Paediatric rheumatology - A global perspective

This chapter aims to give a global perspective to paediatric rheumatology. The main points covered are the incidence, recognition of paediatric autoimmune diseases, and ethnic/geographic distribution. The most prevalent disease is juvenile idiopathic arthritis; robust data are still required for childhood-onset systemic lupus erythematosus, dermatomyositis, and scleroderma. Mimicking or overlapping infections are a major challenge in developing countries, and immunization policies in our patients in these areas need specific attention. The delivery of paediatric rheumatology care is also overviewed. Discrepancies in health-care resources and priorities are found in developing countries. Although most anti-rheumatic treatments are available worldwide, they are prohibitively expensive in many countries. For more traditional antirheumatic drugs there is still an ongoing need for good core outcome data across the world to ensure valid comparisons. Parent/patient education has been implemented worldwide in paediatric rheumatology through the power of the Internet. Physician and undergraduate training goals must be met to facilitate competent musculoskeletal assessment, a proper understanding of age-dependent variations, diagnosis, referral to specialists, and improved standards of care.

Cone Beam Computed Tomographic Imaging: Perspective, Challenges, and the Impact of Near-Trend Future Applications

Cone beam computed tomography (CBCT) can be considered as a valuable imaging modality for improving diagnosis and treatment planning to achieve true guidance for several craniofacial surgical interventions. A new concept and perspective in medical informatics is the highlight discussion about the new imaging interactive workflow. The aim of this article was to present, in a short literature review, the usefulness of CBCT technology as an important alternative imaging modality, highlighting current practices and near-term future applications in cutting-edge thought-provoking perspectives for craniofacial surgical assessment. This article explains the state of the art of CBCT improvements, medical workstation, and perspectives of the dedicated unique hardware and software, which can be used from the CBCT source. In conclusion, CBCT technology is developing rapidly, and many advances are on the horizon. Further progress in medical workstations, engineering capabilities, and improvement in independent software-some open source-should be attempted with this new imaging method. The perspectives, challenges, and pitfalls in CBCT will be delineated and evaluated along with the technological developments.

Quantifying the Economics of Medical Malpractice - A View from a Civil Law Perspective

Life is full of uncertainties. Legal rules should have a clear intention, motivation and purpose in order to diminish daily uncertainties. However, practice shows that their consequences are complex and hard to predict. For instance, tort law has the general objectives of deterring future negligent behavior and compensating the victims of someone else's negligence. Achieving these goals are particularly difficult in medical malpractice cases. To start with, when patients search for medical care they are typically sick in the first place. In case harm materializes during the treatment, it might be very hard to assess if it was due to substandard medical care or to the patient's poor health conditions. Moreover, the practice of medicine has a positive externality on the society, meaning that the design of legal rules is crucial: for instance, it should not result in physicians avoiding practicing their activity just because they are afraid of being sued even when they acted according to the standard level of care. The empirical literature on medical malpractice has been developing substantially in the past two decades, with the American case being the most studied one. Evidence from civil law tradition countries is more difficult to find. The aim of this thesis is to contribute to the empirical literature on medical malpractice, using two civil law countries as a case-study: Spain and Italy. The goal of this thesis is to investigate, in the first place, some of the consequences of having two separate sub-systems (administrative and civil) coexisting within the same legal system, which is common in civil law tradition countries with a public national health system (such as Spain, France and Portugal). When this holds, different procedures might apply depending on the type of hospital where the injury took place (essentially whether it is a public hospital or a private hospital). Therefore, a patient injured in a public hospital should file a claim in administrative courts while a patient suffering an identical medical accident should file a claim in civil courts. A natural question that the reader might pose is why should both administrative and civil courts decide medical malpractice cases? Moreover, can this specialization of courts influence how judges decide medical malpractice cases? In the past few years, there was a general concern with patient safety, which is currently on the agenda of several national governments. Some initiatives have been taken at the international level, with the aim of preventing harm to patients during treatment and care. A negligently injured patient might present a claim against the health care provider with the aim of being compensated for the economic loss and for pain and suffering. In several European countries, health care is mainly provided by a public national health system, which means that if a patient harmed in a public hospital succeeds in a claim against the hospital, public expenditures increase because the State takes part in the litigation process. This poses a problem in a context of increasing national health expenditures and public debt. In Italy, with the aim of increasing patient safety, some regions implemented a monitoring system on medical malpractice claims. However, if properly implemented, this reform shall also allow for a reduction in medical malpractice insurance costs. This thesis is organized as follows. Chapter 1 provides a review of the empirical literature on medical malpractice, where studies on outcomes and merit of claims, costs and defensive medicine are presented. Chapter 2 presents an empirical analysis of medical malpractice claims arriving to the Spanish Supreme Court. The focus is on reversal rates for civil and administrative decisions. Administrative decisions appealed by the plaintiff have the highest reversal rates. The results show a bias in lower administrative courts, which tend to focus on the State side. We provide a detailed explanation for these results, which can rely on the organization of administrative judges career. Chapter 3 assesses predictors of compensation in medical malpractice cases appealed to the Spanish Supreme Court and investigates the amount of damages attributed to patients. The results show horizontal equity between administrative and civil decisions (controlling for observable case characteristics) and vertical inequity (patients suffering more severe injuries tend to receive higher payouts). In order to execute these analyses, a database of medical malpractice decisions appealed to the Administrative and Civil Chambers of the Spanish Supreme Court from 2006 until 2009 (designated by the Spanish Supreme Court Medical Malpractice Dataset (SSCMMD)) has been created. A description of how the SSCMMD was built and of the Spanish legal system is presented as well. Chapter 4 includes an empirical investigation of the effect of a monitoring system for medical malpractice claims on insurance premiums. In Italy, some regions adopted this policy in different years, while others did not. The study uses data on insurance premiums from Italian public hospitals for the years 2001-2008. This is a significant difference as most of the studies use the insurance company as unit of analysis. Although insurance premiums have risen from 2001 to 2008, the increase was lower for regions adopting a monitoring system for medical claims. Possible implications of this system are also provided. Finally, Chapter 5 discusses the main findings, describes possible future research and concludes.

