The Alzheimer’s Dementia Patients’ Observed Illness Course and Experience in Ghana and Care Lessons to Be Learnt: A Mental Health Professional’s Perspective

Alzheimer’s disease (AD) and associated dementia patient numbers continue to increase globally with associated economic costs to healthcare systems. Of note is the increase in numbers in lower and middle-income countries (LMICs) including Sub-Saharan African (SSA) countries, which already face challenges with their health budgets from communicable and non-communicable diseases. Ghana, an SSA country, faces the problem of healthcare budgetary difficulties and the additional impact of AD as a consequence of increasing population strata of old aged persons (OAPs) due to the demographic transition effect. This article uses examples of known patients’ illness courses to give a perspective on the lived experience of patients with dementia (PWD) in Ghana, living amongst a populace with a culture of stigmatization of PWD, and a relatively fragile public mental health system (PMHS) for those with mental illness, including AD. The lived experience of AD patients is characterised by stigmatisation, discrimination, non-inclusiveness, diminished dignity and human rights abuses in the face of their mental disability, and eventually death. This article is an advocacy article giving voice to the voiceless and all persons suffering from AD and other dementias in Ghana, whilst pleading for a call to action from healthcare professionals and responsible state agencies.

基于AGREEⅡ和RIGHT对医患沟通指南的质量评价研究

目的对医患沟通的临床实践指南进行方法学和报告质量评价,以期确定高质量指南,提供临床参考。方法通过检索MEDLINE(PubMed)、Web of Science、中国知网(CNKI)、万方数据知识服务平台、维普(VIP),补充医脉通、用药助手、丁香园网站的相关临床实践指南(CPG),使用AGREEⅡ和RIGHT工具进行指南质量评价,采用组内相关系数(ICC)用于评估评审者对每个项目理解的一致性。结果共纳入2份临床实践指南,每个领域的评审人员的总体一致性是可以接受的。AGREEⅡ评价结果显示,2篇指南推荐级别均为B级,CPG所有7个领域的平均报告率为50.64%,其中领域1最高(88.89%),领域3最低(30.95%)。RIGHT评价结果显示,指南平均报告率为29.22%。结论医患沟通相关指南质量与数量仍有待提高,指南制订者应严格按照AGREEⅡ和RIGHT的要求规范撰写,以期提出高水平、高标准的循证指南,来指导医护人员的临床实践。

Prognostic value of the echocardiographic right/left ventricular end-diastolic diameter ratio in patients with idiopathic pulmonary arterial hypertension

Background Previous studies have shown that an echocardiographic right/left ventricular end-diastolic diameter ratio(RV/LV ratio)≥0.9 is an independent predictor of poor prognosis in patients with acute pulmonary embolism. The prognostic value of the RV/LV ratio in patients with idiopathic pulmonary arterial hypertension(IPAH) is still unknown. Methods We retrospectively enrolled 95 consecutive patients with newly diagnosed IPAH and 16 of them were reevaluated by echocardiography at 3-12 months following targeted therapy.Follow-up data were obtained by telephone interviews and review of the patients’ records.Results The RV/LV ratio was in parallel with the severity of World Health Orgnization(WHO) functional class and mean right atrial pressure.The RV/LV ratio was positively correlated with total pulmonary resistance(P P P 2 saturation(P P = 0.001),weight and absence of targeted therapy were independent predictors of death.No significant changes in the RV/LV ratio before and after targeted therapy were observed. A baseline RV/LV ratio≥0.84 or a further increase in the RV/LV ratio during targeted therapy indicated a poor prognosis. Conclusions The RV/LV ratio helps to assess the severity of IPAH and serves as an independent predictor of prognosis in patients with IPAH.

A Patient Bill of Rights for Psychotropic Prescription: A Call for a Higher Standard of Care

The pharmaceutical industry has made it very difficult to know what the clinical trial evidence actually is regarding psychotropics. Consequently, primary care physicians and other front-line practitioners are at a disadvantage when attempting to adhere to the ethical and scientific mandates of evidence based prescriptive practice. This article calls for a higher standard of prescriptive care derived from a risk/benefit analysis of clinical trial evidence. The authors assert that current prescribing practices are often empirically unsound and unduly influenced by pharmaceutical company interests, resulting in unnecessary risks to patients. In the spirit of evidenced based medicine’s inclusion of patient values as well as the movement toward health home and integrated care, we present a patient bill of rights for psychotropic prescription. We then offer guidelines to raise the bar of care equal to the available science for all prescribers of psychiatric medications.

