The UK National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project – a feasibility study of large‐scale clinical service peer review

Rationale, aims and objectives Service provision and clinical outcomes for patients admitted with chronic obstructive pulmonary disease remain unacceptably variable despite guidelines and performance feedback of national audit, data. This study aims to assess the impact of mutual peer review on service improvement. The initial phase of this study was to assess the feasibility and determine the practicalities of delivering such a peer review programme on a large scale. Methods All UK acute hospitals were invited to participate in a reciprocal peer review programme administered by a central team from three UK health organizations. Hospitals with the most resources were paired with those with the least (as defined in a baseline survey) and pairs randomized on a 3:2 basis into intervention or control groups. A number of key quality indicators were derived to measure service levels at the beginning and end of the study. Peer review teams included clinicians and managers from acute and primary care organizations and when possible a patient representative. Visits were focussed on four key areas of chronic obstructive pulmonary disease service. Teams were to agree service improvements and submit plans signed off by participants. Monthly change diaries were to be used to record progress towards agreed goals. Results A total of 100 hospitals participated in the programme. Overall, 52 of 54 peer review visits took place within a 4‐week time frame and all units submitted service improvement plans within an agreed time frame. Secondary care representatives participated in all visits, primary care in 30 but patients in only 17. The mean number of diaries returned was 2, but 94% of units returned initial and final versions. Conclusions It is possible to deliver successful large‐scale mutual peer review using a limited but focussed programme. Participation of patients and use of change diaries requires further evaluation.     

人文关怀对新诊2型糖尿病患者焦虑、抑郁状态的影响

目的探讨人文关怀对新诊2型糖尿病患者焦虑、抑郁状态的影响。方法用随机对照原则,将80例新诊2型糖尿病患者随机分为人文关怀组及常规教育组(各40例),应用焦虑自评量表(SAS),抑郁自评量表(SDS)分别进行干预前后测评,同时与正常人群对照。结果人文关怀组与常规教育组比较,抑郁、焦虑症状等问题得到改善(p0.05);人文关怀组患者糖化血红蛋白水平下降幅度大于常规教育组(p0.05),差异均具有统计学意义。结论人文关怀可更好地改善抑郁、焦虑症状及糖代谢情况。     

2型糖尿病合并慢性心力衰竭患者pro-BNP和hs-CRP与心功能的相关性研究

目的观察2型糖尿病(T2DM)合并心力衰竭患者B型脑利钠肽前体(pro-BNP)、超敏C-反应蛋白(hs-CRP)与心功能的相关性。方法测定60例T2DM合并慢性心功能衰竭(CHF)患者(观察组)和20例健康体检者(对照组)血浆pro-BNP和血清hs-CRP水平。心脏彩色多普勒超声测定左室射血分数(LVEF)。比较两组pro-BNP、hs-CRP浓度变化与临床NYHA心功能分级、左室射血分数的情况。结果观察组血清hs-CRP水平和血浆pro-BNP水平显著高于对照组,差异有统计学意义(P<0.01),且随着心功能分级的升高而升高,呈正相关(r=0.825,P<0.05)。随着LVEF值下降而升高,呈明显的负相关(r=-0.712,P<0.05)。结论 pro-BNP、hs-CRP与T2DM合并慢性心力衰竭患者心功能状态有显著的相关性,可以作为诊断和病情检测、指导用药的客观指标。     

手术治疗Ⅱ型糖尿病合并肥胖患者术中核心体温变化及干预措施

目的 研究Ⅱ型糖尿病合并肥胖患者行腹腔镜胃旁路术术中体温的变化并及时干预,从而降低手术风险。方法 选择2013年1月-12月在上海交通大学附属第六人民医院普外科择期手术患者60例,随机分为实验组和对照组各30例,通过术中收集数据进行观察和记录,分析体温变化、手术时间、术后并发症发生的相关性,为采取有效的护理措施提供依据。结果2组60例患者均予以腹腔镜胃旁路术,对照组患者术中核心体温较实验组显著下降,复苏后寒颤的强度及频率均高于实验组,且术后1例发生腹腔感染,无手术死亡及中转开腹患者。结论本研究首次以Ⅱ型糖尿病合并肥胖患者行腹腔镜胃旁路术术中低体温发生为切入点,进一步分析此类患者术中低体温发生的可能性,系统分析相关危险因素,从而采取针对性的护理干预措施并提供理论支持。多方法联合复温是治疗Ⅱ型糖尿病合并肥胖患者在手术中安全护理的重要环节。     

