对现行医疗服务定价的分析

目的：通过对现行医疗服务定价模式的利弊分析，笔者提出医疗服务价格体系的改革必须要考虑到医疗服务的特殊性，应科学地反映医疗服务所包含的科技与知识的含量、医务人员的劳动价值和医院实际成本的消耗；应进一步完善补偿机制，转换物价部门管理职能，实行按等级定价，建立动态的调价机制等改革措施。     

基于前瞻性队列研究体外受精-胚胎移植对不良妊娠结局的影响

目的：评价体外受精-胚胎移植(in vitro fertilization-embryo transfer,IVF-ET)技术本身是否会增加子代不良妊 娠结局(adverse pregnancy outcomes,APOs)的风险。方法：选择诊断为不孕症通过IVF-ET受孕的妇女为暴露组,诊断为 不孕症但通过非辅助生殖技术治疗(如促排卵或简单药物治疗)后自然怀孕的妇女作为非暴露组,建立前瞻性队列。 通过单因素分析找出两组除IVF-ET操作因素外存在差异的因素,再采用多因素logistic回归分析控制这些因素,分析 IVF-ET技术对APOs的独立作用。结果：多因素logistic回归分析显示,在控制混杂因素后,IVF-ET受孕孕妇较诊断为 不孕症但自然受孕孕妇显著增加早产(OR=1.28,95% CI：1.05~1.56)、低出生体重(OR=1.69,95% CI：1.27~2.31)、围 生期死亡(OR=5.33,95% CI：2.44~11.81)和先天畸形(OR=1.83,95% CI：1.12~2.94)的风险。结论：IVF-ET操作因素本 身可能会增加APOs的风险。     

金花清感颗粒治疗成人新型冠状病毒肺炎患者的多中心前瞻性队列研究

目的探讨金花清感颗粒应用于成人新型冠状病毒肺炎(coronavirus disease 2019, COVID-19)患者的有效性和安全性。方法选取2020年1月27日至3月23日北京地区15家医院收治的成人COVID-19患者245例,建立前瞻性研究队列,服用金花清感颗粒≥3 d的队列为观察组,常规治疗的队列为对照组。收集所有患者的临床资料,比较两组各指标的差异。结果观察组71例(29.0%),对照组174例(71.0%)。治疗后观察组咳嗽好转率和倦怠乏力好转率,显著优于对照组[65.9%比38.4%,87.0%比54.4%],差异有统计学意义(P<0.05)。观察组新型冠状病毒核酸平均转阴时间显著低于对照组[(13.85±7.96)d比(17.90±8.89)d],差异有统计学意义(P<0.05)。Kaplan-Meier曲线和log-rank检验提示观察组有较低的新冠病毒核酸阳性率(χ2=10.337,P<0.05)。观察组与对照组的住院时间和病死率比较,差异无统计学意义(P>0.05)。两组均未出现明显的不良事件。结论金花清感颗粒治疗COVID-19不改...     

舍曲林治疗脑梗死后抑郁的对照研究

目的:观察抗抑郁剂舍曲林对脑梗死后抑郁及神经功能康复的影响。方法:随机将60例脑梗死患者分为治疗组和对照组,在治疗前和治疗6周后分别评汉密尔顿抑郁量表(HAMD)和脑卒中患者临床神经功能缺损程度评分标准。结果:治疗6周后治疗组HAMD和脑卒中患者临床神经功能缺损程度评分均显著低于对照组(P<0.01);使用舍曲林治疗的患者在抑郁疗效和神经功能康复疗效方面均显著优于对照组(P<0.01或P<0.05)。结论:舍曲林可明显改善脑梗死后抑郁程度并能促进神经功能康复。     

