The pathology clinic - pathologists should see patients

This invited review describes why and how a pathologist should talk to patients in order to enhance the patient care pathway. The pathologist-patient interaction should become a natural extension to multidisciplinary team decision making, and also become the forum in which patients are helped to understand important aspects of their conditions and the pathological basis for their treatment plans. There is a vast amount of information available through the internet and to digest this can be a difficult process for a patient who is already having to cope with a medical condition. The pathologist is often best placed to sieve through this information and offer the patient the relevant detail necessary to understand the condition and the management pathway. Pathologists can provide up-to-date, simple information about malignant and even certain significant benign conditions, and they can do this with the help of several pictorial tools. In this way, the pathologist becomes an even more active member of a clinical team and helps both clinicians and patients to deal with illnesses in a novel way hitherto not considered.     

Measuring and improving the quality of mental health care: a global perspective

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology‐based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient‐centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement‐based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.     

Growing into My White Coat: Improving the Patient-Provider Relationship Through Diverse Patient Interviews

The “Patient Diversity” assignment is an integral component for all medical and other health care professional students rotating through the Surgery clerkship at the Yale School of Medicine. Students are instructed to interview a surgical patient who is of a varied social or cultural background to identify how psychosocial factors impact patient coping strategies. In the process, students often appreciate how health care providers’ own social and cultural backgrounds similarly shape their sentiments and reactions in patient care. In this interview with a 26-year-old surgical patient, one student strives to come to terms with her personal insecurities in patient interactions and seeks to overcome them through open conversation and honest introspection. By working to acknowledge and understand patient diversity, health care providers can enhance understanding of their patients’ conditions and form more trustful and empathic relationships with both their patients and colleagues.     

When a physician and a clinical ethicist collaborate for better patient care

Bioethics is a relatively new addition to bedside medical care in Arab world which is characterized by a special culture that often makes blind adaptation of western ethics codes and principles; a challenge that has to be faced. To date, the American University of Beirut Medical Center is the only hospital that offers bedside ethics consultations in the Arab Region aiming towards better patient‐centered care. This article tackles the role of the bedside clinical ethics consultant as an active member of the medical team and the impact of such consultations on decision‐making and patient‐centered care. Using the case of a child with multiple medical problems and a futile medical condition, we describe how the collaboration of the medical team and the clinical ethics consultant took a comprehensive approach to accompany and lead the parents and the medical team in their decision‐making process and how the consultations allowed several salient issues to be addressed. This approach proved to be effective in the Arab cultural setting and indeed did lead to better patientcentered care.     

Perceptions and preferences on denture marking in an Indian sample

doi: 10.1111/j.1741‐2358.2011.00499.x Perceptions and preferences on denture marking in an Indian sample Aim: Denture marking is useful in institutional settings and post‐mortem identification. Numerous markers have been developed, and their advantages and limitations assessed previously; however, patient perception to denture marking is paramount. We evaluated this in an Indian sample and also gauged their preference for different markers. Materials and methods: One‐hundred and one edentulous patients seeking prosthodontic treatment in our institution were shown four denture markers (stainless steel matrix band, paper strip with name inscribed on it, patient photograph and optically readable laminated bar code) and asked whether they wanted similar markers in their dentures; patients were also asked to rank the markers based on preference and indicate their satisfaction with it. Results: Approximately two‐thirds of patients (65/101) were uninterested in getting their dentures marked; among the 36 who agreed, 10 preferred the stainless steel band followed by photographs (9), paper strip (6) and bar code (2); nine gave multiple responses and were excluded from analyses. Sixteen patients expressed dissatisfaction with the photographic marker and bar code, while this number reduced for the stainless steel band (13) and paper strip (10). Conclusions: The results are in contrast to European studies wherein the majority of patients agreed to denture marking, indicating patient background (e.g. education level) may affect perception to denture marking; amongst those who agreed to marking, most preferred, or were satisfied with, the stainless steel and paper strip markers over photographic marker and a complex method such as bar‐coding, implying that simple methods harbouring basic patient information may suffice in the Indian context.     

