Read 1
What causes hypertension?
Blood pressure refers to the pressure acting on the wall of blood vessels when blood flows in them. The heart, like a water pump, sends blood to various arteries and blood vessels. When hypertension or hypertension occurs, the heart has to increase the load to transport blood to all parts of the body, thus causing arteriosclerosis or atherosclerosis, and even developing into heart failure. Therefore, high blood pressure is dangerous.
As many as 95% of the recorded cases of hypertension in the United States, the cause of hypertension cannot be determined. This hypertensive disease with unknown etiology is called essential hypertension. Although essential hypertension is still mysterious, its occurrence is related to some risk factors. Hypertension usually runs in the family, and men are more likely to suffer from hypertension than women. In addition, age and race can also affect the occurrence of hypertension. In the United States, blacks are twice as likely to have high blood pressure as whites. However, whether black or white, when they reach the age of about 44, the difference in their chances of developing hypertension will begin to narrow. Black women over 65 have the highest incidence of hypertension.
Essential hypertension is greatly influenced by diet and living habits. The relationship between salt intake and hypertension is particularly obvious. Most hypertensive patients are "salt allergic", which means that once the salt intake slightly exceeds the minimum requirement of the body, their blood pressure will rise immediately. Other factors such as obesity, diabetes, stress, insufficient intake of potassium, calcium and magnesium, lack of physical activity and long-term heavy drinking will also increase the incidence of essential hypertension.
Hypertension with definite etiology is called secondary hypertension. Among many known causes, kidney disease is the most important factor leading to secondary hypertension. In addition, tumors or other abnormalities cause the adrenal glands (small glands scattered on the surface of the kidney) to secrete too many hormones that will raise blood pressure, which will also cause hypertension.
Reading 2
How did the requirements of euthanasia change before and after the implementation of the Dutch euthanasia act?
In 2002, the Netherlands passed the Euthanasia Act, which legalized euthanasia and the practice of doctors assisting patients to end their lives. Euthanasia has existed in Holland for a long time. After the implementation of this bill, euthanasia is more transparent and provides legal protection for doctors involved in assisted euthanasia. But the premise is that doctors must act in strict accordance with legal procedures.
However, an interesting question still exists, that is, does the implementation of the euthanasia bill affect the number of people who ask for euthanasia, or change the underlying reasons why people ask for euthanasia? These questions and the possible differences caused by gender have been answered in this study. This study compares people's requirements for euthanasia five years before and five years after the implementation of the bill, using the data of the Dutch sentinel practice network.
In the five years before the implementation of the bill, the number of people asking for euthanasia showed a downward trend, and after the implementation of the bill for five years, the number of people asking for euthanasia remained stable. Before and after the implementation of the Act, there was not much difference in the average annual total incidence of euthanasia. The situation in the first five years and the last five years is 3.110 000 and 2.8/ 10 000 respectively. However, men and women have different demands for euthanasia. The average number of men asking for euthanasia has dropped a lot, from 3.7/ 10 000 to 2.6/ 10 000 (see table 1, p value is 0.008). Although the average number of women asking for euthanasia has not increased significantly, it has also increased from
2.6/ 10 000 increased to 3.110 000.
Before and after the implementation of the bill, cancer was the main disease that led patients to ask for euthanasia. In terms of ten-year investigation dimension, the average incidence of male patients' death is
79% (the fluctuation range is between 69% and 89%), and the average incidence of euthanasia in female patients is 73% (wave
The dynamic range is between 65-8 1%), where the p value is 0.07. However, there is no significant difference in the average incidence of euthanasia between men and women from the five-year investigation time alone.
The relevant data of "request" comes from 10 000 patient's euthanasia request probability; Other data come from the average percentage of patients with certain diseases or patients who express their wish to be euthanized and give specific reasons; P value is a parameter to measure significance in systematics. The smaller the p value, the more significant the result.
