Views regarding the training of ethics consultants: a survey of physicians caring for patients in ICU

BACKGROUND: Despite the expansion of ethics consultation services, questions remain about the aims of clinical ethics consultation, its methods and the expertise of those who provide such services. OBJECTIVE: To describe physicians' expectations regarding the training and skills necessary for ethics consultants to contribute effectively to the care of patients in intensive care unit (ICU). DESIGN: Mailed survey. PARTICIPANTS: Physicians responsible for the care of at least 10 patients in ICU over a 6-month period at a 921-bed private teaching hospital with an established ethics consultation service. 69 of 92 (75%) eligible physicians responded. Measurements: Importance of specialised knowledge and skills for ethics consultants contributing to the care of patients in ICU; need for advanced disciplinary training; expectations regarding formal-training programmes for ethics consultants. RESULTS: Expertise in ethics was described most often as important for ethics consultants taking part in the care of patients in ICU, compared with expertise in law (p<0.03), religious traditions (p<0.001), medicine (p<0.001) and conflict-mediation techniques (p<0.001). When asked about the formal training consultants should possess, however, physicians involved in the care of patients in ICU most often identified advanced medical training as important. CONCLUSIONS: Although many physicians caring for patients in ICU believe ethics consultants must possess non-medical expertise in ethics and law if they are to contribute effectively to patient care, these physicians place a very high value on medical training as well, suggesting a "medicine plus one" view of the training of an ideal ethics consultant. As ethics consultation services expand, clear expectations regarding the training of ethics consultants should be established.     

脑出血患者双重任务训练中功能与皮质脊髓束变化1例报道

<正>双重任务训练能有效改善脑卒中患者的运动和平衡功能[1],促进患者更好地参与社区生活[2]。现报道1例脑出血患者在9周双重任务训练过程中,各个功能结局指标进展与皮质脊髓束神经结构的变化。1病例介绍患者,男,63岁,于2019年2月27日首次发病。诊断"脑出血,左侧基底节区"。病情稳定后,于2019年4月29日转至昆明医科大学第二附属医院康复医学部住院部进行康复训练。患者及家属同意参加实验并签署知情同意书。     

他克莫司治疗难治性重症肌无力36例疗效与安全性的观察

目的 通过长期的随访评价小剂量他克莫司在难治性重症肌无力中的效果与不良反应.方法 我们按0.1 mg·kg-1·d-1的剂量把他克莫司应用于中山大学附属第一医院神经内科2008年11月至2010年12月收治的36例全身型/眼肌型的重症肌无力患者.疗效评价应用重症肌无力日常生活量表(MG-ADL)与美国重症肌无力基金会分型(MGFA分型)来评定,同时检测每一例患者的不良反应.结果(1)36例患者随访7～23个月,其中6例患者出现药物不良反应而停用,不良反应发生率为16.67％.(2)24例患者治疗后可见MG-ADL评分减少,MGFA分型进步,有效率为66.67％,治疗前后比较差异有统计学意义(P =0.000).(3)全身型患者的疗效优于眼肌型患者(P =0.032).(4)24例有效患者的平均药物血谷浓度均低于国外推荐的维持数值.结论 他克莫司可改善MG患者的临床症状,尤其在全身型重症肌无力患者中,在应用的同时需监测药物的不良反应.     

Knowledge, attitude and practices of Nigerian anaesthetists in HIV infected surgical patients: a survey

In the light of increasing prevalence of the human immunodeficiency virus (HIV), anaesthetists are likely to see more patients with this virus in their practice. This study evaluated, using a questionnaire format, the knowledge, attitude and practices of anaesthetists in the management of HIV infected surgical patients. The questionnaire sought demographic information, the knowledge of risks involved as well as attitude and practices. One hundred (66.7%) out of 150 questionnaires distributed amongst members of the Nigerian Society of Anaesthetists were completed and returned. Fifty-five per cent (55%) of the respondents confirmed their willingness to be screened but only 45% had had a personal HIV screening test. Even though 23% of all the respondents will transfuse unscreened blood in an emergency, only 1(8.3%) of the consultants will do so. This trend was also reflected in gloving behaviour as 11(91.6%) of consultants will routinely wear gloves whilst only 12(70.5%) of the senior house officers will routinely glove for venepuncture despite the availability of gloves. Other precautionary facilities such as goggles, sharp disposal bins, routine screening of all surgical patients were more available in private than in government hospitals. Ninety- six per-cent of all respondents will initiate an action after a needle stick injury whilst 4% will ignore. General Anaesthesia was the choice of anaesthetic in an HIV/AIDS infected patient by 43% of respondents whilst 22% of respondents would choose regional technique. However, only 85% of respondents were willing to anaesthetise an infected patient. This study suggested a dearth of knowledge and perception of risks of HIV/AIDs amongst Nigerian Anaesthetists. Appropriate training and greater education is highly recommended. Rigorous infection control policy is imperative and hospital authorities must ensure availability of protective facilities.     