310例育龄妇女孕前保健社区常态化管理模式

目的:探讨创立社区卫生孕前保健常态化管理模式,提高孕产妇生活质量,降低母婴并发症。方法:利用属地卫生保健专业卫技人员结合社区居委公干、义工、慈善关爱团队等机构人员对社区育龄妇女建档、复档"一对一"入户调研孕前保健,孕产妇咨询、体检、服务和关爱、问卷调查,对有生育要求的310例育龄妇女进行社区定期围产保健监测和孕期营养指导咨询,追踪服务至产后,同期设立对照组310例,比较产后结局。本组育龄妇女孕前保健至产后,追踪2年,均在社区内完成。结果:2组产后24 h出血量、阴道分娩例数、剖宫产例数、新生儿出生体重、妊娠糖尿病例数、产褥期感染例数的差异有统计学意义(均P<0.05);两组孕妇女生活质量评定显示,生活质量整体评价、健康状况整体评价、生活领域评价、自我评价总分等方面研究组均优于对照组(P<0.05)。结论:创立社区卫生孕前保健常态化管理模式,可以提高围产期管理水平,降低母婴并发症。     

多中心产后门诊妇女抑郁和/或焦虑症状现况研究

目的 了解中国大城市产后妇女中抑郁和／或焦虑症状患病率。方法 采用现况研究方法．于2004年6月1日到9月1日在北京、上海和成都3家医院的产科随访门诊连续收集分娩后妇女317例。由经培训的调查员用统一的调查表进行面对面调查,同时使用综合医院焦虑抑郁量表（HAD）、Hamilton焦虑量表和Hamilton抑郁量表进行心理测评。结果 产后妇女中抑郁自评症状的检出率为3．5％．焦虑自评症状的检出率为4．4％,在具有抑郁和／或焦虑症状（HAD≥9分）的患者中,中重度抑郁症状的检出率为10．0%,中重度焦虑症状的检出率为28．6％。具有抑郁和／或焦虑自评症状者所生育的新生儿的健康状况都良好．统计学检验未提示产妇妊娠合并症、分娩合并症与产妇抑郁和焦虑自评症状检出有显著关系,行剖宫术产妇焦虑自评症状的检出率显著高于顺产产妇。结论 中国大城市产后妇女抑郁、焦虑症状检出率尽管低于发达国家．但鉴于我国每年较大的分娩基数,产后妇女中抑郁和焦虑现象仍应引起卫生管理部门和临床医务人员的关注。     

认知疗法治疗脑卒中后抑郁对比观察

目的：观察中国道家认知疗法对脑卒中后抑郁及神经功能康复的影响。方法：随机将49例卒中患者分为认知疗法治疗组和对照组,在治疗前和治疗后4周、8周分别进行汉密尔顿抑郁量表（HAMD）和改良爱丁堡-斯堪的纳维亚卒中量表（MESSS）评分。结果：与对照组比较,8周后治疗组HAMD评分和MESSS评分的减分率均较高,差异有显著性（P〈0.05）。结论：中国道家认知疗法可明显改善卒中后抑郁的程度并能促进神经功能的康复。     

Singapore SPICE: sedation practices in intensive care evaluation in Singapore – a prospective cohort study of the public healthcare system

INTRODUCTIONA study was conducted to describe the sedation practices of intensive care units (ICUs) in Singapore in terms of drug use, sedation depth and the incidence of delirium in both early (< 48 hours) and late (> 48 hours) periods of ICU admission.METHODSA prospective multicentre cohort study was conducted on patients who were expected to be sedated and ventilated for over 24 hours in seven ICUs (surgical ICU, n = 4; medical ICU, n = 3) of four major public hospitals in Singapore. Patients were followed up to 28 days or until ICU discharge, with four-hourly sedation monitoring and daily delirium assessment by trained nurses. The Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) were used.RESULTSWe enrolled 198 patients over a five-month period. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 25.3 ± 9.2, and 90.9% were emergency hospital admissions. Patients were followed up for 1,417 ICU patient days, of which 396 days were in the early period and 1,021 days were in the late period. 7,354 RASS assessments were performed. Propofol and fentanyl were the sedative agents of choice in the early and late periods, respectively. Patients were mostly in the light sedation range, especially in the late period. At least one episode of delirium was seen in 23.7% of patients.CONCLUSIONSedation practices in Singapore ICUs are characterised by light sedation depth and low incidence of delirium, possibly due to the drugs used.     

