Improving the quality of child health services: participatory action by providers.

OBJECTIVE: To test a quality improvement approach called COPE (Client-Oriented, Provider-Efficient services), for use in strengthening health systems and supporting Integrated Management of Child Health (IMCI) efforts. DESIGN: Pre- and post-intervention observations of client/provider interactions, facility audits, staff and client surveys, and focus groups to evaluate differences between eight COPE intervention and eight matched non-intervention facilities after a 15-month intervention in 2001. SETTING: Primary care clinics in Guinea and Kenya. STUDY PARTICIPANTS: Health care providers and child caregivers. INTERVENTIONS: Over 15 months, the intervention supported four COPE exercises at each intervention site, supported supervisor training in quality management, and organized minimal training in topics selected by site staff as areas where training was needed. MAIN OUTCOME MEASURES: Differences in staff's and child caregiver's knowledge, attitudes, and practices; differences in the quality of services provided. RESULTS: On almost every quality indicator (over 65 indicators), whether reported by staff, observed by evaluators, or reported by clients, the intervention sites performed statistically significantly better than control sites. INTERVENTION: sites were cleaner and more pleasant, with more respect and information for clients, and more privacy. Staff had better personal communication skills, better diagnostic skills, and prescribing practices and gave better home care instructions to carers. Clients in intervention sites were more informed and more satisfied, and their children had better immunization coverage than those in control sites. CONCLUSION: COPE is a simple process, yet our study confirms that it can have a very dramatic effect on the quality of services. This study demonstrated how all areas of quality can be addressed by empowering health care providers to take action by using COPE. We suggest that COPE can complement Integrated Management of Childhood Illness (IMCI) training and can help to achieve better health for children.     

儿童白血病合并暴发型水痘带状疱疹病毒感染临床分析

目的探讨白血病患儿合并水痘带状疱疹病毒感染的临床特点及防治措施.方法回顾性分析1995年1月～2003年2月某院收治的6例合并水痘带状疱疹病毒感染的白血病患儿病历情况.结果 6例患儿均有发热及典型皮损,其中4例为持续高热(39～40.4℃)达1周,皮疹均为全身性分布.6例患儿均治愈,无水痘并发症发生.结论白血病患儿合并水痘带状疱疹病毒感染多呈暴发性感染,临床症状较重,容易出现并发症,应采取积极有效的防治措施.大剂量静脉用免疫球蛋白联合抗病毒药物等综合治疗效果较好.     

儿童胃电图与胃镜对照观察136例

目的比较分析胃电图和胃镜对于儿童胃病诊断的一致性,探讨胃电图在儿童胃病检查中的临床诊断价值。方法136例因消化道症状住院或就诊的人同时经胃镜及胃电图检查的患儿进行比较,按胃镜诊断结果,观察胃电图与胃镜诊断的符合率,对比分析胃电图的主频、振幅和节律变化,探讨变化规律。结果与胃镜诊断相比,胃电图对慢性浅表性胃炎的诊断符合率高达95.8%,对器质性胃部疾病的诊断符合率不到40%。结论虽然胃镜仍为一种不可替代的检查手段,但胃电图对于儿童胃部功能性疾病的诊断却有着重要意义,可作为初筛的一种重要手段。     

儿童嗜酸性淋巴肉芽肿的临床特点与治疗

目的 探讨儿童嗜酸性淋巴肉芽肿（ELG）的临床特点和诊治方法，以提高对本病的认识。方法 回顾性分析5例ELG患儿的临床特征、实验室检查、病理、治疗及疗效，并进行相关文献复习。结果 ELG5例均为男童，主要表现为多发性皮肤软组织肿块和淋巴结大，其中1例并肾病综合征，2例有反复湿疹样皮疹，1例2次发生喘息性支气管炎，患儿均无肝脾大，生长发育良好。最初单纯化疗4例均复发，经配合局部放疗或加用环孢素（CsA）等治疗后未复发。结论 儿童ELG临床及病理特点与成人相似，但儿童发病较少。单纯化疗易复发，配合放疗、手术、应用CsA等综合治疗可提高疗效。     

