辨体-辨病-辨证诊疗模式在慢性病防治中的应用策略

依据中国防治慢性病中长期规划(2017—2025年),按照国医大师王琦教授倡导的"辨体-辨病-辨证诊疗模式",提出慢性病"3+4+3"防治路向:面向三类人群(一般、高危、患病人群),朝向四种状态(无病、病前、病中、病后状态),指向三辨模式(辨体-辨病-辨证诊疗模式)。进而探讨其应用策略:对于一般人群无病状态——辨体养生,固本防病;对于高危人群病前状态——辨体干预,治本救萌;针对患病人群病中状态——"三辨"施治,标本兼顾;针对患病人群病后状态——辨体调理,固本防复。文中结合案例加以佐证,具有临床指导价值。     

经阴道骶棘韧带悬吊治疗盆腔器官脱垂的疗效观察

【目的】探讨经阴道骶棘韧带悬吊治疗盆腔器官脱垂(POP)的临床疗效。【方法】选取2016年1月至2018年11月在本院治疗的POP患者47例,根据选取的手术方案分为观察组(n=27)和对照组(n=20),观察组给予阴道骶棘韦刃带悬吊术,对照组给予骨盆漏斗韧带悬吊术,比较两组患者手术时间、术中出血量等;所有患者均于术后3个月进行POP-Q测量,其中Ba指阴道前壁中线距处女膜缘3cm处,C指阴道残端和Bp指阴道穹窿的反摺及阴道残端距阴道处女膜中线点最远处。术后1年采用盆底功能障碍问卷-20(PFDI-20)和性生活问卷-12(PISQ-12)评估两组患者生活质量和性生活质量并比较。【结果】观察组手术时间、术中出血量和留置尿管时间分别为(64.02±13.22)min、(87.20±12.23)mL和(87.92±12.21)h,明显少于对照组(P<0.05);观察组和对照组术后3个月Ba、C和Bp较术前改善(P<0.05),但两组术后3个月Ba、C和Bp比较差异无统计学意义(P>0.05);观察组术后1年PDFI-20评分为(20.03±2.19)分,明显低于对照组(P<0.05),而PISQ-12评分为(43.30±5.10)分,明显高于对照组(P<0.05);两组术后并发症发生率比较差异无统计学意义(P>0.05);两组随访期间无复发病例发生。【结论】经阴道骶棘韧带悬吊术治疗POP疗效显著,减少手术时间和术中出血量,提高患者生活及性生活质量,值得临床推广应用。     

Identifying Syndemics for Sexually Transmitted Infections Among Young Adults in the United States: A Latent Class Analysis

Purpose

Syndemic theory suggests that the convergence of social, environmental, and ecological factors can interact to exacerbate behavioral health problems and are often intensified by social conditions and disparities. This study used latent class analysis (LCA) to determine gender and racial/ethnic specific classes for sexually transmitted infection (STI) risk.

