The impact of a computerized care records service (CRS) on doctors’ work patterns in urological outpatient clinics

Objective: Government targets to reduce waiting times are putting enormous pressures on outpatient services. The implementation of an electronic care records service (CRS) at our hospital in 2008 has led to widespread press coverage of ensuing chaos in clinical administration. We wanted to know how this new electronic system impacted on our working patterns in outpatient clinics and – more specifically – on the time actually spent with the patients. Material & methods: This study was performed 4 and 12 months after implementation of CRS to assess its impact on the time distribution in clinic. Senior doctors were monitored with a stop clock during consultations. Timings for pre- and post-consultation administration, and the actual consultation with the patient were recorded. A total of 170 consultations were evaluated in this way. Results: The key findings were that the total time needed to spend on a urological outpatient of 16 minutes remains unchanged from the pre-CRS era, but a majority (57%) of this time is spent in administration on the computer without the patient involved. Conclusion: No more than 15 patients should be seen in a 4 hour outpatient clinic per doctor. This recommendation drawn up by BAUS before CRS remains still valid. Patient administration related to the consultation that has previously been done by administrative aides is now to be done by the doctors on the computer in the same consultation session. Intended to streamline patient pathways, this does reduce the quality interaction-time between doctor and patients significantly.

Trends in outpatient breast cancer surgery among Medicare fee-for-service patients in the United States from 1993 to 2002

The practice of outpatient breast cancer surgery has been controversial in the United States. This study aimed to update time trends and geographic variation in outpatient breast cancer surgery among elderly Medicare fee-for-service women in the United States. Using the 1993-2002 linked Surveillance, Epidemiology and End Results (SEER)-Medicare claims data and the Area Resource Files, we identified 2 study samples, including the women whose breast cancers were the first-ever-diagnosed cancer at age 65 years or older from 9 regions continuously covered by the SEER registries since 1993. The first sample included the women receiving unilateral mastectomy for stage 0-IV cancer; the second included the women receiving the breast-conserving surgery with lymph node dissection (BCS/LND) for stage 0-II cancer. The proportions of patients receiving outpatient surgery increased from 3.2% to 19.4% for mastectomy and from 48.9% to 77.8% for BCS/LND from 1993 to 2002. We observed substantial geographic variation in the average proportion of the patients receiving outpatient surgery in the studied areas across the 10-year period, ranging from 3.9% in Connecticut to 27.2% in Utah for mastectomy and from 54.7% in Hawaii to 78.1% in Seattle, Washington, for BCS/LND. As the popularity of outpatient breast cancer surgery continues to grow, more evidence-based analyses related to quality and outcomes of outpatient breast cancer surgery among various populations are needed in order to facilitate the public debates about state and federal mandated health benefit legislations.

Outpatient telephonic transitional care after hospital discharge improves survival in cirrhotic patients

BACKGROUND Intervention to improve outcomes in cirrhotic patients (CP) after hospital discharge often focus on 30 d readmission rate (RR). However, recent studies suggest dissociation between RR and survival. At our center, CP are now offered outpatient telephonic transitional care (OTTC) by a care coordinator for 30 d after hospital discharge. AIM To determine the effect of OTTC on survival in CP. METHODS In this cohort study from a tertiary center, CP who received OTTC formed the intervention group. They were compared with a control group discharged during the same period. Mortality and RR were compared between the groups. RESULTS After OTTC introduction, 194 CP were discharged. After applying exclusion criteria, 169 CP (51% male, mean age 58 years ± 12 years) were included. OTTC group comprised 76 patients and was compared with 93 controls. Baseline disease and index admission related characteristics were not significantly different between the groups. The intervention group showed significantly higher 6 mo survival compared to controls (84.2% vs 68.8%;P = 0.03), while RR at 1, 3, and 6 mo were comparable. On multivariable analysis, the intervention group showed lower odds for mortality compared to the controls (hazard ratio: 0.4;95% confidence interval: 0.2-0.82;P = 0.012), while higher model for endstage liver disease scores were associated with higher mortality (hazard ratio: 1.05;95% confidence interval: 1.01-1.1;P = 0.024).CONCLUSION CP provided OTTC had higher 6 mo survival compared to controls without a difference in RR. Use of RR to gauge quality of care provided during hospitalization or subsequent transitional care programs should be revisited.

