北京市16区患者基层医疗卫生机构就诊情况及影响因素研究

背景　近年来北京市分级诊疗服务体系已初现雏形,其中基层首诊作为分级诊疗的基础,对提高医疗服务体系运行效率十分重要。患者作为医疗服务的需方,研究其就医选择意愿及影响因素对落实基层首诊具有重要意义。目的　了解北京市患者在“生小病”时的就医选择及影响因素,从而为将患者引流至基层提出针对性建议。方法　于2019年5月在北京市16个区的48家区属二、三级医院中采用方便抽样的方式对门诊和住院患者的基层就诊选择意愿及其个人基本信息、健康状况和政策知晓情况进行调查。采用多因素Logistic逐步回归分析患者“生小病”时选择基层医疗卫生机构的影响因素。结果　共有3 732例调查对象纳入本研究,其中1 541例（41.29%）患有慢性病;知晓北京开展家庭医生制度和分级诊疗制度的患者分别为1 509例（40.43%）、1 641例（43.97%）,但签约了家庭医生的患者仅占12.43%（464/3 732）。1 349例（36.15%）调查对象“生小病”时会选择前往基层医疗卫生机构就医。多因素Logistic逐步回归分析结果显示,户籍、年龄、文化程度、社会医疗保险情况、家庭月收入、健康自评情况、慢性病数量、家庭医生制度知晓情况、家庭医生签约情况及分级诊疗制度知晓情况是调查对象就诊机构选择的影响因素（P<0.05）。结论　老年人、北京市户籍人口、有社会医疗保险、文化程度和收入较低、知晓分级诊疗和家庭医生相关政策、签约了家庭医生的患者在“生小病”时更倾向选择基层医疗卫生机构,因此对于非北京户籍、无社会医疗保险患者人群,应努力提高医疗保障,加强健康宣教;同时提高基层医疗技术水平和就诊环境,加大医改政策的宣传力度,并继续扩大家庭医生签约覆盖率,吸引更多患者下沉基层。     

The influence of gene expression profiling on decisional conflict in decision making for early-stage breast cancer chemotherapy

BackgroundWomen with early-stage breast cancer, of whom only 15% will experience a recurrence, are often conflicted or uncertain about taking chemotherapy. Gene expression profiling (GEP) of tumours informs risk prediction, potentially affecting treatment decisions. We examined whether receiving a GEP test score reduces decisional conflict in chemotherapy treatment decision making.MethodsA general population sample of 200 women completed the decisional conflict scale (DCS) at baseline (no GEP test score scenario) and after (scenario with GEP test score added) completing a discrete choice experiment survey for early-stage breast cancer chemotherapy. We scaled the 16-item DCS total scores and subscores from 0 to 100 and calculated means, standard deviations and change in scores, with significance (p < 0.05) based on matched pairs t-tests.ResultsWe identified five respondent subgroups based on preferred treatment option; almost 40% did not change their chemotherapy decision after receiving GEP testing information. Total score and all subscores (uncertainty, informed, values clarity, support, and effective decision) decreased significantly in the respondent subgroup who were unsure about taking chemotherapy initially but changed to no chemotherapy (n =33). In the subgroup of respondents (n = 25) who chose chemotherapy initially but changed to unsure, effective decision subscore increased significantly. In the overall sample, changes in total and all subscores were non-significant.ConclusionsGEP testing adds value for women initially unsure about chemotherapy treatment with a decrease in decisional conflict. However, for women who are confident about their treatment decisions, GEP testing may not add value. Decisions to request GEP testing should be personalised based on patient preferences.     

探讨剖宫产术后瘢痕子宫再次妊娠分娩方式的选择

目的：探讨剖宫产术后瘢痕子宫再次妊娠分娩方式的选择。方法随机抽取2015年3月—2016年2月到该院住院并分娩的剖宫产术后瘢痕子宫再次妊娠的孕妇120例,对其临床分娩方式的选择、临床表现以及分娩结果等展开回顾性的分析。结果120例剖宫产术后瘢痕子宫再次妊娠的孕妇均于分娩前接受健康妊娠方式的知识宣教,之后共有66例孕妇主动选择阴道试产,占比55.0%(66/120),其余的54例孕妇仍选择剖宫产术进行再次分娩,占比45.0%(54/120)。结论经临床实践证明,剖宫产术后瘢痕子宫再次妊娠的孕妇在全面了解并符合阴道试产的适应证后,选择阴道试产的分娩方式比再行剖宫产术分娩的安全性和可行性要高得多,能更好地保障母儿的安全健康。     

Optimizing antibiotic prescribing: collective approaches to managing a common-pool resource

