Evidence-informed evidence-making

The extent to which clinical and public health guidance developed by the National Institute for Health and Clinical Excellence (NICE) can effectively serve the public by improving quality and efficiency across the National Health Service (NHS) and the broader public sector depends largely on the quality and relevance of the available evidence which informs its decisions. There are well-established organizational and procedural links between NICE and academic and professional organizations that undertake evidence synthesis. However, there are fewer means for evidence gaps identified during the development of NICE guidance to lead to the commissioning of new prospective studies. In this paper, we discuss the importance of a publicly funded clinical and public health research agenda that includes new prospective studies aimed at addressing knowledge gaps identified by NICE. We describe the early experience of NICE and the National Institute for Health Research (NIHR) working together to articulate and commission research to inform best practice recommendations. We propose ways in which NICE can collaborate more effectively with research funders to improve the evidence base upon which it bases its recommendations.     

学龄前儿童意外伤害流行病学调查

目的了解幼儿园儿童意外伤害发生状况。方法回顾性调查武汉市某幼儿园463名3~6岁学龄前儿童1年间意外伤害的发生情况。结果幼儿园儿童意外伤害发生率为11.45%;家中和幼儿园是易发生伤害的场所;意外跌落为最常见的伤害;伤害部位以头部为主;发生季节以夏、冬季较多;伤害程度以轻度居多;伤害的人均治疗费用453.43元,以自费为主。结论幼儿园儿童意外伤害发生率较高,应加强安全管理和教育,预防儿童意外伤害。     

深圳市社区儿童意外伤害教育干预效果评价

目的:探索有效预防儿童意外伤害的干预措施。方法:以深圳市横岗镇19所幼儿园和4个社康中心的学龄前儿童和家长为研究对象,对儿童和家长进行教育干预,干预期为一年,分别在干预前后进行问卷调查,并对干预效果进行评价。结果:干预后家长对伤害的认知水平有所提高。与干预前比较,各类伤害发生率均有下降。经统计学检验,机械伤、中毒、意外跌落差异有统计学意义。结论:对学龄前儿童及其家长进行意外伤害教育干预,能有效预防儿童意外伤害的发生。     

英国临床诊疗规范的制定程序和执行机制

介绍了英国国家卫生质量标准署(National Institute for Health and Clinical Excellence,NICE)制定临床诊疗规范的程序和组织机制,其中重点探讨了在英国卫生医疗体系内,NICE作为法定授权的独立标准制定机构所起到的平衡器作用,分析了其诊疗规范的执行保障机制,为我国诊疗规范的制定和有力实施提出了政策参考.     

1349例意外损伤住院儿童分析

目的:分析儿童意外损伤的类别及相关因素。方法:对1349例儿童意外损伤住院病例按国际损伤分类标准,对损伤类别、构成、年龄、性别、住院费用及天数进行分析。结果:儿童意外损伤占同期住院患儿及全部意外损伤住院人数的8%,是导致同期1月以上年龄住院患儿死亡的第1位原因。儿童意外损伤的前4位原因是交通事故、意外跌落、烧烫伤和意外中毒。男女比为1.79∶1。交通事故和意外跌落高峰年龄段在4～9岁,烧烫伤和意外中毒主要发生在3岁前。其中交通事故的平均住院费用最高,平均住院时间最长。坠落物致伤及机器致伤也占一定比例,分别为3.92%和1.33%。结论:应当大力开展儿童意外损伤危险因素的识别和干预,以减少儿童意外损伤的发生。     