Impact of Pharmaceutical Care on Self-Administration of Outpatient Low-Molecular-Weight Heparin Therapy

Outpatient subcutaneous (s.c.) therapies are becoming more and more common in the treatment of different diseases. The effectiveness of community-pharmacy-based interventions in preventing problems that arise during s.c. self-injections of low-molecular-weight heparins (LMWH) is unknown. Our objective was to provide a standard operating procedure (SOP) for community pharmacists and to compare pharmaceutical vs. standard care in both clinical and daily life settings. We hypothesized that: pharmaceutical care results in improved adherence, safety, and satisfaction, and in fewer complications;the interventions used are feasible in daily life;and the results achieved in clinical and daily life settings are comparable. In the clinical setting (randomized controlled trial), patients were recruited sequentially in hospital wards;in the daily life setting (quasi-experimental design with a comparison group), recruitment took place in community pharmacies by pharmacists and trained master students during their internship. Interventions were offered according to patient needs. Data were collected by means of a monitored self-injection at home and structured questionnaire-based telephone interviews at the beginning and the end of the LMWH treatment. The main outcome measures were: scores to assess patient’s skills;syringe count to assess adherence;and frequency, effectiveness, and patient’s assessment of received interventions. The results show a median age of the 139 patients of 54 years. Interventions resulted in improved application quality (p p = 0.03). Oral instructions were pivotal for improving patients’ application quality. We found no significant score differences between the intervention groups in the clinical and daily life settings. Patients’ baseline skills were high, with the lowest score being 0.86 (score range ?2.00 to +2.00). Adherence rate was high (95.8%). In conclusion, our SOP for pharmacist interventions was of good quality, adequate, appreciated, and feasible in daily life. Patients are capable of managing s.c. injection therapies if adequate assistance is provided.

Outpatient Experience of Human Caring Scale （OEHC-Scale）： Improvement by Delphi Method

Based on the outpatient interview and literature review, the initial framework of the outpatient experience of human caring scale was formed with 9 dimensions of outpatient process. The research aim was to improve the scale by Delphi method. Sixteen experts in medical management, human caring or medical education were invited to evaluate the importance of the dimensions and items of the scale and provided some expertise via filling out the DeLphi consultation questionnaires twice in the consulting round. In the first round, the recovery rate showing the experts＇ positivity was 80%; the coefficient of reliability （Cr） ascertaining the authority of the evaluation was 0.92; the mean and full mark ratios responding the concentration of the evaluation were 2.88-4.94 and 6.25%-93.75% respectively; the coefficients of variation （CV） and the Kendall＇s W determining the concordance of the evaluation were 5.06%-52.15% and 0.21-0.24 respectively. In the second round, the recovery rate was 93.75%; the Cr was 0.93; the mean was 3.93-4.93; the full mark ratios were 26.67%-93.33%; the Kendall＇s W was 0.14- 0.31, the CV was 5.25%-23.61%. Via the two-round Delphi study, the scale that included 10 dimensions and 61 items has been improved. Ten dimensions are pre-hospital medical service, guidance, registration, waiting, diagnosis ＆ treatment, paying, inspection ＆ assay, medicine receiving, therapy/injection/transfusion and global evaluation. It was concluded that Chinese scholars have paid high attention to human caring and outpatient experience. The experts have given high agreements about the dimensions which were established with Chinese outpatient process. The dimensions are different from the similar researches about outpatient experience study. In the future, it is necessary to survey the outpatients to test the construct validity, internal consistency reliability and others of the scale to improve the scale.

The patients’ opinion on the use of information technologies at the Seskine Outpatient Clinic and “Centro poliklinika” Outpatient Clinic of the city of Vilnius according to the age of patients

Objectives: The objective of this study is to assess patients’ opinion of the information technologies (IT) electronic registration systems at the “Centro poliklinika” and Seskine outpatient clinics in Vilnius City. Material and Methods: The survey was conducted in May-June, 2012. In the course of the primary survey, one questionnaire was handed out to one in tenth of the newly arrived patients. Total number of 650 questionnaires was distributed. 563 respondents participated in the survey (feedback rate—86.6%). Statistical analysis of data was performed by means of personal computer using SPSS software package. Results: 54.7% of respondents state that they make use of the possibility of online registration with the family doctor. 85.05% of respondents indicate that a doctor, when making the next appointment or referring to the medical specialist, registers a patient on site by means of computer. Upon arrival of a respondent to the reception desk of the medical establishment, 90.3% of respondents are registered by means of computer. 72.4% of respondents say that they have a choice to telephone and inquire about the time of visit if they have forgotten the visit time or lost the appointment sheet. Majority of respondents using the online registration option belong to the age group between 21 and 40 years—35.3%. Conclusions: Answers by the respondents and the breakdown between “Centro poliklinika” and Seskine outpatient clinics are very similar and no essential differences have been determined.

