Validation of a novel Artificial Pharmacological Intelligence (API) system for the management of patients with polypharmacy.

OBJECTIVE: Medication management of patients with polypharmacy is highly complex. We aimed to validate a novel Artificial Pharmacological Intelligence (API) algorithm to optimize the medication review process in a comprehensive, personalized, and scalable way. MATERIALS AND METHODS: The study was conducted on anonymized retrospective electronic health records (EHR) of 49 patients. Each patient's file was reviewed by the API system, a clinical pharmacist, and a judging committee. Validation was assessed by comparing the overall agreement of the judging committee (as the gold standard, blinded to the identity of the analyzer) to both the API system and clinical pharmacists' conclusions. Five medication-related problem (MRP) categories were assessed: duplication of therapy, age-related issues, incorrect dose, current side effects and future side effects' risk. For each category the overall validity parameters, agreement, positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity were analyzed. RESULTS: The agreement between the API system and the judging committee was 93.5 % (95 % CI 92.7-94.4), while the agreement between the clinical pharmacists and the judging committee was 73.9 % (95 % CI 72.5-75.3). The PPV was 92.2 % (90.9-93.5) and NPV was 94.2 % (93.1-95.2) for the API system and 76.3 % (69.8-82.8) and 73.5 % (72.3-74.8) respectively for the clinical pharmacists. DISCUSSION: AI systems can equip clinicians with sophisticated tools and scale manual processes such as comprehensive medication reviews, thus reducing MRPs and drug-related hospitalizations related to multidrug treatments. The API system validated in this study provided comprehensive, multidrug, multilayered analysis intended to bridge the innate complexity of personalized polypharmacy treatment. CONCLUSIONS: The API system was validated as a tool for providing actionable clinical insights non-inferior to a manual clinical review of a clinical pharmacist. The API system showed promising results in reducing MRPs.

Drug-eluting stents compared with bilateral internal thoracic artery grafts for diabetic patients.

BACKGROUND: Diabetic patients with multivessel coronary artery disease who undergo coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI) are at greater risk of late morbidity and mortality than nondiabetic patients. We questioned earlier comparisons of these two approaches that showed no differences in survival rates. This study compares drug-eluting stents (DES) and bilateral internal thoracic artery (BITA) grafting in diabetic patients with multivessel coronary artery disease. METHODS: All diabetic patients who underwent left-sided arterial revascularization with BITA grafting between January 2002 and May 2006 were evaluated. Their outcomes were compared with those of diabetic patients who underwent PCI with DES (Cypher). The Cox proportional hazards model defined predictors of outcome events after forcing propensity score with patients' characteristics into the model. RESULTS: The outcomes of 226 BITA patients were compared with those of 271 DES patients (mean follow-up 62 months). The 5-year reintervention-free survival (Kaplan-Meier 86% versus 65%, log rank p = 0.000) and major adverse cardiovascular events-free survival (81% versus 54%, p = 0.001) were significantly better in the BITA group. Assignment to the PCI group was associated with decreased adjusted survival (hazard ratio 3.01, 95% confidence interval: 1.59 to 5.73, p = 0.000) and increased risk of target vessel reinterventions (hazard ratio 7.00, 95% confidence interval: 3.1 to 15.70). The adjusted risk of major adverse cardiovascular events increased with the number of DES-treated vessels. CONCLUSIONS: This is the first demonstration of significantly better long-term adjusted survival and outcomes of diabetic patients who underwent CABG with BITA grafting compared with diabetic patients who underwent PCI with DES.

Sustained virologic response to treatment in 100% of patients recently infected, nosocomially, with HCV genotype 2.