Dietetic practice in refeeding syndrome

Background: The physiology and consequences of refeeding syndrome have long been recognised, although its management continues to be debated, despite the recommendations made by The National Institute for Health and Clinical Excellence (NICE) in their guideline ‘Nutrition Support in Adults’ (2006). The present study aims to assess current dietetic opinion and practice in this area, as well as whether the NICE recommendations have been adopted. Methods: An anonymous, self‐completed Internet survey was designed investigating current practice and opinions on the NICE (2006) guidance on this subject. A link to the questionnaire was distributed with a covering letter via e‐mail to the heads of department of National Health Service Trusts in the London region, UK, requesting that it be disseminated to all dietitians working with adults. After the closing date, all responses were collated and analysed. Results: The survey elicited a 30.8% response rate. Some 89.8% of respondents have read the NICE guidance on Nutrition Support in Adults (2006) and 66.9% have changed their practice regarding refeeding syndrome management as a result. Sixty‐two percent do not wait for biochemistry to normalise before commencing nutrition. Ninety‐two percent of respondents completed the mini case studies indicating that current practice is inconsistent among dietitians. Neither NICE criteria for recognising patients at risk of refeeding, nor the recommended starting rates are universally followed. Seventy‐five percent continue to supplement electrolytes reactively. Conclusions: Although limited by a small sample size, the findings of the present study suggest that dietetic practice regarding refeeding syndrome management remains inconsistent with the recommendations made by NICE, although some aspects have been adopted.     

陕西省4668名0～12岁农村儿童意外伤害现状调查

目的 了解陕西省农村0～12岁儿童意外伤害现状.方法 采用三阶段分层随机抽样法,于2010年对陕西省5个县农村0～12岁4668名儿童一年中意外伤害的发生情况进行调查.结果 4668名儿童意外伤害年发生率为27.3％,男童为28.7％,女童为25.6％,男童明显高于女童(x2=5.91,P=0.015);不同年龄组儿童意外伤害发生率存在明显差异(x2=9.91,P=0.007),0～3岁组儿童意外伤害发生率最高,其次为7～ 12岁组和4～6岁组;在发生的各种意外伤害中,跌落伤的发生率占首位;随家庭经济状况的下降儿童意外伤害的发生率不断上升.结论 陕西省农村儿童意外伤害的类型主要是跌落伤;伤害的高发年龄段为0～3岁;家庭经济状况对儿童意外伤害的发生有一定影响.     

厦门市城区集居学龄前儿童意外伤害危险因素病例对照研究

目的 了解厦门市城区集居学龄前儿童意外伤害影响因素，为制定有效的预防措施提供依据。方法 根据厦门市的特点，选择有代表性的两个城区，随机抽取１０所幼儿园３～６岁儿童共２１４６名。收集１９９８年４月至１９９９年３月意外伤害的情况，筛选出病例２３１人进行１：１配对。结果 意外伤害发生率为１６．２％；男童意外伤害发生率明显高于女童（Ｐ〈０．０５）；随着年龄的增加发生率呈下降趋势（Ｐ〈０．００１）。意外伤害发生类型以碰伤、跌伤为主，占６５．４％。经单变量配对χ＾２检验及多变量条件Ｌｏｇｉｓｔｉｃ逐步回归分析，伤害直接影响因素为：父毒的工作类型、母亲怀孕次数、分娩方式、父亲年龄、儿童参加活动情况及儿童性格行为。用多元线性逐步回归分析，发现另外一些家庭因素通过影响儿童行为对伤害产生间接影响。结论 意外伤害是多因素相互作用的结     

4～14岁儿童意外损伤相关因素分析

目的 研究学龄期儿童意外损伤的危险因素,为制定有效的预防措施提供依据.方法 分析1994年1月1日～2004年12月31日收治的儿童意外损伤中4～14岁学龄期儿童病例的损伤类别、发生地点及时间、年份趋势及年龄、性别特点.结果 803例4～14岁学龄期儿童意外损伤占同期全部儿童意外损伤住院人数的59.52%.意外损伤的前四位原因是交通事故、意外跌落、烧烫伤和意外中毒.男女之比为1.95：1.全部统计的损伤中在学校发生的9.33%.交通事故损伤发生的地点以放学及上学路上最多,占全部交通事故损伤的33.30%,其他前三位发生地点以家内及家周围为多.意外损伤随年龄增长逐渐减少,女孩随年龄增长减少更为明显.交通事故及意外跌落伤在近5年有明显增多趋势.结论 学龄期儿童是意外损伤的高危人数,在年龄、性别及发生地点上有其特点.社会、学校及家庭应密切配合,制定有效的预防措施.     