Guidelines for a palliative approach for aged care in the community setting: A suite of resources

In Australia, many people ageing in their own homes are becoming increasingly frail and unwell, approaching the end of life. A palliative approach, which adheres to palliative care principles, is often appropriate. These principles provide a framework for proactive and holistic care in which quality of life and of dying is prioritised, as is support for families. A palliative approach can be delivered by the general practitioner working with the community aged care team, in collaboration with family carers. Support from specialist palliative care services is available if necessary.The Guidelines for a Palliative Approach for Aged Care in the Community Setting were published by the Australian Government Department of Health and Ageing to inform practice in this area. There are three resource documents. The main document provides practical evidence based guidelines, good practice points, tools, and links to resources. This document is written for general practitioners, nurses, social workers, therapists, pastoral care workers, and other health professionals and responded to needs identified during national consultation. Evidence based guidelines were underpinned by systematic reviews of the research literature. Good practice points were developed from literature reviews and expert opinion. Two ‘plain English’ booklets were developed in a process involving consumer consultation; one is for older people and their families, the other for care workers.The resources are intended to facilitate home care that acknowledges and plans for the client’s deteriorating functional trajectory and inevitable death. At a time when hospitals and residential aged care facilities are under enormous pressure as the population ages, such a planned approach makes sense for the health system as a whole. The approach also makes sense for older people who wish to die in their own homes. Family needs are recognised and addressed. Unnecessary hospitalisations or residential placements and clinically futile interventions are also minimised.     

Prevalence of juvenile fibromyalgia syndrome in an urban population of Turkish adolescents: impact on depressive symptoms, quality of life and school performance

Background Juvenile Fibromyalgia Syndrome （JFMS） is a chronic health condition characterized by widespread musculoskeletal pain and multiple tender points （TP）.The objective of this study was to determine the prevalence of JFMS in the urban population of Samsun and to determine the impact of JFMS on depression symptoms,school performance and quality of life （QOL）.Methods A cross-sectional study was conducted in 1109 children （mean age （14.8±2.0） years old）.A questionnaire was applied to the children and a medical examination including TP was performed.Yunus and Masi＇s criteria were used for diagnosis of JFMS.The children with JFMS were compared with an age and sex matched non-JFMS group.Depression was assessed with Children＇s Depression Inventory （CDI） and QOL was evaluated with Pediatric Quality of Life Inventory 4.0 （PedsQL4.0）.Results Sixty-one （5.5%） （13 boys and 48 girls） of 1109 children met the diagnostic criteria of JFMS.While PedsQL scores of children with JFMS were lower than the non-JFMS group for physical,emotional,social,school functioning and total score （P=0.001）,CDI total score was higher in the JFMS group than in the non-JFMS group （P=0.001）.The JFMS group reported more school absences （P=0.001） and the average school grade was lower in the JFMS group than in the non-JFMS group （P=0.03）.Conclusion The prevalence of JFMS is high in school age children.Since JFMS is a common problem of childhood,early diagnosis and identification of the disorder and more comprehensive and successful treatment approaches with appropriate psychological assistance may prevent more complex and severe problems in adulthood.     

Health care worker burnout during the COVID-19 pandemic: A cross-sectional survey study in Saudi Arabia

Objectives:To estimate the prevalence of burnout among health care workers (HCWs) who are working in Saudi Arabia during the Coronavirus disease 2019 (COVID-19) pandemic, and explore individual and work-related factors associated with burnout in this population.Methods:In this cross-sectional study conducted between June to August of 2020, we invited HCWs through social channels to complete a questionnaire. The questionnaire inquired about demographics, factors related to burnout, and used the Copenhagen Burnout Inventory scale to indicate burnout. A total of 646 HCWs participated.Results:The mean (SD) age of participants was 34.1 (9.5) years. Sixty-one percent were female. The prevalence of burnout among HCWs was 75%. Significant factors associated with burnout were age, job title, years of experience, increased working hours during the pandemic, average hours of sleep per day, exposure to patients with COVID-19, number of times tested for COVID-19, and perception of being pushed to deal with COVID-19 patients.Conclusion:Health care workers as frontline workers, face great challenges during this pandemic, because of the nature of their work. Efforts should be made to promote psychological resilience for HCWs during pandemics. This study points out the factors that should be invested in and the factors that may not be influential.     

