建设的形势；二是处理好人才的外部引进与内部培养的关系，即培养为主引进为辅；三是处理好对人才政治上关心与生活上照顾的关系，即创造拴心留人的良好环境；四是处理好人才的重点培养与平等竞争的关系，即建立人才成长的激励机制；五是处理好学科带头人的选拔与保留的关系，即形成学科人才的梯次配备；六是处理好提高人才临床能力与科研能力的关系，即注重以临床为主的导向；七是处理好人才培养中党委用力与科室使劲的关系，即形成齐抓共管育人才局面；八是处理好人才的近期使用和远期培养的关系，即描绘培养跨世纪人才的宏伟蓝图。     

Adolescent suicide in Quebec and prior utilization of medical services

BACKGROUND: Psychopathology is the main risk factor for adolescent suicide but several studies have shown that only a small proportion of suicide victims receive mental health care during the months preceding their suicide. The goal of this study is to describe the utilization of medical services by Quebec adolescent suicide victims during the year preceding their suicide. METHODS: All suicides of persons aged 19 or less that occurred during a five-year period were retrieved from the Quebec Coroner's database. Corresponding medical services utilization data were retrieved from the Quebec physician payment database (RAMQ) and the Quebec hospitalization database (MED-ECHO). Data were analyzed in terms of types and intensity of medical services (physical or psychiatric), types of providers (general practitioners, psychiatrists, and other medical specialists), and timing of interventions relative to the date of suicide. RESULTS: 78% of all Quebec adolescent suicide victims utilized medical services during the year before their suicide. However, only 12% of all victims received medical attention for psychiatric problems, and only 9.9% met with a psychiatrist during that same period of time. General practitioners and non-psychiatric medical specialists provided medical attention for psychiatric problems to only 5.6% and 0.7% of those future suicide victims with whom they met in outpatient settings, and the intensity of their interventions was low. INTERPRETATION: These results suggest that the level of recognition and treatment of psychopathology in Quebec adolescents who later commit suicide is low, despite the fact that a large proportion of them meet with physicians during the year preceding their suicide. This suggests that information and training programs pertaining to adolescent suicide and psychopathology should be implemented for GPs and non-psychiatric medical specialists as well.     

Why are some medical specialists working part-time, while others work full-time?

Although medical specialists primarily work full-time, part-time work is on the increase, a trend that can be found worldwide. This article seeks to answer the question why some medical specialists work part-time, while others do not although they are willing to work part-time. Two approaches are used. First, we studied reported reasons and as a second approach we used a theoretical model, based on goal-directed behavior and restrictions. A questionnaire was sent to all internists (N=817), surgeons (N=693) and radiologists (N=621) working in general hospitals in The Netherlands. Questions were asked about personal traits, characteristics of the work situation, and motives for working full-time or part-time. Frequencies were reported for the reasons given, and multilevel analysis was used to test the theoretical model. The results show that the reported reasons for working part-time and being willing to work part-time are the same: the importance of family and leisure pursuits. The second approach showed that medical specialists working part-time tend to be female, older, and have children below the age of five. Surgeons are least likely to work part-time. A willingness to work part-time is purely individual and not related to any of the explanatory variables. We conclude that working part-time is related to both professional and personal circumstances. Policy should be aimed at removing the organizational difficulties that obstruct the realization of part-time work. Alternatively, perhaps there should be a change in working hours for all medical specialists. As the majority of all full-time working medical specialists are willing to work part-time, this might indicate that most medical specialists actually prefer "normal" working hours.     

Value of hospital-employed medical officers in rural Australia

The author reports on a unique experience of the issues relating to recruitment and retention of specialist medical staff in a regional hospital in rural Tasmania, Australia. Based on a particular time of a high specialist medical staff resignation, the author identifies the importance to sustainability of rural medical specialists, of quality hospital-employed medical officer (HMO) support staff, a factor that has not been well recognized previously. It was found that HMOs, in particular senior or specialist-in-training HMOs, considerably reduced the workload of rural specialists, especially their after-hours workload. A rating scale to assess the acceptability of after-hours workload for rural specialists, taking into account the impact of HMO support, was developed and is presented in the article. The presence of quality supporting HMOs was a vital recruitment and retention issue for rural medical specialists at that time and can be generalised to other rural situations and should be officially recognised. The observations made support increasing the number of senior or specialist-in-training-HMO positions in rural hospitals in order to retain and recruit more rural specialists.     

