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Biomedical subjects

R W M Giard

Publications and source records attributed to R W M Giard.

18 recordsLinked to original sources
PubMed2006

[The Medical Code of Practice: clear reasons for existing, benefit less certain].

The Medical Code of Practice (Dutch acronym TG) aims to maintain and advance the quality of professional practice. Working together, lawyers and medical practitioners consider and make judgements on the procedures and methods practiced by caregivers. They also aim to protect citizens against the inexpert and careless execution of medical practice. Are they successful in this? Where the quality of practice is concerned, more thought must be given to the lasting effects on medical practitioners of the decisions made by the TG. Where protection ofcitizens is concerned, patients have a legal right to complain and there are various ways of doing this. Moreover, the TG is not primarily meant as a right of complaint. More empirical research is necessary into the effects of the TG.

Clinical Competence↗
PubMed2006

[Cancer registries and the quality of oncological care].

In 1971, President Nixon of the US declared war on cancer. To ascertain what progress has been made since then, national cancer registries may provide informative data. However, if standardised morbidity and mortality summary rates for cancer are dropping, we cannot conclude that there is a causal relation between increased diagnostic or therapeutic efforts and this decline. Cancer is a biologically complex disease with more than 400 different histological types of tumour. Many different efforts are made simultaneously to improve diagnostic accuracy and therapeutic effectiveness in selected types of malignancies. Since most cancers occur in elderly people, comorbidity is also a frequent problem. Final figures are therefore influenced by many different factors. Cancer registries reflect the result of all these factors, but figures indicating progress in the war on cancer have to be interpreted with caution.

Adolescent↗
PubMed2006

[Top 100 hospitals: varying lists, varying reputations].

In the month of September no fewer than 3 different hospital rankings appeared in the media. These rankings do not reliably portray the quality of hospitals. Since they mutually differ substantially, they provide insufficient information to motivate hospitals with lower scores to make meaningful improvements, and they only partly influence the choice of patients. Another unfavourable effect of these rankings is that hospitals may begin to focus on measured factors at the expense of unmeasured factors, such as innovation, long-term goals and cooperation. Improvements in patient care can be expected to come only from the ethics of medical professionals.

Ethics, Medical↗
PubMed2006

[Emergency procedures for taking care of the victims of bomb attacks: logistical and medical aspects].

In The Netherlands the threat of terrorist attacks also exist. Both doctors and hospitals alike should be prepared for such attacks both on the logistical as well as the medical level. Most terrorist attacks are carried out with explosives. This results in many victims and in cases of explosions in closed or semi-closed areas, often results in complex medical problems in many of the victims. An explosion that occurs as the result ofa bomb detonating can result in 4 patterns of injury: the primary explosion injury caused by the pressure of the blast, the secondary injuries caused by flying debris, the tertiary injuries caused by the explosion wind, and the quaternary caused by heat and fire. Common injuries seen following an explosion include: lung damage, neurological damage, abdominal injuries, bone fractures and skeletal damage and crush-syndrome. The triage occurs at the site of the explosion as well as on arrival in hospital. One especially important aspect of this is the sorting and selecting between victims who are likely to develop complex problems and who therefore need to receive aggressive treatment in a specially equipped centre and those patients for whom the nearest emergency department will suffice their needs. The triage should be repeated considering the possibility that initial estimates on these points may have been wrong. Epidemiological research should be carried out for each attack in order to make an inventory of the number of victims, the injuries incurred, the assessment of the effects of the medical help received and an assessment of the effectiveness of the total aid received.

Amputation, Traumatic↗
PubMed2005

[Performance indicators as a measure of the quality of medical care: rhetoric and reality].

Performance indicators may provide an indication of insufficient quality of medical care but they do not identify the cause of the problem. The political context for performance indicators is based on market ideology, where quality improvement is the goal and consumer pressure is the means. It is usually difficult to compare performance indicators among hospitals given the differences in definitions, methods of assessment, case mix, preclinical factors and data quality. Performance indicators are risk assessments and therefore subject to chance variation. Conclusions regarding performance indicators cannot be drawn due to the lack of clear, predefined benchmarks. At this time, the presence and degree of consumer pressure is unclear, and the ultimate effects of making performance factors publicly available on the quality of care is unknown. The question is whether mandatory reporting of a set of performance indicators by hospitals can provide sufficient insight into the quality of care; the measure appears to be too rough and too many factors influence the outcome. Procedure assessment is a good alternative to the use of performance indicators.

Hospital Mortality↗
PubMed2005

[The epidemiology of medical errors: a few issues in methodology].