OBJECTIVE: In 2003, a cluster of hepatitis C virus (HCV)-infected patients with a common history of a surgical procedure, performed during 2001 to 2003, was identified in a medical center. An epidemiologic investigation linked a physician, infected with HCV genotype 2, as the possible source of infection in 35 patients. The evaluation, therapy, and outcome of this unique cohort are presented. DESIGN: HCV-RNA was isolated from sera of all patients and the double-stranded phosphorylation homology domain region was sequenced. After a routine clinical investigation 33 patients were offered antiviral therapy. Two patients were not treatment candidates due to old age and comorbidity. RESULTS: Twenty-two (66%) were women. The mean age was 48.5+/-16.9 years. Alanine aminotransferase level was 117+/-135 IU/L. Thirty patients were treated with pegylated interferon alpha 2a, 1 with pegylated interferon alpha 2b, and 1 with standard interferon. All received ribavirin 800 mg daily. One patient refused to be treated and was lost for follow-up. Time from acquisition of disease to initiation of therapy was 14.8+/-4.9 month (5.5 to 26). Therapy duration was 24 weeks except for 1 patient who stopped therapy after 16 weeks. Sustained virologic response was achieved in all 32 treated patients. The sequence motif of the phosphorylation homology domain region, studied in all patients, predicted good response to interferon. CONCLUSIONS: Our excellent results can be explained by a constellation of favorable viral characteristics, a short-term disease and adherence to therapy.

Mass casualty incident after the Taba terrorist attack: an organisational and medical challenge.

Two suicide bombings in and around Taba, Egypt, on 7 October 2004 created a complex medical and organisational situation. Since most victims were Israeli tourists, the National Emergency and Disaster Management Division handled their evacuation and treatment. This paper describes the event chronologically, as well as the organisational and management challenges confronted and applied solutions. Forty-nine emergency personnel and physicians were flown early to the disaster area to reinforce scarce local medical resources. Two hundred casualties were recorded: 32 dead and 168 injured. Eilat hospital was transformed into a triage facility. Thirty-two seriously injured patients were flown to two remote trauma centres in central Israel. Management of mass casualty incidents is difficult when local resources are inadequate. An effective response should include: rapid transportation of experienced trauma teams to the disaster zone; conversion of local medical amenities into a triage centre; and rapid evacuation of the seriously injured to higher level medical facilities.

Burn injuries and adolescents in Israel.

Burn injury is a public health concern often associated with individual pain, emotional stress, prolonged hospitalizations, permanent disfigurement and family stress. In this paper we studied the avaliable data on burn injury among adolescents in Israel through a Medline search and found three relevant studies with data on this population. The incidence rate of burn injury was 0.46 per 1,000 children aged 5-14 years for Jews and 0.91 for Bedouin. Most of the burn injury in this age group was caused by hot liquids, followed by fire and chemical burns for both Jews and Bedouin, but electical burns occurred more often in Bedouins. Mortality was very low for the adolescent group. Prevention programs in schools since the 1980s have been found effective, but the public health focus should now be geared towards groups at risk.

Adolescent injury risk behavior.

Health-risk behaviors that contribute to the leading causes of morbidity and mortality among adolescents and young adults are often established during adolescence and extended into adulthood. Unintentional motor vehicle injury is the leading cause of mortality in childhood and adolescence in developed countries. This review presents some of the risk factors found in research on unintentional injury and death in adolescence, including risk factors for siblings and adolescents with intellectual disability. These findings should be connected with the findings of a recent study that showed that about one third of all unintentional childhood injury deaths in the United States were preventable. For injury prevention to take place and being effective a multidisciplinary approach is needed to identify host, agent and environmental factors using epidemiology research and biomechanics. In the population of adolescents with intellectual disability there has been little research on injury epidemiology or injury prevention and the service provider will need to focus and educate staff on this issue in order to prevent injury that can result in further disability.

Trends in adolescent injury mortality in Israel.

Epidemiology is an important and powerful tool in public health used to monitor health, observe trends and identify risk factors for utilization in strategy, policy and planning of services and interventions. Unintentional injury is the leading cause of death in adolescents worldwide with motor vehicle injury and drowning the leading causes. In Israel the mortality rate for motor vehicle mortality rate for adolescents was found to be 10.6 per 100,000 and 1.0 per 100,000 for drowning. Studies have shown a decrease in injury and mortality over time, but there is still much to do and calculation studies have shown that it is possible to prevent further with targeted serious effort and strategies employed.

Clinical holistic medicine: holistic sexology and treatment of vulvodynia through existential therapy and acceptance through touch.