Validating an image segmentation program devised for staging lymphoma

Hybrid positron emission tomography–computed tomography (PET–CT) imaging systems are an important tool for assessing the progression of lymphoma. PET–CT systems offer the ability to quantitatively assess lymphocytic bone involvement throughout the body. There is no standard methodology for staging lymphoma patients using PET–CT images. Automatic image segmentation algorithms could offer medical specialists a means to evaluate bone involvement from PET–CT images in a consistent manner. To devise and validate an image segmentation program that may assist staging lymphoma by determining the degree of bone involvement based from PET–CT studies. A custom-made program was developed to segment regions-of-interest from images by utilising an enhanced fuzzy clustering technique that incorporates spatial information. The program was subsequently tested on digital and physical phantoms using four different performance metrics before being employed to extract the bony regions of clinical PET–CT images acquired from 248 patients staged for lymphoma. The algorithm was satisfactorily able to delineate regions-of-interest within all phantoms. When applied to the clinical PET–CT images, the algorithm was capable of accurately segmenting bony regions in less than half of the subjects (n?=?103). The performance of the algorithm was adversely affected by the presence of oral contrast, metal implants and the poor image quality afforded by low dose CT images in general. Significant changes are necessary before the algorithm can be employed clinically in an unsupervised fashion. However, with further work performed, the algorithm could potentially prove useful for medical specialists staging lymphoma in the future.     

军队医疗专业高级技术职务任职标准的研究

目的 比较中高级职称医疗专家对军队高级技术职务任职标准的看法,为全面掌握医疗人员思想情况,科学制定任职标准奠定基础。方法 通过德尔菲法组织两轮专家函询,比较不同职称专家最终赋予各指标权重的差异。结果 不同职称的专家对一级指标的看法基本一致（Kendall协和系数W=0.949,p=0.091）,都认为医疗工作最重要。对二级指标思想品德、医疗工作、教学工作、科研工作、三级指标医疗数量的看法基本一致（W=1,p=0.135;W=0.974,p=0.120;W=0.929,p=0.156;W=0.929,p=0.156;W=1,p=0.135）。对二级指标专业知识、三级指标医疗质量、教学成果的看法不一致（W=0.833,p=0.155;W=0.819,p=0.146;W=0.75,p=0.223）。结论 中高级职称专家在多项指标上意见一致。针对个别意见不同的指标,要客观分析,科学、客观的制定军队医疗专业高级技术职务任职标准。     

The role of allied medical personnel in developing a program of primary medical and sanitary services in the Republic of Afghanistan

When analyzing the role of paramedical and allied medical staff in the development of programmes of primary medical care in the DRA it is pointed out that not only the problems of disease prevention and treatment should be taken into account but also of the resources necessary for this personnel training. Since the DRA has a low literacy level, it is difficult to enroll students into secondary medical schools. As a result the number of medical school-leavers declines. The Ministry of Public Health of the DRA changed the level of general education sufficient for entering secondary medical schools and set up the programme for raising the rates of training of these specialists. At the modern stage of development the DRA should make a wider use of allied medical staff. Examples of such use are found in child and maternal health, control of communicable diseases, etc.     

Cultural adaptation and validation of questionnaires measuring satisfaction with the French health system

Two questionnaires measuring satisfaction of the population with regard to health care offer were constructed from measures validated in the USA (the Consumer Satisfaction Survey Questionnaire or CSS, and the Visit-Specific Satisfaction questionnaire, the VSQ). This work was comprised two stages: i) translation and cultural adaptation of the American instrument to the French health care context, implicating 6 translators, users and experts; and ii) a telephone survey in the general population (n = 706) to test the psychometric qualities of the French instrument (content and internal validity). The French version, the CSS-VF comprises 9 scales: access to primary care, access to secondary care, scope for choice, health cover, communication with and competence of GPs, communication with specialists, competence of specialists, human qualities of practitioners and overall satisfaction. The VSQ-VF, which measures satisfaction with the last medical consultation is unidimensional. The results of the psychometric analyses are good overall, and endorse the use of these scales in assessment studies.     

