Cardiovascular mortality among immigrants to England and Wales

The Office of Population Censuses and Surveys (OPCS) is analysing mortality of immigrants to England and Wales. On average, immigrants are healthier and have a lower mortality then people who remained in the country of origin—demonstrating the ‘selection’ effect of migration. For cardiovascular diseases, the mortality of immigrants reflects the pattern in the country from which they came. Thus, immigrants to England and Wales from France, Spain and Italy (low-rate countries) have a low standardized mortality ratio from ischaemic heart disease. Immigrants from the West Indies and Africa have a high mortality from hypertension and cerebrovascular disease. It is noted that the mortality from ischaemic heart disease is high among immigrants from India and Pakistan.     

A New Approach to Bacterial Vaccines

Immunizing antigens against only 10 bacterial diseases—cholera, diphtheria, paratyphoid, pertussis, plague, scarlet fever, staphylococcal disease, tetanus, tuberculosis and typhoid—have been licensed for sale in Canada and the United States. Convincing evidence of efficacy is available for only four of these—diphtheria and tetanus toxoids, and pertussis and typhoid vaccines.

The principles which determine the efficacy of different immunizing antigens are not always the same. Toxoids, for example, stimulate the formation of antitoxin-producing mechanisms which can neutralize toxins produced by invading organisms, thereby rendering them harmless. Conversely, vaccines stimulate the formation of antibacterial mechanisms which stop the growth of organisms before they can produce disease.

Use of enzyme-lysed vaccines for prevention of staphylococcal disease represents a new approach in vaccine research. Animal tests have shown lysed vaccines to be 10 to 100 times less toxic, and about eight times more effective, than whole bacterial vaccines. Studies with lysed vaccines for other diseases are now in progress.

     

Automation bias: a systematic review of frequency,effect mediators,and mitigators

Automation bias (AB)—the tendency to over-rely on automation—has been studied in various academic fields. Clinical decision support systems (CDSS) aim to benefit the clinical decision-making process. Although most research shows overall improved performance with use, there is often a failure to recognize the new errors that CDSS can introduce. With a focus on healthcare, a systematic review of the literature from a variety of research fields has been carried out, assessing the frequency and severity of AB, the effect mediators, and interventions potentially mitigating this effect. This is discussed alongside automation-induced complacency, or insufficient monitoring of automation output. A mix of subject specific and freetext terms around the themes of automation, human–automation interaction, and task performance and error were used to search article databases. Of 13 821 retrieved papers, 74 met the inclusion criteria. User factors such as cognitive style, decision support systems (DSS), and task specific experience mediated AB, as did attitudinal driving factors such as trust and confidence. Environmental mediators included workload, task complexity, and time constraint, which pressurized cognitive resources. Mitigators of AB included implementation factors such as training and emphasizing user accountability, and DSS design factors such as the position of advice on the screen, updated confidence levels attached to DSS output, and the provision of information versus recommendation. By uncovering the mechanisms by which AB operates, this review aims to help optimize the clinical decision-making process for CDSS developers and healthcare practitioners.     

EHR Safety: The Way Forward to Safe and Effective Systems

Diverse stakeholders—clinicians, researchers, business leaders, policy makers, and the public—have good reason to believe that the effective use of electronic health care records (EHRs) is essential to meaningful advances in health care quality and patient safety. However, several reports have documented the potential of EHRs to contribute to health care system flaws and patient harm. As organizations (including small hospitals and physician practices) with limited resources for care-process transformation, human-factors engineering, software safety, and project management begin to use EHRs, the chance of EHR-associated harm may increase. The authors propose a coordinated set of steps to advance the practice and theory of safe EHR design, implementation, and continuous improvement. These include setting EHR implementation in the context of health care process improvement, building safety into the specification and design of EHRs, safety testing and reporting, and rapid communication of EHR-related safety flaws and incidents.     

A comparison of general and disease-specific machine learning models for the prediction of unplanned hospital readmissions

Unplanned hospital readmissions are a burden to patients and increase healthcare costs. A wide variety of machine learning (ML) models have been suggested to predict unplanned hospital readmissions. These ML models were often specifically trained on patient populations with certain diseases. However, it is unclear whether these specialized ML models—trained on patient subpopulations with certain diseases or defined by other clinical characteristics—are more accurate than a general ML model trained on an unrestricted hospital cohort. In this study based on an electronic health record cohort of consecutive inpatient cases of a single tertiary care center, we demonstrate that accurate prediction of hospital readmissions may be obtained by general, disease-independent, ML models. This general approach may substantially decrease the cost of development and deployment of respective ML models in daily clinical routine, as all predictions are obtained by the use of a single model.     

