Évaluation du risque suicidaire. Entre analyse théorique et applications en pratique clinique

Since the mid-1990s and its recognition as a “public health priority”, suicide has remained at the centre of various mental health policies. With one of the highest suicide deaths at the European level, France is particularly impacted by this issue. The predictability of a self-aggressive act remains the main concern for a patient in suicidal crisis. The Dangerous Emergency Risk Assessment, established at the consensus conference in October 2000, marked a turning point in the analysis of suicidal risk. Through a triple evaluation corresponding to each of its three items, this tool has made it possible to better clarify the proposed therapeutic management and in particular the decision or not of a hospitalization. However, the latter remaining perfectible in its analysis, a mapping of key points at the clinical level has been proposed in this article in order to have the widest possible vision of a patient in suicidal crisis. The assessment of suicidal potential remains subject, despite everything, to a part of improbability. As such, a brief hospitalization in the context of the suicidal crisis has all its interest whether in front of a suicidal person or in front of a suicidal person, this in the absence of a decompensated psychiatric pathology, in order to allow a “distance” from the anxiety-provoking environment and to create a bond of trust facilitating outpatient work.     

慢性心力衰竭护理结局分类评价表的构建研究

目的本研究以护理结局分类(NOC)为基础,筛选符合慢性心力衰竭患者的相关护理结局,由此构建具有专科专病特点的慢性心力衰竭患者护理结局评价表。方法成立研究核心小组,应用文献回顾法、专家函询法确定护理结局分类指标,并进行统计学分析,最终建立慢性心力衰竭护理结局分类评价表。结果通过研究,确定慢性心力衰竭护理结局中包含4个领域、8个一级指标、68个二级指标。4个领域分别是生理健康、功能健康、健康知识和行为、心理社会健康。一级指标中包含心脏泵血功能、活动耐力、社会支持、抑郁水平等。二级指标中包含心脏指数、血压、呼吸困难、情绪波动大、步行距离、步行速度等68个指标。统计学分析中:第一、二轮函询专家的积极系数分别为90%、100%,专家权威系数为0.895,专家意见协调程度(P<0.05)。结论本研究成功建立慢性心力衰竭护理结局分类评价表,有助于临床护士用于评价护理措施的有效性,也使其成为一种标准化语言,便于应用到护理电子信息系统中进行绩效测算等。但是本研究不足之处是未能将该研究进行临床实证,未能进一步确认其有效性。     

Reproducibility of LI-RADS treatment response algorithm for hepatocellular carcinoma after locoregional therapy

PurposeTo determine inter-reader agreement in categorizing hepatocellular carcinoma (HCC) treated with locoregional therapy using the Liver Imaging Reporting and Data System (LI-RADS) treatment response (LR-TR) algorithm.Materials and methodsA total of 93 patients with a total of 112 HCC nodules that were treated using thermal ablation or transarterial chemoembolization were prospectively included. There were 79 men and 14 women with a mean age of 55 ± 2.6 (SD) years (range: 48–63 years). All patients underwent magnetic resonance imaging (MRI) examination of the liver and MR images were analyzed by two independent observers. Treated HCC nodules were categorized into four groups according to LR-TR scoring system including: (i) LR-TR non-evaluable (treated, response not evaluable); (ii) LR-TR nonviable (treated, probably or definitively not viable); (iii) LR-TR equivocal (treated, equivocally viable) and (iv) LR-TR viable (treated, probably or definitively viable). The inter-observer agreement in LR-TR categorization was assessed using the kappa statistics.ResultsThere was excellent inter-observer agreement between the two reviewers for overall treated HCC according to LR-TR algorithm (kappa = 0.938; 95% CI: 0.89–1.00; P = 0.001) with 97.31% agreement. The LR-TR categories by both reviewers were non-viable (77/112; 69.6% and 76/112; 67.9%), viable (30/112; 26.8% and 32/112; 27.7%) and equivocal (5/112; 4.4% and 4/112; 3.6%). There was excellent inter-observer agreement for LR-TR nonviable (kappa = 0.938; 95% CI: 0.87–1.0; P = 0.001) with 97.3% agreement, LR-TR viable (kappa = 0.955; 95% CI: 0.89–1.00; P = 0.001) with 98.2% agreement and good inter-observer agreement for LR-TR equivocal (kappa = 0.700; 95% CI: 0.28–1.0; P = 0.001) with 97.3% agreement.ConclusionLR-TR algorithm conveys high degrees of inter-observer agreement for the evaluation of treatment response of HCC after thermal ablation and transarterial chemoembolization.     

医养结合型养老机构卫生服务质量指标体系构建研究

目的:构建基于SERVQUAL模型的医养结合型养老机构卫生服务质量评价指标体系。方法:围绕医养结合型养老机构卫生服务的概念、特性、内涵、内容等,采用文献研究法、半结构式访谈法、Delphi—AHP法等定性与定量相结合的研究方法,构建指标体系并确定指标权重。结果:构建了具有7个一级指标,27个二级指标和77个三级指标的养老机构卫生服务质量评价指标体系。指标体系三轮咨询专家权威系数Cr均高于0.84,专家综合权威性系数均高于0.83;总体专家协调系数Kendall W第一、二轮为0.309,第三轮为0.706,且均通过显著性检验;内容效度指数I-CVI介于0.90~1.00之间,S-CVI为0.94,kappa值均高于0.74;信度系数Cronbachα总体为0.972,各维度Cronbachα系数在0.792~0.921之间。评价指标体系具有较好的稳定性、可靠性和一致性。结论:本研究建立的评价指标体系有利于医养结合型养老机构全面建立贴近老年人卫生服务需求的内设医疗机构,改善机构内卫生服务质量。在对指标体系进行应用时,可转化为机构中老年人对各指标项目的感受(P)与期望(E),以两者的差值(P-E)代表机构的卫生服务质量。根据专家赋权结果,应重点加强医养结合养老机构对可靠性、有效性、经济性等指标项目的建设。     