我国远程医疗中患者知情同意权和隐私权保护研究

近年来我国的远程医疗服务发展迅速,由于服务涉及的参与方和环节多,专门立法薄弱,出现了患者的知情同意权与隐私权保护不足而被侵权的情况。在患者知情同意权方面的保护不足表现为医生未尽告知义务、地区差异削弱患者知情同意权、患者信息知情同意权的界定不明确。在患者隐私权方面的保护不足表现为远程医疗全过程被监控、医患身处场合存在隐私风险、患者难以自主掌控信息。我国有必要修订《远程医疗服务管理规范(试行)》,包括:增加远程医疗的法律依据、增加远程医疗的适用前提、增加患者知情同意权保护内容、增加患者隐私权保护内容。

大数据时代公权力执行与患者个人信息保护

自医疗产业进入了信息智能化发展阶段,若延续对隐私权的严苛保护理念,以私权执行机制为核心,并将其应用于患者个人信息的保护中,在功能与效果上显然欠佳。故建议正视患者个人信息的双重属性,重新确定患者个人信息保护的价值目标——风险防范与损害救济,形成以国家公权力为主导的公共监管与法律执行机制,并辅之以民事实体权益遭到损害时激活民事诉讼救济功能,由此形成防范各类患者个人信息处理风险、覆盖信息处理全过程、公法和私法协同合作的大数据时代患者个人信息保护机制。

麦芪苈汤联合穴位贴敷佐治老年慢性肺源性心脏病并右心衰竭临床研究

目的探讨麦芪苈汤联合穴位贴敷佐治老年慢性肺源性心脏病(简称肺心病)并右心衰竭的临床疗效。方法选取医院2021年1月至2022年7月收治的老年慢性肺心病并右心衰竭患者102例,按随机数字表法分为对照组和观察组,各51例。两组患者均予常规西医治疗+穴位贴敷,观察组患者加服麦芪苈汤。两组均以1周为1个疗程,治疗2个疗程。结果观察组患者的总有效率为94.12%,显著高于对照组的76.47%(P<0.05)。治疗后,两组患者的中医证候(咳嗽咳痰、胸闷气短、心悸乏力、口唇发绀)积分,血清炎性指标(肿瘤坏死因子-α、白细胞介素1β、白细胞介素6)水平及心肌损伤指标(氨基末端脑钠肽前体、心肌肌钙蛋白T、肌酸激酶同工酶MB)水平均显著降低,且观察组患者上述中医证候积分及心肌损伤指标水平均显著更低(P<0.05)。观察组与对照组不良反应发生率相当(7.84%比9.80%,P>0.05)。结论麦芪苈汤联合穴位贴敷佐治老年慢性肺心病并右心衰竭,可有效改善患者的中医证候,缓解心肌损伤。

A Qualitative Assessment of People-Centeredness of Inpatient Tuberculosis Treatment Services in Armenia

Background: People-centered tuberculosis (TB) care promotes treatment adherence and outcomes. TB patients’ and families’ health education and protection of their rights are among the core components of people-centered care. We aimed to assess the level of people-centeredness of TB care as a proxy to quality in the largest inpatient unit of the National Pulmonology Center (NPC) in Armenia. Methods: We conducted a qualitative study by interviewing clinical and administrative staff, TB patients, and family members to learn their experiences about patient and family education and rights (PFE&R) protection practices focusing on two Joint Commission International (JCI) Standards for Hospital Accreditation. Mixed-conventional inductive and directed deductive content approach guided the analysis of data. Results: The study revealed various gaps in the provided services. According to the TB physicians and nurses, they routinely educated patients and families and took actions to protect their rights. However, practices reported by TB providers varied across clinical departments and professionals and did not meet the recommendations of the JCI standards. The document review revealed that no written policies or procedures existed in the NPC inpatient unit to guide the implementation of PFE&R. Lastly, patients’ inconsistent experiences were also indicative of the lack of standardization and issues with PFE&R implementation. Conclusion: Bridging the gap between existing and recommended practices by establishing and enforcing new people-centered policies and procedures is a pledge for improving operations and patients’ experiences with a potential nationwide impact in Armenia.

