Quality Indicators for Continuous Monitoring to Improve Maternal and Infant Health in Maternity Departments: A Modified Delphi Survey of an International Multidisciplinary Panel

Objective

Measuring the quality of inpatient obstetrical care using quality indicators is becoming increasingly important for both patients and healthcare providers. However, there is no consensus about which measures are optimal. We describe a modified Delphi method to identify a set of indicators for continuously monitoring the quality of maternity care by healthcare professionals.

Methodology and Main Findings

An international French-speaking multidisciplinary panel comprising 22 obstetricians-gynaecologists, 12 midwives, and 1 paediatrician assessed potential indicators extracted from a medical literature search, using a two-round Delphi procedure followed by a physical meeting. Each panellist rated each indicator based on validity and feasibility. In the first round, 35 panellists from 5 countries and 20 maternity units evaluated 26 indicators including 15 related to the management of the overall population of pregnant women, 3 to the management of women followed from the first trimester of pregnancy, 2 to the management of low-risk pregnant women, and 6 to the management of neonates. 25 quality indicators were kept for next step. In the second round, 27 (27/35: 77%) panellists selected 17 indicators; the remaining 8 indicators were discussed during a physical meeting. The final set comprised 18 indicators.

Conclusion

A multidisciplinary panel selected indicators that reflect the quality of obstetrical care. This set of indicators could be used to assess and monitor obstetrical care, with the goal of improving the quality of care in maternity units.     

Relationship of serum adiponectin and resistin levels with the severity of liver fibrosis in patients with chronic hepatitis B

BackgroundRecent research has closely linked adipocytokines to liver inflammation and fibrosis progression in patients with non-alcoholic liver disease. This study aimed to determine the relationship of serum adiponectin and resistin levels with the severity of liver fibrosis in patients with chronic hepatitis B (CHB), depending on the duration of antiviral therapy.MethodsThe cross-sectional study included 75 patients with CHB divided into two groups: the T1 group (undergoing antiviral therapy for up to 2 years) and the T2 group (undergoing antiviral therapy over 2 years). The control group consisted of 40 healthy people. Serum concentrations of adiponectin and resistin were estimated with the ELISA method, while the degree of liver fibrosis was determined using FIB-4 and APRI score.ResultsThere were no statistically significant differences in the mean serum adiponectin levels in relation to the duration of antiviral therapy. Higher values of serum resistin concentration were confirmed in patients of the T1 group compared to healthy controls (p=0.001) and to the T2 group (p=0.031). The mean level of serum resistin concentration was significantly higher in the group of patients with a higher FIB-4 score (9.12±3.39 vs 5.58±3.36 ng/mL, p=0.001) and higher APRI score (17.45±3.96 ng/mL vs 4.82±1.11 ng/mL, p=0.001). A positive correlation was found between serum resistin levels and the degree of liver fibrosis (p<0.001). There was no significant difference between mean serum adiponectin levels according to the values of FIB-4 and APRI scores.ConclusionsProgression of liver fibrosis estimated by FIB4 and APRI scores as well as the length of antiviral treatment had a significant effect on serum resistin values in CHB patients on antiviral therapy.     

基于循证评价的现代化综合性中医院医疗质量评价指标体系的建立

目的 建立一套科学合理、量化可比、简便易行的现代化综合性中医院医疗质量评价指标体系。方法 对我国现有的医疗质量评价的文献进行循证分析,按循证医学的标准和引用频率提取综合性医院的共性指标和中医院特有的非共性指标,从而拟定指标体系草案。运用德尔菲法,进行3轮专家咨询,采用相乘模型的综合指数法筛选指标,用层次分析法和比例分配法确定指标权重。结果 指标体系由5个一级指标、23个二级指标构成,其中反映中医院特色的二级指标6个,占26%。结论 整套指标体系既有医院的共性指标,又强调了综合性中医院的特性指标,既能突出中医医疗质量管理与质量控制的特色,又能结合中医医院现代化发展的需要。     

医学院校附属医院科研能力评估指标体系构建

目的 构建医学院校附属医院科研能力评估指标体系。方法 运用德尔菲法筛选并确定各项评价指标。 结果 经过两轮德尔菲法专家咨询,构建出医学院校附属医院科研能力评估指标体系,包括一级指标3个,二级指标8个,三级指标25个。结论 所构建的指标体系具有较高的信度、效度,可以作为评估医院科研能力的工具。     

