Assessment of variables contributing to Cyclosporine distribution in blood

Factors which can account for the poor correlation between whole blood and plasma Cyclosporine (CsA) levels in patients on CsA prophylaxis are evaluated. The study took account of the influence of plasma separation procedures, and the sample haematocrit on CsA distribution in the blood of renal transplant patients (n=35). CsA was measured using both specific and non-specific CsA radioimmunoassays. Significant negative correlations occurred between CsA distribution and the haematocrit, independently of the plasma separation procedure or the specificity of the assay. All results were lower when using the specific assay but a significantly higher percentage of CsA was measured in the plasma by specific assay compared to nonspecific assay when plasma was separated at both 22°C (t-test, p<0.02) and at 37°C, p<0.01). This may relate to the selective binding of CsA and its analogues by blood cells. This study is a prelude to the development of more consistent plasma separation procedures in the monitoring of this drug.     

Response to Kuhse

In this short paper, we respond to critics of our original paper, The agony of agonal respiration: is the last gasp necessary?. A common thread in both Hawryluck''s and Kuhse''s responses is the difficulties encountered when using the agent''s intentions to make moral distinctions between using neuromuscular blocking drugs to palliate versus using neuromuscular blocking drugs to kill. Although this difficulty does exist we maintain that the intentions of the physician must matter when providing end-of-life care.     

Motivating adolescents to reduce risk for chronic disease.

Motivating children to reduce risk for future disease can only be effective within a framework of personal involvement and peer interaction. The ''Know Your Body'' programme of disease prevention is attempting to achieve this goal by means of medical screening for risk factors, giving students their own results in a ''Health Passport'', and following up with educational activities integrated into existing school curricula. Didactic teaching alone has been unsuccessful because children cannot relate information about diseases in adult life to themselves. Screening for risk factors provides the ''reality factor'' which makes health education pertinent and personal, since approximately half of all students screened will already have one or more risk factors for heart disease, cancer or stroke. This high prevalence of risk factors among our children suggests that chronic-disease prevention must assume a critically important position within the health and science curricula of every school. It is as important to teach our children healthy ways of living as it is to teach reading, writing, and arithmetic.     

Holistic Approach to Functional Constipation: Perspective of Traditional Persian Medicine

Traditional Persian medicine (TPM) proposes a different viewpoint to the chronic diseases. Diagnosis and implemented treatment are based on individual differences among patients. Constipation or Ea''teghal-e-batn is a condition in which the patient develops difficult or painful defecation. Based on TPM concepts, the first digestion step starts from halq (oral cavity), and ends via defecation from the maq''ad (anus). Avicenna believed that four faculties, ha''zemeh (digestive), ja''zebeh (absorptive), ma''sekeh (retentive) and da''fe''eh (propulsive), are involved in the process of digestion and absorption of the ingested food and expelling the waste materials. The bowel movement and appearance of the stool is a measure for evaluating the gastrointestinal healthy function. Defecation should be with no pain and fecal material should have no burning and acuity. Low food intake or foods with dry temperament, dryness of gastrointestinal tract, diaphoresis and heavy exercise as well as intestine sensory loss were discussed as main causes of constipation. Management of constipation in TPM includes dietary schemes, oil massages and subsequently simple herbal medicines. According to TPM theories, the first step in treating a disease is the elimination of disease causes (asbab e-maraz) and also providing the causes of health (asbab-e-sehhat). Health care providers should know the proper condition which the herbal medicines should be administered in and be able to guide the patients about the benefits and hazards of herbal remedies, commonly used in their living origin.     

Reactive Airways Dysfunction Syndrome (RADS) due to chlorine gas exposure

Reactive Airways Dysfunction Syndrome (RADS) has been described following exposure to various irritant gases⁽¹⁾. We describe a case of RADS occurring following exposure to chlorine gas and which has persisted at 6 years follow-up.     