Doctors' authoritarianism in end-of-life treatment decisions. A comparison between Russia, Sweden and Germany

Objectives—The study was performed in order to investigate how end-of-life decisions are influenced by cultural and sociopolitical circumstances and to explore the compliance of doctors with patient wishes Participants and measurement—Five hundred and thirty-five physicians were surveyed in Sweden (Umeå), Germany (Rostock and Neubrandenburg), and in Russia (Arkhangelsk) by a questionnaire. The participants were recruited according to availability and are not representative. The questionnaire is based on the one developed by Molloy and co-workers in Canada which contains three case vignettes about an 82-year-old Alzheimer patient with an acute life-threatening condition; the questionnaire includes different levels of information about his treatment wishes. We have added various questions about attitudes determining doctors'' decision making process (legal and ethical concerns, patient''s and family wishes, hospital costs, patient''s age and level of dementia and physician''s religion). Results—Swedish physicians chose fewer life-prolonging interventions as compared with the Russian and the German doctors. Swedish physicians would perform cardiopulmonary resuscitation (CPR) in the event of a cardiac arrest less frequently, followed by the German doctors. More than half the Russian physicians decided to perform CPR irrespective of the available information about the patient''s wishes. Level of dementia emerged as the most powerful determining attitude-variable for the decision making in all three countries. Conclusions—The lack of compliance with patient wishes among a substantial number of doctors points to the necessity of emphasising ethical aspects both in medical education and clinical practice. The inconsistency in the treatment decisions of doctors from different countries calls for social consensus in this matter. Key Words: End-of-life decision • DNR order • advance directive • physicians • cross-cultural comparison • survey     

A survey of the dose of ACE inhibitors prescribed by general physicians for patients with heart failure

AIM—To describe the pattern of angiotensin converting enzyme (ACE) inhibitor doses prescribed by general physicians for patients with chronic heart failure and to review the current evidence favouring the use of higher doses.
DESIGN—A retrospective survey of the medications of 125 patients with chronic heart failure (in both inpatient and outpatient settings) was carried out between December 1999 and February 2000.
RESULTS—Altogether 18.4% of patients surveyed were receiving no ACE inhibitor, the majority of these (65%) having a contraindication to such an agent. Of those patients who were prescribed an ACE inhibitor, 65% were receiving a high dose. The majority of patients who were prescribed a low dose of ACE inhibitor had no identifiable contraindication to receiving a higher dose. Of all patients with chronic heart failure studied, 25% were receiving either no ACE inhibitor or only a low dose in the absence of contraindication.
CONCLUSION—Since no objectively measurable variable has been shown to share a clear relationship with the outcome benefits of ACE inhibitors, no convenient and reliable assessment exists for determining when an adequate dose has been reached for each patient. There is an abundance of evidence favouring high dose ACE inhibitors in heart failure; evidence for the role of low doses is much less clear. The fact that only half of the patients with chronic heart failure were found to be receiving a high dose of ACE inhibitor is probably testimony to inaccurate perceptions and unreliable assumptions among physicians. It is likely that a change in current prescribing patterns would benefit patients with chronic heart failure.


     

基于岗位需求的远程护理学专业课程体系改革的实践研究

目的 探索构建基于岗位需求的远程护理学专业专升本课程体系.方法 遵循“从初学者到专家”的职业成长规律,按照工作过程系统化,即工学结合一体化的课程模式搭建课程体系.结果 课程体系将专业基础课程与专业课程进行融合,根据岗位实践和发展需要设置相应课程.同时增加了选修课程的比例,满足不同学生学习的需求.结论 打破学科界限,按照职业成长发展规律构建远程护理学专业专升本课程体系并实施教学,符合在职成人学习需求,应当继续实践和完善.     

Information seeking and social support in online health communities: impact on patients' perceived empathy

Objective

Many healthcare organizations (HCOs) including Kaiser Permanente, Johns Hopkins, Cleveland Medical Center, and MD Anderson Cancer Center, provide access to online health communities as part of their overall patient support services. The key objective in establishing and running these online health communities is to offer empathic support to patients. Patients'' perceived empathy is considered to be critical in patient recovery, specifically, by enhancing patient''s compliance with treatment protocols and the pace of healing. Most online health communities are characterized by two main functions: informational support and social support. This study examines the relative impact of these two distinct functions—that is, as an information seeking forum and as a social support forum—on patients'' perceived empathy in online health communities.

