糖尿病住院患者的常用药物临床应用及安全性分析

目的 分析糖尿病住院患者的常用药物临床应用及安全性,为合理用药提供参考.方法 选取2009年5月至2012年6月我院收治的糖尿病住院患者256例为研究对象,采用回顾性分析的方法,对收集到的临床资料进行分类整理,统计患者的用药情况（药物名称、药物种类、联合用药）及并发症等,评价其使用的合理性,并对其安全性进行讨论.采用SPSS17.0为统计学分析软件对数据进行分析处理.结果 256例患者中仅用一种药物患者119例（占46.48％）,一种药物的多为胰岛素类药物;应用两种降糖药物患者107例（占41.80％）,2种药物联合应用的多为胰岛素与α-葡萄糖苷酶抑制剂;应用三种及以上降糖药物患者30例（占11.72％）,三种及三种以上药物多为胰岛素、α-葡萄糖苷酶抑制剂及二甲双胍的联合应用.196例患者（76.56％）存在各种并发症,例如肾病、眼病、皮肤及软组织感染等,均存在并发症用药,其余60例（23.44％）未发生糖尿病并发症,用药情况基本合理,符合糖尿病治疗指南要求.结论 糖尿病患者的用药安全需要各级医疗机构积极配合,形成合理用药体系,确保患者安全.     

单片复方制剂降压药物在基层医疗机构中的临床应用专家建议

单片复方制剂（SPC）降压药物的应用,目前已经成为提高血压达标率的重要手段之一。基层高血压的控制率低,而基层医疗机构又是我国高血压防控的主战场,为了使基层医务工作者更好地理解及掌握SPC、推动其在基层的规范应用,心血管高血压领域专家基于我国高血压患者主要分布在基层的现状,结合SPC良好的降压有效性、器官保护性、服药依从性、基层可及性等特点,提出SPC基层临床应用的专家建议,其目的是使基层医生合理应用SPC、有助于提升高血压患者的血压达标率。     

Heart and mind: (2) psychotropic and cardiovascular therapeutics

There is a plausible biological basis for the association between psychiatric morbidity and cardiovascular disease. Anxiety, panic disorder, and depression are common in patients with coronary heart disease and hypertension. Despite this evidence there is poor recognition of anxiety disorders and depression in primary care and hospital medical practice. Concern also surrounds the use of psychotropic drugs in patients with cardiovascular disease. In the first of the two articles on this subject, we highlighted the current evidence regarding the association between cardiovascular and psychotropic conditions. In this second article, we discuss the interaction of the drugs used in the management of these two varied but commonly coexistent group of diseases as well as their relative effects on either system. Finally, we summarise the data regarding the safe use of these medications based on the recommendations from the currently available evidence.     

523例老年心血管内科门诊患者用药情况调查

目的 调查我院老年心血管内科患者门诊用药情况。方法 采用整群抽样的方法,入选2013年11月在我院老年心血管内科就诊的患者523例,分析门诊930张处方中的心血管疾病诊断及用药情况。结果 老年心内科就诊的患者平均年龄（77.35±10.14）岁,平均诊断疾病（2.50±0.91）种/人,同时诊断3种疾病者占47.6%。疾病诊断前3位是血脂异常、高血压和冠心病。人均处方用药（4.98±2.31）种,联合用药≥5种者占总调查人数的39.96%。其中,高频处方药物为抗血小板药、他汀类调脂药和钙离子拮抗剂。单病种用药分析显示,高血压联合用药方案与指南推荐略有差异,冠心病或血脂异常处方用药基本符合二级预防要求。非治疗性用药,如维生素、钙片及活血化瘀类中成药处方占总用药的9.3%。结论 老年心血管内科门诊患者同时患多种疾病、联合用药者多见,门诊处方基本符合疾病的循证推荐方案,但与指南仍有一定差距,且存在非治疗用药比例偏高等不合理用药倾向。     

Diabetes management in Australian rural aged care facilities: A cross--sectional audit

Background

There is gap in the literature regarding the current practice of diabetes management of the elderly in Australia and its compliance with available Australian diabetes practice guidelines.

