重庆市孕前生殖健康与出生结局队列：设计简介与建设概况

出生队列是研究生命早期暴露对健康结局影响的重要工具, 但目前缺乏有力支撑孕前暴露特别是父系暴露对生殖健康和妊娠结局影响研究的大型队列平台。重庆市孕前生殖健康与出生结局队列研究是起始于孕前阶段, 同等关注男女双方的环境、心理、行为等暴露因素对生殖健康和不良妊娠结局影响的前瞻性队列研究。项目于2019年正式启动, 计划招募有生育意愿的育龄夫妇20 800人。通过随访, 调查志愿者2年内是否自然受孕。对进入妊娠期的女性志愿者, 在孕早、中、晚期进一步随访, 并对分娩的子代随访至2岁, 监测早产、低出生体重、出生缺陷、神经功能发育障碍等结局发生情况。各阶段分别采集相应的数据信息和生物样本, 包括精液、外周血、尿液、胎盘、脐带、脐带血、口腔拭子等。截至2022年1月, 已纳入志愿者8 698人, 分布于重庆市所有38个区/县。本队列建设目标是成为涵盖父母双方的前瞻性大样本孕前出生队列, 将以独特的设计和更加全面的视角阐明全生育周期特别是孕前期暴露因素对生殖健康和不良出生结局的影响及机制。     

Public satisfaction with health care system in 30 countries: The effects of individual characteristics and social contexts

In this article, the associations among individual socio-economic characteristics, the institutional set-up of health care systems, and satisfaction with the health care system are investigated. Data from the 2011 International Social Survey Program (30 countries, 34,212 respondents) is used. Multilevel analyses across countries have shown how the state financing context affects satisfaction at the individual level. Consistent with previous research, at individual level, personal experiences with medical providers, age, gender as well as income are significant predictors of satisfaction with the health care system. At the country level, real input indicators such as density of physicians and density of hospital beds are negative predictors of satisfaction with the health care system whereas the percentage of total health expenditures comprised by public sources is a positive predictor of satisfaction with the health care system. However, findings from the cross-level interactions indicate that the negative effect of lower income is more prominent in predominantly publicly-funded health care systems. Specifically, in primarily publicly-funded health care systems, the model-predicted probability of satisfaction with the health care system is higher, but the gap in the probability of satisfaction with the health care system between individuals with lower income and those with higher income is greater than that in mostly privately-financed health care systems. The findings in this study suggest that the future direction of health care system reform should be focused on balancing the distribution of resources between private and public sectors.     

Common wrist and elbow injuries in primary care

The wrist and elbow, an intricate arrangement of bones, tendons, and ligaments, frequently are the source of reported problems in the primary care setting. Understanding the functional anatomy and acquiring adeptness for examination are the key to proper diagnosis of injuries and conditions that plague the wrist and elbow. A brief overview of the anatomy and physiology of the wrist and elbow joints is given. Diagnosis and management of common injuries and reported problems faced by practitioners are discussed. The provider is offered guidance on when to refer for specialty evaluation.     

Economics and policy of day surgery

With advances in technology, day surgery has become more efficient and has expanded remarkably due to the policies and economic incentives in some countries. In addition, day surgery could potentially serve as a model of explicit accountability for quality assurance and institutional processes for continuous improvement. It is recommended that Japan adapt its policies and systems to facilitate day surgery after a thorough analysis of the health effects and cost structure. Cost shifts to other services and parties should be considered carefully from a long-term, comprehensive perspective. It could be socially beneficial to subsidize start-up costs for the establishment of day surgery units, since significant capital and human resources are required for quality assurance. The encouragement of day surgery could be a driving force for the improvement of clinical technology and patient quality of life. It would foster collaboration between health service providers, including during preparation and follow-up, and allow patients to participate as partners in clinical processes and decisions. To ensure constant readiness, day surgery environments should be equipped with multisite, standardized databases on clinical and economic performance. An expansion of day surgery facilities could lead to the development of a new mechanism of professional quality improvement and to a new health insurance reimbursement system based on clinical achievements and resources.     

Troponin I sensitivity and specificity for the diagnosis of acute myocardial infarction

This article describes the sensitivity and specificity of troponin I when compared to creatine kinase-MB (CK-MB) and electrocardiography (ECG) for diagnosing acute myocardial infarction (AMI). Two different lower levels for defining positive results with troponin I were evaluated. A retrospective study of 153 patients who presented to the emergency department of a community hospital supplied the pool of patients for this study. Patients included in this study were those for whom a CK-MB was ordered. The majority of these patients were evaluated for chest pain or symptoms suggesting an acute cardiac event. Of the 153 patients studied, CK-MB results were positive in 91 (59%) patients; ECG revealed AMI in 72 (47%) patients. There were 103 (67%) patients who had either positive CK-MB or ECG results. Ninety (59%) patients had a troponin I level greater than 2.0 ng/mL, and 18 (12%) patients had a troponin I level between 0.6 and 2.0 ng/mL. Seven patients whose troponin I level was between 0.6 and 2.0 ng/mL had negative CK-MB and ECG results. Therefore, 11 patients with troponin I between 0.6 and 2.0 ng/mL had AMI. Five patients with positive troponin I results (> 2.0 ng/mL) had negative CK-MB and ECG results. When a troponin I level greater than 0.6 ng/mL was used as a positive value, compared to CK-MB and ECG using either time zero or time 6 hours, the sensitivity was 94% and specificity was 81%. When troponin I greater than 2.0 ng/mL was used to define a positive test, the sensitivity was 85% and specificity was 91% when compared to CK-MB and ECG.     

