Chronic noncancer pain management in primary care: family medicine physicians’ risk assessment of opioid misuse

Objective: The majority of patients with chronic noncancer pain (CNCP) are managed in the primary care settings. The primary care family physician (PCFP) generally has limited time, training, or access to resources to effectively evaluate and treat these patients, particularly when there is the added potential liability of prescribing opioids. The aim of this study is to make a favorable change in PCFPs’ knowledge, attitudes, and practices about opioid use in CNCP via education on assessment of the risk of opioid misuse. Materials and methods: The universe of this cross-sectional study comprised 36 family physicians working at Family Health Centers affiliated to Antalya Provincial Directorate of Health who volunteered to participate in the study. Initially, a survey on patients risk assessment was performed in both intervention and control groups; whereas the intervention group received education on assessment of the risk of opioid misuse, the control group did not. The survey was repeated after 6 months and the intervention group underwent a core examination. Data obtained were analyzed with Statistical Package for the Social Sciences 18.0 statistics program. Intervention and control groups were compared. Additionally, pre- and post-education results of the intervention group were also compared. Results: About 61.1% of family physicians reported concern and hesitation in prescribing opioids due to known risks, such as overdose, addiction, dependence, or diversion, and agreed that family physicians should apply risk assessment before opioid use in CNCP. Only 16.6% of PCFP reported that risk assessment is not so necessary, whereas 22.2% of PCFP were undecided. Although 47.2% of the family physicians expressed a willingness to apply risk assessment before starting opioids, the rate of eagerness increased markedly to 77.7% after the education, but the rate of increase in practicing was not statistically significant. Conclusion: Knowledge and competency of the family physicians in managing CNCP were improved as was expected. Although the rate of eagerness about risk assessment of opioid misuse was increased, expected increase in the rate of using risk assessment was not achieved. Further studies are needed to identify the reasons of the difficulties on changing the attitudes and practices of primary care physicians about this subject.     

Short-term effects of a pay-for-performance programme for diabetes in a primary care setting: an observational study

Objective A pay-for-performance (P4P) programme for primary care was introduced in 2011 by a Swedish county (with 1.6 million inhabitants). Effects on register entry practice and comparability of data for patients with diabetes mellitus were assessed.Design and setting Observational study analysing short-term outcomes before and after introduction of a P4P programme in the study county as compared with a reference county.Subjects A total of 84 053 patients reported to the National Diabetes Register by 349 primary care units.Main outcome measures Completeness of data, level and target achievement of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL cholesterol (LDL).Results In the study county, newly recruited patients who were entered during the incentive programme were less well controlled than existing patients in the register – they had higher HbA1c (54.9 [54.5–55.4] vs. 53.7 [53.6–53.9] mmol/mol), BP, and LDL. The percentage of patients with entry of BP, HbA1c, LDL, albuminuria, and smoking increased in the study county but not in the reference county (+26.3% vs –1.5%). In the study county, with an incentive for BP < 130/80 mmHg, BP data entry behaviour was altered with an increased preference for sub-target BP values and a decline in zero end-digit readings (38.3% vs. 33.7%, p < 0.001).Conclusion P4P led to increased register entry, increased completeness of data, and altered BP entry behaviour. Analysis of newly added patients and data shows that missing patients and data can cause performance to be overestimated. Potential effects on reporting quality should be considered when designing payment programmes.

Key points

• A pay-for-performance programme, with a focus on data entry, was introduced in a primary care region in Sweden.
• Register data entry in the National Diabetes Register increased and registration behaviour was altered, especially for blood pressure.
• Newly entered patients and data during the incentive programme were less well controlled.
• Missing data in a quality register can cause performance to be overestimated.

     

氢质子磁共振波谱分析在儿童癫痫诊断中的应用

目的：探讨氢质子磁共振波谱分析对儿童癫痫诊断中的应用价值。方法将34例经24 h动态脑电图确诊的癫痫患儿设为患者组,20例无神经系统症状和体征、无脑实质病变的非癫痫患儿设为对照组,采用3．0T M R扫描仪,先行常规T1WI、T2WI扫描,氢质子磁共振波谱检查采用多体素解析波谱采集序列,分析双侧海马区代谢产物乙酰‐天门冬氨酸、复合胆碱、肌酸的波峰特点,计算乙酰‐天门冬氨酸／（复合胆碱＋肌酸）和乙酰‐天门冬氨酸／肌酸的比值,并与动态脑电图进行比较。结果两组常规磁共振检查均未见脑结构及信号异常。患者组病灶侧乙酰‐天门冬氨酸峰可见不同程度降低,复合胆碱、肌酸峰可见不同程度增高;患者组病灶侧乙酰‐天门冬氨酸／（复合胆碱＋肌酸）和乙酰‐天门冬氨酸／肌酸的比值较病灶对侧、对照组明显减小（P＜0．01）,病灶对侧与对照组比较差异无显著性（P＞0．05）。氢质子磁共振波谱诊断准确率为85．2％、敏感度为94．1％。结论氢质子磁共振波谱能够定量反映患儿海马代谢异常,有助于癫痫的早期诊断。     

