36年（1970～2005年）乳腺癌住院病例的动态分析

目的 动态分析36年来乳腺癌临床流行病学的特征变迁。方法 应用我院1970～2005年乳腺癌住院病例521例分析发病情况，发病年龄，性别，肿瘤大小，病程，淋巴结转移及手术方式构成等变化。并按1970～1979年，1980～1989年，1990～1999年及2000～2005年等4个年段进行统计，从纵横两个方面来分析乳腺癌外科治疗发展情况。结果 从1970～2005年，乳腺癌病例数明显上升，发病年龄高峰前移，中位发病年龄从1970年的56．0岁下降到2005年的49．0岁；青年人患病率从70年代的5．3％上升到2000年后的22．5％（P〈0．05）；〉4cm肿瘤在70年代占34．2％，2000年后占34．4％（P〉0．05）；腋淋巴结转移率在70年代占81．6％，90年代后占67．7％（P〉0．05）。结论 乳腺癌发病呈明显上升的趋势，青年人发病上升，发病年龄高峰前移，但中、晚期肿瘤的格局无改变。传统根治术比例下降，改良根治术上升。     

乳腺肿块与外科治疗的问题

目的 探讨乳腺肿块与外科治疗的问题.方法 分析我院1970～2005年因乳腺肿块在3年以上才手术的乳腺癌病例共68例,登记其年龄,性别,肿块发生的时间,大小,手术方式,肿瘤分期及治疗预后等资料,从中了解乳腺肿块与乳腺癌的临床特点.结果 全部为女性,年龄26～84岁,平均58岁.肿块手术时存在最短时已3年,最长时间60年,平均9.4年.发现肿块明显增大后最早入院手术时间10d,最迟12个月.其中传统根治术18例,改良根治术50例.结论 乳腺肿块发现后应及时手术治疗.     

A transformed pregnancy: the psychosocial consequences of gestational diabetes

Gestational diabetes (i.e. diabetes diagnosed during pregnancy) has important implications for maternal and foetal well-being. This paper presents an ethnographic study of gestational diabetes, an unexpected, potentially life-threatening illness diagnosed during the second half of pregnancy. While previous research has conceptualised gestational diabetes as producing few consequences since it commonly disappears after delivery, this study explores the meaning women attach to the disorder. It found that gestational diabetes had a profound effect on the respondents, resulting in fear, depression and anxiety. The respondents' imagery of diabetes as a debilitating disease concomitant with blindness, amputations, and premature death generated increased anxiety throughout pregnancy and six-weeks postpartum. The personal disruption in complying with the diabetic regimen as well as health care provider transactions exaggerated the unique stress of a ‘normal’ pregnancy. We suggest that a strictly medical view of gestational diabetes minimises its broader psychosocial significance and recommend effective provider-patient interactions with ‘high-risk’ pregnant women.     

糖尿病肾移植后并发背痈的营养治疗

一例糖尿病性肾病尿毒症患者,肾移植术后2个月餐前尿糖仍在 ～ ,体重渐降,术后5月,因右肩痤疮感染并发展成痈,伴高热,经切开引流术后,营养需求矛盾突出。营养治疗分三个阶段进行:第一阶段血糖达30.3mmol/L。尿糖 ～ ,普通胰岛素(RI)40～64u/d,因糖尿病控制不力,供热130.2～142.8kJ/(kg~(-1)·d~(-1)),蛋白质1.5～1.66g/(kg~(-1)·d~(-1))。第二阶段R172～52u/d,病情控制,热能摄入172.2kJ/(kg~(-1)·d~(-1))。蛋白质1.84g/(kg~(-1)·d~(-1))。第三阶段RI用64～56u/d病情稳定,供热189～214.2kJ/(kg~(-1)·d~(-1)),蛋白质2.11～2.23g/(kg~(-1)·d~(-1)),中等脂肪,复合碳水化物,高纤维的低盐普食治疗。一个切口长约12c×8cm深3.5cm脓腔经16天治疗,伤口明显缩小变浅,经50天创面治愈。     

Real-time adjudication: collecting copayments and balances before the patient sees the doctor

Doctors need to become better businesspeople, which means making sure that they collect all the monies that they deserve for all the services they provide to their patients. One method to achieve this is to use real-time adjudication. This article will describe real-time adjudication and how it can improve your collections by 7% to 10%.     

On the remarkable persistence of asymmetry in doctor/patient interaction: a critical review

Doctor/patient interaction has been the object of various reform efforts in Western countries since the 1960s. It has consistently been depicted as enacting relationships of dominance or oppression. Most younger medical practitioners have received interaction skills training during their professional education, intended to encourage more equal forms of consultation behaviour. However, the evidence that 'patient-centredness' has a positive impact on health outcomes is at best mixed. At the same time, empirical studies of consultations point to the remarkable persistence of asymmetry. These two factors together suggest that asymmetry may have roots that are inaccessible to training programmes in talking practices. Illustrating our argument with findings from conversation analytic studies of doctor/patient interaction, we suggest that asymmetry lies at the heart of the medical enterprise: it is founded in what doctors are there for. As such, we argue that both critical and consumerist analysts and reformers have crucially misunderstood the role and nature of medicine.     

