中医“四诊”在急诊预检分诊中的应用

目的探讨中医四诊法在急诊预检分诊中的应用效果及中医诊断思维与西医临床的结合。方法选取我院2008年1月-2010年12月急诊预检分诊中采用中医四诊法的患者382例,分析预检分诊时中医四诊的具体应用及分诊效果,探讨临床价值。结果382急诊患者分诊时间平均为（3．5±1．5）min,初步诊断与最终诊断符合率达到96．07％（367／382）。达到急诊预检分诊目的,符合分诊要求。结论中医四诊在急诊预检分诊中具有快速、简便的特点,有较高的诊断符合率,具有积极的临床应用价值。     

Role of a rapid response system and code status discussion as determinants of prognosis for critical inpatients: An observational study in a Japanese urban hospital

Rapid response systems (RRS) have been introduced worldwide to reduce unpredicted in-hospital cardiac arrest (IHCA) and in-hospital mortality. The role of advance care planning (ACP) in the management of critical patients has not yet been fully determined in Japan.We retrospectively assessed the characteristics of all inpatients with unpredicted IHCA in our hospital between 2016 and 2018. Yearly changes in the number of RRS activations and the incidence of unpredicted IHCA with or without code status discussion were evaluated from 2014 to 2018. Hospital standardized mortality ratios were assessed from the data reported in the annual reports by the National Hospital Organization.A total of 81 patients (age: 70.9 ± 13.3 years) suffered an unpredicted IHCA and had multiple background diseases, including heart disease (75.3%), chronic kidney disease (25.9%), and postoperative status (cardiovascular surgery, 18.5%). Most of the patients manifested non-shockable rhythms (69.1%); survival to hospital discharge rate was markedly lower than that with shockable rhythms (26.8% vs 72.0%, P < .001). The hospital standardized mortality ratios was maintained nearly constant at approximately 50.0% for 3 consecutive years. The number of cases of RRS activation markedly increased from 75 in 2014 to 274 patients in 2018; conversely, the number of unpredicted IHCA cases was reduced from 40 in 2014 to 18 in 2018 (P < .001). Considering the data obtained in 2014 and 2015 as references, the RRS led to a reduction in the relative risk of unpredicted IHCA from 2016 to 2018 (ie, 0.618, 95% confidence interval 0.453–0.843). The reduction in unpredicted IHCA was attributed partly to the increased number of patients who had discussed the code status, and a significant correlation was observed between these parameters (R² = 0.992, P < .001). The reduction in the number of patients with end-stage disease, including congestive heart failure and chronic renal failure, paralleled the incidence of unpredicted IHCA.Both RRS and ACP reduced the incidence of unpredicted IHCA; RRS prevents progression to unpredicted IHCA, whereas ACP decreases the number of patients with no code status discussion and thus potentially reducing the patient subgroup progressing to an unpredicted IHCA.     

Advances of radiation oncology in China

Radiation therapy is one of the main treatment .modalities used in cancer management. It is the primary curative modality for about 30% of patients with cancer, and more than half of all cancer patients received radiation therapy sometime during the course of their disease. It is estimated that 70% of the patients with cancer required radiation therapy in China.1 Radiation oncology is based on the development of radiological physics, radiological biology and clinical oncology.     

中医经皮给药研究进展

中医经皮给药即中药外治,本文主要从中医经皮给药渊源、临床应用及中药透皮吸收促进剂三方面进行综述,提出中医经皮给药应遵循辨证的原则、加大开发中药透皮吸收促进剂、临床给药应结合中医经络穴位理论、借助现代仪器促进透皮吸收、利用现代新的制剂技术等新观点。     