Workarounds to Barcode Medication Administration Systems: Their Occurrences,Causes, and Threats to Patient Safety

The authors develop a typology of clinicians'' workarounds when using barcoded medication administration (BCMA) systems. Authors then identify the causes and possible consequences of each workaround. The BCMAs usually consist of handheld devices for scanning machine-readable barcodes on patients and medications. They also interface with electronic medication administration records. Ideally, BCMAs help confirm the five “rights” of medication administration: right patient, drug, dose, route, and time. While BCMAs are reported to reduce medication administration errors—the least likely medication error to be intercepted— these claims have not been clearly demonstrated. The authors studied BCMA use at five hospitals by: (1) observing and shadowing nurses using BCMAs at two hospitals, (2) interviewing staff and hospital leaders at five hospitals, (3) participating in BCMA staff meetings, (4) participating in one hospital''s failure-mode-and-effects analyses, (5) analyzing BCMA override log data. The authors identified 15 types of workarounds, including, for example, affixing patient identification barcodes to computer carts, scanners, doorjambs, or nurses'' belt rings; carrying several patients'' prescanned medications on carts. The authors identified 31 types of causes of workarounds, such as unreadable medication barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient identification wristbands (chewed, soaked, missing); nonbarcoded medications; failing batteries; uncertain wireless connectivity; emergencies. The authors found nurses overrode BCMA alerts for 4.2% of patients charted and for 10.3% of medications charted. Possible consequences of the workarounds include wrong administration of medications, wrong doses, wrong times, and wrong formulations. Shortcomings in BCMAs'' design, implementation, and workflow integration encourage workarounds. Integrating BCMAs within real-world clinical workflows requires attention to in situ use to ensure safety features'' correct use.     

医药科研院所党员干部法治思维和依法办事能力问题思考

提高党员干部法治思维和依法办事能力,是推进全面从严治党和加强党的执政能力建设的基本要求,也是依法治国和推进国家治理体系与治理能力现代化建设的基本要求。党员干部法治思维和依法办事能力的高低,直接影响着全面从严治党和依法治国的成效。本文针对当前医药科研院所党员干部法治思维和依法办事能力总体有待进一步提高的现状,具体分析表现和形成原因,并提出相应对策。     

A problem-oriented approach to medical information systems

A relatively simple computer-based information system developed for a primary care group practice at the San Francisco Veterans Administration Hospital contributes to the management of the practice, to improvement of medical care for patients within the group, and to research studies on resource utilization in the management of chronic diseases and the evaluation of care of chronically ill patients. Preliminary results from the use of the information system are encouraging and demonstrate that much may be achieved by information systems that do not attempt to computerize the entire medical record.     

Disease due to echovirus type 19 in Birmingham, England, 1975: relationship to 'epidemic neuromyasthenia'.

In the summer of 1975 an extensive epidemic of disease due to echovirus type 19 occurred in the West Midlands. The features of this outbreak, and their relationship to the syndrome referred to as ''epidemic neuromyasthenia'', are discussed. The two diseases are considered to be separate entities.     

Severe haemolytic anaemia due to cold anti-'i' antibodies associated with cytomegalovirus infection.

A 66 year old patient with multiple myeloma and monoclonal cryoglobulinaemia who developed a severe haemolytic anaemia following a cytomegalovirus infection is reported. The presence of a high titre of anti-''i'' cold antibody of IgM subclass is demonstrated. Anti-''i'' antibody disappeared when complement-fixation antibody titres against cytomegalovirus decreased. Various pathogenetic mechanisms involved in the development of haemolytic anaemia associated with cytomegalovirus infection are discussed. To our knowledge, this is the first case described in the English language publications associating severe haemolytic anaemia with an anti-''i'' antibody after a cytomegalovirus infection in an immunocompromised patient.     

Guidelines for use access to compuuterized medical records

Computerization of the medical record allows the unique capability to provide differential access to various components of the record by users outsid of the immediate provider/patient health care setting Guidelines for designers, programmers, and users of computerizeid medical records have been defined in order to clarify which data elements or categories are appropriate for communication to various parties involved in utilizing patients information.     

Epidemiological approaches to 'epidemic neuromyasthenia': syndromes of unknown aetiology (epidemic myalgic encephalopathies).

The study of future outbreaks of ''epidemic neuromyasthenia'' syndromes would be easier if there were a standing advisory arrangement for the co-ordination of basic standart studies, diagnostic tests and long term survey of patients. It is proposed that this might be achieved by establishing an ''EN Outbreaks Panel'' at Colindale which, in addition to epidemiologists and virologists might include specialists in infectious diseases, neurology and psychiatry and other fields. The approach to such a panel would be through the Communicable Diseases Surveillance Centre (CDSC) when outbreak is suspected. Arrangements could then be made by the CDSC with the Epidemiological Research Laboratory and the Virus Reference Laboratory to assist immediate investigations and for a follow-up to ascertain the incidence of sequelae, as well as for long storage of sera and other specimens.     