Nonverbal emotional regulation in psychotherapy process according to an intersubjective perspective

In recent decades fascinating studies in developmental psychology, especially in infant research (for review see Lavelli, 2007) and recent discoveries in neuroscience (Welsh, et al, 2007; Siegel, 2001; Pally, 2007) have brought great interest to study the mode of sharing subjective experiences (affective states, intentions and attentional focus) in children and adults.It therefore appears today in the clinic is a growing consensus about the fact that the psychological disorder can be read as a deficit in intersubjective processes of affect regulation (see Benecke C. et al 2005; psychodynamic Diagnostic Manual-PDM, 2006) leading many authors to assume the centrality of affect regulation in the construction of the psychotherapeutic process of change (just to name a few Tronick, Greenberg, Stern, Sander, Fonagy, Beebe, Philippot, Rimé etc..). As previously stated, this study has led us to hypothesize that the long process of therapy is to assist with the sessions continue, a growing "emotional attunement" between the communication styles of both patient and therapist. And also to speculate that this synchronization can represent the existence of a significant positive correlation between the increased level of "emotional synchronization" and increased capacity for regulation of emotions by the patient.The research results despite the limitations of small sample showed encouraging results about the verification of the existence of an increasing degree of attunement between therapist and patient long psychotherapy sessions and also showed a good degree of positive correlation between the increase the latter construct and emotional regulation through the implicit mode of expression and nonverbal communication.

[Pathogenesis of functional gastrointestinal disorders - an interdisciplinary perspective]

Functional gastrointestinal disorders (FGD) are highly prevalent worldwide. Recent research demonstrates that complex and interacting biological and behavioral mechanisms contribute particularly to the pathogenesis of irritable bowel syndrome and functional dyspepsia. Dysregulation of the enteral, neuroenteric, visceral-autonomic, and central nervous systems are important biological contributors, whereas the psychological state of a patient may evidently modulate aspects related to biological stress reactivity and somatic perception both playing a role in the clinical manifestation of FGD. Our overview clearly shows that an interdisciplinary perspective of the pathogenesis of FGD may best serve clinicians and patients.

[The untellable patient's history]

An essay with personal touch on the interaction between patients and professionals seen from the perspective of an anonymous writer that is presumably preoccupied with midlife reflections.

Clean intermittent self-catheterization: a burden for the patient?

