基于动脉自旋标记技术的麻痹性痴呆患者脑血流量特点及其与认知障碍相关性

目的探讨麻痹性痴呆（GPI）患者脑血流量（CBF）特点及其与认知障碍的相关性。 方法纳入2018年1月至2019年12月于首都医科大学附属北京地坛医院就诊的GPI患者18例和健康体检者18例（健康对照组），采用蒙特利尔认知评估量表评定认知功能。采用磁共振动脉自旋标记技术扫描评估其各个脑区CBF，并进一步应用Spearman相关分析CBF异常区域与认知功能的相关性。 结果GPI患者蒙特利尔认知评估量表评分低于健康对照组[（16.00 ± 7.19）vs. （27.90 ± 1.21）：t =－7.853、P < 0.001）]。18例GPI患者中，头颅MRI正常5例，脑白质病变1例，脑萎缩9例，3例患者同时存在脑萎缩和脑白质病变。健康对照组头颅MRI均未见异常。GPI患者脑13、14、28、37、38、41、42、43、44、46、48、49、50、51、52、69、70、77、78、83、84、88、109、117、165、166、167、168、169、177、178、179、187、188、211、212、213、214、215、216、219、223、227、237和238区CBF显著高于健康对照组（P均< 0.001）。GPI患者认知障碍中的注意力障碍与脑69、70、77、78、166和168区CBF异常有一定的负相关性（r =－0.476、P = 0.046，r =－0.487、P = 0.034，r =－0.604、P = 0.008，r = －0.545、P = 0.019，r =－0.544、P = 0.02，r =－0.522、P = 0.026）。 结论GPI患者存在全脑血流量升高。GPI患者认知功能障碍中的注意力障碍可能与局部脑区血流量升高有一定相关性。局部CBF越高，注意力障碍越严重。这可能也是GPI发病机制之一。     

Process evaluation of implementation strategies to reduce potentially inappropriate medication prescribing in older population: A scoping review

ObjectivesSeveral implementation strategies can reduce potentially inappropriate medication (PIM) prescribing. Although use of PIMs has declined in recent years, it remains prevalent. Various strategies exist to improve the appropriateness of medication use. However, little is known about the processes of these different implementation strategies. This scoping review aims to investigate how the process evaluation of implementation strategies for reducing PIM prescribing in the older population has been studied.MethodsWe searched for process evaluations of implementation strategies for reducing PIM prescribing in PUBMED, SCOPUS and Web of Science published between January 2000 and November 2019 in English. We applied the following inclusion criteria: patients aged ≥65 years, validated PIM criteria, and implementation process evaluated. The review focuses on decision support for health care professionals. We described the findings of the process evaluations, and compared the authors’ concepts of process evaluation of the included publications to those of Proctor et al.( 2010).ResultOf 9131 publications screened, 29 met our inclusion criteria. Different process evaluation conceptualizations were identified. Most process evaluations took place in the initial stages of the process (acceptability, adoption, appropriateness, and feasibility) and sustainability and implementation costs were seldom evaluated. None of the included publications evaluated fidelity.Multifaceted interventions were the most studied implementation strategies. Medication review was more common in acceptability evaluations, multidisciplinary interventions in adoption evaluations, and computerized systems and educational interventions in feasibility evaluations. Process evaluations were studied from the health care professionals’ viewpoint in most of the included publications, but the management viewpoint was missing.DiscussionThe conceptualization of process evaluation in the field of PIM prescribing is indeterminate. There is also a current gap in the knowledge of sustainability and implementation costs. Clarifying the conceptualization of implementation process evaluation is essential in order to effectively translate research knowledge into practice.     

Ketorolac plus Lidocaine vs Lidocaine for pain relief following core needle soft tissue biopsy: A CONSORT-compliant double-blind randomized controlled study

Backgrounds:The main objective of this study was to compare the pain control efficacy of local administration of Lidocaine with or without the nonsteroidal anti-inflammatory drug, Ketorolac, and local conventional Lidocaine injection in core needle biopsy of the musculoskeletal tumor.Methods:The current study was a randomized, double-blind controlled clinical trial that included 128 patients with suspected musculoskeletal tumors. Patients were randomly assigned to either the Ketorolac plus Lidocaine (n = 64) or Lidocaine group (n = 64). The Ketorolac – Lidocaine combination syringe contained 30 mg Ketorolac and 2% Lidocaine – adrenaline dosage, and the Lidocaine syringe contained 2% Lidocaine – adrenaline dosage. The level of pain after core needle biopsy was evaluated for each patient at 1, 6, 12, 24, 48, and >48 hours by a Visual Analog Scale (VAS). The mean VAS changes over time were compared between the Ketorolac plus Lidocaine and Lidocaine groups using a linear mixed model.Results:baseline information including mean age of patients in Lidocaine group (51.5 ± 19.4 years) and in Lidocaine – Ketorolac combination group (50.1 ± 18 years), diagnosis (malignant, benign, metastatic, infection), tumor location (upper and lower extremities, back), VAS score 1-hour post-operation (mild and moderate pain) were noted. The VAS score ratings were significantly lower in Lidocaine – Ketorolac combination group when compared to the Lidocaine group during the 1 to 24 hours post-operation time period.Conclusion:Patients receiving Lidocaine – Ketorolac combination dosage had significantly lower VAS scores, and these results confirm that local injection of Lidocaine – Ketorolac combination had a superior pain-controlling effect during the first 24 hours after the biopsy procedure in comparison to Lidocaine injection alone, as measured by VAS score scale.     

