临床药师在多学科疼痛管理团队中的作用及工作模式

积极采取有效的镇痛措施缓解疼痛,提高患者的舒适度和生活质量,是疼痛管理工作的重要内容。要达到这个目标,医院必须具备完善的镇痛能力和疼痛管理团队。我院通过借鉴国内外先进经验,结合本院临床现状,成立了多学科合作的疼痛管理团队,并将临床药师作为团队重要成员参与用药教育、用药方案的制定与调整以及监测药物治疗情况等临床药学相关工作,形成了临床药师在多学科疼痛管理团队中的初步工作模式。     

Lower anticoagulation for mechanical heart valves: experience with the ATS bileaflet valve

Background: The design of the bileaflet ATS (ATS Medical Inc., Minneapolis, USA) mechanical valve incorporates an open pivot at the hinge mechanism. Total washout of the blood at the pivot area was observed using 3-D computational fluid dynamics modelling. This phenomenon could make the valve less vulnerable to clot formation in patients without major thromboembolic risk factors.

Methods: From January 1993 to June 1999, 286 consecutive patients had the ATS valve inserted in the aortic position. Patients were divided into two groups. Group 1 comprised all patients in regular sinus rhythm with good left ventricular function (144 patients). Group 2 included patients in non-sinus rhythm and/or with large hypocontractile left ventricles (142 patients). The anticoagulation regime in group 1 was used to obtain an international normalised ratio (INR) between 1.5 and 2.5. This contrasts with our regular aim to maintain the INR strictly between 2.5 and 3.5 for all mechanical valves, as achieved in group 2.

Results: The follow-up period (99% completeness) ranged from 18 to 84 months. Survival (Kaplan-Meier) was 97 and 98% and 92 and 81% at 1 and 5 years in group 1 and group 2, respectively (P = 0.12). Log rank analysis failed to detect a statistical difference in thromboembolism or bleeding between both groups (P > 0.05). However, trends were in favour of group 1. Univariate analysis selected poor ventricular function and an ‘erratic’ INR value (P = 0.002) as risk factors for death. The sole independent risk factor for bleeding was the use of aspirin (P = 0.025).

Conclusions: The excellent group 1 data and outcome encouraged us to continue our low intensive anticoagulation regime and perhaps should be regarded as a new concept for treatment of selected mechanical valve patients.     

Inflammatory, abscess-forming foreign body reaction mimics a thrombus formation on an atrial septal defect closure device: A commented case report.

We are presenting a case of floating left and right atrial formations on an atrial septal defect occluder system (23mm StarFLEX)-Occluder) initially supposed to be thrombotic appositions in a 57-year-old man. The closure was performed on the background of left hemispheric stroke and atrial septal aneurysm (ASA) with patent foramen ovale (PFO). The suspect structures were detected in the 6-month follow-up by transesophageal echocardiography (TEE). The patient underwent a successful surgical explantation of the closure device and closure of the patent foramen ovale (PFO) using a pericardial patch. The pathological evaluation of the biatrial device associated appositions revealed hytrophic heart muscle tissue with perifocal scarring and purulent abscess-forming, granulating and foam-cell including inflammatory foreign body reaction instead of the expected thrombus formation.     

山东省改水降氟工程使用现状

目的：了解山东省改水降氟工程运转使用的现状。方法：对山东省所有改水降氟工程的运转使用情况按统一表格进行调查。结果：自1980年至2001年，山东省共建设改水降氟工程5934处，以打低氟井为主；运转基本正常的工程4159处，占70．09％，不正常的工程26处，占0．44％，停用报废的工程1749处，占29．47％。5934处改水降氟工程共涵盖病村7880个。已改水病村中，有5689个村的工程运转基本正常，占73．54％；有2110个村的工程运转不正常和停用报废，占26．46％。停用报废的主要原因是管理不善、工程质量差、管道断裂和水氟超标。在改水工程运转基本正常的病村中，有4050个村的饮水氟≤1．00mg/L，占改水村的51％，占全部病村的35％；改水实际受益人口324万余人，占病区总人口的1/3。结论：山东省改水降氟工程的水氟超标和停用报废现象严重，急需改进。     

Haemophilia care in China: achievements of a decade of World Federation of Hemophilia treatment centre twinning activities

