3497例门诊积乳症患者就诊现状

目的分析门诊积乳症患者的就诊现状,为积乳症患者的规范化诊治提供参考。方法选择2010年1月至2012年12月在上海中医药大学附属曙光医院乳腺外科门诊就诊,临床诊断为积乳症的3497例患者进行就诊现状分析。结果（1）积乳症患者平均年龄（26.7±4.3）岁,初产妇占93.9%,产后一月内发病最多见,占67.6%,均因乳汁排出欠畅就诊,伴乳房疼痛占86.7%,79.3%患者可及乳房包块,其中85.2%为双乳多发,35.2%的患者伴有不同程度发热,4.2%患者乳房局部皮温升高,腋下淋巴结肿大患者仅占2.7%。（2）来院就诊前曾自行按摩、热敷和用药的患者分别占63.5%、41.3%和15.6%,处理后症状改善率分别为37.6%、12.7%和48.2%。因自行治疗不当产生乳头损伤、皮肤水肿、血肿、皮肤挫伤等并发症的发生率分别为20.9%、19.4%、19.3%及17.1%。（3）“六步奶结疏通法”1次治疗有效率及治愈率分别为98.51%、91.19%,2次治疗分别为100%、98.83%,均未见并发症发生。结论积乳症多发生于产后一月内的初产妇,主要表现为乳汁排出欠畅伴乳房疼痛疼痛,双乳可及多发包块,部分患者有不同程度发热,乳房局部皮温多正常,腋下淋巴结一般不肿大。患者自行处理易出现多种并发症。“六步奶结疏通法”治疗产后积乳症临床疗效好,并发症少,值得推广应用。     

海南省“营养改善计划”某试点地区中小学生贫血状况及影响因素分析

目的 分析海南省“农村义务教育学生营养改善计划”（简称“计划”）某试点地区中小学生贫血的变化趋势及影响因素。方法 2014—2017年采用分层整群随机抽样法,在实施“计划”的重点监测县抽取中小学生进行血红蛋白等生化指标检测及问卷调查。多组均值间比较采用方差分析,率的比较采用χ²检验,贫血影响因素分析采用二分类Logistic回归。结果 2014—2017年共抽取学生2 590人,各年血红蛋白平均水平分别为（138.1±12.0）、（136.4±13.4）、（138.1±12.4）、（138.1±15.4）g/L,差异无统计学意义（P>0.05）。4年来各年贫血率分别为5.4%、5.4%、4.5%、6.7%,变化趋势无统计学意义（P>0.05）;其中2015年初中生贫血率高于小学生（P<0.05）,其余年度小学、初中生间,男、女生间贫血率差异均无统计学意义（均P>0.05）。Logistic回归分析结果显示,少数民族学生（OR=6.947）和维生素A亚临床缺乏/缺乏学生（OR=2.030）发生贫血的风险更高。结论 该地区中小学生贫血状况改善不明显,少数民族和维生素A亚临床缺乏/缺乏学生是需改善贫血的重点人群。     

2017—2019年江门市肠道病毒71型灭活疫苗接种水平与手足口病流行病学分析

目的 分析2017—2019年广东省江门市肠道病毒71型（EV 71）灭活疫苗接种水平及接种期间手足口病的流行情况。 方法 从“广东省疫苗接种月报表”收集江门市2017—2019年各预防接种单位每月上报的EV 71接种数据并汇总;从“中国疾病预防控制信息系统”和“广东省急性传染病监测信息系统”提取江门市2017—2019年手足口病疫情数据和哨点监测病原学监测结果,估算EV 71感染手足口病发病情况。 结果 2017—2019年,江门市共报告接种EV 71 456 686剂次,3年估算接种率分别为17.96%、29.33%和30.75%,估算接种率逐年上升（P<0.01）。3年EV 71感染手足口病估算发病率分别为21.21/10万、3.02/10万和0.00/10万,估算发病率逐年下降（P<0.05）;3年手足口病年报告发病率呈季节性波动,每年5—7月为手足口发病高峰,手足口病报告发病率2018年比2017年下降42.17%,2019年比2018年上升54.45%,5岁以下儿童占总报告发病总数的87.24%。 结论 接种EV 71灭活疫苗能有效降低EV 71感染所致的手足口病,尤其是重症,对其他肠道病毒感染引起的手足口病的预防效果有待进一步研究。     

