Konsiliardienste in den Fachgebieten „Psychiatrie und Psychotherapie“ und „Psychosomatische Medizin und Psychotherapie“ im Land Sachsen-Anhalt

Objective To assess the availability and the utilization of specialists for psychiatry, psychotherapy and psychosomatic medicine in somatic hospitals in the German state of Sachsen- Anhalt. Method The “Committee for Issues of Psychiatric Care in Sachsen- Anhalt” sent written questionnaires to the medical chairmen of the 46 hospitals with a somatic department; the return rate was 98% with some information about 48 of 55 hospital locations. Results 17 hospitals use specialists from their own clinical facilities (12 from their own psychiatric department for inpatient care and 4 from their own psychiatric day hospital as well as 9 from their own inpatient psychosomatic unit) for psychiatric consultations on somatic wards and were classified as hospitals with “internal” consultation services. 27 hospitals ask for visits from specialists from another psychiatric hospital (14) and/or call colleagues working in private practice (14) and were classified as “external consultation services”, even if they had psychologists among their own staff (3). In another 4 hospitals, no psychiatric services were offered. Only 16 houses had statistical data regarding the frequency of psychiatric consultations at hand; another 22 hospitals provided estimates. The availability of the consultation service was a strong predictor of its utilization: Hospitals with an “internal” service reported about five times more consultations than those hospitals whose consultation services depended on external specialists. Some formal psychotherapeutic qualification was available in nearly all hospitals with internal and in 37% of the hospitals with external services. Conclusions We were able to gather at least some information regarding psychiatric and/or psychosomatic consultation services in about nearly 90% of the local somatic hospitals of the whole state of Sachsen- Anhalt, which is one of the “new” federal states that emerged from the former “German Democratic Republic” and has to catch up to the standards of medical care of the Federal Republic of Germany. The quality of the data, however, left much room for improvement, as only 36% of the hospitals were able to provide the exact number of psychiatric consultations in the previous year or the last six months. The results, nevertheless, suggest considerable deficits in the care of patients with psychiatric disorders especially in those somatic hospitals with no internal psychiatric consultation service. A service “around the clock” was only available in hospitals with a psychiatric inpatient department of their own. We strongly recommend the implementation of regular reports about the utilization of psychiatric consultations in somatic hospitals as an addition to the current measures of quality assurance. Every somatic hospital should have at least one psychiatrist (with some psychotherapeutic training) on its own staff.     

Auspicious birth dates among Chinese in California

The number eight is considered lucky in Chinese culture, e.g. the Beijing Olympics began at 8:08 pm on 8/8/2008. Given the potential for discretion in selecting particular dates of labor induction or scheduled Cesarean section (C-section), we consider whether Chinese-American births in California occur disproportionately on the 8th, 18th, or 28th day of the month. We find 2.3% “too many” Chinese births on these auspicious birth dates, whereas Whites show no corresponding increase. The increase in Chinese births is driven by higher parity C-sections: the number of repeat C-sections is 6% “too high” on auspicious birth dates. Sons born to Chinese parents account for the entire increase; daughter deliveries do not seem to be timed to achieve “lucky” birth dates. We also find avoidance of repeat C-section deliveries on the 4th, 14th, and 24th of the month, considered unlucky in Chinese culture. Finally, we replicate earlier work finding that Friday the 13th delivery dates are avoided and document a particularly large decrease among Chinese. For Whites and Chinese in California, mothers with higher levels of education are particularly likely to avoid delivering on the 13th.     

新生儿抚触的研究进展

新生儿抚触作为儿科护理的新理念,是一种对新生儿健康十分有益的自然健康医疗技术。开展新生儿抚触对新生儿有特别重要的意义。抚触可以促进婴儿体格和智能的发育、增进睡眠、稳定情绪;抚触可以增强免疫力、促进食物的消化和吸收;抚触可以促进早产儿生长发育、新生儿缺氧缺血性脑病患儿的康复;抚触可以降低新生儿黄疸、避免发生胆红素脑病;抚触可促进母婴之间情感交流;抚触可利于产后妈妈的恢复。总之,无论是对家庭、社会、医院、还是对新生儿自身来讲,抚触都是非常有意义、重要且必要的,作为家长及医院工作人员都应该了解并掌握新生儿抚触的方法以及注意事项,因此,在临床工作和家庭中都应该积极主动的广泛开展新生儿抚触,目前各国都在研究并开展新生儿抚触这种护理技术,未来新生儿抚触将会被越来越多的家庭所认识并在医院中和家庭中广泛开展。     