Opiniones: End‐of‐Life Care Preferences and Planning of Older Latinos

OBJECTIVES: To measure end‐of‐life (EOL) care preferences and advance care planning (ACP) in older Latinos and to examine the relationship between culture‐based attitudes and extent of ACP. DESIGN: Cross‐sectional interview. SETTING: Twenty‐two senior centers in greater Los Angeles. PARTICIPANTS: One hundred forty‐seven Latinos aged 60 and older. MEASUREMENTS: EOL care preferences, extent of ACP, attitudes regarding patient autonomy, family‐centered decision‐making, trust in healthcare providers, and health and sociodemographic characteristics. RESULTS: If seriously ill, 84% of participants would prefer medical care focused on comfort rather than care focused on extending life, yet 47% had never discussed such preferences with their family or doctor, and 77% had no advance directive. Most participants favored family‐centered decision making (64%) and limited patient autonomy (63%). Greater acculturation, education, and desire for autonomy were associated with having an advance directive (P‐values <.03). Controlling for sociodemographic characteristics, greater acculturation (adjusted odds ratio (AOR)=1.6, 95% confidence interval (CI)=1.1–2.4) and preferring greater autonomy (AOR=1.6, 95% CI=1.1–2.3) were independently associated with having an advance directive. CONCLUSIONS: The majority of older Latinos studied preferred less‐aggressive, comfort‐focused EOL care, yet few had documented or communicated this preference. This discrepancy places older Latinos at risk of receiving high‐intensity care inconsistent with their preferences.     

Stages of change for the component behaviors of advance care planning

OBJECTIVES: To develop stages‐of‐change measures for advance care planning (ACP), conceptualized as a group of interrelated but separate behaviors, and to use these measures to characterize older persons' engagement in and factors associated with readiness to participate in ACP. DESIGN: Observational cohort study. SETTING: Community. PARTICIPANTS: Persons aged 65 and older recruited from physician offices and a senior center. MEASUREMENTS: Stages of change for six ACP behaviors: completion of a living will and healthcare proxy, communication with loved ones regarding use of life‐sustaining treatments and quantity versus quality of life, and communication with physicians about these same issues. RESULTS: Readiness to participate in ACP varied widely across behaviors. Whereas between approximately 50% and 60% of participants were in the action or maintenance stage for communicating with loved ones about life‐sustaining treatment and completing a living will, 40% were in the precontemplation stage for communicating with loved ones about quantity versus quality of life, and 70% and 75% were in the precontemplation stage for communicating with physicians. Participants were frequently in different stages for different behaviors. Few sociodemographic, health, or psychosocial factors were associated with stages of change for completing a living will, but a broader range of factors was associated with stages of change for communication with loved ones about quantity versus quality of life. CONCLUSION: Older persons show a range of readiness to engage in different aspects of ACP. Individualized assessment and interventions targeted to stage of behavior change for each component of ACP may be an effective strategy to increase participation in ACP.     

A Comparative,Retrospective, Observational Study of the Prevalence,Availability, and Specificity of Advance Care Plans in a County that Implemented an Advance Care Planning Microsystem

OBJECTIVES: To determine whether outcomes have changed over time for a managed, systematic approach to advance care planning (ACP). DESIGN: Retrospective comparison of medical record and death certificate data of adults who died over a 7‐month period in 2007/08 with those of adults who died over an 11‐month period in 1995/96. SETTING: All healthcare organizations in La Crosse County, Wisconsin. PARTICIPANTS: Five hundred forty adults who died in 1995/96 and 400 adults who died in 2007/08. INTERVENTION: A systematic ACP approach, Respecting Choices, collaboratively implemented in 1993 and continuously improved in subsequent years. MEASUREMENTS: Demographic and cause‐of‐death data were collected from death certificates. Type and content of any advance directive (AD), existence and content of Physician Orders for Life‐Sustaining Treatment, and medical treatment provided at the location of death in the last 30 days of life were abstracted from the medical record. RESULTS: The recent data show a significantly greater prevalence of ADs (90% vs 85%, P=.02) and of availability of these directives in the medical record at the time of death (99.4% vs 95.2%, P<.001) than the data collected over 10 years ago. The new data suggest that quality efforts have improved the prevalence, clarity, and specificity of ADs. CONCLUSION: A system for ACP can be managed in a geographic region so that, at the time of death, almost all adults have an advance care plan that is specific and available and treatment is consistent with their plan.     

