Dissemination of Evidence-based Medicine and Abide to Regulation to Practice Medicine in China

Themulti pathogenetichumandiseasespectrumtendstostabilizeinthe 2 1stcentury ,whilethehumanbeingischallengedbythesuddenoutbreaksofnewcommunicablediseasestriggeredbymono pathogeneses.Astheresultoftheincreasingmedicalresearchinvestments,thedevelopmentofmedicalscienceandtechnologyandtherisinghealthcaredemandsofthepublic ,medicalcostsareskyrocketingataratethatexceedstheincreaseinaveragenationalincome .Inaddition ,theglobalhealthresources,whicharealreadyscarce ,areneitherproperlydistributednoreffici…     

Mechanisms of resistance and clinical relevance of resistance to β-lactams, glycopeptides, and fluoroquinolones

The widespread use of antibiotics has resulted in a growing problem of antimicrobial resistance in the community and hospital settings. Antimicrobial classes for which resistance has become a major problem include the β-lactams, the glycopeptides, and the fluoroquinolones. In gram-positive bacteria, β-lactam resistance most commonly results from expression of intrinsic low-affinity penicillin-binding proteins. In gram-negative bacteria, expression of acquired β-lactamases presents a particular challenge owing to some natural spectra that include virtually all β-lactam classes. Glycopeptide resistance has been largely restricted to nosocomial Enterococcus faecium strains, the spread of which is promoted by ineffective infection control mechanisms for fecal organisms and the widespread use of colonization-promoting antimicrobials (especially cephalosporins and antianaerobic antibiotics). Fluoroquinolone resistance in community-associated strains of Escherichia coli, many of which also express β-lactamases that confer cephalosporin resistance, is increasingly prevalent. Economic and regulatory forces have served to discourage large pharmaceutical companies from developing new antibiotics, suggesting that the antibiotics currently on the market may be all that will be available for the coming decade. As such, it is critical that we devise, test, and implement antimicrobial stewardship strategies that are effective at constraining and, ideally, reducing resistance in human pathogenic bacteria.     

Cancer survivors’ perspectives and experiences regarding behavioral determinants of return to work and continuation of work

Purpose: Supportive interventions to enhance return to work (RTW) in cancer survivors hardly showed positive effects so far. Behavioral determinants might have to be considered in the development of interventions to achieve sustained employability. This study aimed to explore cancer survivors’ perspectives and experiences regarding behavioral determinants of RTW and continuation of work.

Materials and methods: In this qualitative study, semi-structured telephone interviews were held with 28 cancer survivors. All participants were at working age, 1–2 years after diagnosis and employed at time of diagnosis. Thematic content analysis was performed.

Results: Work turned out to be a meaningful aspect of cancer survivors’ life, and most participants reported a positive attitude towards their job. Social support to RTW or to continue working was mainly received from family and friends, but pressure to RTW from the occupational physician was also experienced. Changes in expectations regarding work ability from negative to positive during the treatment process were observed. Those who applied active coping mechanisms felt equipped to deal with difficulties regarding work.

Conclusions: Behavioral determinants should be taken into account in the development of future interventions to support cancer survivors’ RTW. However, the causal relationship still has to be determined.

• Implications for rehabilitation

• Factors influencing occupational motivation among cancer survivors need to be understood in more detail.

• Previous studies in non-cancer populations have demonstrated that behavioral determinants, such as a positive attitude towards work, high social support and self-efficacy may increase return to work rates or shorten the time to return to work.

• Addressing behavioral determinants in future development of work-related interventions for cancer survivors is essential in achieving sustained employability.

     

Do new roles contribute to job satisfaction and retention of staff in nursing and professions allied to medicine?

BACKGROUND: Studies have suggested that job dissatisfaction is a major factor influencing nurses' and occupational therapists' intention to leave their profession. It has also been related to turnover of qualified nurses. However, literature relating to these factors among nurses and professions allied to medicine in innovative roles is scarce. AIMS: This paper considers the views of 452 nurses and 162 professionals allied to medicine (PAMs) in innovative roles, on job satisfaction, career development, intention to leave the profession and factors seen as hindering and enhancing effective working. METHODS: A self-completion questionnaire was developed as part of a larger study exploring new roles in practice (The ENRiP Study). FINDINGS: Overall there was a high level of job satisfaction in both groups (nurses and PAMs). Job satisfaction was significantly related to feeling integrated within the post-holder's own professional group and with immediate colleagues, feeling that the role had improved their career prospects, feeling adequately prepared and trained for the role, and working to protocol. Sixty-eight percent (n = 415) of respondents felt the role had enhanced their career prospects but over a quarter of respondents (n = 163; 27%) said they would leave their profession if they could. Low job satisfaction was significantly related to intention to leave the profession. CONCLUSIONS: The vast majority of post-holders in innovative roles felt that the role provided them with a sense of job satisfaction. However, it is essential that the post-holders feel adequately prepared to carry out the role and that the boundaries of their practice are well defined. Career progression and professional integration both being associated with job satisfaction.     