广州市天河区0～14岁儿童伤害流行病学特征及影响因素分析

目的 探讨广州市天河区0～14岁儿童意外伤害流行病学特征及影响因素,为开展伤害预防干预提供依据。方法 以随机整群抽样的方法调查广州市天河区0～14岁儿童及其家长,以问卷方式调查儿童在过去一年意外伤害发生状况以及家长对意外伤害的认知水平。结果 共调查天河区1285名0～14岁儿童,其意外伤害发生率为16．34％,伤害次数发生率为20．47％,男、女性分别为23．46％和17.43％,男性高于女性(P＜0．01)。跌倒／坠落、碰撞／挤压伤、扭伤和交通事故是最常见类型,最常见的伤害地点是家里／宿舍、学校／幼儿园。2．66％的受伤儿童需住院治疗,44．87％的受伤儿童需医院门诊处理,意外伤害医疗费用支出占家庭人均月收入的14．53％。儿童意外伤害的影响因素为父亲职业、家庭经济状况及儿童性格特点等。95．2％的家长表示听说过“意外伤害”;89．4％的家长表示经常或有时担心孩子会发生伤害;13,4％的家长表示接受过有关预防儿童青少年伤害的培训和指导。结论意外伤害严重影响着天河区0～14岁儿童的健康,给家庭和社会造成经济损失。预防重点是培训家长和教师,开展健康教育,以提高其安全知识水平。     

海门市学龄前儿童意外损伤现状分析

目的　了解海门市学龄前儿童损伤发生现状 ,探讨损伤发生的特征及减少损伤发生的干预措施。方法采取分层随机整体抽样 ,由保健老师询问老师及家长并填写调查表 ,市妇幼保健所医生进行质控汇总。调查了海门市 14所幼儿园 2 3 4 8名学龄前儿童 2 0 0 2年 3月 1日～ 2 0 0 3年 2月 2 8日期间损伤发生的情况。结果海门市学龄前儿童意外损伤发生率为 15.55% ,男童高于女童 (P<0 .0 5) ;意外损伤的发生 3～ 4岁高于 5～ 6岁 (P<0 .0 5) ,夏秋季高于冬春季 (P<0 .0 5) ;男童前 3位损伤类型为跌伤、撞伤、动物伤 ,女童损伤类型前 3位为跌伤、撞伤、烫伤 ;90 .68%属轻度损伤 ,8.50 %属中度损伤 ,0 .82 %属重度损伤 ;家庭中损伤占 45.2 1% ,幼儿园中损伤占 43 .2 9% ,路途中损伤占 11.50 %。结论海门市学龄前儿童意外损伤发生率较高 ,采取综合安全防范措施 ,能够减少学龄前儿童意外损伤的发生     

中学生健康素养和手机依赖行为的交互作用与意外伤害的关联

目的 探讨中学生健康素养和手机依赖行为的交互作用与意外伤害的关联,为青少年意外伤害的防控提供参考。方法 2015年11月至2016年1月采用分层整群抽样方法,在辽宁省沈阳市、安徽省蚌埠市、河南省新乡市、内蒙古自治区乌兰察布市、重庆市和广东省阳江市抽取22 628名中学生进行问卷调查。采用《中国青少年互动性健康素养问卷》、《青少年手机使用依赖自评问卷》和《意外伤害评定量表》分析评估中学生健康素养状况、手机依赖行为及意外伤害情况。结果 中学生手机依赖行为和意外伤害的总检出率分别为25.4%和46.7%。有、无手机依赖行为和低、中、高健康素养的中学生意外伤害分别为53.6%、44.4%和48.8%、48.1%、41.7%,有手机依赖行为及低、中健康素养的中学生意外伤害检出率更高（均P<0.001）;中学生手机依赖行为（OR=1.452,95% CI：1.380~1.527）和中、低水平健康素养（OR=1.196,95% CI：1.118~1.278;OR=1.364,95% CI：1.289~1.444）均与意外伤害呈正向关联,并且健康素养和手机依赖行为对意外伤害存在相乘交互作用（OR=1.217,95% CI：1.041~1.422）。结论 意外伤害在中学生中的发生率较高;健康素养和手机依赖行为与意外伤害正向关联,并对意外伤害存在交互作用。     

