Video analysis of communication in paediatric consultations in primary care.

BACKGROUND: There is a paucity of research evidence concerning communication in paediatric consultations between GPs, adults, and child patients. AIM: This study was carried out to identify features of the interaction between a doctor, a child patient aged 6-12 years, and their carer in the consultation associated with the child's participation. DESIGN OF STUDY: A qualitative analysis of video recordings of 31 primary care paediatric consultations was undertaken, using strategies from the methodology of conversation analysis. SETTING: Primary care, Suffolk, UK. METHOD: NHS GPs from three primary care trusts (PCTs), were invited to participate in this study. Sixteen volunteers from this sample took part. RESULTS: Analysis of the interaction in the consultations revealed that the children had little involvement. Children participated when invited to do so, and took more time than adults to answer a doctor's question. An adult carer was less likely to answer on behalf of a child, when they were in a position to see that the doctor's gaze was directed at the child, and the doctor addressed the child by name. Adult carers, who had not voiced their own concerns first, were seen to interrupt doctor-child talk. In consultations where the participants sat in a triangular arrangement, all parties being an equal distance apart, triadic talk was noted. CONCLUSION: Child involvement in the primary care consultation is associated with adult carers being able to voice their own concerns early in the consultation, and children being invited to speak with the appropriate recipient design.     

An observational study of variation in GPs' out-of-hours emergency referrals.

Out-of-hours organisations are responsible for the care of patients 70% of the time, and their GPs act as gatekeepers to secondary care services. This observational study identifies the variations in GPs' out-of-hours referral rates to secondary care and factors that could explain these variations. One hundred and forty-nine GPs who worked in one UK general practice out-of-hours cooperative which served 19 practices with 167 000 registered patients. Data on patients who accessed the out-of-hours service over 3 years (2001-2004) were examined. Factors thought to be predictors of variation in referral rates were investigated using logistic regression analysis. There was a fivefold difference in referral rates between the lowest and highest referring quartiles of GPs (OR [odds ratio] = 4.56, CI [confidence interval] = 3.86 to 5.38). The sex (female) of the clinician, the time of the consultation (11 pm to 7 am), and the place of the consultation (home visit) accounted for some, but not all, of the increased referral rates. A doctor working out-of-hours disproportionately influences the fate of the patient, the number of hospital admissions, and extra costs to the health service. There is a need for follow-up studies to investigate the factors associated with referral behaviour, and how the variation relates to patient factors and the resources available. These findings could be used when planning the staffing of out-of-hours services to optimise appropriate care and minimise patients' exposure to unnecessary intrusive and expensive hospital care.     

Accessibility, clinical effectiveness, and practice costs of providing a telephone option for routine asthma reviews: phase IV controlled implementation study.

BACKGROUND: Attendance for routine asthma reviews is poor. A recent randomised controlled trial found that telephone consultations can cost-effectively and safely enhance asthma review rates; however, concerns have been expressed about the generalisability and implementation of the trial's findings. AIM: To evaluate the effectiveness of a telephone option as part of a routine structured asthma review service. DESIGN OF STUDY: Phase IV controlled before-and-after implementation study. SETTING: A large UK general practice. METHOD: Using existing administrative groups, all patients with active asthma (n = 1809) received one of three asthma review services: structured recall with a telephone-option for reviews versus structured recall with face-to-face-only reviews, or usual-care (to assess secular trends). Main outcome measures were: proportion of patients with active asthma reviewed within the previous 15 months (Quality and Outcomes Framework target), mode of review, enablement, morbidity, and costs to the practice. RESULTS: A routine asthma review was provided for 397/598 (66.4%) patients in the telephone-option group compared with 352/654 (53.8%) in the face-to-face-only review group: risk difference 12.6% (95% confidence interval [CI] = 7.2 to 17.9, P<0.001). The usual-care group achieved a review rate of 282/557 (50.6%). Morbidity was equivalent in the three groups; however, enablement (P = 0.03) and confidence (P = 0.007) in asthma management were greater in the telephone-option versus face-to-face-only group. The cost per review achieved by providing the telephone-option service was lower than the face-to-face-only service (10.03 pounds versus 12.74 pounds, mean difference 2.71 pounds; 95% CI = 1.92 to 3.50, P<0.001); usual-care costs were 11.85 pounds per review achieved. CONCLUSION: Routinely offering telephone reviews cost-effectively increased asthma review rates, enhancing patient enablement and confidence with management, with no detriment to asthma morbidity. Practices should consider a telephone option for their asthma review service.     