Genotype Distribution of Vitamin D Receptor Polymorphisms among Indonesian Patients with Chronic Hepatitis B

Background:Chronic hepatitis B is a necro-inflammatory of the liver parenchyma caused by hepatitis B virus (HBV) infection leading to liver cirrhosis and hepatocellular carcinoma (HCC). Genetic variants including single nucleotide polymorphisms (SNPs) within genes regulating immune response may contribute to the progression of chronic hepatitis B (CHB) infection. This study aimed to examine the genotype distribution of vitamin D receptor (VDR) polymorphism among patients with CHB infection and to study its association with the development of cirrhosis and hepatoma.Methods:This cross-sectional study analysed 75 CHB patients, consisting of 36 CHB patients without cirrhosis, 25 CHB patients with cirrhosis, and 14 CHB patients with hepatoma. VDR polymorphism was examined using the Amplification Refractory Mutation System Polymerase Chain Reaction (ARMS-PCR) method.Results:Alanine aminotransferase (ALT) and alpha fetoprotein (AFP) levels did not show any significant differences between study groups, but albumin levels in CHB patients with cirrhosis and hepatoma were significantly lower than CHB patients without cirrhosis (p< 0.05). In contrast, the bilirubin levels in CHB patients with cirrhosis was higher than in CHB patients’ cirrhosis. The most common genotypes of VDR polymorphisms were Ff (57.3%), TT (72%), aa (48%) and bb (74.7%) for Fok1, Taq1, Apa1 and Bsm1 respectively. There was no significant different in the genotype distribution of VDR polymorphism between CHB patients without cirrhosis and CHB with cirrhosis or hepatoma. Conclusion:This study suggest that VDR gene polymorphism may not contribute to the progression of CHB infection.Key Words: Cirrhosis, Hepatitis B, Hepatoma, Polymorphism, Vitamin D Receptor     

Impact of a New Reimbursement Program on Hepatitis B Antiviral Medication Cost and Utilization in Beijing,China

Background

Hepatitis B virus (HBV) infection is a significant clinical and financial burden for chronic hepatitis B (CHB) patients. In Beijing, China, partial reimbursement on antiviral agents was first implemented for the treatment of CHB patients in July 1, 2011.

Aims

In this study, we describe the medical cost and utilization rates of antiviral therapy for CHB patients to explore the impact of the new partial reimbursement policy on the medical care cost, the composition, and antivirals utilization.

Methods

Clinical and claims data of a retrospective cohort of 92,776 outpatients and 2,774 inpatients with non-cirrhotic CHB were retrieved and analyzed from You''an Hospital, Beijing between February 14, 2008 and December 31, 2012. The propensity score matching was used to adjust factors associated with the annual total cost, including age, gender, medical insurance type and treatment indicator.

Results

Compared to patients who paid out-of-pocket, medical cost, especially antiviral costs increased greater among patients with medical insurance after July 1, 2011, the start date of reimbursement policy. Outpatients with medical insurance had 16% more antiviral utilization; usage increased 3% among those who paid out-of-pocket after the new partial reimbursement policy was implemented.

Conclusions

Direct medical costs and antiviral utilization rates of CHB patients with medical insurance were higher than those from paid out-of-pocket payments, even after adjusting for inflation and other factors. Thus, a new partial reimbursement program may positively optimize the cost and standardization of antiviral treatment.     

Long-Term Nucleos(t)ide Analogues Therapy for Adults With Chronic Hepatitis B reduces the Risk of Long-Term Complications: a meta-analysis

Background

The effect of antiviral therapy in chronic hepatitis B (CHB) on reducing the risk of long-term complications (LTCs) remains unclear so far. To study whether long-term nucleos(t)ide analogues therapy can reduce the risk of long-term complications.

Methods

We searched MEDLINE, EMBASE, OVID, the Cochrane Central Register of Controlled Trials. Relative risks (RRs) of long-term complications with or without treatment were studied. Also subgroup analyses including the status of drug-resistance, HBeAg and pre-existing compensated cirrhosis were done using relative risks of long-term complications either with or without treatment or among nucleos(t)ide analogues treatment groups.