Attitudes of a Mediterranean population to the truth-telling issue.

The attitudes of the Greeks, a Mediterranean population, to the issue of telling the truth to the patient have been studied. There is no clear answer to the question: ''Do the Greeks wish to be informed of the nature of their illness?''. The answer is: ''It depends''. It depends on age, education, family status, occupation, place of birth and residence and on whether or not they are religious people. However, it does not depend on their sex--men and women have similar reactions to the issue of truth-telling. Although the present study shows lower percentages of those who wish to know the truth than studies on other populations, the conclusion is that, emphasising the need for good communication between doctors and patients, doctors should not lie, but should disclose to their patients the part of the truth they are ready to accept.     

社区直接挂号市医院的双向转诊系统

为实现上下级医疗机构之间的无缝对接,简化患者由社区转诊到上级医院的流程,镇江市第一人民医院设计由社区直接挂号该院的双向转诊系统平台,介绍该平台的设计流程、特点和实现步骤。平台能够实现社区和医院之间患者信息的共享,方便患者就医,提高医疗服务水平。     

Whipple's disease in a female with impaired cell-mediated immunity unresponsive to co-trimoxazole and levamisole therapy.

A case of Whipple''s disease in a female is described. Malabsorption of iron, vitamin B12, folic acid and fat was present. These abnormalities reverted to normal after introduction of co-trimoxazole therapy. The patient''s humoral immune system was normal, in contrast to impairment of cell-mediated immunity, which has not improved in spite of co-trimoxazole treatment for 2 years, and a therapeutic trial of levamisole. These findings are further evidence that there may be a primary immune deficiency in patients with Whipple''s disease.     

Response to Ronald M Perkin and David B Resnik: the agony of trying to match sanctity of life and patient-centred medical care

Perkin and Resnik advocate the use of muscle relaxants to prevent the "agony of agonal respiration" arguing that this is compatible with the principle of double effect. The proposed regime will kill patients as certainly as smothering them would. This may lead some people to reject the argument as an abuse of the principle of double effect. I take a different view. In the absence of an adequate theory of intention, the principle of double effect cannot distinguish between the intentional and merely foreseen termination of life, and cannot rule out end-of-life decisions that are often regarded as impermissible. What Perkin and Resnik are in effect saying is that there are times when physicians have good reasons to end a patient''s life—deliberately and intentionally—for the patient''s (and the family''s) sake. Why not say so—instead of going through the agony of trying to match sanctity of life and patient-centred medical care?     

Handheld Technology to Improve Patient Care: Evaluating a Support System for Preference-based Care Planning at the Bedside

