Prevalence and associations of the metabolic syndrome among patients prescribed clozapine

Background  There is increasing concern that the use of second-generation antipsychotic medications in schizophrenia is associated with the development of metabolic syndrome. Aims  This study assessed the prevalence and clinical associations of metabolic syndrome among patients receiving clozapine within the catchment area of a mental health service in the west of Ireland. Method  A total of 84 patients (96% response rate) taking clozapine were interviewed and thoroughly investigated using physical assessments, comprehensive laboratory testing and review of medical records. Results  Of the patients, 46.4% taking clozapine fulfilled the criteria for metabolic syndrome. Male gender, high body mass index, high insulin level and receiving a concomitant antipsychotic medication were significantly associated with the presence of metabolic syndrome. Conclusion  Almost half of the patients receiving clozapine have metabolic syndrome and are consequently at risk of cardiovascular morbidity and mortality. Such patients should be closely monitored in order to facilitate interventions, which could alleviate the adverse health consequences of this syndrome.     

A Malaysian Well Person's Clinic--review of patients seen between April and December 1995

The Well Man & Well Woman's Clinic in Ipoh Hospital provides screening for coronary risk factors and early detection of cancer. This retrospective review of 1095 patients screened between April and December 1995 showed 48% had one or more coronary risk factors--1 risk (29%), 2 risks (14%), 3 or more risks (5%). Modifiable risks included hypertension (10%), obesity (9%), diabetes mellitus (8%) and smoking (7%). Sixteen abnormal Papanicolaou smears and six cancers (three cervical, two breast and one ovarian) were detected. Public response was good. There is a need for clinics offering comprehensive screening in Malaysian primary health care.     

Audit on cardiovascular disease preventive care in general practice

INTRODUCTION: Cardiovascular disease is a major cause of morbidity and mortality. Primary care doctors as general practitioners (GPs) play a central role in prevention, as they are in contact with a large number of patients in the community through provision of first contact, comprehensive and continuing care. This study aims to assess the adequacy of cardiovascular disease preventive care in general practice through a medical audit. METHODS: Nine GPs in Malaysia did a retrospective audit on the records of patients, aged 45 years and above, who attended the clinics in June 2005. The adequacy of cardiovascular disease preventive care was assessed using agreed criteria and standards. RESULTS: Standards achieved included blood pressure recording (92.4 percent), blood sugar screening (72.7 percent) and attaining the latest blood pressure of equal or less than 140/90 mmHg in hypertensive patients (71.3 percent). Achieved standards ranged from 11.1 percent to 66.7 percent in the maintenance of hypertension and diabetic registries, recording of smoking status, height and weight, screening of lipid profile and attaining target blood sugar levels in diabetics. CONCLUSIONS: In the nine general practice clinics audited, targets were achieved in three out of ten indicators of cardiovascular preventive care. There were vast differences among individual clinics.     

Computer assisted shared care in hypertension

A computer assisted shared care scheme for the long term management and follow up of hypertensive patients has been developed in the Grampian Region. The scheme aims at facilitating the exchange of clinically important information between doctors and at achieving target levels of blood pressure with treatment in patients at highest risk of cardiovascular events. The shared care scheme has been well received by the local practitioners. Two hundred and fifty seven patients (18%) of 1426 patients under current long term follow up are assigned to follow up in the hospital aspect of the scheme. At the most recent visit 32% of patients in the hospital aspect and 10% of 1169 patients in the general practice aspect had blood pressure recordings above the target levels of 160/95 mm Hg. The stratification of patients formerly attending hospital clinics into grades of risk has rationalised our follow up procedures to allow the specialist resources to be freed and concentrated on those patients at highest risk and with the most complex problems. This computer assisted patient records system could be applied to other groups of high risk patients in whom long term follow up and surveillance are necessary--for example, patients with diabetes mellitus--and has implications for optimising and monitoring the delivery and outcome of care without overwhelming limited hospital resources.     

怀化市基层儿童保健服务能力现状调查分析

目的：为了解怀化市基层儿童保健服务现状、存在的问题以及探讨解决办法，促进全市儿童保健门诊规范化建设工作的开展。方法：根据《湖南省儿童保健工作规范实施细则（试行）》对乡级儿保门诊的要求，自拟调查表，对318家乡级医疗机构进行问卷调查。结果：在儿保人员构成、门诊用房和设备和可开展的服务项目均存在不足。结论：我市儿保服务能力的提升，主要需要加大财政投入，改善硬件设施，稳定儿保队伍以及加强儿保专干的技能培训。     

医院门诊收费处服务满意度调查分析

目的：探讨提高门诊收费处服务满意度的途径。方法：设计满意度调查问卷,随机抽样调查291例门诊病人对医院门诊收费处服务的满意度,并与门诊导医、药剂科、注射室等门诊服务窗口单位作对比分析。结果：病人对门诊收费处的满意度评价在所调查的6个门诊窗口中居最末位,满意度仅68．04％（P〈0．05）。病人最不满意的是排队时间长。结论：应从增强服务意识,规范服务行为,优化服务流程以及提高服务技能等多方面持续改进门诊收费处的服务质量,提高病人对门诊收费处的满意度和医院门诊服务的综合满意度。     

