肥胖患者HFA小鼠模型的建立

目的研究肥胖患者的肠道菌群在无菌小鼠体内的定植规律。方法选取20只无菌KM小鼠,接种肥胖患者的粪便,构建菌群人源化(HFA)动物模型,利用变性梯度凝胶电泳技术(DGGE)评价患者肠道菌群在无菌小鼠体内的定植规律。结果 HFA小鼠菌群平均丰富度(richness,S)为12.04±3.68,肥胖患者的条带S为24,为HFA小鼠S的2倍;肥胖患者Shannon指数(H')为3.02,HFA小鼠平均H'为2.46±0.33;HFA小鼠与人肠道菌群的总相似度为26%;大部分雌性HFA小鼠与雄性HFA小鼠在聚类分析图上分离,且雄性HFA小鼠与患者更为相似。结论HFA小鼠体内能部分模拟肥胖患者的微生物区系,且与患者性别相同的小鼠模拟得更好。本实验建立的HFA模型为肥胖与肠道菌群关系的进一步研究提供新的选择。     

Patient Safety in Medical Education: Students’ Perceptions,Knowledge and Attitudes

Patient safety is a new and challenging discipline in the Iranian health care industry. Among the challenges for patient safety improvement, education of medical and paramedical students is intimidating. The present study was designed to assess students’ perceptions of patient safety, and their knowledge and attitudes to patient safety education. This cross-sectional analytical study was conducted in 2012 at Urmia University of Medical Sciences, West Azerbaijan province, Iran. 134 students studying medicine, nursing, and midwifery were recruited through census for the study. A questionnaire was used for collecting data, which were then analyzed through SPSS statistical software (version 16.0), using Chi-square test, Spearman correlation coefficient, F and LSD tests. A total of 121 questionnaires were completed, and 50% of the students demonstrated good knowledge about patient safety. The relationships between students’ attitudes to patient safety and years of study, sex and course were significant (0.003, 0.001 and 0.017, respectively). F and LSD tests indicated that regarding the difference between the mean scores of perceptions of patient safety and attitudes to patient safety education, there was a significant difference among medical and nursing/midwifery students. Little knowledge of students regarding patient safety indicates the inefficiency of informal education to fill the gap; therefore, it is recommended to consider patient safety in the curriculums of all medical and paramedical sciences and formulate better policies for patient safety.     

Comparisons between written and computerised patient histories.

Patient histories were obtained from 99 patients in three different ways: by a computerised patient interview (patient record), by the usual written interview (medical record), and by the transcribed record, which was a computerised version of the medical record. Patient complaints, diagnostic hypotheses, observer and record variations, and patients'' and doctors'' opinions were analysed for each record, and records were compared with the final diagnosis. About 40% of the data in the patient record were not present in the medical record. Two thirds of the patients said that they could express all or most of their complaints in the patient record. The doctors found that the medical record expressed the main complaints better (52%) than the patient record (15%) but that diagnostic hypotheses were more certain in the patient record (38%) than in the medical one (26%). The number of diagnostic hypotheses in the patient record was about 20% higher than that in the medical record. Intraobserver agreement (51%) was better than interobserver agreement (32%), while the inter-record agreement varied from 25% (between the medical and patient records) to 35% (between the transcribed and patient records). One third of final diagnoses were seen in the medical record, with 29% and 22% for the transcribed and patient records, respectively. Interobserver agreement in the final diagnosis was 35%. The results of the study suggest that computerised history taking is suitable for certain patients in addition to, and not as a substitute for, the oral interview with a doctor.     

The epidemiology and medical management of low back pain during ambulatory medical care visits in the United States

Background

Low back pain (LBP) is a common symptom.

Methods

Patient visits attributed to LBP in the National Ambulatory Medical Care Survey (NAMCS) during 2003–2004 served as the basis for epidemiological analyses (n = 1539). The subset of patient visits in which LBP was the primary reason for seeking care (primary LBP patient visits) served as the basis for medical management analyses (n = 1042). National population estimates were derived using statistical weighting techniques.