肿瘤介入治疗后疼痛特点及治疗原则分析

目的：探讨肿瘤介入治疗后的疼痛特点及其合理镇痛的治疗原则。方法：选取于2013年1月-2014年1月来院进行介入治疗的恶心肿瘤患者92例作为研究对象,共进行187次介入治疗,统计其疼痛发生率,分析治疗后疼痛特点。重度疼痛患者给予阿片类荮物止痛,观察其治疗效果及不良反应。结果：术后出现疼痛121例（64．71％）,重度疼痛89人次、中度疼痛轻度26人次、轻度疼痛5人次;治疗后疼痛完全缓解62例,部分缓解24例,轻微缓解6例;有86例次（45．99％）出现不良反应,经对症治疗后均可缓解和消失。结论：介入治疗后主要以急性疼痛为主,以三阶梯止痛原则为指导,通过药物止痛,可明显改善症状。     

2015—2019年广州市登革热本地病例流行病学特征分析

目的 了解广州市2015—2019年登革热流行病学特征,为制定预防控制措施提供依据。方法 从“中国疾病预防控制信息系统”收集广州市2015—2019年登革热发病资料,采用描述流行病学方法对登革热的流行特征进行分析。结果 2015—2019年广州市共报告登革热3 712例,死亡1例,年平均发病率为5.14/10万,总体呈上升趋势（χ²=1 570.55,P<0.01）。病例报告高峰为8—11月,流行前期4—8月报告登革热本地病例数与9—12月本地病例数呈高度正相关（r=0.930,P<0.05）;20~59岁年龄组2 742例（占73.87%）,就业人员1 969例（占53.04%）;本地病例主要集中在荔湾、白云、海珠、天河、越秀5个中心城区,共报告2 685例（占72.33%）;各区年均发病率差异有统计学意义（P<0.01）。2018—2019年登革热本地病例中周边地区报告767例（占29.72%）,高于2015—2017年周边地区报告病例（260例,占22.99%）,差异有统计学意义（χ²=17.67,P<0.01）。结论 广州市登革热本地病例数、发病率逐年增加,存在一定的空间、时间和人群聚集,应及时发现,及早处置,防止扩散。     

加巴喷丁治疗难治性带状疱疹后神经痛60例临床研究

目的观察与探讨加巴喷丁治疗难活性带状疱疹后神经痛（PHN）的疗效及副作用。方法对应用强阿片类药物仍无法有效控制疼痛PHN患者60例,VAS评分≥7分,应用加巴喷丁治疗前,患者所用阿片类镇痛药均不停药,而停用除阿片类镇痛药以外的其他药物。实行第1天开始1：7服加巴喷丁100mg／次、3次／d,第2天200mg／次、3次／d,第3天开始维持300mg／次、3次／d,如疼痛缓解不明显可每间隔2～4d增加剂量300mg／d,直至疼痛缓解或出现难以耐受的副作用,最高用量为1800mg／d。以疼痛明显缓解或疼痛缓解的剂量维持用药并逐渐减少镇痛药用量。治疗前以及治疗后2周以VAS评定疼痛程度,观察用药前后的VAS评分变化、药物的用量及副作用。结果治疗期间的副作用主要有乏力4例、头晕2例、嗜睡12例、恶心2例,2例因出现眼球震颤、四肢肌肉抽搐而停药,停药时剂量为900mg／d。其余58例患者中,17．2％患者治疗后基本不痛,不需再用阿片类镇痛药;24．1％稍有疼痛,镇痛药用量减少75％以上;34．5％仍有疼痛,镇病药用量减少50％～75％;24．1％疼痛改善不明显,镇痛药用量减少50％以下。治疗后VAS评分为5．31&#177;1．44,显著低于治疗前（p〈0．01）。所有患者用药前后血、尿常规、肝酶和血尿素氮、肌酐的改变基本一致,未见显著性差异。结论加巴喷丁用于治疗带状疱疹后神经痛效果确切,应用强阿片类药物的PHN患者对加巴喷定有良好的耐受性,但不良反应存在个体差异。对于难治性PHN,单独应用加巴喷丁仍无法良好控制疼痛,阿片类药物与加巴喷丁合用可更有效缓解疼痛,并明显减少阿片类药物的用量。     