An audit of structured diabetes care in a rural general practice

OBJECTIVE: To assess the impact of structured diabetes care in a rural general practice. DESIGN AND SETTING: A cohort study of structured diabetes care (care plans, multidisciplinary involvement and regular patient recall) in a large general practice in a medium-sized Australian rural town. Medical care followed each doctor's usual practice. PARTICIPANTS: The first 404 consecutive patients with type 2 diabetes who consented to take part in the program were evaluated 24 months after enrolment in July 2002 to December 2003. MAIN OUTCOME MEASURES: Change in cardiovascular disease risk factors (waist circumference, body mass index, serum lipid levels, blood pressure); change in indicators of risks associated with poorly controlled diabetes (glycated haemoglobin [HbA1c] concentration, foot lesions, clinically significant hypoglycaemia); change in 5-year cardiovascular disease risk. RESULTS: Women had a lower 5-year risk of a cardiovascular event at enrolment than men. Structured care was associated with statistically significant reductions in mean cardiovascular disease risk factors (waist circumference, - 2.6 cm; blood pressure [systolic, - 3 mmHg; diastolic - 7 mmHg]; and serum lipid levels [total cholesterol, - 0.5 mmol/L; HDL cholesterol, 0.02 mmol/L; LDL cholesterol, - 0.4 mmol/L; triglycerides, - 0.3 mmol/L]); and improvements in indicators of diabetic control (proportion with severe hypoglycaemic events, - 2.2%; proportion with foot lesions, - 14%). The greatest improvements in risk factors occurred in patients with the highest calculated cardiovascular risk. There was a statistically significant increase in the proportion of patients with "ideal" blood pressure (systolic, < 130 mmHg; diastolic, < 80 mmHg) and LDL cholesterol level (< 2.5 mmol/L) of 6.4% and 20.5%, respectively. CONCLUSIONS: Implementing structured care in this rural general practice coincided with improved risk factor management, and may have contributed to the improvement. The greatest benefits were in patients with high cardiovascular risk.     

Anticoagulation control in atrial fibrillation patients present to outpatient clinic of cardiology versus anticoagulant clinics

Nonvalvular atrial fibrillation (NVAF) is the most common sustained cardiac arrhythmia in clinical practice, which if untreated results in a doubling of cardiovascular morbidity and mortality. AF is an independent predictor of stroke, with an annual risk 5 to 6 times higher than patients in sinus rhythm. During recent years,     

Transmission of infectious diseases in outpatient health care settings

Increased provision of health care in outpatient settings and concerns about occupational transmission of infections have focused attention on the risk of transmission of infectious diseases in ambulatory health care settings. In contrast to inpatient nosocomial infections, infections transmitted in outpatient settings are neither systematically monitored nor likely to be detected by routine qi surveillance. To better define the spectrum of such events, we reviewed the literature to identify cases and clusters of infections associated with outpatient health care. In this review, we identified and epidemiologically characterized 53 such reports that occurred from 1961 through 1990. Transmission occurred in general medical offices, clinics, and emergency departments (23); ophthalmologists' offices and clinics (11); dental offices (13); and alternative-care settings (six). Our findings suggest that inpatient infection-control practices should be extended to outpatient health care settings by assigning specific responsibility for infection control and by adapting surveillance methods and prevention measures.     

Agreement of Medicaid claims and electronic health records for assessing preventive care quality among adults

To compare the agreement of electronic health record (EHR) data versus Medicaid claims data in documenting adult preventive care. Insurance claims are commonly used to measure care quality. EHR data could serve this purpose, but little information exists about how this source compares in service documentation. For 13 101 Medicaid-insured adult patients attending 43 Oregon community health centers, we compared documentation of 11 preventive services, based on EHR versus Medicaid claims data. Documentation was comparable for most services. Agreement was highest for influenza vaccination (κ =  0.77; 95% CI 0.75 to 0.79), cholesterol screening (κ = 0.80; 95% CI 0.79 to 0.81), and cervical cancer screening (κ = 0.71; 95% CI 0.70 to 0.73), and lowest on services commonly referred out of primary care clinics and those that usually do not generate claims. EHRs show promise for use in quality reporting. Strategies to maximize data capture in EHRs are needed to optimize the use of EHR data for service documentation.     

