The Western journal of medicine最新文献

{"title":"Diagnosis and treatment of opiate-resistant pain in advanced AIDS.","authors":"Wayne C. McCormick, R. L. Schreiner","doi":"10.1136/EWJM.175.6.408","DOIUrl":"https://doi.org/10.1136/EWJM.175.6.408","url":null,"abstract":"A 35-year-old man with AIDS [acquired immunodeficiency syndrome] was admitted for end-of-life care. He had tested positive for the human immunodeficiency virus (HIV) in 1986, when he was diagnosed with Pneumocystis carinii pneumonia. He subsequently developed non-Hodgkin’s lymphoma with involvement of abdominal and periaortic lymph nodes. He had responded initially to antiretroviral therapy and chemotherapy, although his CD4 cell count never rose above 100 10/L (100/μL), indicating ongoing severe immune deficiency. He had stopped HIV therapy because of side effects 1 year before admission, and lymphoma had progressed. At the time of admission, he had severe neuropathic leg and abdominal pain with partial bowel obstruction from the lymphoma. Symptoms had made care at home (rendered by his mother and partner) very difficult, even though both were intensive care unit nurses. On admission, the patient was receiving patient-controlled-analgesia (PCA) morphine sulfate through a subclavian central line at an already high rate of 90 mg per hour with the ability to selfor partner-deliver 30 mg every 6 minutes. This was completely ineffective in managing his pain. The patient was remarkably responsive and coherent, even though narcotic hallucinosis (visual and auditory hallucinations) was intermittently present. The baseline dose of morphine was dramatically increased during the first 48 hours to 620 mg per hour; this brought no change in pain relief but worsening of his hallucinosis.","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"3 1","pages":"408-11"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87431248","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pharmaceutical companies must make decisions based on profit.","authors":"Lawrence Perkins","doi":"10.1136/EWJM.175.6.422","DOIUrl":"https://doi.org/10.1136/EWJM.175.6.422","url":null,"abstract":"To criticize pharmaceutical companies for researching and marketing medications for some diseases but not others is akin to criticizing Victoria's Secret for biasing their line of products primarily toward women. \u0000 \u0000 \u0000Regardless of what a company is selling, they are in the business of making money and satisfying their fiduciary duties. Whether the company is pedaling widgets, cigarettes, or other companies, at the end of the day the company's future existence depends on the bottom line of the income statement. Pharmaceutical companies are no different. They are in the business of making money by selling pharmaceuticals. As with every company, for them to exist, they must ensure that the result of the following equation is greater than zero: \u0000 \u0000 \u0000 \u0000 \u0000 \u0000 \u0000 \u0000 \u0000For them to operate, the management must generate the highest level of profitability possible to fulfill its fiduciary duty of maximizing shareholder value. \u0000 \u0000Chandrasoma argues that pharmaceutical companies have an obligation to society to produce medicines that address all afflictions and to avoid discriminating against a particular disease or condition. But pharmaceutical companies have to discriminate because, like other commercial enterprises, every day they must answer the following question: can we afford this venture? This decision must be based purely on sales and costs. \u0000 \u0000As any consumer knows, pharmaceuticals are expensive to purchase. Treatments for HIV infection can cost thousands of dollars per year. The reason for these high costs is the tremendous amount of time and money necessary to develop, approve, and distribute these medications. \u0000 \u0000Over the past 10 years, Bristol-Meyers Squibb has spent more than 10% of its total sales on research and development.1 Merck alone spent more than $9.4 billion on research and development between 1996 and 2000.2 To put things in perspective, Merck could hand every American citizen a $5 bill or purchase every good produced in Tanzania for less than they have spent in 5 years on research and development. \u0000 \u0000Once the research and development is complete, pharmaceutical companies can expect to spend many billions more on clinical trials, political lobbying, and other costs associated with launching a new product. On top of that, they must wait, on average, 10 years to begin selling the products and recouping cost. \u0000 \u0000The revenue generated from a successful product must recover the cost of not only that product's research and development but also the cost of failed ventures. Companies can either charge phenomenally high prices for drugs that affect relatively small patient populations (for example, patients in the United States with AIDS or multiple sclerosis) or charge a more commercially viable price for drugs that address the needs of a huge portion of the population (for example, those with erectile dysfunction or allergies). Based on the medical system that is currently in place, insurance companies are more likely to lobby against high-pri","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"17 1","pages":"422-423"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84773325","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Why should primary care physicians know about the genetics of dementia?","authors":"L. Pinsky, W. Burke, T. Bird","doi":"10.1136/EWJM.175.6.412","DOIUrl":"https://doi.org/10.1136/EWJM.175.6.412","url":null,"abstract":"Alzheimer disease begins with subtle memory failure that then