Chronic diseases: what are they? How are they inherited?

BACKGROUND: Chronic diseases (CD), miasms or reactional modes, remain one of the darkest concepts of homeopathy. They are supposed to be heritable and originate after suppression of other diseases. Besides this nothing is known about how they might produce the large number of diseases mentioned in homeopathic books. They have been described in a variety of terms, ranging from Kent and Gathak's spiritual or metaphysic conception; the biological-allergic by Paschero, and, Robert's materialist-nutritional point of view. Flores-Bejar et al have outlined an approach to CD from a cellular and bioenergetic point of view. RESULTS: Cellular pathology has led to an understanding of the basic repair mechanisms of every cell and tissue. These mechanisms exist in order to avoid necrosis or cell death. The main mechanisms are molecular repair, apoptosis and cell proliferation. Failure of these mechanisms leads to 'dysrepair'. Consequences of these 'dysrepair' mechanisms resemble the homeopathic reactional modes or miasms. These abnormal or 'dysrepair' mechanisms are probably the basis of miasms or reactional modes. A new interpretation of miasms is proposed: Psora corresponds to the dysmolecular reactional mode. Syphilis corresponds to dysapoptotic reactional mode. Sycosis corresponds to dysproliferative reactional mode.     

Blood cell microRNAs: what are they and what future do they hold?

The advent of blood component storage revolutionized health care by allowing for a managed supply of transfusion quality blood products. During storage, blood components undergo a series of physiological changes that affect the product quality, which ultimately can interfere with the safety and efficacy of such products after transfusion. Despite continuous improvements in blood component quality and safety, it is still desirable to have in vitro standard markers of measurable characteristics that predict blood component safety and efficacy in vivo following their transfusion. Over the last decade, research on the feasibility of using microRNAs as biomarkers for various clinical manifestations and cellular pathologies has exploded. Here, we review the literature on blood cell microRNAs and discuss the potential of these molecules to act as measurable characteristics (product biomarkers) for stored blood component quality and safety.     

Clinical prediction rules: What are they and what do they tell us?

QUESTION: Clinical prediction rules are research-based tools that quantify the contributions of relevant patient characteristics to provide numeric indices that assist clinicians in making predictions. Clinical prediction rules have been used to describe the likelihood of the presence or absence of a condition, assist in determining patient prognosis, and help the classification of patients for treatment. The recent rapid rise in the use of clinical prediction rules raises questions about the conditions under which they may be used most appropriately. What is the potential role of clinical prediction rules in physiotherapy practice and what are the strategies by which clinicians can determine their appropriate use for a given clinical setting? CONCLUSION: Clinical prediction rules use quantitative methods to build upon the body of literature and expert opinion and can provide quick and inexpensive estimates of probability. Clinical prediction rules can be of great value to assist clinical decision making but should not be used indiscriminately. They are not a replacement for clinical judgment and should complement rather than supplant clinical opinion and intuition. The development of valid clinical prediction rules should be a goal of physiotherapy research. Specific areas in need of attention include deriving and validating clinical prediction rules to screen patients for potentially serious conditions for which current tests lack adequate diagnostic accuracy or have unacceptable cost and risk, and to assist in classification of patients for treatments that are likely to result in substantially different outcomes in heterogeneous groups of patients.     

Internet-based patient information systems: what are they, why are they here, how will they be used, and will they work?

Web-based patient information systems are an emerging tool in the drive towards improving efficiency and effectiveness of health care. Providers and health plans may be able to achieve three key objectives with these systems: improve the health status of patients, improve marketing programs, and reduce costs. To discover what we know about these systems, we examine how they perform today, review the trends that are shaping their development, present a case study of a large East Coast HMO, and postulate future trends.     

Parental expectations from three different perspectives: what are they based on?

The aim of this article is to highlight parental expectations as they are expressed in three different studies: an intervention programme, a study on conductive education and a study on information and communication technology. Traditions and views on knowledge within school and child and youth habilitation may affect the expectations of the family. The possibilities of a family to be part of the planning process of the child's habilitation and tutoring are important. Common for all three studies is that the parents, when they participated in projects or courses, increased their hopes for improvements for the child and increased the possibilities for activity and communication. Even if the results did not yield exactly what they had expected, they developed new and other expectations, for example, that their experiences would result in long-term development.     

Registered nurses working in oncology outpatient clinics: what are they doing?

Several studies have indicated that outpatient nurses are often under-utilised with regard use of their professional skills with an over-reliance on undertaking tasks that could be done by others. Many of these studies were undertaken overseas. The aim of this study was to explore the current situation in England. A cross-sectional questionnaire survey of trained nurses working in hospitals in England with radiotherapy facilities was carried out. Completed questionnaires were received from 127 nurses who worked in 42 of the 48 hospitals sampled. This represented a response rate of 53% of the 240 questionnaires originally mailed. Almost all the nurses were engaged in direct care/education of patients and their families in the outpatient department. However, 68% n = 86) were required to set up consultation rooms, 60% (n = 76) locating and preparing records for the clinic, 53% (n = 67) scheduling appointments, and 46% (n = 58) organising transport. Those sampled felt other staff could undertake these tasks. Nearly all grades of staff represented indicated they would like to spend less time on clinic functions, and more time on patient counselling/education activities. Overall, clinical nurse specialists appeared to be the most satisfied group with their work, and F grade staff nurses the least satisfied. This study has shown that many trained nurses who work in oncology outpatient departments are undertaking tasks that take them away from direct patient care. This impacts upon job satisfaction and also prevents staff from engaging in professional development. Further work needs to be undertaken to investigate the skill mix of staff who work in these areas so that the recommendations set out in recent Government reports on cancer care can be fulfilled.     

