A predictive Bayesian approach to risk analysis in health care

Background  

The Bayesian approach is now widely recognised as a proper framework for analysing risk in health care. However, the traditional text-book Bayesian approach is in many cases difficult to implement, as it is based on abstract concepts and modelling.     

A practical approach to ichthyoses with systemic manifestations

Inherited ichthyoses are rare disorders in terms of patient numbers, but abundant in terms of clinical‐genetic subtypes. These disorders are often associated with severe systemic manifestations, in addition to significant medical, cosmetic and social problems. There are 17 subtypes of syndromic ichthyosis identified so far and most patients with these syndromes are living in countries with high consanguinity rates. Frequently, clinicians cannot make a definitive diagnosis and patients are not managed properly owing to the rarity and complexity of these disorders. These difficulties make this group of ichthyosis and the patients living with them ‘orphan’. After skin and skin appendages, nervous system is the most frequently involved system in ichthyosis syndromes. Thus, association of ichthyosis with neurological symptoms provides an important clue for diagnosis. In this article, we aim to increase clinicians' comprehension of ichthyosis syndromes by providing a symptomatology‐based approach based on this observation. Additionally, we provide a review of ichthyosis syndromes, with special emphasis on neurological symptoms, hoping to attract interest to this complicated field.     

CLARION: a novel interprofessional approach to health care education.

The authors describe the development and impact of CLARION, a student-run organization at the University of Minnesota founded in 2001 and dedicated to furthering interprofessional education for health professions students. CLARION's student founders recognized that three recent reports from the Institute of Medicine will fuel significant changes in health professions education. Moreover, they deduced that targeted, interprofessional education in the preclinical years could provide fundamental skills and understanding needed to make today's patient care safer and more effective. By engaging health care professionals and faculty, CLARION creates and conducts extracurricular, interprofessional experiences for students that are reflective of the six IOM aims for health care. Student members are from four separate schools of the university's academic health center: medicine, nursing, pharmacy, and public health. The organization's capstone event, the Interprofessional Case Competition, challenges interprofessional teams of students to compete in conducting and presenting a root cause analysis of a fictitious sentinel event. The interprofessional organizational structure of the CLARION board models the kind of interprofessional equality needed to effectively solve problems in the health care system. The interaction among students from different health professions has led them to many new understandings about health care and the realization that many fundamental biases about other professions are firmly rooted in students before they enter the workplace. CLARION has enabled continued professional development of students, faculty, and practitioners, leading individual students to enhanced understanding of the health care system. It is a grassroots catalyst that has prompted faculty to reexamine traditional health professions curricula and look for ways to integrate more interprofessional opportunities into it.     

A simulation model approach to analysis of the business case for eliminating health care disparities

Background  

Purchasers can play an important role in eliminating racial and ethnic disparities in health care. A need exists to develop a compelling "business case" from the employer perspective to put, and keep, the issue of racial/ethnic disparities in health care on the quality improvement agenda for health plans and providers.     

Specifying computer-based counseling systems in health care: A new approach to user-interface and interaction design

Computer-based counseling systems in health care play an important role in the toolset available for medical doctors to inform, motivate and challenge their patients according to a well-defined therapeutic goal. The design, development and implementation of such systems require close collaboration between users, i.e. patients, and developers. While this is true of any software development process, it can be particularly challenging in the health counseling field, where there are multiple specialties and extremely heterogeneous user groups. In order to facilitate a structured design approach for counseling systems in health care, we developed (a) an iterative three-staged specification process, which enables early involvement of potential users in the development process, and (b) a specification language, which enables an author to consistently describe and define user interfaces and interaction designs in a stepwise manner. Due to the formal nature of our specifications, our implementation has some unique features, like early execution of prototypes, automated system generation and verification capabilities.     

A new approach to medicare: implications for health care reform and for medical education.

