责任指数在医学生医师职业精神评测中的应用初探

目前对于医学生医师职业精神的培养和测评已成为国内外医学院校医学教育当中的热点问题,但是对于低年级医学生职业精神评测的研究较少。介绍了责任指数的基本概念并通过介绍国外医学院校应用责任指数对于在校医学生医师职业精神的评测,分析该方法的优劣。认为责任指数是基于具体行为的评测、其结果更加真实准确,是适用于低年级医学生的医师职业精神评测系统,与其他评测系统相比,责任指数更注重预先的指导和规范。但责任指数也有一些不足之处,如责任指数评估过程中须面对一些伦理挑战,且评测框架设计缺乏整体性。     

Ethical Issues and Management of Fetal Hemolytic Anemia Caused by Anti-Rh17 in a Multipara with Rare −D– Phenotype

BackgroundThe development of allo-anti-Rh17 (anti-Hr0) in a −D– phenotype whose red blood cells (RBCs) lack CcEe antigens is most likely triggered by transfusion, transplantation, or pregnancy. Gene conversion is the predominating factor in generating RHD-CE-D and RHCE-D-CE hybrids like −D–.MethodsWe report here immunohematological and obstetrical data from 2 of the 5 pregnancies of a 24-year-old woman presenting with the −D– phenotype with anti-Rh17. Blood group typing, antibody screening, antibody differentiation, direct antiglobulin test (DAT), and antibody titers were performed by routine gel technology and tube testing. Additionally, molecular genetic analysis was performed. Fetal surveillance was done by sonographic evaluation of the fetal middle cerebral artery peak systolic velocity (MCA-PSV).ResultsBlood group typing showed O, C-c-D+E-e- and the DAT was negative. DNA sequencing revealed homozygosity for an RHCE-D(3–9)-CE null allele. Anti-Rh17 titers in the fourth pregnancy remained between 1:8 and 1:128, and no signs for a fetal anemia were observed. However, in the fifth pregnancy, the antibody titers increased up to 1:4,096. Signs of moderate fetal anemia were detected and cesarean section was performed at 34 + 6 weeks of gestation. The newborn presented with hemolytic anemia (cord blood hemoglobin [Hb] = 8.5 mg/dL). She received 2 compatible (small) packed RBC concentrates, phototherapy, and intravenous immunoglobulins.ConclusionOur case shows that the risk for hemolytic complications increases with the number of pregnancies of sensitized women. Only people who also lack CcEe antigens are compatible as donors. The role of such rare donors as lifesavers, their freedom, and voluntariness conflict with the urgent need for compatible blood.     

基层医疗机构多学科主题药学查房模式的探索与实践

目的：探索适合基层医疗机构的新药学查房工作模式,为临床药师开展药事服务提供参考。方法：于2019年建立以主题为导向的多学科联合药学查房模式,建立健全药学查房的内容和流程,对药学查房用药干预类别及临床接受率进行统计分析。结果：主题药学查房共涉及10个主题,干预用药问题247例,临床接受干预231例,接受率为93.52%。开展多学科主题药学查房后,本院抗菌药物使用率、住院抗菌药物使用强度、抗菌药物使用金额比例及一类切口围手术期预防用药率均低于未开展前;基本药物使用率和处方合格率均高于未开展前（P<0.05）。结论：医院开展多学科主题药学查房模式,可有效提升临床合理用药水平,优化药学服务质量。     

心理健康管理对综合医院体检慢性病筛查与管理的有效性

目的探讨心理健康管理对体检慢性病筛查与管理的有效性。方法随机抽取体检筛查的慢性病231例,排除相关因素,对其中的201例进行体检后心理健康管理,主要采用体检报告与心理测评报告结合方式进行讲解答疑工作,对筛选出的慢性病患者进行心理健康指导与效果评估。结果参与心理健康管理后,83.58%的患者主观感受较好,67.67%自感心理健康水平有所提升,79.10%疾病复发次数降低,90.55%体检结果转好,73.13%经访谈后表示会继续参加心理健康管理。结论心理社会因素在心身疾病的发生、发展、治疗和预后中起重要的作用,心理健康管理对慢性病康复有促进作用。     