Contribution of PKMζ-dependent and independent amplification to components of experimental neuropathic pain

Injuries can induce adaptations in pain processing that result in amplification of signaling. One mechanism may be analogous to long-term potentiation and involve the atypical protein kinase C, PKMζ. The possible contribution of PKMζ-dependent and independent amplification mechanisms to experimental neuropathic pain was explored in rats with spinal nerve ligation (SNL) injury. SNL increased p-PKMζ in the rostral anterior cingulate cortex (rACC), a site that mediates, in part, the unpleasant aspects of pain. Inhibition of PKMζ within the rACC by a single administration of ζ-pseudosubstrate inhibitory peptide (ZIP) reversed SNL-induced aversiveness within 24 hours, whereas N-methyl-d-aspartate receptor blockade with MK-801 had no effects. The SNL-induced aversive state (reflecting "spontaneous" pain), was re-established in a time-dependent manner, with full recovery observed 7 days post-ZIP administration. Neither rACC ZIP nor MK-801 altered evoked responses. In contrast, spinal ZIP or MK-801, but not scrambled peptide, transiently reversed evoked hypersensitivity, but had no effect on nerve injury-induced spontaneous pain. PKMζ phosphorylation was not altered by SNL in the spinal dorsal horn. These data suggest that amplification mechanisms contribute to different aspects of neuropathic pain at different levels of the neuraxis. Thus, PKMζ-dependent amplification contributes to nerve injury-induced aversiveness within the rACC. Moreover, unlike mechanisms maintaining memory, the consequences of PKMζ inhibition within the rACC are not permanent in neuropathic pain, possibly reflecting the re-establishment of amplification mechanisms by ongoing activity of injured nerves. In the spinal cord, however, both PKMζ-dependent and independent mechanisms contribute to amplification of evoked responses, but apparently not spontaneous pain.     

Value of deanxit in the treatment of anxiety and depression due to pharyngeal paraesthesia

Background：Alotoffactorsmaycontributetothedevelop－mentofpharyngealparaesthesiawhichischaracterizedbypharyngealsymptomsandabnormalmentalmanifestations．InHilger＇sopinion，mentalstressproducedvegetativenervedisorderbyaffectingcentralvegetativenervesystem，lowerthalam．Inthecurrentstudy，weconcludedthatanxietyanddepressionweremanifestedbypharyn－gealparaesthesia．Itcontainstwoingredients：flupentixolandmelitracen，andfunctionsbyregulatingcentralnervesystemandsignificantlyimprovedanxiety，depr…     

Audio frequency and acupuncture point pressing to treat retention of urine

Background：Retentionofurineisacommandcomplicationforthepostoperativepatientswhoreceptethegeneralorvertebralcanalanesthesia．Becausethemicturitionreflexcenteristemporarilydis－turbedbytheanesthetic，thevegetativenervesystemthatcontrolthebladderisfunctionaldisorder．Theurinarybladdersphincterrela－tivelycontracts，andthedetrusorurinaeofbladderrelativelyrelax．Objective：Todiscusstheeffectofaudiofrequencyandacupuncturepointpressingtotreatretentionofurine．Unit：GeneralHospitalofShenyangMilita…     

Patients' experiences of shoulder problems prior to and following intervention

Health can be viewed from several perspectives. It has been shown that impingement of the shoulder leads to functional inability and decreased life quality. The aim of this study was to investigate the complexity of the effect of shoulder problems and discern and describe what it entails to be a patient suffering from shoulder problems. The study delineated patients' situations prior to and following medical intervention. This study is qualitative, and the data were collected through focus group interviews. Interviews with 26 respondents aged 43-63 (mean age 53) were made in 2005-2007. The sample group consisted of patients with supraspinatus tendinitis receiving either conservative treatment or surgery. Thematic analysis was used. Meaning units or themes were identified and interpreted in context and related to the ICF model and Antonovsky's theory for the factors capable of affecting health. Prior to intervention, pain was the attribute most strongly associated with shoulder problems. Four clear focus categories, all of which contain a dimension of pain, were identified. Postintervention interviews permitted data analysis from two main perspectives: 1) process and 2) result. Patients should feel part of the care process and their experience should include comprehensibility, manageability, and meaningfulness. A supportive environment helps ensure such, allowing for a successful rehabilitation process.     