Oral implants in dependent elderly persons: blessing or burden?

doi:10.1111/j.1741‐2358.2009.00314.x
Oral implants in dependent elderly persons: blessing or burden? Background: Implant‐supported (partial) dentures may raise problems in patients who have become dependent on others for daily oral health care. Dental hygienists and general dental practitioners, as well as care providers, volunteer aiders and even health care insurance companies, should anticipate the growing demand for specific oral health care for patients provided with implant‐supported (partial) dentures. Objective: To report three cases of dependent patients and to present recommendations to prevent or resolve implant‐related oral problems. Materials and methods: The three case reports are demonstrating that implant insertion in (dependent) elderly people needs careful consideration. Discussion: When considering implant treatment, some questions should be raised: (1) Is the treatment appropriate in contributing to the patient’s well‐being and quality of life? (2) Is the treatment the most suitable treatment? (3) Does the treatment integrate with the patient’s oral health care plan? (4) Is the patient sufficiently cooperative? (5) Is the patient supported by a well‐functioning oral (self) care assisting network? (6) Is it possible for the patient to regular see an oral health care professional and is oral health care easily accessible in cases of an emergency? Conclusion: Dependent elderly people can benefit from oral implants, providing that adequate oral health care and aftercare can be provided. When indicated, removal of the anchorage structure is easily performed by putting the implants to sleep. All implant patients should be provided with an ‘implant passport’. Regular information and instruction for care providers about the oral condition of the patient are essential.     

Suffering at the end of life

In the end‐of‐life context, alleviation of the suffering of a distressed patient is usually seen as a, if not the, central goal for the medical personnel treating her. Yet it has also been argued that suffering should be seen as a part of good dying. More precisely, it has been maintained that alleviating a dying patient’s suffering can make her unable to take care of practical end‐of‐life matters, deprive her of an opportunity to ask questions about and find meaning in and for her existence, and detach her from reality. In this article, I argue that the aims referred to either do not support suffering or are better served by alleviating it. When the aims would be equally well served by enduring suffering and relieving it, the latter appears to be the preferable option, given that the distress a patient experiences has no positive intrinsic value. Indeed, as the suffering can be very distressing, it may not be worth bearing even if that was the best way to achieve the aims: the distress can sometimes be bad enough to outbalance the worth of achieving the goals. Having considered an objection to the effect that a patient can have a self‐regarding moral duty to endure the distress she faces at the end of life, I conclude that the burden of proof is on the side of those who maintain that the suffering experienced at the end of life ought to be endured as a part of dying well.     

The Impact of Obesity on Primary Care Visits

Objective: To investigate the influence of patient obesity on primary care physician practice style. Research Methods and Procedures: This was a randomized, prospective study of 509 patients assigned for care by 105 primary care resident physicians. Patient data collected included sociodemographic information, self‐reported health status (Medical Outcomes Study Short Form‐36), evaluation for depression (Beck Depression Index), and satisfaction. Height and weight were measured to calculate the BMI. Videotapes of the visits were analyzed using the Davis Observation Code (DOC). Results: Regression equations were estimated relating obesity to visit length, each of the 20 individual DOC codes, and the six DOC Physician Practice Behavior Clusters, controlling for patient health status and sociodemographics. Obesity was not significantly associated with the length of the visit, but influenced what happened during the visit. Physicians spent less time educating obese patients about their health (p = 0.0062) and more time discussing exercise (p = 0.0075). Obesity was not related to discussions regarding nutrition. Physicians spent a greater portion of the visit on technical tasks when the patient was obese (p = 0.0528). Mean pre‐visit general satisfaction for obese patients was significantly lower than for non‐obese patients (p = 0.0069); however, there was no difference in post‐visit patient satisfaction. Discussion: Patient obesity impacts the medical visit. Further research can promote a greater understanding of the relationships between obese patients and their physicians.     

Patient and public involvement: Two sides of the same coin or different coins altogether?

Patient and public involvement (PPI) has gained widespread support in health research and health policy circles, but there is little consensus on the precise meaning or justifications of PPI. We argue that an important step towards clarifying the meaning and justification for PPI is to split apart the familiar acronym and draw a distinction between patient and public involvement. Specifically, we argue that patient involvement should refer to the practice of involving individuals in health research or policy on the basis of their experience with a particular condition, while public involvement should refer to the practice of involving individuals in health policy or research based on their status as members of a relevant population. Analyzing cases from the UK, Australia, and the USA, we show how our proposed distinction can deliver much needed clarity to conversations on PPI, while guiding the development and evaluation of future PPI‐based policies.     