Medicare Parts A and B engender a system of payment and delivery at odds with that of health maintenance organizations (HMOs). Most evident in the conflicting incentives and requirements levied on primary care physicians participating today in both traditional Medicare and HMOs, the dichotomy has vitiated the promise of managed care and constitutes a significant factor in both the rising cost inflation in health care and the growing dissatisfaction of patients, physicians, payers, and insurers. The resulting impact affects the robustness and quality of medical education as well as the character and quality of health care delivery. An innovative incentive-based system of payment and delivery is proposed as an alternative option for Medicare, with expectation that the system, which the authors title Medicare-New, or Part N, could trigger a more effective approach to health care reform for Medicare, foster more rational support for medical education and the care of the indigent, and benefit private insurance programs as well. Positive changes in both public and private sectors would strengthen both medical education and the access to and quality of health care throughout the nation.     

A clinical approach to autoantibody testing in systemic autoimmune rheumatic disorders

Musculoskeletal (MSK) disorders constitute one of the most common clinical presentations to clinical care givers. Within this category of illnesses, systemic autoimmune rheumatic diseases (SARD) such as systemic lupus erythematosus (SLE), systemic sclerosis (SSc), Sj?gren's syndrome (SjS) and rheumatoid arthritis (RA) are included in the differential diagnosis. A hallmark of SARD is the production of autoantibodies, which are routinely requested as a guide to diagnosis and clinical decision making. The field of serological tests, including the detection of autoantibodies, is complex and often leads to confusion and misunderstanding. When used appropriately, autoantibodies can be a valuable adjunct to the diagnosis, and occasionally therapy and prognosis, of SARD. The role of autoantibody testing and a 'practical' approach to using these tests is the focus of this paper.     

A systemic evolutionary approach to cancer: Hepatocarcinogenesis as a paradigm

The systemic evolutionary theory of cancer pathogenesis posits that cancer is generated by the de-emergence of the eukaryotic cell system and by the re-emergence of its archaea (genetic material and cytoplasm) and prokaryotic (mitochondria) subsystems with an uncoordinated behavior. This decreased coordination can be caused by a change in the organization of the eukaryote environment (mainly chronic inflammation), damage to mitochondrial DNA and/or to its membrane composition by many agents (e.g. viruses, chemicals, hydrogenated fatty acids in foods) or damage to nuclear DNA that controls mitochondrial energy production or metabolic pathways, including glycolysis. Here, we postulate that the two subsystems (the evolutionarily inherited archaea and the prokaryote) in a eukaryotic differentiated cell are well integrated, and produce the amount of clean energy that is constantly required to maintain the differentiated status. Conversely, when protracted injuries impair cell or tissue organization, the amount of energy necessary to maintain cell differentiation can be restricted, and this may cause gradual de-differentiation of the eukaryotic cell over time. In cirrhotic liver, for example, this process can be favored by reduced oxygen availability to the organ due to an altered vasculature and the fibrotic barrier caused by the disease. Thus, hepatocarcinogenesis is an ideal example to support our hypothesis. When cancer arises, the pre-eukaryote subsystems become predominant, as shown by the metabolic alterations of cancer cells (anaerobic glycolysis and glutamine utilization), and by their capacity for proliferation and invasion, resembling the primitive symbiotic components of the eukaryotic cell.     

A novel approach to training pediatrics primary care residents

From 1984 through 1987, 12 pediatrics residents from the Yale University School of Medicine took part in a three-year program that emphasized four areas in primary care: well-child care, developmental-behavioral pediatrics, chronic illness, and adolescent medicine. Program evaluation included a videotaped interview, an assessment of the residents' skill in the management of patients' behavioral problems, and multiple-choice examinations. The program residents improved their interviewing skills more than did the comparison residents, particularly in the process and psychosocial content areas, and also did better in the management of patients' behavioral problems. There was no difference in factual knowledge of behavioral and developmental pediatrics and adolescent medicine. While traditional residency training in primary care may provide the resident with comparable cognitive knowledge, such training may not always improve the resident's ability to apply the knowledge in the primary care setting.