Treating the individual hypertensive patient: considerations on dose, sequential monotherapy and drug combinations.

For the general practitioner to be able to prescribe optimal therapy to his individual hypertensive patients, he needs accurate information on the therapeutic agents he is going to administer and practical treatment strategies. The information on drugs and drug combinations has to be applicable to the treatment of individual patients and not just patient study groups. A basic requirement is knowledge of the dose-response relationship for each compound in order to choose the optimal therapeutic dose. Contrary to general assumption, this key information is difficult to obtain and often not available to the physician for many years after marketing of a drug. As a consequence, excessive doses are often used. Furthermore, the physician needs comparative data on the various antihypertensive drugs that are applicable to the treatment of individual patients. In order to minimize potential side effects due to unnecessary combinations of compounds, the strategy of sequential monotherapy is proposed, with the goal of treating as many patients as possible with monotherapy at optimal doses. More drug trials of a crossover design and more individualized analyses of the results are badly needed to provide the physician with information that he can use in his daily practice. In this time of continuous intensive development of new antihypertensive agents, much could be gained in enhanced efficacy and reduced incidence of side effects by taking a closer look at the drugs already available and using them more appropriately in individual patients.

Inefficacité de la gestion de l'hyperglycémie du patient hospitalisé: origines et remèdes [The inefficacy of glycemic control in the hospitalized patient: origins and solutions]

La prévalence du diabète peut être estimée entre 20 et 30% parmi les patients en hôpital aigu. Il a été démontré que l'hyperglycémie, même modérée, est associée à une augmentation de la morbi-mortalité hospitalière, tandis que le contrôle glycémique efficace a un impact favorable sur celle-ci. La prise en charge de l'hyperglycémie demeure pourtant largement inefficace hors des soins intensifs, en raison de la persistance d'une pratique inadaptée. Nous développons actuellement un projet de soins destiné à faire changer les pratiques. Pour un contrôle glycémique efficace, une formation des soignants à une gestion basée sur le concept de couverture des besoins en insuline du patient est nécessaire. La démarche doit être intégrée à une approche de type systémique, prenant en compte le contexte dans lequel les soignants évoluent. The hospital inpatient prevalence of diabetes mellitus can be estimated between 20 and 30%. Even moderate hyperglycemia is associated with increased morbidity and mortality in the acute care setting, whereas efficient glycemic control has been shown to improve both of them significantly. Glycemic control however remains largely inefficient outside of the intensive care unit due to the persistance of an inadequate glycemic management practice. We are currently developing a clinical care project aimed at changing this practice. For an efficient glycemic control, a training programme for health care professionals based on the concept of covering the insulin needs of the patient is mandatory. This programme needs to be integrated in a systemic approach, which takes the professionals' context in account.

A patient with Hypertension Uncontrolled by Previous treatment

Co-administration of antihypertensive agents with different modes of action is required in most hypertensive patients to control blood pressure. This led to the development of fixed-dose combinations of established efficacy and tolerability, with the convenience of a single tablet facilitating long-term adherence with therapy. Blockade of the renin-angiotensin system (RAS) is widely used in hypertensive patients, particularly in those at high risk of cardiovascular or renal diseases. There is therefore a strong rationale for including a blocker of the RAS in fixed combinations, together with either a diuretic or a calcium antagonist. Patient characteristics and cardiovascular risk profiles are useful in guiding the choice of combinations administered. Adding a diuretic or a calciumantagonist to aRAS blocker is a valuable option in practically all patients, whether or not they have comorbidities. Amajor task is to individualize the treatment, ie, to find a drug regimen that normalizes the patient's blood pressure while preserving his or her quality of life. This can be achieved in most patients using the fixeddose combination containing the angiotensin-converting enzyme inhibitor perindopril and the diuretic indapamide. A number of trials have established the antihypertensive efficacy and the protective effects of this combination in hypertensive patients, which justifies its broad use in patients with blood pressure uncontrolled by other blood pressure-lowering agents.

Well, you have hepatic metastases: Use of technical language by medical students in simulated patient interviews.