Results

There were 61.7 million (SE, 4.0 million) LBP patient visits and 42.4 million (SE, 3.1 million) primary LBP patient visits. Only 55% of LBP patient visits were provided by primary care physicians. Age, geographic region, chronicity of symptoms, injury, type of physician provider, and physician specialty were associated with LBP patient visits. Age, injury, primary care physician status, type of physician provider, and shared physician care were associated with chronicity of LBP care. Osteopathic physicians were more likely than allopathic physicians to provide medical care during LBP patient visits (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.75–3.92) and chronic LBP patient visits (OR, 4.39; 95% CI, 2.47–7.80). Nonsteroidal anti-inflammatory drugs (NSAIDs) and narcotic analgesics were ordered during 14.2 million (SE, 1.2 million) and 10.5 million (SE, 1.1 million) primary LBP patient visits, respectively. Drugs (OR, 0.29; 95% CI, 0.13–0.62) and, specifically, NSAIDs (OR, 0.40; 95% CI, 0.25–0.64) were ordered less often during chronic LBP patient visits compared with acute LBP patient visits. Overall, osteopathic physicians were less likely than allopathic physicians to order NSAIDs for LBP (OR, 0.43; 95% CI, 0.24–0.76). Almost two million surgical procedures were ordered, scheduled, or performed during primary LBP patient visits.

Conclusion

The percentage of LBP visits provided by primary care physicians in the United States remains suboptimal. Medical management of LBP, particularly chronic LBP, appears to over-utilize surgery relative to more conservative measures such as patient counseling, non-narcotic analgesics, and other drug therapies. Osteopathic physicians are more likely to provide LBP care, and less likely to use NSAIDs during such visits, than their allopathic counterparts. In general, LBP medical management does not appear to be in accord with evidence-based guidelines.     

Refractoriness at peripheral and pituitary receptors in general and pituitary types of thyroid hormone resistance.

Patients with the general type (patient #1 and #2) and the selective pituitary type (#3) of thyroid hormone refractoriness (TR) were studied to clarify defects at peripheral and pituitary receptors. Products of T3 and TSH (n = 63) were calculated when T3 was above the normal limit (T3 > 1.8 ng/ml, 2.8 nmol/l) as one of the indices of pituitary resistance. Means of T3 (ng/ml) x TSH (mU/l) of patient #1 (mean; 40.8), #2 (15.0) and #3 (8.6) were significantly greater than patients with Graves' disease (2.1), suggesting pituitary refractoriness in the 3 patients. The products of patient #1 and #2 were also significantly larger than patient #3, demonstrating that the pituitary insensitivity in the latter (#3) was less than the former patients. Means of serum cholesterol in patients #1 and #2 were higher than patient #3 and patients with Graves' disease. Products of T3 (ng/ml) and cholesterol (mg/ml) (n = 28) in the patient #1 (541.9) and #2 (461.0) were significantly greater than the patient #3 (292.8) and the patients with Graves' disease (275.3). The results demonstrate generalized refractoriness in the patient #1 and #2 and selective pituitary resistance in the patient #3. It is suggested that our patient with the pituitary type (#3) had less severely affected receptors at the pituitary than our two patients with the general type. These results are consistent with the previous hypothesis that the pituitary type of TR is a partial form of this disease.     

Specific antibody response in a patient with Candida dubliniensis fungemia

We report a case of fungemia caused by Candida dubliniensis in a non-HIV infected patient. Multiple cultures of blood performed over a period of 13 days were positive for this recently described yeast species. The C. dubliniensis isolates recovered were susceptible to fluconazole in vitro and the patient responded to intravenous therapy with this antifungal agent. It was possible to differentiate the fungemia caused by C. dubliniensis in this patient from that caused by C. albicans in other patients on the basis of the analysis of the antibody response since the C. dubliniensis-infected patient exhibited a characteristic and specific antibody response against a cell wall component of 160-170 kDa.     

Control of blood-transmitted infections in dentistry

As knowledge has accumulated on the blood-transmitted pathogenic agents, the contact with biological fluids (blood, plasma, saliva, etc.) from apparently healthy individuals has started to be regarded as a real professional risk for dentists. Theoretically, exposure to a contaminated biological specimen may have as a consequence transmission of infection from patient to dentist, from dentist to patient and from patient to patient via inadequately decontaminated and sterilized dental equipment. The present study is concerned with the analysis of the specific conditions that favor the occurrence of the epidemic process, the estimation of the risk degree of transmission of infections caused by hepatitis B, C viruses as well as of HIV infection in Romania. The data for the study were collected using two processes. First a self reporting survey and secondly an experimental procedure were performed. The testing of dentists' knowledge of blood transmissible diseases and infection control in their offices were performed using a questionnaire with 129 questions. The professional incidents/accidents representing a potential risk were counted using a questionnaire (with 37 questions). Serological markers were tested with ELISA kits. The monitoring of sterilization was accomplished with a questionnaire and biological tests. Many conclusions result from the study. There is an extremely reduced probability and infection transmission from the dentist to the patient. The transmission of infection from the patient to the dentist represents a low risk (for all that, the risk should not be minimized). The rigorous control and observation of infection prevention measures in dental offices is necessary to stop the infection transmission from patient to patient. The dentists' postgraduate training in infection control measures should be completed with knowledge regarding the blood transmissible infections epidemiology. Learning more about the epidemiological process enables the dentists to avoid wrong attitudes and behaviors.     