Results

Six eligible studies (3644 patients in all) were included. Data showed the incidence of long-term complications in treatment groups was induced by 74%(RR:0.26, 95% CI: 0.15-0.47) compared with no treatment. Whether drug-resistant happened or not during the long-term therapy, the incidence of long-term complications was still significantly induced respectively by 45%(RR: 0.55,95%CI:0.40-0.76) and 78% (RR:0.22, 95%CI: 0.13-0.36). For both different status of HBeAg and pre-existing compensated cirrhosis, there was significant lower incidence of long-term complications in treatment groups compared with no treatment, too. Moreover, among the NA treatment groups, patients with drug-resistance had 2.64 times (RR:2.64, 95%CI: 1.58-4.41) higher chance of developing to long-term complications, and patients with pre-existing compensated cirrhosis also had 3.07 times (RR:3.07, 95%CI: 1.04-9.11) higher chance of developing to long-term complications.

Conclusions

Long-term nucleos(t)ide analogue therapy for adults with CHB prevents or delays the development of long-term complications including decompensated cirrhosis, CHB-related death or CHB-related HCC in patients with CHB. The patients who need take antiviral drugs should receive the antiviral therapy as soon as possible.

     

基于德尔菲法的外科手术风险因素评价指标构建

目的 构建外科手术风险因素评价指标体系,为有效监管外科手术质量与安全提供参考依据。方法 运用文献分析法、德尔菲法、层次分析法进行外科手术风险因素评价体系的构建和指标权重的确定。结果 建立了一个由手术固有风险、医疗机构风险、医务人员风险、患者风险4 个一级指标和手术本身风险、医务人员专业技术水平、患者个体差异、医务人员责任心、医学科学的局限性、医院诊疗流程、医务人员团队协作,医院诊疗服务水平、工作负荷等等20 个二级指标组成的手术风险因素评价指标体系。结论 建立一套完善的外科手术风险因素评价指标体系,对于保障手术患者安全、有效进行外科手术质量与安全监管具有重要意义。     

Measuring endemicity and burden of leprosy across countries and regions: A systematic review and Delphi survey

BackgroundLeprosy is a chronic infectious disease caused by Mycobacterium leprae, the annual new case detection in 2019 was 202,189 globally. Measuring endemicity levels and burden in leprosy lacks a uniform approach. As a result, the assessment of leprosy endemicity or burden are not comparable over time and across countries and regions. This can make program planning and evaluation difficult. This study aims to identify relevant metrics and methods for measuring and classifying leprosy endemicity and burden at (sub)national level.MethodsWe used a mixed-method approach combining findings from a systematic literature review and a Delphi survey. The literature search was conducted in seven databases, searching for endemicity, burden and leprosy. We reviewed the available evidence on the usage of indicators, classification levels, and scoring methods to measure and classify endemicity and burden. A two round Delphi survey was conducted to ask experts to rank and weigh indicators, classification levels, and scoring methods.ResultsThe literature review showed variation of indicators, levels, and cut-off values to measure leprosy endemicity and/or burden. The most used indicators for endemicity include new case detection rate (NCDR), new cases among children and new cases with grade 2 disability. For burden these include NCDR, MB cases, and prevalence. The classification levels ‘high’ and ‘low’ were most important. It was considered most relevant to use separate scoring methods for endemicity and burden. The scores would be derived by use of multiple indicators.ConclusionThere is great variation in the existing method for measuring endemicity and burden across countries and regions. Our findings contribute to establishing a standardized uniform approach to measure and classify leprosy endemicity and burden at (sub)national level, which would allow effective communication and planning of intervention strategies.     

TACE联合抗病毒治疗HBV相关性肝癌的预后观察及相关因素分析

摘要 目的：分析影响肝动脉化疗栓塞（TACE）联合抗病毒治疗乙型肝炎病毒（HBV）相关性肝癌预后的相关因素。方法：纳入的130例HBV相关性肝癌选自于本院2018年2月至2020年3月期间所收治，所有患者均行TACE联合抗病毒治疗，记录其生存情况，并对影响患者预后的相关因素进行分析与探讨。结果：130例患者随访截止时，死亡58例，存活72例，中位生存期为24个月，1年生存率为82.31%，2年生存率为55.38%；单因素及多因素Cox回归分析结果显示，肿瘤最大直径、血清AFP、Child-Pugh分级、腹腔转移、门静脉癌栓是患者预后不良的的危险因素。结论：肿瘤最大直径、血清AFP、Child-Pugh分级、腹腔转移、门静脉癌栓是影响TACE联合抗病毒治疗HBV相关性肝癌病患预后的影响因素。     

