General medicine in the 'eighties.

The general physician with or without an interest is directly responsible for the initial and continuing care in most acute medicine. Specialty interests cover the whole range of medicine but in most instances are subordinate to the claims of general medicine. Consultants in district general hospitals carry a bigger caseload in acute medicine than their colleagues in teaching hospitals, and this has implications for undergraduate and postgraduate training. The management of patients in intensive care units remains very much the task of the general physician. The general physician will continue to be an essential member of the hospital service in the foreseeable future.     

Industry calling! Is there a doctor in the house?

Medical service is needed in industry by both management and labor as never before. Industry is just beginning to awaken to this need. The medical profession is largely unaware of it. Unless physicians are prepared to heed this call, there is danger that management and labor will come to a bipartisan agreement over the bargaining table which will specify the amount, quality, and price of medical service irrespective of the effects of such an agreement on the practice of medicine. Such agreements should invariably be tripartite-between management, labor and medicine-if we are to continue to strive for medicine's traditional ideals: The best of medical care for all alike. This situation imposes at least two important obligations on organized medicine at the national level and especially at state and local levels where there is industrial concentration:1. Provision of a strong and competent committee or council whose members are especially interested in occupational medicine and who will make their presence known to management and labor alike, offering to advise with them on all medical problems, to mediate their disagreements or medical questions, and to help them attain a common goal.2. Assisting the members of organized medicine who are interested, to learn more about the medical problems peculiar to occupational health.     

Beyond sepsis pathophysiology with cytokines: what is their value as biomarkers for disease severity?

Sepsis is a major challenge in medicine. It is a common and frequently fatal infectious condition. The incidence continues to increase, with unacceptably high mortality rates, despite the use of specific antibiotics, aggressive operative intervention, nutritional support, and anti-inflammatory therapies. Typically, septic patients exhibit a high degree of heterogeneity due to variables such as age, weight, gender, the presence of secondary disease, the state of the immune system, and the severity of the infection. We are at urgent need for biomarkers and reliable measurements that can be applied to risk stratification of septic patients and that would easily identify those patients at the highest risk of a poor outcome. Such markers would be of fundamental importance to decision making for early intervention therapy or for the design of septic clinical trials. In the present work, we will review current biomarkers for sepsis severity and especially the use of cytokines as biomarkers with important pathophysiological role.     

Neuroimagerie dopaminergique par TEMP cérébrale. Enquête espagnole

At the occasion of the 11th France-Spain Nuclear Medicine Meeting, a national survey was conducted regarding the practice of dopaminergic neuroimaging studies. Such explorations represent 1.4% of the overall procedures performed in the nuclear medicine services. In most cases they focus on the assessment of the presynaptic transporters of dopamine, the main indication being the differential diagnosis between essential tremor and Parkinson's disease. Most of the acquisitions are performed with a double-head gamma camera (92.9%) equipped with a parallel-hole collimator (78.8%). Filtered backprojection is the most common reconstruction technique (81.8%). The results are generally visually interpreted by one or two nuclear medicine physicians and quantification is routinely utilized in 42.4% of the centers; half of them have normal values obtained from groups of control patients. The fundamental result of the present survey is that this technique remains generally rarely used. However, there has been a progressive increase during the last years, likely as a consequence of its clinical impact.     

INDUSTRY CALLING!—Is There a Doctor in the House?

Medical service is needed in industry by both management and labor as never before. Industry is just beginning to awaken to this need. The medical profession is largely unaware of it. Unless physicians are prepared to heed this call, there is danger that management and labor will come to a bipartisan agreement over the bargaining table which will specify the amount, quality, and price of medical service irrespective of the effects of such an agreement on the practice of medicine. Such agreements should invariably be tripartite—between management, labor and medicine—if we are to continue to strive for medicine''s traditional ideals: The best of medical care for all alike.This situation imposes at least two important obligations on organized medicine at the national level and especially at state and local levels where there is industrial concentration:1. Provision of a strong and competent committee or council whose members are especially interested in occupational medicine and who will make their presence known to management and labor alike, offering to advise with them on all medical problems, to mediate their disagreements or medical questions, and to help them attain a common goal.2. Assisting the members of organized medicine who are interested, to learn more about the medical problems peculiar to occupational health.     