Pain is the main reason for patients to ask for euthanasia, but unlike before the implementation of the bill, since the implementation of the bill, the overall situation of asking for euthanasia due to pain has declined. This is mainly related to the fact that fewer and fewer women will choose euthanasia because of pain (P value is 0. 1). The probability of choosing euthanasia for pain before and after the implementation of the bill is 27% and 22%, respectively, and there is not much difference.
After the implementation of the Euthanasia Act in 2002, the number of patients who chose euthanasia because of unbearable torture increased. Although the number of patients who choose euthanasia because of dyspnea is not obvious, it is also on the rise. Like despair and pain, there is no significant difference in the average probability of choosing euthanasia because of unbearable torture and dyspnea before and after the implementation of the bill.
In contrast, the number of patients who choose euthanasia because of loss of dignity is decreasing year by year. Especially for female patients, when considering euthanasia, the loss of dignity becomes a less important factor. Generally speaking, the average probability of choosing euthanasia due to loss of dignity decreased from 18% before the implementation of the bill to10% after the implementation of the bill (P value is 0.04). Before the implementation of the bill, 17% of female patients will choose euthanasia because they lose their dignity. After the implementation of the bill, its percentage dropped to 6%( P value was 0.02). Under the same conditions, the percentage of male patients was 20% and15% respectively (P value was 0.6).
One of the main findings of this study is that the Euthanasia Act implemented in 2002 did not lead to a sharp increase in the number of people who requested euthanasia. As early as a study before the Euthanasia Act came into effect in 2002, Ma Kai published a report. The results showed that the number of people asking for euthanasia in the Netherlands increased from 1977 to 1995 year by year, but it has remained stable since then. This study shows that the number of people asking for euthanasia has remained the same since 2002. It is worth noting that the euthanasia bill came into effect after extensive discussions and reports in political circles and the media, so the significance of this bill is more to formalize the existing euthanasia behavior in the Netherlands than to become a turning point in changing people's attitude towards euthanasia.
In the whole ten-year investigation, cancer has always been the most important factor leading people to choose euthanasia. Cardiovascular disease seems to be a secondary factor, and chronic obstructive pulmonary disease is increasingly making people choose euthanasia. This change may be related to the morbidity and mortality of these two diseases in recent years.
Pain is an important cause of euthanasia. The author reported earlier that applying for euthanasia registration at an early stage (
1977 rpm 1987) 50% patients asked for euthanasia because of pain. But this proportion gradually decreased to 25% in the next decade.
This is probably related to the improvement of palliative care and professional pain management. Even though the influence of pain on patients' request for euthanasia has decreased in recent years, this study shows that the pain factor remains at 25%, and its percentage has not changed much before and after the implementation of the bill. As for why the percentage of pain factors has decreased in recent years, it is probably related to the increasing use of continuous deep sedation therapy for dying patients in the Netherlands. This therapy effectively relieves the pain and anxiety of patients and improves their breathing difficulties. This statement is supported by relevant research results: the utilization rate of continuous deep sedation therapy in the Netherlands increased from 5.6% to 5,438+0 in 2006 to 7. 1% in 2005, and most patients received this therapy through family doctors. In addition, the Dutch outpost found that palliative sedation therapy was not used much in recent years.
Unbearable pain is listed as a single item in the current investigation and study. However, it is actually a general term with general nature. Just like the word "despair", it contains many factors that lead patients to ask for euthanasia. It should be pointed out that in the Dutch euthanasia bill, patients suffer unbearable pain, which is the key factor to allow euthanasia in the bill. In this study, there is no significant difference in the degree of unbearable pain before and after the implementation of the bill. However, after the implementation of the bill in 2002, it can be observed that its proportion has increased, which may be related to the more use of this term by family doctors in order to meet the requirements of the bill. The factors of despair and unbearable pain are similar, so it is not surprising that the trends of the two are generally the same.
