个体化教育方案对压疮患者居家照顾者照顾行为的影响

目的探讨个体化教育方案对改善压疮患者居家照顾者照顾行为的作用。方法采用方便抽样法选取2010年3-11月复旦大学附属华山医院伤口造口护理门诊就诊患者的照顾者46例作为研究对象,以随机数字表法将其分为干预组和对照组各23例。对照组接受门诊常规护理教育;干预组在门诊常规护理教育的基础上,实施个体化教育方案,为期3个月。以主要照顾者照顾行为、照顾者为患者翻身和换药行为、患者压疮愈合率和再发生率作为评价指标,分别于干预后1周、1个月和3个月进行效果评价。结果干预后1周,干预组照顾者为患者翻身和换药行为总均分明显高于对照组,差异有统计学意义(P0.01);干预后1、3个月,干预组照顾者照顾行为优于对照组,差异均有统计学意义(均P0.01);干预后3个月,干预组患者压疮愈合率和再发生率与对照组差异均无统计学意义(均P0.05)。结论个体化的教育方案可有效改善压疮患者居家照顾者的照顾行为,但其对促进压疮愈合、降低再发生率的效果需延长干预时间进一步评价。     

A meta-analysis of protein binding of flucloxacillin in healthy volunteers and hospitalized patients

ObjectivesThe aim of this study was to develop a mechanistic protein-binding model to predict the unbound flucloxacillin concentrations in different patient populations.MethodsA mechanistic protein-binding model was fitted to the data using non-linear mixed-effects modelling. Data were obtained from four datasets, containing 710 paired total and unbound flucloxacillin concentrations from healthy volunteers, non-critically ill and critically ill patients. A fifth dataset with data from hospitalized patients was used for evaluation of our model. The predictive performance of the mechanistic model was evaluated and compared with the calculation of the unbound concentration with a fixed unbound fraction of 5%. Finally, we performed a fit-for-use evaluation, verifying whether the model-predicted unbound flucloxacillin concentrations would lead to clinically incorrect dose adjustments.ResultsThe mechanistic protein-binding model predicted the unbound flucloxacillin concentrations more accurately than assuming an unbound fraction of 5%. The mean prediction error varied between –26.2% to 27.8% for the mechanistic model and between –30.8% to 83% for calculation with a fixed factor of 5%. The normalized root mean squared error varied between 36.8% and 69% respectively between 57.1% and 134%. Predicting the unbound concentration with the use of the mechanistic model resulted in 6.1% incorrect dose adjustments versus 19.4% if calculated with a fixed unbound fraction of 5%.ConclusionsEstimating the unbound concentration with a mechanistic protein-binding model outperforms the calculation with the use of a fixed protein binding factor of 5%, but neither demonstrates acceptable performance. When performing dose individualization of flucloxacillin, this should be done based on measured unbound concentrations rather than on estimated unbound concentrations from the measured total concentrations. In the absence of an assay for unbound concentrations, the mechanistic binding model should be preferred over assuming a fixed unbound fraction of 5%.     

造口旁疝相关国内外指南和专家共识解读

由于造口旁疝在诊治过程中存在的争议较多,我国腹壁疝相关指南中缺乏对造口旁疝的系统性阐述,检索国内外与造口旁疝诊治相关的指南或共识,并对其中提出的共性和个性问题进行分析：（1）在造口旁疝发生率方面,造口术后不同随访时间的累积发生率更有临床价值。（2）造口旁疝合并无法解除的肠梗阻或肠绞窄时需要行急诊手术,而择期手术则需要有经验的医生根据病人的具体情况个体化制定治疗方案,须全面评估风险和收益。（3）在临床诊疗过程中应注重结合病人的具体情况,巧妙运用各术式独特优势,选择适合病人的治疗方案。Sugarbaker、Keyhole和Sandwich 3种术式各有优缺点,目前临床中Sugarbaker手术相对开展较多,复发率低。（4）推荐造口手术预防性使用不可吸收补片。     

成人腹股沟疝外科治疗的个体化方案选择

目前治疗成人腹股沟疝的外科手段为有开放式疝修补术和腹腔镜疝修补术。虽然治疗方法很多,总体效果良好,但每一种方法均有其弊端,外科医生常根据患者的性别、伴随疾病、既往病史、文化、收入水平等情况来选择手术。如何选择适当的手术方式有助于降低并发症率和减轻患者经济负担。本文就成人腹股沟疝个体化外科治疗进行综述。     

个体化健康教育改善急性心肌梗死患者预后

目的：比较个体化健康教育与传统健康教育方式对急性心肌梗死患者心绞痛及心肌梗死再发率的影响。方法：选择130例于我院住院治疗的急性心肌梗死患者,随机分为两组：个体化健康教育组(63例)与传统健康教育组(67例)。分别给予个体化健康教育和传统健康教育,1年后随访各组心绞痛、心肌梗死再发情况。结果：个体化健康教育组急性心肌梗死患者心绞痛、心肌梗死再发率较传统健康教育组明显下降,差异具有统计学意义(P<0.05)。结论：个体化健康教育可改善急性心肌梗死患者预后,值得进一步推广。     

Delivered Dose: A Drug-centric Phenotype for Chemotherapy Dose Individualization

It is pointed out that genotype-based approaches are unlikely to be effective at dose individualization. Delivered dose, which refers to the amount of drug delivered to the point of action to be measured by quantitative imaging techniques, is a drug-centric phenotype that separates pharmacokinetic effects from pharmacodynamic effects. Delivered dose serves as a midway measurable numeric parameter between drug administration and therapy outcome. One potential way to reduce chemotherapy outcome variation is to individualize prescribed drug so that uniform delivered dose is achieved across the patient population.     