Partie 3. Aspects structurels spécifiques du service de médecine nucléaire

A nuclear medicine department is made up of several sectors whose layout, governed by the level of exposure to radiation (“cold” or “hot” sectors), must necessarily take into account the constraints of preparation and distribution of radiopharmaceuticals, storage/management of contaminated waste and effluent, and the patient pathway (reception, MRP injection, image acquisition. ASN Guide No. 32 specifically specifies the rules for the design and operation of nuclear medicine departments. Without forgetting that the ASN is not the only body with requirements concerning the structuring of a service, it is sometimes complex to modulate the premises in an optimal way with all the difficulties and architectural specificities that this can cause. anticipated RIV, through its impact on the layout of the service, is a structural issue in the short/medium term.     

A clinical study of the EMI scanner: implications for provision of neuroradiological services.

The records of the first 571 patients to be examined with an EMI brain scanner were assessed. The patients were divided into diagnostic categories according to their clinical presentation. The intracranial investigations that would have been performed had the scanner not been available were compared with the investigations that were actually performed. As expected, the number of contrast investigations fell, but the reduction surpassed expectation. If the full clinical impact of the scanner is to be realised the patient''s illness must be defined in detail and strict attention paid to radiographic detail. By reducing the number of special contrast investigations use of the scanner enables existing contrast facilities to serve a wider population; and use of the brain scanner in district general hospitals would improve the service to patients, especially those with head injuries.     

Nuclear transfer into mouse oocytes

Nuclear transfer into an unfertilized oocyte can restore developmental potential to a differentiated cell. This demonstrates that the processes underlying development, differentiation and aging are epigenetic rather than genetic processes. The reversibility of these processes opens exciting perspectives in basic research, and in the more distant future, in regenerative medicine. In the mouse, embryonic stem cells can be derived from cloned preimplantation stage embryos. Such embryonic stem cells have the ability to give rise to all cell types of the adult organism. Importantly, these cells are genetically identical to the donor. If applicable to human, this would allow the derivation of stem cells from a patient. These cells could then be differentiated into the affected cell type of the patient and studied in vitro, or used to replace the damaged or missing cells. The study of nuclear transfer in the mouse remains important as it can inform us about the principles of nuclear reprogramming. This movie and the accompanying protocol are intended to help learning nuclear transfer in the mouse, a method initially developed in the group of Prof. Yanagimachi (WAKAYAMA et al. 1998).     

From autonomy to accountability: the role of clinical practice guidelines in professional power

Evidence-based medicine (EBM) aims to address the persistent problem of clinical practice variation with the help of various tools, including standardized practice guidelines. Based on a systematic evaluation of the available scientific evidence, these guidelines offer recommendations for clinicians about details of patient care and clinical decision making. Because clinical practice guidelines specify how health care should be performed, they could be considered a threat to clinical and professional autonomy. Inspired by the theory of countervailing powers, this article explores how clinical practice guidelines have shifted the focus of professional power from autonomy to accountability. Professional organizations develop clinical practice guidelines as a service to their members but do not require strict adherence to the guidelines. Indeed, implementation studies show at best a modest change in clinical behavior. Such non-adherence might render a profession vulnerable, however, when third parties seize upon guidelines and offer financial incentives to keep clinicians accountable for delivering optimal patient care.     

Surgical instruments and dressings: an information service.

A regional information service on surgical equipment, instruments, and dressings is proposed that would be staffed by information scientists. It would appreciably reduce the time spent on administration and make the buying of equipment more efficient. Such a service could be extended to all health service staff.     

Organisation of vascular surgical services: evolution or revolution?

The trend towards subspecialisation in hospital services is likely to lead to the development of vascular surgery as a separate specialty. If vascular surgery is to emerge as a high quality service then vascular emergencies--a substantial component of the workload--should be dealt with by surgeons with adequate training, and all patients should have equal access to the service. A specialist vascular surgical unit would have to be large enough to make efficient use of other services that it needs, such as radiology, and so may require the amalgamation of smaller health district units. Because of the differing local degrees of subspecialisation, national or regional strategies for vascular surgery must be developed.     