Epidemiological research is needed to determine how many medical errors are made in hospitals. An estimation of error risk requires knowledge of the number of errors made and the total number of patients treated. But how do we define the term 'error'? The outcome of a medical intervention alone is insufficient; the entire treatment process has to be taken into account. For the estimation of error, two different approaches are available: retrospective chart review or prospective ethnographic observation. Both methods should account for processes and outcomes. Both methods have their limitations and can produce measurement errors. In particular, the low reproducibility of the determination of error is worrisome. To achieve safer health care, emphasis should be placed on control of processes, rather than outcomes.

Delivery of Health Care↗
PubMed2005

[Abnormalities in tattooed skin: sometimes sarcoidosis].

A 43-year-old man presented with a nodular tattoo lesion on his right upperarm. Histologically it resembled the granulomatous reaction seen in systemic sarcoidosis. Further evaluation revealed asymmetrical hilar lymphadenopathy with no interstitial lung disease. Since the patient was a heavy smoker, bronchus carcinoma could not be excluded and cervical mediastinoscopy was performed in order to obtain a lymph-node biopsy. This confirmed the diagnosis of systemic sarcoidosis. The patient was treated by local application of corticosteroids, but with little result. Skin lesions in scars or tattoos may be the first symptom of systemic sarcoidosis. Skin biopsy for histological confirmation of the diagnosis is recommended, as is further investigation to evaluate other organ systems which may be affected.

Administration, Topical↗
PubMed2004

[Diagnosis of pigmented skin lesions: how to recognize a malignant melanoma].

An accurate answer to the clinical question of whether a pigmented skin lesion has become a malignant melanoma or not is difficult because of the clinical variability of this lesion. Because of the low incidence of 2400 new melanoma cases each year in The Netherlands, a general practitioner only sees one new case every 3-4 years. The best way to distinguish between a benign lesion and a malignant melanoma is the combined use of several criteria, such as in the ABCD-formula: asymmetry, border irregularity, colour variation and a diameter > 6 mm. Dermatoscopical examination, provided that the technique is used by well-trained and experienced physicians, is a valuable adjunct to clinical examination. A pigmented lesion should always be excised if there is not enough convincing evidence to exclude its malignant nature. Histological classification of pigmented lesions may prove difficult because of morphological overlap between benign and malignant melanocytic tumours.

Diagnosis, Differential↗
PubMed2003

[The physician as an expert in medical negligence cases].

Whenever a physician is charged with negligence, the professional opinion of another doctor is always required. The quality of the expert report is a decisive factor in the quality of the ruling by the adjudicator. Three main problems may arise here: the medical expert may push up the professional standard, experts may differ in opinion, and finally their judgment may be influenced by prior knowledge of the outcome (hindsight bias). To avoid these problems, a systematic approach is needed, taking into account the scientific context, the clinical context, the procedure followed, the degree to which the outcome corresponds with the predicted outcome, reappraisal of the facts and the organisational context. In particular, the problem of hindsight bias through prior knowledge of the (unhappy) outcome highlights the need for greater attention to scientific and procedural aspects in the formation of an expert opinion.

Clinical Competence↗
PubMed2003

[Collagenous colitis: macroscopically invisible, but with various treatment options].

Two female patients, aged 54 and 67 years, respectively, had suffered from watery diarrhoea for several weeks or months without cramps or blood in the stools. The findings upon physical examination, blood and faecal examination and endoscopy were normal, and subsequent histological examination of intestinal biopsies revealed collagenous colitis. After treatment with a high-fibre diet, sulphasalazine and either prednisone or budesonide, the symptoms subsided. Collagenous colitis is a chronic watery diarrhoea disorder with unknown aetiology and pathogenesis. It is characterised by macroscopically normal mucosa, while histopathologically an abnormal thickening of the subepithelial collagenous layer and an increase in the number of intra-epithelial lymphocytes is found. There are various treatment options such as dietary fibre, mesalazine or bismuthsubsalicylate. Recently budesonide has been found to have a favourable effect both clinically and histologically. Complications of the disease are rare.

Aged↗
PubMed2003

[Diagnostic significance of human papillomavirus overestimated].

Human papillomavirus (HPV) is a group of oncogenic viruses, of which some are known to cause cervical cancer in women. The causal relation between infection and cervical cancer is well established. There is however a discrepancy between the rate of infection and the incidence of (pre)neoplastic lesions of the cervix. Cohort studies of the natural history of this virus show that many, if not most, young females become infected, but that the infection usually clears without any consequences. This high infection rate precludes the use of HPV diagnosis for primary screening for cervical cancer. The low specificity precludes its use for triage of borderline cervical lesions. Critical appraisal of different diagnostic approaches using a direct or indirect molecular detection method of HPV does not show a convincing advantage over 'conservative' diagnostic cytological regiments. Perhaps the absence of the virus is more significant than its presence.

Cohort Studies↗
PubMed2003

[More safety for patients requires confidentiality in the enquiry into medical errors].

