Physician-assisted lethal injection vs. the plastic bag: will euthanasia legislation ever come? A comparison of standards in the Netherlands and the United States.
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Advance Directives↗
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Results for “European Community Medical Association”
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International coordination of biomedical research.
Recent efforts at international coordination in biomedical research have taken place at two levels. At the level of the working clinician and scientist, European regionalism has become increasingly manifest in such organizations as the European Society for Clinical Investigation, the European Organization for Research into the Treatment of Cancer, the European Molecular Biology Organization and many others. These have developed largely, though not entirely, independently of government funding. At the level of science policy, i.e. of bodies supporting biomedical research mainly from public funds, the major developments have been the Comité de la Recherche Médicale of the European Community and the much wider association of European Medical Research Councils, based on the whole of Western Europe; in October 1975 the latter group became incorporated into the new European Science Foundation as the first Standing Committee of that body. Wider, interregional, cooperation presents greater problems, though there have been some modest successes, and the multinational drive on research into six of the major health problems of the Third World now being proposed by WHO holds further promise for the future.
Europe↗
Sporadic Creutzfeldt-Jakob disease and surgery: a case-control study using community controls.
BACKGROUND: The cause of sporadic Creutzfeldt-Jakob disease (CJD) is unknown. Previous studies found a link with a history of surgery but had methodologic problems. OBJECTIVE: To help elucidate medical and associated risk factors for sporadic CJD as part of the 1993 to 1995 European Union collaborative studies of CJD. METHODS: Medical and associated risk factors from 326 patients with sporadic CJD, taken from population-based studies performed between 1993 and 1995 in France, Germany, the Netherlands, and the UK, were compared with 326 community controls recruited by telephone in 2000. RESULTS: A history of surgery was significantly associated with the risk of sporadic CJD (odds ratio [OR]: 1.8; 95% CI: 1.2 to 2.6), which was not dependent on the number of surgical procedures, and was stronger in females (OR: 2.5; 95% CI: 1.5 to 4.0). Gynecologic (OR: 1.5; 95% CI: 1.0 to 2.3) and "other" operations (any operation other than neurologic, eye, ear, gallbladder, gastrointestinal, and gynecologic operations, tonsillectomy, and appendectomy) (OR: 1.5; 95% CI: 1.1 to 2.1) were associated with risk of CJD. Tonsillectomy (OR: 0.3; 95% CI: 0.2 to 0.5) and appendectomy (OR: 0.6; 95% CI: 0.4 to 0.8) were observed less frequently in cases. An increased risk was also found with a history of ear piercing in females (OR: 1.6; 95% CI: 1.1 to 2.5) and psychiatric visit(s) (OR: 2.6; 95% CI: 1.5 to 4.3). CONCLUSIONS: These results support the hypothesis that cases of sporadic CJD may result from hitherto unrecognized surgical contamination events. However, because of the limits of the study design, the rarity of the disease, and the potential for bias, the results should be interpreted with caution.
Aged↗
[Cross-national comparison of drug compliance and non-compliance associated factors in the elderly with polypharmacotherapy].