Aims

The aims of this study were to describe the pharmacological management of elderly residents with diabetes living in aged care facilities and to identify areas for improvement in the current management as recommended by the current diabetes management guidelines in Australia.

Method

Residents with diabetes from three rural aged care facilities were identified by nursing staff. A cross-sectional medical record audit was carried out to obtain data of residents diagnosed with diabetes.Thirty-four medical records were audited from three aged care facilities.Data including demographics, medical histories and medications were collected and analysed.

Results

This study had two key findings; Firstly, it showed that about a third of residents with type 2 diabetes are managed with diet only. Secondly, of the residents who are managed with medications, less than half of those audited (41%) were managed according to the current diabetes guidelines in terms of pharmacological treatment which included anti- hypertensive, lipid lowering and anti- platelet therapies. Of those patients with a history of CVD, all were receiving an antihypertensive medication, 71% were not managed for their lipids and 20% were not on any prophylactic anti- platelet therapy.

Conclusion

Management of patients with diabetes living in rural aged care facilities is inconsistent with the current management guidelines. Educational interventions targeting health professionals and patients might be beneficial to increase compliance with the current diabetes guidelines.     

老年高血压伴发抑郁症患者的临床研究

目的观察抑郁症对老年高血压患者临床指标的影响,及常见合并症与抑郁症发生的相关性。方法选择内科住院的年龄大于65岁的高血压患者,抑郁症和非抑郁症各46例,对2组的临床资料和生化指标进行统计学分析。结果抑郁症组患者的心率较快[(77.74±5.62)次/minvs(71.23±8.36)次/min,P=0.041],血清纤维蛋白原含量较高[(3.55±0.59)g/Lvs(2.95±0.67)g/L,P=0.028],心脏舒张末期内径较大[(56.31±2.31)mmvs(53.26±2.83)mm,P=0.012],而高密度脂蛋白较低[(1.11±0.17)mmol/Lvs(1.36±0.35)mmol/L,P=0.025],心输出量较低[(5.90±0.96)L/minvs(7.42±1.64)L/min,P=0.038];多元回归分析显示糖尿病和脑梗死与抑郁症发生明显相关,偏相关系数分别为10.63和3.79,P<0.01。结论患抑郁症的老年高血压患者心功能降低,且有形成血栓的倾向;合并糖尿病和脑梗死是抑郁症的促发因素。     

Antidepressants in the general hospital.

An approach to the use of antidepressant medication in the general hospital is presented. The type of depression most likely to respond to chemotherapy is described, categories of available antidepressant agents are discussed, and relevant pharmacologic aspects are outlined. This paper suggests clinical guidelines for the use of these drugs, particularly in medical and surgical patients.     

Patient-centred and not disease-focused: a review of guidelines and multimorbidity

INTRODUCTIONSingle-disease clinical practice guidelines (CPGs) are not designed to consider patients with multiple chronic conditions, or multimorbidity. Applying multiple CPGs to a single patient may create an overwhelming treatment burden resulting in poor adherence and clinical outcomes. No studies on the cumulative treatment burden from multiple CPGs have been done in Singapore. We described the treatment burden on a hypothetical patient with six chronic conditions when multiple CPGs were applied, and appraised each CPG with respect to the patient-centred care of older adults with multimorbidity.METHODSA treatment plan was developed for a hypothetical 72-year-old woman with asthma, depression, diabetes mellitus, dyslipidaemia, hypertension and osteoarthritis according to the latest CPG recommendations. Treatment burden was quantified in terms of time spent, cost, and the number of appointments and medications. Each CPG was appraised with respect to the care of older adults, patients with multimorbidity and patient-centred care.RESULTSFollowing the CPGs strictly, an average of about two hours was spent daily taking 14 different medications and following 21 non-pharmacological recommendations. Her out-of-pocket payment was SGD 104.42 monthly despite a near 90% subsidy on healthcare bills. Patient-centred care of older adults with multimorbidity was inadequately addressed in all six CPGs.CONCLUSIONWhen six CPGs were cumulatively followed, the treatment burden was time-consuming, costly and disruptive. Patients’ goals and preferences must guide prioritisation of care such that treatment burden remains minimally disruptive to their lives. Developing future CPGs to deliver patient-centred rather than disease-focused care will be crucial to the management of multimorbidity.     