肾囊内注射甲泼尼龙治疗儿童难治性紫癜性肾炎

目的探讨肾囊内注射甲泼尼龙治疗儿童难治性紫癜性肾炎(HSPN)的疗效。方法难治性HSPN患儿22例随机分为3组:Ⅰ组,口服泼尼龙组;Ⅱ组,静脉注射大剂量甲泼尼龙组;Ⅲ组,肾囊内注射甲泼尼松组。连续观察8周,分别于0、4、8周检测患儿24 h尿蛋白量、血清清蛋白(Alb)、肌酐(Scr)、血浆胆固醇(Cho)。结果4周时3组24 h尿蛋白分别为(2.35±1.09)(、0.97±0.37)、(0.99±0.52)g,3组间有显著差异(P<0.01);8周时3组24 h尿蛋白分别为(2.13±1.68)(、1.57±0.89)(、0.19±0.11)g,3组间有显著差异(P<0.05)。观察治疗期间肾囊注药组患儿血清Alb、血浆Cho渐恢复至正常水平。结论肾囊内注射甲泼尼龙可减少难治性HSPN儿童尿蛋白排出。     

脱髓鞘疾病51例

目的分析小儿脱髓鞘疾病的临床特点,以提高对该疾病的诊断与治疗。方法对51例小儿脱髓鞘疾病的发病年龄、前驱症状、临床表现及辅助检查特点等进行回顾性分析。结果51例脱髓鞘疾病患儿中学龄期38例,有前驱感染史32例,疫苗接种史3例,大多以急性起病。周围神经脱髓鞘疾病32例以双下肢或四肢瘫痪为首发;中枢神经脱髓鞘疾病以视力障碍、肢体无力、发热、抽搐、头痛等为首发。周围神经脱髓鞘疾病患儿中15例行肌电图检查,均显示为神经源性改变;18例中枢神经脱髓鞘疾病患儿中17例行CT或MRI,均发现异常信号。结论小儿脱髓鞘疾病的临床表现复杂多变,通过病史及辅助检查,进行综合分析,不难得出诊断,预后良好。     

更昔洛韦治疗特发性血小板减少性紫癜应用指征

目的探讨更昔洛韦(GCV)治疗人巨细胞病毒(HCMV)感染相关的特发性血小板减少性紫癜的(ITP)应用指征。方法选择血清HCMV DNA PCR和(或)HCMV IgM检测呈阳性ITP患儿46例,采用逆转聚合酶扩增反应(RT-PCR)检测巨核系祖细胞中HCMV晚期抗原mRNA,并行GCV治疗,判定其疗效及应用指征。结果46例血清HCMV-DNA PCR阳性和(或)血清HCMV-IgM阳性的ITP骨髓巨核祖细胞HCMV晚期抗原基因mRNA阳性19例,GCV治疗有效16例,mRNA阴性27例,GCV治疗有效4例。阳性组疗效高于阴性组,有显著性差异(P<0.01)。结论HCMV感染的ITP患儿,若对常规治疗无效,应检测其巨核祖细胞内HCMV晚期抗原基因mRNA,阳性者是应用更昔洛韦的有效指征。     

1980例孕中晚期胎儿彩色多普勒超声检查结果回顾性分析

目的:利用彩色多普勒超声筛查孕中晚期胎儿异常或畸形,降低围产死亡率,提高人口出生质量。方法:对我院2002年1月至2005年3月1980例孕中晚期胎儿彩色多普勒超声检查结果回顾性分析。结果:检出胎儿畸形45例,死胎12例,低置胎盘24例,38周～42周胎位不正51例、脐绕颈316例。其中绝大多数在本院或外院引产证实,少数经过尸解证实。结论:彩色多普勒超声可发现大多数的胎儿形态结构异常,使一些致死性的畸形及早终止妊娠,非致死性的异常或畸形有了选择的空间;在提高人的出生质量上彩色多普勒超声起着不可或缺的作用,而且越来越显现出其独特的功能所在。