BACKGROUND: Population of seniors in the Czech Republic consumes more than 35 % of all prescribed medications. Currently, Czech seniors take on the average 4-5 prescribed drugs. However, our knowledge about factors influencing drug compliance is scarce particularly in seniors with polypharmacotherapy. Non-compliance can contribute to treatment failure and increases the risk of adverse drug reactions. The aim of the study is to compare drug compliance in the elderly in 11 European countries and to assess the impact of demographic and drug-related factors on non-compliance to medication. METHODS AND RESULTS: Cross-sectional comparative study in 3881 elderly subjects living in the community receiving home-care services in 11 European countries participating in ADHOC (Aged in Home Care) study. In the sample of Czech subjects we performed in-depth analysis of causes and factors associated with non-compliance in patients with polypharmacotherapy. 12.5% (n=456) of European seniors were non-compliant with prescribed medication with significantly higher prevalence of non-compliance in the CR (33.5 %) and Germany (17.0 %). In the Czech sample following non-compliance risk factors have been identified: taking > or = 7 drugs per os (OR= 2.2), 10 single applications/day (OR= 2.5), more than twice daily dosing (OR= 2.4), problems with drug preparation (OR= 4.6), polypharmacotherapy 5 years and longer (OR= 5.5) and drug preparation without supervision or help (OR= 2.8). The highest prevalence of non-compliance was found for antidepressants (80 %), antiasthmatics (68 %), fibrates (60 %), nonsteroidal antiinflammatory drugs, vasodilatators, anticoagulants/antiplatelet drugs and nootropics (50 %). Among the most common causes, patients reported forgetting to take the drug (74.3 % patients), mistrust in drug effect (10.6%) and fear of taking "too many drugs" (8.6 %). CONCLUSIONS: Non-compliance to prescribed drug regimen is a prevalent problem in one third of the Czech seniors and was found to be the highest among 11 European countries. Doctors prescribing to older people have to monitor purposefully compliance and strenghten co-operation and motivation of the patient to adhere with prescribed drug regimen. Particularly in seniors with polypharmacotherapy it seems necessary to simplify drug regimen as much as possible. In elderly patients with physical disability, cognitive impairment or depression supervision and/or help of another person with drug preparation and application may improve drug compliance.
Aged↗
[Industrial progress concerning latex allergy in surgery].
Latex allergy has been well described in the literature, but it remains a constant worry for high-risk groups. We wish to show that the manufacturing industry has made real progress in response to this iatrogenic pathology. The high-risk groups are defined, in addition to the allergies with which they are associated: foodstuffs, ethylene oxide, airborneallergens. The criteria necessary to have available high-quality sterile surgical gloves are stated: they must be either hypo-allergenic or non-allergenic dependent upon the circumstances of use, they must guarantee protection against the transmission of infection and allow the medical practitioner complete freedom of movement. In the same way urinary catheters for intermittent probing, penile sheaths and condoms are mentioned. Powder must definitely be eliminated from any medical glove, because it can both be a vector for latex particles and can be the cause of granulomas in the abdominal cavity. The European Community standards (CE) and the recommendations of the American Associations of Allergology are explained. Sterilization by gamma irradiation is one sign of real progress, outperforming ethylene oxide which is too allergenic. The composition of the gloves must ensure an effective barrier against both allergens and infections. Pre-lubricated latex-free urinary catheters, penile sheaths and latex-free condoms represent substantial improvements for the population at risk. Since 1995 considerable progress has been made by the manufacturing industry in response to the needs of both allergologists and surgeons.
Drug Industry↗
What physicians should know about Africanized honeybees.
The Africanized honeybee, popularly known as the "killer bee," is already well established in Texas and has recently entered California and Arizona. As the Africanized honeybee spreads in North America, the medical community must become aware of the problems associated with this insect and ensure that sting emergencies can be handled quickly and appropriately. The major differences between Africanized and European honeybees are that the former are more irritable, they swarm more readily and frequently, they defend their hives more vehemently, and they sting more collectively. It is not the composition nor the volume of an individual bee's venom, but rather the cumulative dose of multiple stings that accounts for the morbidity and mortality associated with Africanized honeybee-sting incidents. Even nonallergic persons are susceptible to the toxic effects of these large combined venom loads. Africanized honeybee-sting victims are treated the same as victims of European honeybee stings. Authorities will prepare for the bees' arrival by expanding public awareness, teaching risk-avoidance behavior, providing for the removal of troublesome hives, and developing sting treatment protocols that can be initiated rapidly in the field or emergency departments. Health care professionals should participate in the educational efforts and in the development of needed emergency response protocols so that the effects of the Africanized honeybee will be merely a nuisance rather than a plague.
Animals↗
Expert groups, task groups and committees, national societies and the nuclear medicine community: towards "EANM protocols". European Association of Nuclear Medicine.
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Data Collection↗
Carpal tunnel syndrome and hand-arm vibration syndrome. A diagnostic enigma.