Trends in Outpatient MRI Seem to Reflect Recent Reimbursement Cuts

PurposeTo determine whether recent reimbursement cuts have resulted in a shift of outpatient MRI from private offices to hospital outpatient departments (HOPDs); and to study office MRI utilization trends among radiologists and other specialists.MethodsThe Medicare Part B Physician/Supplier Procedure Summary Master Files were used. MRI codes were aggregated, and total MRI volumes from 2002 to 2012 were studied. Medicare place-of-service codes were used to identify studies performed in private offices and HOPDs and create trend lines. Specialty codes were used to categorize private office MRI users as radiologists, orthopedic surgeons, other physicians, and independent diagnostic testing facilities.ResultsMedicare office and HOPD utilization of MRI (all specialties) rose rapidly from 2002 to 2006, reaching 2,727,807 in offices and 2,355,641 in HOPDs. Thereafter, office volume steadily declined, whereas HOPD volume steadily increased. By 2012, more studies were done in HOPDs than in offices. Over the entire period from 2002 and 2012, office MRI volume among radiologists increased 27%, compared with 216% among orthopedic surgeons and 124% among other physicians.ConclusionsAlthough the majority of Medicare outpatient MRI studies had previously been performed in private offices, recent years brought a shift, with more now being performed in HOPDs. This change will increase costs to payers, because reimbursements to HOPDs are generally higher than those to offices. Although radiologists perform the majority of MRI exams that are conducted in private offices, the rate of growth for such exams from 2002 to 2012 was considerably higher among orthopedic surgeons and other physicians than among radiologists.     

The Claims Management Committees trial: Experience of an Italian Hospital of the National Health System

Introduction: In Italy, health care is mainly financed by earmarked central and regional taxes, with regions receiving their allocated share of resources from the National Health Fund. The Council of the Tuscany Region in 2009 began an experimentation aimed to enforce the extrajudicial conciliation. The Council established the Claims Management Committees (CMC) for civil liability in the Tuscan Health Service. The CMC trial provides that the damages are compensated directly by the hospital, removing the cost of liability insurance. The aim of this study is to collect and compare the liability-insurance-period and the CMC trial-period. Materials and methods: Data were derived from the management claims database of the Health Directorate of the Careggi Hospital in Florence between 2006 and 2012. Two main periods are considered for the comparison of data: 2006–2007–2008 during the insurance management and 2010–2011–2012 during the CMC trial. Results: During the insurance management period, the total expenditure was equal to the €14,846,334.44 paid in the 3-year period. The total expenditure during the CMC trial 3-years period was equal to €7.076.370,75. Under the CMC management, we observed a marked decrease in the recourse to legal action in the face of a substantial maintenance of the number of claims opened for each year. The CMC trial showed a greater speed in setting claims for damages. Discussion and conclusions: Under CMC management, a greater and more diligent efficiency is matched by a lower economic outlay. The use of the direct management of damage compensation may be an important tool for risk management, thus guaranteeing the recourse to targeted and appropriate interventions.     

An audit of consenting practices in a district general hospital. Can we improve?

Introduction

Informed consent, as the declaration of patients’ will, forms the basis of legality of medical procedures. A standard form based on the Department of Health model is widely used in the National Health Service (NHS). The aim of this audit process was to assess the current consent practice in comparison to the UK’s General Medical Council guidance and local policy and make any appropriate improvements.

Patients and methods

254 adult consent forms were reviewed during the patients’ admission. Data collected included legible documentation, grade of health professional completing the consent form, providing additional written information, use of abbreviations, securing the consent form in the medical records and, providing a copy to the patient. After initial assessment, interventions in an attempt to improve adherence to guidelines were introduced. A repeat audit of a further set of 110 notes was completed to assess the effectiveness of our interventions.

Results

Our baseline assessment of 254 consent forms comprised of 198 (78%) elective and 56 (22%) emergency procedures. 87 (34%) consent forms were secure in the medical records. Grade of health professional was recorded in 211 (83%). 191 (75%) forms were legible. 48 (19%) patients were given copy of the consent. Only 24 (9%) patients were given additional written information. Abbreviations were used in 68 (27%) forms. Only 12 (5%) of consent forms met all criteria simultaneously.Re-audit after intervention assessed 110 consent forms; 30 (27%) for elective and 80 (72%) for emergency procedures. 52 (47%) of consent forms were secure in medical records, grade of health professional was recorded in 94 (85%), 101 (75%) forms were legible, 42 (38%) patients received copy of consent and 41 (37%) of patients received additional written information.

Conclusion

Initially only 5% of consent forms completely met GMC guidelines. This demonstrates an alarmingly poor adherence to such guidance that plays a vital role in patient safety, patient ethics autonomy, not to mention potential medico-legal and clinical governance implications for surgical practice.Our intervention has improved the quality of consenting within our hospital according to these guidelines. With these interventions set to continue and further develop, we expect that the quality of the consenting process will continue to provide patients with all that it is designed to.     