AIM: To assess patients' perception of clean intermittent self-catheterization (CISC) for voiding dysfunction. PATIENTS AND METHODS: A total of 101 patients performing CISC because of voiding dysfunction were invited to participate in this questionnaire survey. The response rate was 91% (92/101). RESULTS: The mean time over which CISC was performed was 5 years (standard deviation (SD) +/- 6.3) and the mean frequency of CISC per day was three times (SD +/- 2). Almost 80% (72/92) of the patients perceived CISC as easy or very easy and CISC did not interfere at all or interfered a little bit with work or other regular daily activities in more than 80% (76/92). Almost 90% (80/92) reported no or minimal pain while performing CISC. This did not interfere at all or interfered a little bit with work or other regular daily activities in almost 90% (80/92). Quality of life improved considerably due to CISC in more than 60% (56/92) and 12% (11/92) complained of a deterioration. In multivariable analysis, severe pain performing CISC (odds ratio 20.9, 95% confidence interval 1.7-259.9, P = 0.018) was the only factor that predicted poor quality of life. CONCLUSIONS: The majority of patients considered CISC to be an easy and painless procedure which did not interfere with daily activities. Consequently, quality of life improved in more than 60% of the patients. Therefore, CISC does not appear to be a burden for the patient and, from a patient's perspective, can be recommended.

Dermatology in the immunosuppressed patient

This anniversary book gives an animated description of the first one hundred years of the Swiss Society of Dermatology and Venereology (SSDV – SGDV). The approximately 60 authors write from the subjective perspective of the contemporary witness and thus create a vibrant picture of their field and the times in which we live. “Spirit and Soul of Swiss Dermatology and Venereology 1913 – 2013” is therefore an ideal companion to the medical history book “Dermatologie und Venerologie in der Schweiz – ein historischer Rückblick” (2002 Editions Alphil, ISBN 2-940235-08-2), published in 2003 by the SSDV – SGDV for its 90th anniversary. The anniversary edition for the centennial is written in English in order to make the history of the SSDV – SGDV accessible to a larger international public. The introductory chapter is written in all four national languages (German, French, Italian, and Romansh) and also translated into English. It is followed by chapters about the university and non-university public dermatology and venereology departments, the memoirs of those presidents still living, and the depiction of the numerous sub-disciplines of dermatology. Further important chapters include a large contribution on the beginnings of dermatological research in Switzerland, a series of pieces on medical education and continuing education, and finally an overview of healthcare politics in Switzerland. Our friends in Germany, Austria, France, Italy and the USA have provided the outside perspective on Swiss dermatology and venereology in their essays. All in all an informative and entertaining overview of a very diverse medical specialty has been created, which combines historical facts with dynamic insights into this topical field and the current political healthcare framework.

Models for intensive care training. A European perspective.

The diversity of European culture is reflected in its healthcare training programs. In intensive care medicine (ICM), the differences in national training programs were so marked that it was unlikely that they could produce specialists of equivalent skills. The Competency-Based Training in Intensive Care Medicine in Europe (CoBaTrICE) program was established in 2003 as a Europe-based worldwide collaboration of national training organizations to create core competencies for ICM using consensus methodologies to establish common ground. The group's professional and research ethos created a social identity that facilitated change. The program was easily adaptable to different training structures and incorporated the voice of patients and relatives. The CoBaTrICE program has now been adopted by 15 European countries, with another 12 countries planning to adopt the training program, and is currently available in nine languages, including English. ICM is now recognized as a primary specialty in Spain, Switzerland, and the UK. There are still wide variations in structures and processes of training in ICM across Europe, although there has been agreement on a set of common program standards. The combination of a common "product specification" for an intensivist, combined with persisting variation in the educational context in which competencies are delivered, provides a rich source of research inquiry. Pedagogic research in ICM could usefully focus on the interplay between educational interventions, healthcare systems and delivery, and patient outcomes, such as including whether competency-based program are associated with lower error rates, whether communication skills training is associated with greater patient and family satisfaction, how multisource feedback might best be used to improve reflective learning and teamworking, or whether increasing the proportion of specialists trained in acute care in the hospital at weekends results in better patient outcomes.

Improvement of research quality in the fields of orthopaedics and trauma: a global perspective.