Mitogen-stimulated phospholipid synthesis in normal and immune-deficient human B cells

Eight patients with common variable panhypogammaglobulinemia were shown in the in vitro Ig biosynthesis assay to have defective B cell responses to pokeweed mitogen (PWM). Phospholipid synthesis was assessed in the B cell plus monocyte fraction (MB) and irradiated T cells (T*) of patients and paired normal controls. Cell populations were studied separately and in the four possible combinations (1:1), with and without PWM, to reveal the effect of cell interactions. At 16 to 20 hr the mean stimulation index (SI) +/- standard error for MB cells alone was 1.01 +/- 0.02 for eight patients and 0.99 +/- 0.02 for the paired normals; the T* cell SI was 1.25 +/- 0.04 for patients and 1.28 +/- 0.05 for normals. Combinations of normal MB cells with normal T* cells showed significantly higher SI when compared with the combinations of normal MB cells with patient T* cells (p less than 0.005). However, the combination of patient MB cells with patient T* cells and the combination of patient MB cells with normal T* cells were not significantly different in SI (0.05 less than p less than 0.1). Isolation of patient and normal B cells, T* cells, and monocytes after the choline pulse showed that patient B cells gave a higher SI with normal T* help than with patient T* help. Of greatest interest is the finding that patient B cells that were defective in PWM-stimulated Ig production nevertheless showed a phospholipid synthesis response to PWM in the normal range, suggesting that the maturation defect in these B cells occurs later than the phospholipid synthesis acceleration step, or on a different pathway.     

Rapid culture-free identification and molecular typing of Shiga toxin-producing Escherichia coli by PCR-RFLP

Using culture-independent technology, PCR-RFLP were used to identify and type STEC in the stool of a patient with HUS. Fecal PCR-RFLP patterns were identical to those of the STEC O157:H7 isolated from the patient.     

Influence of patient characteristics on test ordering in general practice.

Information regarding all consultations was collected in seven general practices for one year. From these data we report on the use of laboratory tests and its association with patient characteristics--including social class, age, sex, and diagnosis--and with which doctor was consulted. Most of the requests were for technically simple tests of low cost. There was a noticeable variation in the use of tests with regard to all patient characteristics. Diagnosis, identity of doctor, age of patient, and social class were each shown by multivariate techniques to be independently related to use of tests. Whereas fewer tests were used per consultation for social classes III-V compared with other social classes, more were used per patient per year for these same groups, reflecting in part the higher consultation rates of social classes III-V. Variation in diagnoses fully accounted for the greater test ordering for women. Nearly two thirds of all tests were ordered for 10% of all patients who consulted and 7% of all registered patients. The results of our analysis suggest that this concentration is determined primarily by those patient characteristics most indicative of medical need and by which doctor is providing care.     

Glycosylated hemoglobins in a diabetic patient with sickle cell anemia

Results of analysis of blood samples from a diabetic sickle cell anemia (SS) patient and 4 nondiabetic SS patients for glycosylated hemoglobins by Bio-Rex 70 chromatography, high-pressure liquid chromatography, and affinity chromatography are presented. Glycosylated components of Hb S and Hb A2 and total glycosylated hemoglobins were quantitated in this manner. The levels of the various glycosylated hemoglobins were increased twofold in the diabetic patient compared to nondiabetic SS patients. The glycosylated hemoglobin levels in the diabetic SS patient and in the nondiabetic SS patients, however, were significantly lower than the levels normally seen in nonsickle diabetics and normal adults, respectively. In contrast to a previously reported diabetic SS patient, the present case appears to be not severely affected by sickle cell disease.     

