2018年台州市玉环市流动人口艾滋病相关认知和危险行为现状调查[* 基金项目：浙江省自然科学基金项目(LY19H260001)；台州市科技计划项目(1801KY45)。 ①复旦大学公共卫生学院 上海200032 ②台州市疾病预防控制中心 浙江 台州 318000 #通讯作者 ]

目的 了解台州市玉环市流动人口艾滋病相关认知和危险行为的现状，为开展有效的艾滋病健康教育和干预提供参考依据。方法 采用问卷调查的方法，2018年6—8月对台州市玉环市流动人口开展人口学特征、行为学特征和艾滋病相关认知等方面的调查。结果 共招募403人。未发现HIV抗体、梅毒阳性者；发现1例HCV阳性者，检出率为0.2%。最近一年暗娼占3.3%，临时性伴发生过性行为占1.9%，且42.9%从未使用安全套。艾滋病知识知晓率为62.3%。多因素logistic回归分析显示，高中及以上文化程度者艾滋病知识知晓率高。结论 台州市玉环市流动人口艾滋病知识知晓率较低，存在一定比例的暗娼和临时性行为等高危行为，应加大宣传教育力度。已婚或同居者在艾滋病知识应用上存在欠缺，使用安全套意识不强，应开展行为干预活动，实现“知信行”的统一，以有效地防治艾滋病的流行。     

Appropriateness of End-of-Life Care in People Dying With Dementia: Applying Quality Indicators on Linked Administrative Databases

ObjectivesDementia is a progressive incurable life-limiting illness. Previous research suggests end-of-life care for people with dementia should have a symptomatic focus with an effort to avoid burdensome interventions that would not improve quality of life. This study aims to assess the appropriateness of end-of-life care in people who died with dementia in Belgium and to establish relative performance standards by measuring validated population-level quality indicators.DesignWe conducted a retrospective observational study.Setting and ParticipantsWe included all persons deceased with dementia in 2015 in Belgium. Data from 8 administratively collected population-level databases was linked.MeasuresWe used a validated set of 28 quality indicators for end-of-life dementia care. We compared quality indicator scores across 14 healthcare regions to establish relative benchmarks.ResultsIn Belgium in 2015, 10,629 people died with dementia. For indicators of appropriate end-of-life care, people who died with dementia had on average 1.83 contacts with their family physician in the last week before death, whereas 68.4% died at home or in their nursing home of residence. For indicators of inappropriate end-of-life care, 32.4% were admitted to the hospital and 36.3% underwent diagnostic testing in the last 30 days before death, whereas 25.1% died in the hospital. In the last 30 days, emergency department admission varied between 19% and 31%, dispensing of gastric protectors between 18% and 42%, and antihypertensives between 40% and 53% between healthcare regions, with at least 25% of health regions below 46%.Conclusions and ImplicationsOur study found indications of appropriate as well as inappropriate end-of-life care in people with dementia, including high rates of family physician contact, as well as high percentages of diagnostic testing, and emergency department and hospital admissions. We also found high risk-adjusted variation for multiple quality indicators, indicating opportunity for quality improvement in end-of-life dementia care.     

Obesity as a Causal Risk Factor for Aortic Valve Stenosis

BackgroundCausal risk factors for aortic valve stenosis are poorly understood, limiting the possibility of preventing the most common heart valve disease.ObjectivesThe hypothesis was tested that genetically based obesity measured by body mass index is causally associated with risk of aortic valve stenosis and replacement.MethodsThe authors included 108,211 individuals from the Copenhagen General Population Study. Participants had measurements of body mass index, waist-hip ratio, and waist circumference, and information on 5 genetic variants associated with obesity. A Mendelian randomization design was used to investigate genetic and observational associations of obesity with incident aortic valve stenosis (n = 1,215) and replacement (n = 467) for a median follow-up time of 8.7 years.ResultsGenetically increased body mass index was causally associated with increased risk of aortic valve stenosis. Compared with an unweighted allele score of 0 to 3, individuals with an allele score 7 to 10 had a mean increase in body mass index of 0.87 kg/m², and the age and sex–adjusted hazard ratio for aortic valve stenosis was 1.3 (95% confidence interval [CI]: 1.0 to 1.7) for allele score 4, 1.4 (95% CI: 1.1 to 1.8) for allele score 5 to 6, and 1.6 (95% CI: 1.3 to 2.1) for allele score 7 to 10 (p for trend: 9 × 10⁻⁵). A 1-kg/m² increase in body mass index was associated with causal risk ratios for aortic valve stenosis and replacement, respectively, of 1.52 (95% CI: 1.23 to 1.87) and 1.49 (95% CI: 1.07 to 2.08) genetically, and with corresponding hazard ratios of 1.06 (95% CI: 1.05 to 1.08) and 1.06 (95% CI: 1.03 to 1.08) observationally.ConclusionsObesity from human genetics was causally associated with higher risk of aortic valve stenosis and replacement.     