OBJECTIVE: This article serves to draw attention to the risk to workers from repetitive strain and hand-arm vibration in the workplace and to the diagnostic difficulty in distinguishing carpal tunnel syndrome from the sensorineural component of hand-arm vibration syndrome. DATA SOURCES: Journal publications, textbooks on hand-arm vibration, guidelines of the International Standards Organisation, and European Economic Community directives. STUDY SELECTION: Recent reports and current standards. CONCLUSION: Carpal tunnel syndrome can be distinguished from hand-arm vibration syndrome if all factors--anatomical, associated physiological and medical conditions, work exposure history, and ulnar nerve involvement--are evaluated. In some circumstances, the conditions may be present together. A correct diagnosis is crucial because surgical intervention is not usually beneficial if hand-arm vibration exposure has been a contributing factor. The further reduction in grip strength may constitute a serious additional handicap for a worker.
Carpal Tunnel Syndrome↗
Image formats: five years after the AAPM standard for digital image interchange.
The publication of AAPM Report No. 10 was the first attempt to standardize image formats in the medical imaging community. Since then, three other groups have formed (CART--the Scandinavian collaboration for Computer Assisted Radiation Therapy treatment planning; ACR-NEMA, a collaboration whose purpose is to formulate a standard digital interface to medical imaging equipment; and COST B2 Nuclear Medicine Project a European collaboration whose purpose is to define a format for digital image exchange in Nuclear Medicine). The AAPM format uses key-value pairs in plain text to keep track of all information associated with a particular image. The radiation oncology community in the U.S. has been defining key-value pairs for use with CT, nuclear medicine and magnetic resonance (MR) images. The COST B2 Nuclear Medicine Project has also adopted this format and together with the Australian/New Zealand Society of Nuclear Medicine Technical Standards Sub-Committee which has also adopted this format, has defined an initial set of key-value pairs for Nuclear Medicine images. Additionally, both ACR-NEMA and CART have been defining fields for use with the same types of images. The CART collaboration has introduced a database which is available electronically, but is maintained by a group of individuals. ACR-NEMA operates through committee meetings. The COST B2 Nuclear Medicine Project operates through electronic (and postal where necessary) mail. To insure a consistent set of field names in such a rapidly developing arena requires the use of a server rather than a committee. Via a server a person would inquire if a particular field had been defined. If so, the defined name would be returned.(ABSTRACT TRUNCATED AT 250 WORDS)
Health Physics↗
Pathways into and through services for the elderly in Europe: a research design.
Services for the elderly fall short of demand in all European countries. Resources are clearly inadequate. But are they most effectively used? This contribution presents the research design being used to study these questions in eight countries of the European Community. It postulates that shortage of shortage of services is aggravated by fragmentation between organisations and professions, by associated inflexibility in planning, transfer of resources and adaptation to changing needs, and by over-concentration of resources and influence upon medical and residential institutions. The study involves the observation of cohorts of patients/clients entering and passing through the health and social services and the relationship between this experience and the expectations of the clients, their relatives and their service providers. The key question is how far structural features of each health and social service system facilitate or hinder the effective delivery of care. Methodological problems of cross-national research are discussed.
Aged↗
Potentially inappropriate medication use among elderly home care patients in Europe.