2型糖尿病患者营养干预联合家庭主要成员烹饪实践教育

目的 探讨基于食物交换份法的营养干预联合对家庭主要成员进行烹饪实践教育在2型糖尿病患者管理中的应用效果。方法 将67例2型糖尿病患者随机分为观察组33例和对照组34例,对照组采用食物交换份法的营养干预及运动指导,观察组在对照组的基础上联合对家庭主要成员进行烹饪实践教育,随访6个月。分别在研究开始前、随访6个月时比较2组空腹血糖、餐后2 h血糖、糖化血红蛋白、总胆固醇、甘油三酯、低密度脂蛋白、高密度脂蛋白的变化情况,比较2组患者饮食治疗依从性及满意度评分差异。结果 干预6个月后,除高密度脂蛋白外,2组血糖及血脂均有改善（P<0.05）。观察组血糖及血脂下降明显;除对照组规范烹饪外,其他饮食治疗依从性评分均有提高（P<0.01）,观察组提高更明显（P<0.01）;2组患者干预后满意度评分均明显提高（P<0.01）,观察组提高更明显（P<0.01）。结论 基于食物交换份法的营养干预联合对家庭主要成员进行烹饪实践教育,有助于患者血糖控制,降低血脂,提高患者饮食治疗依从性,增加患者对医护满意度,可在糖尿病患者家庭教育中广泛推广。     

人文关怀护理在多因素干预对新发2型糖尿病患者颈总动脉内中膜厚度增厚影响研究中的意义

目的：探讨人文关怀护理在多因素干预对新发2型糖尿病患者颈总动脉内中膜厚度增厚影响研究的应用。方法：90例新发2型糖尿病患者随机分为干预组及对照组各45例。对照组实施常规护理,干预组在此基础上给予人文关怀护理,实施多元化的健康教育和心理干预。结果：干预后干预组患者颈总动脉内中膜厚度、糖化血红蛋白、血清总胆固醇、甘油三酯水平下降幅度均大于对照组（P〈O．05）。结论：人文关怀护理能延缓多因素综合干预条件下新诊2型糖尿病患者颈总动脉内中膜厚度的进展。     

心理干预对2型糖尿病病人血糖控制的影响

目的研究心理干预对2型糖尿病病人血糖的影响。方法选择2011年3—9月在我院内分泌科住院的60例2型糖尿病病人作为研究对象。将其随机分为对照组和试验组,每组30例。对照组病人给予饮食控制、药物治疗、对症治疗以及糖尿病病人常规护理;试验组病人在与对照组相同治疗的基础上进行心理干预护理。1个月后分别测定两组病人的空腹血糖和餐后2h血糖,分析心理干预对2型糖尿病血糖控制的影响。结果试验组病人的空腹血糖及餐后2h血糖下降值显著高于对照组（t=3.994、6.107,P〈0.05）。结论心理干预能显著改善2型糖尿病病人血糖控制状况。     