Study on the Effect of High-quality Nursing Combined with Breathing Exercises on Patients with Chronic Obstructive Pulmonary Disease

Objective:To study the effect of high-quality nursing combined with breathing exercises on patients with COPD.Methods:Using the random number table method of medical experiments,60 patients with COPD received in our hospital from March 2020 to March 2021 were used as research samples.According to the differences in treatment measures,they were equally divided into control group and intervention group.Symptomatic support treatment and nursing routine,high-quality nursing combined with respiratory function exercise treatment and nursing were given respectively,and the application effects of the two groups were compared and analyzed.Results:The controllable rate of disease between the intervention group and the control group was 93.33%(28/30)and 66.67%(20/30)respectively,which was statistically significant(P<0.05).The comparison between the intervention group and the control group on the pulmonary function indexes of VT,TPTEF/Te,VEF/Te/,Ti/Te was statistically significant(P<0.05).The results of the intervention group on exercise pulse and 6-minute walking distance were significantly higher than those of the control group(P<0.05).Conclusions:The combination of high-quality nursing care and breathing exercises has outstanding disease controllable rate in patients with COPD,especially in improving the lung function of the patients and the level of treatment and care.It can be used as a feasible measure in the subsequent clinical treatment and nursing practice of patients.It is worthy of clinical promotion and implementation.

Effect of High-Quality Nursing on Patients with Hemorrhagic Fever with Renal Syndrome

Objective:To explore and analyze the effect of high-quality nursing on patients with epidemic hemorrhagic fever with renal syndrome.Methods:Ninety patients with epidemic hemorrhagic fever with renal syndrome treated in Huyi District People’s Hospital from October 2021 to January 2022 were randomly divided into an experimental group and a control group,with 45 cases in each group.The control group received routine nursing and the experimental group received high-quality nursing.The effect of routine nursing and high-quality nursing were compared and analyzed based on the Self-Rating Anxiety Scale(SAS),Self-Rating Depression Scale(SDS),the degree of satisfaction with nursing care,and the patients’quality of life.Results:Before nursing,there was no significant difference in the patients’psychological state between the two groups(P>0.05);after nursing,there was significant difference in the patients’psychological state between the two groups(P<0.05);the degree of satisfaction with nursing care of the experimental group was significantly higher than that of the control group(P<0.05);comparing the quality of life of the two groups,the quality-of-life score of the control group was significantly lower than that of the experimental group(P<0.05).Conclusion:For patients with epidemic hemorrhagic fever with renal syndrome,high-quality nursing can significantly and effectively improve their psychological state,level of satisfaction with nursing care,and quality of life.

Heart Failure: Organization of Care after Hospitalization at the Abidjan Cardiology Institute

Introduction: The care pathway for heart failure (HF) patients is poorly documented in sub-Saharan Africa. A multidisciplinary management reduces hospitalizations and mortality. In our context of frequent rehospitalization of heart failure patients, the objective of this study was to analyse the post-hospital follow-up health care. Methods: We conducted a prospective study in the medical department of a Heart Institute from January 1st to December 31, 2015. Patients over 18 years of age, hospitalized for heart failure, consenting and followed up on an outpatient basis for 2 years were included. Results: We collected 396 patients hospitalized for HF. The mean age was 57.4 ± 16 years with a male predominance (59.3%). Retired and unemployed people represented 27% and 16.2% respectively. During the post-hospitalization follow-up, patients who were regularly followed up represented 10.8% of the cases. 74.1% of the cases were regular patients. Patients were not followed up by the usual practitioner (58.2%). Only 94 patients had undergone a cardiovascular rehabilitation programme, of which 21.3% for exercise rehabilitation and 78.7% for therapeutic education. Patients who had attended titration sessions (n = 59) had reached optimal doses of ACE inhibitors, ARB II and beta blockers in 67.8%, 7.3% and 38.5% respectively. The rates of decompensation (73.3%) and rehospitalization (49.5%) were higher. The paraclinic check-up (ECG, X-ray, Cardiac Doppler ultrasonography, Biology) was rarely requested. The probability of survival was higher in patients regularly monitored than in those irregularly monitored. Conclusion: The organisation of care and coordination between professionals should be structured or planned. Therapeutic strategies need to be intensified in order to optimise their long-term benefits.