Readability of standard appointment letters

Introduction and aims The first contact a clinical service has with a patient is often an appointment letter and thus it is important that this letter is written in a way which is accessible. One concern is to write in language which is easily able to be read by the majority of recipients. A simple initial way to assess this is by using measures of readability of text.Methods We applied measures to examine the readability of appointment and administrative letters sent to young people by clinicians in the Young People's Department at the Royal Cornhill Hospital in Aberdeen.Results Many letters were unlikely to be understood by our youngest patients. We revised the letters to meet an agreed standard of readability, and agreed their routine use within the team. All letters were significantly improved on standard measures of readability and were preferred by patients.Conclusions The methods used are feasible, easily available and may be helpful to clinicians working in other specialties to improve the level of readability of written communication. This will help patients and families in their first contact with any clinical service.     

Classification of early‐stage non‐small cell lung cancer by weighing gene expression profiles with connectivity information

Pathway‐based feature selection algorithms, which utilize biological information contained in pathways to guide which features/genes should be selected, have evolved quickly and become widespread in the field of bioinformatics. Based on how the pathway information is incorporated, we classify pathway‐based feature selection algorithms into three major categories—penalty, stepwise forward, and weighting. Compared to the first two categories, the weighting methods have been underutilized even though they are usually the simplest ones. In this article, we constructed three different genes’ connectivity information‐based weights for each gene and then conducted feature selection upon the resulting weighted gene expression profiles. Using both simulations and a real‐world application, we have demonstrated that when the data‐driven connectivity information constructed from the data of specific disease under study is considered, the resulting weighted gene expression profiles slightly outperform the original expression profiles. In summary, a big challenge faced by the weighting method is how to estimate pathway knowledge‐based weights more accurately and precisely. Only until the issue is conquered successfully will wide utilization of the weighting methods be impossible.     

RECLAIMING THE PATIENT'S VOICE AND SPIRIT IN DYING: AN INSIGHT FROM ISRAEL

In the latter half of the 20th century, Western medicine moved death from the home to the hospital. As a result, the process of dying seems to have lost its spiritual dimension, and become a matter of prolonging material life by means of medical technology. The novel quandaries that arose led in turn to medico‐legal regulation. This paper describes the recent regulation of dying in Israel under its Dying Patient Law, 2005. The Law recognizes advance directives in principle, but limits their effect and form through complex medico‐legal artifices. It reflects a culture that places high value on both scientific medicine and the sanctity of life as such, and illustrates a medical culture that pitches battle against death. At the same time, the Law constructs the will of the individual in a medico‐legal language that is alien to the lay person. The paper suggests an alternative approach to advance care planning that is patient‐centred and addresses the psycho‐social needs of the individual in terms of her relational autonomy. From this perspective, advance care planning becomes an opportunity to extract the patient from the medical context and allow her to speak about her approaching death with close ones in her own terms of reference. To this end, there is a need for facilitation of an intimate encounter where patients can speak about their concerns with their loved ones. The paper also presents a methodological approach of attentive listening, which can be applied across diverse cultures and circumstances.     

Retrofitting coal‐fired power plants with biomass co‐firing and carbon capture and storage for net zero carbon emission: A plant‐by‐plant assessment framework

The targets of limiting global warming levels below 2°C or even 1.5°C set by Paris Agreement heavily rely on bioenergy with carbon capture and storage (BECCS), which can remove carbon dioxide in the atmosphere and achieve net zero greenhouse gas (GHG) emission. Biomass and coal co‐firing with CCS is one of BECCS technologies, as well as a pathway to achieve low carbon transformation and upgrading through retrofitting coal power plants. However, few studies have considered co‐firing ratio of biomass to coal based on each specific coal power plant's characteristic information such as location, installed capacity, resources allocation, and logistic transportation. Therefore, there is a need to understand whether it is worth retrofitting any individual coal power plant for the benefit of GHG emission reduction. It is also important to understand which power plant is suitable for retrofit and the associated co‐firing ratio. In order to fulfill this gap, this paper develops a framework to solve these questions, which mainly include three steps. First, biomass resources are assessed at 1 km spatial resolution with the help of the Geography Information Science method. Second, by setting biomass collection points and linear program model, resource allocation and supply chain for each power plants are complete. Third, is by assessing the life‐cycle emission for each power plant. In this study, Hubei Province in China is taken as the research area and study case. The main conclusions are as follows: (a) biomass co‐firing ratio for each CCS coal power plant to achieve carbon neutral is between 40% and 50%; (b) lower co‐firing ratio sometimes may obtain better carbon emission reduction benefits; (c) even the same installed capacity power plants should consider differentiated retrofit strategy according to their own characteristic. Based on the results and analysis above, retrofit suggestions for each power plant are made in the discussion.     

