Вопрос № 992273 - Английский язык

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             The Dichotomy of Inpatient and Outpatient Internal Medicine
1. The hospital environment has transformed dramatically over the past few decades. In more recent times, emergency departments and critical care units have evolved to identify and manage critically ill patients, allowing them to survive formerly fatal diseases. There is increasing pressure to reduce the length of stay in the hospital and to manage complex disorders in the outpatient setting. This transition has been driven not only by efforts to reduce costs but also by the availability of new outpatient technologies, such as imaging and percutaneous infusion catheters for long-term antibiotics or nutrition, and by evidence that outcomes are often improved by minimizing inpatient hospitalization.
2. Hospitals now consist of multiple distinct levels of care, such as the emergency department, procedure rooms, overnight observation units, critical care units, and palliative care units, in addition to traditional medical beds. Clearly, one of the important challenges in internal medicine is to maintain continuity, of care and information flow during these transitions, which threaten the traditional one-to-one relationship between patient and physician.
3. In the current environment, teams of physicians, specialists, and other health care professionals have often replaced the personal interaction between doctor and patient. The patient can benefit greatly from effective collaboration among a number of health care professionals; however, it is the duty of the primary physician to provide cohesive guidance through an illness. In order to meet this challenge, the primary physician must be familiar with the techniques, skills, and objectives of specialist physicians and allied health professionals.
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             The Dichotomy of Inpatient and Outpatient Internal Medicine
1. The hospital environment has transformed dramatically over the past few decades. In more recent times, emergency departments and critical care units have evolved to identify and manage critically ill patients, allowing them to survive formerly fatal diseases. There is increasing pressure to reduce the length of stay in the hospital and to manage complex disorders in the outpatient setting. This transition has been driven not only by efforts to reduce costs but also by the availability of new outpatient technologies, such as imaging and percutaneous infusion catheters for long-term antibiotics or nutrition, and by evidence that outcomes are often improved by minimizing inpatient hospitalization.
2. Hospitals now consist of multiple distinct levels of care, such as the emergency department, procedure rooms, overnight observation units, critical care units, and palliative care units, in addition to traditional medical beds. Clearly, one of the important challenges in internal medicine is to maintain continuity, of care and information flow during these transitions, which threaten the traditional one-to-one relationship between patient and physician.
3. In the current environment, teams of physicians, specialists, and other health care professionals have often replaced the personal interaction between doctor and patient. The patient can benefit greatly from effective collaboration among a number of health care professionals; however, it is the duty of the primary physician to provide cohesive guidance through an illness. In order to meet this challenge, the primary physician must be familiar with the techniques, skills, and objectives of specialist physicians and allied health professionals.
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                                                  The Era of Genomics
1. In the spring of 2003, the complete sequencing of the human genome was announced, officially ushering in the genomic era. Today, gene expression profiles are being used to guide therapy and inform prognosis for a number of diseases; the use of genotyping is providing a new means to assess the risk of certain diseases as well as variation in response to a number of drugs; we are understanding better the role of certain genes in the causality of certain common conditions such as obesity and allergies. Despite these advances, we are still in the infancy of understanding and utilizing the complexities of genomics in the diagnosis, prevention, and treatment of disease.
2. Our task is still complicated nowadays by the fact that phenotypes are generally determined not by genes alone but by the interplay of genetic and environmental factors. Indeed, we have just begun to scratch the surface of possibilities that the era of genomics will provide to the practice of medicine.
3. The rapidity of these advances may seem overwhelming to the practicing physician. However, he or she has an important role to play in ensuring that these powerful technologies and sources of new information are applied with sensitivity and intelligence to the patient. Since genomics is such a rapidly evolving field, physicians and other health care professionals must continue to educate themselves so that they can apply this new knowledge to the benefit of their patients' health and well-being.
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What complicates the application of genomics nowadays?