基于专家咨询法的公立医院门诊药学服务评价体系构建研究

目的:构建门诊药学服务的三级评价指标体系,并确定各级指标的权重。方法:通过文献回顾、运用结构-过程-结果(SPO)模型、德尔菲专家咨询法,研究公立医院门诊药学服务评价指标。结果:最终入选的15名咨询对象均为各自领域的专家,两轮专家咨询结果趋于一致,咨询专家意见集中,结果可信度高,专家积极程度达93.33%(14名专家提出各自的修改意见),权威系数为0.880,指标重要性赋值均数均>3.5分,而变异系数则<0.25。结论:经过两轮专家咨询,建立了公立医院门诊药学服务三级评价指标体系,其中,一级指标3个,二级指标10个,三级指标39个,并赋予各指标权重。

Effects of high-quality neurosurgical nursing care on improving clinical nursing quality

BACKGROUND With continuous advancements in medical technology,neurosurgical nursing is constantly developing and improving to provide higher-quality nursing services.AIM To explore the effects of different types of high-quality nursing care on clinical nursing quality and patient satisfaction in neurosurgical nursing.METHODS Eighty patients who received neurosurgical treatment in the Affiliated Hospital of Southwest Medical University from June to December 2020 were selected as study participants and categorised into study and control groups.The study group comprised 40 patients who received 4 different types of high-quality nursing care,whereas the control group comprised 40 patients who received conventional nursing care.After a specific period,nursing satisfaction levels and adverse event and complication rates were compared between the two groups.RESULTS Satisfaction with high-quality care was higher than that with conventional care,and high-quality health services and regional services showed the highest satisfaction levels,with an average score of 12 on the Glasgow scale.The satisfaction levels of the study and control groups were 75%and 57%,respectively,with a statistically significant difference(t=7.314,P<0.05).During the nursing period,the adverse event and complication rates were the highest in patients with level III pathology grade and those who underwent neurosurgery(40.02%and 85.93%,respectively),and the difference was statistically significant.CONCLUSION In neurosurgical nursing,employing appropriate high-quality nursing methods can effectively reduce adverse event and complication rates in patients,thereby improving the quality of nursing care and increasing clinical nursing value.

三级综合医院门诊护士人文关怀现状、影响因素及其与情绪智力、职业认同的相关性

目的 探讨综合医院门诊护士人文关怀现状,并分析其影响因素。方法 采用方便抽样的方法,选取2021年2—3月某三所三级综合医院门诊护士226例为研究对象。应用一般资料调查表、护士人文关怀量表、情绪智力量表及护士职业认同量表对其进行调查并分析其影响因素。结果 226例综合医院门诊护士人文关怀得分(113.23±15.14)分,情绪智力得分(117.97±11.79)分,职业认同得分(106.49±21.65)分;综合医院门诊护士人文关怀总分及各维度评分均与情绪智力、职业认同总分及各维度评分呈正相关(P<0.01);情绪智力、职业认同及职称是人文关怀的主要影响因素(P<0.01),共解释总变异的40.3%。结论 综合医院门诊护士人文关怀现状总体处于中等水平,而情绪智力、职业认同及职称是影响综合医院门诊护士人文关怀水平的主要因素。护理管理者应关注门诊护士人文关怀水平,制定针对性培训计划,以提高门诊护士群体的人文关怀水平。

门诊患者膝关节腔注射治疗中应用专科护理小组多学科合作模式的效果分析

目的:分析在门诊患者膝关节腔注射治疗中应用专科护理小组多学科合作模式的效果。方法:选取2020年6月—2021年3月于苏北人民医院门诊注射室行膝关节腔注射治疗的260例患者作为研究对象,将2020年6—10月的130例患者设为对照组,2020年11月—2021年3月的130例患者设为观察组。对照组实施常规护理,观察组建立专科护理小组并实施多学科合作模式。比较两组护理效果。结果:观察组穿刺失败、穿刺部位感染、疼痛加剧、残肢血运障碍及并发症总发生率高于对照组,差异有统计学意义(P<0.05)。观察组满意率高于对照组,差异有统计学意义(P=0.043)。结论:门诊患者膝关节腔注射治疗中建立专科护理小组的效果显著,能够降低并发症发生率,提高患者满意度,值得临床应用并予以推广。