CONTEXT: Criteria for potentially inappropriate medication use among elderly patients have been used in the past decade in large US epidemiological surveys to identify populations at risk and specifically target risk-management strategies. In contrast, in Europe little information is available about potentially inappropriate medication use and is based on small studies with uncertain generalizability. OBJECTIVE: To estimate the prevalence and associated factors of potentially inappropriate medication use among elderly home care patients in European countries. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional study of 2707 elderly patients receiving home care (mean [SD] age, 82.2 [ 7.2] years) representatively enrolled in metropolitan areas of the Czech Republic, Denmark, Finland, Iceland, Italy, the Netherlands, Norway, and the United Kingdom. Patients were prospectively assessed between September 2001 and January 2002 using the Minimum Data Set in Home Care instrument. MAIN OUTCOME MEASURES: Prevalence of potentially inappropriate medication use was documented using all expert panels criteria for community-living elderly persons (Beers and McLeod). Patient-related characteristics independently associated with inappropriate medication use were identified with a multiple logistic regression model. RESULTS: Combining all 3 sets of criteria, we found that 19.8% of patients in the total sample used at least 1 inappropriate medication; using older 1997 criteria it was 9.8% to 10.9%. Substantial differences were documented between Eastern Europe (41.1% in the Czech Republic) and Western Europe (mean 15.8%, ranging from 5.8% in Denmark to 26.5% in Italy). Potentially inappropriate medication use was associated with patient's poor economic situation (adjusted relative risk [RR], 1.96; 95% confidence interval [CI], 1.58-2.36), polypharmacy (RR, 1.91; 95% CI, 1.62- 2.22), anxiolytic drug use (RR, 1.82; 95% CI, 1.51-2.15), and depression (RR, 1.29; 95% CI, 1.06-1.55). Negatively associated factors were age 85 years and older (RR, 0.78; 95% CI, 0.65-0.92) and living alone (RR, 0.76; 95% CI, 0.64-0.89). The odds of potentially inappropriate medication use significantly increased with the number of associated factors (P<.001). CONCLUSIONS: Substantial differences in potentially inappropriate medication use exist between European countries and might be a consequence of different regulatory measures, clinical practices, or inequalities in socioeconomic background. Since financial resources and selected patient-related characteristics are associated with such prescribing, specific educational strategies and regulations should reflect these factors to improve prescribing quality in elderly individuals in Europe.
Aged↗
Symptoms of asthma, bronchial responsiveness and atopy in immigrants and emigrants in Europe. European Community Respiratory Health Survey.
Migration studies on asthma may provide information on its environmental causes. The European Community Respiratory Health Survey has potential advantages due to the number of countries involved, standardized collection of information, assessment of directionality of migration, and availability of physiological data on bronchial responsiveness and atopy. Prevalence rates of symptoms associated with asthma were compared for immigrants, emigrants and nonmigrants living in centres mostly in western Europe. Similar analyses were carried out for bronchial responsiveness (provocative concentration causing a 20% fall in forced expiratory volume in one second and slope) and atopy. Medication and use of health services were also explored. Overall, 1,678 (8.6%) of 19,516 participants were immigrants in the 18 countries participating in the study, of whom 581 were emigrants from one of the participating countries. Rates of asthma symptoms were higher in immigrants (odds ratio (OR): 1.21, 95% confidence interval (CI): 1.00-1.51) and emigrants (OR: 1.31, 95% CI: 0.96-1.51) compared to nonmigrants after controlling for area, sex, age and smoking status. However, bronchial responsiveness and atopy were equally distributed between immigrants, emigrants and nonmigrants. Use of health services was observed to be similar in migrants and nonmigrants with asthma. In the European Community Respiratory Health Survey, migrants reported more asthma symptoms, but had similar bronchial responsiveness, atopy, and use of health services when compared with the nonmigrant population.
Adult↗
Recent progress in drug treatment for acute ischemic stroke.
The publication of the positive results of the National Institute of Neurological Disorders and Stroke (NINDS) trial of alteplase (a recombinant tissue plasminogen activator; rt-PA) for acute stroke patients in 1995 and its approval by the US Food and Drug Administration as well as the American Academy of Neurology and American Heart Association increased the interest and attention of the medical community in acute stroke treatment. However, the implication of this NINDS Stroke Study and other thrombolytic trials in clinical practice remains controversial and debated. Furthermore, the recent publication of the results from the European Cooperative Acute Stroke Study II (ECASS II) and Alteplase Thrombolysis of Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) studies will feed the controversy, since the results of these two studies are disappointing and do not confirm the positive results of the NINDS Stroke Study as expected by clinicians managing patients with acute stroke. The Standard Treatment with Alteplase to Reverse Stroke (STARS) and Cleveland studies, which involved a large number of community hospitals to assess the safety profile and the benefit of rt-PA thrombolysis for acute stroke patients in clinical practice, have shown controversial results. Consequently, the issue arises of which is the more reasonable position concerning thrombolysis by alteplase, which seems to work but has not been proven yet beyond reasonable doubt? The recent publication of the results from the Prolyse in Acute Cerebral Thromboembolism (PROACT II) study has shown that intra-arterial thrombolysis with prourokinase is a benefit treatment in stroke patients with a proven middle cerebral artery occlusion within 6 h of stroke onset. Numerous trials devoted to neuroprotection against acute ischemic stroke have been prematurely stopped because of safety concerns or poor risk-benefit ratios, but some new neuroprotective drugs seem promising and are being tested in ongoing studies. The third issue under study concerns the use of antithrombotic drugs in the acute phase of stroke, particularly the new potent platelet glycoprotein IIb/IIIa antagonists such as abciximab. In this paper, we have reviewed selected recent clinical trials focusing on recent advances in acute stroke therapy.