The impact of heat waves on children’s health: a systematic review

Young children are thought to be particularly sensitive to heat waves, but relatively less research attention has been paid to this field to date. A systematic review was conducted to elucidate the relationship between heat waves and children’s health. Literature published up to August 2012 were identified using the following MeSH terms and keywords: “heatwave”, “heat wave”, “child health”, “morbidity”, “hospital admission”, “emergency department visit”, “family practice”, “primary health care”, “death” and “mortality”. Of the 628 publications identified, 12 met the selection criteria. The existing literature does not consistently suggest that mortality among children increases significantly during heat waves, even though infants were associated with more heat-related deaths. Exposure to heat waves in the perinatal period may pose a threat to children’s health. Pediatric diseases or conditions associated with heat waves include renal disease, respiratory disease, electrolyte imbalance and fever. Future research should focus on how to develop a consistent definition of a heat wave from a children’s health perspective, identifying the best measure of children’s exposure to heat waves, exploring sensitive outcome measures to quantify the impact of heat waves on children, evaluating the possible impacts of heat waves on children’s birth outcomes, and understanding the differences in vulnerability to heat waves among children of different ages and from different income countries. Projection of the children’s disease burden caused by heat waves under climate change scenarios, and development of effective heat wave mitigation and adaptation strategies that incorporate other child protective health measures, are also strongly recommended.     

News and Views

We surveyed the sleep‐wake patterns and lifestyle habits in a sample of Japanese first to third year junior high school children (n=638, age 12 to 15 yrs), of whom 29.3% were evening type, 64.1% intermediate type, and 6.6% morning type in preference. The morningness‐eveningness (M‐E) score was lower (more evening typed), 16.1 vs. 15.4 in first compared to third year students. There were significant gender differences, with girls showing a greater evening preference. Evening preference was associated with longer sleep latency, shortened sleep duration during schooldays and weekends, bad morning feeling, and episodes of daytime sleepiness. In contrast, morning preference was associated with higher sleep drive and better sleep‐wake parameters and lifestyle habits. Our results suggest the morning preference should be promoted among junior high school children to increase the likelihood of more regular sleep‐wake patterns and lifestyle habits.     

“True clinical fictions”: Medical and literary narratives from the Civil War hospital

Where to find stories of the “real” Civil War? Since Walt Whitman, observers have suggested the place to look is the military hospital. This paper offers a comparative analysis of medical case histories and literary stories written by S. Weir Mitchell, head contract-surgeon at one of the largest Union army research hospitals. I illustrate that Mitchell's case histories and stories were at once complementary and antagonistic in their use of medical knowledge and narrative technique as a means of achieving truth-value.     

Cesarean Sections Among Syrian Refugees in Lebanon from December 2012/January 2013 to June 2013: Probable Causes and Recommendations

Introduction: There are nearly 3 million Syrian refugees, with more than 1 million in Lebanon. We combined quantitative and qualitative methods to determine cesarean section (CS) rates among Syrian refugees accessing care through United Nations High Commissioner for Refugees (UNHCR)-contracted hospitals in Lebanon and possible driving factors.Methods: We analyzed hospital admission data from UNHCR’s main partners from December 2012/January 1, 2013, to June 30, 2013. We collected qualitative data in a subset of hospitals through semi-structured informant interviews.Results: Deliveries accounted for almost 50 percent of hospitalizations. The average CS rate was 35 percent of 6,366 deliveries. Women expressed strong preference for female providers. Clinicians observed that refugees had high incidence of birth and health complications diagnosed at delivery time that often required emergent CS.Discussion: CS rates are high among Syrian refugee women in Lebanon. Limited access and utilization of antenatal care, privatized health care, and male obstetrical providers may be important drivers that need to be addressed.     

Relation of cord blood thyroxine and thyrotropin levels to gestational age and birth weight.