社区老年多病共存患者多重用药情况评价研究

背景　多病共存指同时患有2种或以上慢性病，是老年人群高发临床情况，尤为突出的是多重用药问题。多重用药带来了潜在不合理用药（PIM），是影响疾病预后的危险因素。对多重用药的评估、管理、优化是多病共存临床管理中非常重要的部分，可能是改善多病共存患者临床治疗效果、减少医疗费用的途径。目的　回顾性分析社区老年多病共存患者多重用药情况，分析其影响因素。方法　通过社区健康管理系统获得目前本社区2016年6月-2018年6月签约的≥65岁患者的基本资料，按国际疾病分类（ICD-10）标准进行系统分类统计，按照患2种及以上慢性病的定义，获取签约老年人中的多病共存患者。在老年多病共存人群中，根据随机数字表随机抽取400例患者进行多重用药（≥5种）情况调查，应用Beers标准及老年人处方筛查工具/老年人处方遗漏筛查工具（STOPP/START）标准，对所收集资料存在的PIM情况进行评估。结果　社区多病共存患者占≥65岁老年患者总数的81.01%（10 908/13 465），多病共存的主要组合类型为：高血压+冠心病（22.0%）、高血压+糖尿病（15.8%）、冠心病+糖尿病（16.2%）。所调查的400份问卷，有效回收360份，其中271例患者存在多重用药情况，多重用药率为75.3%，平均用药种数5.7种，最多服用10种药物，服用的药物以心血管及内分泌疾病治疗药物为主。应用STOPP/START标准检出80例（22.2%）存在PIM，共计95项；检出18例（5.0%）存在21项潜在的遗漏用药；Beers标准检出57例（15.8%）存在PIM，共计72项。多因素Logistic回归分析显示，年龄、处方主要获得方式是PIM的影响因素（P<0.05）。结论　多病共存在≥65岁老年人中患病率高，社区老年多病共存患者多重用药比例高，同时很大一部分存在不合理用药状况，高龄、未按期进行药物随访和评估、单科化的治疗模式可能是造成多重用药不合理用药的原因，作为管理多病共存主体的全科医生，应掌握不合理用药评估原则，改善多病共存多重用药的不合理用药情况。     

抑郁症的抗炎诊疗策略

抑郁症是一类现代社会常见、流行的精神障碍,其诊断常基于症状学评估,治疗方式以药物为主,心理及物理治疗等为辅。鉴于目前单胺能经典抗抑郁药的临床疗效不够理想,相关机制与防治研究仍在推进。近年研究表明,炎症细胞因子通过改变神经传递、神经可塑性和神经内分泌功能等途径介导抑郁症的发生、发展及转归;抗炎疗法或可作为增强抗抑郁药物疗效的新选项。该文整合国内外应用抗炎药物治疗抑郁症及躯体疾病合并抑郁症状的临床研究,分析抗炎疗法用于抑郁症诊疗的具体路径,提出针对抑郁症诊断分类、个性化治疗和预后评估的新策略。     

社区高血压人群抗高血压药物应用分析

目的调查社区高血压人群抗高血压药物的应用情况,以指导规范用药。方法采用问卷调查方法,于2009年3月—8月对我院所管辖的社区452例高血压患者进行相关病史资料搜集及问卷调查,对用药名称、类型,联合用药等进行分析。结果在452例高血压患者中,343例患者服用降血压药物(75.88%),其中151例单用非复方制剂(44.02%),89例采用2种药物联用(25.95%),11例采用3种药物联用(3.21%),采用复方制剂92例(26.82%)。服用钙离子拮抗制剂(CCB)184例(53.64%),血管紧张素转换酶抑制剂(ACEI)61例(17.78%),血管紧张素Ⅱ受体拮抗剂(ARB)66例(19.24%),β受体阻滞剂51例(14.86%)利尿剂11例(3.2%),氨氯地平及复方降压片处于排序前两位。结论规范社区高血压患者降压药物的合理应用,可以干预各种危险因素,提高降压效果,减少并发症的发生。     