Initiation of therapy: when and what to start with?

Introduction of HAART (highly active antiretroviral therapy) has resulted in dramatic reductions in AIDS-related opportunistic complications and death. We have faced, however, severe complications due to HAART such as lactic acidosis and lipodystrophy syndrome. Regimens currently employed in the treatment may be complex, require multiple drugs to take, difficult to tolerate owing to adverse effects, and decrease level of quality of life in some patients. Decisions about when and with what to initiate HAART must take into account the risk-benefit ratio associated with the therapy. In this article, issues that must be considered in determining timing of initiation and choice of anti-retroviral drugs are discussed.     

Why study pain? A qualitative analysis of medical and nursing faculty and students' knowledge of and attitudes to cancer pain management

Although effective means for pain management have long been available, cancer pain remains widely undertreated. Surveys of medical personnel have revealed knowledge deficits and attitudinal barriers to pain management, but have not determined why such attitudes persist and how they may be addressed in medical and nursing curricula. This paper presents findings from a qualitative study of the beliefs and attitudes toward pain and cancer pain management held by medical and nursing students and faculty who participated in the Cancer Education Module for the Management of Pain (CEMMP) project. Analysis centered on informants' prioritization and knowledge of pain and cancer pain management and on the meanings informants assigned to pain in a clinical context. Themes in prioritization included the importance of learning about pain versus cancer pain and the responsibility of primary care providers versus specialists for pain and cancer pain management. Themes in informants' knowledge of pain included knowledge deficits about medications and adjunct therapies and the presence of pain management in the curriculum, and the role of knowledgeable faculty members and mentors in the dissemination of information about pain management. Themes in the meanings informants' assigned to pain included opioidphobia, and the (inter-)subjectivity of pain. The discussion focuses in particular on tensions within the prioritization, knowledge and meanings of pain that must be resolved before students can be appropriately educated for optimal pain management.     

Role of the Outer Membrane and Porins in Susceptibility of β-Lactamase-Producing Enterobacteriaceae to Ceftazidime-Avibactam

This study examined the activity of the novel antimicrobial combination ceftazidime-avibactam against Enterobacteriaceae exhibiting different outer membrane permeability profiles, specifically with or without porins and with or without expression of the main efflux pump (AcrAB-TolC). The addition of the outer membrane permeabilizer polymyxin B nonapeptide increased the antibacterial activities of avibactam alone, ceftazidime alone, and ceftazidime-avibactam against the characterized clinical isolates of Escherichia coli, Enterobacter aerogenes, and Klebsiella pneumoniae. This enhancement of activities was mainly due to increased passive penetration of compounds since inhibition of efflux by the addition of phenylalanine-arginine β-naphthylamide affected the MICs minimally. OmpF (OmpK35) or OmpC (OmpK36) pores were not the major route by which avibactam crossed the outer membranes of E. coli and K. pneumoniae. In contrast, Omp35 and Omp36 allowed diffusion of avibactam across the outer membrane of E. aerogenes, although other diffusion channels for avibactam were also present in that species. It was clear that outer membrane permeability and outer membrane pore-forming proteins play a key role in the activity of ceftazidime-avibactam. Nevertheless, the MICs of ceftazidime-avibactam (with 4 mg/liter avibactam) against the ceftazidime-resistant clinical isolates of the three species of Enterobacteriaceae studied were ≤8 mg/liter, regardless of outer membrane permeability changes resulting from an absence of defined porin proteins or upregulation of efflux.     

Early treatment of deep burn of hand to keep the function and prevent scar proliferation

Background:Deepburnofhandscancauseseveredysfunc-tion.Earlyplerosistothehandswillplayanimportantroletothefunctionalexerciseandtherecovery.Objective:Toobservetheeffectofearlytreatmentofdeepburnofhandstothefunctionalreservationandpreventionofscarproliferation.Unit:DepartmentofBurn,People'sHospitalofGansuProvince.Subjects:1118burnedpatientswererecruitedduringDe-cemberof1998toDecemberof2001.Inthem252patientswerecomplicatedwithburnofhands,inwhich129handsweredeepburns(96malesand33females,agedfro…     

Autoantibodies to prothrombin and phosphatidylserine/prothrombin-complexes: do they contribute to the serodiagnosis of primary and secondary anti-phospholipid syndrome?