Ten years' investigation shows that the loss of dignity is becoming less and less important as a factor affecting patients' request for euthanasia, especially for female patients. Previous studies show that for terminally ill patients, their main concern is the loss of dignity, which urges medical staff to further improve palliative care and strive to help patients achieve a safe and dignified death. In the Netherlands, information therapy has been greatly improved in the past decade, which is mainly due to the insufficient efforts of the palliative care broadcasting network for terminally ill patients. Nowadays, more and more guidelines on palliative care are introduced and applied to hospitals, nursing homes, hospices and doctors, which may be an important reason why the improvement of palliative care constitutes why the loss of dignity has become less and less considered by patients when choosing euthanasia.
Reading 3
Policy issues related to hospice care
Nowadays, hospice care has become the focus of public controversy. On the topic of life dignity, people are divided into two groups, conservative and liberal, and put forward opposing views. In the past 30 years, with the continuous improvement of clinical science, bioethics and legal norms, hospice care has also made great progress, but the pace of relevant policy reform is still slow. The deep-rooted financial policy of medical care is one of the main constraints. In addition, due to different political views and religious beliefs, people can't find a unified solution to solve the problem of which medical care is correct or most suitable for terminally ill patients, which is also an important aspect that restricts policy reform.
The contradiction between the traditional drug treatment idea centered on rehabilitation and the real concern for the psychological needs of the elderly is an important factor restricting the development of hospice care. In modern America, 70% of patients die of chronic diseases, which means that the health of patients can be predicted to get worse. However, when treating these patients, many hospitals in the United States still use first-aid drugs by default. Hospitals treat elderly patients with chronic diseases through emergency care, which sometimes leads to differences between clinicians, or between patients' families and hospitals in deciding which nursing scheme is more suitable for patients.
In addition, although palliative care has developed rapidly, there are still a large number of hospitals that have not adopted this approach. The American Hospital Association found that only about 30% of about 4,000 hospitals were suitable for palliative care, and made a plan for palliative care.
Even if the hospital can provide hospice care as opposed to rescue treatment, whether it can provide high-quality hospice care for dying patients depends on the clinicians themselves. Clinicians are worried that using too many sedatives or anesthetics will lead to addiction, worrying about communicating the bad news of their illness with patients, lacking confidence in handling the death process of patients, insufficient training in controlling patients' symptoms, and adopting defensive medical care in high-end care for critically ill patients, which will hinder doctors from providing high-quality hospice care for dying patients. The national hospice care medicine and nursing training program has made great contributions to improving the related abilities of clinicians. However, hospice care-related courses and hospice care physician qualification examination are only exceptions, and have not formed a routine.
Although 90% of Americans claim to prefer to die at home, only a quarter of them can get it. The reality of modern American society is that, influenced by independent mainstream values, most people live alone or find a companion when they are old. Family members are often away, and children are unlikely to live near their elderly parents or relatives as in the past.
Although more and more people receive hospice care in hospice care, it often requires doctors and patients to give up treatment, so the time to transfer to hospice care is often delayed. Family members, usually the patients themselves, generally refuse to give up their ideas. After all, they all know what it means to transfer. In the diagnosis of non-cancer, although the average time of dying patients in hospice care in 2006 was 265,438+0 days, which was one-third of the treatment time of other diseases, the characteristic of most disease diagnoses was that they could not predict the remaining life time of patients, especially when they were transferred to hospice care seven days before their death. Obviously, only seven days is not enough for hospice institutions to provide good hospice care for patients.
Although it has been publicized to the public for decades, the US federal government's "Patient Self-determination Act" came into effect on 199 1, which requires hospitals to provide patients with a living will form when they are admitted to hospital, so that patients can decide what kind of medical care they want or don't want when incurable injuries end or die, in a healthy or conscious way. However, people who follow the requirements in different regions are different, and the situation is not ideal. Sometimes, although patients explain in advance, the care they require is often not specific enough, or it is not available when needed. Family members mentioned in the will documents often cannot represent the true wishes of patients. Another problem is that many states in the United States have a narrow definition of "family", and same-sex couples or lifelong friends are excluded from the category of "family", so they cannot have a legal social status representing patients' wishes.