Epidermal growth factor receptor and DNA double strand break repair: the cell's self-defence

The purpose of this review is to discuss the relation between the repair of DNA double strand breaks (DSB)--the main lethal lesion inflicted by ionising radiation-and the function of receptors of epidermal growth factor (EGFR) and similar ligands (other members of the ERBB family). The reviewed experimental data support the assumption that in mammalian cells, one consequence of EGFR/ERBB activation by X-rays is its internalisation and nuclear translocation together with DNA-dependent protein kinase (DNA-PK) subunits present in lipid rafts or cytoplasm. The effect of EGFR/ERBB stimulation on DSB rejoining would be due to an increase in the nuclear content of DNA-PK subunits and hence, in activity increase of the DNA-PK dependent non-homologous end-joining (D-NHEJ) system. Such mechanism explains the radiosensitising action of "membrane-active drugs", hypertonic media, and other agents that affect nuclear translocation of proteins. Also, one radiosensitising effect of the recently introduced into clinical practice EGFR/ERBB inhibitors would consist on counteracting the nuclear translocation of DNA-PK subunits. In result, D-NHEJ may be less active in inhibitor-treated cells and this will contribute to an enhanced lethal effect of irradiation. The reviewed observations point to a heretofore not understood mechanism of the cell's self-defence against X-rays which can be exploited in combined radio- and chemotherapy.     

Guide du bon usage de la TDM en médecine nucléaire. IntroductionCT good practices for hybrid nuclear medicine (SPECT/CT and PET/CT): Introduction

Nuclear medicine hybrid imaging is a technological evolution of gamma camera scintigraphy or positron emission tomography imaging methods that are now often coupled with an anatomical imaging device, essentially a CT scanner. Following a large demand from the nuclear physicians themselves, but also from the French Nuclear Safety Authority, this guide is intended for the entire nuclear medicine community to integrate both the aspects of radiation protection related to coupled CT and those related to the quality of the CT images according to the clinical context.     

Emerging approaches for imaging vulnerable plaques in patients

The diagnosis of vulnerable plaques, which have the propensity to develop atherothrombosis, remains an elusive goal in clinical medicine. The most accepted features of vulnerable plaques, such as a large lipid core, increased inflammatory milieu and thin fibrous caps, have been well characterized through pathological studies. The ability to image a vulnerable plaque in susceptible patients would theoretically result in useful prognostic information that can be used to either monitor or treat patients at risk more aggressively. Several invasive techniques, such as integrated backscatter, virtual histology, palpography, optical coherence tomography and thermal heterogeneity, have been validated ex vivo and are now being evaluated in clinical studies. Non-invasive techniques, such as nuclear imaging, show promise in identifying increased metabolic activity and characteristic features of vulnerable plaques in patients. Natural history and intervention studies will need to be performed to determine whether identifying and treating vulnerable plaques will lead to improved clinical outcomes.     

Correlated versus uncorrelated frailty Cox models: A comparison of different estimation procedures

In many studies in medicine, including clinical trials and epidemiological investigations, data are clustered into groups such as health centers or herds in veterinary medicine. Such data are usually analyzed by hierarchical regression models to account for possible variation between groups. When such variation is large, it is of potential interest to explore whether additionally the effect of a within‐group predictor varies between groups. In survival analysis, this may be investigated by including two frailty terms at group level in a Cox proportional hazards model. Several estimation methods have been proposed to estimate this type of frailty Cox models. We review four of these methods, apply them to real data from veterinary medicine, and compare them using a simulation study.     

L'utilisation des tests diagnostiques dans une unité de médecine familiale.

For a random sample of 1029 visits occurring over a 1-year period in a family medicine service 1067 diagnostic tests were done within 1 week (or within 3 weeks in the case of nuclear medicine) following the visit; this represents a mean of 1.04 tests, costing $ 8.30, per visit. There was no test ordered in most (62.5%) of the visits. The results of 909 tests were recorded; 36.6% were abnormal. The pattern of use of diagnostic tests varied considerably among the physicians; however, no association was observed between this pattern and the status of the physician, the site of the encounter, or the age or sex of the patient. There was a weak and not statistically significant correlation between the number of problems identified and the number of tests with abnormal results per visit. These results suggest that the problem of overuse of diagnostic tests may not be as acute in a family medicine service as it has been observed to be in other settings.     