河南省非订单定向全科住院医师规范化培训结业学员的就业状况及影响因素研究

背景 全科医生数量和质量是人力资源管理的两个重要维度，其中，医生数量的新增、保持和流失，是全科人力动态规划、管理和评价的重要考量，也是全科住院医师规范化培训（简称全科住培）的绩效指标。探讨全科住培学员的就业状况及影响因素，可以为今后住培政策和激励机制的制定提供参考，但目前针对非订单定向全科住培学员的相关研究较为缺乏。 目的 了解河南省非订单定向全科住培学员的就业状况，分析学员结业后未从事全科医学相关工作的原因，从而为完善培训管理和人力资源激励机制提供参考。 方法 于2021年8月，采用分层随机整群抽样法，在河南省选取2014—2017年入培且已结业的非订单定向全科住培学员326例进行问卷调查。问卷由课题组自行设计，主要内容为学员的基本信息、全科住培情况、目前工作情况及结业后从事与未从事全科医学相关工作的原因。问卷通过"问卷星"平台发放，由学员自行填写。 结果 共发放问卷326份，回收有效问卷271份（83.1%）。结业后，从事全科医学相关工作者77例（28.4%），从事非全科医学相关工作者194例（71.6%）。多因素Logistic回归分析结果显示，年龄、文化程度、生源类型、全科住培基地所在区域是学员结业后是否从事全科医学相关工作的影响因素（P<0.05）。与结业后未从事全科医学相关工作的学员相比，结业后从事全科医学相关工作学员注册为全科医学专业的比例更高〔70.1%（54/77）比32.0%（62/194），P<0.05〕，在乡镇卫生院/社区卫生服务中心执业的比例更高〔49.4%（38/77）比6.2%（12/194），P<0.05）〕。194例未从事全科医学相关工作的学员中，从事内科学工作者78例（40.2%），从事急诊及危重症医学工作者33例（17.0%），从事外科学工作者17例（8.8%）。不选择从事全科医学相关工作的前3位原因分别为：单位安排〔34.5%（67/194）〕，所在单位没有全科医学科〔29.9%（58/194）〕，薪酬低〔26.8%（52/194）〕。 结论 非订单定向全科住培学员选择从事全科医学相关工作的比例较低，年龄、文化程度、生源类型及基地所在区域是影响因素。建议加大全科医学理念宣传，加快综合医院全科医学科建设，提高全科医生薪酬待遇，以此增加全科医生的职业吸引力。     

2022年上海市医师协会全科医师分会年会主题报告（一）

本文内容来源于2022年7月22日由上海市医师协会、上海市医师协会全科医师分会主办的"第二届海上全科医师论坛"，主要包括《基层医疗在整合医疗中的作用》《创建全科医学科为国家临床重点专科》《上海市基层卫生发展趋势》《拥抱变化，更好更强》四部分。其中，《基层医疗在整合医疗中的作用》从整合程度、整合层面、整合方向3个维度阐释了"整合医疗"的概念与内涵，并就整合医疗在制度、管理、支付、服务模式、技术应用5个层面的实现路径做了详细介绍；在分析基层医疗和整合医疗共性特征的基础上，阐释基层医疗在上述5个层面对整合医疗的助推作用。《创建全科医学科为国家临床重点专科》从全科医学科在卫生保健改革、满足居民卫生服务需求中的重要作用出发，阐述了创建全科医学科为国家临床重点专科的必要性，认为创建临床重点专科需做到：提高全科医学科学术地位，推进全科医学人才建设，提升全科医学科区域协同能力，形成全方位全周期健康照护专科特色，加快全科医学科研创新发展。《上海市基层卫生发展趋势》肯定了基层卫生对城市健康发展的贡献，提出在"大健康"的背景下进一步的重点工作为推进健康老龄化和实现出生人口提升计划；上海基层卫生的发展趋势在于创新，而基层卫生高质量发展工作的创新需要由全科医生作为推动者和牵头者，创造出新的健康服务模式。《拥抱变化，更好更强》，认为当前社区卫生服务的"薄弱"之处，并非发展之初的硬件或人员配置不足，而是体现在全科学科建设方面。全科医学领域工作者应主动面对和接纳当前国家健康战略的变化、健康需求的变化、医学模式的变化、自身发展/管理的变化，开展主动健康，应对多病共存，加强全-专结合，关注需方角度的服务评价，以助力全科医学学科建设。     

