Expert systems in treating substance abuse.

Computer programs can assist humans in solving complex problems that cannot be solved by traditional computational techniques using mathematic formulas. These programs, or "expert systems," are commonly used in finance, engineering, and computer design. Although not routinely used in medicine at present, medical expert systems have been developed to assist physicians in solving many kinds of medical problems that traditionally require consultation from a physician specialist. No expert systems are available specifically for drug abuse treatment, but at least one is under development. Where access to a physician specialist in substance abuse is not available for consultation, this expert system will extend specialized substance abuse treatment expertise to nonspecialists. Medical expert systems are a developing technologic tool that can assist physicians in practicing better medicine.     

19th-century academic examinations for physicians in the United States Army Medical Department.

During the latter half of the 19th century, the United States Army commissioned medical officers or hired civilian physicians to serve its troops. The civilian physician signed a contract for services, and the candidate for a commission was subjected to rigorous examinations before becoming an officer. The rigorous testing of prospective medical officers was necessary because of the lack of standardization in the education of physicians. Examples of the test, statistics, and individual records show how the Army dealt with unqualified candidates.     

Where have all the giants gone? Reconciling medical education and the traditions of patient care with limitations on resident work hours

The Accreditation Council for Graduate Medical Education recently approved regulations that would prohibit residents from working more than 80 hours per week and more than 24 hours at a stretch. These regulations are scheduled to take effect in all U.S. teaching hospitals on 1 July 2003. Those who approve of the proposed regulations argue that house staff fatigue is responsible for physician error, depression, anger, and a lack of compassion for patients. But critics point to the adverse effects on key goals of house staff training--the development of accountability and responsibility. Can the rigorous discipline of medical education and the long tradition of medicine as a profession be reconciled with the current calls for limiting resident duty hours and on-call schedules? The intensity of patient care in teaching hospitals today is far greater than it was in the past. These changes in medical care make it critical to develop new programs that will reconcile rigorous, scientifically based humanistic medicine with the needs of patients and physicians. This will require imaginative and creative solutions that take a larger view of medical education and medical care than mere manpower calculations and numerical solutions focused simply on compliance with an 80-hour work week.     

医疗损害鉴定制度的改革与发展

医疗损害指因医疗机构及其医务人员的故意或过失（即医疗过错）,造成就医患者身体上或精神上的损害结果。医疗损害鉴定是指医疗机构及其医务人员在日常医疗行为中存在法定过错并造成患者人身损害而导致的医疗损害民事诉讼,人民法院针对医疗技术的高风险、高技术等问题对外委托的鉴定。其内容主要针对医疗行为整个过程的审查和分析,对照卫生行政法规、部门规章诊疗护理规范及常规,判定医师有无过错,医疗过错行为与损害结果之间是否存在因果关系,医疗过错行为在损害结果中的责任程度以及人体损伤残疾程度等方面。     

Psychiatric illness in physicians.

Psychiatric illness and behavioural problems among physicians are reviewed in this paper. Some studies suggest that the medical profession has a high rate of alcoholism, drug abuse and marital discord. As well, physicians appear to commit suicide and to seek admission to psychiatric institutions more frequently than comparable populations. Considered as etiologic factors in psychiatric illness among physicians are the role strain inherent in the profession and the personality development of individual practitioners prior to their entering medical school. The review concludes with suggestions for an improved approach to treatment and prevention.     

The diffusion of new genetic tests for predicting disease.

This paper examines the pathways by which new genetic tests will become available to the public. In view of the scarcity of genetic specialists, the pathway is likely to involve primary care physicians. Other pathways entail state-mandated testing, community-based programs, or testing by laboratories without much involvement of primary care physicians. When testing does become available the "destination" will be either family-centered testing or population-oriented screening. The deterrent to screening will not be the inability to detect disease-causing mutations but the costs and attitudes of providers and the public. When tests are provided primarily to provide information about risks to future children, some people will oppose screening on religious or moral grounds. When there are no inexpensive treatments, some will fear that insurance companies and employers will use tests to deny them health care coverage. Some may not want to know their risks for disorders about which little can be done. For common, multifactorial disorders, genetic tests will have low predictive value. Because of these problems, the decision to be tested, regardless of the destination, requires that "testees" be fully informed and consent to testing. When acceptance rates are low, screening is less likely to be cost-effective; family-centered testing becomes the default destination.     