Hidden posttraumatic stress disorder in the mother of a boy with traumatic limb amputation

Posttraumatic stress disorder (PTSD) is usually diagnosed in the primary victim of a psychologically distressing event who demonstrates the criteria symptomatology. Presented here is a case study of PTSD symptoms in a mother whose 4-year-old boy underwent bilateral arm amputation. Discussed is how the mother became the primary PTSD victim and why the particular injury (electrical shock) can be explained as readily giving rise to her problems. Consultants to pediatric and trauma services are reminded that the primary patient's medical care may suffer if disorders such as PTSD are not recognized in those responsible for making treatment decisions for the young victim.     

Stage, survival and delays in lung, colorectal, prostate and ovarian cancer: comparison between diagnostic routes

BACKGROUND: Very few studies have reported cancer outcomes of patients referred through different routes, despite the prominence of current UK cancer urgent referral guidance. AIM: This study aimed to compare outcomes of cancer patients referred through the urgent referral guidance with those who were not, with respect to stage at diagnosis, survival, and delays in diagnosis. Design of study: Analysis of hospital records. SETTING: One hospital trust in England. METHOD: The records of 889 patients diagnosed in 2000-2001 with one of four types of cancer were analysed: 409 with lung cancer; 239 with colorectal cancer; 146 with prostate cancer; and 95 with ovarian cancer. Outcome measures were diagnostic stage, survival, referral and secondary care delays. RESULTS: For lung cancer, urgent referrals had more advanced TNM (tumor, node, metastasis) stage than patients diagnosed through other routes (P = 0.035) and poorer survival (P = 0.020). There was no difference in stage or survival for the other cancers. For each cancer, a higher proportion of urgent referrals was seen within 2 weeks. Secondary care delays for lung and colorectal cancer were shorter for inter-specialty referrals. CONCLUSION: For patients with lung cancer, the guidance appears to be prioritising those in the more advanced stages of disease. This was not the case for the other three cancers. Referral delays were shorter for patients urgently referred, as is the intention of the guidance. The avoidance of delays in outpatient diagnostics probably accounts for shorter secondary care delays for inter-specialty referrals.     

中国ESI高被引科学家和ESI学术期刊的学科分布探析与比较

【目的】 结合国家对学术期刊发展的指导政策,为中国英文学术期刊发展路径提供思路、数据支撑和理论指导。【方法】 以中国ESI高被引科学家和ESI期刊在ESI 22个学科的分布为研究对象,对两者分别在世界ESI高被引科学家和世界ESI高被引期刊中的发展脉络进行分析。【结果】 两类研究对象的发展现状不均衡,中国ESI期刊行业布局尚未对中国ESI高被引学者的跨学科发展趋势做出响应。【结论】 在中国基础学科的高被引科学家不断涌现的背景下,除了大力发展基础学科的高质量期刊以外,扶持交叉领域期刊、综合性学术期刊以及文科和应用型学科期刊的发展对促进中国ESI期刊学科分布均衡发展有重要意义;中国ESI期刊应将扶植国内科研工作者作为首要使命。     

国际典型综合类科技期刊公众传播特点及对我国综合类科技期刊公众传播能力建设的启示

【目的】 分析国际顶级综合类科技期刊公众传播模式及特点,为我国科技期刊公众传播能力建设提供建议。【方法】 以Altmetric Top 100入选论文数量最多的Nature、Science和PNAS三刊为研究对象,剖析其在公众传播产品、媒体传播体系和新闻媒体人才支撑等方面的模式和特征。对照分析我国最有影响力的综合类科技期刊《国家科学评论》和《科学通报》的公众传播特点。【结果】 以《国家科学评论》和《科学通报》为代表的我国综合类科技期刊的公众传播能力提升迅速,但仍存在新闻传媒人才短缺、期刊集约化程度不高、公众传播机制尚未建立等问题。【结论】 我国综合类科技期刊需要着力增强传媒人才培育、集约化品牌发展、公众传播机制建设,以促进我国科技期刊公众传播能力提升。     

外科常见腹腔感染多学科诊治专家共识

腹腔感染是临床常见的急危重症之一,其诊治涉及外科、重症医学、感染、检验、临床药学等多个学科,包括局部病灶处置、病原学检测、抗菌药物合理应用及因感染导致的全身各系统异常状况纠正等过程,具有特殊性及复杂性。本共识参考国内外最新进展并结合临床经验,以问题为导向,以循证为基础,对急性阑尾炎、上消化道穿孔、下消化道穿孔、急性胆道感染、肝脓肿、重症急性胰腺炎、胰瘘、胆瘘、吻合口瘘、内镜诊治后消化道穿孔等外科常见腹腔感染的诊断、病原学检测、外科及抗菌药物治疗等临床热点问题进行评述,并根据证据等级提出诊治相关的推荐意见,旨在规范外科常见腹腔感染的诊疗行为,在临床决策、抗菌药物应用等方面为临床医师提供参考及指导,以提高诊治水平并改善患者预后。