我国三级医院急性缺血性脑卒中院前预警与院内绿色通道流程管理现况调查

目的 通过对全国三级甲等医院神经介入医师进行调研,了解我国不同行政区域三级甲等医院急性缺血性脑卒中患者院前预警与院内绿色通道流程管理的现况及同质性.方法 采用便利抽样法,通过问卷星微信小程序、邮件等方式向我国脑血管病介入治疗领域的专家发放ALICE调查问卷(中文版脑血管病血管内治疗现状问卷调查-ALICE研究),调查内容包括医院基本信息、脑血管病(急性缺血性脑卒中、颅内动脉瘤、动静脉畸形、非狭窄性颈动脉斑块)治疗现况、患者转运制度等,并分析不同行政区域(华北、东北、华东、华中、华南、西南、西北七大行政区)的绿色道管流程通理现状及不同优化管理策略所能节省的入院至治疗时间.结果 共发放问卷142份,剔除内容不完整的问卷11份,回收有效问卷131份.131名神经介入医师来自126家医院,所有医院均为三级甲等医院.126家医院中,年机械取栓治疗例数>100例的医院占31.0％(39/126),救护车直接入院是急诊急性缺血性脑卒中患者的主要收治方式[53％(35％,70％)].不同行政区域医院的院前预警机制、急诊预检、CT机与导管室空间布局、常规麻醉方案、机械取栓准备均存在轻度差异,但差异均无统计学意义(P均>0.05).麻醉医师全天处于可呼叫状态、优化影像学检查流程、CT机位置优化或功能整合、提前预警机制分别可缩短入院至治疗时间21(19,30)、20(15,30)、20(12,25)、19(10,23)min.结论 我国不同行政区域三级甲等医院之间急性缺血性脑卒中院内绿色通道救治流程的同质性较高.避免非必要步骤、规划合理的卒中绿色通道及采用并联化管理可极大提高救治效率.     

青海省与甘肃省城市医疗救助试点情况调查报告

介绍了甘肃和青海两省城市医疗救助试点的组织、救助与管理的基本结构。同时,在救助对象、救助项目资金分配三个方面比较了“青海模式”与“甘肃模式”的相异之处,提出了医疗救助和现有医保制度整合的难点以及基层财政困境对于医疗救助效果产生影响的机制。     

中国对外援助医疗卫生机构的历史、现状与发展趋势

本研究估算中国政府每年在医疗卫生机构援助项目上的投入约2.67亿美元,接近双边卫生援助排名第五的德国的水平。援助的医疗卫生机构多为综合医院或卫生中心,地理分布上非洲最多,规模较为统一,并采用"交钥匙"的援建方式。这些项目一定程度上缓解了当地医疗卫生资源稀缺和居民就医可及性问题,并促进当地人就业与生活水平提高,但由于援助缺乏总体战略和规划的指导与统筹,缺乏对受援国卫生体系的知识经验积累,强调"需求牵引"却忽视需求评估,立项管理"重工程建设可行性、轻项目功能可行性"等问题,难以实现精准援助。未来医疗卫生机构援助应实现三个转变,即从以交付基础设施为导向的"实物援助"向"功能性援助"转变,从项目援助向方案援助转变,从单一的政府官方援助向投援结合转变。     

How do elderly outpatients manage polypharmacy including DOAC - A qualitative analysis highlighting a need for counselling

BackgroundPatients with polypharmacy are challenged with the management of their daily medication. Medication management strategies for direct oral anticoagulants (DOAC) are especially important to guarantee medication adherence and to prevent thromboembolic events. Patients are often left alone with finding an appropriate strategy.Objective(s)To explore medication management strategies, to measure adherence to DOAC with the aim of deducing recommendations for practice.MethodsFace-to-face semi-structured interviews were conducted at the home of outpatients who were taking ≥4 medications daily including a DOAC, and self-managing their medication. A small electronic device (Time4Med?) was given to record medication intake during the four following weeks. During a second home visit, participants saw a graph of their medication intake as dot chart, and obtained a feedback. Interviews were transcribed verbatim and thematically analysed. Medication adherence was calculated with electronic data.ResultsEighteen individuals (61.1% female; median age 77.5 years) were interviewed and reported 30 different medication management strategies, together with triggers, advantages and limitations. They combined at least five strategies, composed of internal (memory-based) and external (packaging-based or intake-based) strategies. The number of strategies was neither associated with the number of medications nor with medication adherence. Taking adherence was <100% for eight patients (44.4%). The inability of any medication management strategy to adapt to ageing and cognitive decline emerged as its most dramatic limitation, especially because individuals would fail to notice when their strategy became unsuited.ConclusionsElderly patients develop manifold medication management strategies, which can inspire future medication users. Limitations are present such as forgetting medication intake in spite of a management strategy. The moment to adapt the strategy to ageing or cognitive decline is crucial and often goes unnoticed. It is therefore decisive that healthcare professionals regularly re-evaluate the appropriateness of the medication management strategies during counselling or ideally during home visits.     