Objective: Despite an increasing movement toward shared decision making and the incorporation of patients'' preferences into health care decision making, little research has been done on the development and evaluation of support systems that help clinicians elicit and integrate patients'' preferences into patient care. This study evaluates nurses'' use of choice, a handheld-computer–based support system for preference-based care planning, which assists nurses in eliciting patients'' preferences for functional performance at the bedside. Specifically, it evaluates the effects of system use on nurses'' care priorities, preference achievement, and patients'' satisfaction.Design: Three-group sequential design with one intervention and two control groups (N=155). In the intervention group, nurses elicited patients'' preferences for functional performance with the handheld-computer–based choice application as part of their regular admission interview; preference information was added to patients'' charts and used in subsequent care planning.Results: Nurses'' use of choice made nursing care more consistent with patient preferences (F=11.4; P<0.001) and improved patients'' preference achievement (F=4.9; P<0.05). Furthermore, higher consistency between patients'' preferences and nurses'' care priorities was associated with higher preference achievement (r=0.49; P<0.001).Conclusion: In this study, the use of a handheld-computer–based support system for preference-based care planning improved patient-centered care and patient outcomes. The technique has potential to be included in clinical practice as part of nurses'' routine care planning.With the recent movement toward shared decision making in health care, a number of models, methods, and evaluative strategies to foster shared decision making have been developed. In the clinical, health services, and methodological literature, shared decision making refers to the concept of involving patients and their health care providers in making treatment decisions that are informed by the best available evidence about treatment options and that consider patients'' preferences.Devices to assist patients in shared decision making have been called “decision aids,”¹ and cumulative evidence supports their effectiveness. Studies evaluating decision aids for patients have reported higher scores on cognitive functioning and social support,² more active and satisfying participation in decision making,³ better scores on general health perceptions and physical functioning,⁴ improved knowledge,⁵ and reduced decisional conflict.¹ However, decision aids have so far been confined to the relatively narrow segment of decisions about single episodes of screening or treatment choices. Little attention has been given to the development of systems that help clinicians elicit and integrate patients'' preferences into the ongoing processes of care over time and as part of clinical practice.Although decision aids have been shown to be helpful to patients, it has been argued that decision support systems for eliciting patients'' preferences could also support clinicians in making care decisions consistent with patients'' preferences, and that successful efforts in this direction would lead to better patient outcomes.^6,7 However, the development of decision support systems designed to support clinicians in eliciting and integrating patients'' preferences into their clinical practice has received little attention. Developments of decision support systems for clinicians have mainly been devoted to knowledge-based systems designed to produce patient-specific options and recommendations, such as computer-based clinical guidelines. Other examples of clinical decision support systems include systems that apply rules to detect undesirable trends and events during treatment, offer reminders and messages about diagnostic and therapeutic possibilities, and alert clinicians to potential serious situations.⁸Evidence shows that clinical decision support systems can enhance clinicians'' compliance with system recommendations and to some degree improve clinical patient outcomes.^9,10 Yet such systems rarely offer systematic methods for eliciting patients'' preferences or incorporate algorithms for the integration of patients'' preferences into care planning. Furthermore, there has been only limited research addressing 1) whether the use of computer-based decision support systems to assist in the elicitation of patients'' preferences would in fact prompt clinicians to make care decisions consistent with patients'' preferences, and 2) whether decisions based on the use of such tools would improve patient outcomes. Developing and testing the effects of clinical support systems for preference elicitation and care planning on clinical decisions and patient outcomes can, therefore, make an important contribution to research in this area and, ultimately, to patient-centered care.This paper reports the results of nurses'' use of Choice (Creating better Health Outcomes by Improving Communication about Patients'' Expectations), a handheld-computer–based support system for preference-based care planning, which helps nurses elicit patients'' preferences for functional performance at the bedside—specifically, the effects of its use on nurses'' care priorities and patient outcomes of preference achievement and satisfaction.     

Cushing's syndrome due to autonomous macronodular adrenal hyperplasia: long-term follow-up after unilateral adrenalectomy

This report describes a case of Cushing''s syndrome due to autonomous macronodular adrenocortical hyperplasia in which unilateral resection of the right adrenal resolved the Cushing''s syndrome.     

Enhancing laboratory report contents to improve outpatient management of test results

In today''s environment, providers are extremely time-constrained. Assembling relevant contextual data to make decisions on laboratory results can take a significant amount of time from the day. The Regenstrief Institute has created a system which leverages data within Indiana Health Information Exchange''s (IHIE''s) repository, the Indiana Network for Patient Care (INPC), to provide well-organized and contextual information on returning laboratory results to outpatient providers. The system described here uses data extracted from INPC to add historical test results, medication-dispensing events, visit information, and clinical reminders to traditional laboratory result reports. These “Enhanced Laboratory Reports” (ELRs) are seamlessly delivered to outpatient practices connected through IHIE via the DOCS4DOCS clinical messaging service. All practices, including those without electronic medical record systems, can receive ELRs. In this paper, the design and implementation issues in creating this system are discussed, and generally favorable preliminary results of attitudes by providers towards ELRs are reported.     

How to pass the MRCP (UK) examination--ask a successful candidate!

Recently successful MRCP (UK) candidates were asked to rate the value of clinical experience, reading, practice with past or simulated examination papers and commercially organised courses as preparation for parts 1 and 2 of the examination. With respect to part 1, practice with past and simulated papers was unanimously felt to be of crucial importance with examination-focused reading helpful. Clinical experience was deemed irrelevant and commercially organised courses a matter of individual choice. For part 2, clinical experience was felt to be of fundamental importance but needed to be practised in an ''examination atmosphere''. Both general reading and practice with past and simulated papers were judged helpful and commercially organised courses were perceived to be of more value than for part 1. Trainees should be advised to seek advice on examination preparation from both ''authoritative sources'' and their recently successful colleagues.