摘要:

Although clinicians have an obligation to act in patients' best interests, patients frequently choose to act in ways that adversely affect health. Consequently, clinicians are often left questioning where the responsibility for optimum care lies.The criteria for determining responsibility (the Jonas criteria) are as follows: causality, control and foresight. Two types of choices lead to health problems − lifestyle and noncompliance. Patients are responsible to themselves and society for unhealthy lifestyles. Patients are subject to the consequences of unhealthy lifestyles in the form of suffering; society's consequence is increased costs. Providers are not justified to increase an individual's consequences because the degree of responsibility cannot be specified, and clinicians should not be deciding who deserves care. Society is justified in setting prospective consequences in the form of taxes, education and prevention.Noncompliance challenges the clinician's duty to respect patient autonomy. Respect for autonomy requires clinicians to actively assist patients in making reasoned decisions about treatment and then to accept such decisions. The clinician must simultaneously assess patients' competence to make decisions, and take increased responsibility for decisions when competence is impaired. Factors that need to be considered in determining an appropriate level of coercion include: the nature and degree of potential harm to the patient and to society from noncompliance; the likelihood of the harm's occurrence; the intrusiveness of the planned coercive activity and; the degree to which the intervention is likely to be effective.

ISSN:1173-8790    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

The Internet represents a substantial advance in information exchange and presents the healthcare industry with a significant opportunity to fundamentally enhance the manner in which individuals manage their relative wellness. As the World Wide Web matures, usage patterns are becoming more precisely defined. These patterns can be examined and used to enhance accessibility and encourage user loyalty to a particular site. The internet, coupled with future technology advances, could enable healthcare providers to offer individually tailored disease management programmes, adapt to patient needs in real-time and deliver vast amounts of information with virtually no fulfilment costs. However, a planned and well co-ordinated approach is needed if the benefits of this new communication medium are to be fully realised. If this is achieved, Web-based disease management could be a cost-effective means of lowering patient health risk and an excellent asynchronous link between patient and provider.

ISSN:1173-8790    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

Home infusion therapy, i.e. home infusion of deficient or missing clotting factors, is one of the mainstays of haemophilia care in developed countries. The aims of home therapy are:to prevent profuse bleedings by giving treatment immediately in the event of incipient bleeding;to save time and money in terms of transport to and from hospital;to reduce absence from school or work; andto render patients independent so that they can lead ‘normal’ lives.Home therapy should be started immediately when there is an indication for replacement therapy. Initially, parents administer the infusions to the patient with assistance; eventually, the patient can treat themselves. Virtually all patients are eligible for home therapy within the frame of a comprehensive care programme. Studies have shown a dramatic beneficial outcome in both social functioning and joint disease after introduction of this treatment modality.

ISSN:1173-8790    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

Dyslipidaemias are major modifiable risk factors for the development of atherosclerosis and its sequelae, namely coronary heart disease (CHD) and peripheral vascular disease. CHD is the leading cause of morbidity and mortality in men and women in Western countries; the costs associated with this disease are substantial and place a large burden on society.The goal of therapy in patients with dyslipidaemia is to achieve target serum lipid levels (established by treatment guidelines) in an effort to reduce the risk of asymptomatic individuals developing CHD (primary prevention) or to slow or retard the progression of atherosclerosis in patients with established CHD (secondary prevention). A multifactorial approach including lifestyle modifications and, if necessary, pharmacological intervention is recommended.Simvastatin is a competitive and reversible inhibitor of the enzyme 3-hydroxy-3-methylglutaryl-coenzyme-A (HMG-CoA) reductase. It causes marked reductions in serum low density lipoprotein cholesterol (LDL-C) levels and reductions in serum triglyceride levels in patients with hypertriglyceridaemia. Simvastatin also increases serum high density lipoprotein cholesterol (HDL-C) levels and is the first HMG-CoA reductase inhibitor indicated for this use.The Scandinavian Simvastatin Survival Study (4S) established that simvastatin 20 to 40 mg/day reduces total mortality (by 30% at 5 years compared with placebo) in patients with CHD, mostly because of a reduction in cardiovascular mortality (42% reduction at 5 years). This reduction in mortality was maintained for at least 8 years in simvastatin-treated patients in 4S. As secondary prevention simvastatin is cost effective in men, women and diabetic patients with CHD as shown by data from 4S. Available evidence also indicates that simvastatin slows the progression of coronary atherosclerosis. In patients with diabetes and CHD, 5-years' treatment with simvastatin during 4S reduced the risk of coronary death and nonfatal myocardial infarction by 55% compared with a 32% reduction in nondiabetic patients with CHD. In high risk patients with CHD, other cardiovascular risk factors and dyslipidaemia, simvastatin 40 to 80 mg/day effectively reduced serum LDL-C and triglyceride levels and raised HDL-C levels.The most common adverse events associated with simvastatin in clinical trials of 5 to 10 years' duration were gastrointestinal upset and headache. These events were similar in incidence to that with placebo and did not necessitate a discontinuation of therapy. Asymptomatic elevations in hepatic transaminase levels and, rarely, myopathy have been described during simvastatin treatment.ConclusionsThe efficacy and tolerability of simvastatin at doses of up 80 mg/day are well established. Together with favourable effects on serum lipoprotein levels compared with related compounds and, more importantly, beneficial long term effects on morbidity and mortality in patients with CHD, simvastatin is firmly established as a first-line agent when cholesterol-altering pharmacotherapy is indicated for treatment of dyslipidaemia.

ISSN:1173-8790    

出版商:ADIS    

年代:2000

数据来源: ADIS