The international orthopaedic community aims to achieve the best possible outcome for patient care by constantly modifying surgical techniques and expanding the surgeon's knowledge. These efforts require proper reflection within a setting that necessitates a higher quality standard for global orthopaedic publication. Furthermore, these techniques demand that surgeons acquire information at a rapid rate while enforcing higher standards in research performance. An international consensus exists on how to perform research and what rules should be considered when publishing a scientific paper. Despite this global agreement, in today's "Cross Check Era", too many authors do not give attention to the current standards of systematic research. Thus, the purpose of this paper is to describe these performance standards, the available choices for orthopaedic surgeons and the current learning curve for seasoned teams of researchers and orthopaedic surgeons with more than three decades of experience. These lead to provide an accessible overview of all important aspects of the topics that will significantly influence the research development as we arrive at an important globalisation era in orthopaedics and trauma-related research.

Ethical procedures and patient consent differ in Europe.

BACKGROUND Research ethics approvals, procedures and requirements for institutional research ethics committees vary considerably by country and by type of organisation. OBJECTIVE To evaluate the requirements and procedures of research ethics committees, details of patient information and informed consent based on a multicentre European trial. DESIGN Survey of European hospitals participating in the prospective observational study on chronic postsurgical pain (euCPSP) using electronic questionnaires. SETTING Twenty-four hospitals in 11 European countries. PARTICIPANTS From the 24 hospitals, 23 local investigators responded; 23 answers were analysed. OUTCOME MEASURES Comparison of research ethics procedures and committee requirements from the perspective of clinical researchers. Comparison of the institutions' procedures regarding patient information and consent. Description of further details such as costs and the duration of the approval process. RESULTS The approval process lasted from less than 2 weeks up to more than 2 months with financial fees varying between 0 and 575 &OV0556;. In 20 hospitals, a patient information sheet of variable length (half page up to two pages) was provided. Requirements for patients' informed consent differed. Written informed consent was mandatory at 12, oral at 10 and no form of consent at one hospital. Details such as enough time for consideration, possibility for withdrawal and risks/benefits of participation were provided in 25 to 30% of the institutions. CONCLUSION There is a considerable variation in the administrative requirements for approval procedures by research ethics committees in Europe. This results in variation of the extent of information and consent procedures for the patients involved. TRIAL REGISTRATION euCPSP in Clinicaltrials.gov identifier: NCT01467102; PAIN-OUT in Clinicaltrials.gov identifier: NCT02083835.

The new final Clinical Skills examination in human medicine in Switzerland: Essential steps of exam development, implementation and evaluation, and central insights from the perspective of the national Working Group

Objective: Since 2011, the new national final examination in human medicine has been implemented in Switzerland, with a structured clinical-practical part in the OSCE format. From the perspective of the national Working Group, the current article describes the essential steps in the development, implementation and evaluation of the Federal Licensing Examination Clinical Skills (FLE CS) as well as the applied quality assurance measures. Finally, central insights gained from the last years are presented. Methods: Based on the principles of action research, the FLE CS is in a constant state of further development. On the foundation of systematically documented experiences from previous years, in the Working Group, unresolved questions are discussed and resulting solution approaches are substantiated (planning), implemented in the examination (implementation) and subsequently evaluated (reflection). The presented results are the product of this iterative procedure. Results: The FLE CS is created by experts from all faculties and subject areas in a multistage process. The examination is administered in German and French on a decentralised basis and consists of twelve interdisciplinary stations per candidate. As important quality assurance measures, the national Review Board (content validation) and the meetings of the standardised patient trainers (standardisation) have proven worthwhile. The statistical analyses show good measurement reliability and support the construct validity of the examination. Among the central insights of the past years, it has been established that the consistent implementation of the principles of action research contributes to the successful further development of the examination. Conclusion: The centrally coordinated, collaborative-iterative process, incorporating experts from all faculties, makes a fundamental contribution to the quality of the FLE CS. The processes and insights presented here can be useful for others planning a similar undertaking. Keywords: national final examination, licensing examination, summative assessment, OSCE, action research

Out-of-Body Experiences and Other Complex Dissociation Experiences in a Patient with Unilateral Peripheral Vestibular Damage and Deficient Multisensory Integration