OBJECTIVE: This research explored medical students' use and perception of technical language in a practical training setting to enhance skills in breaking bad news in oncology. METHODS: Terms potentially confusing to laypeople were selected from 108 videotaped interviews conducted in an undergraduate Communication Skills Training. A subset of these terms was included in a questionnaire completed by students (N=111) with the aim of gaining insight into their perceptions of different speech registers and of patient understanding. Excerpts of interviews were analyzed qualitatively to investigate students' communication strategies with respect to these technical terms. RESULTS: Fewer than half of the terms were clarified. Students checked for simulated patients' understanding of the terms palliative and metastasis/to metastasize in 22-23% of the interviews. The term ambulatory was spontaneously explained in 75% of the interviews, hepatic and metastasis/to metastasize in 22-24%. Most provided explanations were in plain language; metastasis/to metastasize and ganglion/ganglionic were among terms most frequently explained in technical language. CONCLUSION: A significant number of terms potentially unfamiliar and confusing to patients remained unclarified in training interviews conducted by senior medical students, even when they perceived the terms as technical. PRACTICE IMPLICATIONS: This exploration may offer important insights for improving future physicians' skills.

Swiss DRGs : patient heterogeneity and hospital payments

In this paper, we analyze the prospective method of paying hospitals when the within-DRG variance is high. To avoid patients dumping, an outlier payment system is implemented. In the APDRG Swiss System, it consists in a mixture of fully prospective payments for low costs patients and partially cost-based system for high cost patients. We show how the optimal policy depends on the degree to which hospitals take patients' interest into account. A fixed-price policy is optimal when the hospital is sufficiently benevolent. When the hospital is weakly benevolent, a mixed policy solving a trade-off between rent extraction, efficiency and dumping deterrence must be preferred. Following Mougeot and Naegelen (2008), we show how the optimal combination of fixed price and partially costbased payment depends on the degree of benevolence of the hospital, the social cost of public funds and the distribution of patients severity. [Authors]

Outpatient prescription writing quality in a paediatric general hospital

Introduction The writing of prescriptions is an important aspect of medical practice. Since 2006, the Swiss authorities have decided to impose incentives to prescribe generic drugs. The objectives of this study were 1) to determine the evolution of the outpatient prescription practice in our paediatric university hospital during 2 periods separated by 5 years; 2) to assess the writing quality of outpatient prescriptions during the same period.Materials & Methods Design: Copies of prescriptions written by physicians were collected twice from community pharmacies in the region of our hospital for a 2-month period in 2005 and 2010. They were analysed according to standard criteria regarding both formal and pharmaceutical aspects. Drug prescriptions were classified as a) complete when all criteria for safety were fulfilled, b) ambiguous when there was a danger of a dispensing error because of one or more missing criteria, or c) containing an error.Setting: Paediatric university hospital.Main outcome measures: Proportion of generic drugs; outpatient prescription writing quality.Results: A total of 651 handwritten prescriptions were reviewed in 2005 and 693 in 2010. They contained 1570 drug prescriptions in 2005 (2.4 ± 1.2 drugs per patient) and 1462 in 2010 (2.1 ± 1.1). The most common drugs were paracetamol, ibuprofen, and sodium chloride. A higher proportion of drugs were prescribed as generic names or generics in 2010. Formal data regarding the physicians and the patients were almost complete, except for the patients' weight. Of the drug prescriptions, 48.5% were incomplete, 11.3% were ambiguous, and 3.0% contained an error in 2005. These proportions rose to 64.2%, 15.5% and 7.4% in 2010, respectively.Discussions, Conclusion This study showed that physicians' prescriptions comprised numerous omissions and errors with minimal potential for harm. Computerized prescription coupled with advanced decision support is eagerly awaited.Disclosure of Interest None Declared

A study compared nine patient-specific indices for musculoskeletal disorders.

BACKGROUND AND OBJECTIVE: Patient-specific quality of life indices show great potential, but certain conceptual and methodological concerns have yet to be fully addressed. The present study reviewed nine patient-specific instruments used in musculoskeletal disorders: the Canadian Occupational Performance Measure (COPM), Juvenile Arthritis Quality of life Questionnaire (JAQQ), McMaster-Toronto Arthritis questionnaire (MACTAR), Measure Yourself Medical Outcome Profile (MYMOP), Patient-Specific Index (PASI) for total hip arthroplasty, Problem Elicitation Technique (PET), Patient Generated Index (PGI) of quality of life, Patient-Specific Functional Scale (PSFS), and Schedule for the Evaluation of Individual Quality of Life (SEIQoL). STUDY DESIGN AND SETTING: Each tool was evaluated for purpose, content validity, face validity, feasibility, psychometric properties, and responsiveness. RESULTS: This critical appraisal revealed important differences in terms of the concept underlying these indices, the domains covered, the item-generation techniques and the scoring (response scale, methods) in each scale. The nine indices would generate different responses and likely scores for the same patient, despite the fact that they all include patient-generated items. CONCLUSION: Although the value of these indices in treatment planning and monitoring at an individual level is strong, more studies are needed to improve our understanding of how to interpret the numeric scores of patient-specific indices at both an individual and a group level.