Specialist training

Specialist training must be reshaped to meet the challenges of new systems for the delivery of health care and rapid expansion in biomedical knowledge. An adequate and affordable supply of trained specialists and generalists able to deal with the health problems of populations served, is the responsibility of governments and policymakers that fund and those who deliver graduate education. Clearly defined objectives for specialist training are needed, linked to planning for the medical workforce size. A balance between numbers of specialists and generalists is essential, although flexibility in programmes should allow individuals to change. Curricula for all specialties should be published. Strategies and methods for delivery of graduate education and training must be coherent with those of medical schools. Training should be planned and sequenced to meet the identified needs of individuals. Those who teach should themselves learn how to train and assess trainees. The location for training should reflect present and future clinical practice if disfunction between medical education and the health of populations served and their need is to be avoided. Specialist training should form the basis for continuing education by encouraging lifelong, evidence-based learning. Any reshaping of specialist training must be consistent with the continuum of medical education. Instruments for assessment of specialists in training have to be refined, based on action research. Ensuring mastery in the competencies of each component of the curriculum is essential. Those competencies will change in consequence of altered societal needs plus advances in technology and biomedical knowledge.     

Settings for learning: the community beyond

The primary objective of medical education to medical students should not be the recruitment of specialists or to provide instructions about highly sophisticated clinic medicine. Our responsibility towards them is rather to enable them to learn about medical practice in its most prevalent context, which is the community medical practice, and to contribute to their general medical education and the health welfare of their community. The health needed by the nation cannot possibly be provided by specialists. It is a task for all doctors. If we agree that the ultimate goal of medical education is to secure health and proper care (whether primary, secondary or tertiary) for the population, medical curricula and learning settings should be open for any modifications that ensure a proper approach to our patients' practicalities, resources and needs. A major modification involved in that process would be for the educational setting to move from the hospital into the community and doctors to acquire the skills and conviction of working as part of a health team, in which they are not necessarily the leaders.     

The language of medicine

The idiom of physicians has evolved from Latin to the genetic code, in parallel with a change in the paradigm of disease. From the end of the 18th century, disease was no longer attributed to a disturbance of the body equilibrium, but to a localised abnormality--of organs, cells and eventually genes. A further step in this direction is the proposed creation of physician-engineers to replace broken parts in the human machinery. Such blind reductionism fails to offer a solution for somatisation, a scourge of modern western societies. Even organ specialists should be able to revert to the holistic notion of 'disequilibrium' to account for unexplained symptoms. For the medical profession, an education in the humanities is no less important than that in science.     

Email teleconsultations: well formulated clinical referrals reduce the need for clinic consultation

We examined how well primary-care physicians formulated their clinical referrals when asking for help with patient-related clinical problems using an email-based teleconsultation service. Over 100 family physicians made use of the service. The specialists were medical school faculty members. The service was initiated in May 1996 with 19 specialists and expanded to 34 specialties over the next five years. A total of 1618 patient-related clinical questions were analysed, the outcome for the analysis being whether specialists recommended a clinic consultation. Specialists recommended a clinic consultation in response to 10% of their clinical questions about patients. There was a strong association between how family physicians formulated their clinical questions and whether the specialist recommended a clinic consultation. When the family physicians specified a clinical task (P < 0.001), intervention (P = 0.004) and outcome (P < 0.001) in their questions, specialists were less likely to recommend a clinic consultation. This influence was independent of the amount of clinical information included with the question (P > 0.05). About 5% of the questions that included all three question components resulted in the recommendation for a clinic consultation, compared with nearly 30% of the questions containing none of these components. How family physicians formulate their clinical questions influences whether specialists request a clinic consultation.     

老年严重多发伤急诊救治结局分析

目的分析老年严重多发伤急诊救治结局的影响因素,探讨提高老年严重多发伤急诊救治成功率的措施。方法回顾性分析237例老年严重多发伤急诊患者的诊治资料,按照救治结局的不同将其分为4组,统计4组患者的一般资料、急诊时相关联动科室情况、不同年份患者救治结局,分析患者因素、医疗因素等对老年严重多发伤急诊救治结局的影响。结果经过分析发现,高龄、多发伤发生前合并疾病多、创伤严重程度高、创伤发生至首次急诊手术时间越长是导致患者救治结局差的主要原因;同时,院前急救指导、患者就诊时的相关联动科室工作效率也对患者救治结局有重要影响。随着时间的推移,医疗设备的添置,急诊救治人员技术的不断提高,不同年份的老年严重多发伤患者的急诊救治结局存在明显的差异,不同年份之间治愈出院率比较,差异有统计学意义(P﹤0.05)。结论影响老年严重多发伤急诊救治结局的主要因素是患者因素和医疗因素,通过改善急诊管理流程、加强急诊设备配备、人员培训等方式可有效改善老年严重多发伤的急救结局。     

