The pathology clinic – pathologists should see patients

S. Manek 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.     

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.     

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.     

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.     

The clinical psychologist; his role in private medical practice

The independent diagnosis and treatment of mental and nervous disorders according to California law constitutes practicing medicine. By this yardstick, an increasing number of clinical psychologists are entering the private practice of medicine. The medical profession has not provided through its leadership the opportunity for clinical psychologists to utilize their skills in a legitimate and supervised way in the treatment of private patients, nor has the medical profession taken sufficient interest in modern methods of treating patients with psychogenic disorders. If the psychiatric team is a feasible and practical approach to spreading the base of psychiatric treatment in hospitals and clinics, it should be applicable to private practice settings too. In the team setting, the psychologist can render great assistance to the physician in the diagnosis and treatment of patients with psychogenic disorders without compromising the principle that the primary responsibility for the patient is the physician's. By virtue of his training and experience, it is the psychiatrist who is best qualified to supervise the work of the psychologist; and until such time as the medical profession is better acquainted with psychotherapeutic techniques, the employment of psychologist assistants should be (according to good medical practice) left to the psychiatrist. The need for some regulation of the use of the title "psychologist" is increasing in order to protect the public from quacks who pose as psychologists. However, any law which is directed toward elimination of the quack should specifically define psychotherapy and contain provisions for its use under adequate medical supervision. The medical profession is obligated to take its traditional role in providing the best possible treatment for patients who are in need of it, and psychotherapy is an inherent part of treatment.     

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.     

Heart teams in the Netherlands: From teamwork to data‑driven decision-making

For all patients with cardiovascular disease requiring an intervention, this is a major life event. The heart team concept is one of the most exciting and effective team modalities to ensure cost-effective application of invasive cardiovascular care. It optimises patient selection in a complex decision-making process and identifies risk/benefit ratios of different interventions. Informed consent and patient safety should be at the centre of these decisions. To deal with increased load of medical data in the future, artificial intelligence could enable objective and effective interpretation of medical imaging and decision support. This technical support is indispensable to meet current patient and societal demands for informed consent, shared decision-making, outcome improvement and safety. The heart team should be restructured with clear leadership, accountability, and process and outcome measurement of interventions. In this way, the heart team concept in the Netherlands will be ready for the future.

     

ClinMine: Optimizing the Management of Patients in Hospital

Context

A better understanding of “patient pathway” thanks to data analysis can lead to better treatments for patients. The ClinMine project, supported by the French National Research Agency (ANR), aims at proposing, from various case studies, algorithmic and statistical models able to handle this type of pathway data, focusing primarily on hospital data.

Amotivational syndrome: The real management problem of schizophrenia

Impaired insight is a prominent feature of the schizophrenic syndrome, and failure to take major tranquillizers by the oral route has resulted in many relapses. The introduction of the long-acting phenothiazine fluphenazine enanthate (Moditen Enanthate) has greatly facilitated the control of the florid symptoms of this disorder by transferring most of the responsibility for phenothiazine administration from the patients to the clinic or family physician. The educational maturing process, to enable these patients to cope with the challenges of adult life and the reality of their condition, can be handled more effectively through a therapeutic team approach, operating within the framework of a structured program, than by the traditional psychiatrist/patient relationship alone.     

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.     

International Study to Predict Optimized Treatment for Depression (iSPOT-D), a randomized clinical trial: rationale and protocol

Background

Asthma is a prevalent and costly disease resulting in reduced quality of life for a large proportion of individuals. Effective patient self-management is critical for improving health outcomes. However, key aspects of self-management such as self-monitoring of behaviours and symptoms, coupled with regular feedback from the health care team, are rarely addressed or integrated into ongoing care. Health information technology (HIT) provides unique opportunities to facilitate this by providing a means for two way communication and exchange of information between the patient and care team, and access to their health information, presented in personalized ways that can alert them when there is a need for action. The objective of this study is to evaluate the acceptability and efficacy of using a web-based self-management system, My Asthma Portal (MAP), linked to a case-management system on asthma control, and asthma health-related quality of life.

Methods

The trial is a parallel multi-centered 2-arm pilot randomized controlled trial. Participants are randomly assigned to one of two conditions: a) MAP and usual care; or b) usual care alone. Individuals will be included if they are between 18 and 70, have a confirmed asthma diagnosis, and their asthma is classified as not well controlled by their physician. Asthma control will be evaluated by calculating the amount of fast acting beta agonists recorded as dispensed in the provincial drug database, and asthma quality of life using the Mini Asthma Related Quality of Life Questionnaire. Power calculations indicated a needed total sample size of 80 subjects. Data are collected at baseline, 3, 6, and 9 months post randomization. Recruitment started in March 2010 and the inclusion of patients in the trial in June 2010.

Discussion

Self-management support from the care team is critical for improving chronic disease outcomes. Given the high volume of patients and time constraints during clinical visits, primary care physicians have limited time to teach and reinforce use of proven self-management strategies. HIT has the potential to provide clinicians and a large number of patients with tools to support health behaviour change.

Trial Registration

Current Controlled Trials ISRCTN34326236.     