Monitoring the introduction of a surgical intervention with long-term consequences

Surgical innovations are often introduced for their expected long-term benefits, but the decision to abandon the existing treatment must be based on the available short-term data and rational judgment. We present a framework for monitoring the introduction of a surgical intervention with long-term consequences and failure-time endpoints. The framework is based on Bayesian methods, and formally combines study data, clinical opinion, and external evidence to construct a posterior survival function from which intuitive summary statistics can be extracted to aid decision making. It incorporates learning effects and is adaptable to a wide variety of settings. The methods are illustrated on survival data from a cohort of 325 consecutive neonates treated for simple transposition of the great arteries with either the Senning or the Switch operation during the period 1978-1998.     

Development of a patient decision aid for choice of surgical treatment for breast cancer

Purpose A patient decision aid for the surgical treatment of early stage breast cancer was developed and evaluated. The rationale for its development was the knowledge that breast conserving therapy (lumpectomy followed by breast radiation) and mastectomy produce equivalent outcomes, and the current general agreement that the decision for the type of surgery should rest with the patient.
Methods A decision aid was developed and evaluated in sequential pilot studies of 18 and 10 women with newly diagnosed breast cancer who were facing a decision for breast conserving therapy or mastectomy. Both qualitative (general reaction, self-reported anxiety, clarity, satisfaction) and quantitative (knowledge and decisional conflict) measures were assessed.
Results The decision aid consists of an audiotape and workbook and takes 36 min to complete. Based on qualitative comments and satisfaction ratings, 17 of 18 women reported a positive reaction to the decision aid, and all 18 reported that it helped clarify information given by the surgeon. Women did not report an increase in anxiety and 17 of 18 women were either satisfied or very satisfied with the decision aid.
Conclusion This pilot study supports the hypothesis that this decision aid may be a helpful adjunct in the decision for surgical management of early stage breast cancer. We are currently conducting a randomized trial of the decision aid versus a simple educational pamphlet to evaluate its efficacy as measured by knowledge, decisional conflict, anxiety and post-decisional regret.     

Continuity in UK general practice: a multilevel model of patient,doctor and practice factors associated with patients seeing their usual doctor

BACKGROUND: Personal continuity is a 'core value' for UK general practice, but often appears ignored by organizational change. OBJECTIVES: The aim of the present study was to examine practice, GP and patient factors associated with personal continuity of care. METHODS: A cross-sectional survey was carried out of 25 994 people aged >15 consulting over a 2-week period in 53 general practices in four regions of the UK. The outcome measure was whether or not the patient was seeing their usual or regular doctor. RESULTS: Compared with the smallest quintile of practices, the odds ratios [95% confidence interval (CI)] for patients seeing their usual doctor for the two largest quintiles of list size (6337-11 036 and >11 037) were 0.24 (0.12-0.46) and 0.19 (0.10-0.37). Patients in the five practices with personal list systems were more likely to be seeing their usual doctor (odds ratio 3.27, 95% CI 1.87-5.70). Older patients were considerably more likely to be seeing their usual doctor. Young men were less likely, but by middle age there were no differences between men and women. Compared with patients who only wished to discuss a new or urgent physical problem, those wishing to discuss psychological (odds ratio 2.28, 95% CI 2.01-2.58) or longstanding physical problems (odds ratio 1.92, 95% CI 1.78-2.08) were more likely to be seeing their usual doctor. CONCLUSIONS: In this study, list sizes over approximately 6000-6500 were associated with marked reductions in personal continuity. If GPs are serious about the importance of personal continuity, then the size of the primary care team needs to be examined. There may be potential in separating the administrative functions of the practice from the clinical functions of the primary care team.     

The unexpected in primary care: a multicenter study on the emergence of unvoiced patient agenda

PURPOSE: Within the time constraints of a typical physician-patient encounter, the full patient agenda will rarely be voiced. Unexpectedly revealed issues that were neither on the patient's list of items for discussion nor anticipated by the physician constitute an emerging agenda. We aimed to quantify the occurrence rate of emerging agendas in primary care practices and to explain the variation between patients and practices. METHODS: This observational cross-sectional study involved 182 primary care practices in 9 European cultural regions. Consecutive primary care consultations were videotaped and rated. Patients completed preconsultation and postconsultation questionnaires assessing their expectations and perceived care. Emerging agenda, determined by using 11-item preconsultation and postconsultation questionnaires, was defined as care perceived by the patient to be in addition to expected care, after adjustment for cultural variations of patient expectations. RESULTS: For consultations involving 2,243 patients (mean age, 44.8 years, 58.4% women), every sixth (15.8%) consultation revealed emerging psychosocial agenda. Biomedical agenda emerged in 14.5% of the consultations. Rates for unmet expectations were 13.6% and 10.3%, respectively, for psychosocial and biomedical problems. Practices showed considerable heterogeneity of occurrence of emerging agenda (biomedical, median 13%, range 0%-67%; psychosocial, median 14%, range 0%-53%). After controlling for region and patient baseline characteristics, variables significantly related to emerging agenda were patient expectations and biomedical or psychosocial discourse content, but not consultation time or sex of the patient. A large proportion of the variance attributable to physicians remained concealed in a practice dummy variable (explaining up to 8% of the variance). CONCLUSION: Unexpected agenda emerges in every sixth to seventh consultation in outpatient primary care visits.     

Surrendering the keys: a doctor tries to get an impaired elderly patient to stop driving

In the interest of public safety, the author argues for a vastly improved policy framework to help get dangerous older drivers off the road.