A program of screening cord blood for evidence of primary neonatal hypothyroidism was implemented in a general hospital. In 13 months 3456 newborns were screened: the thyroxine (T4) and triiodothyronine (T3) concentrations were measured in cord blood samples, and when the T4 level was below 8.0 micrograms/dl thyrotropin was also assayed in the sample. The two-tier program was effective. One hypothyroid newborn was detected and treated. More boys than girls had T4 levels below 8.0 micrograms/dl (9.7% v. 4.7%). The T4 level correlated with birth weight slightly better in the boys (r = 0.28 v. 0.21), and in the boys this correlation was stronger when the birth weight was lower. Regression analysis of the data for 54 sets of twins indicated that the T4 level was more strongly related to gestational age than to birth weight.     

Insuring Care: Paperwork,Insurance Rules,and Clinical Labor at a U.S. Transgender Clinic

What is a clinician to do when people needing medical care do not have access to consistent or sufficient health insurance coverage and cannot pay for care privately? Analyzing ethnographically how clinicians at a university-based transgender clinic in the United States responded to this challenge, I examine the U.S. health insurance system, insurance paperwork, and administrative procedures that shape transgender care delivery. To buffer the impact of the system’s failure to provide sufficient health insurance coverage for transgender care, clinicians blended administrative routines with psychological therapy, counseled people’s minds and finances, and leveraged the prestige of their clinic in attempts to create space for gender nonconforming embodiments in gender conservative insurance policies. My analysis demonstrates that in a market-based health insurance system with multiple payers and gender binary insurance rules, health care may be unaffordable, or remain financially challenging, even for transgender people with health insurance. Moreover, insurance carriers’ “reliance” on clinicians’ insurance-related labor is problematic as it exacerbates existing insurance barriers to the accessibility and affordability of transgender care and obscures the workings of a financial payment model that prioritizes economic expediency over gender nonconforming health.     

Saudis’ Attitudes toward Chemical Pollution of the Environment,Al-Baha Region,Saudi Arabia

The results of a public opinion survey were used to assess the variation in attitudes toward the chemical pollution of the environment among Saudi residents of the Al-Baha region, Saudi Arabia. A total of 17 statements were given to respondents, addressing general opinions about health risks from chemical pollution. The main findings of this study are: (1) Most Saudis consider the place where they live unhealthful; (2) there was substantial concern about exposure to chemicals with more than 77% of respondents indicating a conscious effort to avoid chemicals in their daily life; (3) chemicals were seen as predominantly being “dangerous” and leading to more harm than good, and they see that the more a person is exposed to chemicals causing cancer the more likely he/she will get cancer; (4) Respondents see that chemicals in the environment are less harmful than chemicals from lifestyle factors and they disagree with the statement that “use of chemicals has improved their health more than it has harmed them”; (5) Saudis are not prepared to accept some health risks in order to benefit the economy. The study did not find any potential relationship between gender, age range, place of residence, and education level and attitude toward chemical pollution among Saudi residents.     

Is the medical value of the “personal touch” being underestimated as costs are cut?

Those involved in health care planning and the possible closure of health care facilities should remember that patients must have confidence and feel secure with the health care team in order to achieve rapid recovery. Dr. Jack Rothstein, staff surgeon at a Montreal hospital that has been slated for closure, points out the medical value of personalized, attentive care delivered by community hospitals. At a time when patients are being given more responsibility for managing their own care, he argues, elements of the health care system that help achieve continuity of care and patient empowerment should be protected. The issue is important in Montreal because the government has announced plans to close seven hospitals with 1224 acute-care beds.     

Patient Referral Patterns and the Spread of Hospital-Acquired Infections through National Health Care Networks

Rates of hospital-acquired infections, such as methicillin-resistant Staphylococcus aureus (MRSA), are increasingly used as quality indicators for hospital hygiene. Alternatively, these rates may vary between hospitals, because hospitals differ in admission and referral of potentially colonized patients. We assessed if different referral patterns between hospitals in health care networks can influence rates of hospital-acquired infections like MRSA. We used the Dutch medical registration of 2004 to measure the connectedness between hospitals. This allowed us to reconstruct the network of hospitals in the Netherlands. We used mathematical models to assess the effect of different patient referral patterns on the potential spread of hospital-acquired infections between hospitals, and between categories of hospitals (University medical centers, top clinical hospitals and general hospitals). University hospitals have a higher number of shared patients than teaching or general hospitals, and are therefore more likely to be among the first to receive colonized patients. Moreover, as the network is directional towards university hospitals, they have a higher prevalence, even when infection control measures are equally effective in all hospitals. Patient referral patterns have a profound effect on the spread of health care-associated infections like hospital-acquired MRSA. The MRSA prevalence therefore differs between hospitals with the position of each hospital within the health care network. Any comparison of MRSA rates between hospitals, as a benchmark for hospital hygiene, should therefore take the position of a hospital within the network into account.     