Summary. The World Federation of Hemophilia (WFH) began its involvement in China in 1993, supporting Chinese haemophilia centre twinning programmes in 1997. Although only three Chinese centres were in a twinning relationship (Tianjin/Calgary 1997–2004, Guangzhou/Ottawa 2000–2006, Shanghai/Ottawa, Calgary 2002–2007), WFH helped establish a collaborative network of six Chinese centres (Tianjin, Guangzhou, Shanghai, Beijing, Hefei, Jinan) in 2004. These network centres, in collaboration with haemophilia patients, shared and coordinated several successful ongoing priority projects (Registry, Nursing, Laboratory Diagnosis, Physiotherapy and Prophylaxis). A number of physicians, nurses and technologists have received WFH fellowships for training internationally. They are becoming haemophilia‐care leaders and are key personnel working towards comprehensive care in China. National and regional workshops/conferences in addition to educational material development have been successful in reaching out to healthcare professionals and persons with haemophilia across the country. Key elements of success include the enthusiasm and commitment of the Chinese professionals and patient leaders in their desire to advance haemophilia care and their commitment to work collaboratively in a coordinated manner. They are beginning to gain national and international recognition and are launching outreach education and care programmes to cover other parts of China. WFH is now transitioning support in China from a twinning program to country programme (Global Alliance for Progress). Haemophilia work in China is still in the beginning, but there is now a solid foundation for future progress.     

Familial Risk of Type I diabetes in European Children

Summary The characteristics of familial Type I (insulin-dependent) diabetes mellitus – that is Type I diabetes in a first degree relative were investigated for children diagnosed before the age of 15 years using data from an international network of population-based registries (the Eurodiab Ace network) and from a case-control study (Eurodiab Ace Substudy 2) conducted by eight of the network's centres. Ecological analysis across the 18 centres showed a positive association between the population incidence rate of Type I diabetes and the prevalence of Type I diabetes in fathers of affected children (Spearman's rank correlation coefficient r _s = 0.70, p < 0.001). A similar association was observed with the prevalence in sibling (r _s = 0.71, p < 0.001), but the association with prevalence in mothers was weaker and not significant. Pooling results from all centres showed that a greater proportion of fathers (3.4 %) of affected children had Type I diabetes than mothers (1.8 %) giving a risk ratio of 1.8 (95 % CI 1.4 to 2.5). Affected girls were more likely to have a father with Type I diabetes than affected boys (odds ratio 1.56, 95 % CI 1.07 to 2.27), but there was no evidence of a similar finding for mothers or siblings. Children with disease onset in the 0–4 year age-range were more likely to have an affected father than were children who were older at onset, and similar although weaker associations were seen in mothers and siblings. This suggests that familial Type I diabetes patients have a younger age at onset than non-familial patients. In conclusion, a positive association between the prevalence of familial Type I diabetes and the population Type I diabetes incidence rate was shown and the characteristics of familial Type I diabetes (younger age at onset and preferential transmission of disease from tather to child and particularly from father to daughter) were described. [Diabetologia (1998) 41: 1151–1156] Received: 16 February 1998 and in revised form: 4 May 1998     

基于《国际功能、残疾和健康分类》的居家脊髓损伤患者功能变化的纵向研究

目的:以移动APP“脊髓损伤患者远程延续护理系统”中的《国际功能、残疾和健康分类》(ICF)相关随访指标为结局评定指标,纵向探讨脊髓损伤患者出院后功能状态的变化趋势。方法:2018年6月-2019年9月,选取广州市、十堰市和成都市4家医院的6个临床科室的符合纳入排除标准的91例脊髓损伤患者,随访护士以APP中的32个随访指标(31个ICF类目和1个不能被ICF涵盖的指标“照顾者的能力”)为测量工具,分别在患者出院时、出院后3个月和出院后6个月使用APP评定患者的功能状态。结果:75%(24个)ICF类目的适用率占90%以上,适用率最低的两个类目分别是性功能(29.67%)和生殖功能(14.29%);在32个随访指标中,21个ICF类目(5个身体功能领域的类目,全部10个活动和参与领域的类目,6个背景性因素领域的类目)和1个不能被ICF涵盖的指标“照顾者的能力”在3个时点的评定结果之间的差异均有显著性意义,表明居家SCI患者的这些功能状态随时间发展有所好转。未呈现明显好转趋势的10个类目涉及生理功能障碍和常见并发症,均属于身体功能和身体结构成份。结论:SCI患者出院后6个月内,大部分个体功能状态随着时间的推移逐渐好转。但部分生理功能障碍和并发症难以随着时间推移有明显改善,仍需要长期的康复和科学管理。     

Maternal fat mass at mid-pregnancy and birth weight in Brazilian women

Abstract

Background: The relationship between maternal body composition and foetal development is unclear.