Circadian activity rhythm abnormalities in ill and recovered bipolar I disorder patients

OBJECTIVES: Most physiological indicators of bipolar disorder (BPD) reflect current acute illness, and rarely have proved to be state-independent. Activity rhythms are highly abnormal in acute phases of BPD; we compared circadian activity rhythms in BPD I patients during ill and recovered states to those of normal controls to test the hypothesis that some abnormalities may persist. METHODS: We compared 36 adult DSM-IV BPD I patients during acute mania or mixed states, and during full and sustained clinical recovery, to 32 healthy controls of similar age and sex distribution, using wrist-worn, piezoelectric actigraphic monitoring for 72 h and computed cosinor analysis of circadian activity rhythms. RESULTS: We verified expected major differences between manic or mixed-state BPD I patients and matched normal controls, including phase advances averaging 2.1 h in ill BPD I patients and 1.8 h in recovered patients. Moreover, recovered BPD patients differed highly significantly from controls in several measures, including acrophase advance, higher percentage of nocturnal sleep, and lower average daily activity (mesor). Actigraphic measures among recovered BPD patients were independent of ratings of mania (on the Young Mania Rating Scale), depression (on the Hamilton Depression Rating Scale), or rating-scale scored subjective distress, as well as the type and dose of concurrent psychotropic medication. CONCLUSIONS: These findings suggest that abnormal activity rhythms, including sustained phase advances, may represent enduring (trait) characteristics of BPD patients even during clinical recovery. If verified, such indices may be useful in supporting diagnoses and as an objective phenotype for genetic or other biological studies.     

适用于青少年与年轻成人的预立医疗照护计划文件的汉化研究：《说出我的选择》

目的将适用于青少年与年轻成人的预立医疗照护计划(advance care planning, ACP)文件Voicing My CHOiCES进行汉化,为在我国该人群中进行ACP实践提供基础。方法汉化流程包括背对背翻译、译本整合、医务人员评审、患者评审、背对背回译、回译本整合、原文件作者修订、定稿。医务人员评审的参与者为ACP实践中涉及的各类医务工作者,包括医生、护士、社工等。审评内容为文件整体结构合理性,以及各个主题的重要性、适用性和语言本土化水平。医务人员评审包括3轮评审过程,每轮评审后对文件进行修订,形成文件初稿。文件初稿再经患有致命性疾病的年轻患者及其家属进行评审,审评内容包括各个主题的适宜程度、帮助程度、压力程度,在此基础上对文件进一步修订,形成文件终稿,经原作者修订后定稿。结果因中美在语言、文化、医疗和法律体系上的差异,汉化过程针对文件中的部分主题进行本土化调适。中文版文件包括13个主题,涉及医疗与护理决策、日常生活规划、后事规划等内容。91.67%的患者和80%的患者父母认为所有主题均与患者的年龄和文化相适宜,符合年轻人需求和中国文化特征。75%的患者和70%的患者父母认为所有主题均是有帮助的。在压力程度评价中,死亡相关主题会为患者及其家属带来较大压力。结论《说出我的选择》是我国首个适用于青少年和年轻成人的ACP文件。该文件可帮助中国年轻患者思考和表达自己的偏好、意愿和价值观,确定未来医疗和护理的目标以及生活规划,并与亲属和医务人员讨论此类问题。     

Front Line Workers’ Attitudes towards Psychiatric Advance Directives

Studies have begun to explore provider attitudes’ toward psychiatric advance directives (PADs) and how those attitudes are related to provider characteristics. The study gathered attitudinal data from a sample of 193 social workers serving mentally ill adults. Social workers with pro-healthcare power of attorney (HCPA) attitudes were likely to have prior experience with an HCPA and to believe that involuntary treatment violates the NASW Code of Ethics. Social workers are more favorable of HCPAs than advance instructions. The findings suggest that clinical experiences with PADs may positively impact social worker’s perceptions of the law.