progresses \u0000 \u0000Courtesy of Alzheimer's Association","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"107 1","pages":"412-6"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90653069","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Thoughts on a new health care paradigm.","authors":"T. Davidson","doi":"10.1136/EWJM.175.6.429","DOIUrl":"https://doi.org/10.1136/EWJM.175.6.429","url":null,"abstract":"The insurance industry has removed the joy from health care delivery with authorizations, documentation, guidelines for evaluation and treatment, diminished reimbursement, reimbursement delays, and denied payments. Physicians are now paid for what they write on the chart, not for what they do for the patient. Failure to document may mean fines or criminal charges. The legal system has rendered the medical record an abomination by requiring every piece of paper to be saved. We, as physicians, have lost control of our profession. \u0000 \u0000Patients are demanding quality health care. Health care practitioners need stability. If we allow the situation to go on, our government is sure to increase industry regulations. This may mean legislation expanding the scope of practice for allied health care providers, thereby circumventing physicians and undermining our control. If we do not want to become regulated government employees, we should initiate a major overhaul of health care delivery. \u0000 \u0000Physicians must band together to recommend an improved health care paradigm. Medicine is a unique profession. Supply, demand, and competition run counterproductive to cost-effective quality health care. Individuals, groups, and medical organizations must stop lobbying for their own special interests, and present a single voice.","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"44 1","pages":"429-30; discussion 430-1"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84205852","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Demystifying critical care: a new series provides a succinct, modern approach aimed at primary care physicians.","authors":"R. Rodriguez","doi":"10.1136/EWJM.175.6.366","DOIUrl":"https://doi.org/10.1136/EWJM.175.6.366","url":null,"abstract":"Since their inception, intensive care units (ICUs) have continually grown in scope and complexity. Today's ICU—and the whole field of critical care medicine—can seem daunting to some physicians. With this in mind, wjm begins a new series that aims to demystify the workings of the 21st century ICU and to provide a succinct, modern approach to critical care medicine for primary care practitioners.","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"5 1","pages":"366-7"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86663786","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Have drug companies hyped social anxiety disorder to increase sales. Yes: marketing hinders discovery of long-term solutions.","authors":"D. Healy","doi":"10.1136/EWJM.175.6.364","DOIUrl":"https://doi.org/10.1136/EWJM.175.6.364","url":null,"abstract":"Social phobia, also called social anxiety disorder, can lead to alcoholism, drug abuse, job loss, and even suicide. It has been relatively unrecognized in the West compared with in the East, where it is seen as the most common neurotic condition.1 GlaxoSmithKline's recent license to promote the use of paroxetine to treat social phobia looks certain to increase the recognition of this potentially serious condition. What could be wrong with this win-win situation? \u0000 \u0000The first problem lies in interpreting what a license means. A license is not a statement by the Food and Drug Administration that paroxetine will be effective for treating social phobia. Licenses legally cannot be denied if a treatment can be shown to do something for a condition, but they are no guarantee that this treatment is worth-while. Although simply increasing the recognition of social phobia may reduce the isolation of sufferers, unless sufferers receive an effective treatment that makes a substantial difference in their lives, the treatment may not be worth the risks. \u0000 \u0000What are the risks? It is clear from studies undertaken by SmithKline in the 1980s that even a brief exposure to paroxetine can lead many takers to become physically dependent.2 Trials have also shown that the use of selective serotonin reuptake inhibitors (SSRIs) can precipitate suicidality in patients and that these agents can cause sexual dysfunction and neurologic disorders.3 Although the SSRIs have been marketed as being freer of side effects than older agents, results on the quality-of-life scales that should reflect this freedom, which have been used in up to 100 clinical trials, have been left unpublished.4 This strongly suggests that SSRIs may be the wrong drugs for many people. All of these hazards could be minimized if SmithKline marketed the hazards of treatment as assiduously as they market the condition. \u0000 \u0000Unlike obsessive-compulsive disorder, which was recently marketed by companies, social phobia is more like depression—a syndrome that may result from a variety of conditions. In some instances, it may be a prodrome for a psychotic disorder. Whereas some patients may get better with the use of paroxetine, it is sobering to realize that the discovery of the first antidepressant agents came about because they made some patients psychotic. In trials of SSRIs to treat depression, a significant proportion of patients not already having psychosis became psychotic. The same can be expected for social phobia. What people with this potentially debilitating condition need is research to understand why this is the case, rather than the marketing of a drug that may