健康教育对肥胖患者进行干预的效果评价

目的评价健康教育对肥胖患者的干预效果。方法选取北京牛街社区肥胖患者40人,通过健康教育进行干预,1年后进行效果评价。结果健康教育后患者体重指数下降有显著性。结论通过健康教育对肥胖患者进行减肥干预是必要的。     

Comparison of black and white patients attending hypertension clinics in England.

Reports suggest that hypertension and death due to hypertensive disease are commoner among black than among white people. One hundred and thirty-five black patients attending hypertension clinics at three English hospitals were compared with age-, sex-, and clinicmatched white patients. The black women had higher blood pressures and weighed more than the white women, but there were no differences between the men. The black patients had not increased risk from family, obstetric, or smoking history. Proteinuria and nocturia were more common in black patients while urinary infections were less common. Heart size and left ventricular voltage were greater in black patients. Haemoglobin and plasma cholesterol and triglyceride concentrations were smaller and serum globulin concentration greater in black patients. No difference in response to treatment, attributable to race, was observed during the period of clinic attendance, which averaged 1.7 years. There was a slightly greater rate of default among black men during the first year of attendance.     

消化系统肿瘤患者术后肠内与肠外营养支持对比的Meta分析

目的运用Meta分析方法 ,评价消化系统肿瘤患者术后应用肠内营养(EN)与肠外营养(PN)两种临床营养支持方式的有效性、安全性和经济性。方法检索Medline(Pubmed)、Embase和Cochranedatabase数据库,根据Cochrane系统评价手册对纳入的随机对照试验(RCT)进行质量评价,采用RevMan 5.1软件进行Meta分析。选择血清白蛋白(ALB)、术后并发症发生率、住院天数和治疗费用作为评估指标,得出合并后的均数差值(WMD)或比值比(OR),以及95%可信区间(95%CI)等进行定量综合评估。结果共纳入20篇文献,其中10篇文献用于分析两种营养支持的营养指标,16篇文献分析两种营养支持的安全性,10篇文献分析两种营养支持的住院时间,3篇文献分析两种营养支持的治疗费用。营养指标ALB的合并WMD=1.22,95%CI(1.14,1.30),P<0.05;术后并发症发生率的合并OR=0.74,95%CI(0.63,0.87),P<0.05;住院天数的合并WMD=-1.47,95%CI(-1.90,-1.05),P<0.05;治疗费用的合并WMD=-175.00,95%CI(-213.51,-136.49),P<0.05。结论消化系统肿瘤患者术后采用EN相对于PN支持,可更有效地改善患者营养状况,减少术后并发症,缩短住院时间,降低治疗费用。要得出远期结果需对更多高质量的RCT进行分析。     

Comparison of patient outcomes with bivalirudin versus unfractionated heparin in percutaneous coronary intervention

OBJECTIVE: To compare clinical outcomes and glycoprotein IIb-IIIa inhibitor use in patients undergoing percutaneous coronary intervention (PCI) who received bivalirudin or unfractionated heparin (UFH) in a real-world setting. DESIGN: Retrospective cohort analysis. SETTING: University-affiliated medical center. PATIENTS: One thousand seventy-five adult patients who underwent PCI and received either bivalirudin (539 patients) or UFH (536 patients) from April 1, 2003-April 1, 2004. MEASUREMENT AND MAIN RESULTS: Patient data on demographics, comorbidities, laboratory values, and reports of radiologic examinations, cardiac catheterizations, and discharge summaries were obtained. Outcomes evaluated included rates of in-hospital mortality, myocardial infarction, revascularization, and length of stay (LOS), as well as Randomized Evaluation of PCI Linking Angiomax to Reduced Clinical Events (REPLACE-2) and Thrombosis in Myocardial Infarction (TIMI) bleeding categorization. Bivalirudin use was associated with a significant reduction in TIMI major (5.0% vs 9.7%, p=0.003), REPLACE-2 major (5.4% vs 12.9%, p<0.001), and TIMI minor (1.7% vs 6%, p<0.001) bleeding complications compared with UFH use. Significantly fewer patients in the bivalirudin group received glycoprotein IIb-IIIa inhibitors (27.3% vs 62.7%, p<0.001). Patients receiving bivalirudin had significantly fewer myocardial infarctions after catheterization (10.7% [40/375] vs 18.0% [51/284], p=0.007). No differences were noted in mortality and revascularization rates between groups. A shortened LOS was observed in the bivalirudin group. CONCLUSIONS: This real-world analysis that included high-risk patients provides further evidence that bivalirudin is an attractive alternative to UFH because of a decrease in bleeding events without compromising efficacy.     