Aim: To determine the relationship between maternal body composition [fat mass (FM) and fat-free mass (FFM)] and foetal growth and birth weight, independent of potential confounding factors.

Subjects and methods: This study consisted of 92 women, normal and overweight/obese, recruited from the Instituto Fernandes Figueira in Rio de Janeiro, Brazil. Body composition (FM and FFM) was estimated using bioelectrical impedance. Foetal growth was assessed using serial ultrasound measurements at the second and third trimester and infant's weight and length were measured at birth. Multiple linear regression analyses were used to determine the association between maternal FM and FFM and birth weight adjusted for gestational age (BWt) and change in estimated foetal weight (ΔEFW), controlling for infant gender, maternal serum glucose, energy intake, parity, height and income.

Results: Maternal FM, but not FFM, was positively associated with BWt (p?=?0.02) and borderline with ΔEFW (p?=?0.05). FM expressed as a percentage of body weight (%FM) showed a significant positive association with BWt (p?<?0.001) and ΔEFW (p?<?0.01). Using backward linear regression analysis, FM was a significant predictor of BWt (p?<?0.001) and ΔEFW (p?=?0.03), but not change in femur length.

Conclusion: In this small sample of normal and overweight/obese women, maternal FM at mid-pregnancy is associated with neonatal BW and foetal growth.     

Liver steatosis assessment: Correlations among pathology,radiology, clinical data and automated image analysis software

Quantitating hepatic steatosis is important in many liver diseases and liver transplantation. Since steatosis estimation by pathologists has inherent intra- and inter-observer variability, we compared and contrasted computerized techniques with magnetic resonance imaging measurements, pathologist visual scoring, and clinical parameters. Computerized methods applied to whole slide images included a commercial positive pixel count algorithm and a custom algorithm programmed at our institution. For all liver samples (n = 59), including pediatric, adult, frozen section, and permanent specimens, statistically significant correlations were observed between pathology, radiology, and each image analysis modality (r = 0.75–0.97, p < 0.0001), with the strongest correlations in the pediatric cohort. Statistically significant relationships were observed between each method and with body mass index (r = 0.37–0.56, p from <0.0001 to <0.05) and with albumin (r = 0.55–0.64, p < 0.05) but not with alanine aminotransferase or aspartate aminotransferase. Although pathologist assessments correlated (r = 0.64–0.86, 0.92–0.97, and 0.78–0.91 for microvesicular, macrovesicular, and overall steatosis, respectively), the absolute values of hepatic steatosis visual assessment were susceptible to intra- and inter-observer variability, particularly for microvesicular steatosis. Image analysis, pathologist assessments, radiology measurements, and several clinical parameters all showed correlations in this study, providing evidence for the utility of each method in different clinical and research settings.     

抗凝/抗血小板治疗患者拔牙术后出血的研究进展

对接受抗凝/抗血小板治疗的患者进行拔牙手术,常因术后出血风险较高被许多口腔颌面外科门诊医生视为禁忌。多种因素与其发生术后出血相关,但目前还未达成共识。本文以近年文献为基础,对接受抗凝/抗血小板治疗患者发生拔牙术后出血的相关因素进行综述。文献复习结果表明,服用抗血小板药物的患者术后出血风险较服用抗凝药物的患者低;抗凝药物与非甾体类抗炎药、抗抑郁药选择性5-羟色胺抑制剂和5-羟色胺-去甲肾上腺素抑制剂合用,以及术前使用抗生素时,出血风险增加。此外,特定的全身疾病如糖尿病、拔牙位点感染史、较大的手术创伤等与更高的术后出血风险有一定相关性。目前普遍认为拔牙术前不停药、术后合理运用不同的止血措施是安全可行的。未来还需要更多前瞻性的对照试验,以建立不同条件下接受抗凝/抗血小板治疗的患者进行拔牙手术时的安全体系。