Out-of-body experiences (OBEs) are illusory perceptions of one's body from an elevated disembodied perspective. Recent theories postulate a double disintegration process in the personal (visual, proprioceptive and tactile disintegration) and extrapersonal (visual and vestibular disintegration) space as the basis of OBEs. Here we describe a case which corroborates and extends this hypothesis. The patient suffered from peripheral vestibular damage and presented with OBEs and lucid dreams. Analysis of the patient's behaviour revealed a failure of visuo-vestibular integration and abnormal sensitivity to visuo-tactile conflicts that have previously been shown to experimentally induce out-of-body illusions (in healthy subjects). In light of these experimental findings and the patient's symptomatology we extend an earlier model of the role of vestibular signals in OBEs. Our results advocate the involvement of subcortical bodily mechanisms in the occurrence of OBEs.

Doctor-patient communication in the medical interaction: Context, implications, and practice

Effective communication; whether from an interpersonal, mass media, or global perspective, is a critical component in public health. It is an essential conduit in increasing public awareness of available health resources, potential health hazards and related disease prevention strategies, and in delivering better health care. Within this context, available literature asserts doctor-patient communication as central to healthcare delivery. It has been shown to affect patient health outcomes, satisfaction with care, adherence to treatment recommendations, and even understanding of medical information. While research supports the essential imperative of interventions aimed at teaching doctors and patients the communication skills necessary for a successful and meaningful medical interaction, most interventions to date, focus on teaching these communication skills to doctors and seem to rely, largely, on mass media for providing patients with the information needed to increase communication efficacy. This study sought to fill a significant gap in the doctor-patient communication literature by reviewing the context of the doctor-patient exchange in the medical interaction, the implications of this exchange in resulting care of the patient, and the potential improvements to practice through interventions aimed at improving the communication exchange. Closing with an evaluation of a patient-centered communication intervention, the “How to Talk to Your Doctor” (HTTTYD) program that combines previously identified optimal strategies for improving communication between doctors and patients, this study examined the patients’ perspective of their potential as better communicators in the medical interaction. ^ Specific Aims, Hypotheses or Questions (Aim I) To examine the context of health communication within a public health framework and its relation to health care delivery. (Aim II) To review doctor-patient communication as a central focus within health care delivery and the resulting implications to patient care. (Aim III) To assess the utility of interventions to improve doctor-patient communication. Specifically, to evaluate the effectiveness of a patient-centered community education intervention, the “How to Talk to Your Doctor” (HTTTYD) program, aimed at improving patient communication efficacy.^

Understanding Mastectomy from a Self Psychology Perspective: The Breast as a Self Object

For many women, if not all, breasts are an important component of bodyself-image; a woman may love them or dislike them, but she is rarely neutral" (Young, 2003, p.152). Breast cancer may be one of the oldest forms of cancer known to humans (American Cancer Society, 2010), and in 2008 in the United States over 182,000 women and almost 2,000 men were diagnosed with some form of breast cancer (American Cancer Society, 2008). In that same year 40,480 women and 450 men died from the disease. While any type of cancer diagnosis can instill a fear of mortality and incapacitation in the recipient, breast cancer holds a special meaning for women because of the significance placed on the breast both personally and societally. Removal of the breast tissue and muscle, or mastectomy, remains one of the primary forms of treatment for this disease. The breast plays an important role in a woman's identity, and the loss of one or both breasts due to breast cancer can have a monumental impact on her sense of self. A mastectomy affectsnot only a woman's relationship with herself, but with her family, friends, and society. It changes her outlook on life, her perception of her roles in the world, and her interest in interacting with others. Exploring these issues is important to understanding how doctors, nurses, mental health professionals, family members and support networks can best assist patients in coping with their illness. This paper attempts to understand the psychological issues and injuriesassociated with mastectomy through the lens of Self Psychology. It postulates that the breast itself is a selfobject for most women, and that its loss results in the fragmentation of the self. I will focus particularly on women between the ages of 25 and 40 years of age, in the marital and parental phases of developmental (Wolf, 1988), as the effect of a mastectomy on body image, sexuality, and genderbased roles such as motherhood has been shown to differ according to the age of the patient, with younger patients experiencing more distress (Ashing-Giwa et al, 2004).