A cost-utility analysis of second-line chemotherapy in metastatic breast cancer. Docetaxel versus paclitaxel versus vinorelbine

The aim of this study was to determine the incremental effectiveness, the incremental health-related quality of life (differences in quality-adjusted progression-free survival between treatments), the incremental cost and the incremental cost-effectiveness and cost-utility ratios, for docetaxel, paclitaxel and vinorelbine, when these drugs were used as second-line treatment in patients with metastatic breast cancer. In the absence of comparative direct evidence of the relative efficacy of docetaxel, paclitaxel and vinorelbine in this setting, a model was designed to determine the effects of the 3 interventions on health outcome and cost. A Markov process model, based on 53 disease states, was thus constructed to evaluate the socioeconomics of the 3 treatment regimens. The model allows assessments from the start of second-line chemotherapy until death. Costs were evaluated from the combined view of the healthcare system and the patient. Direct nonmedical and indirect costs were excluded. Consumption per episode of care was estimated by retrospective analysis of 153 medical reports from 5 different hospitals. Hospital costs were allocated values from the national accounting costs by diagnosis-related group (DRG). The content of the health states was based on the multiattribute health states classification system (MASH). Preference values were assigned by application of a standard reference lottery using 20 oncological nurses as proxies for the patients. The health-related quality-of-life score was used as a quality adjustment weighting factor to calculate quality-adjusted progression-free survival associated with the 3 different regimens. Docetaxel reduces the time spent in progression, decreases the number of complications due to progressive disease and thereby provides better quality of life. It provides a benefit of 57 disease- and discomfort-free days compared with vinorelbine and 22 days compared with paclitaxel. Docetaxel may be thought of as self-financing as a result of savings in hospital admissions, providing net savings of 6800 French francs (FF; 1993 values) compared with expenditure associated with vinorelbine treatment and FF700 compared with the equivalent figures for paclitaxel.     

Management of gestational diabetes mellitus and pharmacists' role in patient education.

PURPOSE: The pathophysiology, diagnosis, complications, and management of gestational diabetes mellitus (GDM) are discussed, along with considerations in setting up a pharmacist-run GDM education service. SUMMARY: GDM occurs when there is insufficient insulin secretion to counteract pregnancy-related decreases in insulin sensitivity. GDM can be diagnosed by using the same criteria used to diagnose types 1 and 2 diabetes mellitus (DM): a fasting blood glucose concentration of > 126 mg/dL on two separate occasions or a random blood glucose concentration of > 200 mg/dL on two separate occasions. Complications of GDM include maternal type 2 DM, maternal hypertension, macrosomia, shoulder dystocia, and neonatal hypoglycemia. GDM is managed with medical nutritional therapy (MNT), exercise, and therapy with human or synthetic insulin. The American Diabetes Association recommends starting insulin therapy when MNT fails to maintain plasma glucose concentrations at < or = 105 mg/dL during fasting, < or = 155 mg/dL one hour after eating, or < or = 130 mg/dL two hours after eating. A pharmacist interested in establishing a GDM education service must assess the feasibility of providing such education in his or her practice and whether such a program is needed. Other considerations are developing a curriculum, marketing the service, maintaining records, calculating costs, and obtaining reimbursement. CONCLUSION: GDM can have serious effects if not treated properly. A major part of managing GDM involves educating the patient about diet, exercise, blood glucose self-monitoring, and insulin self-administration. A successful pharmacist-run GDM education service must have a market and prices sufficient to generate profit.     