Design

This study tests the impact of two variables that reflect the above functions of online health communities—information seeking effectiveness and perceived social support—on perceived empathy. The model also incorporates the potential moderating effect of homophily on these relationships.

Measurements

A web-based survey was used to collect data from members of the online health communities provided by three major healthcare centers. A regression technique was used to analyze the data to test the hypotheses.

Results

The study finds that it is the information seeking effectiveness rather than the social support which affects patient''s perceived empathy in online health communities run by HCOs. The results indicate that HCOs that provide online health communities for their patients need to focus more on developing tools that will make information seeking more effective and efficient.     

The Contributions of Biomedical Informatics to the Fight Against Bioterrorism

A comprehensive and timely response to current and future bioterrorist attacks requires a data acquisition, threat detection, and response infrastructure with unprecedented scope in time and space. Fortunately, biomedical informaticians have developed and implemented architectures, methodologies, and tools at the local and the regional levels that can be immediately pressed into service for the protection of our populations from these attacks. These unique contributions of the discipline of biomedical informatics are reviewed here.Current outbreaks of anthrax exposure and cases test our health care delivery and public health systems with threats of large spatial scope—the entire nation—that demand a very short temporal latency in our responses. Other potential bioterrorist attacks only increase the dimensions of this unprecedented challenge. The dimensions, however, are not unprecedented; rather, they are quite familiar to many researchers in biomedical informatics over the last 40 years. The task of comprehensive real-time monitoring on the regional and national scale has been the subject of full-fledged design and large-scale implementations led by biomedical informaticians.Nonetheless, we run the risk that the knowledge gained in the decades of informatics research will not, in the appropriate haste to safeguard the population of the United States from the threats of bioterrorism, be reflected in the national public health information infrastructure. And that may result not only in wasteful expenditures but also in ineffective measures to prevent future attacks on the health of the U.S. population. This is, therefore, a timely juncture to review some of the most germane contributions from the biomedical informatics armamentarium to the tasks at hand, particularly data acquisition, threat detection, and response.     

Amoxycillin: pharmacokinetic studies in normal subjects, patients with pernicious anaemia and those with renal failure

This paper presents data on the absorption and disappearance of a new semisynthetic antibiotic—amoxycillin—in patients with pernicious anaemia and those with renal failure. Absorption of this drug is unimpaired in these patients. Adequate serum and urine levels are obtained even in patients with creatinine clearance levels below 10 ml/min. The half-life of this drug is markedly prolonged in patients undergoing regular dialysis therapy, and a single 250 mg dose will provide adequate serum levels for 24 hr, if this is given after dialysis is complete.     

Consultations and referrals for dyspepsia in general practice--a one year database survey

OBJECTIVE—Dyspepsia usually presents first in primary care. There are many reasons for referral including urgent problems (for example, haematemesis and melaena), treatment failure, or to exclude serious pathology. Referral will change the population characteristics of primary and secondary care dyspeptics. Many of the guidelines for primary care dyspepsia, however, are based on secondary care research on these referred patients. The aim of this study was to describe the prevalence of dyspepsia in general practice, the characteristics of patients presenting with dyspepsia in primary care, and the clinical and non-clinical determinants of referral in these patients.
DESIGN—Cross sectional survey of the consultation records of patients presenting with dyspepsia in primary care during a one year period.
METHODS—Dyspeptic patients who consulted their general practitioner (GP) in 1997 were selected on the basis of International Classification of Primary Care codes using a computer search among 20 sentinel practices affiliated with the Utrecht Network of General Practitioners. Cross tables and logistic regression analysis were carried out to reveal patient characteristics and determinants of referral.
RESULTS—The prevalence of dyspepsia presenting in primary care in 1997 was 3.4% (1740/48958). These patients were usually not referred during the first consultation. Men, elderly patients, and patients with a previous history of dyspepsia were referred to secondary care more frequently than other dyspeptic patients. Patients diagnosed with both irritable bowel syndrome and dyspepsia were at risk of being referred most.
CONCLUSION—Dyspepsia is a frequently occurring complaint in primary care and patients are usually treated by their GP. Besides clinically relevant reasons for referral, dyspeptic patients with irritable bowel syndrome seem to be more "at risk" of being referred to secondary care than other dyspeptic patients. The differences between primary and secondary care dyspeptic patients should be taken into account when interpreting research for guideline purposes. Further research is needed to clarify the background of the relation between irritable bowel syndrome and dyspepsia and its influence on referral.


