上海市社区药学服务需求现状

背景 随着患者就诊下沉明显，联合家庭医生团队开展社区药学服务日益重要，但如何发挥家庭医生团队作用以满足患者社区药学服务需求仍有待进一步探索。 目的 了解上海市社区药学服务需求现状，为改进社区药学人员参与家庭医生团队开展服务的方式提供参考建议。 方法 于2020年9—12月，采用多阶段抽样法抽取349例老年慢性病患者和855例家庭医生团队主要成员〔全科医生（n=481）、护士（n=234）、公共卫生医生（n=140）〕进行问卷调查。针对老年慢性病患者的调查问卷主要内容包括基本情况、患病情况、用药情况、社区药学服务需求情况和社区药学服务利用情况。针对家庭医生团队成员的调查问卷主要内容包括基本情况、社区药学服务认知情况和社区药学服务需求情况。 结果 349例老年慢性病患者中，125例（35.8%）同时患有≥3种慢性病，305例（87.4%）每日需多次用药。用药管理类药学服务方面，"用药重整及随访"需求人数最多，为52例（14.9%），"用药随访"利用人数最多，为49例（14.0%）。用药教育类药学服务方面，"慢性病用药特殊性的普及教育"需求人数最多，为247例（70.8%），"宣传健康生活方式"利用人数最多，为33例（9.4%）。家庭医生团队成员中，全科医生、护士、公共卫生医生对药学服务的了解程度方面，分别有440例（91.5%）、202例（86.3%）、112例（80.0%）表示了解；对药师的信任程度方面，分别有302例（62.8%）、183例（78.2%）、103例（73.6%）表示非常信任；"协同医师做好药物使用遴选"服务项目的需求人数分别有359例（74.6%）、112例（47.9%）、81例（57.8%）；"指导护士使用与管理药品"服务项目的需求人数分别有190例（39.5%）、153例（65.4%）、57例（40.7%）。 结论 一方面患者实际迫切需要用药管理类药学服务，另一方面患者的用药教育类药学服务需求远未得到满足。鉴于社区药学人员队伍薄弱及家庭医生团队对社区药学服务认知局限的现状，社区药学人员应通过培训团队成员，提升团队的社区药学服务认知水平及服务能力，借助团队力量及成员特性，更广泛高效地开展社区药学服务。     

以就业为导向的脊柱相关疾病的推拿教学策略

目的培养脊柱及相关疾病推拿治疗的应用型人才。方法采用编写应用型教材、把教室转移到诊室和示教室、教材-案例“逼真”教学法、创造学生在临床真实环境下的动手操作机会和产-学-研相结合教学法等手段和方法,在内容改革上纳入目前医院和社会机构多使用的规划教材之外的手法技术、现代康复技术和世界各地的脊柱手法技术,拓宽知识面,与临床应用接轨;发挥考试的导向功能,通过改革考试和评价方法,切实培养应用型人才。结果教学效果良好,有效提升了学生临床适应能力和社会生存能力。结论以就业为导向的脊柱及相关疾病的推拿教学模式值得进一步探索。     

Quality indicators for breast cancer care: A systematic review

ObjectivesWe evaluated breast cancer (BC) care quality indicators (QIs) in clinical pathways and integrated health care processes.MethodsFollowing protocol registration (Prospero n^o: CRD42021228867), relevant documents were identified, without language restrictions, through a systematic search of bibliographic databases (EMBASE, Scopus, Web of Science, MEDLINE), health care valuable representatives and the World Wide Web in April 2021. Data concerning QIs, measurement tools and compliance standards were extracted from European and North American sources in duplicate with 98% reviewer agreement.ResultsThere were 89 QIs found from 22 selected documents (QI per document mean 13.5 with standard deviation 11.9). The Belgian (38 QIs) and the EUSOMA (European Society of Breast Cancer Specialists) (34 QIs) documents were the ones that best reported the QIs. No identical QI was identified in all the documents analysed. There were 67/89 QIs covering processes (75.3%) and 11/89 (12.4%) for each structure and outcomes QIs. There were 21/89 QIs for diagnosis (30.3%), 43/89 for treatment (48.3%), and 19/89 for staging, counselling, follow-up and rehabilitation (21.4%). Of 67 process QIs and 11 outcome QIs, 20/78 (26%) did not report a minimum standard of care. Shared decision making was only included as a QI in the Italian document.ConclusionMore than half of countries have not established a national clinical pathway or integrated breast cancer care process to achieve the excellence of BC care. There was heterogeneity in QIs for the evaluation of BC care quality. Over two-thirds of the clinical pathways and integrated health care processes did not provide a minimum auditable standard of care for compliance, leaving open the definition of best practice. There is a need for harmonisation of BC care QIs.     