Unintentional and violent injuries among pre-school children of teenage mothers in Sweden: a national cohort study

STUDY OBJECTIVE: This study investigates the risk and mediating mechanisms of unintentional and violent injuries in pre-school children of teenage mothers. DESIGN: Cohort study based on Swedish national registers. Cox analyses of proportional hazard were used to estimate the relative risk of hospital admission and death attributable to injuries in analyses of data from national registers. PARTICIPANTS: The study population was a national cohort of 800,192 children born in Sweden during 1987-93 who were followed up prospectively from birth to their 7th birthday. MAIN RESULTS: Children of teenage mothers had higher relative risks (RRs) of hospital admissions for violent as well as unintentional injuries; age adjusted RRs of 2.7 (95% CI 1.2 to 6.1) and 1.6 (1.4 to 1.8), respectively, for children of mothers under 18 years of age and 2.5 (1.6 to 3.8) and 1.5 (1.4 to 1.6) of mothers aged 18-19 are compared with those with mothers aged at least 32 at the birth of the child. When the models were adjusted to socioeconomic variables and indicators of parental substance misuse and psychiatric illness the risk decreased slightly but remained well above that of children with older mothers. In addition, children of teenage mothers had an increased risk of death attributable to violent injuries (RR 6.7 (2.6 to 16.0), as well as to unintentional injuries (RR 3.5 (2.0 to 6.1). CONCLUSIONS: Maternal age is an important determinant of injuries in pre-school children in Sweden and the children of teenage mothers are at particular risk. Young parents should be given priority in injury prevention programmes.     

Incidence and pattern of unintentional injuries and resulting disability among children under 5 years of age: results of the National Health Survey of Pakistan

National estimates of injuries for children under 5 years based on population representative surveys are not readily available globally and have not been reported for developing countries. This study estimated the annual incidence, pattern and distribution of unintentional injuries according to age, gender, socio‐economic status, urban/rural residence and disability caused among children aged under 5 years in Pakistan. The National Health Survey of Pakistan (NHSP 1990–94) is a nationally representative survey of households to assess the health profile of the country. A two‐stage stratified design was used to select 3223 children under 5 years of age for interview and examination. Data were used for boys and girls in urban and rural areas over the preceding year. A community development index was developed to assess the relationship between socio‐economic status and injuries. Weighted estimates were computed adjusting for complex survey design using surveyfreq and surveylogistic option of SAS 9.1 software. Post hoc power calculations were made for each variable keeping the design effect at 3.0. The overall annual incidence of unintentional injuries was 47.8 [95% CI 36.6, 59.0] per 1000 per year; 50.2 [95% CI 37.0, 63.4] and 45.2 [95% CI 29.4, 61.0] per 1000 per year among boys and girls under 5 years of age respectively. An estimated 1.1 million unintentional injuries occur in Pakistan annually among these children. Injury rates increase with age among the under‐5s. Urban and rural injuries were 56.1 [95% CI 33.5, 78.7] and 44.1 [95% CI 31.1, 57.1] per 1000 per year respectively. The children living in least developed communities had almost 3 times higher risks of injuries than most developed communities. The annual incidence of types of injuries were: falls 28.7 [95% CI 19.5, 37.9], cuts/bruises 9.7 [95% CI 5.3, 14.1] and burns 6.6 [95% CI 3.0, 10.2] per 1000 per year. Falls were the most common type of injury (60%) followed by cuts/bruises (21%) and burns (14%). The majority of injuries occur at home (85%), with just 10% due to road traffic. Road traffic injuries and injuries to the female child were more likely to result in disability. There is a high burden of unintentional injuries and disability among children under 5 in Pakistan. These results are useful for planning further research and for prioritising prevention programmes nationally and in other developing countries with similar situation.     