Fitness characteristics of a suburban special weapons and tactics team

Special Weapons and Tactics (SWAT) operators are specialized law enforcement officers who traditionally perform their duties with higher anticipated workloads because of additional body armor, weapons, and equipment used for enhanced operations and protection. This elevated workload increases the need for SWAT operators to improve or maintain their physical fitness to consistently perform routine operations. Typical tasks require trunk rotation, overhead upper extremity use, upper and lower body strength use, and long waiting periods followed by explosive movements while wearing additional equipment. Eleven male SWAT operators from 1 SWAT team performed flexibility, strength, power, and aerobic capacity tests and a variety of job-related tasks. Data were compared with age- and gender-based normative data. Fitness testing revealed that officers ranked high on tests of muscular strength (leg strength, 90th percentile; bench press, 85th percentile); however, body composition (55th percentile), core body strength, and flexibility ranked lower. Furthermore, aerobic capacity and muscular power had a wide range of scores and were also not ideal to support maximal performance during routine operations. These data can assist exercise specialists choose fitness programs specifically for job-related tasks of SWAT operators when creating fitness programs. Fitness programming for law enforcement should focus on improving aerobic fitness, flexibility, core strength, and muscular power while maintaining muscular strength to meet the needs of these specialized officers.     

Impact of education and network for avian influenza H5N1 in human: knowledge, clinical practice, and motivation on medical providers in Vietnam

Background

Knowledge, clinical practice, and professional motivation of medical providers relating to H5N1 infection have an important influence on care for H5N1 patients who require early diagnosis and early medical intervention.

Methods/Principal Findings

Novel educational programs including training and workshops for medical providers relating to H5N1 infection in Vietnam were originally created and implemented in 18 provincial hospitals in northern Vietnam between 2008 and 2010. A self-administered, structured questionnaire survey was conducted in 8 provincial hospitals where both educational training and workshops were previously provided. A total of 326 medical providers, including physicians, nurses, and laboratory technicians who attended or did not attend original programs were enrolled in the survey. Knowledge, clinical attitudes and practice (KAP), including motivation surrounding caring for H5N1 patients, were evaluated. The study indicated a high level of knowledge and motivation in all professional groups, with especially high levels in laboratory technicians. Conferences and educational programs were evaluated to be the main scientific information resources for physicians, along with information from colleagues. The chest radiographs and the initiation of antiviral treatment in the absence of RT-PCR result were identified as gaps in education. Factors possibly influencing professional motivation for caring for H5N1 patients included healthcare profession, the hospital where the respondents worked, age group, attendance at original educational programs and at educational programs which were conducted by international health-related organizations.

Conclusions

Educational programs provide high knowledge and motivation for medical providers in Vietnam caring for H5N1 patients. Additional educational programs related to chest radiographs and an initiation of treatment in the absence of RT-PCR are needed. Networking is also necessary for sharing updated scientific information and practical experiences. These enhanced KAPs by educational programs and integrated systems among hospitals should result in appropriate care for H5N1 patients and may reduce morbidity and mortality.     

Current management of the Wolff-Parkinson-White syndrome.