Sexual problems are found in four major forms: lack of libido, lack of arousal and potency, pain and discomfort during intercourse, and lack of orgasm. It is possible to work with a holistic approach to sexology in the clinic in order to find and repair the negative beliefs, repressions of love, and lack of purpose of life, which are the core to problems like arousal, potency, and pain with repression of gender and sexuality. It is important not to focus only on the gender and genitals in understanding the patient"s sexual problems. It is of equal importance not to neglect the body, its parts, and the feelings and emotions connected to them. Shame, guilt, helplessness, fear, disgust, anger, hatred, and other strong feelings are almost always an important part of a sexual problem and these feelings are often "held" by the tissue of the pelvis and sexual organs. The patient with sexual problems can be helped both by healing existence in general and by discharging old painful emotions from the tissues. The later process of local healing is often facilitated by a simple technique: accepting contact via touch. This is a very simple technique, where the self-acceptance of the patient is to be promoted, for example, asking the female patient to put her hand on her stomach (uterus) or vulva, after which the holistic physician puts his hand supportively around hers. When done with care and after obtaining the necessary trust of the patient, this aspect of holding often releases the old negative emotions of shame bound to the touched areas. Afterwards, the emotional problems become a subject for conversational therapy and further holistic processing. Primary vulvodynia seems to be one of the diseases that can be cured after only a few successful sessions of working with acceptance through touch. The technique can be used as an isolated procedure or as a part of a pelvic examination. When touching the genitals with the intention of sexual healing, a written therapeutic contract with the patient is highly recommended and a strict ethical code is necessary to avoid malpractice. As about one woman in three suffers from sexual problems, many of which seemingly can be efficiently alleviated by the simple holistic techniques of "holding and processing", it is very important that the holistic physician is also trained to work in the sexual sphere in order to be able to support his patients fully.

Prevention of infections associated with permanent cardiac antiarrhythmic devices by implementation of a comprehensive infection control program.

OBJECTIVE: To implement a comprehensive infection control (IC) program for prevention of cardiac device-associated infections (CDIs). DESIGN: Prospective before-after trial with 2 years of follow-up. SETTING: A tertiary-care, university-affiliated medical center. PATIENTS: A consecutive sample of all adults undergoing cardiac device implantation between 1997 and 2002. INTERVENTION: An IC program was implemented during late 2001 and included staff education, preoperative modification of patient risk factors, intraoperative control of strict aseptic technique, surgical scrubbing and attire, control of environmental risk factors, optimization of antibiotic prophylaxis, postoperative wound care, and active surveillance. The clinical endpoint was CDI rates. RESULTS: Between 1997 and 2000, there were 7 CDIs among 725 procedures (mean annual CDI incidence, 1%). During the first 9 months of 2001, there were 7 CDIs among 167 procedures (4.2%; P = .007): CDIs increased from 7 among 576 to 3 among 124 following pacemaker implantation (P = .39) and from 0 among 149 to 4 among 43 following cardioverter-defibrillator implantation (P = .002). Of the 14 CDIs, 5 involved superficial wounds, 7 involved deep wounds, and 2 involved endocarditis. Following intervention, there were no cases of CDI among 316 procedures during 24 months of follow-up (4.2% reduction; P = .0005). CONCLUSIONS: We observed a high CDI rate associated with substantial morbidity. IC measures had an impact on CDI. Although the relative weight of each measure in the prevention of CDI remains unknown, our results suggest that implementation of a comprehensive IC program is feasible and efficacious in this setting.

Clinical holistic medicine: when biomedicine is inadequate.

The modern physician is using pharmaceuticals as his prime tool. Unfortunately, this tool is much less efficient than you might expect from the biochemical theory. The belief in drugs as the solution to the health problems of mankind, overlooking important existing knowledge on quality of life, personal development, and holistic healing seems to be one good reason why approximately every second citizen of our modern society is chronically ill. The biomedical paradigm and the drugs are certainly useful, because in many situations we could not do without the drugs (like antibiotics), but curing infections or diseases in young age is not without consequences, as the way we perceive health and medicine is influenced by such experiences. When we get a more severe disease in midlife, we also believe drugs will make us healthy again. But at this age, the drugs do not work efficiently anymore, because we have turned older and lost much of the biological coherence that made us heal easily when we were younger. Now we need to assume responsibility, take learning, and improve our quality of life. We need a more holistic medicine that can help us back to life by allowing us to access our hidden resources. The modern physician cannot rely solely on drugs, but must also have holistic tools in his medical toolbox. This is the only way we can improve the general health of our populations. Whenever NNT (Number Needed to Treat) is 2 or higher, the likelihood of the drug to cure the patient is less than 50%, which is not satisfying to any physician. In this case, he must ethically try something more in order to cure his patients, which is the crossroads where both traditional manual medicine and the tools of a scientific holistic medicine are helpful.