祛除癌症疼痛的三阶梯止痛法

治疗癌症疼痛的三阶梯止痛法是一种根据癌症患者的疼痛程度不同,而分别使用不同等级麻醉止痛药物为治疗原则的止痛方法。作为一种最常用的且非常有效的治疗癌症疼痛的止痛方法,已为世界卫生组织所大力推荐,目前已被世界各国包括中国在内广泛应用于治疗各类慢性疼痛,尤其适用于癌症引发的各种疼痛。 第一阶梯:轻度疼痛给予非阿片类加减辅助止痛药。用药中应注意非阿片类药存在着超过最大有效剂量时,止痛效果不再增加的问题。临床常用药     

德阳地区妇女“两癌”防治知识知晓现状及影响因素分析

目的 调查德阳地区妇女乳腺癌和宫颈癌（简称“两癌”）防治知识的掌握情况,探讨影响女性“两癌”防治知识认知的相关因素,为更好地开展 “两癌”筛查工作提供参考依据。方法 采用分层整群抽样方法于2019年6—9月抽取德阳市妇女作为研究对象进行“两癌”防治知识知晓情况现场问卷调查,采用描述流行病学分析方法进行分析,并采用单、多因素分析方法对“两癌”防治知识知晓影响因素进行分析。结果 共对1 835名德阳市女性居民进行分析,年龄20~69岁,平均（42.36±5.22）岁。文化程度以初中（653人,35.59%）和高中（634人,34.55%）为主。城镇居民占60.60%。职业以企事业职工为主（594人,32.37%）。“两癌”防治知识的总均分为（23.6±5.3）分,总知晓率为49.30%。答对“两癌”防治知识问卷60%以上题的有878人,了解率为47.85%。年龄越大（OR=0.730）的女性居民“两癌”防治知识了解的可能性较小,文化程度越高（OR=2.787）、居住地在城镇（OR=5.512）、职业为企事业单位职工或个体户（OR=5.124、1.713）、家庭人均月收入越高（OR=2.298）、乳腺疾病史（OR=1.775）和妇科疾病史（OR=1.320）是女性“两癌”防治知识了解率的促进因素。结论 德阳市适龄妇女“两癌”防治知识的掌握情况不佳,应重点针对高龄、文化程度低、农村地区的低收入女性人群加强“两癌”健康知识宣传教育工作。     

肿瘤患者癌性疼痛治疗依从性现状及其影响因素分析

目的 调查肿瘤患者癌性疼痛治疗依从性现状并分析其影响因素。方法 选取2019年1—10月在成都某医院行癌性疼痛治疗的患者进行依从性现状调查,采用单、多因素方法分析其影响因素。结果 195名患者中,男122例,女73例,平均（63.10±11.72）岁。癌性疼痛治疗依从性得分为（0.91±1.40）,依从性好的患者有120例（61.5％）。二分类Logistic回归分析结果显示结算方式自费（OR=0.486）、肿瘤病程越长（OR=0.561）及无合并症（OR=2.395）是肿瘤患者癌痛治疗依从性的影响因素。结论 肿瘤患者癌痛治疗依从性有待提高,医务人员应多关注患者依从性的影响因素,从而采取针对性措施提高患者治疗依从性。     

海安市幽门螺杆菌阳性者流行特征及病原菌耐药情况

目的 分析幽门螺杆菌（Hp）阳性者流行特征及病原菌耐药情况,为制定预防Hp感染及治疗提供依据。方法 收集2015—2019年海安市某医院Hp阳性者病历信息及Hp药物试验结果,采用描述流行病学方法进行分析。结果 本研究共分析海安市某医院2015—2019年Hp阳性者2 546例。全年各月有Hp阳性病例,阳性病例以6—8月较多,占38.64%,男性1 363例（占53.53％）,女性1 183例（占46.47％）。均为≥18岁成年人, ≥60老年组1 143例（占44.89%）。初中及以下文化程度者1 664例（占65.36%）。家务（348例,占13.67%）、农民（335例,占13.16%）,以及个体、商、企服务人员（256例,占10.05%）所占比例较高。Hp对甲硝唑（95.44%）、克拉霉素（21.56%）、左氧氟沙星（20.54%）耐药率较高,其中2015—2019年对甲硝唑的耐药率整体呈上升趋势（P<0.01）。结论 2015—2019年海安市Hp阳性者主要分布在农村镇街,主要以文化程度较低者为主,Hp对甲硝唑、克拉霉素、左氧氟沙星抗生素的耐药率较高,在对流行人群制定预防措施及治疗用药时应考虑Hp耐药性。     

