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Sleep medicine is a relatively new specialty in the medical community. The practice of sleep medicine in Saudi Arabia (KSA) began in the mid to late nineties. Since its inception, the specialty has grown, and the number of specialists has increased. Nevertheless, sleep medicine is still underdeveloped in the KSA, particularly in the areas of clinical service, education, training and research. Based on available data, it appears that sleep disorders are prevalent among Saudis, and the demand for sleep medicine service is expected to rise significantly in the near future. A number of obstacles have been defined that hinder the progress of the specialty, including a lack of trained technicians, specialists and funding. Awareness about sleep disorders and their serious consequences is low among health care workers, health care authorities, insurance companies and the general public. A major challenge for the future is penetrating the educational system at all levels to demonstrate the high prevalence and serious consequences of sleep disorders. To attain adequate numbers of staff and facilities, the education and training of health care professionals at the level of sleep medicine specialists and sleep technologists is another important challenge that faces the specialty. This review discusses the current position of sleep medicine as a specialty in the KSA and the expected challenges of the future. In addition, it will guide clinicians interested in setting up new sleep medicine services in the KSA or other developing countries through the potential obstacles that may face them in this endeavor.

Background

Sleepiness is a significant problem among residents due to chronic sleep deprivation. Recent studies have highlighted medical errors due to resident sleep deprivation. We hypothesized residents routinely use pharmacologic sleep aids to manage their sleep deprivation and reduce sleepiness.

Methods

A web-based survey of US allopathic Emergency Medicine (EM) residents was conducted during September 2004. All EM residency program directors were asked to invite their residents to participate. E-mail with reminders was used to solicit participation. Direct questions about use of alcohol and medications to facilitate sleep, and questions requesting details of sleep aids were included.

Results

Of 3,971 EM residents, 602 (16%) replied to the survey. Respondents were 71% male, 78% white, and mean (SD) age was 30 (4) years, which is similar to the entire EM resident population reported by the ACGME. There were 32% 1st year, 32% 2nd year, 28% 3rd year, and 8% 4th year residents. The Epworth Sleepiness Scale (ESS) showed 38% of residents were excessively sleepy (ESS 11–16) and 7% were severely sleepy (ESS>16). 46% (95 CI 42%–50%) regularly used alcohol, antihistamines, sleep adjuncts, benzodiazepines, or muscle relaxants to help them fall or stay asleep. Study limitations include low response and self-report.

Conclusion

Even with a low response rate, sleep aid use among EM residents may be common. How this affects performance, well-being, and health remains unknown.

Current strategies for drug discovery have reached a bottleneck where the paradigm is generally “one gene, one drug, one disease.” However, using holistic and systemic views, network pharmacology may be the next paradigm in drug discovery. Based on network pharmacology, a combinational drug with two or more compounds could offer beneficial synergistic effects for complex diseases. Interestingly, traditional chinese medicine (TCM) has been practicing holistic views for over 3,000 years, and its distinguished feature is using herbal formulas to treat diseases based on the unique pattern classification. Though TCM herbal formulas are acknowledged as a great source for drug discovery, no drug discovery strategies compatible with the multidimensional complexities of TCM herbal formulas have been developed. In this paper, we highlighted some novel paradigms in TCM-based network pharmacology and new drug discovery. A multiple compound drug can be discovered by merging herbal formula-based pharmacological networks with TCM pattern-based disease molecular networks. Herbal formulas would be a source for multiple compound drug candidates, and the TCM pattern in the disease would be an indication for a new drug.

Family physicians are naturally concerned with the work effects or causes of their patients' health problems. As occupational risk factors have become better understood, however, a new specialty of occupational medicine has been recognized by the Royal College of Physicians and Surgeons in 1984, two years after the Canadian Board of Occupational Medicine started its own certification. Occupational physicians are available to act as an extension of the family doctor's care and can provide trustworthy medical resources in the workplace. The family physician should be aware of some of the games poorly trained or ill-informed personnel managers may play in the workplace if they have no medical consultant to rely on. New human rights legislation has given more opportunities to rehabilitate workers back to their jobs, and occupational physicians and family physicians can achieve a great deal in co-operation as a result.

