Do patient age and medical condition influence medical advice to stop smoking?

OBJECTIVE: to determine whether the age and medical condition of a patient influences hospital-based doctors' decision making when advising patients to stop smoking cigarettes. METHODS: we presented 142 doctors from four grades (consultant, registrar, senior house officer and house officer) and four specialities (medicine, surgery, psychiatry and anaesthetics), based in a Dublin teaching hospital, with 20 clinical vignettes. Each vignette described a patient from one of five age groups with one of four levels of health. The vignettes were randomly mixed. We asked doctors to say whether they would advise the patient in each case to quit smoking. RESULTs: hospital-based doctors are significantly less likely to advise patients aged over 65 years than younger patients of the hazards of cigarette smoking, irrespective of the person's physical or mental health (P < 0.001). CONCLUSION: the advice given to patients about their cigarette smoking habits by hospital doctors is strongly influenced not only by the patient's health, but also by the patient's chronological age.     

Complications of radiotherapy--a medical problem?

The ever increasing number of solid tumours and revival of radiotherapy as the method of choice of locoregional treatment in particular in combination with surgery in curative treatment of not advanced diseases leads to the fact that the specialist in internal medicine is faced with early as well late postirradiation changes which may play a part in the differential diagnosis in internal medicine The radiation effects on the living organism can be divided into those conditioned by cellular losses (deterministic) and structural DNA changes in surviving cells (stochastic). Both types of changes must be taken into account in relation to the administered radiation dose, size and site of the irradiated volume, fractionation and time interval after radiation. Modern radiotherapy uses for axternal irradiation as well as for brachytherapy specialized equipment and facilities which make optimalization of treatment possible so that the defined clinical target volume is irradiated homogeneously by a defined dose with minimal damage of surrounding tissue. Contemporary oncological multimodal therapy is ever more successful, patients survive in a satisfactory clinical condition without signs of neoplastic disease for increasing periods of time. In the differential diagnosis in the subsequent development of every patient it is important to record in the case-history whether the patient was irradiated and when and it must be taken into consideration that late postirradiation changes are permanent and develop even several years after completed radiotherapy. In case of doubt, one way leading to a correct diagnosis (and thus also treatment) is consultation with the radiotherapist who treated the patient and who should follow him up permanently after completed treatment.     

Estimating medical costs of gastroenterological diseases

AIM:To estimate the direct medical costs of gaslyoenterologicaldiseases within the universal health insurance programamong the population of local residents in Taiwan.METHODS:The data sources were the first 4 cohortdatasets of 200 000 people from the National HealthInsurance Research Database in Taipei.The ambulatory,inpatient and pharmacy claims of the cohort in 2001 wereanalyzed.Besides prevalence and medical costs of diseases,both amount and costs of utilization in procedures and drugswere calculated.RESULTS:Of the cohort with 183 976 eligible people,44.2%had ever a gastroenterological diagnosis during the year.The age group 20-39 years had the lowest prevalence rate(39.2%) while the elderly had the highest (58.4%).Theprevalence rate was higher in women than in men (48.5%vs.40.0%).Totally,30.4% of 14 888 inpatients had ever agastroenterological diagnosis at discharge and 18.8% of51 359 patients at clinics of traditional Chinese medicine hadsuch a diagnósis there.If only the principal diagnosis on eachclaim was considered,16.2% of admissions,8.0% of outpatientvisits,and 10.1% of the total medical rests (8 469 909 US dollars/83 830 239 US dollars) were attributed to gastroenterologicaldiseases.On average,46.0 US dollars per insured person ina year were spent in treating gastroenterological diseases.Diagnostic procedures related to gastroenterological diseasesaccounted for 24.2% of the costs for all diagnostic proceduresand 2.3% of the total medical costs.Therapeutic proceduresrelated to gastroenterological diseases accounted for 4.5%of the costs for all therapeutic procedures and 1.3% of thetotal medical costs.Drugs related to gastroenterologicaldiseases accounted for 7.3% of the costs for all drugs and1.9% of the total medical costs.CONCLUSION:Gastroenterological diseases are prevalentamong the population of local residents in Taiwan,accountingfor a tenth of the total medical costs.Further investigationsare needed to differentiate costs in screening,ruling out,confirming,and treating.     

When is medical treatment futile?

A difficult ethical conundrum in clinical medicine is determining when to withdraw or withhold treatments deemed medically futile. These decisions are particularly complex when physicians have less experience with these discussions, when families and providers disagree about benefits from treatment, and when cultural disparities are involved in misunderstandings. This paper elucidates the concept of "medical futility," demonstrates the application of futility to practical patient care decisions, and suggests means for physicians to negotiate transitions from aggressive treatment to comfort care with patients and their families. Ultimately, respect of persons and beneficent approaches can lead to ethically and morally viable solutions.