Antimicrobial Treatmdent of "Complicated" Intra-Abdominal Infections and The New IDSA Guidelines - A Commentary and an Alternative European Approach According to Clinical Definitions

Recently, an update of the IDSA guidelines for the treatment of complicated intraabdominal infections has been published. No guideline can cater for all variations in ecology, antimicrobial resistance patterns, patient characteristics and presentation, health care and reimbursement systems in many different countries. In the short time the IDSA guidelines have been available, a number of practical clinical issues have been raised by physicians regarding interpretation of the guidelines. The main debatable issues of the new IDSA guidelines are described as follows: The authors of the IDSA guidelines present recommendations for the following subgroups of "complicated" IAI: community-acquired intra-abdominal infections of mild-to-moderate and high severity and health care-associated intra-abdominal infections (no general treatment recommendations, only information about antimicrobial therapy of specific resistant bacterial isolates). From a clinical point of view, "complicated" IAI are better differentiated into primary, secondary (community-acquired and postoperative) and tertiary peritonitis. Those are the clinical presentations of IAI as seen in the emergency room, the general ward and on ICU. Future antibiotic treatment studies of IAI would be more clinically relevant if they included patients in studies for the efficacy and safety of antibiotics for the treatment of the above mentioned forms of IAI, rather than conducting studies based on the vague term "complicated" intra-abdominal infections. - The new IDSA guidelines for the treatment of resistant bacteria fail to mention many of new available drugs, although clinical data for the treatment of "complicated IAI" with new substances exist. Furthermore, treatment recommendations for cIAI caused by VRE are not included. This group of diseases comprises enough patients (i.e. the entire group of postoperative and tertiary peritonitis, recurrent interventions in bile duct surgery or necrotizing pancreatitis) to provide specific recommendations for such antimicrobial treatment. - A panel of European colleagues from surgery, intensive care, clinical microbiology and infectious diseases has developed recommendations based on the above mentioned clinical entities with the aim of providing clear therapeutic recommendations for specific clinical diagnoses. An individual patient-centered approach for this very important group of diseases with a substantial morbidity and mortality is essential for optimal antimicrobial treatment.     

Management of migraine in Australian general practice

OBJECTIVES: To determine the proportion of patients who have a diagnosis of migraine in a sample of Australian general practice patients, and to review the prophylactic and acute drug treatments used by these patients. DESIGN, SETTING AND PARTICIPANTS: A cohort of general practitioners collected data from about 30 consecutive patients each as part of the BEACH (Bettering the Evaluation and Care of Health) program; this is a continuous national study of general practice activity in Australia. The migraine substudy was conducted in June-July 2005 and December 2005-January 2006. MAIN OUTCOME MEASURES: Proportion of patients with a current diagnosis of migraine; frequency of migraine attacks; current and previous drug treatments; and appropriateness of treatment assessed using published guidelines. RESULTS: 191 GPs reported that 649 of 5663 patients (11.5%) had been diagnosed with migraine. Prevalence was 14.9% in females and 6.1% in males. Migraine frequency in these patients was one or fewer attacks per month in 77.1% (476/617), two per month in 10.5% (65/617), and three or more per month in 12.3% (76/617) (missing data excluded). Only 8.3% (54/648) of migraine patients were currently taking prophylactic medication. Patients reporting three or more migraines or two migraines per month were significantly more likely to be taking prophylactic medication (19.7% and 25.0%, respectively) than those with less frequent migraine attacks (3.8%) (P < 0.0001). Prophylactic medication had been used previously by 15.0% (96/640). The most common prophylactic agents used currently or previously were pizotifen and propranolol; other appropriate agents were rarely used, and inappropriate use of acute medications accounted for 9% of "prophylactic treatments". Four in five migraine patients were currently using acute medication as required for migraine, and 60.6% of these medications conformed with recommendations of the National Prescribing Service. However, non-recommended drugs were also used, including opioids (38% of acute medications). CONCLUSIONS: Migraine is recognised frequently in Australian general practice. Use of acute medication often follows published guidelines. Prophylactic medication appears to be underutilised, especially in patients with frequent migraine. GPs appear to select from a limited range of therapeutic options for migraine prophylaxis, despite the availability of several other well documented efficacious agents, and some use inappropriate drugs for migraine prevention.     