Clinical holistic medicine: induction of spontaneous remission of cancer by recovery of the human character and the purpose of life (the life mission).

The recovery of the human character and purpose of life with consciousness-based medicine seems to be able to induce spontaneous remissions in several diseases. On two different occasions, we observed breast tumors reduced to less than half their original diameters (clinically judged) during a holistic session, when working with the patients in accordance with the holistic process theory of healing, the life mission theory, and the theory of human character. One tumor was histologically diagnosed as malign breast cancer prior to the session, while the other was under examination. As both patients had the affected regions of the breast surgically removed immediately after the session, we are unable to determine if they were actually healed by the holistic treatment. We find it extremely interesting that the size of a tumor can be reduced dramatically within a few hours of holistic treatment, when the patient is highly motivated for personal development. The reduction of tumor size is in accordance with the holistic view that many types of cancer are caused by emotional and existential disturbances. From a holistic perspective, cancer can be understood as a simple disturbance of the cells, arising from the tissue holding on to a trauma with strong emotional content. This is called "a blockage", where the function of the cells is changed from their original function in the tissue to a function of holding emotions. The reduction of the tumor in the two cases happened when old painful emotions were identified in the tissues, in and around the tumor, and processed into understanding; when the patients finally did let go of negative beliefs and attitudes that had kept the feeling(s) repressed to that part of the body, the tumor first softened and then disappeared, presumably by apoptosis. We believe that the consciousness-based/holistic medical toolbox has a serious additional offer to cancer patients, and we will therefore strongly encourage the scientific society to explore these new possibilities. Our holistic medical research meets both ethical dilemmas and practical difficulties, as it obviously is important for the research in induced spontaneous remissions that surgery and chemotherapy is not used before it is absolutely necessary. On the other hand, is it important for the patient"s survival that they receive any well-documented treatment as soon as possible. An additional aspect for the patient who is able to cure her own cancer is that she is much less likely to get cancer again and much better prepared to deal with other diseases and challenges in life. Knowing that one can fight even cancer gives a strong belief in life and the need to improve quality of life. The high incidence of secondary cancers and the physical and emotional wounds from the biomedical treatment seem to justify a focus on prevention and additional holistic treatment modules. To support the patient in learning the mastery of coherence of body and life, using the crisis of cancer to recover the human character and the purpose of life, seems turning a personal potential disaster into the greatest gift of all. When it comes down to it, life is not just about surviving; what is more important is to live fully, to learn from the great challenges of life, and to obtain the optimal quality of life while being here.

Adolescence, chronic illness and disability.

The prevalence of chronic illness or disability in adolescence has increased in recent years. In the past, children with certain chronic diseases did not reach adolescence, but over the last decade the survival rate has increased manyfold. The old morbidity (infectious disease, poor housing, poverty, lack of immunisation) has been exchanged with a new morbidity of adolescence, where a longer life expectancy is followed by an increase in lifelong disability. This review discusses issues concerned with the definition of disability in adolescence, reviews prevalence studies in several countries, the causes of disability, disparities, access and expenditure of health care, psychosocial aspects, and how to promote better outcomes.

Clinical holistic medicine: use and limitations of the biomedical paradigm.

The biomedical paradigm is so convincing from a biochemical point of view, and highly efficient in many cases of acute medical problems and emergencies, but unfortunately most patients do not get much better only treated with drugs; they need to do something about their lives themselves. It is highly important for the modern physician to understand the strengths and weaknesses of the modern biomedical paradigm, to understand when and when not to administer drugs to their patients. Often a symptom can be eliminated for a while with drugs, but this is not always good as the patient might need to learn to study the imbalances in life that cause the disturbances and symptoms. For the elderly patient, sometimes life can be extended in spite of the subjective fact that life has come to its end. Sometimes treatment with a drug can teach the patient that quality of life is the responsibility of the physician and not the patient. This learned attitude can give the patient problems later or make them less active in helping themselves (responsibility transfer in the wrong direction). This paper gives a number of examples where medical drugs really are the treatment of choice in general practice and some more doubtful examples of using of the biomedical paradigm.