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。     

门诊药房在医院药学服务中的作用

目的:探讨如何充分发挥我院门诊药房在医院药学服务中的作用。方法:从门诊药房的现实情况和医院药学的发展方向,探讨其作用。结果:通过提高服务水平和增加服务项目来增强门诊药房在医院药学服务中的作用。结论:我们既要考虑现实的困难,又要有发展的眼光,循序渐进地提高门诊药房的药学服务工作。     

浅谈医院门诊排队叫号系统在医院的实施

以河北工程大学附属医院皮肤科为例,针对医院皮肤科门诊患者流量大,存在排队管理中无序、医生诊室纷乱、病人的心理焦虑、医生看病环境差、医护人员工作强度大等问题,医院上线了门诊排队叫号系统,实行病人挂号直接到医生,病人在候诊大厅等待语音广播叫号等,改善了医院就医环境,提高了工作效率与医院为病人服务质量,使医院的管理更加规范化、数字化。     

Factors that influence the patient uptake of diabetic retinopathy screening

Aim  To assess whether patients were receiving regular diabetic retinopathy screening and to examine factors influencing screening uptake. Methods  A questionnaire covering demographics, diabetic medical history and the knowledge of and attitudes to diabetic retinopathy was administered to all adults who were due to attend diabetes clinics in two centres in Dublin, Ireland over two months in 2001/2002. Results  Of the 209 people who completed the questionaire, 169 (81%) had a dilated fundal examination within the last year. The most significant predictor for receiving screening was a previous physician recommendation about the necessity of a regular eye examination. The main barriers to receiving adequate screening were lack of knowledge regarding the need for ocular examination and the effect of mydriasis in prohibiting driving. Conclusions  It is essential that patients are fully aware of the need for a regular eye examination. Once a physician recommends this the screening rate improves.     

云南省新型农村合作医疗乡村两级医疗机构门诊处方费用分析

目的了解云南省新型农村合作医疗20个试点县乡、村两级医疗机构门诊处方合作医疗实施前、后变化情况。方法采取典型整群方法抽取样本,由经培训合格的调查员对所抽取的乡镇卫生院和村卫生室的处方进行调查。结果在合作医疗运行4个月后83%试点县的乡镇卫生院每张门诊处方平均费用出现不同程度的上涨,村级医疗机构每张门诊处方平均费用升降各异,但总体上涨不明显。结论合作医疗影响乡村医疗机构的门诊处方费用,应对其医疗服务提供的行为加强管理与监督,控制门诊处方费用的不合理增长。     

An audit of the impact of implementation of a stroke care pathway in an acute teaching hospital

Background  In 2002, a survey of stroke management was conducted in our institution benchmarked against the UK National Stroke Audit 2002. The conclusion was that management of stroke patients lacked organised and specialised care. The introduction of a stroke care pathway was recommended. Aims  This audit assessed the clinical impact of implementation of a stroke care pathway by the general medical teams in an acute teaching hospital. Methods  A random sample of 48/131 patients were surveyed in 2002 compared to 55 consecutive patients admitted with stroke in 2005. Results  Despite introduction of a stroke care pathway, marked deficits persisted in acute management including delays in brain imaging and aspirin administration, assessment of acute parameters and interdisciplinary care. Conclusions  Optimal care of stroke patients cannot be achieved by introducing a stroke care pathway alone. We recommend the urgent establishment of a stroke unit with a specialist consultant-led multidisciplinary stroke team.     

A Randomized Trial of Electronic Clinical Reminders to Improve Medication Laboratory Monitoring

Objective

Recommendations for routine laboratory monitoring to reduce the risk of adverse medication events are not consistently followed. We evaluated the impact of electronic reminders delivered to primary care physicians on rates of appropriate routine medication laboratory monitoring.

Design

We enrolled 303 primary care physicians caring for 1,922 patients across 20 ambulatory clinics that had at least one overdue routine laboratory test for a given medication between January and June 2004. Clinics were randomized so that physicians received either usual care or electronic reminders at the time of office visits focused on potassium, creatinine, liver function, thyroid function, and therapeutic drug levels.

Measurements

Primary outcomes were the receipt of recommended laboratory monitoring within 14 days following an outpatient clinic visit. The effect of the intervention was assessed for each reminder after adjusting for clustering within clinics, as well as patient and provider characteristics.

Results

Medication-laboratory monitoring non-compliance ranged from 1.6% (potassium monitoring with potassium-supplement use) to 6.3% (liver function monitoring with HMG CoA Reductase Inhibitor use). Rates of appropriate laboratory monitoring following an outpatient visit ranged from 14% (therapeutic drug levels) to 64% (potassium monitoring with potassium-sparing diuretic use). Reminders for appropriate laboratory monitoring had no impact on rates of receiving appropriate testing for creatinine, potassium, liver function, renal function, or therapeutic drug level monitoring.

Conclusion

We identified high rates of appropriate laboratory monitoring, and electronic reminders did not significantly improve these monitoring rates. Future studies should focus on settings with lower baseline adherence rates and alternate drug-laboratory combinations.     

The effect of rheumatoid arthritis on the risk of cerebrovascular disease and coronary artery disease in young adults

Background

Only a few studies have investigated the affect of rheumatoid arthritis (RA) on the risk of cerebrovascular disease (CVD)/coronary artery disease (CAD) in young adults. This study, therefore, examined the association between RA and the risk of CVD/CAD in young adults and the interaction effects between cardiovascular risk factors and RA on the risk of CVD/CAD.