Robotic vs laparoscopic right colectomy—the burden of age and comorbidity in perioperative outcomes: An observational study

BACKGROUND Several studies have shown the safety,feasibility and oncologic adequacy of robotic right hemicolectomy(RRH).Laparoscopic right hemicolectomy(LRH)is considered technically challenging.Robotic surgery has been introduced to overcome this technical limitation,but it is related to high costs.To maximize the benefits of such surgery,only selected patients are candidates for this technique.In addition,due to progressive aging of the population,an increasing number of minimally invasive procedures are performed on elderly patients with severe comorbidities,who are usually more prone to post-operative complications.AIM To investigate the outcomes of RRH vs LRH with regard to age and comorbidities.METHODS We retrospectively analyzed 123 minimally invasive procedures(68 LRHs vs 55 RRHs)for right colon cancer or endoscopically unresectable adenoma performed in our Center from January 2014 until September 2019.The surgical procedures were performed according to standardized techniques.The primary clinical outcome of the study was the length of hospital stay(LOS)measured in days.Secondary outcomes were time to first flatus(TFF)and time to first stool evacuation.The robotic technique was considered the exposure and the laparoscopic technique was considered the control.Routine demographic variables were obtained,including age at time of surgery and gender.Body mass index and American Society of Anesthesiologists physical status were registered.The age-adjusted Charlson Comorbidity Index(ACCI)was calculated;the tumornode-metastasis system,intra-operative variables and post-operative complications were recorded.Post-operative follow-up was 180 d.RESULTS LOS,TFF,and time to first stool were significantly shorter in the robotic group:Median 6[interquartile range(IQR)5-8]vs 7(IQR 6-10.5)d,P=0.028;median 2(IQR 1-3)vs 3(IQR 2-4)d,P<0.001;median 4(IQR 3-5)vs 5(IQR 4-6.5)d,P=0.005,respectively.Following multivariable analysis,the robotic technique was confirmed to be predictive of significantly shorter hospitalization and faster restoration of bowel function;in addition the dichotomous variables of age over75 years and ACCI more than 7 were significant predictors of hospital stay.No outcomes were significantly associated with Clavien-Dindo grading.Sub-group analysis demonstrated that patients aged over 75 years had a longer LOS(median6-IQR 5-8-vs 7-IQR 6-12-d,P=0.013)and later TFF(median 2-IQR 1-3-vs 3-IQR 2-4-d,P=0.008),while patients with ACCI more than 7 were only associated with a prolonged hospital stay(median 7-IQR 5-8-vs 7-IQR 6-14.5-d,P=0.036).CONCLUSION RRH is related to shorter LOS when compared with the laparoscopic approach,but older age and several comorbidities tend to reduce its benefits.

我国医疗损害司法鉴定标准重塑

医疗损害司法鉴定标准具有的技术性和复杂性,要求运用具体标准和抽象标准相结合的方式认定是否有医疗过失行为,同时需要考虑医疗的专门性、地域性、紧急性等因素。根据英美法“二分法”因果关系理论,从事实因果关系和法律因果关系两个方面判断医疗损害因果关系。根据医疗过失行为原因力规则认定因果关系损伤参与度及医方承担责任的比例。对于侵害患者知情同意权责任纠纷涉及的专业性问题,应当采取鉴定的方式作出判断。通过制定专门的行政法规合理设置医疗损害司法鉴定标准,确保鉴定人运用统一的鉴定规则作出能够反映真实情况的鉴定意见,为纠纷处理主体公正解决医疗损害案件提供证据,保护医患双方的权益,维护正常的医疗秩序,促进医患关系和谐发展。