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                                                     Cancer
1. Low- and middle-income countries accounted for 53% and 56%, respectively, of the 10 million cases and 7 million deaths due to cancer in 2000. By 2020, the total number of new cancer cases will rise by 29% in developed countries and by 73% in developing countries. Also by 2020, overall mortality from cancer will increase by 104%, and the increase will be fivefold higher in developing than in developed countries. "Western" lifestyle changes will be responsible for the increased incidence of cancers of the breast, colon, and prostate, but historic realities, sociocultural and behavioral factors, genetics, and poverty itself will also have a profound impact on cancer-related mortality and morbidity.
2. While infectious causes are responsible for <10% of cancers in developed countries, they account for 25% of all malignancies in low- and middle-income countries. Infectious causes of cancer such as human papillomavirus (cervical cancer), hepatitis B virus (liver cancer), and Helicobacter pylori (stomach cancer) will continue to have a much larger impact in developing countries.
3. Environmental and dietary factors, such as indoor air pollution and high-salt diets, also help account for increased rates of certain cancers (e.g., lung and stomach cancers). Tobacco use (both smoking and chewing) is the most important source of increased mortality from lung and oral cancers. In contrast to decreasing tobacco use in many developed countries, the number of smokers is growing in developing countries, especially among women and young people.
4. For many reasons, outcomes of malignancies are far worse in developing countries than in developed nations. Health systems in poor countries simply are not capable of early detection; 80% of patients already have incurable malignancies at diagnosis. Treatment of cancers is available for only a very small number of mostly wealthy citizens in the majority of poor countries, and, even when treatment is available, the range and quality of services are often substandard.
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                                           Medicine on the Internet
1. On the whole, the Internet has had a very positive effect on the practice of medicine; a wide range of information is available to physicians and patients through personal computers almost instantaneously at any time and from anywhere in the world. This medium holds enormous potential for delivering up-to-date information, practice guidelines, journal contents, textbooks, and direct communications with other physicians and specialists, thereby expanding the depth and breadth of information available to the physician about the diagnosis and care of patients.
2. Most medical journals are now accessible online, providing rapid and comprehensive sources of information. This medium also serves to lessen the information gap felt by physicians and health care providers in remote areas of the world by bringing them into direct and instant contact with the latest developments in medical care.
3. Patients, too, are turning to the Internet in increasing numbers to acquire information about their illnesses and therapies and to join Internet-based support groups. Physicians are increasingly faced with the prospect of dealing with patients who arrive with sophisticated information about their illness. In this regard, physicians are challenged in a positive way to keep themselves abreast of the latest relevant information while serving as an «editor» for the patients as they navigate through this seemingly endless source of information.
4. A critically important caveat is that virtually anything can be published on the Internet, with easy circumvention of the peer-review process that is an essential feature of quality publications. Physicians or patients who search the Internet for medical information must be aware of this danger. Notwithstanding this limitation, appropriate use of the Internet is revolutionizing information access for physicians and patients and in this regard is a great benefit that was not available to our predecessors.
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                                        Role of Genes versus Environment
1. Inheritance is usually not Mendelian, however, and it is difficult to distinguish the role of genes and environmental factors. Adoptees more closely resemble their biologic than adoptive parents with respect to obesity, providing strong support for genetic influences. Likewise, identical twins have very similar BMIs whether reared together or apart, and their BMIs are much more strongly correlated than those of dizygotic twins. These genetic effects appear to relate to both energy intake and expenditure.
2. Whatever the role of genes, it is clear that the environment plays a key role in obesity, as evidenced by the fact that famine prevents obesity in even the most obesity-prone individual. In addition, the recent increase in the prevalence of obesity in the United States is far too rapid to be due to changes in the gene pool. Undoubtedly, genes influence the susceptibility to obesity in response to specific diets and availability of nutrition. Additional environmental factors may contribute to the increasing obesity prevalence. Both epidemiologic correlations and experimental data suggest that sleep deprivation leads to increased obesity.
3. Cultural factors are also important – these relate to both availability and composition of the diet and to changes in the level of physical activity. In industrial societies, obesity is more common among poor women, whereas in underdeveloped countries, wealthier women are more often obese. In children, obesity correlates to some degree with time spent watching television. Although the role of diet composition in obesity continues to generate controversy, it appears that high-fat diets may promote obesity, especially when combined with diets rich in simple (as opposed to complex) carbohydrates.
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