Skilled birth attendant competence: an initial assessment in four countries, and implications for the Safe Motherhood movement.

OBJECTIVES: Percentage of deliveries assisted by a skilled birth attendant (SBA) has become a proxy indicator for reducing maternal mortality in developing countries, but there is little data on SBA competence. Our objective was to evaluate the competence of health professionals who typically attend hospital and clinic-based births in Benin, Ecuador, Jamaica, and Rwanda. Methods: We measured competence against World Health Organization's (WHO) Integrated Management of Pregnancy and Childbirth guidelines. To evaluate knowledge, we used a 49-question multiple-choice test covering seven clinical areas. To evaluate skill, we had participants perform five different procedures on anatomical models. The 166 participants came from facilities at all levels of care in their respective countries. Results: On average, providers answered 55.8% of the knowledge questions correctly and performed 48.2% of the skills steps correctly. Scores differed somewhat by country, provider type, and subtopic. Conclusion: A wide gap exists between current evidence-based standards and current levels of provider competence.     

活动性结核标志物'H-多肽的实验与临床研究

本题研究是经免疫学途径直接检测人体感染结核菌的情况，为现代结核病的实验诊断、临床监测、流行病调查提供了一个全新的检验指标。作者首先发现了一种仅存在于活动性结核病患者体液中的蛋白成份—活动性结核标志物（ＡｃｔｉｖｅＴｕｂｅｒｃｕｌｏｓｉｓＭａｒｋ—ＡＴＭ）１Ｈ—多肽；并为之创立了独特的检测方法，经四年多临床１９４６０例样本调查中确定了ＡＴＭ的临床价值。将ＡＴＭ检测与ＯＴ皮试、酶联免疫ＥＬＩＳＡ、ＤＮＡ探针、ＰＣＲ基因扩增技术及典型病例组患者行Ｘ线计算机断层摄影（ＣＴ）、磁共振像（ＭＲＩ）等多组对比试验中，实验与临床研究资料分析证明：ＡＴＭ检测的总敏感度为８６．０６％、特异度９６．２４％、准确度９３．４５％、诊断效率为８２．８２％、批内ＣＶ１．２％、批间ＣＶ２．０％、Ｐ＜０．０５。经ＮＭＲ光谱分析结构含有ＣＣＨ２官能团。     

浅谈临床教师的角色素养及道德要求

探讨了临床教师的角色特征;认为临床教师的角色要求与现实状况之间存在反差;据此就其原因进行了分析。提出要强化临床教师的角色意识;在教学实践中自觉加强对其角色素养的自我锻炼和培养。     

Intra-observer and inter-observer agreement of the manual examination of the lumbar spine in chronic low-back pain

Examination is a cornerstone in the manual procedures leading to mobilisation/manipulation of the low back. The observer variation of the more specific segmental tests remains to be investigated. Two skilled specialists in manual medicine examined the segmental changes in the lumbar spine. The patients were unknown to the examiners and no information of the case history was given. All test results were recorded by an observer present in the room who ensured that no conversation was allowed during the examination. The primary outcome measures were the kappa values for each test. The matching was defined as acceptable (acc) within two neighbouring levels and perfect (per) on the same level. Intra-observer variation (tested in 33 patients and 10 subjects without low-back pain): The agreement between first and second segmental diagnosis examination was 70% (per) and 82% (per + acc). Kappa values were: segmental diagnosis 0.60 (per) and 0.70 (per + acc), multifidus test 0.51 (per) and 0.60 (per + acc), sideflexion 0.57 (per) and 0.69 (per + acc), and ventral flexion 0.31 (per) and 0.45 (per + acc). Inter-observer variation (tested in 60 patients): The agreement for segmental diagnosis between the examiner A and B was 42% (per) and 75% (per + acc). Kappa values were: segmental diagnosis 0.21 (per) and 0.57 (acc), multifidus test 0.12 (per) and 0.48 (acc), sideflexion 0.22 (per) and 0.45 (acc), and ventralflexion 0.22 (per) and 0.44 (acc). By manual tests, skilled examiners seem to be able to diagnose segmental dysfunctions in the low back. The clinical implication of these dysfunctions remains to be clarified.     

Disc replacement using Pro-Disc C versus fusion: a prospective randomised and controlled radiographic and clinical study