CPAP治疗对2型糖尿病合并OSAHS患者血糖及生活质量的影响

目的评价持续气道正压通气治疗对2型糖尿病(T2DM)合并阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者血糖及生活质量的影响。方法选择2014年1-12月我院收治的2型糖尿病合并OSAHS患者60例,随机分为干预组和对照组。对照组给予2型糖尿病的常规治疗及OSAHS的一般治疗,干预组患者在此基础上同时使用持续气道正压通气呼吸机治疗。比较两组治疗前后呼吸暂停低通气指数(AHI)、最低血氧饱和度(LSpO2)、空腹血糖(FPG)、餐后2h血糖(PPG)、糖化血红蛋白(HbA1c)及Calgary生活质量指数(SAQLI)。结果3个月后,干预组AHI、LSpO2及SAQLI总分较对照组高,FPG、PPG及HbA1c较对照组低,差异均有统计学意义(P0.05)。结论持续气道正压通气治疗T2DM合并OSAHS患者可以改善睡眠呼吸情况,有效降低血糖,提高生活质量。     

社区护理干预对糖尿病病人遵医行为的影响

[目的]探讨社区护理干预对乡镇糖尿病病人遵医行为的影响.[方法]将110例病人按出院顺序随机分为干预组和对照组,每组55例,两组病人住院期间均接受了糖尿病知识的健康教育,干预组出院后进行护理干预,对照组未施加任何影响,1年后比较两组的遵医率.[结果]干预组糖尿病病人的遵医率高于对照组,血糖值明显低于对照组,差异均有统计学意义(P＜0.01).[结论]社区护理干预可提高糖尿病病人遵医率及降低血糖,从而提高糖尿病病人的生活质量.     

心理干预对2型糖尿病患者心理弹性水平、应对方式及生活质量的影响

目的：探讨心理干预对2型糖尿病患者心理弹性水平、应对方式及生活质量的影响。方法：对72例2型糖尿病患者进行问卷调查,将72例2型糖尿病患者随机分为干预组(36例)和对照组(36例),对照组实施常规护理,干预组进行心理护理干预,干预3个月后应用中文版心理弹性问卷,医学应对问卷和糖尿病特异性生存质量量表评估两组心理弹性水平、应对方式及生活质量情况。结果：2型糖尿病患者心理弹性较差,干预组经过相应的护理干预后患者的心理弹性明显提高,且干预组应对方式和生活质量水平明显好于对照组,差异有统计学意义(P<0.01)。结论：加强对糖尿病患者心理弹性的重视,探索合适的心理护理干预方式,帮助患者积极应对,接受现实,增强心理弹性水平,达到有效提高生活质量的目的。     

糖尿病及其控制程度与心力衰竭预后的相关性分析

目的 评价糖尿病与糖尿病血糖控制程度对慢性心力衰竭患者5年预后的影响.方法 回顾分析139例住院的慢性心力衰竭患者临床资料,根据是否合并糖尿病,分成糖尿病组(n=64)和非糖尿病组(n=75例);再以血糖控制是否满意,将糖尿病组患者分为血糖控制满意组(n=39)和不满意组(n=25);于首次住院后第5年对所有患者进行临床随访,记录临床情况、生化指标、治疗及不良事件(全因死亡、心肌梗死、心绞痛、心力衰竭再住院、脑血管事件)发生情况.结果 糖尿病组冠心痛患者所占比例高于非糖尿组(73.4%vs 53.3%,P=0.036),而两组患者在年龄,性别,高血压病史,入院时美国纽约心脏病学会(NYHA)心功能分级,心力衰竭治疗药物和治疗依从性等方面均无明显差异(P＞0.05).随访主要不良事件中,糖尿病组心绞痛发病率明显高于非糖尿病组(15.6%vs 2.7%,P=0.016),其他不良事件和总事件发生率在两组间差异无统计学意义.糖尿病患者血糖控制满意组病死率显著低于血糖控制不满意组(35.9%vs 64.0%,P=0.043).多因素logistic回归分析显示,糖尿病控制程度是心力衰竭死亡的独立预测因素(OR=0.342,95% CI0.119～0.981,P=0.046).结论 糖尿病血糖控制程度是慢性心力衰竭合并糖尿病患者死亡的独立预测因素,而糖尿病对慢性心力衰竭预后的影响尚不能肯定.     