非体外循环下冠状动脉旁路移植术对冠心病老年患者右心室功能的影响分析

目的探究非体外循环下冠状动脉旁路移植术(OPCAB)对冠心病老年患者右心室收缩及舒张功能的影响。方法以2021年4月—2022年4月在淄博市中心医院行OPCAB手术治疗的老年冠心病患者44例为研究对象进行回顾性分析。采用经胸超声心动图评估患者右心室功能,比较OPCAB术后7 d较术前右心室收缩及舒张功能参数的变化情况。结果与术前比较,OPCAB术后7 d冠心病患者三尖瓣环收缩期位移(TAPSE)、三尖瓣环收缩期速度(s′)、等容收缩时间(IVCT)、等容舒张时间(IVRT)、射血时间(ET)降低(P<0.05)。OPCAB术后7 d冠心病患者较术前三尖瓣E峰减速时间(DT)、三尖瓣环侧壁和间隔运动速度(e′)降低(P<0.05),舒张早期血流峰值速度(E)、舒张晚期血流峰值速度(A)及E/e′比值升高(P<0.05)。根据超声心动图左心室射血分数结果,12例(27.3%)患者出现左心室收缩功能障碍。按左心室收缩功能分层后,OPCAB术后7 d冠心病患者TAPSE值、s′值、DT值较术前降低(P<0.05),E/e′比值较术前升高(P<0.05)。结论OPCAB术后7 d冠心病老年患者较术前表现出纵向收缩功能降低,舒张功能恶化。此外,按左心室收缩功能分层后,OPCAB术后7 d右心室功能变化无显著差异。

生态系统理论下长期住院精神分裂症患者的生存困境及提升生存质量的路径探索

目的:探讨长期住院精神分裂症患者当前的康复环境和生活状况,探索其现状与需求,探索改善长期住院精神分裂症患者生存质量的路径。方法:对上海市某精神卫生中心的12名长期住院患者(住院时间>1年)进行半结构式访谈。结果:通过分析归纳,整合出5个主题:长期住院的患者对疾病具有更全面的认知;家属和患者对医院存在依赖;患者对人生的态度经历了渴望到绝望的转变;患者对履行民事权利存在事实性受限。结论:本研究提示对突破长期住院精神分裂症患者困境的路径:培养患者的自我管理能力,减轻病耻感,提升自信心,创造希望;完善患者的社会支持系统,拓展患者及家庭对疾病的应对方式;畅通政策渠道,保护患者的民事权利。

患者近亲属代为行使知情同意权的法定情形

患者近亲属代为行使知情同意权的法定情形是《民法典》第1291条第1款后段规定的患者无同意能力、保护性治疗两种。当患者不拥有理解、分析、决定能力时,不赋予其同意的资格,而由其利益维护者近亲属代为行使知情同意权;“不能向患者说明”就是指患者无同意能力。患者患有重大疾病等特殊情况下,医务人员对患者保密,患者无法知悉治疗的相关信息而不能行使知情同意权,此时也由近亲属代为行使;“不宜向患者说明”就是指保护性治疗。由于不存在法律漏洞、不具有相似性、与判决的其他理由相矛盾,有的法院创设的“类推适用保护性治疗”并不妥当,不应当是患者近亲属代为行使知情同意权的法定情形。不论是基于解释论的视角,还是基于立法论的视角,有的法院创设的“在医院一直护理”不应当是患者近亲属代为行使知情同意权的法定情形。

早泄诊治医患沟通临床实践指南的质量评价

目的甄选高质量早泄诊治医患沟通指南,促进医患之间更加有效和富有同理心的沟通,并为后续制定高质量指南提供参考。方法计算机检索中英文数据库,补充医脉通、用药助手、丁香园等网站的指南,使用临床实践指南研究与评价系统Ⅱ(appraisal of guidelines,research and evaluation,AGREEⅡ)和医疗保健实践指南的报告项目(reporting items for practice guidelines in heal thcare,RIGHT)检查表来评估符合条件的临床实践指南的方法和报告质量,计算评审者对组内相关系数(intra-class correlation coefficient,ICC)的总体一致性。结果共纳入3份指南,每个领域评审人员的总体一致性是可以接受的。AGREEⅡ评价结果显示,3篇指南推荐级别均为B级,3篇指南6个领域的平均报告率为44.07%,其中领域一最高(92.59%),领域六最低(16.67%)。RIGHT评价结果显示,指南平均报告率为24.08%。结论早泄诊治医患沟通指南质量有待提高,指南制订者应严格按照AGREEⅡ和RIGHT的要求规范撰写,重视对患者的情感关怀,以期提高临床早泄的诊治效率,并为后续制定高水平指南提供参考。