The long-term outcomes of mechanical ventilation: what are they and how should they be used?

In the critical care setting, usually the most important outcome is survival. However, this is not the only important outcome of critical care. There are increasing data that the patient's quality of life and functional status can be affected long after an intensive care unit stay, and some data suggest that mechanical ventilation strategies could influence those outcomes. Critical care clinicians' decisions regarding mechanical ventilation and related treatments such as level of sedation might have more profound and far-reaching residual effects than has been previously recognized. To deliver effective, cost-effective, and patient-centered care, critical-care clinicians must consider outcomes other than survival. These outcomes include such diverse concepts as quality of life, functional status, and neuropsychological function. This review addresses theoretical and practical challenges to measuring and interpreting those other outcomes.     

Mechanisms: what are they evidence for in evidence‐based medicine?

Even though the evidence‐based medicine (EBM) movement labels mechanisms a low quality form of evidence, consideration of the mechanisms on which medicine relies, and the distinct roles that mechanisms might play in clinical practice, offers a number of insights into EBM itself. In this paper, I examine the connections between EBM and mechanisms from several angles. I diagnose what went wrong in two examples where mechanistic reasoning failed to generate accurate predictions for how a dysfunctional mechanism would respond to intervention. I then use these examples to explain why we should expect this kind of mechanistic reasoning to fail in systematic ways, by situating these failures in terms of evolved complexity of the causal system(s) in question. I argue that there is still a different role in which mechanisms continue to figure as evidence in EBM: namely, in guiding the application of population‐level recommendations to individual patients. Thus, even though the evidence‐based movement rejects one role in which mechanistic reasoning serves as evidence, there are other evidentiary roles for mechanistic reasoning. This renders plausible the claims of some critics of EBM who point to the ineliminable role of clinical experience. Clearly specifying the ways in which mechanisms and mechanistic reasoning can be involved in clinical practice frames the discussion about EBM and clinical experience in more fruitful terms.     

Illness perceptions of low back pain patients in primary care: what are they, do they change and are they associated with outcome?

We describe the illness perceptions of patients with low back pain, how they change over 6 months, and their associations with clinical outcome. Consecutive patients consulting eight general practices were eligible to take part in a prospective cohort study, providing data within 3 weeks of consultation and 6 months later. Illness perceptions were measured using the Revised Illness Perception Questionnaire (IPQ-R). Clinical outcome was defined using the Roland and Morris Disability Questionnaire (RMDQ) and patients’ global rating of change. Associations between patients, perceptions and poor outcome were analysed using unadjusted and adjusted risk ratios (RR) and 95% confidence intervals. 1591 completed questionnaires were received at baseline and 810 at 6 months. Patients had a mean age of 44 years and 59% were women. Mean (SD) RMDQ score at baseline was 8.6 (6.0) and 6.2 (6.1) at 6 months. 52% and 41% of patients had a poor clinical outcome at 6 months using RMDQ and global rating scores, respectively. There were strong, statistically significant, associations (RRs of 1.4 and over) between IPQ-R baseline consequences, timeline acute/chronic, personal control and treatment control scores and poor outcome. Patients who expected their back problem to last a long time, who perceived serious consequences, and who held weak beliefs in the controllability of their back problem were more likely to have poor clinical outcomes 6 months after they consulted their doctor. These results have implications for the management of patients, and support the need to assess and address patients’ cognitions about their back problems.     

Handicap questionnaires: what do they assess?

Background and purpose: There is an increasing need to get insight into the social and societal impact of chronic conditions on a person's life, i.e. person-perceived handicap. The purpose of this study is to report how current handicap questionnaires assess handicap. Method: A literature search using both Medline and the database of the Dutch Institute of Allied Health Professions (NPi) was conducted for handicap questionnaires. Questionnaires were included if addressing handicaps or life roles, environmental influences and social consequences of a disease. Excluded were questionnaires focusing on only impairments, disabilities or quality of life. Results and conclusion: 20 questionnaires were identified. Handicap is not uniformly defined in these questionnaires. Based on different concepts, the various questionnaires encompass different domains and different aspects are emphasized in similar domains. Fourteen questionnaires assess societyperceived handicaps, and do not address the life roles, care needs or individual problem-experience. Six questionnaires are to some extent person-perceived, but a generic person-perceived handicap questionnaire could not be identified. It is concluded that development of a generic person-perceived handicap questionnaire is essential for adequate assessment of needs, outcome, and relevance of rehabilitation interventions from the individual's point of view.     

SGLT2 inhibitors: are they safe?

Sodium–glucose linked transporter type 2 (SGLT2) inhibitors are a relatively new class of antidiabetic drugs with positive cardiovascular and kidney effects. The aim of this review is to present the safety issues associated with SGLT2 inhibitors. Urogenital infections are the most frequently encountered adverse events, although tend to be mild to moderate and are easily manageable with standard treatment. Although no increased acute kidney injury risk was evident in the major trials, the mechanism of action of these drugs requires caution when they are administered in patients with extracellular volume depletion or with drugs affecting renal hemodynamics. Canagliflozin raised the risk of amputations and the rate of fractures in the CANVAS trial, although more data are necessary before drawing definite conclusions. The risk of euglycemic diabetic ketoacidosis seems to be minimal when the drugs are prescribed properly. Regarding other adverse events, SGLT2 inhibitors do not increase the risk of hypoglycemia even when co-administered with insulin, but a decrease in the dose of sulphonylureas may be needed. The available data do not point to a causative role of SGLT2 inhibitors on malignancy risk, however, these drugs should be used with caution in patients with known hematuria or history of bladder cancer. SGLT2 inhibitors seem to be safe and effective in the treatment of diabetes but more studies are required to assess their long-term safety.