Anterior cervical discectomy and fusion (ACDF) may be considered to be the gold standard for treatment of symptomatic degenerative disc disease within the cervical spine. However, fusion of the segment may result in progressive degeneration of the adjacent segments. Therefore, dynamic stabilization procedures have been introduced. Among these, artificial disc replacement by disc prosthesis seems to be promising. However, to be so, segmental motion must be preserved. This, again, is very difficult to judge and has not yet been proven. The aim of the current study was to first analyse the segmental motion following artificial disc replacement using a disc prosthesis. A second aim was to compare both segmental motion as well as clinical result to the current gold standard (ACDF). This is a prospective controlled study. Twenty-five patients with cervical disc herniation were enrolled and assigned to either study group (receiving a disc prosthesis) or control group (receiving ACDF, using a cage with bone graft and an anterior plate.) Radiostereometric analysis was used to quantify intervertebral motion immediately as well as 3, 6, 12 and 24 weeks postoperatively. Further, clinical results were judged using visual analogue scale and neuro-examination. Cervical spine segmental motion decreased over time in the presence of disc prosthesis or ACDF. However, the loss of segmental motion is significantly higher in the ACDF group, when looked at 3, 6, 12 and 24 weeks after surgery. We observed significant pain reduction in neck and arm postoperatively, without significant difference between both groups (P > 0.05). Cervical spine disc prosthesis preserves cervical spine segmental motion within the first 6 months after surgery. The clinical results are the same when compared to the early results following ACDF.     

Application of Animal Toxicology Data to Clinical Study of Experimental Drugs

The pharmaceutical industry performs safety studies in animals to underwrite administration of new chemical entities to man. Early clinical evaluation of drugs in volunteers is performed, generally, using highdose acute studies in rodents and 1-month repeat dose studies in one rodent species and one non-rodent species as a basis for risk assessment. Results from the 1-month toxicology studies enable a ceiling for initial clinical doses to be set and give some indication of the major target organs for toxicity. Extrapolation of these results to man helps determine the preliminary safety endpoints, including clinical chemistry parameters, for use in early clinical studies in man.Originally presented at ECCP 93.     

营养不良老年人非药物干预临床实践指南

老年人是营养不良的高发人群,营养不良与众多不良临床结局密切相关,严重影响老年人的身体健康和生活质量,给家庭和社会造成沉重负担。因此,采取有效措施改善老年人的营养不良至关重要,非药物干预是改善营养状况的重要措施。然而,国内尚无专门针对营养不良老年人的非药物干预临床实践指南,因此,中国老年护理联盟、国家老年医学中心和国家老年疾病临床医学研究中心的营养专家,通过对老年人营养不良最新的国内外文献的全面检索与分析,采用推荐意见评估、制订及评价(GRADE)分级体系制订了本指南,针对营养不良老年人非药物干预提出9条推荐意见,以期能够改善老年人营养不良状况,提高生活质量。本指南侧重于可经口进食的营养不良老年人,聚焦于肠内营养,肠外营养不在本指南讨论范围内。     

Allergic bronchopulmonary aspergillosis: Reactivity of IgE and IgG antibodies with antigenic components of Aspergillus fumigatus (IgE/IgG antigen complexes)

Sera of patients with ABPA were tested by XRIE tests incorporating their own serum (self-XRIE) to detect the presence of IgG/IgE antigen complexes to a “reference” Aspergillus fumigatus preparation. Of the 32 sera studied, 29 (90%) had visible precipitin (IgG) peaks, and 27 of these 29 as well as the three apparently precipitin-negative sera, i.e., 30 (94%), showed binding of specific IgE by autoradiography. The two precipitin-positive sera that did not show IgE binding were also skin test negative and RAST negative to this A. fumigatus antigen. Specific IgG as determined in ELISA correlated well with the grading of the XIE precipitin peaks (p < 0.05). There was also a highly significant correlation between specific IgE by RAST and grading the radioactive uptake seen in the autoradiograph (p < 0.001) indicating, for each serum, the presence of IgG antibodies to most of the components to which there was specific IgE. In the self-XRIE tests there was considerable variation of reactivity from serum to serum, in numbers of antigen/antibody peaks observed, in relative peak heights, and in the intensity of the respective staining. By comparing each test to a “reference” pattern developed with the use of an ABPA serum pool, the antigenic components of A. fumigatus were found to be of two main types: (1) antigens that appeared to be poorly precipitating (possibly low-molecular-weight components) but showed strong IgE binding (these were apparently major allergenic components and with one exception proved to be the faster migrating components) and (2) antigens that produced the strongest precipitin reactions with only weak binding of specific IgE and therefore minor allergenic components.     

Gross anatomy: An outdated subject or an essential part of a modern medical curriculum? Results of a questionnaire circulated to final-year medical students

Final-year undergraduate medical students were given a questionnaire on the gross anatomy curriculum they had experienced in their first year at medical school 5 years earlier. They were asked to evaluate the relevance of the dissection course, lectures and seminars in gross anatomy for clinical courses, clerkships, and everyday practical work on the ward. About two-thirds of the students found the time spent on 10 different regions in anatomy to be adequate, and a considerable number of students would have liked even more details. The vast majority expressed a wish to repeat topographical anatomy during their clinical teaching. Furthermore, ～75% of the students showed interest in short, specialized dissection courses during the clinical curriculum. Medical students just before graduation ranked gross anatomy with the dissection course and integrated clinical topics as a keystone for their clinical courses. The results of such surveys should be taken into consideration when discussing modification to teaching gross anatomy or arguing about a balanced dissection course. © 1993 Wiley-Liss, Inc.