Overprotection and the psychological states of cerebral palsy patients and their caretakers in Hong Kong: a preliminary report

OBJECTIVE. To examine the relation between perceived overprotection and the psychological states of cerebral palsy patients and their primary caretakers in Hong Kong. DESIGN. Cross-sectional survey, in which data of 14 pairs of cerebral palsy patients and their caretakers were analysed. SETTING. Duchess of Kent Children's Hospital, Hong Kong. PARTICIPANTS. Cerebral palsy patients and their primary caretakers in Hong Kong. MAIN OUTCOME MEASURES. Perceived overprotection and psychological states. RESULTS. Nearly two thirds of the 14 patients (mean age of 15 years) and 86% of the 14 primary caretakers (mean age of 47 years) perceived various levels of overprotection. For both patients and caretakers, perceived overprotection was positively associated with anxiety and unhappiness. The patients' and caretakers' psychological states and perception of overprotection were not related to the actual motor ability of the patients. Perceived overprotection of the patients was not related to that of the caretakers. CONCLUSION. Caretakers should be mindful that a well-meaning move may have undesirable consequences. More support and child-rearing education should be considered for caretakers.     

Efficacy and safety of itraconazole as empirical antifungal therapy in febrile neutropenic patients with hematologic malignancies: an open-lable, multicenter, observational trial in a Chinese cohort

Background  Invasive fungal infection (IFI) is a common and fatal complication in neutropenic patients with hematological malignancy. Empirical antifungal therapy is widely used in practice due to the difficulty of pathogens determination and illness of the hosts. The aim of this study was to evaluate the efficacy and safety of itraconazole as empirical antifungal therapy for persistent fever in neutropenic patients with hematologic malignancies.

Methods  Two hundred and seventy-four patients with hematologic malignancies who had suspected fungal infections were enrolled in 18 centers across China between April 2008 and April 2009. Empirical antifungal therapy with intravenous itraconazole 200 mg twice daily was given for the first two days, followed by 200 mg once daily for the next 12 days. Oral itraconazole solution was sequential for follow-up therapy if necessary. Five composite end points were evaluated for the response, which was more restrictive and adopted for the first time in such study in China.

Results  The intent-to-treat analysis included data from 274 patients (full analysis set, FAS), of whom 248 were included as the per-protocol population (PPS). As the composite end point of five indices was concerned, the overall response rate was 43.4%. Seperately, defervescence was achieved in 90% of patients in which 55.5% occured during neutropenia. The mean time to defervescence was 2.71 days. Absence of breakthrough IFI during drug administration or within the first 7 days after study completion was observed in 71.5% of patients. Fifty-five point five percent patients with IFI at baseline was successfully treated. Ninety point five percent patients survived for at least 7 days after completing the study. PPS analysis revealed that the duration of neutropenia ≥10 days was a statistically significant negative predictor for the response. The withdrawal rate due to drug-related toxicity or lack of efficacy was 11.0%. The incidence of adverse events was 22.6%, in which 11.6% was study drug related. The most frequent adverse events were mild to moderate liver toxicity.

Conclusion  Itraconazole shows desirable efficacy and safety as empirical antifungal therapy for febrile neutropenic patients with hematologic malignancies.

     

Efficacy and safety of Shaoyang Xibi decoction in patients with knee osteoarthritis: a multi-center,single-blind,randomized controlled trial

PURPOSE

To observe the efficacy and safety of Shaoyang Xibi decoction (SYXBD) in patients with knee osteoarthritis (KOA), and to verify that the theory of “Shaoyang dominating bone” in Traditional Chinese Medicine (TCM) can be applied to KOA treatment.