Outcomes of elderly survivors of intensive care: a review of the literature

An increasing proportion of critically ill patients are elderly (ie, >or= 65 years of age). This poses complex challenges and choices for the management of elderly patients. Outcome following admission to the ICU has been traditionally concerned with mortality. Beyond mortality, outcomes such as functional status and health-related quality of life (HRQOL) have assumed greater importance. This article reviews the literature, published in English from 1990 to December 2003, pertaining to HRQOL and functional status outcomes of elderly patients. Functional status and HRQOL of elderly survivors of ICUs has been underinvestigated. There is no agreement as to the optimal instrument choice, and differences between studies preclude meaningful comparison or pooling of results.     

Coronary angiographic morphology in myocardial infarction: a link between the pathogenesis of unstable angina and myocardial infarction

It has previously been shown that analysis of coronary morphology can separate unstable from stable angina. An eccentric stenosis with a narrow neck or irregular borders, or both, is very common in patients who present with acute unstable angina, whereas it is rare in patients with stable angina. To extend these observations to myocardial infarction, the coronary morphology of 41 patients with acute or recent infarction and nontotally occluded infarct vessels was studied. For all patients, 27 (66%) of 41 infarct vessels contained this eccentric narrowing, whereas only 2 (11%) of 18 noninfarct vessels with narrowing of 50 to less than 100% had this lesion (p less than 0.001). In addition, a separate group of patients with acute myocardial infarction who underwent intracoronary streptokinase infusion were also analyzed in similar fashion. Fourteen (61%) of 23 infarct vessels contained this lesion after streptokinase infusion compared with 1 (9%) of 11 noninfarct vessels with narrowing of 50 to less than 100% (p less than 0.01). Therefore, an eccentric coronary stenosis with a narrow neck or irregular borders, or both, is the most common morphologic feature on angiography in both acute and recent infarction as well as unstable angina. This lesion probably represents either a disrupted atherosclerotic plaque or a partially occlusive or lysed thrombus, or both. The predominance of this morphology in both unstable angina and acute infarction suggests a possible link between these two conditions. Unstable angina and myocardial infarction may form a continuous spectrum with the clinical outcome dependent on the subsequent change in coronary supply relative to myocardial demand.     

Noninvasive in vivo and in vitro study of the St. Jude mitral valve prosthesis: Evaluation using two dimensional and M mode echocardiography,phonocardiography and cinefluoroscopy

Fifteen patients with clinically normal function of a St. Jude mitral valve prosthesis were studied with two dimensional and M mode echocardiography, Cinefluoroscopy and phonocardiography 8 to 292 days after valve replacement. The valve was readily imaged from the left sternal edge and cardiac apex in all patients. On two dimensional echocardiography from the long axis and four chamber views, minimal end-diastolic and endsystolic distances between the interventricular septum and prosthetic valve were 18 ± 5 mm and 13 ± 3 mm, respectively (mean ± standard deviation). On M mode echocardiography both leaflets were imaged throughout the cardiac cycle from the left sternal edge and their motion relative to the valve ring and to one another was easily evaluated. The apical transducer position permits quantitative assessment of individual leaflet motion. Maximal individual diastolic leaflet excursion was 8.7 ± 1 mm and the velocity of leaflet opening and closure was 364 ±103 and 678 ±115 mm/s, respectively.Asynchronous early closure of the posterior leaflet was observed during long cardiac cycles in six of seven patients with atrial fibrillation; the seventh patient had a rapid ventricular response and no long cardiac cycles. Diastolic fluttering of one or both leaflets was also seen during atrial fibrillation after rotation of the patient from the supine to the left lateral decubitus position. Three of the six patients with asynchronous leaflet closure underwent Cinefluoroscopy, and similar leaflet behavior was documented in all. An atrial systolic wave was inscribed in the valve echogram in six of eight patients with sinus rhythm.Phonocardiography recorded prosthetic valve opening and closing sounds occurring 60 ± 20 ms after aortic closure and 61 ± 12 ms after the QRS complex, respectively. The prosthetic valve opening and closure sound amplitude ratio was 0.11 ± 0.06.A clear plexiglass water bath phantom was fitted to a pulse duplicator and constructed so as to permit in vitro simulation of valve echograms under a variety of conditions. With this method, it was possible to reproduce or approximate all images obtained in patients from both echocardiographic transducer positions.