Sick Euthyroid Syndrome on Presentation of Patients With COVID-19: A Potential Marker for Disease Severity

ObjectivePrecise risk stratification and triage of coronavirus disease 2019 (COVID-19) patients are essential in the setting of an overwhelming pandemic burden. Clinical observation has shown a somewhat high prevalence of sick euthyroid syndrome among patients with COVID-19. This study aimed to evaluate the predictive value of free triiodothyronine (FT3) at the clinical presentation of COVID-19 for disease severity and death.MethodsThis retrospective cohort study was based on electronic medical records. The study was conducted at Sheba Medical Centre, a tertiary hospital where several acute and chronic wards have been dedicated to the treatment of patients with COVID-19. The primary outcome measure was death during hospitalization; secondary outcomes included hospitalization in intensive care, mechanical ventilation, and length of hospitalization.ResultsOf a total of 577 polymerase chain reaction-positive patients with COVID-19 hospitalized between February 27 and July 30, 2020, 90 had at least 1 measurement of thyroid-stimulating hormone, free thyroxine, and FT3 within 3 days of presentation. After applying strict exclusion criteria, 54 patients were included in the study. Patients in the lowest tertile of FT3 had significantly higher rates of mortality (40%, 5.9%, and 5.9%, P = .008), mechanical ventilation (45%, 29.4%, and 0.0%; P = .007) and intensive care unit admission (55%, 29.4%, and 5.9%, P = .006). In multivariate analyses adjusted for age, Charlson comorbidity index, creatinine, albumin, and white blood cell count. FT3 remained a significant independent predictor of death.ConclusionFT3 levels can serve as a prognostic tool for disease severity in the early presentation of COVID-19.     

三级医院医疗质量评价指标体系的构建及优化

目的 在原有医疗质量评价体系的基础上,建立一套科学合理、可操作性强的三级综合性医院医疗质量评价指标体系。方法 采用典型研究方法,通过文献研究筛选初始指标,通过知情人访谈法确定质量评价框架,运用德尔菲法并借鉴平衡积分卡的原理和思想优化并确定指标及权重系数。结果 确定了以医疗基础质量、环节质量和终末质量为基本结构的三级综合性医院质量评价框架和指标体系,由3个一级维度、8个二级维度、24个三级维度指标体系及其相应权重。结论 医疗质量评价指标体系关注医院质量管理中的难点和重点环节,能够满足上海市三级综合性医院医疗质量管理的实际需要。     

Association between hepatic steatosis and entecavir treatment failure in Chinese patients with chronic hepatitis B

Background

The coexistence of HBV infection and nonalcoholic fatty liver disease (NAFLD) becomes characteristic of liver disease in China, with unknown bilateral influence. We aimed to investigate the effect of hepatic steatosis, a common hepatocyte change in NAFLD, on antiviral therapy in patients with chronic hepatitis B (CHB).

Methods and Findings

We carried out a prospective nested case control study in CHB patients receiving Entecavir for initial antiviral therapy, by recording demographic, anthropometric and clinical data at baseline, 24^wk, 48^wk and 96^wk. Univariate analysis and multivariate logistic regression were applied to find out independent factors of hepatic steatosis and Entecavir treatment failure. The rates of HBV-DNA clearance, HBeAg seroconversion and ALT normalization were compared between CHB patients with and without steatosis by post hoc analysis. A total of 267 Chinese patients with CHB entered final analysis, with overall percentages of hepatic steatosis and HBeAg positive as 30.5% and 62.4%. Multivariate analysis showed waist circumference, serum TG and uric acid levels were independent factors of hepatic steatosis. The response rates to Entecavir were 54.9%, 63.8%, 74.2% at 24^wk, 48^wk and 96^wk. Hepatic steatosis was revealed as an independent factor of Entecavir treatment failure by multivariate logistic regression at 24^wk, 48^wk and 96^wk. In CHB patients with hepatic steatosis, HBV-DNA clearance and HBeAg seroconversion were both lower throughout the follow-up, but only the former reached statistical significance. Besides, ALT normalization was also significantly lower at 24^wk and 48^wk.