Efficacy and safety of cilostazol, a novel phosphodiesterase inhibitor in patients with intermittent claudication

Pharmacotherapy is limited for the relief of intermittent claudication (IC), a common manifestation of peripheral arterial disease (PAD). Pentoxyfylline, the only current pharmacological therapy for IC, has been shown to have similar efficacy as placebo. Cilostazol, a new phosphodiesterase III (PDE III) inhibitor, is a potent inhibitor of platelet aggregation with vasodilatory, antithrombotic, antiproliferative and positive lipid-altering effects. To evaluate the efficacy and safety of cilostazol for the treatment of IC in Indian patients, 123 patients were selected from 6 centres in India. The patients, aged 58-73 years, with the diagnosis of stable moderate-to-severe IC received cilostazol 100/50 mg twice daily for a period of 12 weeks. Primary efficacy measures included initial claudication distance (ICD) and absolute walking distance (ACD) by treadmill testing and ankle-brachial index (ABI) using Doppler ultrasonography-measured systolic pressures. Secondary efficacy outcomes included subjective assessment of symptom improvement by patient and investigator and estimation of lipid values. Adverse events were monitored throughout the study. Laboratory investigations were carried out at baseline and end of study. At the end of week 12 of cilostazol therapy, there was a significant improvement in the raw walking distances (ICD and ACD). Percentage change in ICD and ACD was 46.77% and 64.5%, respectively, at the end of study. There was a significant increase (32.7%) in the ABI by the end of study period. According to patient and investigator assessment of symptoms, 58-60% of the subjects showed significant improvement to complete resolution of claudication symptoms by the end of 12 weeks of therapy. In addition, there was a significant increase of 20.24% in the mean plasma HDL-cholesterol levels and a decrease of 29.55% in the mean plasma triglyceride concentrations by the end of study period. Headache, diarrhoea, palpitation and dizziness were the commonly reported adverse effects during the study. No adverse effect led to discontinuation of therapy. The present study suggests that cilostazol is an effective therapeutic option with an acceptable tolerability profile for the treatment of IC in patients with PAD.     

88例肝病患者CHE、TBA以及PT测定结果分析

为了解血清中CHE活性、TBA含量以及PT测定与各类肝脏疾病的关系 ,对 88例经临床确诊为各类型肝病患者血清CHE、TBA以及PT测定结果进行分析 ,结果表明 :各类肝脏疾病TBA、PT均增高 ,CHE活性均降低 ,与正常对照组相比 ,除CHE指标差异无显著性外 ,其余各组差异有高度显著性 (P均 <0 .0 0 1) ,同时可以看到 ,慢性肝炎与肝硬化组的PT测定值差异无显著性 ,其余各组间此三项指标比较差异有显著性 ,P均为 0 .0 5～ 0 .0 0 1,提示血清CHE、TBA及PT测定对肝脏疾病的诊断均有较高的敏感性 ,均可作为评价肝病轻重程度的判断指标     

传染性非典型肺炎流行病学特征及临床诊疗措施的初步探讨

目的　探讨传染性非典型肺炎的流行病学、临床诊断及治疗 ,为防治该病提供经验和依据。方法　采用回顾性分析的方法对本院所收治的传染性非典型肺炎病例进行分析。结果　 6例患者平均年龄 2 8.8岁 ,有明显接触史者 1例 ,呈聚集发病者 3例 ,无医务人员感染 ,均于 4月份发病 ;全部治愈。结论　传染性非典型肺炎是一种新的传染病 ,临床上以发热、咳嗽、白细胞总数正常或下降、胸片渗出性改变为特点 ,其流行病学特点、诊断与治疗方面需进一步认识     

Tetanus in adults--a continuing problem: an analysis of 217 patients over 3 years from Delhi, India, with special emphasis on predictors of mortality

Tetanus is still widely prevalent in many parts of the world especially in the developing countries. This study was conducted to assess the demographic and clinical features, treatment and outcome of tetanus in adults with a special emphasis on identification of predictors of mortality. This was a retrospective study of all adult patients admitted with tetanus over a three-year period from 1998 to 2000 at Lok Nayak Hospital, New Delhi, India. The demography, clinical features, treatment and complications of the patients were assessed and were evaluated against two possible outcomes- survival or death, to identify the predictors of mortality. There were 217 adults (148 males, 69 females) admitted with generalized tetanus during the study period. The mean age of the patients was 36.08 +/- 18.84 years. In most instances (63.5%), wounds / injuries served as the source of infection. Overall 31.8% had mild, 21.7% had moderate and 46.5% had severe disease at presentation. Respiratory failure and dysautonomia were the frequently observed complications. Of the 217 patients, 82 died - a mortality rate of 37.78%. Parameters that were significantly associated with increased mortality were: age (especially > 60 years); shorter duration of symptoms - trismus, rigidity and dysphagia; severe disease at presentation and shorter period of onset. Tetanus is a preventable disease associated with a high fatality rate. Universal coverage of immunization programme and appropriate wound prophylaxis is the corner stone of tetanus eradication. The treatment of tetanus is difficult and requires specialized and intensive care. The presence of parameters indicating an adverse outcome at the beginning in the patients will help identify the subset of patients that need more intensive management especially in resource poor nations.     