Applying Ontology Techniques to Develop a Medication History Search and Alert System in Department of Nuclear Medicine

Nowadays, patients usually take more than three drugs for diseases such as hypertension, diabetes, and dyslipidemia. Hence, nuclear medicine physicians should be very careful about the medication history of each patient and ensure that their medication will not cause false positive or false negative imaging results, because either condition will interfere with adequate treatment of the patient and result in a wrong diagnosis. The aim of the present paper is to develop an ontology-based medication search and alert system for scintiphotography of Chang Gung Memorial hospital at Kaohsiung. Composed of four sub-systems, including Medication History Collect Agent (MHCA), Medication History Search System (MHSS), Patient Medication Consultation System (PMCS), and Patient Medication Alert System (PMAS), this medication search and alert system for scintiphotography is expected to support decision making of nuclear medicine examination, improve accuracy of image reading, and offer detailed data for further research. The ultimate goal of this system is to ensure patient safety.     

居民电子健康档案在社区慢性病药品预算管理中的应用

上海对社区卫生服务中心实施医保总量预付政策,糖尿病、高血压为主导的心脑血管疾病组相关的用药对总量控制的影响权重在50％以上。慢性病用药可分成治疗性和辅助性两大类,有限总量中,确保治疗性药物充分应用是慢性病控制结果改善的关键之一。利用居民健康档案相关的数据,对长期利用社区卫生服务中心的群体和与全科医生签约服务的亚群进行细分量化统计,并建立相关预算框架,对供应商、全科医生个体进行预算管理,配套建立机制,使供应方和全科医生个体有明确预期,从而保证用药的平稳有序,药品资源使用效率得到提升。     

某院高血压合并2型糖尿病患者的用药情况分析

目的 了解该院高血压合并2型糖尿病患者常用降压药和降糖药的种类及治疗方案,为合理治疗高血压合并2型糖尿病提供临床依据.方法 分析调查该院191例确诊为高血压伴2型糖尿病患者的用药情况,统计分析降压药和降糖药的使用及治疗方案.结果 该院191例确诊为高血压合并2型糖尿病患者,降压方案中单一用药占9.42％,二联用药占64.91％,三联用药占17.8％,四联用药占7.85％,用药以血管紧张素Ⅱ受体拮抗剂(ARB)+钙离子通道阻滞剂(CCB)使用频次最高;降压总有效率为96.86％.降糖方案中胰岛素使用占30.37％,降糖药使用以二甲双胍+格列齐特使用频次最高;降糖总有效率为98.43％.结论 该院对高血压合并2型糖尿病患者的用药较为合理,值得在临床中推广应用.     

血浆肾素活性与降压药物选择的研究进展

高血压是世界范围内流行的疾病,原发性高血压病因未明,因此高血压治疗的目标也是血压控制和靶器官保护。高血压降压的个体化差异较大,且目前五大类降压药均为一线药物,为临床选择降压药带来困难。以血浆肾素活性(PRA)为依据将高血压分型,有利于指导临床医师合理选择降压药,增加高血压患者的依从性和降压达标率。现将PRA与降压药物选择的研究予以综述。     

社区内科疾病构成及基本药物的合理应用研究

目的了解社区门诊内科常见病构成与排序,针对性提高社区门诊对基本药物合理应用的水平。方法对黎苑社区卫生服务中心2007年1月-2008年12月2年门诊内科疾病资料进行有关统计。分析有关内科疾病用药占基本药物中的比例。比较这些内科常见疾病的临床诊治指南等推荐的用药与基本药物的之间关系。结果 2年中就诊的内科疾病5 243例次,其中前20位常见疾病4 471例次,占内科全部就诊人次的85.3%。内科疾病用药占治疗性基本药物的90.0%,前20位常见病占内科用药的70.0%。前20位常见病临床指南推荐的用药与基本药物是一致的。结论建立国家基本药物制度对于满足人民基本医疗卫生需求具有重要意义。只有在社区内科前20位或20余位常见病临床指南、国家处方集等指导下,才能合理、安全、规范应用基本药物。