缓控释强阿片类药物治疗老年中、重度癌痛的临床观察

目的观察缓控释强阿片类药物在老年癌痛患者中的疗效及毒副作用。方法对2011年1月至2012年1月我科就诊的56例年龄t〉65岁的老年中,重度癌痛患者使用缓控释强阿片类药物的治疗情况进行回顾性研究。结果硫酸吗啡缓释片、盐酸羟考酮控释片以及芬太尼透皮贴剂这三类缓控释强阿片类药物,对老年癌痛均有较好的疗效并且安全性高。结论缓控释强阿片类药物治疗老年癌痛患者疗效好,临床中需注重个体化治疗。     

Managing Chronic Pain in an Opioid Crisis: What Is the Role of Shared Decision-Making?

ABSTRACT

Shared decision-making (SDM) is a widely-advocated practice that has been linked to improved patient adherence, satisfaction, and clinical outcomes. SDM is a process in which patients and providers share information, express opinions, and build consensus toward a treatment decision. Chronic pain and its treatment present unique challenges for SDM, especially in the current environment in which opioids are viewed as harmful and a national opioid crisis has been declared. The purpose of this qualitative study is to understand treatment decision-making with patients taking opioids for chronic pain. Ninety-five clinic visits and 31 interviews with patients and primary care providers (PCPs) were analyzed using the constant comparison method. Results revealed that 1) PCPs desire patient participation in treatment decisions, but with caveats where opioids are concerned; 2) Disagreements about opioids, including perceptions of lack of listening, presented challenges to SDM; and 3) PCPs described engaging in persuasion or negotiation to convince patients to try alternatives to opioids, or appeasing patients requesting opioids with very small amounts in an effort to maintain the patient-provider relationship. Results are discussed through the lens of Charles, Gafni, and Whelan’s SDM model, and implications of the role of the patient-provider relationship in SDM and chronic pain treatment are discussed.     

Chronic pain: treatment barriers and strategies for clinical practice

BACKGROUND: Chronic pain is a clinical challenge for the practicing physician. Lack of knowledge about opioids, negative attitudes toward prescribing opioids, and inadequate pain-assessment skills combine to create major barriers to pain relief. Patient-related barriers, such as lack of communication and unwarranted fears of addiction, further complicate pain assessment and treatment. The health care system itself can hinder pain relief through practical constraints in the community and fear of regulatory scrutiny by the physician. METHODS: Information was gathered by doing a literature search, collating clinical information from practice and additional research findings from national meetings, and reviewing the Bulletin of the American Pain Society. Key search terms included "pain," "chronic pain," "pain management," "pain assessment," "pain treatment," and "barriers to pain management." RESULTS AND CONCLUSIONS: Concrete steps for the clinician engaged in the treatment of chronic pain include selection and administration of an effective opioid, dose titration, short- vs long-acting opioids, opioid rotation, ongoing assessment, and consideration of patient preferences. In addition, communication, coping behaviors, and pain education play important roles in the pain equation.     

Just one opioid prescription?

It can be said that chronic pain patients comprise a large part of general practice. It would be accepted that general practitioners treat pain to the best of their abilities and, where indicated, use opioids for this purpose. After all, opioids have been used for the treatment of cancer and acute pain for many years. While a growing body of literature documents the trend of acceptance to prescribe opioids for the treatment of chronic noncancer pain, recent evidence suggests opioids may not achieve key outcomes of chronic pain management.     

