教学督导会诊在超声医学科住院医师规范化培训中的应用

目的总结住院医师规范化培训阶段的会诊需求概况，评价教学督导会诊在住院医师规范化培训阶段的作用。 方法回顾性收集2015年8月至2017年8月间于北京协和医院超声医学科参加北京市住院医师规范化培训的住院医师43名及其于2017年11月至2018年8月申请教学督导会诊的病例，随访申请教学督导会诊的病例，总结会诊原因和部位，参照病理或临床诊断，对会诊医师作出教学评价（技术操作、定位、定性）。采用χ²检验比较不同年资、不同学历住院医师申请会诊原因和部位的差异，并采用t检验比较应用教学督导会诊前、后3年以下住院医师客观结构化临床考试（OSCE）阶段考核平均成绩的差异。 结果43名住院医师共随访1727份会诊病例。第一、二、三年住院医师申请会诊次数占比分别为53.0%（915/1727）、42.9%（741/1727）、4.1%（71/1727）。住院医师申请会诊原因：定性70.9%（1224/1727）、技术操作22.7%（392/1727）、定位6.4%（111/1727）。第一、二、三年住院医师因技术操作原因申请会诊比例分别为26.9%（246/915）、18.6%（138/741）、11.3%（8/71）；因定位原因申请会诊比例分别为7.8%（71/915）、4.5%（33/741）、9.8%（7/71）；因定性原因申请会诊比例分别为65.3%（598/915）、76.9%（570/741）、78.9%（56/71），不同年资住院医师申请会诊的原因不同，差异具有统计学意义（χ²=33.293，P＜0.001）。申请会诊的检查部位前三位为妇科27.9%（482/1727）、浅表器官23.3%（402/1727）和腹部20.1%（347/1727），共占71.3%，不同年资住院医师申请会诊的部位不同，差异具有统计学意义（χ²=167.583，P＜0.001）。第一、二年住院医师申请会诊主要为腹盆腔脏器技术操作和定性，第三年住院医师申请会诊集中在浅表器官病变的定性。不同学历住院医师申请会诊部位分布不同，差异具有统计学意义（χ²=64.942，P＜0.001），申请会诊原因分布差异无统计学意义（χ²=8.131，P=0.087），平均申请会诊次数相近。97.7%（383/392）的技术操作问题通过教学督导会诊得到解决；教学督导会诊定位正确率73.0%（81/111）；定性正确率92.7%（1135/1224）。应用教学督导会诊后的住院医师OSCE成绩高于应用前［（85.7±6.6）分vs（75.7±7.5）分］，差异具有统计学意义（t=-2.426，P=0.036）。 结论随着住院医师年资增加，申请会诊次数减少。不同年资住院医师申请会诊的部位和原因不同。住院医师因技术操作原因申请会诊次数逐年下降，定性需求逐年增加。教学督导会诊能有效帮助住院医师解决技术操作难点、定位和定性，提升住院医师临床胜任力。     

临床药师参与236例感染性病例的会诊分析

目的 了解临床药师参与感染性疾病会诊病例特点,探讨多重耐药及泛耐药细菌感染的特点及治疗策略.方法 回顾性分析236例感染性病例的资料,按照性别、年龄、高危感染因素、病原菌及其耐药情况、治疗结果等进行统计分析.结果 会诊患者年龄分布中60岁以上老年人的比例占63.98％,会诊意见总体被采纳情况较好(总体接受率占99.15％),多重耐药细菌(MDR)、广泛耐药细菌(XDR)、泛耐药细菌(PDR)总体治疗效果较好,总有效率为78.05％.结论 临床药师通过参与感染性病例的会诊,在为患者进行抗感染治疗方案的制定和患者病情的转归方面发挥了重要作用.     

多学科联合门诊会诊工作实践与探索

目的 探讨开展多学科联合门诊会诊工作制度在妇幼保健医院中的实施策略.方法 医院服务中心对申请会诊患者进行预约登记,并与医务部组织3位或3位以上的产科、遗传优生科、超声科、妇科等多学科专家进行会诊作出诊断,服务中心追踪随访并提供帮助和指导.结果 42例患者通过多学科会诊:6例分娩正常新生儿,9例引产终止妊娠,1例稽留流产,24例继续妊娠(其中4例多胎妊娠实施了减胎术),2例门诊治疗观察.结论 妇幼保健医院开展多学科联合门诊会诊对早期干预出生缺陷儿、改善胎儿预后有积极意义.多学科联合门诊会诊让门诊患者及时得到了合理、有效的综合诊疗,并且加强了各个学科间的交流协作,促进了学科的发展.多学科联合门诊需完善信息化建设,会诊工作的发展需要医院给予激励措施.     