be beneficial for a few sufferers but hazardous for an equally large group. \u0000 \u0000Undoubtedly some patients with social phobia will not become suicidal, dependent, or psychotic while taking paroxetine, and their quality of life will not be poor. Even these patients have something to worry about, however. When a condition like social phobia become","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"25 1","pages":"364"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85952464","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Tragedy and the healing response.","authors":"S. Chandrasoma","doi":"10.1136/EWJM.175.6.420","DOIUrl":"https://doi.org/10.1136/EWJM.175.6.420","url":null,"abstract":"September 11 found me, like most of America, riveted to CNN, watching a hijacked commercial airliner fly into the World Trade Center in an endless, multiangled loop. To this day, I am still partially dissociated from the reality of what happened on that day. Attending school and worrying about an internal medicine final, I find it difficult to realize that the United States is at war. CNN is still buzzing with exposes on Afghanistan, but in the few moments I have to watch television, I find myself guiltily switching to see what “Scrubs” is all about. Walking through the quad at lunchtime, I see a posted reminder of a blood drive, and I marvel that such a horrific event, burned into memory, could turn a nation of people into healers and helpers. \u0000 \u0000 \u0000 \u0000 \u0000Figure 1 \u0000 \u0000 \u0000 \u0000 \u0000 \u0000In all tragedies, many different people become healers \u0000 \u0000AP/Pat Carter \u0000 \u0000 \u0000 \u0000 \u0000The palliative medicine that I saw practiced in America that day and the days following transcended the medical profession. People donated blood at such a rate that CNN commentator Paula Zahn said that she had tried to donate but didn't get enough of a leave from reporting to stand in the 5-hour line of people waiting to give. At the USC campus and campuses across the country, emergency blood drives were organized, and students were informed via e-mail. Along with my friends and family, I spent much of the day on the phone, checking up on loved ones on the East Coast and trying to talk over the insanity of the day. Each person served as a psychological consultation to family and friends, and each person had countless other people helping to deal with the tragedy. \u0000 \u0000Through the donations, support, and consoling, America proved itself to be a “collective physician,” treating itself. The definition of “physician” opened wide to rise above degrees, accolades, and educational prowess. In the darkest hour America has seen in decades, a vast population beyond that of just health professionals carried out the practices of medicine and palliative care. There was medicine in the comfort offered by a police officer, a respirator shared at the cost of burning lungs, and the overwhelming donation of blood products across America. \u0000 \u0000A week after the event, a different type of story came in, not from CNN but through local television and radio. These were sad tales of intolerance and bigotry. An Egyptian storeowner was shot in his place of business 10 minutes from my house, his murderers leaving behind a full cash register and any chance of robbery as a motive. Muslim students and their families received death threats via phone and mail. Although tragic, the response to these stories was positive; people of all races and creeds denounced the hate crimes, and people took action to see that the perpetrators would be punished as severely as those responsible for the World Trade Center attack. In “the body” that is America, a few bad bacteria find themselves outnumbered by unified red blood cells and pursued by a st","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"7 1","pages":"420-1"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91104892","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Injury in the developing world.","authors":"C. Mock","doi":"10.1136/EWJM.175.6.372","DOIUrl":"https://doi.org/10.1136/EWJM.175.6.372","url":null,"abstract":"Injury is the commonest cause of death for children and young adults in developed and middle-income countries. In low-income countries, deaths in this age group are most often due to infectious disease, but there is a rising rate of deaths from injury.1 \u0000 \u0000The Global Burden of Disease Study highlighted the overall toll from injury in the developing world.2 The table shows the major causes of death for the 2 main age groups affected by injury.3 Injury-related causes account for 3 of the top 6 killers of older children and 4 of the top 6 killers of young adults. Road traffic accidents alone are second only to AIDS as a killer of young adults. Other major causes include nonintentional or accidental causes (such as drowning, fires and burns, poisoning, falls, and home injuries) and intentional causes (such as violence and suicide). In addition to mortality, disability is often due to injury, especially with the success of the global efforts to control polio. Injury is also a leading contributor to health-related economic losses. \u0000 \u0000Despite the toll from injury, scarce attention has been paid to the problem. Although a tremendous amount of resources are consumed caring for injured patients at hospitals throughout the developing world, minimal attention has been directed toward better understanding of injury, prevention efforts, or organized efforts to improve trauma treatment systems. The amount of funding devoted to such efforts is a small percentage of that devoted to other health problems in developing countries.4 \u0000 \u0000 \u0000 \u0000 \u0000Table 1 \u0000 \u0000Major causes of death in developing countries (both low and middle-income) in 1998* \u0000 \u0000 \u0000 Rank 5-14 yr Rate† 15-44 yr Rate† \u00001 Respiratory infections 19.7 HIV/AIDS 67.0 \u00002 Malaria 19.4 Road traffic injuries‡ 21.9 \u00003 Road traffic injuries‡ 14.5 Interpersonal violence‡ 20.2 \u00004 Drowning‡ 14.5 Self-inflicted injuries‡ 19.0 \u00005 Diarrheal diseases 12.4 Tuberculosis 17.8 \u00006 War injuries‡ 5.3 War injuries‡ 15.5 \u0000 \u0000 \u0000View it in a separate window \u0000 \u0000 \u0000*Source: Krug et al.3 \u0000 \u0000†Rates of death expressed as deaths per 100,000 per year. \u0000 \u0000‡Injury-related causes. \u0000 \u0000 \u0000 \u0000 \u0000Part of the reason for such neglect may be that many of the solutions to the problem lay outside the usual domain of health professionals. For example, possible solutions include road engineering and road use legislation. Another reason for the neglect may be a sense of futility. Injuries are conceptualized by much of the public around the world as due to bad luck or to carelessness, with little that can be done to prevent them.","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"33 1","pages":"372-4"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88305727","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hyperlipidemia : Part 2. Pharmacologic management","authors":"N. Link, M. Tanner","doi":"10.1136/EWJM.175.6.396","DOIUrl":"https://doi.org/10.1136/EWJM.175.6.396","url":null,"abstract":"Pharmacologic therapy for lipid disorders is now dominated by hydroxymethyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins). They have been conclusively proved to prevent coronary events and save lives in a wide variety of situations and are acceptably safe. \u0000 \u0000 \u0000 \u0000Alternatives to statins include resins (eg, cholestyramine), fibric acid derivatives (eg, gemfibrozil), and nicotinic acid (table 1, see p 400). They all have a place in lipid management but should be considered second-line agents. \u0000 \u0000 \u0000 \u0000Table 1 \u0000 \u0000Agents for treating hyperlipidemia","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"10 1","pages":"396-401"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88384629","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"News stories need human drama, not dry data","authors":"S. M. Collins","doi":"10.1136/ewjm.175.6.384","DOIUrl":"https://doi.org/10.1136/ewjm.175.6.384","url":null,"abstract":"“If it bleeds, it leads” is a catchy and convenient criticism of a certain segment of American journalism. But in our dismissal of it as a foundation for newsgathering and storytelling, we should not forget that the audience (and journalists) are human beings. And human beings have an innate desire to be told and to tell dramatic stories. I am at a loss to name a single operatic work that treats coronary artery disease as its subject, although I can name several where murder, incest, and assassination play a key part in the story. Check your own instinct for storytelling by asking yourself this: If driving home from work, you passed a burning building, would you wait to tell your spouse about it until you first explained the number of people who died that day from some form of neoplastic disease? \u0000 \u0000Journalism is not run by a scientific formula. There is no “treatment algorithm” to guide decision making in the newsroom. Decisions about a story being newsworthy come from the head, the heart, and the gut. The notion that the results of that decision making should parallel morbidity and mortality statistics in the area is a peculiar one. We report on the newsworthy death of a patient with the West Nile virus south of the Mason-Dixon line, but according to McArthur and colleagues' logic, we should instead be reporting on the ravages of diabetes because so many more people succumb to the latter than to the former. Similarly, journalism will likely focus on the “story” of 4 particular hijackings, the collapse of the World Trade Center, and an attack on the Pentagon far out of proportion to the relative weight of the 7,000 deaths. Why? Because sometimes we have to tell stories that resonate someplace other than the epidemiologist's spreadsheet. \u0000 \u0000There is much in McArthur and associates' study for newspeople to take away and consider. Chief among the lessons is the criticism of television's penchant for telling stories that are sometimes only visually compelling over stories that are important for their content alone. It is a hard lesson for television to learn. And it calls the managers of television newsrooms to be genuine leaders. The audience is prepared to listen to a story of importance—even in the absence of dramatic video; indeed, many millions of people get their news from their radios each day. \u0000 \u0000The authors rightly point to the matter of the public's poor medical literacy and to the issue of who is responsible for improving it. Journalists, I believe, have a role in communicating medical information to the public, but the responsibility for this education rests squarely on the shoulders of the medical community. Physicians and other health care professionals should be talking to journalists about issues of importance, becoming their sources of medical information. They should invite news directors (and their deputies) to seminars. Raise these issues with them. The medical professions are the ones who can educate the media about the importan","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"28 1","pages":"384-384"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85080434","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}