胸腔镜在陷闭肺综合征手术治疗中的应用

目的：探讨陷闭肺综合征合理的手术治疗方法，方法：24例陷闭肺病例均作胸腔镜探查，纤维板剥脱术，其中6例凝固性血胸需行肺楔形切除，6例支气管胸膜瘘作带蒂大网膜转移术修补，3例乳糜胸需作胸导管结扎术，3例脓胸需作带蒂大网膜转移术，2例食道自发性破裂作带蒂大网膜转移修补术，2例结核毁损肺作左侧全肺切除，2例肺癌行左全肺切除，结果：全部病例症状缓解，无术后并发症。结论：陷闭肺的治疗要实施个体人方案，胸腔镜手术可提供准确的诊断同时可施行清创术和纤维板剥脱术，纤维板剥脱术是治疗肺萎陷的最有效术式，带蒂大网膜转移术对瘘的治疗成功率高。     

Rapid i.v. loading with phenytoin with subsequent dose adaptation using non-steady-state serum levels and a Bayesian forecasting computer program to predict maintenance doses

Objective: To evaluate the suitability of a phenytoin loading dose regimen; to assess whether dose‐individualization was necessary and to investigate the reliability of a Bayesian forecasting method for phenytoin dose adaptation using non‐steady‐state levels in hospital‐admitted patients. Method: An initial loading dose (15 mg phenytoin acid/kg BW) was given i.v. over 4 h, followed by standardized maintenance doses given i.v. in 12‐h intervals from days 1 to 5 (175 mg ≤ 70 kg; 202 mg > 70 kg BW). The evening dose of day 5 was individualized based on three serum trough levels: L1 (after 16 h), L2 (morning day 4) and L3 (morning day 5). Results: Ninety of 136 consecutive patients were evaluable in a prospective study for the standardized phase; 50 of them had additional serum levels in the individualized phase. There was no exclusion of patients with interacting co‐medication. Seventy‐seven per cent (L1) and 68% (L3) of patients showed therapeutic values (10–20 mg/L). The prediction error of the forecasting was 3·95 mg/L, the root mean squared error 6·27 mg/L (target trough level 11 mg/L). Seventy per cent of the levels (n=50) were within the 68% confidence interval. Conclusion: The effectiveness and safety of the regimen with rapid i.v. loading and the necessity to individualize phenytoin dosing after day 5 were demonstrated.     

Balancing extensive ambition and a context overflowing with opportunities and demands: A grounded theory on stress and recovery among highly educated working young women entering male-dominated occupational areas

Several factors underline the issue of stress-related health among young highly educated women. Major societal changes might provide more new challenges with considerably changed and expanded roles than were expected by earlier generations, especially among women. The quantity of young women with higher education has also increased threefold in Sweden in less than two decades and there are a growing number of young women that hereby break with traditional gender positions and enter new occupational areas traditionally dominated by men. The research questions in the present study were: “What is the main concern, regarding stress and recovery, among young highly educated working women breaking with traditional gender positions and entering male-dominated occupational areas?” and “How do they handle this concern?” We conducted open-ended interviews with 20 informants, aged 23-29 years. The results showed that the synergy between highly ambitious individuals and a context overflowing with opportunities and demands ended up in the informants’ constantly striving to find a balance in daily life (main concern). This concern refers to the respondents experiencing a constant overload of ambiguity and that they easily became entangled in a loop of stress and dysfunctional coping behavior, threatening the balance between stress and sufficient recovery. In order to handle this concern, the respondents used different strategies in balancing extensive ambition and a context overflowing with opportunities and demands (core category). This preliminary theoretical model deepens our understanding of how the increasing numbers of highly educated young women face complex living conditions endangering their possibility of maintaining health and work ability.     

个体化临床教学在普通外科的应用体会

目的探讨针对不同授课对象在普通外科开展个体化教学的体会。方法明确实习医生、规范化培训医生、研究生以及进修医生的层次,进而制定教学目标,进行不同深度和方式的个体化教学。结果经上述教学改革,实习医师对普通外科常见疾病认识加深,培训医师的外科技能以及相关理论更扎实,研究生理论水平明显提高,而且进修医生对重大疾病及术后合并症的认识和处理水平也得到提高。结论个体化临床教学可大大提高不同授课对象的教学绩效。