阿普唑仑联合降压药治疗顽固性高血压的临床疗效和安全性评价

目的观察阿普唑仑联合降压药治疗顽固性高血压的临床疗效和安全性。方法于2008年2月—2010年10月治疗顽固性高血压患者102例,随机分为试验组和对照组各51例,2组在常规治疗基础上分别加用阿普唑仑或安慰剂治疗8周,观察患者的血压情况及不良反应。在治疗结束后随访8周,再次评价临床疗效。结果试验组显效37例(72.6%),有效10例(19.6%),总有效率92.2%,而对照组显效21例(41.2%),有效15例(29.4%),总有效率70.6%;2组间显效率和总有效率比较差异均有统计学意义(P<0.05)。试验组早期不良反应率(31.4%)高于对照组(21.6%),但差异无统计学意义(P>0.05)。随访8周时和试验结束时相比,试验组临床症状改善且血压稳定;而对照组舒张压水平升高(P<0.05)。结论阿普唑仑联合降压药治疗顽固性高血压疗效肯定,且不良反应少而轻微。     

Implementing clinical ethics in German hospitals: content, didactics and evaluation of a nationwide postgraduate training programme

The Hannover qualifying programme 'ethics consultation in hospitals', conducted by a four-institution cooperation partnership, is an interdisciplinary, scientifically based programme for healthcare professionals interested in ethics consultation services and is widely acknowledged by hospital managements and healthcare professionals. It is unique concerning its content, scope and teaching format. With its basic and advanced modules it has provided training and education for 367 healthcare professionals with 570 participations since 2003 (until February 2010). One characteristic feature is its attractiveness for health professionals from different backgrounds. Internationally, the Hannover programme is one of the few schedules with both academics and non-academics as target groups and a high participation rate of physicians. The concept of the Hannover programme is in great demand, and its schedule is continuously optimised through evaluation. The goals of enabling healthcare professionals from different professional backgrounds to define and reflect ethical problems, to facilitate and support the process of decision-making and to work out structures for their own institutions seem to have been achieved. However, in order to obtain effective and sustainable results, participation in the programme should be supplemented regularly by in-house training sessions or individual expert consultations. Future challenges include new thematic courses and providing a network for former participants, especially when they come from non-academic hospitals. The network is a reasonable platform to discuss participants' experiences, successes and pitfalls. A further task will be research on how the programme's concept can support the sustainability of ethics structures in the various institutions.     

Efficacy and safety of first-line chemotherapy plus bevacizumab in patients with metastatic colorectal cancer: a meta-analysis

Background What benefits and toxicities patients acquire from the use of bevacizumab combined with first-line chemotherapy remains controversial.This study was performed to evaluate the efficacy and safety of first-line chemotherapy plus bevacizumab in patients with metastatic colorectal cancer （mCRC）.Methods Several databases,including PubMed,Embase,and Cochrane Library,were searched up to April 30,2013.Eligible studies were only randomized,controlled trials （RCTs） with a direct comparison between mCRC patients treated with and without bevacizumab.Overall risk ratio （RR）,hazard ratio （HR）,odds ratio （OR）,and 95％ confidence intervals （CO were calculated employing fixed or random-effects models depending on the heterogeneity of the included trials.Results Six RCTs,including 1582 patients in chemotherapy plus bevacizumab group and 1484 patients in chemotherapyalone group,were included.Overall,the addition of bevacizumab to first-line chemotherapy increased overall response rate （ORR） by 4.5％,prolonged both progression-free survival （PFS） and overall survival （OS）,and increased the rate of total Grades 3 or 4 adverse events （G3/4AEs） by 6.9％.Significant differences were found in ORR （RR=1.22 （95％ CI 1.01-1.46）,P=0.03）,PFS （HR=0.60 （95％ Cl 0.47-0.77）,P ＜0.0001）,OS （HR=0.83 （95％ Cl 0.70-0.97）,P=0.02）,and any G3/4AEs （OR=1.56 （95％ Cl 1.29-1.89）,P ＜0.00001）.Conclusion Bevacizumab is a valuable addition to the current first-line chemotherapy regimens used in patients with mCRC,because of conferring a significant improvement in ORR,PFS,and OS,even though it increased adverse events.