     

Epstein-Barr virus antibodies in patients with ataxia-telangiectasia and other immunodeficiency diseases

An unusual antibody response to the Epstein—Barr virus (EBV) has been noted in patients with ataxia—telangiectasia. Of a group of 16 such patients 8 were found to have antibodies in their serum to the EBV viral capsid antigen (VCA), and 4 of them also had antibodies to the EBV early antigen (EA); antibodies to the nuclear antigen (EBNA), however, were absent in 3 of the 8. The antibody pattern persisted for more than 2 years in the patients available for follow-up study. In comparison, of 24 patients with various other immunodeficiency syndromes 9 were found to have EBV-VCA antibodies in their serum, but none of the 9 had EA antibodies and 3 lacked EBNA antibodies. Two other groups of subjects, all of whom had EBV-VCA and EBNA antibodies in their serum late after an EBV infection, were also studied; 82 had infectious mononucleosis and 55 were healthy and had no such history. EA antibodies were detected in 45 of the first group during the acute phase of the illness but persisted in only 6 of the 68 who were followed up for more than 2 years, and they were detected in only 7 of the second group.

All eight lymphoblastoid cell lines established from the peripheral blood of the four patients with ataxia—telangiectasia who are still available for follow-up study express EBV-VCA, whereas most similar cell lines established from normal individuals express only EBNA. In two of these patients cell-mediated immunity, as assessed from lymphocyte transformation induced by mitogens, was markedly decreased but autologous cell-mediated immune regression of EBV-induced transformation of B (bone-marrow-derived)-lymphocytes was normal. The percentage of T (thymus-derived)-helper cells was greatly decreased in two of the three patients in whom it was measured, and the percentage of T-suppressor cells was greatly increased in one of them, but the percentage of total T-lymphocytes was within normal limits in all three.

The possible significance of these findings — in particular, the persistence of EA antibodies and the diminished restriction of expression of EA — in the late development of tumours after an EBV infection in patients with ataxia-telangiectasia deserves careful attention. Finally, the apparent correlation between immunoglobulin deficiency and poor or absent EBNA antibody response warrants further study.

     

Glucose intolerance, diabetes mellitus and atherosclerosis; prospects for prevention

Increased prevalence and incidence of arterial disease has become the major cause of disability and death in diabetics in Western cultures—but is much less common among Japanese and African diabetics. In the West, the presence of lesser, ‘subdiabetic’ degrees of glucose intolerance are probably independent ‘risk factors’ for accelerated atherosclerosis. Although many explanations for the link have been advanced—among them direct effects of glucose and insulin on the arterial wall, less direct effects of circulating lipoproteins, abnormalities of blood clotting and fibrinolysis and elevated blood pressure, even the influence of antidiabetic treatment itself—none has been clearly established. Nevertheless there is scope and hope that appropriate measures may reduce the raised arterial disease risk in the diabetic.     

Gallstones and cholecystectomy in modern Britain

BACKGROUND—It has been suggested that gallstone disease is now commoner, and that this might explain an increase in cholecystectomy rates, though conclusive evidence has been lacking.
METHODS—All the non-forensic necropsy results for Dundee 1953-98 were examined to assess the prevalence of gallstone disease. The NHS Scotland annual cholecystectomy figures were extracted from their earliest availability in 1961 up to the present. The subgroup of patients from Dundee was analysed separately, as were laparoscopic procedures, which were recorded from 1991.
RESULTS—Gallstone disease was much commoner in 1974-98 than in 1953-73. Increasing age was the main determinant of gallstone disease. Though gallstone disease was commoner in women than men aged 40-89, there was no sex difference under 40 or over 90 years. Cholecystectomy became much commoner in the 1960s when frequency of gallstone disease did not change. It increased further in the 1970s, peaking in 1977-8. There was a gradual fall in rates in the 1980s when gallstone prevalence remained high. There was a further moderate rise in the 1990s after the wide introduction of laparoscopic cholecystectomy. Cholecystectomy is now much commoner in young women and this change started in the 1960s. By contrast, cholecystectomy in men has become more prevalent in the older age group.
CONCLUSIONS—Gallstones were definitely more common in both sexes at all ages over 40 in the last 25 years. Changes in the cholecystectomy rates are only partly explained by changes in gallstone prevalence, and are more determined by surgical practice.