近期上呼吸道感染史对儿童围术期呼吸系统不良事件的影响:前瞻性队列研究

目的:观察近期上呼吸道感染史对接受全身麻醉的儿童围术期呼吸系统不良事件风险的影响.方法:选择2015年1 1月至2016年5月期间在北京大学第一医院接受全身麻醉下眼科择期手术的232例儿童,术前通过儿童父母填写问卷的形式采集并记录儿童的术前基础资料及相关疾病史,包括性别、年龄、身高、体重、术前2周内有无上呼吸道感染史、有无早产史、长期被动吸烟史、经常性夜间打鼾史和哮喘病史.同时记录围术期相关信息(喉罩成功置入所需的次数、麻醉时间等),观察围术期出现的呼吸不良事件,包括氧饱和度下降、气道分泌物增加、咳嗽、喉痉挛、支气管痉挛的发生情况.应用多因素Logistic回归模型筛选儿童全身麻醉围术期呼吸系统不良事件的危险因素.结果:入选的232例儿童中,术前2周内有上呼吸道感染史的占28.0％(65/232),其全身麻醉苏醒期发生氧饱和度降低(23.1％vs.12.0％,P=0.034)、气道分泌物增加(15.4％vs.6.6％,P=0.036)或一种及以上呼吸系统不良事件(32.3％vs.18.6％,P=0.024)的风险增加.多因素Logistic回归分析显示,术前2周内的上呼吸道感染史(OR =2.021,95％ CI:1.023 ～3.994,P=0.043)和经常性夜间打鼾史(OR=3.660,95％ CI:1.517～8.832,P=0.004)是儿童围术期呼吸系统不良事件的独立危险因素.结论:术前2周内的上呼吸道感染史伴随儿童围术期呼吸系统不良事件的风险增加.     

Prevalence, risk factors, clinical course, and outcome of acute kidney injury in Chinese intensive care units: a prospective cohort study

Background Acute kidney injury （AKI） has been recognized as a major healthcare problem affecting millions of patients worldwide.However,epidemiologic data concerning AKI in China are still lacking.The objectives of this study were to characterize AKI defined by RIFLE criteria,assess the association with hospital mortality,and evaluate the impact of AKI in the context of other risk factors.Methods This prospective multicenter observational study enrolled 3,063 consecutive patients from 1 July 2009 to 31 August 2009 in 22 ICUs across mainland China.We excluded patients who were admitted for less than 24 hours （n=1623）,younger than 18 years （n=127）,receiving chronic hemodialysis （n=29）,receiving renal transplantation （n=1） and unknown reasons （n=28）.There were 1255 patients in the final analysis.AKI was diagnosed and classified according to RIFLE criteria.Results There were 396 patients （31.6％） who had AKI,with RIFLE maximum class R,I,and F in 126 （10.0％）,91 （7.3％）,and 179 （14.3％） patients,respectively.Renal function deteriorated in 206 patients （16.4％）.In comparison with non AKI patients,patients in the risk class on ICU admission were more likely to progress to the injury class （odds ratio （OR） 3.564,95％ confidence interval （CI） 1.706-7.443,P =0.001],while patients in the risk class （OR 5.215,95％ CI 2.798-9.719,P ＜0.001） and injury class （OR 13.316,95％ CI 7.507-23.622,P ＜0.001） had a significantly higher probability of deteriorating into failure class.The adjusted hazard ratios for 90-day mortality were 1.884 for the risk group,3.401 for the injury group,and 5.306 for the failure group.Conclusions The prevalence of AKI was high among critically ill patients in Chinese ICUs.In comparison with non-AKI patients,patients with RIFLE class R or class I on ICU admission were more susceptibility to progression to class I or class F.The RIFLE criteria were robust and correlated well with clinical deterioration and mortality.     