Effects of perceived patient demand on prescribing anti-infective drugs

BACKGROUND: Although patient demand is frequently cited by physicians as a reason for inappropriate prescribing, the phenomenon has not been adequately studied. The objectives of this study were to determine the prevalence of perceived patient demand in physician-patient encounters; to identify characteristics of the patient, physician and prescribing situation that are associated with perceived demand; and to determine the influence of perceived demand on physicians'' prescribing behaviour. METHODS: An observational study using 2 survey approaches was conducted in February and March 1996. Over a 2-day period 20 family physicians in the Toronto area completed a brief questionnaire for each patient encounter related to suspected infectious disease. Physicians were later asked in an interview to select and describe 1 or 2 incidents from these encounters during which perceived patient demand influenced their prescribing (critical incident technique). RESULTS: Perceived patient demand was reported in 124 (48%) of the 260 physician-patient encounters; however, in almost 80% of these encounters physicians did not think that the demand had much influence on their decision to prescribe an anti-infective. When clinical need was uncertain, 28 (82%) of 34 patients seeking an anti-infective were prescribed one, and physicians reported that they were influenced either "moderately" or "quite a bit" by perceived patient demand in over 50% of these cases. Of the 35 critical prescribing incidents identified during the interviews, anti-infectives were prescribed in 17 (49%); the reasons for prescribing in these situations were categorized. INTERPRETATION: This study provides preliminary data on the prevalence and influence of perceived patient demand in prescribing anti-infectives. Patient demand had more influence on prescribing when physicians were uncertain of the need for an anti-infective.     

A Hypernychthemeral Sleep-Wake Syndrome: A Treatment Attempt

The wake and sleep-onset times of a patient with a sleep-wake cycle longer than 24 hr were recorded by the patient for 4 years. During this time, the patient found himself unable to maintain a 24-hr sleep-wake schedule. When treated with 1-2 mg clonazepam, taken nightly, he was able to become entrained to a 24-hr day. Despite entrainment of his sleep-wake cycle, the patient reported depression, lack of motivation and fatigue and chose not to continue taking the drug.     

Events upstream of mitochondrial protein import limit the oxidative capacity of fibroblasts in multiple mitochondrial disease

To investigate whether protein import is defective in mitochondrial disease, we compared the rate of import and the expression of protein import machinery components in skin fibroblasts from control subjects and a patient with multiple mitochondrial disease (MMD). The patient exhibited a 35% decrease in cytochrome c oxidase activity and a 59% decrease in cellular oxygen consumption compared to control. Western blot analyses revealed that patient levels of MDH, mtHSP70, HSP60, and Tom20 protein were 57%, 20%, 75% and 100% of control cells, respectively. MDH and Tom20 mRNA levels were not different from control levels, whereas mtHSP70 mRNA were 50% greater than control. Radiolabeled MDH was imported into mitochondria with equal efficiency between patient (44% of total synthesized) and control (43%) cells, although the total MDH synthesized in patient cells was reduced by about 40%. The unaffected levels of mRNA and post-translational import into mitochondria, combined with reduced protein levels of MDH, mtHSP70, and HSP60 suggest a translational defect in this patient with MMD. This was verified by the 50% reduction in overall cellular protein synthesis in the patient compared to control. Further, the similar import rates between patient and control cells suggest an important role for Tom20, but a lesser role for mtHSP70 in regulating protein import into mitochondria.     

进行性骨化性纤维増殖不良症临床及基因突变分析

目的：研究一例具有超经典型临床特征的FOP患者,并对其ACVR1/ALK2基因进行分析。方法：根据患者的大踇趾畸形和进行性异位骨化等表现进行临床诊断,确诊为FOP。经患者及家属同意,采集患者、父母外周血,提取DNA,通过PCR扩增并直接测序测定ACVR1基因全部外显子序列,以此来确定突变位点。结果：患者具有超经典型FOP的临床表现：先天性大踇趾畸形,先天性双手拇指、食指远端关节僵直和进行性异位骨化,父母无FOP的相关临床表现。基因测序分析示该患者在ACVR1第七外显子发现存在c.1067G〉A（p.G356D）杂合错义突变,而其父母无此杂合突变。结论：该患者在ACVR1的c.1067G〉A（p.G356D）发生杂合错义突变,这有助于我们更好地理解认识中国FOP患者的临床表现和发病机制。     

Determination of antithrombocyte antibodies in the blood serum of patients with idiopathic thrombocytopenic purpura by an immunoenzyme method