Background

Multicomponent therapeutics offer bright prospects for the control of complex diseases in a synergistic manner. However, finding ways to screen the synergistic combinations from numerous pharmacological agents is still an ongoing challenge.

Results

In this work, we proposed for the first time a “network target”-based paradigm instead of the traditional "single target"-based paradigm for virtual screening and established an algorithm termed NIMS (Network target-based Identification of Multicomponent Synergy) to prioritize synergistic agent combinations in a high throughput way. NIMS treats a disease-specific biological network as a therapeutic target and assumes that the relationship among agents can be transferred to network interactions among the molecular level entities (targets or responsive gene products) of agents. Then, two parameters in NIMS, Topology Score and Agent Score, are created to evaluate the synergistic relationship between each given agent combinations. Taking the empirical multicomponent system traditional Chinese medicine (TCM) as an illustrative case, we applied NIMS to prioritize synergistic agent pairs from 63 agents on a pathological process instanced by angiogenesis. The NIMS outputs can not only recover five known synergistic agent pairs, but also obtain experimental verification for synergistic candidates combined with, for example, a herbal ingredient Sinomenine, which outperforms the meet/min method. The robustness of NIMS was also showed regarding the background networks, agent genes and topological parameters, respectively. Finally, we characterized the potential mechanisms of multicomponent synergy from a network target perspective.

Conclusions

NIMS is a first-step computational approach towards identification of synergistic drug combinations at the molecular level. The network target-based approaches may adjust current virtual screen mode and provide a systematic paradigm for facilitating the development of multicomponent therapeutics as well as the modernization of TCM.

Sleep problems are highly prevalent in cancer patients undergoing chemotherapy. This article reviews existing evidence on etiology, associated symptoms, and management of sleep problems associated with chemotherapy treatment during cancer. It also discusses limitations and methodological issues of current research. The existing literature suggests that subjectively and objectively measured sleep problems are the highest during the chemotherapy phase of cancer treatments. A possibly involved mechanism reviewed here includes the rise in the circulating proinflammatory cytokines and the associated disruption in circadian rhythm in the development and maintenance of sleep dysregulation in cancer patients during chemotherapy. Various approaches to the management of sleep problems during chemotherapy are discussed with behavioral intervention showing promise. Exercise, including yoga, also appear to be effective and safe at least for subclinical levels of sleep problems in cancer patients. Numerous challenges are associated with conducting research on sleep in cancer patients during chemotherapy treatments and they are discussed in this review. Dedicated intervention trials, methodologically sound and sufficiently powered, are needed to test current and novel treatments of sleep problems in cancer patients receiving chemotherapy. Optimal management of sleep problems in patients with cancer receiving treatment may improve not only the well-being of patients, but also their prognosis given the emerging experimental and clinical evidence suggesting that sleep disruption might adversely impact treatment and recovery from cancer.

As presently understood, evidence based medicine aims to advance practice from its traditional unverifiable mix of art and science to rational use of measurable inputs and outputs. In practice, however, its advocates accept uncritically a desocialised definition of science, assume that major clinical decisions are taken at the level of secondary specialist rather than primary generalist care, and ignore the multiple nature of most clinical problems, as well as the complexity of social problems within which clinical problems arise and have to be solved. These reductionist assumptions derive from the use of evidence based medicine as a tool for managed care in a transactional model for consultations. If these assumptions persist, they will strengthen reification of disease and promote the episodic output of process regardless of health outcome. We need to work within a different paradigm based on development of patients as co-producers rather than consumers, promoting continuing output of health gain through shared decisions using all relevant evidence, within a broader, socialised definition of science. Adoption of this model would require a major social and cultural shift for health professionals. This shift has already begun, promoted by changes in public attitudes to professional authority, changes in the relation of professionals to managers, and pressures for improved effectiveness and efficiency which, contrary to received wisdom, seem more likely to endorse cooperative than transactional clinical production. Progress on these lines is resisted by rapidly growing and extremely powerful economic and political interests. Health professionals and strategists have yet to recognise and admit the existence of this choice.