上海市徐汇区45~55岁居民动脉粥样硬化性心血管疾病风险的影响因素分析

背景　动脉粥样硬化性心血管疾病（ASCVD）是我国居民健康的首要威胁，也是我国居民的首要死亡原因，占城市居民的41.8%，占农村居民的44.8%。家庭医生及其团队对社区中年人群相关风险因素的调研评估、干预及综合管理，可尽早预防ASCVD的发生发展。目的　调查上海市徐汇区45~55岁居民ASCVD风险因素，为日后对相关人群开展针对性的健康干预提供参考意见和建议。方法　采集2019年1-5月在上海市徐汇区枫林街道社区卫生服务中心门诊就诊、信息平台留存准确个人资料（性别、年龄、联系电话）及在本单位体检留存生理、生化数据〔身高、体质量、BMI、血压和血清总胆固醇（TC）、三酰甘油（TG）、高密度脂蛋白胆固醇（HDL-C）、低密度脂蛋白胆固醇（LDL-C）及空腹血糖（FPG）〕的530例居民的信息。采用电话回访或现场面对面调查，参照《中国成人血脂异常防治指南（2016年修订版）》中“总体心血管危险评估”相关章节内容定义ASCVD 风险，同时基于社区实际情况，将评估低危和中危人群归为ASCVD低风险组，高危和极高危人群归为ASCVD高风险组。采用多元Logistic逐步回归分析探究居民ASCVD风险的影响因素。结果　发放问卷530份，回收有效问卷502份，有效回收率为94.7%。ASCVD低风险组38例，ASCVD高风险组464例。ASCVD高风险组年龄、TG、FPG、男性比例、心脑血管病史比例、糖尿病史比例、高血压史比例、服用降压药史比例、服用调脂药史比例高于ASCVD低风险组（P<0.05）。多元Logistic逐步回归分析结果显示，≥50岁、TG≥1.5 mmol/L、FBG≥6.1 mmol/L、男性是居民ASCVD风险的危险因素（P<0.05）；服用调脂药史是居民ASCVD风险的保护因素（P<0.05）。结论　上海市徐汇区45~55岁居民ASCVD风险的主要可控危险因素是血脂（TG）及血糖的异常；不可控危险因素是年龄、性别。对于增龄、男性、合并脂代谢异常的居民更应关注ASCVD的风险并予以生活方式干预和调脂药规范使用指导。社区开展多重风险因素评估及管理对ASCVD的早期筛查、早期干预及治疗均非常重要，对家庭医生及其团队开展相关一、二级预防工作有指导借鉴意义。     

P53 Expression in benign Breast Disease Development: A Systematic Review

Background: Benign breast disease (BBD) is one of main breast cancer risk factors. Dysfunctions on p53 protein, which has a genome protective role, have been related to breast cancer developments. However, its role on BBD development is still unclear. Methods: A systematic review of literature was proceeded according to PRISMA-P guidelines. PubMed, BVS, MEDLINE and Scholar Google were used as databases, complemented by a manual search in articles references.  Articles searches were conducted from May to July 2019 and publications in English, Spanish and Portuguese were selected. P53 expression was set as outcome among women with BBD and were included only articles with good quality according STROBE tools. Data concerning p53 expression frequencies were independently extracted by two review authors, and eligible articles were synthesized. Results: From 12 studies selected for this review, the majority analyzed p53 expression in non-proliferative lesions and general p53 expressions ranged from 0 to 100%. P53 expression was more frequently observed in cases series studies (91.7%) and in studies conducted in Occidental Europe (41.7%). P53 expression was more frequent among tissues with fibrocystic disease (22.5%) and fibroadenoma (22.5%). Conclusion: When compared with all breast tissues types, benign breast disease corresponds to 34.39% of p53 expression. Second outcomes were not evaluated because the heterogeneity observed in selected studies. In addition, more studies considering ethnicity and benign breast disease classification should also be considered for further analysis.     

毫针加锋钩针治疗乳腺增生疗效观察

目的观察毫针加锋钩针治疗乳腺增生的临床疗效。 方法选取2019年2月至2019年5月山西中医学院附属医院针灸门诊治疗的女性乳腺增生患者27例，所有患者均用毫针加锋钩针治疗。每3日治疗1次，连续治疗3次后评价疗效。 结果连续治疗3次后，治愈12例，占44.4%，好转14例，占51.8%，未愈1例，占3.8%，总有效率为96.2%(26/27)。2个月后随访，26例有效患者中有1例轻度复发。 结论毫针加锋钩针治疗乳腺增生疗效确切，值得推广。     

温病学教学中的“三全育人”战略

温病学是中医学四大经典课程之一,是基础理论向临床实践过渡的桥梁课程,对于中医药高校学生具有重要意义。“三全育人”战略是高校思想政治工作的重点,新时期,我们应把“三全育人”战略贯穿温病学教育教学全过程和各环节,全员全过程全方位为培养具有坚实的温病理论知识和技能、医德高尚的现代化应用型中医药人才服务。     