Interpreting Diabetes Mellitus: Differences between Patient and Provider Models of Disease and their Implications for Clinical Practice

Current medical literature suggests that Type 2 diabetes mellitus can becontrolled by diet and hypoglycemic agents or diet and insulin therapy.Nevertheless, adhering to a low glucose dietary regimen remainsproblematic for a majority of patients, and management of the disease isan ongoing source of frustration for physicians and other providers.While calling for more research on the physician's experience oftreating chronic conditions like diabetes, the authors argue that muchof the current frustration stems from the different frames orexplanatory models that physicians and patients use to understand thedisease. By comparing physician narratives collected in several clinicalcontexts (e.g., medical lectures, precepting sessions, patient caresessions and personal interviews) with patient stories obtainedprimarily through narrative interviews, the authors highlight crucialdifferences in the way physicians and patients experience and thinkabout the disease. In particular, the authors highlight differencesbetween physicians and patients across five dimensions: etiology,symptoms/signs, factors which affect blood sugar, ideal blood sugar,and future prospects. In concluding, the authors sketch out elements ofa theory of clinical practice involving diabetes care. Data for thestudy was collected at two family practice training sites in Chicago.     

Electronic Medical Records and Electronic Health Records: Overview for Nurse Practitioners

Electronic medical records (EMRs) and electronic health records (EHRs) have become essential systems by which nurse practitioners (NPs) communicate vital patient information to other members of the health care team as well as to patients. In this article we examine the important distinctions between EMRs and EHRs; review the genesis of these types of records; summarize applicable provisions of the Health Insurance Portability and Accountability Act from a recent legal case centered around NP utilization of EMRs and EHRs; address open patient access to medical information; and examine threats to security. Suggestions are offered on ways in which NPs can safeguard confidential patient information.     

Cadaver nephrectomy: an operation on the donor's family.

Thirty-two relatives of cadaver kidney donors were interviewed six months or longer after the donor''s death. Most had positive attitudes to kidney transplantation that had been strengthened by experience, especially when they knew that they were fulfilling the donor''s wishes. Twenty-three of the relatives had gained some solace from knowing that others might benefit from their misfortune, but three claimed adverse effects. In identifying the factors that influenced them to grant permission or hesitate, relatives revealed defects in the way their permission had been sought. Twelve did not clearly understand the donor''s hopeless prognosis until then, and seven reacted adversely to the interviewers, finding them blunt and callous. Nevertheless, most were pleased that they had been asked. Doctors who care for unconscious, dying patients should try to give relatives explicit information on the patient''s condition, whether or not the patient is a potential kidney donor, and permission for organ recovery should not be sought until they understand that death is inevitable.     

Metastasizing keratoacanthomas? The difficulties in differentiating keratoacanthomas from squamous cell carcinomas

The problem in diagnosis of keratoacanthoma versus squamous cell carcinoma has been reviewed, and 13 patients are presented to illustrate the difficulties in differentiating between these two lesions. If the pathologist is in doubt, the lesion should be called "probable keratoacanthoma, but squamous cell carcinoma cannot be ruled out." We should all be aware that even the most careful pathologist, using all the information and material available, may still erroneously diagnose a lesion as a benign keratoacanthoma--one which, if inadequately treated, may metastasize or recur as a squamous cell carcinoma. Therefore, it is important for the clinician to treat most keratoacanthomas by adequate removal and close follow-up.     

L’adolescent malade: quand le soin devient violence Clinique des pathologies digestives

Admitting an adolescent suffering from a chronic disease to a somatic healthcare service for adults involves staff’s capacity to understand the specificity of the psychological working-through of the illness, in this category of patients, and staff’s consequent adaptation to the care services’ settings offered to the patient. In certain cases, healthcare staff members become subject to adolescents’ violent attitudes and feel attacked in this maternal capacity. The staff members could halt this violence and work through their own negative emotional concern. They must be able to face the painful problems of the ill child and his/her family may be confronted to questions that arise in this situation are related to the impact of a chronic disease on a child’s developmental course, the involvement of this traumatic experience into the family’s functioning, the prevention of risks of pathological interactions or the patient’s and his/her family members’ decompensation. While listening in a comprehensive way, staff may search for signs of life instinct in these patients. Then, caregivers can rely on it and realize a resuscitation of the psyche and contribute to restore the mental processes in the patient and assist his/her working-through of the traumatic experience.