Disentangling the Effects of Risk Factors and Clinical Care on Subnational Variation in Early Neonatal Mortality in the United States

Objective

Between 1990 and 2010, the U.S ranking in neonatal mortality slipped from 29^th to 45^th among countries globally. Substantial subnational variation in newborn mortality also exists. Our objective is to measure the extent to which trends and subnational variation in early neonatal mortality reflect differences in the prevalence of risk factors (gestational age and birth weight) compared to differences in clinical care.

Methods

Observational study using linked birth and death data for all births in the United States between 1996 and 2006. We examined health service area (HSA) level variation in the expected early neonatal mortality rate, based on gestational age (GA) and birth-weight (BW), and GA-BW adjusted mortality as a proxy for clinical care. We analyzed the relationship between selected health system indicators and GA-BW-adjusted mortality.

Results

The early neonatal death (ENND) rate declined 12% between 1996 and 2006 (2.39 to 2.10 per 1000 live births). This occurred despite increases in risk factor prevalence. There was significant HSA-level variation in the expected ENND rate (Rate Ratio: 0.73–1.47) and the GA-BW adjusted rate (Rate ratio: 0.63–1.68). Accounting for preterm volume (defined as <34 weeks), the number of neonatologist and NICU beds, 25.2% and 58.7% of the HSA-level variance in outcomes was explained among all births and very low birth weight babies, respectively.

Conclusion

Improvements in mortality could be realized through the expansion or reallocation of clinical neonatal resources, particularly in HSAs with a high volume of preterm births; however, prevention of preterm births and low-birth weight babies has a greater potential to improve newborn survival in the United States.     

Reproductive pattern,perinatal mortality,and sex preference in rural Tamil Nadu,south India: community based,cross sectional study.

OBJECTIVES: To study reproductive pattern and perinatal mortality in rural Tamil Nadu, South India. DESIGN: Community based, cross sectional questionnaire study of 30 randomly selected areas served by health subcentres. SETTING: Rural parts of Salem District, Tamil Nadu, South India. SUBJECTS: 1321 women and their offspring delivered in the 6 months before the interview. MAIN OUTCOME MEASURES: Number of pregnancies, pregnancy outcome, spacing of pregnancies, sex of offspring, perinatal and neonatal mortality rates. RESULTS: 41% of the women (535) were primiparous; 7 women (0.5%) were grand multiparous (> 6 births). The women had a mean age of 22 years and a mean of 2.3 pregnancies and 1.8 live children. The sex ratio at birth of the index children was 107 boys per 100 girls. The stillbirth rate was 13.5/1000 births, the neonatal mortality rate was 35.3/1000, and the perinatal mortality rate was 42.0/1000. Girls had an excess neonatal mortality (rate ratio 3.42%; 95% confidence interval 1.68 to 6.98; this was most pronounced among girls born to multiparous women with no living sons (rate ratio 15.48 (2.04 to 177.73) v 1.87 (0.63 to 5.58) in multiparous women with at least one son alive). CONCLUSIONS: In this rural part of Tamil Nadu, women had a controlled reproductive pattern. The excess neonatal mortality among girls constitutes about one third of the perinatal mortality rate. It seems to be linked to a preference for sons and should therefore be addressed through a holistic societal approach rather than through specific healthcare measures.     

Neonatal intensive care and cost effectiveness.