The Wolff-Parkinson-White syndrome is a multifaceted disorder that ranges from asymptomatic to life threatening. Accounting for approximately 20% of cases of paroxysmal supraventricular tachycardia and with a prevalence perhaps as high as 1 per 500, it is far from a rare disorder. Considering the potentially lethal complications following the administration of digoxin or verapamil, all physicians treating arrhythmias should know when to suspect the Wolff-Parkinson-White syndrome. A careful review of electrocardiograms helps identify cases of the disorder despite a wide range of findings that may mimic other conditions. Major advances in the efficacy of surgical procedures to cure this syndrome make this a reasonable alternative to life-long medical therapy for many patients. Unfortunately, available diagnostic tests lack the positive predictive value to reliably distinguish patients at risk of sudden death. This review is an update for general internists of the major developments in the evaluation and treatment of the disorder and provides specific examples helpful in differentiating these patients.     

Government Regulations and the Use of Drugs

I have tried to trace the new drug development pattern from 1766, when Withering obtained his medical degree, to the present.The role of governmental authority as defined by the 1962 Kefauver-Harris amendments to the 1906 law and the subsequently issued regulations has been summarized. Four phases of testing in man have been detailed.Something of the scientific or research capability of the pharmaceutical industry has been presented.It is concluded that in the period of over two hundred years of medical education in the United States, the university hospital has become more and more the focus of medical research, teaching and practice in the community. The safety and effectiveness in the use of drugs in the future will depend upon the liaison and rapport of the industry physicians, government officials and the university hospital teacher-clinical investigators (phase 1 and 2) in designing the most critical studies of the safety and effectiveness of new drugs.Whether the medical profession as we know it will participate more in the future than has been possible since 1962 in mass clinical trial (phase 3) before new drug approval by governmental authority remains to be seen.The final approbation or disapproval of a drug after NDA approval (phase 4) will continue to be in the hands of the participating physician as long as he can establish scientifically that the drug is the best possible agent for him to use in healing the sick and comforting the dying.     

The Future Emerges from the Past

The case of Jordan (Mason 2017) highlights the gamble of connecting with the past through genomic testing. Unfortunately for Jordan, his genomic testing identified two variant genes which account for up to 75 per cent of early-onset Alzheimer’s disease cases. Furthermore, his children were identified as having a 50 per cent risk of inheriting the gene which corresponds to the majority of early-onset Alzheimer’s disease cases. Now Jordan is not only burdened with the foreknowledge that he will most likely develop Alzheimer’s disease at a relatively young age but also burdened with the knowledge that his children may share his fate. Jordan was overwhelmed by his attempts to understand the genetic tests and experienced substantial distress. This response highlights the need for industry-wide regulations that adequately prepare individuals for the decision of whether to initiate genomic testing and require the results to be interpreted with genetic counsellors or other suitably skilled doctors. Furthermore, these industry-wide regulations need to be accountable to the same evidence-based standards that regulate the rest of the medical professions.     

Chemical dependency and drug testing in the workplace.

Urine testing for drug use in the workplace is now widespread, with the prevalence of positive drug tests in the work force being 0% to 15%. The prevalence of marijuana use is highest, and this can be reliably tested. Though it is prudent to rid the workplace of drug use, there is little scientific study on the relationship of drug use and workplace outcomes, such as productivity and safety. Probable-cause testing and preemployment testing are the most common applications. Random testing has been less accepted owing to its higher costs, unresolved legal issues, and predictably poor test reliability. Legal issues have focused on the right to policy, discrimination, and the lack of due process. The legal cornerstone of a good program is a policy that is planned and agreed on by both labor and management, which serves both as a contract and as a procedure in which expectations and consequences are known. The National Institute on Drug Abuse is certifying laboratories doing employee drug testing. Testing methods when done correctly are less prone to error than in the past, but screening tests can be defeated by adulterants. Although the incidence of false-positive results is low, such tests are less reliable when the prevalence of drug abuse is also low.     