Acute Disease↗
Standardisation in medical image management.
A medical image without the relevant associated data is of no value. What is relevant depends on the use which is to be made of the image. The associated data may be divided into groups associated with the patient, the image data (array size, data type), the image itself (e.g. acquisition method), the requested imaging procedure to which it belongs, graphical, numerical and time information associated with the images, relevant results of other medical procedures, etc. Images, digital images and the associated data must be managed in an efficient manner in order to deliver appropriate patient care. In order to realise fully the potential of digital imaging, digital image data must be transmitted from acquisition units and stored in such a way as to allow appropriate access to health care practitioners in the imaging department, hospital and community. Standards exist for the formatting and transmission of image and related data (Digital Imaging and Communications in Medicine (DICOM). NEMA PS 3.1-PS3.12, The National Electrical Manufacturers Association, Rosslyn, VA, 1992, 1993, 1995; Health Level Seven, An Application Protocol for Electronic Data Exchange In Healthcare Environment, version 2.2, Health Level Seven Inc., Ann Arbor, MI, 1994; Comite European de Normalisation, Technical Committee 251: Medical Informatics) although further work is required in order to improve interoperability. There is some overlap in current standards, thus an important area is the agreement on the scope of the work to be done by different bodies. Standards are lacking in the areas of image management and presentation. Strategies for the efficient use of a memory hierarchy to achieve satisfactory archiving and access must be developed and this depends on the existence of appropriate descriptive data fields. Specific issues exist regarding security of image data. Key areas requiring immediate work are the profiling of descriptive data elements according to different clinical application needs in order to improve interoperability and the development of strategies for evolution from legacy systems to modern networked systems. The best way forward is to consolidate and refine existing specifications.
Data Display↗
Standards for performance measurements of PET scanners: evaluation with the UGM PENN-PET 240H scanner.
A standard set of performance measurements is proposed for use with positron emission tomographs. This set of measurements has been developed by the Computer and Instrumentation Council of the Society of Nuclear Medicine and the National Electrical Manufacturers Associations. These measurements are discussed and compared to the set of standard measurements being proposed by the Instrumentation Task Group of the European Economic Community Concerted Action of Cellular Regeneration and Degeneration. The performance of the PENN-PET 240H scanner from UGM Medical Systems is tested with this set of measurements. The PENN-PET scanner consists of six continuous position-sensitive NaI(T1) detectors, which results in a 50 cm transverse field-of-view and a 12.8 cm axial field-of-view. The fine spatial sampling in the axial direction allows the data to be sorted into as many as 64 transverse planes, each 2 mm thick. A large axial acceptance angle, without inter-plane septa, results in a high sensitivity, with a low scatter and randoms fraction, due to the use of a narrow photopeak energy window. This paper emphasizes those performance measurements which illustrate the special characteristics of a volume imaging scanner, compared to a more traditional multi-ring scanner.
Equipment Design↗
Ethical issues arising in pharmacoepidemiologic research in a community hospital in Crete, Greece.
This paper presents the various issues encountered in planning, designing, performing, and reporting pharmacoepidemiologic research. Five hundred and fifty-one indigent patients insured by Social Care visited the Hospital Pharmacy of Chania General Hospital, and were compared with 551 patients insured under Social Security funds who visited three community pharmacies. The study had no external funding. Before we started the study, we officially sought approval from the Scientific Committee of our Hospital and from the local Pharmaceutical Association. We asked also for approval from the Medical School of the University of Crete. Patient privacy was of great concern in the design and performance of the study. The law in Greece, according to the directives of European Union, affects the way we use records in hospitals and protect patient rights. After these studies were completed, we made proposals to the authorities concerning continuous health education for both patients and health workers. Pharmacoepidemiologic research is difficult in hospitals outside universities or institutions, because of the lack of adequate funding and grants to support research staff.