Care provided by general practitioners to patients with psychotic disorders: a cohort study

Background

There is a decline in the relative numbers of general practitioners in Germany. Earlier research showed that the professional relationship between general practitioners and specialists is overshadowed by conflicts which could influence medical students not to choose a career in general practice. The aim of the study is to analyse potential discrepancies between general practitioners' self-perception of their professional role and their social self-image in relation to medical specialists and to identify potential barriers that might prevent medical students from becoming a general practitioner.

Methods

A qualitative study design consisting of 16 interviews with general practitioners was chosen. Data analysis was carried out using the qualitative content analysis by Philipp Mayring.

Results

There is a discrepancy between general practitioners' professional self-perception and how they perceive they are viewed by specialists. General practitioners communicate a positive self-perception of their professional role. While general practitioners think that specialists in outpatient care have a positive view on general practice, it is assessed to be negative by specialists working in hospitals and as medical teachers.

Conclusion

The negatively influenced social self-image may originate particularly from "badmouthing" general practitioners at universities and in hospitals. "Badmouthing" demonstrates the importance of the consideration of psychological aspects in medical teachers and hospital specialists acting as role models. Negative comments should be considered as an important factor in influencing medical students and trainees' career choices. These aspects should be more integrated in future medical education curricula.     

The Composition of Rural Hospital Medical Staffs: The Influence of Hospital Neighbors

The local supply of physicians has a strong influence on the availability and the quality of services provided by rural hospitals. Nevertheless, there are no published studies that describe the composition of rural hospital medical staffs and, in particular, the availability of specialists on these staffs. This study uses 1991 and 1994 survey data from rural hospitals located in eight states to describe the specialty composition and factors that influence the presence of specialists on rural hospital medical staffs. The results show a strong, positive association between the level of medical staff specialization in rural hospitals and the level of medical specialization of their closet rural neighbors, which suggests there is competition among rural hospitals based on the composition of the hospital medical staff. Analysis by specialty type, however, indicates that the degree of competition may differ for different types of specialists.     

Various randomized designs can be used to evaluate medical tests

ObjectiveTo explore designs for evaluating the prognostic and predictive value of medical tests and their effect on patient outcome.Study designTheoretical analysis with examples from the medical literature.ResultsFor evaluating the prognostic value of a test, one can include the test at baseline in prognostic studies. To evaluate the value of test in predicting treatment outcome, the test results can be used as baseline information in randomized controlled trials of treatment. To compare the prognostic or predictive value of two or more tests, the test result combinations can be used as baseline information. To evaluate the effect on patient outcome, randomized controlled trials of test strategies are an option. Randomization can apply to all tested or be restricted to specific subgroups, such as those with discordant test results, to increase the efficiency of trials.ConclusionThe prognostic and predictive value of medical tests can and should be evaluated, to demonstrate the test's ability to guide clinical decision making and to improve patient outcome. Various randomized designs can be used to evaluate the effects on testing on patient outcome.     

A snail leaves trails--how delayed provision of information affects the general practitioner and patient

Two patients were seen by medical specialists at hospital, but the general practitioner received their discharge letters too late. The first patient was a man aged 50 referred to the emergency department of the hospital with suspected pulmonary embolism. He was sent home and was found dead two days later. The cause of death was pulmonary embolism. The day after, the GP received the discharge letter from the hospital, in which no attention was paid to the possibility of a pulmonary embolism. The second patient, a 57-year-old man, was send to the hospital by his GP for a suspected urinary tract infection. The urologist diagnosed a prostate carcinoma, but the GP was not informed for 4 months. If the GP had been informed in time, the death of the first patient maybe could have been prevented. The second patient was very anxious and uncertain for a long time, as the GP could not offer appropriate guidance and support, due to a lack of information. In both cases the medical specialist did not follow the guidelines for mutual communication established by the professional associations of GPs and medical specialists.