Conclusion

Hepatic steatosis is significantly associated with Entecavir treatment failure and metabolic factors are independent factors of hepatic steatosis in CHB patients, which called for a specified antiviral strategy in CHB patients with NAFLD.     

Caspase-1、OPN在慢加急性乙型肝炎肝衰竭患者血清中的表达及其临床意义

摘要 目的：探讨半胱氨酸蛋白酶-1 (Caspase-1)、骨桥蛋白（OPN）在慢加急性乙型肝炎肝衰竭（HBV-ACLF）患者血清中的表达及其临床意义。方法：选择2020年6月至2022年6月中国人民解放军联勤保障部队第九七Ο医院收治的86例HBV-ACLF患者（HBV-ACLF组）;另选取同时段接诊的58例慢性HBV感染患者（CHB组）;收集同时间段60例体检的健康志愿者（对照组）。检测所有受试者血清Caspase-1、OPN、肝功能指标水平,探讨HBV-ACLF患者血清Caspase-1、OPN水平与肝功能指标的相关性,单因素分析及Logistic多元逐步回归分析影响HBV-ACLF患者预后的危险因素。结果：三组血清Caspase-1、OPN、肝功能指标水平比较差异有统计学意义（P＜0.01）。HBV-ACLF组、CHB组血清Caspase-1、OPN、丙氨酸转氨酶（ALT）、天冬氨酸转氨酶（AST）、总胆红素（TBIL）水平高于对照组（P＜0.05）,白蛋白（Alb）、胆碱酯酶（CHE）水平低于对照组（P＜0.05）,HBV-ACLF组血清Caspase-1、OPN 、ALT 、AST 、TBIL水平高于CHB组（P＜0.05）,Alb、CHE水平低于CHB组（P＜0.05）。Pearson相关分析显示,HBV-ACLF患者血清Caspase-1、OPN水平均与ALT、AST、TBIL呈正相关（P＜0.05）,与Alb、CHE呈负相关（P＜0.05）。单因素分析显示,HBV-ACLF患者预后与肝硬化、肝性脑病、腹膜炎发生率、终末期肝病评分模型（MELD）评分、白细胞计数（WBC）、血小板计数（PLT）、肌酐（Cr）、国际标准化比值（INR）、TBIL、HBV-DNA载量（HBV-DNA）、Caspase-1、OPN有关（P＜0.05）;而与年龄、性别、血红蛋白（HGB）、BUN、ALT、AST、CHE、Alb无关（P>0.05）。Logistic多元逐步回归分析模型结果显示,HBV-DNA、MELD评分、Caspase-1、OPN是影响HBV-ACLF患者预后的危险因素（P＜0.05）。结论：HBV-ACLF患者血清Caspase-1、OPN水平呈异常高表达,且Caspase-1、OPN高表达水平与肝功能恶化和不良临床结局有关,可为HBV-ACLF患者病情进展及预后评估提供依据。     

公立医院绩效评价PATH优化模型指标体系的构建

目的 构建适用于三级公立医院的绩效评价体系,为医院开展绩效考核与管理工作提供决策参考。方法 应用文献法、个人访谈法和头脑风暴法构建评价模型和初始指标库,运用德尔菲法和层次分析法确定指标权重。结果 运用医院质量改进的绩效评价工具（The Performance Assessment Tool for Quality Improvement in Hospitals,PATH）理念构建了以病人为中心、以员工为导向、临床效率效果、运营表现、响应治理、卓越提升6个核心维度的三级公立医院绩效评价体系。结论 指标体系的可信程度较高、权威性高、具有较好的适用性。

     

Deep Sequencing Analysis of HBV Genotype Shift and Correlation with Antiviral Efficiency during Adefovir Dipivoxil Therapy

Background

Viral genotype shift in chronic hepatitis B (CHB) patients during antiviral therapy has been reported, but the underlying mechanism remains elusive.

Methods

38 CHB patients treated with ADV for one year were selected for studying genotype shift by both deep sequencing and Sanger sequencing method.