The Newborn Infant Parasympathetic Evaluation (NIPE™) monitor predicts post-operative pain in children undergoing day-procedures: A prospective observational study

BackgroundPain assessment is essential for the administration of appropriate analgesia. Currently, clinicians use surrogate methods, such as heart rate or behavioural pain scales, to estimate pain in neonates and infants. The Newborn and Infant Parasympathetic Evaluation (NIPE™) monitor aims to provide an objective numeric value (NIPE index) of pain through a continuous assessment of the patient's parasympathetic activity. The aim of this study was to determine if the intraoperative NIPE index monitoring could predict postoperative pain in neonates and infants.MethodsThis prospective observational pilot study included neonates and infants undergoing elective day-surgical procedures (n = 50). Intraoperatively, NIPE indices at 0 (NIPE₀), 10 (NIPE₁₀), 20 (NIPE₂₀), 30 (NIPE₃₀) minutes and at completion of surgery (NIPEe), were recorded; the median NIPE index (NIPEm) was calculated for the entire procedure. Postoperative Face, Legs, Activity, Cry, Consolability (FLACC) scale scores were calculated by the nursing staff blinded to the intraoperative NIPE indices.ResultsLinear regression documented an association between the NIPEm and postoperative FLACC score at 0 (r = 0.31, p = 0.03) and 10 min (r = 0.36, p = 0.01). No significant associations were observed for FLACC scores at 20 (r = 0.21, p = 0.2) and 30 min (r = 0.36, p > 0.9). Multiple regression analysis revealed that intraoperative NIPE₁₀, NIPE₂₀, NIPE₃₀ and NIPEe also predicted the FLACC score at 0 min (p = 0.003).ConclusionThe intraoperative NIPE index is predictive of pain in the immediate postoperative period. This association was lost at 20 min likely due to nursing intervention to administer analgesia. NIPE monitoring could be useful in facilitating postoperative pain management in infants.Level of evidenceII.Type of studyStudy of Diagnostic Test.     

贵州省"5+3"模式订单定向医学毕业生的离职意愿及影响因素研究

背景 我国基层全科医生的离职意愿较高，调查其离职意愿并分析影响因素，可以为减少基层卫生人才流失提供思路。目前，完成"5+3"模式（5年临床医学本科教育+3年住院医师规范化培训）培养的订单定向医学毕业生逐步履约进入基层工作，而针对该部分全科医生离职意向的研究相对较少。 目的 调查贵州省"5+3"模式订单定向医学毕业生回归基层工作后的离职意愿及影响因素，为完善吸引卫生人才留任、建设基层全科医生队伍相关政策提供依据。 方法 以贵州省截至2020年底已完成"5+3"模式培养并履约到基层医疗卫生机构工作的2015—2017级订单定向医学毕业生为研究对象。于2021-01-20至2021-02-10对其开展电子问卷调查，内容包括毕业生的一般情况、职业满意度、离职意愿、服务期满后职业方向。共回收问卷347份，其中有效问卷311份，问卷有效回收率为89.6%。采用单因素分析及多元逐步线性回归分析全科医生离职意愿的影响因素。 结果 贵州省"5+3"订单定向医学毕业生的整体离职意愿得分为（3.98±0.98）分，具有离职倾向者229例（73.6%）。不同性别、单位地理位置、每日工作量者的离职意愿得分比较，差异有统计学意义（P<0.05）。多元逐步线性回归分析显示，单位负责人对待下属的方式、在工作中获得的成就感、对当前收入满意程度、家人对工作的支持程度、当地激励政策执行程度是"5+3"订单定向医学毕业生离职意愿的影响因素（P<0.05）。服务期满后，计划留任原基层医疗卫生机构者12例（3.9%），计划去其他基层医疗卫生机构者21例（6.7%），计划离开基层去上级医院工作者196例（63.0%），计划攻读全日制硕士学位者60例（19.3%）。 结论 贵州省"5+3"模式订单定向医学毕业生的离职意愿较高，预计服务期满后基层全科人才流失较多，需从提高收入、重视全科医生心理需求、优化全科医生培养与使用、发展基层医疗卫生机构、加强全科宣传等方面着手改善。