Nurse Practitioner Student Clinical Placements: A Rural Community Immersion

This article describes a collaboration between a university and a medically underserved area in California’s central valley. Students participate in a community-based clinical immersion to provide care to a medically underserved population. Faculty collaborate with community-based partners to develop and implement clinical experiences. Students are provided opportunities to meet clinical course objectives while developing skills necessary to care for a medically underserved population as part of an interdisciplinary team.     

医疗保险制度对老年群体死亡风险的影响——基于CLHLS的生存分析

目的:探讨医疗保险制度对老年群体死亡风险的影响,为我国医疗保障制度的改革与完善提供参考依据。方法:基于中国老年健康影响因素跟踪调查(CLHLS)2011—2014年的追踪数据,以添加脆弱因子的Weibull模型与Gompertz模型进行生存分析,并且分年龄组进行异质性分析。结果:相对于无医保的老人,有医保老人的死亡风险随医保制度的不同而发生不同程度的变化,具体而言,新农合、城镇居民基本医疗保险以及城镇职工基本医疗保险分别降低了约20%、25%以及31%的死亡风险。通过分年龄组进一步分析发现,医疗保险对高龄组老人死亡风险有显著影响,而对低龄组老人的死亡风险的影响不显著。结论:医疗保险制度有助于降低老年群体的死亡风险,但影响程度各异,表现为城镇职工医疗保险最高,城镇居民医疗保险次之,新农合最低。基于此,我国医疗保险制度改革的重点方向在于继续扩大医保覆盖面,并弥合不同医保之间的待遇差异,在统筹城乡居民医疗保险的基础上,进一步推进城镇职工医疗保险与居民医疗保险的整合,最终实现城乡医疗保险制度的一体化发展。     

The effects of age on health-related quality of life in cancer populations: A pooled analysis of randomized controlled trials using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 involving 6024 cancer patients

BackgroundCancer incidence increases exponentially with advancing age, cancer patients live longer than in the past, and many new treatments focus on stabilizing disease and HRQOL. The objective of this study is to examine how cancer affects patients' HRQOL and whether their HRQOL is age-dependent.MethodsData from 25 EORTC randomized controlled trials was pooled. EORTC QLQ-C30 mean scores for the cancer cohort and five general population cohorts were compared to assess the impact of cancer on patients' HRQOL. Within the cancer cohort, multiple linear regressions (two-sided level P-value = 0.05 adjusted for multiple testing.) were used to investigate the association between age and HRQOL, adjusted for gender, WHO performance status (PS), distant metastasis and stratified by cancer site. A difference of 10 points on the 0–100 scale was considered clinically important.ResultsCancer patients generally have worse HRQOL compared to the general population, but the specific HRQOL domains impaired vary with age. When comparing the cancer versus the general population, young cancer patients had worse financial problems, social and role functioning, while the older cancer groups had more appetite loss. Within the cancer cohort, HRQOL was worse with increasing age for physical functioning and constipation, and better with increasing age for social functioning, insomnia and financial problems (all p < 0.05).ConclusionHRQOL is impaired in cancer patients compared to the general population, but the impact on specific HRQOL domains varies by age. Within the cancer population, some HRQOL components improve with age while others deteriorate. Optimal care for older cancer patients should target HRQOL domains most relevant to this population.