ABSTRACT

Personalized medicine promises to represent a transformation in clinical care that will be ushered in by the unprecedented growth and development in the field of human genetics. Further examination of the scientific foundations of this new hope reveals a great number of challenges that lie ahead. While basic science research feverishly races to produce solutions, we continue to wait for the translation of deliverables. Products that have and will come to market may leave our clinical communities and systems exposed and unprepared. At each step, from basic science research to infrastructure development, a great deal of creativity and investment are required before the arsenal of more personalized tools can be assimilated into our current models of health care. This commentary seeks to share perspectives on the current status of personalized medicine from the vantage point of several potential investors, and integrate them into a common set of goals and understanding. We conclude that the stylized model of personalized medicine is more akin to a marketing tool than a literal prediction of the future.

Introduction:

The relationship between attention-deficit/hyperactivity disorder (ADHD) and sleep is a complex one which poses many challenges in clinical practice.

Methods:

Studies of sleep disturbances in children with academic and behavioral problems have underscored the role that primary sleep disorders play in the clinical presentation of symptoms of inattention and behavioral dysregulation. In addition, recent research has shed further light on the prevalence, type, risk factors for, and impact of sleep disturbances in children with ADHD.

Results:

The following discussion of the multi-level and bi-directional relationships among sleep, neurobehavioral functioning, and the clinical syndrome of ADHD synthesizes current knowledge about the interaction of sleep and attention/arousal in these children.

Conclusion:

Guidelines are provided, outlining a clinical approach to evaluation and management of children with ADHD and sleep problems.

Clinical studies often use data dictionaries with controlled sets of terms to facilitate data collection, limited interoperability and sharing at a local site. Multi-center retrospective clinical studies require that these data dictionaries, originating from individual participating centers, be harmonized in preparation for the integration of the corresponding clinical research data. Domain ontologies are often used to facilitate multi-center data integration by modeling terms from data dictionaries in a logic-based language, but interoperability among domain ontologies (using automated techniques) is an unresolved issue. Although many upper-level reference ontologies have been proposed to address this challenge, our experience in integrating multi-center sleep medicine data highlights the need for an upper level ontology that models a common set of terms at multiple-levels of abstraction, which is not covered by the existing upper-level ontologies. We introduce a methodology underpinned by a Minimal Domain of Discourse (MiDas) algorithm to automatically extract a minimal common domain of discourse (upper-domain ontology) from an existing domain ontology. Using the Multi-Modality, Multi-Resource Environment for Physiological and Clinical Research (Physio-MIMI) multi-center project in sleep medicine as a use case, we demonstrate the use of MiDas in extracting a minimal domain of discourse for sleep medicine, from Physio-MIMI’s Sleep Domain Ontology (SDO). We then extend the resulting domain of discourse with terms from the data dictionary of the Sleep Heart and Health Study (SHHS) to validate MiDas. To illustrate the wider applicability of MiDas, we automatically extract the respective domains of discourse from 6 sample domain ontologies from the National Center for Biomedical Ontologies (NCBO) and the OBO Foundry.

As in other areas of medicine, the specialty of critical care medicine, which has made important contributions in the pathophysiology of critical illness, is facing challenges that must be recognized and addressed in the current century. In this review, we argue that the skill set required to adequately treat critically ill patients will also require knowledge of molecular biology for better diagnosis and treatment. The foundations of molecular biology and genetics are essential for the understanding of the mechanisms of disease. Incorporating molecular biology techniques in the research arsenal of the intensivist will provide the opportunity to dissect out and define the reversible and irreversible intracellular processes giving rise to the major causes of mortality in intensive care units. Two historical paradigms, the cardiopulmonary resuscitation and polymerase chain reaction, summarize how critical care medicine began, and how it could mature in the years to come.