小剂量米索前列醇加催产素预防产后出血临床观察

目的观察小剂量米索前列醇直肠内给药配伍催产素预防产后出血效果。方法选择有产后出血危险因素的产妇188名,随机分成3组(即研究组和两对照组)进行临床对照观察。研究组在胎儿娩出后立即肌注催产素20U同时给予产妇直肠内放置米索前列醇0.2mg;对照1组在胎儿娩出后给产妇口服米索前列醇0.4mg;对照组2组在胎儿娩出后给产妇静脉点滴催产素20u+5%葡萄糖250ml。结果研究组用药后3～6min宫缩加强,持续3小时之久,产后2小时和24小时出血量均明显少于对照组,解决了产后2小时出血危险的难题。产后出血率、产褥患病率和输血率明显低于对照组,同时也减少了口服米索前列醇的副反应。结论小剂量米索前列醇加催产素能较好地预防产后出血,且用药简便、安全,具有广泛的应用价值。     

Opioids for chronic pain of non-malignant origin—Caring or crippling

Pain management has improved in the past few decades. Opioid analgesics have become the mainstay in the treatment of cancer pain whilst inter-disciplinary pain management programmes are the generally accepted approach to chronic pain of non-malignant origin. Recently some pain specialists have advocated the use of opioids in the long-term management of non-cancer pain. This has raised some fundamental questions about the purpose of pain management. Is it best to opt for maximum pain relief and comfort, or should one emphasise function and activity as higher priorities? Will the use of opioids create more autonomy for pain sufferers or will this add handicaps to lives which are already limited? Until more clinical outcome data are available we advocate caution in the use of opioid analgesia. Such caution can, and does, raise questions about the rights of the patient and the rights of the prescriber in a context where the facts do not point to a clear course of action.     

Multimodal analgesia as an alternative to the risks of opioid monotherapy in surgical pain management

Clinicians have long been aware of the danger of overreliance on opioids to manage acute pain, such as the pain accompanying surgery. The risk of adverse drug events is higher with opioids than with any other common class of drugs. Overreliance on opioids increases length of stay and hospital costs, while decreasing patient satisfaction. Opioids can lead to problems that continue well after discharge, including chronic pain, abuse and addiction, and even death. Increasingly, prescribed opioids have proved to lead to heroin addiction. Studies show that the same professionals who prescribe, administer, and monitor opioids lack basic knowledge about their safe and effective use. The alternative to opioid monotherapy in controlling acute pain is multimodal analgesia, an approach that relies on a nonopioid foundation with addition of adjunctive opioids as needed. An increasing number of nonopioid analgesics have proved effective in this role, with fewer side effects and a higher degree of safety than opioids. Accordingly, multimodal analgesia is recommended as best practice by most recognized authorities. Increasingly, governmental authorities hold prescribing clinicians and institutions legally liable for the downstream negative effects of opioids, including abuse and addiction. Addressing this issue should be a top priority for hospital risk managers.     

Quality of Life and Pain Medication Use in Persons With Advanced Dementia Living in Long-Term Care Facilities

ObjectivesIn residents with dementia living in a long-term care facility (LTCF), un(der)treated pain may trigger behavioral disturbances, mood syndromes, and deterioration of physical functioning and self-maintenance. Because these factors can have considerable impact on the quality of life (QoL), this study aimed to (1) compare characteristics of persons with advanced dementia living in LTCFs with and without pain medication; (2) compare QoL in these persons with and without pain, stratified by type of pain medication use; and (3) explore associations between the use of paracetamol and QoL in persons with advanced dementia living in LTCFs.Design and settingThis study analyzed baseline data from the Communication, Systematic Assessment and Treatment of Pain, Medication Review, Occupational Therapy, and Safety Study; a multicenter, cluster-randomized effectiveness-implementation clinical hybrid trial in 67 Norwegian LTCF clusters.ParticipantsIn total, 407 LTCF residents (rural and urban areas) aged ≥65 years, with Functional Assessment Staging scores of 5–7 (ie, moderate to advanced dementia).Main outcome measureQoL as assessed by the 6 QUALIDEM (validated questionnaire to measure QoL in persons with dementia living in LTCF) domains applicable to persons with moderate to severe dementia. The association between QoL and paracetamol was estimated using linear mixed-effect models, adjusting for confounding variables.Results62.0% used pain medication (paracetamol, opioids, or both). QoL was lower in residents using pain medication, compared with those without pain medication [mean QUALIDEM score 68.8 (standard deviation 17.4 vs) 75.5 (standard deviation 14.6), respectively, P < .001). Multilevel analysis showed that paracetamol use was not associated with QoL.Conclusions and ImplicationsPersons with advanced dementia living in LTCF using pain medication have a lower QoL compared with those not using pain medication. These results are of key importance for the clinician because they stress the need for regular medication review and pain management. When measured cross-sectionally, use of paracetamol is not associated with increased QoL.