Comparison of academic and nonacademic sites in multi-center clinical trials

The selection of appropriate subjects is a critical element of successful clinical trials. Failure to properly identify, select, and retain subjects in clinical trials of antidepressant medications may affect the ability to show separation from placebo. Little is known about which type of site, academic or nonacademic, is superior in selecting and retaining appropriate subjects. In the present investigation, the authors conducted a retrospective analysis comparing the performance of academic and nonacademic sites in selecting and retaining appropriate subjects in a recently completed multi-site clinical study of aripiprazole augmentation. The authors used a set of operationalized criteria called the SAFER to identify appropriate study subjects. No significant differences were found in rates of SAFER interview passing, study completion, and clinical outcomes between academic and nonacademic sites. Our findings suggest that academic and nonacademic sites are equally effective in their ability to identify and retain appropriate study participants.     

The performance of model-based versus rule-based phase I clinical trials in oncology

Phase I studies with anticancer drugs are used to evaluate safety and tolerability and to choose a recommended phase II dose (RP2D). Traditionally, phase I trial designs are rule-based, but for several years there is a trend towards model-based designs. Simulations have shown that model-based designs perform better, faster and are safer to establish the RP2D than rule-based designs. However, the superiority of model-based designs has never been confirmed based on true trial performance in practice. To aid evidence-based decisions for designing phase I trials, we compared publications of model-based and rule-based phase I trials in oncology. We reviewed 172 trials that have been published in the last 2 years and assessed the following operating characteristics: efficiency (trial duration, population size, dose-levels), patient safety (dose-limiting toxicities (DLTs)) and treatment optimality (percentage of patients treated below and at or above the recommended phase 2 dose). Our results showed a non-significant but clinically relevant difference in trial duration. Model-based trials needed 10 months less than rule-based trials (26 versus 36 months; p = 0.25). Additionally, fewer patients were treated at dose-levels below the RP2D (31 % versus 40 %; p = 0.73) while safety was preserved (13 % DLTs versus 14 % DLTs). In this review, we provide evidence to encourage the use of model-based designs for future phase I studies, based on a median of 10 months of time gain, acceptable toxicity rates and minimization of suboptimal treatment.     

Comparison of outcomes by gender and for fee-for-service versus managed care: a study of nine community programs

During-treatment services and 7-month posttreatment entry outcome of cocaine- or alcohol-dependent men (n = 145) and women (n = 149) Target City patients receiving either standard fee-for-services (n = 183) or managed care treatment funding (n = 111) in nine community outpatient programs were compared. No differences were found in treatment services received by the various subgroups. Regression analyses compared the four described subgroups (Gender x Type of Funding) on their seven Addiction Severity Index composite scores at 7 months postadmission controlling for the respective baseline composite score and several background variables on which the groups differed. Surprisingly few outcome differences were revealed between men and women patients and patients receiving the two forms of treatment funding. The only difference noted was that patients treated via managed care showed more improvement in the drug area. The need for further evaluation of the effects of managed care is emphasized.     

Screening for hepatitis B in chemotherapy patients: survey of current oncology practices

Background Hepatitis B virus (HBV) reactivation occurs in up to 78% of patients receiving cytotoxic chemotherapy for nonhepatic malignancies. Reactivation can lead to hepatic dysfunction, jaundice and fulminant hepatic failure. Current recommendations include screening patients at risk for HBV prior to immunosuppressive therapy and initiating antiviral prophylaxis in patients with chronic HBV. Aim To investigate current practice among oncologists regarding HBV screening and antiviral prophylaxis in candidates for chemotherapy. Methods A survey was sent to American Medical Association registered oncologists assessing demographics and HBV screening practices. Statistical analysis was performed using Fisher’s exact test. Results In all, 265 responses were received. Office‐based physicians were less likely to screen for HBV prior to chemotherapy (P < 0.001). Years in practice varied: 51% with <5 years, 29% with 5–15 years and 18% with >15 years, with no difference in screening practices between groups (P = N.S.). Responders screen for HBV as follows: never – 20%, only in the presence of abnormal liver biochemistries – 30%, risk factors or history of hepatitis – 38%. In patients with known HBV, 75% of oncologists refer to specialists, 7% initiate therapy, while 15% do not refer or initiate therapy, most of whom are in an office setting (P = 0.02). Conclusions Twenty per cent of oncologists never screen for HBV prior to initiating chemotherapy. Office‐based physicians were less likely to screen, treat or refer to a specialist prior to chemotherapy. Greater education regarding risk of HBV reactivation is needed for clinicians treating patients with immunosuppressive therapies. Aliment Pharmacol Ther 31 , 240–246