看病是一门学问

50年前,我们第一次到北京,不一定需要地图。故宫不难找。今天,我们第一次到北京,没有地图是很难找到鸟巢、水立方等新景点的。同样的道理,50年前看病简单。今天,去医院看病是一门学问。这就是健康管理中的"需求管理"。看病是一种需求,需要管理。您对看病的学问了解得越多,对日益复杂的医疗服务系统就越能游刃有余。比如:     

Using a serial marker to predict a repeated measures outcome in a cohort design--results of a simulation study

Consider the cohort design and suppose that the outcome of primary interest is a continuous random variable observed repeatedly over time. Suppose that there is a second variable of clinical relevance which is also observed repeatedly. We are interested in assessing whether the "serial marker" is in some sense predictive of the primary outcome. We would also like to predict the trend for the primary outcome assuming that the clinical marker follows a profile of specific clinical interest. In series of earlier papers, we have addressed these issues by applying a bivariate repeated measures model. One regression model was prescribed to relate the primary outcome to important explanatory variables, while a second regression model was prescribed for the serial marker. In this paper, we perform a series of simulation studies to investigate the empirical properties of this approach. Bivariate repeated measures data were generated at random, and basic study parameters including the sample size, the number of time points, the degree of serial correlation within the clinical marker, and type of association between the serial marker and the primary outcome were varied. The ability of the methodology to capture the underlying relationship between the two set of repeated measures was assessed. The ability to predicting the primary outcome corresponding to a known marker profile of specific interest was examined.     

LB50053: a 5-hydroxytrypamine(1a) agent with a high binding affinity and a potency evoking a K(+) current

The newly synthesized N-substituted derivative of 3-aryl-pyrrolidine LB50053, 2-[4-[3-(4-fluoro)-phenylpyrrolidine-1-yl] - butyl]-1,2- benzisothiazol -3(2H)-one-1,1-dioxide, was studied in receptor-binding assays and in electrophysiological measurements. Competitive binding experiments with various radioligands to the rat fore-brain revealed that the (S)-enantiomer of LB50053 had a high affinity (Ki 4.2 nmol/l) and a high selectivity for 5-HT(1A) receptors as compared with 5-HT(2A), D(1) dopamine, D(2) dopamine, or (alpha(2)-adrenergic receptor. In Xenopus oocytes, where coupling of the 5-HT(1A) receptor to the G protein activated inwardly rectifying K(+) channel 1(GIRK1) was established, (S)-LB50053 evoked an inward K(+) current through GIRK1 in a manner consistent with a partial agonism. The K(d) value deduced from the dose-response relationships of the 5-HT(1A) receptor full agonist 8-OH-2-(di-n-propylamino)-1,2,3,4-tetrahydronaphthalene and (S)-LB50053 according to Waud analysis was 64.60 nmol/l. These results demonstrate that LB50053 is a 5-HT(1A) receptor partial agonist and thus can be used asa therapeutic or pharmacological research tool for 5-HT(1A) receptor mediated events in the future.     

Community pharmacy as a performance: a participant observer's account of a day in the life of a locum

Objective — To understand, from a dramaturgical viewpoint, the performance of “community pharmacy.” Method — Participant observation supported by focus groups and semistructured interviews; the study adopted a grounded theory approach. Setting — Fieldwork was conducted within 21 community pharmacies in East Anglia, England. Key findings — Pharmacists identify with their setting and stage props. On the stage of community pharmacy, the pharmacist crucially converts the drug into medicine, during a complex and well‐rehearsed performance. There are sometimes distractions, which make the performance sub‐optimal. Other insights included what counts as error, how to manage stress, and the fact that the trust on which professional practice rests is at stake when expressive performance fails. Conclusion — It is possible to conduct ethnography of community pharmacy and this is among the first such studies of British community pharmacy. Were the pharmacist to leave the stage and its props (the drugs), only to advise patients on medicines, the performance of community pharmacy, as we know it, might disappear.     

Using a modified shepards method for optimization of a nanoparticulate cyclosporine a formulation prepared by a static mixer technique

An innovative methodology has been used for the formulation development of Cyclosporine A (CyA) nanoparticles. In the present study the static mixer technique, which is a novel method for producing nanoparticles, was employed. The formulation optimum was calculated by the modified Shepard's method (MSM), an advanced data analysis technique not adopted so far in pharmaceutical applications. Controlled precipitation was achieved injecting the organic CyA solution rapidly into an aqueous protective solution by means of a static mixer. Furthermore the computer based MSM was implemented for data analysis, visualization, and application development. For the optimization studies, the gelatin/lipoid S75 amounts and the organic/aqueous phase were selected as independent variables while the obtained particle size as a dependent variable. The optimum predicted formulation was characterized by cryo-TEM microscopy, particle size measurements, stability, and in vitro release. The produced nanoparticles contain drug in amorphous state and decreased amounts of stabilizing agents. The dissolution rate of the lyophilized powder was significantly enhanced in the first 2 h. MSM was proved capable to interpret in detail and to predict with high accuracy the optimum formulation. The mixer technique was proved capable to develop CyA nanoparticulate formulations.     

Amelioration of sulfur mustard skin injury following a topical treatment with a mixture of a steroid and a NSAID

The ability to ameliorate sulfur mustard (HD)-induced oedema by treatment with anti-inflammatory drugs was reported previously after screening four steroids and four non-steroidal anti-inflammatory drugs (NSAIDs) using the mouse ear vesicant model. Following the screening study, one steroid and one NSAID (Adexone and Voltaren) were selected as the most effective, and a mixture of the two was chosen for the present more extensive research. The effect of the combined treatment on clinical, biochemical and histopathological parameters following HD insult was studied. Mice ears were exposed to 0.2 micro l of HD for 10 min to produce a moderate skin injury. Oedema development peaked ca. 48 h following exposure, as determined by weighing ear biopsies. Histological observations at that time exhibited damage to the epidermis and dermis. An increase in prostaglandin E (PGE) was measured in skin homogenates, starting 8 h following exposure and lasting at least up to 48 h post-exposure. A topical treatment using the above anti-inflammatory mixture significantly reduced inflammatory parameters when applied up to 4 h following exposure. These parameters included extent of oedema, levels of PGE, area of clinical damage and extent of cytotoxic injury (vesications and damaged epithelial cells). Thus, a combination of a steroid and NSAID was found to be effective in reducing the intensity of HD skin injury and possibly shortening the time to full recovery. The treatment, however, did not prevent completely the ensuing cytotoxic processes in the epithelial layer.     

When a placebo is not a 'placebo': a placebo effect on postprandial glycaemia

AIMS: Placebo effects in clinical trials remain uncertain. To investigate a placebo effect on acute postprandial plasma glucose, we conducted a follow-up investigation on a previous study. METHODS: The effect of placebo (9 g encapsulated cornstarch +500 ml water, taken at -40 min) on the plasma glucose response to a 75-g oral glucose tolerance test (OGTT) was assessed in a previous study in 12 healthy subjects (gender, five male, seven female; age 27 +/- 6 years; body mass index 24 +/- 3.4 kg m(-2)). This was compared with the effect of a water control (500 ml water taken alone at -40 min) on the same outcome in the same subjects in a follow-up study. RESULTS: Cornstarch placebo decreased plasma glucose area under the curve during the 75-g OGTT by 28% [Delta (95% confidence interval) -63.3 min mmol(-1) l(-1) (-218.33, 91.66), P < 0.02] compared with the water control (P < 0.05). CONCLUSIONS: Postprandial plasma glucose outcomes may be vulnerable to placebo effects.