Truth, proof and evidence: homeopathy and the medical paradigm

The study and practice of medicine, in its most personal and intimate functions, its most sophisticated scientific and technological manifestations, and its philosophical and ethical ramifications, are central to our understanding of the human condition. Homeopathic medicine: its insights, the questions that it begs, and the scientific and philosophical challenges it presents, has a significant contribution to make to this process. To be actively and seriously engaged with homeopathy is an adventurous undertaking. It is to be engaged in exploring both human nature and the nature of the world we inhabit. And in that process we are also engaged in the pursuit of truth and the exploration of reality. This paper deals first with the layout of the playing field on which homeopathy has to compete to be taken seriously. It then discusses three concepts: reality, truth and knowledge, which are objectives for which we strive and principles that guide us in that striving. In the third part it introduces the concept of 'personal knowledge' as an essential ingredient of scientific discovery and the pursuit of truth. And finally it proposes that the homeopathic community in general, and the Faculty of Homeopathy in particular, must expand its vision with a definition of a new paradigm, the new model of healthcare and medical science to which the vision aspires.     

Radiology of torture

PURPOSE: Although there are different definitions of torture, there is no contradiction that torture exists. Changes resulting from torture are shown to demonstrate which findings can be visualized with X-rays. MATERIAL: The findings come from rehabilitation centers for victims of torture, collections of others and from personal observations. They are documented with plain films, scintigraphy, computed tomography, and MRI. RESULTS: On fingers, hand, and arm, and on toes, foot and leg, imaging can visualize changes and pathologies which are characteristic for preceding torture. On head, neck, and trunk, this is only rarely the case; this is understandable, when one considers that force having been directed against these regions of the body will more often be deadly than that applied on limbs only. Special forms of torture with the use of water and electricity are also described. It is pointed out that multiple forms of torture do not leave traces, which might be made visible by diagnostic imaging. The cases are part of a selection: the victims have survived (which means that these types of torture permitted survival; injuries of hand and foot do not endanger the survival as opposed to stab wounds to the head, chest, and abdomen, into the anus and the genitals, which are often mortal. Mutilation by torture motivates the torturer to eliminate any proof of his actions and to kill the victim. Public interest induces a selection of methods, which leave no traces. Possibly (and hopefully) some special forms of torture, which use chemical substances that act on the psyche and the central nervous system, might become visible by functional MRI in the near future. CONCLUSION: Torture is likely to occur when findings are seen to be typical or characteristic forms of torture, when age of fractures and pattern of beatings and other injuries corroborate the indications of the victim, and when these findings correspond to the procedures known from the region of application the organization/group/militia, which is said to have executed the torture.     

从证据角度谈病历的书写

客观、真实、准确、及时、完整记载的病历资料是证明医疗行为是否合法、适当、必要、安全的强有力的证据资料.以往病历的书写往往没有想到它的证据作用,因而常不符合证据法的要求,以至于使其失去证据的资格,或者虽有证据资格但证明力较弱.文章主要从民事诉讼证据的角度探讨应当如何书写病历,建议使用事实陈述语言,记载的内容真实、合法、规范等.     

"举证责任倒置"后举证困难的原因分析与对策

回顾性地总结了2003～2006年度发生的医疗纠纷,分析举证困难的原因,并采取有针对性的护理管理对策后,举证成功率提高。认为强化业务学习、重视护士的合法身份等护理管理对策能有效提高举证成功率。     

Zygomatic implant placement using a robot-assisted flapless protocol: proof of concept

Robotic assistance can help in physically guiding the drilling trajectory during zygomatic implant positioning. A new robot-assisted strategy for a flapless zygomatic implant placement protocol is reported here. In this protocol, a preoperative computed tomography scan is used to plan the surgical path. After surface registration, the ROSA robot (Zimmer Biomet Robotics) guides several steps, which are performed with shared control. The surgeon performs the drilling and tapping, guided by the robotic arm, which is positioned according to the planned trajectory. Placement of the zygomatic implant is done manually. Immediate intraoperative 3D verification is performed by cone beam computed tomography (flat-panel detector, Medtronic O-arm II). Four zygomatic implants were placed in the case patient according to the flapless protocol, with a mean vector error of 1.78 mm (range 0.52–4.70 mm). A screw-retained temporary prosthesis was placed on the same day. No significant complications were observed. The application of this robot-assisted surgical protocol, which guarantees a very high degree of precision, may reduce inaccuracies in the positioning of zygomatic implants that could deviate from the surgeon’s plan. This appears to be a potentially safe flapless surgery technique. Drill slipping on the crest or on the maxillary wall is the main source of error in this procedure, emphasizing the usefulness of the assisted surgical guidance with haptic feedback.     