Enzyme-linked immunosorbent assay (ELISA) was developed for determination of serum antiplatelet antibodies. Platelets obtained from healthy donors of blood group 0(1) were washed off plasma and sedimented on the bottom of microtest wells. After washing off unattached platelets and blocking of plastic with albumin platelets were incubated with sera under investigation and binding of serum antibodies was detected using antihuman immunoglobulin antibodies conjugated with peroxidase. Ten patients with idiopathic thrombocytopenic purpura (ITP). 1 patient with systemic lupus erythematosus. 1 patient with red blood cell aplasia and 9 healthy donors (negative control) were studied by ELISA. Serum antibodies which effectively bound to platelets were detected in 5 patients with ITP, in patient with lupus erythematosus and in patient with red blood cell aplasia.     

General practitioner attitudes towards referral of eating-disordered patients: a vignette study based on the theory of planned behaviour

Objective The study examined individual differences between general practitioners (GPs) to determine their impact on variations in intention to refer a hypothetical patient with disordered eating to specialist eating disorder services. The study also examined the impact of patient weight on intention to refer.Method GPs within three primary care trusts (PCTs) were posted a vignette depicting a patient with disordered eating, described as either normal weight or underweight. A questionnaire was developed from the theory of planned behaviour to assess the GPs' attitudes, perception of subjective norms, perceived behavioural control, and intention to refer the patient. Demographic details were also collected.Results Responses were received from 88 GPs (33%). Intention to refer the patient was significantly related to subjective norms and cognitive attitudes. Together these predictors explained 86% of the variance in the intention to refer. GP or practice characteristics did not have a significant effect on the GPs' intention to refer, and nor did the patient's weight.Conclusion Despite National Institute for Health and Clinical Excellence current guidance, patient weight did not influence GPs' decisions to refer. Much of the variance in actual referral behaviour may be explained by cognitive attitudes and subjective norms. Interventions to reduce this variation should be focused on informing GPs about actual norms, and best practice guidelines.     

An Approach to Assessing Patient Safety in Hospitals in Low-Income Countries

Objective

The aim of the study was to assess non-technical aspects of patient safety practices using non-participant observation in different clinical areas.

Design

Qualitative study using non-participant observation and thematic analysis.

Setting

Two eye care units in Uganda.

Participants

Staff members in each hospital.

Main outcome measures

A set of observations of patient safety practices by staff members in clinical areas that were then coded using thematic analysis.

Results

Twenty codes were developed that explained patient safety practices in the hospitals based on the observations. These were grouped into four themes: the team, the environment, patient-centred care and the process. The complexity of patient safety in each hospital was described using narrative reports to support the thematic analysis. Overall both hospitals demonstrated good patient safety practices however areas for improvement were staff-patient communication, the presence and use of protocols and a focus on consistent practice.

Conclusions

This is the first holistic assessment of patient safety practices in a low-income setting. The methods allowed the complexity of patient safety to be understood and explained with areas of concern highlighted. The next step will be to develop a useful and easy to use tool to measure patient safety practices in low-income settings.     

Analysis, identification and determination of urinary modified nucleosides of cancer and AIDS patients

Modified nucleoside levels in urine samples collected before and after surgery from seven patients with malignant gastrointestinal cancer were examined by the reversed-phase HPLC method. Those of an AIDS patient, a breast cancer patient, and pooled normal urines were also compared. To monitor the effects of therapy on cancer patients, the levels of modified nucleosides, especially t6A and MTA, were found to be fairly effective. In an AIDS patient, the levels of most of the nucleosides exhibited remarkable increases compared to normal urine.     

Comparison of Treatment Outcome Measures for Irritable Bowel Syndrome

We have examined the relations among three common treatment outcome measures in irritable bowel syndrome (IBS): end of treatment global ratings by a physician, end of treatment patient global ratings, and measures derived from a daily symptom diary completed by the patient. Eighty-four IBS patients (53 female, 31 male) participated in a randomized controlled evaluation of three psychological treatment conditions for IBS. Treatment outcome measures from this trial (Blanchard et al., 1992) were used in the present methodological study. Physician global ratings were significantly correlated with patient global ratings (r = .45, p < .01). Both of these global ratings also correlated significantly with a composite score from patient diary ratings. Multiple regression analyses revealed that reductions in bloating and constipation account for 18% of the variance in patient global ratings. Global ratings at end of treatment by either patient or physician were only partially related to symptom relief as measured by a daily diary.