Results

Sanger sequencing method found that 7.9% patients showed mixed genotype before ADV therapy. In contrast, all 38 patients showed mixed genotype before ADV treatment by deep sequencing. 95.5% mixed genotype rate was also obtained from additional 200 treatment-naïve CHB patients. Of the 13 patients with genotype shift, the fraction of the minor genotype in 5 patients (38%) increased gradually during the course of ADV treatment. Furthermore, responses to ADV and HBeAg seroconversion were associated with the high rate of genotype shift, suggesting drug and immune pressure may be key factors to induce genotype shift. Interestingly, patients with genotype C had a significantly higher rate of genotype shift than genotype B. In genotype shift group, ADV treatment induced a marked enhancement of genotype B ratio accompanied by a reduction of genotype C ratio, suggesting genotype C may be more sensitive to ADV than genotype B. Moreover, patients with dominant genotype C may have a better therapeutic effect. Finally, genotype shifts was correlated with clinical improvement in terms of ALT.

Conclusions

Our findings provided a rational explanation for genotype shift among ADV-treated CHB patients. The genotype and genotype shift might be associated with antiviral efficiency.     

First real-world experience with mobile health telemonitoring in adult patients with congenital heart disease

Background

Arrhythmias and heart failure are common and invalidating sequelae in adult patients with congenital heart disease (CHD). Mobile health (m-Health) enables daily monitoring and a timely response that might prevent deterioration. We present an observational prospective registry to evaluate feasibility of an m‑Health telemonitoring program for managing arrhythmia, heart failure and blood pressure in symptomatic adults with CHD.

Methods

Symptomatic adult patients with CHD are enrolled in an m‑Health telemonitoring program, which evaluates single-lead ECG, blood pressure and weight measurements. In case of symptoms extra measurements could be performed. Data are collected by mobile apps, matched with individualised thresholds. Patients are contacted if thresholds were exceeded or if arrhythmias were found, for treatment adjustments or reassurance. Data on emergency care utilisation, hospitalisation and patient-reported outcome measures are used to assess quality of life and self-management.

Results

129 symptomatic CHD patients were invited to participate, 55 participated. Reasons for refusing consent included too time consuming to participate in research (30) and to monitor vital signs (14). At baseline 22 patients were in New York Heart Association class ≥ II heart failure, 43 patients had palpitations or documented arrhythmias, and 8 had hypertension. Mean follow-up was 3.0 months, one patient dropped out, and adherence was 97%.

Conclusion

The first results indicate that this program is feasible with high adherence.

     

血清VEGF、miR-122、GDF15及TK1在乙肝相关性肝病表达水平及其临床意义

摘要 目的：分析不同类型乙肝相关性肝病患者血清血管内皮生长因子（VEGF）、microRNA-122（miR-122）、生长分化因子15（GDF-15）及胸苷激酶1（TK1）的表达差异变化及其临床意义。方法：随机选取2020年1月-2022年6月在我院消化内科收治的不同类型乙肝相关性肝病患者135例作为研究组。其中根据乙型肝炎诊断标准分为慢性乙型肝炎组（CHB）76例,乙型肝炎肝硬化组（LC）57例,乙型肝炎肝癌组（HCC）78例,选取同时期在本院进行体检的健康受检者96例作为健康组。比较各组的基本资料、检测研究对象血清VEGF、miR-122、GDF15、TK1、HBV DNA载量水平和AFP表达水平。采用Pearson相关性检验分析乙肝相关性肝病患者血清VEGF、miR-122、GDF15及TK1表达水平与HBV DNA载量水平的相关性,采用受试者工作特征曲线（ROC）诊断LC和HCC的价值。结果：CHB 组、LC 组 和HCC组VEGF、TK1表达水平显著高于健康组,差异具有统计学意义（P<0.01）,CHB 组、LC 组 和HCC组组间两两比较,差异具有统计学意义（P<0.01）。CHB 组、LC 组 和HCC组miR-122表达水平显著低于健康组,差异具有统计学意义（P<0.01）,CHB 组、LC 组 和HCC组组间两两比较,差异具有统计学意义（P<0.01）。LC 组 和HCC组GDF15表达水平显著高于 CHB 组和健康组,差异具有统计学意义（P<0.01）,CHB 组和健康组组间比较差异无统计学意义（P>0.05）。CHB 组、LC 组 和HCC组HBV DNA载量水平显著高于健康组,差异具有统计学意义（P<0.01）,LC 组 和HCC组组间比较,差异无统计学意义（P>0.05）。LC 组 和HCC组AFP表达水平显著高于 CHB 组和健康组,差异具有统计学意义（P<0.01）,LC 组 和HCC组、CHB 组和健康组组间比较差异无统计学意义（P>0.05）。CHB组、LC+HCC组血清VEGF、miR-122、GDF15及TK1水平与HBV DNA载量水平具有相关性（P<0.01或P<0.05）。血清VEGF、miR-122、GDF15及TK1单独检测诊断LC和HCC的曲线下面积（AUC）为0.695、0.783、0.743及0.7687,四项指标联合检测诊断LC和HCC的AUC为0.839,敏感度为84.21,特异度为83.25。结论：血清VEGF、miR-122、GDF15及TK1在各类型乙肝相关性肝病中表达水平存在差异,血清VEGF、miR-122、GDF15及TK1联合检测诊断LC和HCC具有临床价值。     