人文关怀护理联合功能锻炼对骨质疏松症患者焦虑情绪及骨密度的影响

目的:探讨人文关怀护理联合功能锻炼对骨质疏松症患者焦虑情绪及骨密度的影响。方法:将接受常规治疗的98例骨质疏松症患者分为对照组与观察组,各49例。对照组患者实施常规护理,观察组患者给予人文关怀护理和功能锻炼。比较2组患者的治疗总有效率、HAMA评分、HAMD评分、骨密度及生活质量情况。结果:观察组患者的治疗总有效率高于对照组（P < 0.05）;观察组患者治疗后的HAMA和HAMD评分均显著低于对照组（P < 0.01）,股骨颈、腰椎L_1~4部位骨密度、生活质量各维度评分均显著高于对照组（P < 0.01）。结论:人文关怀护理联合功能锻炼对骨质疏松症疗效确切,能够显著缓解患者的焦虑抑郁状态,提高骨密度,改善生活质量。     

大学生抑郁情绪与冲动性攻击性关系的研究

目的 了解有抑郁情绪的大学生的冲动性、攻击性特征.方法 通过分层整群随机抽样法,对哈尔滨市某高校286名学生进行调查研究,使用Beck抑郁问卷、冲动性问卷、攻击性问卷考察有抑郁情绪大学生冲动性、攻击性的特点.结果 有抑郁情绪的学生在冲动性和攻击性的均分[冲动性总体水平(78.81±14.99)分,攻击性总体水平(73.21±16.91)分]都高于无抑郁情绪的学生[冲动性总体水平(68.68±12.39)分,攻击性总体水平(61.69±14.46)分,P＜0.01],抑郁与冲动性、攻击性呈正相关(r=0.308,0.363,P＜0.01),进一步做多元逐步回归分析,发现抑郁与攻击性(面向自我的攻击性维度),冲动性总体水平有关,其回归方程为"抑郁=0.579攻击性(面向自我的攻击性维度)+0.059冲动性(总体水平)-3.213".结论 有抑郁情绪的学生比较无抑郁情绪的学生具有冲动性和攻击性特征,根据这些冲动性和攻击性特征,相关部门应该有针对性的提出相应的心理辅导策略.     

重症患者医疗措施限制撤离的状况研究

目的调查重症患者限制或撤离医疗措施,在重症医学科(intensive care unit,ICU)的实施现状。方法前瞻性观察研究,纳入2009年6月至2011年5月,在首都医科大学附属复兴医院重症医学科住院过程中,由亲属或医生方提出"限制或撤离医疗措施",并签署《医疗措施限制撤离确定书》(下称"签署")的重症患者。搜集该患者群人口学资料,签署原因,医疗费用种类,疾病严重度及预后。并根据签署内容进行分组,分为限制治疗组(A组),撤离治疗组(B组)和仅不实施临终心肺复苏组(C组)。比较上述参数的差别。结果研究期间共有86名患者的亲属进行"签署",占同期收治患者的7.2%,其中68.6%为患者亲属方提出。86例患者高龄且疾病严重度高,53.5%的医疗费用为公费医疗。"签署"至死亡/转出ICU中位数时间41 h,ICU病死率80.2%。"签署"后死亡的患者,占同期死亡患者的30.9%。"签署"主要原因为病情无法逆转和希望减轻痛苦。3组患者疾病严重度、住ICU平均费用差异无统计学意义。C组病死率(50.0%)显著低于A组(89.5%)和B组(91.1%)。"签署"后至死亡/转出ICU间的医疗费用中位数,B组显著低于A组和C组(105.0元/h vs 220.0元/h,160.7元/h,P=0.001)。签署后至转出/死亡中位数时间,B组显著少于C组(24.0 h vs 73.5 h,P=0.000)。结论 ICU住院期间"签署"的比例较低,主要为高龄和疾病严重度高的患者。患者亲属方为主要提出方。"签署"后死亡患者仅占同期死亡患者1/3。撤离治疗在一定程度上降低医疗费用。     

抗抑郁治疗对脑卒中后抑郁患者预后影响的研究

目的了解抗抑郁治疗对脑卒中后抑郁(PSD)患者预后的影响。方法选择120例因脑卒中住院并发抑郁的患者为研究对象,并分为A、B、C三组,三组均给予常规治疗,B组在此基础上予氟西汀抗抑郁治疗,C组予氟西汀联合心理治疗的抗抑郁治疗。随访观察1年。结果①治疗后各时期HAMD评分A组>B组>C组;②治疗后各时期BI评定C组>B组>A组;③治疗6个月、1年神经功能恢复效果C组>B组>A组。结论抗抑郁治疗对于PSD患者的抑郁状态及神经功能的恢复均有积极的作用。