血清β-人绒毛膜促性腺激素与孕酮预测早孕不良结局的临床价值

目的探讨血清β-人绒毛膜促性腺激素(β-HCG)及孕酮的动态监测对早孕不良结局的临床价值。方法选取2013年3月至2014年5月于重庆市渝北区妇幼保健院就诊的212例早孕不良结局患者,根据不良结局类型分为先兆流产组(78例)、稽留流产组(65例)、异位妊娠组(69例)。采用化学发光法检测患者初次就诊的血清β-HCG、孕酮水平,并于48h后复查,比较分析各组血清β-HCG水平与倍增时间,以及孕酮水平与分布情况。结果初次及48h后血清β-HCG水平比较,从高到低依次为先兆流产组、稽留流产组、异位妊娠组,其中先兆流产组与稽留流产组和异位妊娠组分别比较差异均有统计学意义(P0.05)。β-HCG倍增时间比较,从低到高依次为先兆流产组、稽留流产组、异位妊娠组,其中异位妊娠组与先兆流产组和稽留流产组分别比较差异均有统计学意义(P0.05)。孕酮水平比较,从高到低依次为先兆流产组、稽留流产组、异位妊娠组,其中异位妊娠组初次孕酮水平与先兆流产组和稽留流产组分别比较差异均有统计学意义(P0.05)。19.23%的先兆流产组患者初次孕酮水平高于79.25nmol/L,无一例低于15.85nmol/L者,而稽留流产组与异位妊娠组初次孕酮水平低于15.85nmol/L者分别占32.31%、44.93%。结论动态监测血清β-HCG与孕酮水平在预测和诊断早孕先兆流产、稽留流产及异位妊娠中具有重要价值。     

新生儿无乳链球菌感染的危险因素及药敏分析

目的分析新生儿感染无乳链球菌的危险因素及药物敏感性,为预防和治疗新生儿无乳链球菌感染提供依据。方法收集2013年1~12月1 200份临床送检的新生儿血液、胃液、脓液标本,以及相应母体泌尿生殖道标本进行细菌培养与药敏试验,并回顾性分析患儿疾病类型、母体感染状况、分娩方式、孕晚期用药情况、新生儿死亡情况等临床资料。结果共80例新生儿感染无乳链球菌,其中败血症、脐炎、早产、宫内感染、吸入性肺炎患儿分别占8.75%、10.00%、15.00%、22.50%、43.75%;其母体生殖道标本无乳链球菌阳性率达51.25%,且细菌药敏结果与患儿一致;患儿以自然分娩为主,共71例(88.75%),仅9例(11.25%)为剖宫产。80株无乳链球菌对万古霉素、利奈唑胺、青霉素和头孢曲松的敏感率均为100.00%,对红霉素、克林霉素、左氧氟沙星的耐药率较高,分别为77.50%、57.50%、33.75%。结论母体带菌与分娩方式可能是新生儿无乳链球菌感染的重要危险因素,产科医生应重视对围产期孕妇无乳链球菌的常规筛查,实验室应提高对无乳链球菌的检测能力并及时提供药敏检测结果,为临床合理用药提供重要依据。     

Comparison of activities of daily living (ADLs) in two different one arm drive wheelchairs: a study of individuals/participants with hemiplegia

Aims: This pilot study measured activities of daily living performance in individuals/participants with hemiplegia propelling both a standard dual handrim Action 3 wheelchair and a standard Action 3 wheelchair with a Neater Uni-Wheelchair kit attachment. The kit consists of a steerable front. Research questions: Does the use of the NUW affect the performance quality of activities of daily living in individuals/participants with hemiplegia. Is there a difference in the motor and process skills during activities of daily living performance, and in the time taken to complete the activities. Methods: Four individuals/participants with hemiplegia were used in a cross over, repeated measures trial. Assessment of Motor and Process Skills of users undertaking making a bed and laying a table “Swedish style”, tasks were measured and time taken to complete each task were recorded. Results: Bed making completion time was quicker in the Neater Uni-wheelchair (p?p?Conclusion: Activities of daily living tasks in the Neater Uni-wheelchair were completed more efficiently with no loss in quality of motor and process skills performance. This suggests that the Neater Uni-wheelchair is a viable alternative to current one arm drive provision.

• Implications for Rehabilitation

• Inappropriate wheelchair provision can result in capacity limitation and poorer quality of ADL motor skill as well-lowered process performance skill.

• AMPS can help to explain motor and process skill differences in complex activities.