Background

In 1992, Evidence-Based Medicine advocates proclaimed a "new paradigm", in which evidence from health care research is the best basis for decisions for individual patients and health systems. Hailed in New York Times Magazine in 2001 as one of the most influential ideas of the year, this approach was initially and provocatively pitted against the traditional teaching of medicine, in which the key elements of knowing for clinical purposes are understanding of basic pathophysiologic mechanisms of disease coupled with clinical experience. This paper reviews the origins, aspirations, philosophical limitations, and practical challenges of evidence-based medicine.

Discussion

EBM has long since evolved beyond its initial (mis)conception, that EBM might replace traditional medicine. EBM is now attempting to augment rather than replace individual clinical experience and understanding of basic disease mechanisms. EBM must continue to evolve, however, to address a number of issues including scientific underpinnings, moral stance and consequences, and practical matters of dissemination and application. For example, accelerating the transfer of research findings into clinical practice is often based on incomplete evidence from selected groups of people, who experience a marginal benefit from an expensive technology, raising issues of the generalizability of the findings, and increasing problems with how many and who can afford the new innovations in care.

Summary

Advocates of evidence-based medicine want clinicians and consumers to pay attention to the best findings from health care research that are both valid and ready for clinical application. Much remains to be done to reach this goal.

Cellular hypoxia is a fundamental mechanism of injury in the critically ill. The study of human responses to hypoxia occurring as a consequence of hypobaria defines the fields of high-altitude medicine and physiology. A new paradigm suggests that the physiological and pathophysiological responses to extreme environmental challenges (for example, hypobaric hypoxia, hyper-baria, microgravity, cold, heat) may be similar to responses seen in critical illness. The present review explores the idea that human responses to the hypoxia of high altitude may be used as a means of exploring elements of the pathophysiology of critical illness.

Advances in genome technology and other fruits of the Human Genome Project are playing a growing role in the delivery of health care. With the development of new technologies and opportunities for large-scale analysis of the genome, transcriptome, proteome and metabolome, the genome sciences are poised to have a profound impact on clinical medicine. Cancer prognostics will be among the first major test cases for a genomic medicine paradigm, given that all cancer is caused by genomic instability, and microarrays allow assessment of patients' entire expressed genomes. Analysis of breast cancer patients' expression patterns can already be highly correlated with recurrence risks. By integrating clinical data with gene expression profiles, imaging, metabolomic profiles and proteomic data, the prospect for developing truly individualized care becomes ever more real. Notwithstanding these promises, daunting challenges remain for genomic medicine. Success will require planning robust prospective trials, analysing health care economic and outcome data, assuaging insurance and privacy concerns, developing health delivery models that are commercially viable and scaling up to meet the needs of the whole population.

This is the final instalment in a series of three articles by the Terry Fox Research Institute about its pan-Canadian dialogue series, Cancer: Let’s Get Personal, a public research and outreach project undertaken in 2010. The dialogues served to launch a national and continuing conversation on personalized medicine with the medical and scientific communities and the public, including cancer survivors, patients, and caregivers. Participants at the Ontario dialogue, held in Toronto, October 18, 2010, discussed the challenges that Canadians and the health care system face as they move forward on a pathway created by advanced science and technology that will phenomenally transform cancer care and treatment. The one-size-fits-all approach to treating cancer patients is being rapidly eclipsed by an approach that treats patients and their tumours as individually as possible. As a result, a paradigm shift is occurring both in the laboratory and in the clinic, creating new approaches to conducting research and delivering treatment and care that place each and every patient—and tumour—at the centre of treatment. New approaches and practices in health care are necessary to ensure successful uptake and implementation of these advances for the benefit of all Canadians.

Participating partners and supporters of the Ontario dialogue were the Ontario Institute for Cancer Research and the University Health Network.

Treatment of cardiovascular disease, albeit under the auspices of other clinical descriptors to those described in western biomedicine, has a long history in China. Chinese Medicine (CM) is guided by unique philosophical underpinnings and theories. There are differences in how the heart is conceptualised traditionally in CM compared to biomedicine. This paper focusses on how hypercholesterolemia is understood from within the Chinese medical paradigm, including its aetiology, pathogenesis, and treatment. A brief overview of the key characteristics and theories of CM is given to provide context. Modern science has demonstrated that many Chinese herbs have cholesterol-lowering properties. Examples of research into individual herbs and medicinal formulae, combinations of herbs are presented. At a more sophisticated level, some researchers are challenging some of the very assumptions upon which CM is based, including applicability of CM theory to modern clinical entities such as hypercholesterolemia, and are seeking intersections of knowledge between CM and biomedicine that may extend CM theory.