Who will pay for hospice care? Generally speaking, the medical insurance plan pays about two-thirds of the medical expenses of dying patients, the medical assistance plan pays 15%, and the rest is paid by private insurance and individuals. However, the relevant payment and reimbursement regulations and arrangements of the medical insurance system have created various financial incentives for high emergency services. In addition, medical insurance does not pay for supporting services such as family health care, nor does it support continuous medical care for different doctors in different medical environments.
Family members of patients who choose hospice care often have to bear incalculable economic costs. In order to pay the high transportation costs of drugs and medical equipment, nursing fees, special beds and other medical equipment, they often spend all their savings, lose their jobs, go bankrupt and have to apply for mortgage loans again.
Nowadays, sanatoriums are increasingly becoming places for hospice care. However, in the past, 30% patients in nursing homes were transferred to hospitals a few days before their deaths, even though nursing homes could handle most patients' physical conditions well. For terminally ill patients, sanatorium should be the place that can provide them with the most ideal hospice care service. Unfortunately, however, many laws and regulations prevent nursing homes from playing this role. For example, 1987 promulgated and implemented many budget balance bills, which shifted the focus of nursing homes from nursing to rehabilitation treatment, and inadvertently ignored the real needs of terminally ill patients.
In view of the fact that palliative care is usually used in the late stage of diseases, it is necessary to change the treatment methods of chronic diseases in the past and integrate long-term good care, palliative care and hospice care into a close chain. In order to achieve this goal, we should first fundamentally change the financing methods of palliative care and hospice care. The medical insurance plan only pays the emergency expenses of the hospital, regardless of the family medical expenses. However, the hospice insurance subsidy plan stipulates that patients can only be transferred to hospice care if both patients and doctors decide to give up treatment, which delays the time for patients to receive hospice care and is not conducive to hospice care patients to obtain good hospice care. Therefore, reform is needed. In addition, we should give full play to the role of living wills, mobilize more patients to preset doctor's orders, and at the same time relax the scope of "family members". The intermediary service of mediation and dispute resolution should also be standardized and institutionalized step by step in order to try to solve the problems and disputes related to hospice care. When the quality nursing movement develops deeply and the health system rises to a certain height, the pain treatment and other factors related to palliative care are the next issues to be considered.
Reading 4
Causality between genes and obesity
Obesity is a chronic metabolic disease caused by many factors, which is characterized by excessive fat accumulation in the body. Obesity represents a state of endocrine metabolism and is very important to public health. At the same time, obesity can easily lead to a series of diseases, such as type 2 diabetes, cardiovascular diseases, metabolic syndrome and some kinds of cancer. In addition to known environmental factors, many research results show that genes are also an important cause of obesity. In this regard, the data of comprehensive analysis show that about 50%~70% of the changes in body mass index are related to the genes carried by the subjects. Based on this, the interaction between obesity-prone genes and environment is considered to be the main cause of obesity. Only 5% of obesity is caused by a single genetic change or a syndrome with low incidence.
Obesity is a complex disease formed by the interaction of many genes and environment. Genes related to obesity include genes that decode biochemical peptides to transmit signals of hunger or satiety, genes that promote the growth or variation of fat cells, and genes that control energy consumption. At present, 222 studies on the relationship between genes and obesity provide a solid scientific basis for the following discussion: as many as 7 1 gene is a potential factor leading to obesity, and 15 gene is closely related to body fat.
There is also a widely accepted view that gene mutation caused by protein coding and synthesis to regulate appetite is also the main reason for the pathological changes of obesity.
Another gene FTO was considered to have a potential relationship with obesity in the early stage and was widely studied. It is thought that this gene will cause the carrier's weight to soar.
At present, the existing data and research clearly show that there is a very important connection between gene composition and obesity. However, it should be pointed out that due to the interaction between genes and environmental factors, the impact of genetic changes on obesity will be exaggerated. Therefore, in the follow-up research, it is necessary to control the genes related to food intake and metabolic process. However, in any case, the causes of obesity are complex, and further research is needed to explore the possible genetic nature of obesity.