A qualitative assessment of diabetes care access and disease management in Central America

BackgroundDiabetes is a growing concern in low-and middle-income countries. Medical missions play a role in increasing access to care and medicines, but often ignore non-communicable disease prevention and advanced management. Increased knowledge of local community needs and resources can lead to the development and implementation of pharmacist-supported interventions to improve diabetes management in rural areas.ObjectivesThe purpose of this study was to 1) understand the availability of monitoring for diabetes locally; and 2) describe knowledge and health beliefs regarding diabetes management for those with diabetes, and prevention among those at high risk of developing diabetes.MethodsThis qualitative evaluation used semi-structured interviews with key informants in a community in rural Honduras. Participants included those with diabetes, those at-risk for developing diabetes, and community leaders. Data was analyzed using thematic content analysis through an iterative process of coding and theme development.ResultsA total of 35 interviews were conducted with five resulting themes: 1) participants identified multiple barriers to diabetes management including access to monitoring, access to certain medications, and access to advanced levels of care; 2) participants acknowledge the relationship between lifestyle choices and diabetes control, but struggled with adherence to a healthy lifestyle; 3) participants identify that they have limited knowledge of diabetes pathophysiology, diabetes management, and strategies to prevent diabetes; 4) participants felt that opportunities existed within the community to support diabetes education and prevention, and 5) providers should integrate culture, societal norms, and religion in diabetes management.ConclusionThis research identifies challenges and resulting opportunities for managing diabetes in rural Honduras. Health care providers including pharmacy personnel should consider strategies to engage communities around self-care and diabetes education. Further, strategies are needed to enhance access to resources and essential medicines for diabetes management. These themes can guide clinicians in supporting communities to enhance diabetes care.     

Primary vaccination in adult patients after allogeneic hematopoietic stem cell transplantation – A single center retrospective efficacy analysis

Allogeneic hematopoietic stem cell transplantation (alloHSCT) results in a loss of humoral immunity and subsequent risk for severe infections. Thus, re-vaccination is required but may fail due to incomplete immune reconstitution. We retrospectively analyzed predictors of immune response to primary vaccination applied according to the EBMT (European Blood and Marrow Transplantation Group) recommendations. Serologic response to vaccination against diphtheria (D), tetanus (T), Bordetella pertussis (aP) and Haemophilus influenzae (Hib) (administrated as combined DTaP-Hib-IPV vaccination) was studied in 84 alloHSCT patients transplanted between 2008 and 2015 (age at alloHSCT: 18.6–70.6 years). All patients with a relapse-free survival of ≥9 months, at least 3 consecutive vaccinations and absence of intravenous immunoglobulin administration within 3 months before and after vaccination met the primary inclusion criteria. Additionally, immunological response to a pneumococcal conjugate vaccine was analyzed in a subgroup of 67 patients. Patients’ characteristics at the time of first vaccination were recorded. Responses were measured as vaccine-specific antibody titers. Regarding DTaP-Hib-IPV vaccination, 89.3% (n = 75) of all patients achieved protective titers to at least 3 of the 4 vaccine components and were thus considered responders. 10.7% (n = 9) of the patients were classified as non-responders with positive immune response to less than 3 components. Highest response was observed for Hib (97.4%), tetanus (95.2%) and pneumococcal vaccination (83.6%) while only 68.3% responded to vaccination against Bordetella pertussis. Significant risk factors for failure of vaccination response included low B cell counts (p < 0.001; cut-off: 0.05 B cells/nl) and low IgG levels (p = 0.026; mean IgG of responders 816 mg/dl vs. 475 mg/dl of non-responders). Further, a trend was observed that prior cGvHD impairs vaccination response as 88.9% of the non-responders but only 54.7% of the responders had prior cGvHD (p = 0.073). The results demonstrate, that the currently proposed vaccination strategy leads to seroprotection in the majority of alloHSCT patients.