The impact of a nurse-led support and education programme for spouses of stroke patients: a randomized controlled trial

Aims and objectives. The aim of the present study was to determine the impact of a nurse‐led support and education programme for improving the spouses’ perceived general quality of life, life situation, general well‐being and health state. Background. Stroke is a disease with great consequences for the patients and their families. The spouses often feel obligated to care for the patient, providing psychological and physical support and having to cope with the patient's physical and cognitive impairments. This might lead to increased problems, as family members struggle to adapt to their new roles and responsibilities. Design and methods. Longitudinal, randomized controlled trial. One hundred spouses were randomly assigned to intervention or control groups, 50 in each group. The intervention group participated in a support and education programme, six times during six months, led by stroke specialist nurses. Both groups were followed for 12 months. Results. No significant differences were found, between intervention and control groups, over time. In the sub analyses, we found that the group attending 5–6 times had a significant decrease in negative well‐being and increased quality of life over time, while the group attending fewer times had a significant decrease in positive well‐being and health state, similar to the control group, which also had a significant decrease in negative and general well‐being. Conclusions. A support and education programme might have a positive effect on spouses’ well‐being, on condition that they attend at least five times. Relevance to clinical practice. To facilitate the spouses’ role as informal caregivers to the stroke patients, further development of the support and education programme used in the present study is needed, including empowerment approach and implementation of coping strategies.     

糖尿病信息管理系统联合同伴教育对糖尿病门诊患者治疗效果的影响

目的 探讨糖尿病信息管理系统(DIMS)与同伴教育相结合的糖尿病管理模式对患者的自我管理水平及综合指标的影响。方法 选取2型糖尿病患者200例,随机分为3组。A组利用DIMS系统为其建立电子病历,同时给予同伴教育干预。B组在DIMS管理同时对其进行传统健康教育。C组接受普通门诊治疗。观察治疗前及治疗12月后空腹血糖(FPG)、餐后2 h血糖(2 hPG)、糖化血红蛋白(HbA₁c)、血压(BP)、胆固醇(TC)、甘油三酯(TG)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)及体质量指数(BMI)及各指标达标率变化,同时对糖尿病相关知识掌握情况、自我管理行为进行治疗前后评估。结果 治疗12月后A、B组的FPG、2 hPG、HbA₁c、HDL-C、LDL-C、TG、TC、BMI、BP均较治疗前达标率提高(P＜0.05);C组仅血压较治疗前达标率提高(P<0.05)。治疗12月后A组较C组的FPG、2 hPG、HbA₁c、HDL-C、LDL-C、TG、TC、BMI达标率提高(P＜0.05),而较B组的2 hPG、HbA₁c、HDL-C、LDL-C、TG、TC、BMI达标率提高(P＜0.05)。治疗12月后A组较B、C组对糖尿病相关知识掌握情况、自我管理行为得分显著提高(P＜0.05)。结论 DIMS结合同伴教育管理模式能提高糖尿病患者自我管理水平,改善各项代谢指标。     

健康教育对糖尿病合并慢性乙型肝炎患者焦虑抑郁情绪的影响

目的 探讨人文关怀护理对2型糖尿病合并慢性乙型肝炎患者焦虑抑郁情绪的影响.方法 将60例2型糖尿病合并慢性乙型肝炎患者随机分为A组与B组,每组30例,抽取同期健康志愿者30名设为C组.A组与B组患者均予以常规健康教育,A组施以人文关怀护理干预,观察3个月.于干预前及干预3个月末采用焦虑自评量表评定3组焦虑状况,抑郁自评量表评定3组抑郁状况;同时检测A组与B组患者糖化血红蛋白,并进行对比分析.结果 人文关怀护理干预前后两组患者焦虑自评量表及抑郁自评量表评分均显著高于C组(P＜0.01).干预后两组患者焦虑自评量表、抑郁自评量表评分及糖化血红蛋白均较干预前显著下降(P＜0.01),且A组均较B组下降更显著(P＜0.01).结论 2型糖尿病合并慢性乙型肝炎患者均存在不同程度的焦虑抑郁情绪,人文关怀护理干预能显著改善患者的焦虑抑郁情绪,提高治疗依从性,有利于促进患者的全面康复.     