综合营养评估工具在心衰患者中的应用价值

目的 对心衰患者所采用的综合营养评估工具及应用价值进行综述，为我国心衰患者的营养相关研究提供理论基础。方法 以“营养”、“心力衰竭”、“nutrition”、“heart failure”等为关键词，查询PubMed、Web of Science、知网等数据库相关文献，综述材料。结果 对心衰患者运用的综合营养评估工具种类较多，各量表信效度较高，营养风险和营养不良检出率较好，但均为普适量表，测评内容不能与心衰患者的临床特征完全相符，开发针对心衰患者的营养评估工具处于起步阶段。结论 综合营养评估工具对心衰患者的营养评估效果较好，未来需要加强针对心衰患者营养量表的研究。     

Comparing Participation Outcome Over Time Across International Stroke Cohorts: Outcomes and Methods

ObjectiveTo enable a direct comparison of participation levels in the first year post-stroke, assessed by different outcome measures internationally.DesignTwo prospective stroke cohort studies following persons from stroke onset to 12 months post-stroke.SettingCommunity.ParticipantsPersons with stroke (N=495), not living at a nursing home, from Australia STroke imAging pRevention and Treatment-Prediction and Prevention to Achieve optimal Recovery Endpoints after stroke (START-PrePARE; n=100) and the Netherlands (Restore4stroke; n=395).InterventionsNot applicable.Main Outcome MeasuresActivity Card Sort-Australia and Utrecht Scale for Evaluation of Rehabilitation-Participation. Activity domains were matched across measures to find common denominators and original scoring methods were recoded, hereby enabling a direct comparison of retained activities.ResultsNinety-one (START-PrePARE) and 218 (Restore4stroke) persons with stroke were included for analyses. No major differences in background characteristics were observed between the cohorts; the Dutch cohort suffered from slightly more severe stroke. A higher level of participation was observed (radar charts) in the first months post-stroke for the Australian cohort than in the Dutch cohort, especially for unpaid work (P<.003). At 12 months post-stroke, participation levels were similar, without significant differences in retained activities using the defined common denominators (P>.003).ConclusionsAn international comparison of actual activities that persons re-engage in in the first year post-stroke was achieved using a new method and recoding of data. High levels of participation were observed in both cohorts. Unpaid work showed different frequencies at 2-3 months, contributing to different trajectories over time across cultures. Important insights were gained. Although valuable information is inevitably lost with recoding, the approach may assist future studies on the harmonization of data across cohorts, particularly for 1 of the key outcomes of stroke: participation.     

Breast reconstruction after therapeutic or prophylactic mastectomy for breast cancer: A comparison of guideline recommendations

BackgroundThe purpose of this article is to illuminate differences in published clinical practice guideline recommendations for breast reconstruction after prophylactic and therapeutic mastectomy.MethodsTen guidelines were identified through a systematic search of websites and databases of reputable oncology guideline developers, and key differences and gaps in recommendations were noted. Quality assessment of the guidelines was conducted by three reviewers using the AGREE II tool, focusing on breast reconstruction specific documents rather than the general breast cancer guidelines.ResultsThe most comprehensive guidelines were published by Alberta Health Services, Cancer Care Ontario, the American Society of Plastic Surgeons, and the Association of Breast Surgery/British Association of Plastic Reconstructive and Aesthetic Surgeons. AGREE II scores in the domains of “Scope and Purpose” and “Clarity and Presentation” were ranked relatively high for all four guidelines while “Applicability” and “Editorial Independence” were ranked relatively low. The Alberta and Ontario guidelines were the overall highest ranked guidelines across all domains.ConclusionOverall, these guidelines provide consistent recommendations on who should receive breast reconstruction education, who is a candidate for postmastectomy breast reconstruction, and the appropriate timing of reconstruction and extent of mastectomy. Future updates from all should focus on expanding to include alloplastic and autologous forms of reconstruction and should include a broad scope of relevant questions.     

遗传学检测技术的国际评估流程简介

目的通过梳理国际上现有遗传学检测技术评估项目的框架、流程,重点关注现有技术评估流程与其存在的困难,为建立适用于我国遗传学检测技术评估流程提供参考与建议。方法采用文献研究法归纳分析现有不同遗传学检测技术评估流程,进行总结、比较,并提出建议。结果目前已有多个国家及组织开展了遗传学检测技术评估项目,评估框架一般基于ACCE或HTA开发,而评估与决策流程在大体构架上类似,主要包括主题遴选、实施评估、汇报结果和提出建议等环节。遗传学检测技术评估仍面临证据有限、决策具有不确定性等困难。结论为建立适用于我国的遗传学检测技术评估流程,建议开展遗传学检测技术主题遴选,开展检测技术必要性和可行性预评估,进行正式评估及证据审查,进行结果应用与决策转化,制定定期审查与修订机制。