The profile of patients with chronic kidney disease who regularly present at an Australian general practice

Background:

Chronic kidney disease (CKD) is a common, serious and mostly asymptomatic condition that places considerable burden on the Australian healthcare system. Yet there is limited information on the patients with CKD who present to Australian primary care services, which represent the gateway to specialized care.

Methods:

Data pertaining to 31,897 patients who presented to a general practice in Western Australia, from 1 January 2013 to 30 June 2014 (inclusive), were extracted for review. Data included attendance records, comorbidities, diagnoses, and demographic details. Binary logistic regression was used to compare patients diagnosed with CKD by the consulting general practitioner with those without this diagnosis.

Results:

Of the 8629 patients who regularly attended the practice, 184 (2%) were diagnosed with CKD (mean age: 77.7 years; male: 57.1%). The stage of CKD was recorded in only 8.4% of cases. Patients with CKD averaged 11 more consultations in the past 18 months (mean difference 10.8, 95% CI [9.3, 12.3], p?<?.001). They were also more likely to: be male; be ex-smokers; be widowed; and to have a carer. Their most common comorbidities included acute infections, cerebrovascular or ischemic heart disease, osteopenia or osteoporosis, and cancer; 8.7% had died within the previous year.

Conclusions:

Despite the prevalence of CKD, only one in five cases were recorded within this large practice. This reveals lost opportunities to monitor and manage patients with this chronic and common disease. Although this represents an important finding, this study is limited by the reliance on practice records, some of which were incomplete. Nevertheless, this study reveals two key findings. First, this disease is under-diagnosed and/or under-recorded. Second, patients with CKD have other, potentially unrelated, problems that may warrant attention.     

神经症患者就医情况调查

目的：了解神经症患者发病后的在情况。方法：对１９９８年７月～１９９９年８月前来门诊咨询,符合ＣＣＭＤ－２Ｒ神经症诊断标准的患者１００例,了解其发病后的就医情况。结果：有４８例首诊于精神科‘４７例首诊或反复长期就诊于综合医院内科等,尤以焦虑症和凝症症患者为多;５例癔症发作时求助于迷信活动。结论：约有半数神经症患者发病后去综合医院治疗,因此在综合医院普及精神医学知识,设立心理咨询或精神科门诊,开展联络     

Contenu des courriers échangés entre médecins généralistes et cardiologues : consensus d’après une étude Delphi

Aim of the studyTo obtain a consensus from a panel of experts (GP and cardiologists) on the elements to appear on the correspondence sent by GP at the patient's first consultation with the cardiologist and on the response of the cardiologist.MethodA list of proposals concerning the content of the exchanges between the GP and the cardiologist was established by a scientific council of three GPs and one cardiologist, based on a review of the literature and their practices. This list was submitted for evaluation to a panel of GP and cardiologists experts using the modified RAND/UCLA Delphi method.ResultsTwenty nine experts (16 MG and 13 cardiologists) participated in the two evaluation rounds. For the contents of the letter written by the GP, 11 themes have reached consensus: administrative data, reason for consultation, history of the disease, recent constants, current treatments, current or previous pathologies and cardiovascular risk factors, physical activity, psychosocial context, test results, question asked to the cardiologist, cardiologist's perimeter of action. For the contents of the letter of the cardiologist's response, 11 themes were agreed: administrative data, reason for consultation, previous information, clinical examination, ECG, ultrasound, other complementary examinations, answer to the question asked by the GP, dietary treatments, proposed treatments, proposal for follow-up and management.ConclusionThis study have reached consensus on the elements to appear on the letters exchanged between the GP and the cardiologist.     

Effectiveness of multidisciplinary consultation for older adults with Alzheimer's disease in response to acute situations

Background

To avoid emergency hospitalisation of elderly people with dementia, which often has negative consequences, there are two main approaches: consultation and day care hospitalisation. However, it usually takes some time to arrange a consultation, and geriatric day hospital facilities are over-subscribed and costly. In 2014, we created a “consultation de crise” (CMC) programme in our sector of Paris, with several special features: a short wait for an appointment, a consultation involving an interdisciplinary team, a weekly multi-disciplinary meeting to reassess complex patients, and the possibility of a rapid referral to a social worker.