During the past decade the rate of death among newborns weighing less than 1500 g at birth has decreased by approximately half. This dramatic reduction has resulted from the application of research findings and technologic advances, but it has proved expensive. Perhaps as a consequence of articles demonstrating the costs as well as the recognition that the overall prevalence of disabilities in infants is relatively unchanged, neonatal intensive care has recently been viewed as a possible area for cost containment. We reviewed the literature on the cost of neonatal intensive care and the limited information on other expensive medical programs and found that the cost of neonatal intensive care compared favourably, especially for infants whose birth weight was 1000 to 1500 g. Better information on the outcome of infants of very low birth weight and comparable rigorous studies of the cost effectiveness of other expensive medical programs are required, and other less easily quantified factors must be considered before decisions are made to limit neonatal intensive care on the basis of gestational age or birth weight.     

北京市公立医院试点医事服务费调查

北京市在公立医院试点医药分开,取消药品加成、挂号费和诊疗费,收取医事服务费。对试点医院门诊调查发现,医院改变传统管理和经营模式,从关注创收转变为控制成本,从多开药转变为合理用药,门诊患者数量明显增多,多数患者对现行的医事服务费政策支持并感到满意。部分医院管理者认为采用医事服务费并取消药品加成没有真正切断医生和药品之间的利益关系,对医院和医护人员长期影响有待进一步观察。     

Impact of increasing capacity for generating and using research on maternal and perinatal health practices in South East Asia (SEA-ORCHID Project)

Background

Maternal and neonatal mortality and morbidity remain unacceptably high in many low and middle income countries. SEA-ORCHID was a five year international collaborative project in South East Asia which aimed to determine whether health care and health outcomes for mothers and babies could be improved by developing capacity for research generation, synthesis and use.

Methods

Nine hospitals in Indonesia, Malaysia, the Philippines and Thailand participated in SEA-ORCHID. These hospitals were supported by researchers from three Australian centres. Health care practices and outcomes were assessed for 1000 women at each hospital both before and after the intervention. The capacity development intervention was tailored to the needs and context of each hospital and delivered over an 18 month period. Main outcomes included adherence to forms of care likely to be beneficial and avoidance of forms of care likely to be ineffective or harmful.

Results

We observed substantial variation in clinical practice change between sites. The capacity development intervention had a positive impact on some care practices across all countries, including increased family support during labour and decreased perineal shaving before birth, but in some areas there was no significant change in practice and a few beneficial practices were followed less often.

Conclusion

The results of SEA-ORCHID demonstrate that investing in developing capacity for research use, synthesis and generation can lead to improvements in maternal and neonatal health practice and highlight the difficulty of implementing evidence-based practice change.     

How primary health care professionals and residents assess issues related to the oral health of older persons?

doi: 10.1111/j.1741‐2358.2009.00355.x
How primary health care professionals and residents assess issues related to the oral health of older persons? Background and objectives: It is known that older persons need integrated primary health care. However, oral health may not be a frequent concern of multi‐professional teams taking care of older persons. The aim of the present study was to evaluate knowledge and practices related to oral health care, as reported by professionals and residents in a primary health care service. Material and methods: One hundred and seventy‐three health professionals and residents were assessed in this cross‐sectional study by means of a structured questionnaire containing questions pertaining to oral health practices and beliefs. Participants were grouped based on their professions into “primary health care dentists” or “other primary health care professionals” and based on their working status into “permanent team” or “residents”. Results: Permanent team members (other professionals) assessed and recommended dental care more frequently than residents. Permanent team members (other professionals) also reported that they felt they were able to inform older patients in respect to oral health‐related issues more frequently than did residents (68.7% vs. 31.3%, respectively). Conclusion: Oral health‐related knowledge and beliefs were frequent among non‐dentists primary health care workers, suggesting that primary health care which integrates oral health represents an attainable goal.     

Outcomes associated with planned place of birth among women with low-risk pregnancies