Today’s medicine is in the midst of an undeniable crisis. Calls to reform healthcare are in the forefront of economic and political discussions worldwide. Economic pressures reduce the amount of time physicians can spend with patients contributing to burnout among medical staff and endangering the patient iatrogenically. Politicians are getting involved as the public is calling for more affordable healthcare. A new paradigm must be embraced in order to address all aspects of this dilemma. It is clear that science and technology have resulted in vastly improved understanding, diagnosis, and treatment of disease, but the emphasis on science and technology to the exclusion of other elements of healing has also served to limit the development of a model that humanizes healthcare. The healing of a patient must include more than the biology and chemistry of their physical body; by necessity, it must include the mental, emotional and spiritual aspects. Because of these challenges, the development of an integral healthcare system that is rooted in appropriate regulation and supported by rigorous scientific evidence is the direction that many models of integrative healthcare are moving towards in the 21st century.

Abstract

Although personalized medicine appears to be a truism, medical doctors are still generally trained in an old-fashioned manner with a focus on reactive treatment. The aim of this paper is to emphasize the evolution of life sciences into a more predictive science, where the development of quantitative models is starting to take place. Personalized medicine is a consequence of such paradigm shift. To keep up with the change, the various actors within the health system must be trained in a completely different manner, focusing on the ability to work as part of a multidisciplinary team that includes medical doctors, nurses, engineers in medical imaging, and others who collect information from patients. In addition, these teams should include modelers that are able to integrate the flood of data into predictive and quantitative models. The challenge of implementing new training methods in line with the shift is a major bottleneck to the emergence and success of personalized medicine in our societies.

Evolutionary medicine is the application of evolution theory to understanding health and disease. It provides a complementary scientific approach to the present mechanistic explanations that dominate medical science, and particularly medical education. The chronic multifactorial disease of atherosclerosis clearly illustrates the Darwinian paradigm. Recent research, combining the effects of genes and environment, has provided surprising clues to the pathogenesis of this major public health problem. This example makes a strong case for recognizing evolution biology as a basic science for medicine.

Background

This study explored consumer perceptions of complementary and alternative medicine (CAM) and relationships with CAM and conventional medicine practitioners.

A problem detection study (PDS) was used. The qualitative component to develop the questionnaire used a CAM consumer focus group to explore conventional and CAM paradigms in healthcare. 32 key issues, seven main themes, informed the questionnaire (the quantitative PDS component - 36 statements explored using five-point Likert scales.)

Results

Of 300 questionnaires distributed (Brisbane, Australia), 83 consumers responded. Results indicated that consumers felt empowered by using CAM and they reported positive relationships with CAM practitioners. The perception was that CAM were used most effectively as long-term therapy (63% agreement), but that conventional medicines would be the best choice for emergency treatment (81% agreement). A majority (65%) reported that doctors appeared uncomfortable about consumers' visits to CAM practitioners. Most consumers (72%) believed that relationships with and between health practitioners could be enhanced by improved communication. It was agreed that information sharing between consumers and healthcare practitioners is important, and reported that "enough" information is shared between CAM practitioners and consumers. Consumers felt comfortable discussing their medicines with pharmacists, general practitioners and CAM practitioners, but felt most comfortable with their CAM practitioners.

Conclusions

This PDS has emphasized the perceived importance of open communication between consumers, CAM and conventional providers, and has exposed areas where CAM consumers perceive that issues exist across the CAM and conventional medicine paradigms. There is a lot of information which is perceived as not being shared at present and there are issues of discomfort and distrust which require resolution to develop concordant relationships in healthcare. Further research should be based on optimisation of information sharing, spanning both conventional and CAM fields of healthcare, due to both the relevance of concordance principles within CAM modalities and the widespread use of CAM by consumers.