BackgroundAntimicrobial resistance (AMR) is one of the greatest threats in 21st century medicine. AMR has been characterized as a social dilemma. A familiar version describes the situation in which a collective resource (in this case, antibiotic efficacy) is exhausted due to over-exploitation. The dilemma arises because individuals are motivated to maximize individual payoffs, although the collective outcome is worse if all act in this way.ObjectivesWe aim to outline the implications for antimicrobial stewardship of characterizing antibiotic overuse as a social dilemma.SourcesWe conducted a narrative review of the literature on interventions to promote the conservation of resources in social dilemmas.ContentThe social dilemma of antibiotic over-use is complicated by the lack of visibility and imminence of AMR, a loose coupling between individual actions and the outcome of AMR, and the agency relationships inherent in the prescriber role. We identify seven strategies for shifting prescriber behaviour and promoting a focus on the collectively desirable outcome of conservation of antibiotic efficacy: (1) establish clearly defined boundaries and access rights; (2) raise the visibility and imminence of the problem; (3) enable collective choice arrangements; (4) conduct behaviour-based monitoring; (5) use social and reputational incentives and sanctions; (6) address misalignment of goals and incentives; and (7) provide conflict resolution mechanisms.ImplicationsWe conclude that this theoretic analysis of antibiotic stewardship could make the problem of optimizing antibiotic prescribing more tractable, providing a theory base for intervention development.     

基层单位怎样选择交叉配血试验方法

临床输血在抢救患者的生命过程中起着非常重要的作用.在输血之前,需要鉴定患者的ABO血型和Rh血型,还必须做交叉配血试验,这是确保病人安全输血必不可少的.过去传统方法是盐水交叉配血,它只能检测完全抗体,近年来为了临床输血更安全,要求配血时采用两种方法进行,达到取长补短,发挥高效的作用.我科采用盐水交叉配血和凝聚胺试验交叉配血联合进行,收到了较好的效果.现报告如下.     

Time to make up your mind: why choosing is difficult

For many years, the promotion of choice has been a core objective for virtually every service provider working to support people with learning disability. This is confirmed by the 2001 English White Paper Valuing People, A New Strategy for Learning Disability for the 21st Century, which describes choice as one of four key principles at the heart of the UK Government's proposals, and the 2000 review of learning disability services commissioned by the Scottish Executive, People Like Us, which places a similarly high priority on the creation of choice. The present paper gives an overview of our current understanding of the concept of choice. It concludes that our aspirations to promote choice for people with learning disability are undermined by conceptual confusion about the meaning of choice, inappropriate methods for helping people to make choices and an absence of applied research to guide practice in service settings. This review is designed to establish a conceptual framework for examining choice and empowerment for people with learning disability, and to describe the implications for future research and practice.     

A psychophysiological investigation of fluctuating consciousness in neurodegenerative dementias

Fluctuating levels of consciousness (FC) are a key feature in neurodegenerative dementias, yet clinical identification is poor, hindering accurate diagnosis. One hundred and nineteen patients (32 Dementia with Lewy Bodies (DLB), 57 Alzheimer's disease (AD) and 30 controls) with clinical scores of FC were assessed using an attentional task. Cortical arousal was assessed in 25 of these patients using electroencephalography. Over 90 s both variability in attention (p<0·0001) and fluctuations in electrocortical activity (p<0·0001) correlated with clinical FC scores, and with each other (p<0·0001). Variability in attention and electrocortical arousal are accurate FC markers and can assist differential diagnosis of AD and DLB. Previous work has underestimated the intensity and hence impact of FC in dementia. Copyright © 1999 John Wiley & Sons, Ltd.     

Toyama分型在颈段椎管内哑铃形肿瘤手术入路选择中的应用

目的 探讨Toyama分型在颈段椎管内哑铃形肿瘤手术入路选择中的应用效果。方法 回顾性分析2011年1月至2019年12月显微手术治疗的21例颈段椎管内哑铃形肿瘤的临床资料,依据Toyama分型计划手术入路。结果 肿瘤全切除18例,次全切除3例。术中均未发生椎动脉损伤。术后发生脑脊液漏并感染5例,行腰大池置管及抗感染治疗后痊愈;术后出现相应神经根支配区麻木感1例,自行缓解。术后随访1~3年,平均21个月;肿瘤全切除的病人无肿瘤复发;1例次全切除病人局部复发1例;21例均未发生脊柱畸形。结论 Toyama分型几乎囊括了所有颈段椎管内哑铃形肿瘤,详细描述了各亚型的影像学表现,对于手术入路的选择具有较大的指导意义。     

《侵权责任法》系列讲座:概说

《侵权责任法》施行以来,各级卫生行政部门和各级各类医疗卫生服务机构组织从业人员学习、理解和贯彻《侵权责任法》,普法成就斐然。经过一年的研讨,各界就该法的理解达成了许多共识,但在很多环节和关键问题上,仍然歧见纷出,甚至存在着普遍的误读。本文详细阐述侵权责任法的相关概念及立法历程,同时指出其不足之处,并以工作实践为基础,结合法学理论的学习和运用,认为有必要围绕一部《侵权责任法》逐个提出若干重要基础课题,进行深入系统地商兑,以趋利避害,全面地守法、科学地用法。