Healthcare and the hospital chaplain

Many chaplains and most chaplaincy programs in the United States--with encouragement from their accrediting organization, the Association for Clinical Pastoral Education (ACPE)--have begun to assume a more proactive stance toward patients, healthcare professionals, and healthcare facilities. Some chaplains and chaplaincy programs have begun to engage in activities that have ranged from initiating conversations with and perusing the medical records of patients who have not requested their services to proposing that they be permitted to do "spiritual assessments" on patients--in some instances whether these patients have been explicitly informed and have agreed to this beforehand. Moreover, many chaplains and chaplaincy programs have begun to assume that chaplains are full-fledged members of the healthcare team, complete with access to patients' medical records both to gather information and to make notations of their own. It would appear that such novel activities are being justified by a questionable set of claims and assumptions that includes: (1) the claim that chaplains have a spiritual--as opposed to purely religious--expertise that entitles them to interact with patients and/or significant others (even those who have not requested a chaplain)--presumably without in the least compromising patient autonomy or the confidentiality of the patient/healthcare professional relationship; (2) the assumption that the terms "spirituality" and "religiosity" mutually entail one another; (3) the claim that the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandates "spiritual assessments" (which it does not); (4) the assumption that chaplains are full-fledged members of the healthcare team; and (5) the claim that chaplains must, therefore, be permitted access to patients and patients' medical records both to gather information and to make notations of their own. We consider such claims and assumptions disquieting, and suggest that it is high time we revisit the terms "chaplaincy," "healthcare professional," and "member of the healthcare team" in reassessing what our professional commitments to respect and protect the bio-psycho-social integrity of patients require.     

Biomarkers in Spinal Cord Injury: from Prognosis to Treatment

Spinal cord injury (SCI) is considered an incurable condition, having a heterogenous recovery and uncertain prognosis. Therefore, a reliable prediction of the improvement in the acute phase could benefit patients. Physicians are unanimous in insisting that at the initial damage of the spinal cord (SC), the patient should be carefully evaluated in order to help selecting an appropriate neuroprotective treatment. However, currently, neurologic impairment after SCI is measured and classified by functional examination. The identification of prognostic biomarkers of SCI would help to designate SC injured patients and correlate to diagnosis and correct treatment. Some proteins have already been identified as good potential biomarkers of central nervous system injury, both in cerebrospinal fluid (CSF) and blood serum. However, the problem for using them as biomarkers is the way they should be collected, as acquiring CSF through a lumbar puncture is significantly invasive. Remarkably, microRNAs (miRNAs) have emerged as interesting biomarker candidates because of their stability in biological fluids and their tissue specificity. Several miRNAs have been identified to have their expressions altered in SCI in many animal models, making them promising candidates as biomarkers after SCI. Moreover, there are yet no effective therapies for SCI. It is already known that altered lysophospholipids (LPs) signaling are involved in the biology of disorders, such as inflammation. Reports have demonstrated that LPs when locally distributed can regulate SCI repair and key secondary injury processes such as apoptosis and inflammation, and so could become in the future new therapeutic approaches for treating SCI.     

Information transfer in metabolic pathways. Effects of irreversible steps in computer models.

Various metabolic models have been studied by computer simulation in an effort to understand why allowing for the reversibility of the reaction catalysed by pyruvate kinase, normally considered as irreversible for all practical purposes, significantly altered the behaviour of the model of glycolysis in Trypanosoma brucei [Eisenthal, R. & Cornish-Bowden, A. (1998) J. Biol. Chem. 273, 5500-5505]. Studies of several much simpler models indicate that the enzymes catalysing early steps in a pathway must receive information about the concentrations of the metabolites at the end of the pathway if a model is to be able to reach a steady state; treating all internal steps as reversible is just one way of ensuring this. Feedback inhibition provides a much better way, and as long as feedback loops are present in a model it makes almost no difference to the behaviour whether the intermediate steps with large equilibrium constants are treated as irreversible. In the absence of feedback loops, ordinary product inhibition of all the enzymes in the chain can also transfer information; this is efficient for regulating fluxes but very inefficient for regulating intermediate concentrations. More complicated patterns of regulation, such as activation of a competing branch or forcing flux through a parallel route, can also serve to some degree as ways of passing information around an irreversible step. However, they normally do so less efficiently than inhibition, because the extent to which an enzyme or a pathway can be activated always has an upper limit (which may be below what is required), whereas most enzymes are inhibited completely at saturating concentrations of inhibitor.     

Detection of multiple colon and rectal tumors during diagnostic treatment and follow-up

Recognition of the commonly encountered colorectal cancer (CRC) generally begins and takes place because of and based on symptoms and signs, due to the unsettled screening of this type of cancer. Sometimes, because of advanced stage cancer urgent surgical intervention could become necessary and, if this is the case, there is no time and possibility for searching for an eventual second tumor and perhaps the patient's status does not permit performing intraoperative investigations either. The incidence of multiple colon cancer is considered to be between 2.5 and 30% according to the literature. That is why one should exclude them even in the absence of pre- and intraoperative investigations and complaints. On the other hand, colonoscopy and perhaps irrigoscopy of seemingly healthy followed-up patients is mandatory. In the case of the presence of complaints/symptoms denoting impaired intestinal passage seen in a followed-up patient or during the adjuvant setting or metastatic/recurrent disease, treatment and even during hospice care we should evaluate the possibility of a second metachronous tumor. Moreover, if there is no urgency, the multidisciplinary team (oncoteam) should recommend the adequate treatment by balancing gain/utility and risk.     

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.