Bioethics↗
Publication rate of Trauma abstracts presented at an International Orthopaedic conference.
INTRODUCTION: Oral presentations at major conferences are often used to present new material and generate discussion. However, conference abstracts that ultimately fail to be published are of little use to the wider medical community. The aim of this study was to evaluate the publication rate of trauma papers presented at an international orthopaedic conference, and to assess the factors which predict publication. METHODS: All abstracts presented orally at the trauma sessions of the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) Congresses in 1999 (Belgium) and 2001 (Greece) were assessed. A MEDLINE and EMBASE search was performed to identify articles written by the first, second and last authors of each abstract to identify a matching journal article. Subspecialty, country of origin of abstract, study type, journal of publication and publication year were tabulated. RESULTS: Two hundred and seventy eight trauma abstracts were presented orally, and 112 (40.3%) achieved subsequent publication. Abstracts on fractures of the proximal femur were the most common (18.7%) and had one of the highest rates of publication (44.2%). Greece and the UK provided the largest number of abstracts, and randomised trials were the study type with the highest rate of publication (80.0%). Thirty two percent of journal articles appeared within 1 year of the conference and 63% within 2 years. Injury was the journal most likely to publish the articles. CONCLUSION: About 60% of Trauma abstracts presented did not result in a subsequent full-text publication. The citation of conference proceedings should be discouraged, and clinicians should be wary of implementing information gleaned from conference presentations into their clinical practice.
Bibliometrics↗
Monogenic ALB Variants as Determinants of Severe Hypercholesterolemia: A Population-Based Cohort Study.
BACKGROUND: Hypoalbuminemia is associated with several risk factors for myocardial infarction, including hypercholesterolemia, liver disease, kidney disease, and diabetes. Homozygosity of loss-of-function (LoF) variants in the ALB gene, which encodes albumin, is a known cause of congenital hypoalbuminemia. Studies have also shown that heterozygous ALB LoF variants are associated with increases in low-density lipoprotein cholesterol (LDL-C), comparable to those seen in familial hypercholesterolemia. OBJECTIVES: This study examined the effect of ALB LoF variants and other causes of low albumin on LDL-C levels in 2 population biobanks. METHODS: This study used data from 2 large cohorts with linked electronic health record and genetic information: Geisinger's MyCode Community Health Initiative, a health care population based in Pennsylvania, USA; and the National Institutes of Health All of Us Research Program, a nationwide epidemiologic cohort. LDL-C values were adjusted for lipid-lowering medication use. Myocardial infarction diagnoses were extracted from electronic health records using International Classification of Diseases codes. A polygenic score for serum albumin was calculated for participants of European ancestry. Linear regression models were used to estimate associations, and results were meta-analyzed across cohorts using fixed-effects models. RESULTS: Among 155,530 MyCode and 405,701 All of Us adult participants, 77 individuals (1 of 7,289) carried an ALB LoF variant. Among noncarriers, a 1 g/dL decrease in serum albumin was associated with a 10.9 mg/dL (95% CI:, 10.4-11.4) decrease in LDL-C. In contrast, ALB LoF variants were associated with a 0.69 g/dL (95% CI: 0.60-0.78) reduction in serum albumin and a 38.3 mg/dL (95% CI: 28.2-48.5) increase in LDL-C. Paradoxically, whereas monogenic determinants of hypoalbuminemia were associated with increased LDL-C, polygenic determinants of lower albumin were associated with a 0.22 mg/dL (95% CI: 0.17-0.26) decrease in LDL-C per decile. CONCLUSIONS: ALB LoF variants represent a previously underrecognized monogenic cause of elevated LDL-C, with effect sizes slightly less than canonical familial hypercholesterolemia variants. The divergent effects of ALB-mediated vs polygenic or physiological reductions in albumin on LDL-C suggest distinct underlying mechanisms.
Humans↗