共享决策在ICU中的应用进展

共享决策作为“以患者为中心的护理”的核心,是医患之间通过参考现有的最佳临床证据并考虑患者的价值观和偏好,协同合作制订决策的过程。共享决策通过促进患方参与决策,并增强其对预后和治疗护理措施的理解,来制订更加明智的决策。该文介绍共享决策在ICU的实施意义及应用情况,针对患者/家属因素、医疗相关人员因素和评估工具因素3个方面的影响因素进行分析,提出了共享决策在ICU实施的建议,以期为共享决策在ICU中的应用提供参考。     

干休所院前急救人员心肺复苏理论和技能现况调查

目的:调查干体所院前急救参与人员对心肺复苏(CPR)理论和技能的掌握情况,并分析其影响因素,探讨改善的策略。方法:采用问卷调查和现场考核相结合的方式对某部总医院急诊人员、体系内干休所保健人员和随机抽的60名陪护人员进行调查,调查三类人员CPR理论和技能现况和不同职业特征医疗人员间的差异,多元逐步回归探讨其影响因素。结果:陪护人员CPR理论和技能匮乏,保健人员优于陪护人员(P<0.05),但并不理想,急诊人员显著优于其他两类人员(P<0.05),比较理想,但有必要进一步提高;不同职业特征医疗人员间理论和技能水平存在一定差异,影响CPR技能的因素为培训情况、职业性质、工作年限和受教育程度。结论:干体所院前急救人员CPR理论和技能现状并不乐观,需要立足构建CPR"生存链",坚持开展针对性培训。     

用毫针夹持进针器针灸治疗疑难杂症的临床应用研究

针灸治疗在治病、防病、健身等方面的效果都得到了肯定,特别在治疗疑难杂症方面,有着不可替代的重要地位。然而,要在世界医疗单位得到推广,除了要有精湛的技术外,无菌操作也是当今医疗界的一个难题。用毫针夹持进针器针灸,可将复杂的消毒进针过程简洁化,使进针过程更加规范化,能很好地遵守无菌操作技术,减少医源性感染,符合针灸"简、便、廉、验"的特点。     

CHILD SAVING OR CHILD RIGHTS

This paper analyses images of children in international NGO fundraising campaigns on children and conflict in Africa, with a particular focus on the Civil War in the Democratic Republic of Congo. It identifies the key impacts of contemporary civil war in Africa on children and the role of children and young people in these conflicts. The campaigns analysed here use different discursive and rhetorical devices: from melodrama to dispassionate expert. Despite these differences, the academic literature on why children get involved in fighting and the psycho‐social impacts of both forced and voluntary participation are elided by these NGOs who frame war as an assemblage of discrete issues that can be made the target of specific interventions. Despite the commitment of these NGOs to human rights and to the idea of the child as a rights‐bearing subject, child rights are deployed as a supplement rather than an alternative to established discourses of child saving.     

儿内科小儿气管异物的误诊原因及处理对策

目的分析儿内科小儿气管异物的误诊原因并总结小儿气管异物的应急处理措施。方法对于2008年10月至2011年6月在我院儿内科进行就诊治疗的53例小儿气管异物患者的临床资料进行回顾性分析,对其误诊的疾病及原因进行统计分析。结果 53例小儿气管异物患者均因咳嗽、多痰、发热及呼吸急促等表现而就诊于我院儿内科;患者的病程在10d~2年,来院时患者均没有异物吸入史;患者大多为阵发性咳嗽,其中有17例患者伴有气喘,有24例患者伴有发热,仅有4例患者出现紫绀表现及呼吸困难表现。所有患者的肺部均可闻及湿性啰音,其中有7例患者的单侧呼吸音降低;经X线检查,其中有27例患者的肺部纹理增加,并出现了片状阴影;16例患者的胸片未见异常;53例患者中有14例患者被误诊为支气管炎,有6例患者被误诊为肺炎,有3例患者被误诊为急性喉炎。所有患者在我院确诊后,进行手术治疗后均痊愈,住院时间在1~8d。结论气管异物吸入是小儿常见的急症,临床上应该积极了解患者的病史,进行正确的影像学诊断,降低误诊率,对患者早期手术治疗,促进其恢复。     

Self-reported outcome in new hearing aid users over a 24-week post-fitting period

Evidence for the existence of auditory acclimatization is mixed, and the implications for clinical practice are unclear. The aim of this study was to seek evidence of perceived changes in performance over a 24-week post-fitting period. Thirty-two new, elderly subjects were recruited and fitted monaurally with the same model of linear, programmable hearing aid that provided in excess of 20-dB insertion gain at 2000–4000 Hz. The Glasgow Hearing Aid Benefit Profile (GHABP) was used to measure self-reported changes over time. The questions concerning benefit and satisfaction were modified to produce two versions: half of the subjects reported changes relative to the time of fitting, while the remainder reported changes relative to the previous occasion on which they completed the GHABP (3 weeks earlier). Subjects reported using hearing aids in excess of 90% of the time when in listening situations that cause difficulty. The median residual disability measure from the GHABP remained low (10–20%) over the duration of the study. The median scores for additional benefit and satisfaction showed a small but statistically significant improvement over the first 3 months of hearing aid use but only for the subjects who referenced this to their perceived performance 3 weeks earlier. The limited evidence for self-reported improvements in benefit and satisfaction over time reported to date must be tempered by the possibility of response bias arising from the method used to measure changes over time.