A Flexible Bayesian Approach for Modeling Monotonic Dose–Response Relationships in Drug Development Trials

Clinical trials often involve comparing 2–4 doses or regimens of an experimental therapy with a control treatment. These studies might occur early in a drug development process, where the aim might be to demonstrate a basic level of proof (the so-called proof of concept (PoC) studies), at a later stage, to help establish a dose or doses that should be used in phase III trials (dose-finding), or even in confirmatory studies, where the registration of several doses might be considered. When a small number of doses are examined, the ability to implement parametric modeling is somewhat limited. As an alternative, in this paper, a flexible Bayesian model is suggested. In particular, we draw on the idea of using Bayesian model averaging (BMA) to exploit an assumed monotonic dose–response relationship, without using strong parametric assumptions. The approach is exemplified by assessing operating characteristics in the design of a PoC study examining a new treatment for psoriatic arthritis and a post hoc data analysis involving three confirmatory clinical trials, which examined an adjunctive treatment for partial epilepsy. Key difficulties, such as prior specification and computation, are discussed. A further extension, based on combining the flexible modeling with a classical multiple comparisons procedure, known as MCP–MOD, is examined. The benefit of this extension is a potential reduction in the number of simulations that might be needed to investigate operating characteristics of the statistical analysis.     

Pre-Sleep ingestion of two hypnotic drugs and subsequent performance

The present study examined the effect of pre-sleep ingestion of two depressant drugs (nitrazepam and butobarbitone) on subsequent performance. 12 subjects attempted five 15-min tasks in a balanced, latin-square design. The high dose of each drug increased the time on task decline in a short-term memory task. STM did not show a definite time of day effect. Proof reading was superior in the morning, but concept identification was faster in the the afternoons. The implications of these results are briefly discussed.Dr. Donald Broadbent provided invaluable discussion and advice during the preparation of this paper. The M.R.C. provided financial support. I acknowledge the roles of Dr. R. T. Wilkinson and Dr. A. W. Peck who conceived the original research plan. I am grateful to Dr. Peck for collaboration and for medical supervision and to the Wellcome Foundation who provided laboratory facilities, subjects and drugs for this study, which formed part of a programme of research at the Wellcome Research Laboratories, Beckenham, Kent.     

浅析医疗损害赔偿案件中的举证责任

当前,我国因医疗行为引起的侵权诉讼适用举证责任倒置原则,对医疗损害赔偿案件的审判产生重大而深远的影响。本文在分析举证责任的概念及其含义的基础上,论述了举证责任的分配及其渊源,并阐述了医疗机构所应该采取的应对措施,以期增强医务人员的证据意识和知识,提升医疗侵权案件审判的公正性与效率性。     

An ethnographic evaluation of a speciality training pathway for general practice nursing in the UK

AimsThe aim of the study was to evaluate the implementation and impact of the General Practice Nurse – Specialty Training (GPN-ST) programme across seven sites in one geographical location in the UK. The objectives were to understand, describe and evaluate: 1) the implementation of the ‘proof of concept’ training scheme; 2) the learning undertaken during the training; and 3) the impact of the training scheme on individual nurses. These objectives offer the opportunity to describe the potential return on investment for General Practices supporting nurses new to General Practice through the programme.BackgroundGeneral Practice Nurses (GPNs) play a vital role in delivering primary and community care. In the UK there is a shortfall in the GPN workforce. Unlike training for other clinical professions there is currently no standardised training pathway or entry route for nurses wishing to work in General Practice.An ethnographic evaluation was undertaken of a one-year speciality training programme (GPN-ST). The programme, aimed at nurses new to General Practice, included formal higher education training and funded supported learning and mentoring whilst in practice.MethodsA qualitative ethnographic evaluation was undertaken. Observations were conducted of programme implementation, network and education meetings in the scheme. In-depth, semi-structured, interviews and focus groups were conducted with a wide range of professionals (n = 40) including nurse mentors, nursing students, academic providers, commissioners and the programme managers. These data were supplemented by documentary analysis of meeting notes, learning materials, internal student feedback and locally collected evaluation material in line with ethnographic approaches to research. Kirkpatrick’s model for course evaluation and complimentary inductive emergent thematic analysis was used.FindingsThere is evidence of learning at every level of the Kirkpatrick model from reaction through to changes in behaviour and results in practice for patients. The speciality training route offered opportunities for deep learning for GPNs. The scheme offered a comprehensive career pathway to General Practice nursing which in turn benefited General Practices. Practices benefitted from confident, independent nurses who were able to contribute to patient care, practice safely and also contributed widely in the long-term for example in research, workforce development and mentoring.ConclusionsGeneral Practice needs to invest in developing a workforce of GPNs, there are significant benefits to investing in the development of GPNs through a training pathway. This scheme provides scope for application in other clinical settings as well in other countries where there is a gap in career progression into GP practices.Tweetable abstractGPNs play a vital role in delivering primary and community care. Unlike training for other clinical professions there is currently no standardised training pathway or entry route for nurses wishing to work in General Practice. There are significant benefits to investing in the development of GPNs through a training pathway