小儿内科急诊意外伤害分析

目的:为增强人们对小儿意外伤害的预防意识和探索有效防治措施。方法:对珠海市妇幼保健院小儿内科急诊从1994～2003年收治的意外伤害小儿208例,按不同伤害类别、性别、年龄、临床转归进行统计,作回顾性综合分析。结果:各类中毒在小儿内科急诊意外伤害中占绝大多数,以药物中毒为主。结论:预防药物中毒是小儿意外伤害的预防重点,幼儿及学龄前儿童的预防尤其重要,应引起人们的重视。     

菏泽市东明县农村儿童意外伤害特征及其影响因素研究

目的 了解14岁以下农村儿童非致死性意外伤害的流行特征及其影响因素, 为当地儿童意外伤害的预防干预提供理论依据。方法 采用整群分层抽样方法抽取菏泽市东明县乡镇4所中小学及2所幼儿园的儿童475名为调查对象进行自拟问卷调查, 数据经SPSS 13.0软件进行统计分析。结果 调查的475名农村儿童意外伤害发生率为40%。碰撞(20.53%)、跌落(18.95%)、中毒(13.68%)为农村儿童意外伤害类型的前三位。农村儿童意外伤害的发生地点主要在家中(25.3%)和休闲活动场所(23.7%), 发生部位以上肢和头面部为主, 农村儿童意外伤害发生的严重程度中致残占3.1%。性别、(父)母亲文化程度、儿童性格以及是否留守儿童是农村儿童发生意外伤害的危险因素。伤害组家长的意外伤害认知低于非伤害组, 差异有统计学意义(t=-9.952, P<0.05)。结论 菏泽市农村儿童意外伤害发生率较高, 伤害类型以跌落、碰撞为主;影响儿童意外伤害的因素以家长的文化程度及对伤害的认知最为明显。     

Views of Directors of Public Health about NICE Appraisal Guidance: results of a postal survey. National Institute for Clinical Excellence

BACKGROUND: We aimed to determine the views of Directors of Public Health about the Health Technology Appraisal Programme of the National Institute for Clinical Excellence (NICE) before the move to strategic health authorities and primary care trusts in April 2002. METHOD: In December 2001 we sent a questionnaire asking about the work programme, products, decision-making, general approach, resource allocation and success of NICE to all Directors of Public Health in England and Wales. Ninety-two of 100 responded. RESULTS: Three-quarters or more agreed that NICE has covered a number of priority and controversial areas, produced good-quality health technology appraisals, well-presented reports and readable guidance in a consistent format, that it has raised the profile of clinical effectiveness, provided a focus for debate about health technology, and succeeded in making the National Health Service (NHS) set aside resources for approved technologies. A similar proportion, however, also agreed that guidance was not timely, did not address 'whole systems' and made some disappointing recommendations, and that decision-making was not influenced enough by the needs of the NHS. They considered that NICE did not address implementation, decide between competing technologies or help the service prioritization debate, and that guidance sent unrealistic signals about affordability to patients and politicians and caused difficulty for the implementation of other technologies locally. CONCLUSIONS: A majority of Directors are positive about NICE's role of providing high-quality appraisal and central guidance but negative about its influence on local priority setting. Major concerns remain about the affordability of competing demands, whether this is NICE's responsibility or not.     

健康教育对托幼机构儿童及其家长意外伤害认知和行为的影响

目的:探索健康教育在有效预防托幼机构儿童意外伤害中的作用。方法:随机抽取武汉2所幼儿园大、中、小班各2个班3～6岁托幼机构儿童共181名,并将其家长作为调查对象,采用自行编写印制的书籍、儿歌、游戏模具、故事、主题活动、讲座等形式,分别在开展健康教育前后对儿童及其家长进行两次问卷调查。结果:健康教育后,儿童及其家长在儿童乘车安全知识、烫伤、发现煤气泄漏、鼻腔塞入异物的处理、对剪刀、打火机、电插座等有可能造成伤害物品的识别、交通安全等方面的回答正确率均显著增高,差异有统计学意义(P<0.05或P<0.01),在幼儿单独在家时的安全知识、防止跌落等方面的回答正确率也较健康教育前有所提高,但差异无统计学意义(P>0.05)。结论:健康教育干预可明显改善家长和儿童意外伤害的认知和行为。