Relation between prepublication release of clinical trial results and the practice of carotid endarterectomy

Context  Little is known about how clinical practice is affected by disseminating results of clinical trials prior to publication in peer-reviewed journals. Objective  To determine whether prepublication release of carotid endarterectomy (CEA) trial results via National Institutes of Health Clinical Alerts was associated with prompt changes in patient care that were consistent with the new medical evidence. Design, Setting, and Patients  Longitudinal data series analysis using acute care hospital discharge data from the Healthcare Cost and Utilization Project for patients who had CEA performed in acute care hospitals in 7 states (New York, California, Pennsylvania, Florida, Colorado, Illinois, and Wisconsin). The trials were the North American Symptomatic Carotid Endarterectomy Trial (NASCET clinical alert released February 1991) and the Asymptomatic Carotid Atherosclerosis Study (ACAS clinical alert released September 1994). Main Outcome Measure  Carotid endarterectomy rate during each month from 1989 (2 years before the NASCET clinical alert) to 1996 (2 years after the ACAS clinical alert), adjusted for age and sex. Because both trials were limited to patients 80 years or younger in hospitals with low mortality, we also stratified CEA rates by patient age and hospital mortality rate. Results  From 1989 through 1996, 272,849 CEAs were performed in the acute care hospitals in these 7 states, with the annual number increasing from 22,300 to 51,495. After the NASCET clinical alert, the adjusted CEA rate increased 3.4% per month (95% confidence interval [CI], 1.6%-5.3%) during the following 6 months and then increased 0.5% per month (95% CI, 0.2%-0.8%; P<.04) after journal publication of the NASCET study. After the ACAS clinical alert, the CEA rate increased 7.3% per month (95% CI, 6.0%-8.5%) during the following 7 months and then decreased by 0.44% per month (95% CI, -0.86% to -0.0002%; P<.04) after journal publication of the ACAS study. After the ACAS clinical alert, the CEA rate increased more in patients aged 80 years or older than in younger patients; whereas, after journal publication of ACAS, the CEA rate decreased more rapidly in the older population. The overall proportion of CEAs performed in low-mortality hospitals did not change substantially after release of the clinical alerts or after journal publication. Conclusion  In this study, prepublication dissemination of CEA trial results with clinical alerts was associated with prompt and substantial changes in medical practice, but the observed changes suggest that the results were extrapolated to patients and settings not directly supported by the trials.      

Practice variation in perioperative antibiotic use in Japan.

OBJECTIVE: Under the fee-for-service system, the overuse and misuse of perioperative antibiotics have become serious concerns in Japan. The objective of the present study is to investigate practice variations of perioperative antimicrobial prophylaxis between and within hospitals, and to identify any opportunities for improvement. METHODS: We polled 319 surgeons in six specialties employed by 11 teaching hospitals in Japan. We developed questionnaires with vignettes, asking physicians about their practice of antimicrobial prophylaxis in six surgical procedures (gastrectomy, hysterectomy, cataract surgery, clipping of cerebral aneurysm, hip fracture surgery, and coronary artery bypass graft) and utilization of institutional clinical pathways. RESULTS: Average durations of prophylaxis varied by procedure, from 1.6 days for cataract surgery to 5.8 days for clipping surgery. Variation was also observed between institutions for the same procedure, e.g. institutional averages for the duration of prophylaxis for gastrectomy ranged from 2.3 to 7 days. Large intra-institutional variation in prophylaxis duration and inconsistent use of clinical pathways were observed in the cases of gastrectomy, hip fracture surgery, and clipping surgery. At one hospital, 20% of physicians performing gastrectomy indicated the use of an institutional clinical pathway, and prophylaxis duration ranged from 3 to 6 days. For cataract surgery and hysterectomy, clinical pathways were universally applied and intra-institutional practice variation was small, yet prophylaxis duration varied widely between hospitals and third-generation cephalosporins were used extensively. Average length of prophylaxis for hysterectomy ranged from 1.8 to 6 days and 43% of respondents prescribed third-generation cephalosporins. CONCLUSIONS: In Japan, perioperative antimicrobial prophylaxis lacks standardization. Efforts to strengthen an evidence-based approach to antimicrobial prophylaxis need to be made a priority at both the national and institutional levels.     

Pressure ulcer incidence and Braden subscales: Retrospective cohort analysis in general wards of a Portuguese hospital

AimTo study the influence of Braden subscales scores (at the first pressure ulcer risk assessment) on pressure ulcer incidence using a univariate and a multivariate time to event analysis.Materials and methodsRetrospective cohort analysis of electronic health record database from adult patients admitted without pressure ulcer(s) to medical and surgical wards of a Portuguese hospital during 2012. The hazard ratio of developing a pressure ulcer during the length of inpatient stay was calculated by univariate Cox regression for each variable of interest and by multivariate Cox regression for the Braden subscales that were statistically significant.ResultsThis study included a sample of 6552 participants. During the length of stay, 153 participants developed (at least) one pressure ulcer, giving a pressure ulcer incidence of 2.3%. The univariate time to event analysis showed that all Braden subscales, except “nutrition”, were associated with the development of pressure ulcer. By multivariate analysis the scores for “mobility” and “activity” were independently predictive of the development of pressure ulcer(s) for all participants.Conclusion(Im)“mobility” (the lack of ability to change and control body position) and (in)“activity” (the limited degree of physical activity) were the major risk factors assessed by Braden Scale for pressure ulcer development during the length of inpatient stay. Thus, the greatest efforts in managing pressure ulcer risk should be on “mobility” and “activity”, independently of the total Braden Scale score.