医患沟通办公室参与妇科重大疑难手术二次术前谈话的实践

妇科医疗纠纷发生率较高,沟通不充分是引起医疗纠纷的主要原因之一。术前谈话是医方向患方说明病情、医疗措施、医疗风险及替代方案等相关信息的手段,是患者实现知情同意、减少医患矛盾的重要途径。医患沟通办公室参与妇科重大疑难手术的二次术前谈话可发挥在纠纷处理经验、法律知识、沟通技能方面的优势,弥补妇科医生在术前谈话中的不足,保障患者的知情同意权,是规范医疗行为、预防医疗纠纷的创新性举措。

护士保护病人权利的道德行为量表的汉化及信效度检验

目的:汉化护士保护病人权利的道德行为量表(NEBPPR),检验其在中国临床护士中的信度和效度。方法:基于Brislin翻译模型对NEBPPR进行翻译,通过文化调适、预调查形成中文版NEBPPR。采用便利抽样法,于2023年3月—4月选取锦州市、沈阳市和葫芦岛市3所三级甲等医院的临床护士作为研究对象进行调查,检验量表信效度。结果:中文版NEBPPR由5个维度、共28个条目构成。中文版NEBPPR的条目水平内容效度指数(I-CVI)为0.852~1.000,平均量表水平的内容效度指数(S-CVI/Ave)为0.937;探索性因子分析共提取5个特征值>1的公因子,累积方差贡献率为63.701%;验证性因子分析结果显示,卡方自由度比(χ^(2)/ν)=1.699,均方根误差(RMR)=0.045,近似误差均方根(RMSEA)=0.058,比较拟合优度指数(CFI)=0.936,非规范拟合指数(TLI)=0.929,递增拟合指数(IFI)=0.937,模型拟合度良好;量表5个维度的平均提取方差值(AVE)均>0.45,组合信度(CR)均>0.7,在可接受标准范围;其Cronbach′s α系数为0.920,重测信度为0.792,折半信度为0.811。结论:中文版NEBPPR具有较好的信度、效度,可作为评估我国护士保护病人权利道德行为的有效工具。

Healthcare bioethics: a new proposal of ethics for clinical practice

The expression“patient revolution”is the social,educational,cultural,and political movement initiated at the end of the twentieth century and beginning of the twenty-first century,which sustains the protagonism of the patients in their care as the primary decision maker and holder of human rights.The patient revolution comprises varied approaches and references,such as Patient-Centered Care,Shared Decision-Making,Patient Participation,and Patients’Rights,which combine to uphold that the patient is a moral agent and anchor healthcare in the biopsychosocial model.In this sense,this movement is a new proposal of ethics for clinical practice.This theoretical research primary goal is to develop theoretical contributions that support this new Bioethics dimension,emphasizing the context in healthcare that calls for new ethics in clinical practice,characterized as a patient revolution movement.We concluded that the patient revolution had driven a new paradigm in healthcare based on Patient-Centricity,SDM,and Patients’Rights.Despite this critical change in the health sphere,the patient revolution appears to have reverberated in clinical bioethics.Thus,theoretical contributions must be developed for new ethics in the clinic,a task undertaken in this article through the proposal of Healthcare Bioethics as an adequate frame of reference to be adopted at all levels of clinical care.Thus,it is concluded that having Bioethics Healthcare as a beacon of ethics in clinical encounters can contribute to the quality of care and its ethical provision,confronting practices that violate Patients’Rights.It is imperative to change paternalistic theoretical frameworks that mitigate the Patients’Right to participate in every decision regarding their health.Only with the adoption of new approaches and an insight into the patient’s role in clinical interaction can a new culture in Patient-Centered healthcare take shape.