Does physiotherapy management of low back pain change as a result of an evidence-based educational programme?

RATIONALE: The concept of evidence-based medicine is important in providing efficient health care. The process uses research findings as the basis for clinical decision making. Evidence-based practice helps optimize current health care and enables the practitioners to be suitably accountable for the interventions they provide. Little work has been undertaken to examine how allied health professionals change their clinical practice in light of the latest evidence. The use of opinion leaders to disseminate new evidence around the management of low back pain into practice has been proposed. AIMS: The aim of this study was to investigate if physiotherapists' clinical management of patients with low back pain would change following an evidence-based education package, which utilized local opinion leaders and delivered the best evidence. METHOD: Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster randomized by location of work, to two groups. The intervention group received an evidence-based programme on the management of low back pain, including advice regarding increasing activity levels and return to normal activity and challenging patients' fears and beliefs about their pain. The control group received a standard in-service training package on the management of common knee pathologies. The physiotherapists' clinical management of patients with low back pain was measured prior to training and 6 months post training. Outcome measures were based on physiotherapists completing 'discharge summary' questionnaires, which included information relating to the use and importance of therapies for treating their low back pain patients. RESULTS: There were few significant differences in treatment options between the intervention and control groups post training. Whilst there was some indication that physiotherapists were already utilizing aspects of psychosocial management for patients with low back pain, there was little change in what physiotherapists perceived to be important to patient recovery and actual clinical practice following the intervention. CONCLUSIONS: Psychosocial factors have been identified as an important factor in the recovery of patients with low back pain. This project incorporated the latest evidence on the management of low back pain and utilized the theory of opinion leaders to disseminate this evidence into clinical practice. Whilst there were some limitations in the overall size of the study, the results help to give an insight into the challenges faced by the health care system and researchers alike to ensure quality evidence is actually utilized by practitioners for the benefits of patient care.     

External feedback in general practice: a focus group study of trained peer reviewers of significant event analyses

Background and aims Peer feedback is well placed to play a key role in satisfying educational and governance standards in general practice. Although the participation of general practitioners (GPs) as reviewers of evidence will be crucial to the process, the professional, practical and emotional issues associated with peer review are largely unknown. This study explored the experiences of GP reviewers who make educational judgements on colleagues' significant event analyses (SEAs) in an established peer feedback system. Methods Focus groups of trained GP peer reviewers in the west of Scotland. Interviews were taped, transcribed and analysed for content. Results Consensus on the value of feedback in improving SEA attempts by colleagues was apparent, but there was disagreement and discomfort about making a dichotomous ‘satisfactory’ or ‘unsatisfactory’ judgement. Differing views on how peer feedback should be used to compliment the appraisal process were described. Some concern was expressed about professional and legal obligations to colleagues and to patients seriously harmed as a result of significant events. Regular training of peer reviewers using several different educational methods was thought essential in enhancing or maintaining their skills. Involvement of the participants in the development of the feedback instrument and the peer review system was highly valued and motivating. Conclusions Acting as a peer reviewer is perceived by this group of GPs to be an important professional duty. However, the difficulties, emotions and tensions they experience when making professional judgements on aspects of colleagues' work need to be considered when developing a feasible and rigorous system of educational feedback. This is especially important if peer review is to facilitate the ‘external verification’ of evidence for appraisal and governance.     

并发症体验对2型糖尿病患者疾病态度及血糖控制水平的影响

目的 探讨并发症体验对2型糖尿病患者对疾病态度、血糖控制水平的影响,为糖尿病临床护理提供参考依据。方法 方便选取125例2型糖尿病患者分为干预组（61例）和对照组（64例）。2组患者均给予2型糖尿病常规护理,同时干预组给予糖尿病并发症体验干预。对2组患者在入院时、出院时、出院后1个月、3个月、6个月5个时间点的疾病态度、糖化血红蛋白值进行比较。结果 共125例患者完成研究,干预后2组患者对疾病态度差异均有统计学意义（P<0.05）,在出院后3个月、6个月2组患者的糖化血红蛋白值差异有统计学意义（P<0.05）。结论 体验式学习可以改善2型糖尿病患者对疾病的态度,对控制患者的血糖水平具有明显效果。     

Evaluation of cognitive behavioural training and physical activity for patients with stress-related illnesses: a randomized controlled study.