The diagnostic and clinical relevance of Ab to pure and phosphatidylserine-complexed prothrombin for primary and secondary APS was investigated in a total of 357 patients with (n = 169) and without (n = 188) connective tissue diseases. The overall frequency of anti-prothrombin Ab in sAPS, pAPS and patients without APS-related symptoms were found to be 50.0, 37.5 and 22.0%, respectively. From a total of 72 anti-prothrombin-positive samples, 12.5% were specific for pure prothrombin, 31.9% for phosphatidylserine/prothrombin-complexes and 55.6% recognized both antigenic forms. The simultaneous occurrence of other anti-phospholipid Ab was observed in 84% of all sera. Both types of anti-prothrombin Ab are significantly associated with lupus anticoagulant activity, but only Ab to pure prothrombin display such a relationship to clinical manifestations of APS. Based on these results, it cannot be recommended at present to include anti-prothrombin assays in the routine procedure for the serodiagnosis of APS. However, patients negative for lupus anticoagulant and typical APS-related anti-phospholipid Ab should be tested for anti-prothrombin reactivity, favoring, mainly due to its higher specificity, the ELISA containing pure prothrombin as antigen.     

Are adverse events of nevirapine and efavirenz related to plasma concentrations?

OBJECTIVE: The relationships between adverse events (AEs) and plasma concentrations of nevirapine (NVP) and efavirenz (EFV) were investigated as part of the large, international, randomized 2NN study. METHODS: Treatment-naive, HIV-1-infected patients received NVP (once or twice daily), EFV or their combination, each in combination with lamivudine and stavudine. Blood samples were collected on day 3 and weeks 1, 2, 4, 24 and 48. Concentrations of NVP and EFV were quantitatively assessed by a validated HPLC assay. Individual Bayesian estimates of the area under the plasma concentration-time curve over 24 h (AUC24h), and minimum and maximum plasma concentrations (Cmin and Cmax) as measures for drug exposure of NVP and EFV, were generated using a previously developed population pharmacokinetic model. Pharmacokinetic parameters were compared for patients with and without central nervous system (CNS) and psychiatric AEs, hepatic events, liver enzyme elevations (LEEs) and rash. Furthermore, it was investigated whether a clear cut-off for a pharmacokinetic parameter could be identified above which the incidence of AEs was clearly increased. AEs were also related to demographic parameters and baseline characteristics. RESULTS: In total, from 1077 patients, NVP (3024 samples) and EFV (1694 samples) plasma concentrations and AE data (825 observations) were available. For all patients Cmin, Cmax and AUC24h were determined. When corrected for known covariates of gender, CD4 cell count at baseline, region, hepatitis coinfection and possible interactions between these factors, no significant associations between AEs and any tested exposure parameter of NVP was observed. Also, no target Cmin value, above which patients were at increased risk for AEs, could be established. On the other hand, geographical region, hepatitis coinfection, CD4 cell count and gender were found to be significantly related with the incidence of CNS and psychiatric AEs, hepatic events, LEEs and rash during the treatment with NVP. The occurrence of elevated liver enzymes during the first 6 weeks in the EFV-containing arm was significantly (P = 0.036) correlated to the exposure of EFV (Cmin). Only hepatitis coinfection impacted on LEEs during the first 6 weeks of treatment. With an EFV Cmin above 2.18 mg/l during the induction phase, patients were 4.4 (range 1.3-15.5) times more at risk for elevated liver enzymes. No other correlations between AEs and EFV pharmacokinetics or patient characteristics could be identified. CONCLUSIONS: Pharmacokinetic parameters of NVP did not have a relationship to AEs in the 2NN trial when corrected for known covariates. The value of periodical drug monitoring of NVP as a way to prevent toxicity is therefore limited. Treating physicians should instead focus on factors that are more predictive of AEs (gender, CD4 count and hepatitis coinfection). High EFV Cmin levels resulted in elevated liver enzyme values during the first 6 weeks of treatment. Regular measurement of EFV levels and liver enzymes at the start of therapy may therefore be advised.     

Tetany and Rhabdomyolysis Due to Surreptitious Furosemide — Importance of Magnesium Supplementation

Abstract

Diuretics may induce hypokalemia, hypocalcemia and hypomagnesemia. While severe hypokalemia may cause muscle weakness, severe hypomagnesemia is associated with muscle spasms and tetany which cannot be corrected by potassium and calcium supplementation alone (1,2). Surreptitious diuretic ingestion has been described, mainly in women who are concerned that they are obese or edematous. Symptomatic hypokalemia has been reported in such patients (3—7) and in one case hypocalcemia was observed (8), but the effects of magnesium depletion were not noted in these patients.