Assessment of Validation Studies from a Fractionator''s Point of View

NAT testing has become an integral part in the safety programs of both plasma fractionators and transfusion services. NAT testing for HCV RNA is now mandatory for plasma fractionators in Europe and for transfusion services in Germany and Austria. Before NAT testing of plasma could become mandatory, a defined environment had to be created to allow comparison of different NAT procedures. To create such an environment, international virus standards, as well as guidelines for validation, assessment of robustness, and quality assurance of NAT have been released. This paper is a critical review of currently available standards and national reference preparations, detection limits, and national regulations of NAT in view of the specific nature of NAT.     

The future of family practice training in California.

Although the number of physicians in California has doubled since 1963, the number of family and general practice physicians has declined. The ratio of office-based primary care physicians to population has also decreased. Graduate medical education is funded largely from patient care revenues, but the low rate of reimbursement for ambulatory care makes training in primary care specialties especially dependent on public support. Medicare, the Veterans Administration, and the University of California provide more than $325 million a year in support of graduate medical education in California. Federal and state grant programs provide $5 million a year for family physician training in the state, but appropriations to these programs have been reduced in real terms. California family practice residencies are disproportionately located at county hospitals, where funding shortfalls make them especially vulnerable to cuts in grant programs. Additional resources will be needed if more family physicians are to be trained.     

Death Following Inhalation of Mercury Vapor at Home.

Confusion exists among physicians over the legal requirements and appropriate prescribing of narcotics to addicted or habitual users of narcotics. The result has often been either (1) the deprivation of appropriate treatment for patients who desire detoxification or adequate pain relief, or (2) illegal prescribing by physicians. Because most narcotics are potent and dangerous substances, certain legal restrictions are necessary to protect the general public. State-approved programs have been established to prescribe methadone and propoxyphene napsylate for addiction treatment. Current laws and regulations in California permit every practicing physician to provide effective and safe treatment for addiction and pain relief.     

Subspecialty consultations in a teaching hospital.

A chart review of 60 consultations by the nephrology service of a teaching hospital was carried out to determine their diagnostic and therapeutic utility. General medicine residents on elective rotations in nephrology performed 72% of the consultations, only 26% being written by residents in the subspecialty. Consultants made an average of 2.2 diagnoses per patient, of which 57% confirmed the working diagnosis already in the medical record. They made an average of 3.0 recommendations for further investigation per patient, but referring physicians implemented only 58% of these. An average of 1.6 recommendations for therapy were made per patient, of which 64% were implemented. The apparent neglect of the consultant''s advice for investigation and therapy suggests that the written consultation to some extent fails to convey information useful for the referring physician and the patient. Further study is needed to determine if this failure reflects inadequate training of house officers as consultants.     

Laboratory technicians; the Clinical Laboratory Law and its meaning to private physicians

The present laws and regulations relating to clinical laboratories in California are the outcome of over a quarter century of cooperative development. The medical profession, public health department, laboratory workers, and the legislature have worked together in this development.At first the system of certifying technicians and laboratories was on a voluntary basis. The clinical laboratory law in effect legalized and made generally applicable a system which had already been accepted voluntarily. The application of the clinical laboratory law provides physicians a reasonable assurance that competence and reliability will prevail in clinical laboratory operation. Of great importance is the conduct of proper training programs by approved laboratories. Since modern medical practice is so dependent on accurate clinical laboratory work it is essential that special effort be directed by physicians toward influencing young people to enter the profession of medical technology.     

Implementation of biosurety systems in a Department of Defense medical research laboratory

New biosurety regulations and guidelines were implemented in 2003 because of increased concern for the safety and security of biological select agents and toxins (BSAT) that may be used as weapons of mass destruction. Biosurety is defined as the combination of security, biosafety, agent accountability, and personnel reliability needed to prevent unauthorized access to select agents of bioterrorism. These new regulations will lead to increased scrutiny of the use of select biological agents in registered research laboratories, but the regulations may have unintended effects on cost, progress, and perceptions in programs previously considered part of the academic research community. We review the history of biosurety, evolving guidelines, implementation of the regulations, and impacts at the lead research laboratory for medical biological defense for the Department of Defense.