China special issue on gastrointestinal tumors-Improved survival after multidisciplinary team decision for patients with advanced gastrointestinal cancer: A multicenter,noninterventional, controlled study

Formal multidisciplinary team (MDT) discussions in clinical practice require time and space but have unclear survival benefits for advanced gastrointestinal cancer patients. Our study aimed to investigate the long-term survival of patients with advanced gastrointestinal cancer after MDT decision. From June 2017 to June 2019, continuous MDT discussions on advanced gastrointestinal cancer were conducted in 13 medical centers in China. MDT decisions and actual treatment received by patients were prospectively recorded. The primary endpoint was the difference in overall survival (OS) between patients in the MDT decision implementation and nonimplementation groups. The secondary endpoints included the implementation rate of MDT decisions and subgroup survival analysis. A total of 461 MDT decisions of 455 patients were included in our study. The implementation rate of MDT decisions was 85.7%. Previous treatment had an impact on MDT decision-making. The OS was 24.0 months and 17.0 months in the implementation and nonimplementation groups, respectively. The implementation of MDT decisions significantly reduced the risk of death in multivariate analyses (hazard ratio = 0.518; 95% confidence interval: 0.304-0.884, P = .016). Subgroup analysis showed a significant difference in survival of patients with colorectal cancer, but not in survival of patients with gastric cancer. The rate of secondary MDT discussion was only 5.6% among patients who the MDT decisions were discontinued due to changes in their condition. MDT discussion can prolong the OS of patients with advanced gastrointestinal cancer, especially those with colorectal cancer. Timely scheduling of the subsequent MDT discussion is necessary when the disease condition changes.     

重视甲状腺癌多学科综合治疗

甲状腺癌是最常见的内分泌肿瘤之一，其发病率逐年上升。对于复杂疑难的甲状腺癌，其诊断过程涉及超声、CT、放射性核素检查、喉镜检查、血液学检查［甲状腺功能、血清甲状腺球蛋白（Tg）］、病理学检查。其治疗是以外科为主的综合治疗，诊疗过程涉及甲状腺外科、耳鼻喉科、胸外科、麻醉科、内分泌科、核医学科、放疗科、肿瘤内科、ICU、超声科、病理科、影像科等。采用多学科综合治疗协作组（MDT）模式可以发挥多学科优势，为病人提供最佳的诊疗方案，实现个体化、精准化治疗，有助于降低手术并发症发生率，改善病人预后和生活质量，提高综合疗效，最终使甲状腺癌病人获益。     

呼吸内科PBL教学法在全科医师规培中的应用

目的探索基于呼吸治疗团队教学的以问题为基础的教学法(problem based learning,PBL)在全科住院医师规范化培训中的应用。方法呼吸系统以老年人慢性疾病为主,是全科医学生教育的重要环节。开展PBL教学法的教学探索,以期达到对全科医师的专科疾病培训,使其理解并掌握相关疾病知识,能适应未来医学发展和社会需要,为患者提供更好的社区医疗服务。结果PBL教学法的精髓是发挥问题对学习过程的指导作用,调动学生学习的积极性和主动性,整体提升学生的综合素质和能力。结论在全科医学规范化培训教学中运用PBL教学,带教老师以任务为主线、以学员为主体进行引导,可极大的提高学生的学习兴趣、主动性以及自学能力,从而培养学员的分析问题、解决问题的能力。可以更好的帮助学员形成以患者为中心的临床诊断思路、提高解决临床问题的综合能力及团队合作能力。