慢性乙型肝炎患者血清IL-17A、GP73水平与肝功能指标及病情严重程度的关系分析

摘要 目的：探讨慢性乙型肝炎(CHB)患者血清白细胞介素-17A (IL-17A)、高尔基体蛋白73(GP73)水平与肝功能指标及病情严重程度的关系。方法：选取2018年10月至2019年10月于青海大学附属医院就诊的CHB患者93例作为研究对象（CHB组）,另选取同时期于我院体检的健康志愿者33例作为对照组。比较不同病情严重程度、不同乙型肝炎e抗原（HbeAg）表达的CHB患者IL-17A、GP73水平及肝功能相关指标[丙氨酸氨基转移酶（ALT）、门冬氨酸氨基转移酶（AST）、白蛋白、总胆红素（TBiL）]的差异,并分析IL-17A、GP73水平与患者病情严重程度及肝功能相关指标的相关性。结果：CHB组中轻度、中度、重度患者血清IL-17A、GP73、ALT、AST及TBiL水平均高于对照组,白蛋白水平低于对照组（P<0.05）,并且随着CHB患者病情严重程度的加重其血清中IL-17A、GP73、ALT、AST及TBiL水平逐渐升高,白蛋白水平逐渐降低（P<0.05）。CHB组HbeAg阴性患者血清中的IL-17A、GP73、ALT及AST水平均明显高于HbeAg阳性患者（P<0.05）,而白蛋白和TBiL水平无明显差异（P>0.05）。CHB患者血清IL-17A、GP73均与ALT、AST及TBiL呈正相关,与白蛋白呈负相关,与患者病情严重程度呈正相关（P<0.05）。结论：CHB患者血清中IL-17A、GP73水平明显升高,且与患者病情严重程度及肝功能相关指标呈明显相关性,临床中可联合检测用于患者病情评估及预后监测。     

First proposal of quality indicators and standards and recommendations to improve the healthcare in the Spanish National Registry of Hip Fracture

BackgroundThe Spanish National Hip Fracture Registry (or Registro Nacional de Fractura de Cadera, RNFC) is a database of hip fracture patients admitted to Spanish hospitals. Its goals include assessment and continuous improvement of the care process.ObjectivesTo (1) establish a series of indicators, (2) evaluate their initial fulfillment, (3) propose quality standards, (4) suggest recommendations to facilitate standards compliance, and (5) monitor the indicators.MethodThe indicators fulfilled the criteria of (1) evaluating the process or outcome, (2) being clinically relevant for patients, (3) being modifiable through changes in healthcare practice, and (4) being considered important by the RNFC participants. The first quartile obtained by the group of hospitals in each of the respective variables was proposed as the standard. The Indicators Advisory Committee (IAC) elaborated a list of recommendations for each indicator, based on the available evidence.ResultsSeven indicators were chosen. These indicators (its baseline compliance vs. the standard to be reached, respectively) were: the proportion of patients receiving surgery within 48 h (44% vs. 63%), mobilized the first postoperative day (56% vs. 86%), with antiosteoporotic medication at discharge (32% vs. 61%), with calcium supplements at discharge (46% vs. 77%), with vitamin D supplements at discharge (67% vs. 92%), who developed pressure ulcers during hospitalization (7.2% vs. 2.1%) and with independent mobility at 30 days (58% vs. 70%). The IAC has established 25 recommendations for improving care.ConclusionThe indicators and standards chosen are presented, as well as the list of recommendations. This process completes the first step to improve quality of care. The results will be evaluated 6 months after implementing the recommendations.