OBJECTIVE: To evaluate the effects of a cognitive behavioural training programme and a physical activity programme for patients with stress-related illnesses. DESIGN: In a randomized controlled study, patients were allocated randomly to 1 of 3 groups, where group 1 participated in a cognitive behavioural training programme, group 2 participated in a physical activity programme, and group 3, the control group, was offered usual care for the course of the study. SUBJECTS: A total of 75 patients participated in the study. They had been on sick leave for at least 50% of the time for between 1 month and 2 years due to stress-related illnesses. METHODS: Measurements of autonomic activity, pressure-pain thresholds and subjective ratings of health and behaviour were made before and after a 10-week intervention period, and at 6 and 12 months after the intervention. RESULTS: Minor differences in autonomic activity and pressure-pain thresholds were found between the groups immediately after the intervention. At the 6- and 12-month follow-up assessments, the differences were no longer present. Patients in the cognitive behavioural training group improved their ratings of general health compared with the physical activity group throughout the study. CONCLUSION: The study showed little difference in the effect of cognitive behavioural training and physical activity, compared with usual care, for patients with stress-related illnesses.     

Use of antimigraine treatments by general practitioners

(Headache 2011;51:1122‐1131) Objectives.— To assess headache treatment patterns in 2 groups: general practitioners (GPs) who suffered from migraine themselves (GP‐M) and GPs having a close family member with migraine (GP‐CFM). The secondary objective was to assess the impact of migraine on activities of daily living in these 2 groups. Background.— Personal experience of migraine may influence prescribing practices of physicians treating patients with migraine. Little data are available on perceptions of migraine by GPs. Methods.— This was an observational, cross‐sectional, pharmacoepidemiological survey conducted in primary care in France. Most GPs completed 1 of 2 questionnaires, and GPs belonging to both groups could complete both. Data were collected on headache treatments used (GP‐M) or prescribed (GP‐CFM), and on self‐reported (GP‐M) or described (GP‐CFM) migraine features and impact on daily activities. Results.— The most frequently reported acute headache treatments in both groups were triptans and non‐steroidal anti‐inflammatory drugs (>75% of GPs); >81% of GPs in both groups were satisfied with acute headache treatments. Only 6.9% of the GP‐M group used and 17.2% of the GP‐CFM group prescribed a prophylactic treatment, which was considered satisfactory by 46.2% and 56.1%, respectively. In the preceding 3 months, 79.4% of the GP‐M group reported handicap in daily activities due to migraine, 23.6% interruption of extraprofessional activities and 7.6% interruption of work. In the GP‐CFM group, 32.6% described interruption of extraprofessional activities and 57.3% interference with daily activities or work. Conclusions.— Acute headache treatment prescribed by French GPs for their own migraines or those of their relatives respect practice guidelines and is considered as effective and satisfactory. Use of prophylactic medication is low and its effectiveness perceived as limited. Better use of prophylactic treatments may attenuate the impact of migraine on daily activities.     

强化糖尿病健康教育对胰岛素治疗的初诊糖尿病患者效果的影响

[目的]了解强化糖尿病(DM)教育对胰岛素治疗的初诊2 型糖尿病(T2DM)患者效果的影响.[方法]将100例初诊T2DM患者随机分成两组各50例,均予胰岛素降糖治疗,对照组予以常规糖尿病宣教,干预组同时给予强化DM健康教育,比较治疗前后及两组治疗后抑郁自评量表(SDS)评分,糖尿病相关知识得分及血糖等相关指标的变化....