The future of social medicine is based on 150 years of history and the rapidly evolving context within which medicine functions in modern societies. There are two views of social medicine. One is based on the vision of Guerin and, particularly, Virchow 150 years ago that: ”Doctors are the natural advocates of the poor, and social problems are largely within their jurisdiction.” The New York Academy of Medicine's Institute on Social Medicine 50 years ago reflected this broad view. Medicine, however, enamored of the biomedical paradigm and the advances in knowledge through biomedical research, largely abandoned this broad perspective, even as the knowledge about the social, behavioral, and environmental determinants of health was advancing rapidly. A second view of social medicine, and one that has influenced many in the past 30 years, was defined by McKeown and Lowe: ‘Social medicine is concerned with a body of knowledge and methods of obtaining knowledge appropriate to a discipline. This discipline may be said to comprise (a) epidemiology, and (b) the study of the medical needs of society, or in the contemporary short hand medical care.” Social medicine, in my view, includes not only the definition of McKeown and Lowe, but the broader context within which medicine fits in society. The context is changing. The social contract as defined by Bismarck and Beveridge has to be redefined. Just as the New York Academy of Medicine provided the vision of social medicine 50 years ago, the Academy has given us a new vision with the publication ofMedicine and Public Health: the Power of Collaboration in 1997. Authored by Dr. Roz Lasker, director of the Academy's Division of Public Health, the book identifies the key changes required by medicine and public health to advance the goals of medicine and public health for the benefit of both individual patients and the population as a whole. The book points the way for the future of social medicine by identifying not only what needs to be done, but also how to do it.

Problem-based learning is an innovative and challenging approach to medical education--innovative because it is a new way of using clinical material to help students learn, and challenging because it requires the medical teacher to use facilitating and supporting skills rather than didactic, directive ones. For the student, problem-based learning emphasises the application of knowledge and skills to the solution of problems rather than the recall of facts. It is an approach much favoured by curriculum planners in new and more progressive medical schools. This paper describes the educational basis of problem-based learning and gives an example of how it operates in undergraduate medical education.

The Committee to Study the Role of Medicine of the California Medical Education and Research Foundation (CMERF) is grateful to Dr. Watts for the following paper which served as the philosophical basis for the Committee's study and discussions. The Committee is also grateful to CMERF and to its president, James C. Doyle, for the encouragement and cooperation it has received in the course of its intensive study of a problem which is of great interest and concern to the medical profession of California.

Dr. Watts' background paper has served as a potent stimulus in directing the Committee's attention to the continuing dialogue between medicine and society, and in focussing on problems and issues which will be the subject of the Committee's Second Progress Report, excerpts from which are scheduled for publication in the next issue of California Medicine.

During the twentieth century there have been great advances in medicine in the area of science and technology. At the same time, there has been a trend back to a more natural, humanistic approach to counteract patients' feelings of alienation. Holistic medicine approaches the physical, emotional, spiritual, and social aspects of a person as they relate to health and disease. It emphasizes prevention; concern for the environment and the food we eat; patient responsibility; using illness as a creative force to teach people to change; the `physician, heal thyself' philosophy; and appropriate alternatives to orthodox medicine. Family medicine faces the challenge of integrating these humanistic concepts with science.

Chronic skin ulcer (CSU), including diabetic ulcers, venous ulcers, radiation ulcers, and pressure ulcers, remains a great challenge in the clinic. CSU seriously affects the quality of life of patients and requires long-term dedicated care, causing immense socioeconomic costs. CSU can cause the loss of the integrity of large portions of the skin, even leading to morbidity and mortality. Chinese doctors have used traditional Chinese medicine (TCM) for the treatment of CSU for many years and have accumulated much experience in clinical practice by combining systemic regulation and tropical treatment of CSU. Here, we discuss the classification and pathogenic process of CSU and strategies of TCM for the intervention of CSU, according to the theories of TCM. Particularly, we describe the potential intervenient strategies of the “qing-hua-bu” protocol with dynamic and combinational TCM therapies for different syndromes of CSU.