Background:Previous studies have shown that planned home birth is associated with a decreased likelihood of intrapartum intervention with no difference in neonatal outcomes compared with planned hospital birth. The purpose of our study was to evaluate different birth settings by comparing neonatal mortality, morbidity and rates of birth interventions between planned home and planned hospital births in Ontario, Canada.Methods:We used a provincial database of all midwifery-booked pregnancies between 2006 and 2009 to compare women who planned home birth at the onset of labour to a matched cohort of women with low-risk pregnancies who had planned hospital births attended by midwives. We conducted subgroup analyses by parity. Our primary outcome was stillbirth, neonatal death (< 28 d) or serious morbidity (Apgar score < 4 at 5 min or resuscitation with positive pressure ventilation and cardiac compressions).Results:We compared 11 493 planned home births and 11 493 planned hospital births. The risk of our primary outcome did not differ significantly by planned place of birth (relative risk [RR] 1.03, 95% confidence interval [CI] 0.68–1.55). These findings held true for both nulliparous (RR 1.04, 95% CI 0.62–1.73) and multiparous women (RR 1.00, 95% CI 0.49–2.05). All intrapartum interventions were lower among planned home births.Interpretation:Compared with planned hospital birth, planned home birth attended by midwives in a jurisdiction where home birth is well-integrated into the health care system was not associated with a difference in serious adverse neonatal outcomes but was associated with fewer intrapartum interventions.In Ontario, Canada, the College of Midwives of Ontario has regulated midwifery since 1994, and increasing numbers of women with low obstetrical risk and their newborns receive care in a publicly funded, midwifery-led continuity of care model.¹ Midwives have admission and discharge privileges at their local hospitals and are able to consult or transfer care to other health care providers if required. In Ontario, midwives attend a small proportion of all births in the province (10%), and about 20% of the births they attend take place at home.² A comprehensive record is maintained for every woman and infant in a midwife’s care. Until 2009, this record was submitted to the provincial Ministry of Health and Long-term Care (MOHLTC) through the Ontario Midwifery Program to access reimbursement for care provided.In the last century, Western culture has come to view hospital birth as safer than home birth.³ Recently, however, the value of hospital birth for all women with low-risk pregnancies has come into question; it has been suggested that in the absence of benefit, a planned hospital birth for this population may increase the use of intrapartum interventions, including cesarean delivery.^4–7 Even though recent studies comparing planned home and hospital births have had moderate sample sizes, they are individually limited in their ability to report definitively on rare outcomes such as death. Owing to a lack of evidence from randomized controlled trials (RCTs) to show that restricting a woman’s freedom to choose a place of birth prevents harm, the authors of a 2012 Cochrane review of planned hospital versus planned home births concluded that home birth services with collaborative medical backup should be established and offered to women with low-risk pregnancies in all jurisdictions.⁸ This conclusion, along with findings from the large English Birthplace Cohort Study,⁴ may be what prompted the National Institute for Health and Care Excellence (NICE) in England to update its intrapartum care guidelines to recommend that, for women at low risk of birth-associated complications, home birth should be considered a generally safe option.⁹ With the paucity of information derived from RCTs,⁸ observational studies are essential to continue to inform and monitor maternal and infant outcomes for women at low obstetrical risk who plan home or hospital birth, and to continue to provide pregnant women with quality information about choice of birthplace.The primary purpose of this retrospective cohort study was to determine the risk of stillbirth or neonatal death or serious neonatal morbidity among women at low obstetrical risk whose deliveries were attended by midwives and who had planned a home birth at the onset of labour, compared with women at low obstetrical risk who planned a hospital birth at the onset of labour. In addition, we also compared the incidence of maternal death and morbidity, birth interventions and breastfeeding between planned home births and planned hospital births.     

县乡村三级卫生人力资源的构成与分布特征研究

目的 通过分析县乡村三级人力资源配置的内部构成及各级机构间的分布差异情况,为农村卫生人力资源的纵向整合和三级医疗预防保健网的建设提供依据。 方法 用EXCEL2010分析各级医疗机构的人口学特征及内部构成比,用SPSS20.0进行卡方检验分析不同级别,不同地域类型的医疗机构卫生人员的构成与分布是否存在差异。结果 总体上男性医务人员多于女性医务人员,但由于村卫生室以乡村医生为主,所以医务人员的内部构成比例和性别分布情况与县乡两级机构不同。60岁及以上人员在县级医疗机构为2.69%,在村卫生室的比例达27.51%（P<0.05）。与2014年相比,2015年该市乡镇卫生院人员引进了15人,流失了27人,而县级医院引进了50人,流失了24人。结论 分级诊疗相关政策影响农村卫生人力资源的配置和床日负担水平,县乡村三级医疗机构医务人员的性别年龄分布均有差异,不同地域类型乡镇卫生院均需对高学历医务工作者给予针对性的激励措施。