     

General practitioner workload with 2,000 patients

This study was designed to investigate the relationship between general practice workload, the number of partners in the practice, and the use of health centre premises. Thirty general practitioners in twelve randomly selected practices (each with a list size of 2,000 patients per doctor) agreed to record a week's work on pre-printed forms. Information was gathered on content of care in the surgery, number of non-surgery and indirect contacts and time spent on work activities. Content of care was influenced by whether or not the doctors were based in a health centre, rather on how many partners they had. Conversely the numbers of non-surgery and indirect contacts and the time spent on all work activities were more affected by the number of partners. Two factors — consultation rate and the rate at which doctors initiate consultations — were found to be independent of either of the two variables considered.     

An architecture for research computing in health to support clinical and translational investigators with electronic patient data

ObjectiveObtaining electronic patient data, especially from electronic health record (EHR) systems, for clinical and translational research is difficult. Multiple research informatics systems exist but navigating the numerous applications can be challenging for scientists. This article describes Architecture for Research Computing in Health (ARCH), our institution’s approach for matching investigators with tools and services for obtaining electronic patient data.Materials and MethodsSupporting the spectrum of studies from populations to individuals, ARCH delivers a breadth of scientific functions—including but not limited to cohort discovery, electronic data capture, and multi-institutional data sharing—that manifest in specific systems—such as i2b2, REDCap, and PCORnet. Through a consultative process, ARCH staff align investigators with tools with respect to study design, data sources, and cost. Although most ARCH services are available free of charge, advanced engagements require fee for service.ResultsSince 2016 at Weill Cornell Medicine, ARCH has supported over 1200 unique investigators through more than 4177 consultations. Notably, ARCH infrastructure enabled critical coronavirus disease 2019 response activities for research and patient care.DiscussionARCH has provided a technical, regulatory, financial, and educational framework to support the biomedical research enterprise with electronic patient data. Collaboration among informaticians, biostatisticians, and clinicians has been critical to rapid generation and analysis of EHR data.ConclusionA suite of tools and services, ARCH helps match investigators with informatics systems to reduce time to science. ARCH has facilitated research at Weill Cornell Medicine and may provide a model for informatics and research leaders to support scientists elsewhere.     

Drug-Induced Blood Dyscrasias

Categories of undesirable effects of drugs are described. Recent experiments on the production of hypersensitization (1) by the use of ECT solution to enhance skin sensitization to penicillin, (2) through the activity of common metabolites of different drugs, and (3) to a non-sensitizing drug by pretreatment with a sensitizing agent are reviewed. The mechanism of hemolytic anemia due to an inherited enzymatic defect and that of drug-induced purpura and the agranulocytic agents is discussed. The three groups of drugs—(1) rarely toxic, e.g. quinine; (2) always toxic in sufficient amounts, e.g. nitrogen mustard; (3) intermediate, e.g. chloramphenicol—are presented, with special consideration of chloramphenicol. It is the responsibility of the pharmacologist to develop and adopt newer methods for toxicity detection, and of the clinician to practise caution in prescribing drugs and to attempt the early recognition of any disorder they may induce. The incidence, diagnosis, prevention, treatment and prognosis of the drug-induced dyscrasias are discussed.     

Drug related medical emergencies in the elderly: role of adverse drug reactions and non-compliance

BACKGROUND—Adverse drug reactions and non-compliance are important causes of admissions in the elderly to medical clinics. The contribution of adverse drug reactions and non-compliance to admission by the medical emergency department was analysed.
METHODS—A total of 578 consecutive elderly patients admitted to the medical emergency department were interviewed to determine the percentage of admissions due to adverse drug reactions or non-compliance with medication regimens, their causes, consequences, and predictors.
RESULTS—Eighty three (14.4%) of the 578 admissions were drug related: 39 (6.7%) caused by adverse drug reactions and 44 (7.6%) caused by non-compliance with medication. One hundred ninety two (33.2%) patients had a history of non-compliance. Factors associated with an increased risk of admission because of an adverse drug reaction were patients with diabetes or neoplasms, and patients using numerous different medications. Factors associated with a higher risk of hospitalisation because of non-compliance were poor recall of the medication regimen, seeing numerous physicians, female sex, polypharmacy, drug costs, and switching over to non-conventional forms of treatment.
CONCLUSION—Many elderly admissions are drug related, with non-compliance accounting for a substantial fraction of these. Elderly people at high risk of suffering a drug related medical emergency are identified and suitable interventions may be planned by the healthcare policymakers to target them.