La radioprotection des patients en médecine nucléaire : état des lieux en Tunisie

Recent health indicators for Tunisia are encouraging: there is one doctor for every 1000 inhabitants, in contrast to 1471 in 1996; life expectancy at birth is 73.8 years compared with 71.6 years in 1996; and the infant mortality rate is down from 29.7 per thousand in 1996 to 19.5 per thousand. The health infrastructure in Tunisia is partly private and partly public, supported by a well-organized network of university hospitals and clinics and a central pharmaceutical service that imports and distributes drugs. In 1990, there was only one nuclear medicine centre in Tunisia at the Salah Azaiez Institute. In 2013, there are 12 centres, between public and private, with around forty doctors and 50 technicians using 15 gamma cameras, seven single-head, four dual-head and three SPECT/CT. Positron emission tomography (PET) will be acquired in short delay. Training for doctors and technicians in quality control for this new equipment and quality assurance in multimodal molecular imaging will soon become a priority. The protection of patients against radiation remains a major concern for these Departments. The regulatory and institutional framework has been established since 1980. Because of their oldness, they may not be suitable for radiation protection of persons exposed for medical purposes. An assessment of the practice of nuclear medicine can be helpful to standardize used protocols and to optimize the dose delivered to the patients during different nuclear medicine procedures in vivo.     

Measuring readmission rates.

OBJECTIVE--To assess the feasibility of extracting data on readmissions and readmission rates from Körner data for use as health service indicators. DESIGN--Retrospective analysis of inpatient Körner data for January 1988 to April 1989. SETTING--Three districts in North East Thames region. MAIN OUTCOME MEASURES--Number of readmissions after index discharge for all acute specialties combined and by specialty (general medicine, general surgery, gynaecology, trauma and orthopaedics, and geriatrics); readmission rates at 28 days after index discharge; and rates standardised for age group and sex by specialty and by consultant. RESULTS--All specialties showed an early peak in number of admissions, which levelled off by 28 days. Readmission rates at 28 days were appreciably lower in surgical specialties than in medical specialties (for example, general surgery 4.1% v geriatric medicine 15.1%). They were related to age and sex of the patient. Rates standardised for these variables did not significantly differ by district. Likewise, significant differences in standardised rates were not obtained for consultants within a specialty in one district. CONCLUSIONS--Readmission rates may be measured with Körner data. The pattern of readmissions with time means that readmission rates should be measured at not more than 28 days after the index discharge; the rates require standardisation for age and sex. Annual comparisons of standardised rates may be made among districts for combinations of specialties; those among individual consultants or specialties are unlikely to be statistically valid.     

Liposomal blood pool agents for nuclear medicine and magnetic resonance imaging

Abstract

Polymer-coated lipid vesicles labeled with either a radionuclide such as technetium-99m or a paramagnetic cation such as gadolinium or manganese, exhibit an extended half-life in the circulation and reduced reticuloendothelial uptake, and are of potential utility as vascular imaging agents for both nuclear medicine and magnetic resonance. For nuclear medicine applications, lipid vesicles may be prepared with radionuclide either attached to the membrane surface by means of a suitable chelate or else encapsulated within the vesicle and offer two principle advantages compared to radiolabeled red blood cells, (i) vesicle can be prepared prior to patient arrival thereby minimizing delays and scheduling difficulties and (ii) known drug interferences are eliminated. The surface-labeling approach is technically more simple and is better suited to the production of vesicles in a pharmaceutically-acceptable form ready for labeling, however encapsulation results in vesicles which exhibit less renal clearance of entrapped label. The limitations of each approach in real clinical practice are not yet evident. For magnetic resonance applications, paramagnetically-labeled vesicles would be a superior vascular marker compared to small molecular weight paramagnetic chelates and may prove useful for blood volume and perfusion measurements. Surface-associated chelates are the approach of choice for a variety of reasons including increased relaxivity and reduced lipid dose compared to vesicles with entrapped paramagnetic chelates. The presence of polymer on the membrane surface has no effect upon die relaxivity of paramagnetic chelates eitiier entrapped widiin the vesicle or bound to the membrane surface.     

Work of a day-bed unit 1972-8.

From 1972 to 1978 inclusive 32 311 patients were managed in a 24-bedded day-bed unit in a district general hospital. The principal specialties using this were urology, gastroenterology, general surgery, gynaecology, haematology, orthopaedics, and radiology. Patient selection, a high standard of secretarial work, and good liaison with general practitioners, the community nursing service, and the ambulance service are most important. Day care forms a large, important, and increasing part of the work of the hospital, and without it many of the specialties would be unable to cope with the demand, and their waiting lists would lengthen continuously.