Recently, a seven-month-old baby died after a cardiac intervention and a medical error was presumed. An independent committee investigated this mishap after the confidentiality of the report was guaranteed. However, because of a judicial ruling, the report had to be made public, which caused great upheaval. To improve safety, error management requires confidential investigation to ensure co-operation of all parties involved. There are two conflicting and irreconcilable aims: medical professionals want to establish what went wrong, legal professionals want to establish who is at fault. The position of investigative committees should be (legally) fortified with a guarantee of confidentiality and sound underlying principles of investigation should be delineated.

Confidentiality↗
PubMed2002

[Metastasis of an unknown primary tumor, management attuned to histopathology].

Metastases from an unknown primary tumour are found as the first expression of a disease process in about 5-10% of all cancer patients. This situation triggers two subsequent questions: what kind of tumour is it and where does it come from? In the management of these patients close cooperation between the clinician and pathologist is essential. Overdiagnosis and overtreatment should be avoided in these patients, 85% of whom will not survive one year. By combining morphological examination of cell or tissue preparations with immunohistochemistry the pathologist is able to provide reliable information on the type and sometimes the origin of the tumour, as a result of which those malignancies worth treating can be identified. Applying pathological investigation at an early stage may reduce the need for diagnostic imaging and endoscopic investigations.

Humans↗
PubMed2002

[Citing electronic sources in scientific articles].

In 1995 a reference to an electronic source of information first appeared in this journal. Such sources are neither permanently available nor unchangeable. Both qualities are of central importance to the progress of scientific knowledge. Readers must have the opportunity to check the information referred to in scientific publications. It is scientifically useless to refer to a source that readers may not be able to find or where they find something else than the authors did when they wrote their article. However, electronic media, volatile as they may be, can be a very useful means of alerting readers to medical scientific developments. Therefore the editors of this journal have chosen to accept references to electronic information by way of a 'written communication' in parentheses in the text, until electronic scientific information is stored in an unalterable and generally accessible permanent form. The list of references at the end of scientific articles will be reserved to generally available paper and CD-ROM sources.

Computer Communication Networks↗
PubMed2002

[The pretentions and achievements of cancer screening, in particular breast cancer screening].

The 'Vereniging Nederlands Tijdschrift voor Geneeskunde' (Dutch Journal of Medicine Association) recently held a conference about the doubts expressed in recent publications concerning the value of cancer screening and breast-cancer screening in particular. In this the discussion mainly focused on whether disease-specific mortality or overall mortality should be taken as an endpoint in the evaluation of the screening procedure. In a recent advisory report, the Health Council of the Netherlands stated that the present form of breast cancer screening ought to be continued in the Netherlands for the time being. However, during the conference it was emphasized that cancer screening must be viewed as a highly complex system. Therefore, it is impossible to measure the effects of screening by considering just one end-point, such as cancer-specific mortality. The opinion was also expressed that with the introduction of new forms of cancer screening (e.g. colon or prostate-cancer screening), experience should first of all be gained with the small-scale screening of persons with an elevated risk. This is a task in which the government should lead the way. Furthermore, the government will also need to regulate the enthusiasm that can be expected for various types of secondary preventative diagnostics offered on the free market, including cancer screening. Another important aspect of cancer screening is ensuring that the general public are thoroughly and carefully informed about the pros and cons of cancer screening. The public must know that although cancer screening can save lives, it also causes harm. People scarcely realise that screening may more often involve a loss of carefree years of life than a small chance of living longer.

Breast Neoplasms↗
PubMed2002

[Revision needed of follow-up policy for Barrett's esophagus].

The frequency of adenocarcinomas at the oesophagocardial junction is increasing and, if symptomatic, the patients chances of cure are bleak. Given the association of Barrett's oesophagus (Barrett's oesophagus; denoting metaplasia of the oesophageal squamous cell lining to gastric-type mucosa) and oesophageal adenocarcinoma, it is plausible that establishing the presence of Barrett's oesophagus will subsequently enable two preventive strategies: primary, i.e. the treatment and eradication of Barrett's oesophagus, and secondary, the early diagnosis of (pre)malignancy during periodic endoscopic follow-up. Given the frequent occurrence of Barrett's oesophagus and the rarity of oesophageal adenocarcinoma there is a clear risk of overdiagnosis and overtreatment. Most studies on the effect of regular follow-up are uncontrolled and barely give any indication of a favourable outcome. Only a minority of patients with Barrett's oesophagus ought to have periodic endoscopic checkups: those with dysplasia or with one or more of the known risk factors (especially male gender, specialised type Barrett's oesophagus and long segment Barrett's oesophagus). Those patients must be healthy enough beforehand to undergo surgical treatment if necessary. The amount of quantity or quality of life that may be gained from this approach has yet to be established.

Adenocarcinoma↗