三级公立医院绩效考核背景下门诊医疗服务质量提升的实践效果研究

目的通过对内蒙古医科大学第二附属医院三级公立医院绩效考核实施前后门诊医疗服务质量进行对比,分析三级公立医院绩效考核对医院门诊医疗服务质量的影响,并提出改进措施。方法筛选三级公立医院绩效考核实施后2022年1月1日至12月31日及三级公立医院绩效考核实施前2018年1月1日至12月31日的门诊医疗服务质量的门诊运营、门诊预约管理、患者等候时间、门诊医疗安全和患者评价指标,分析三级公立医院绩效考核实施前后门诊医疗服务质量的差异。结果三级公立医院绩效考核实施后门诊总量同比增加11.8%,专家门诊量同比增加63.7%,普通门诊量同比下降45.7%,差异有统计学意义(P<0.05);线上预约挂号数同比增加46.4%,分时段就诊数同比增加41.0%,按时就诊数同比增加43.0%,退号数同比下降95.3%,差异有统计学意义(P<0.05);患者等候时间也都有所降低,差异有统计学意义(P<0.05);门诊医疗安全比较,差异无统计学意义(P>0.05),但是门诊医疗安全管理在逐步完善;门诊患者满意度也有显著提高。结论三级公立医院绩效考核是将各项服务质量进行量化管理,对提升医院门诊服务质量有显著效果。

基于行为诱导法的个性化心理护理结合家属赋权干预对学龄期毛细支气管炎门诊雾化吸入治疗患儿医疗恐惧及配合度的影响

目的探讨基于行为诱导法的个性化心理护理结合家属赋权干预在学龄期毛细支气管炎门诊雾化吸入治疗患儿中的应用效果。方法选取2020年9月至2022年3月我院收治的90例学龄期毛细支气管炎门诊雾化吸入治疗患儿为研究对象,以随机数字表法将其分为对照组和观察组,各45例。对照组采用常规护理,观察组采用基于行为诱导法的个性化心理护理结合家属赋权干预。比较两组的干预效果。结果干预后,观察组的医疗恐惧调查量表(CMFS)各维度评分均低于对照组(P<0.05)。观察组的配合度优良率高于对照组(P<0.05)。干预后,观察组的呼吸频率(RR)、功能残气量(FRC)低于对照组,潮气量(TV)高于对照组(P<0.05)。结论基于行为诱导法的个性化心理护理结合家属赋权干预可减轻学龄期毛细支气管炎门诊雾化吸入治疗患儿的医疗恐惧感,提高其配合度,也能促进患儿肺功能改善,值得临床推广应用。

咳嗽变异性哮喘患儿实施门诊系统化药学服务的效果观察

目的:观察咳嗽变异性哮喘患儿实施门诊系统化药学服务的效果。方法:选取2023年1—11月贵阳市妇幼保健院收治的咳嗽变异性哮喘患儿98例为研究对象,随机分为对照组与观察组,各49例。对照组实施常规门诊用药干预,观察组实施门诊系统化药学服务干预。比较两组肺功能及不良反应发生情况。结果:干预前,两组第1秒用力呼气容积(FEV_(1))、用力肺活量(FVC)、最大呼气流量(PEF)水平比较,差异无统计学意义(P>0.05);干预后,两组FEV_(1)、FVC、PEF水平升高,观察组高于对照组,差异有统计学意义(P<0.05)。观察组药物不良反应总发生率低于对照组,差异有统计学意义(P=0.039)。结论:咳嗽变异性哮喘患儿接受门诊系统化药学服务可改善患儿肺功能,降低不良反应发生率。

某三级甲等医院2020年至2022年西药门诊药房基本药物使用情况分析

目的分析2020年至2022年某三级甲等医院西药门诊药房基本药物的使用现状。方法通过医院信息系统和处方点评系统调取2020年至2022年西药门诊药房基本药物使用数据,并进行统计与分析。结果3年间,医院西药门诊药房在用基本药物品种数分别为354种、365种、362种,基本药物品种占比逐年上升(39.64%,41.15%,41.37%),基本药物配备率分别为51.68%,53.28%,52.85%;其中化学药品和生物制品类基本药物的配备率分别为70.74%,72.66%,71.94%,远高于中成药类的22.01%,23.13%,23.13%。3年间,基本药物使用金额占比呈下降趋势(分别为39.06%,36.74%,34.96%)。3年间,基本药物使用率保持稳定(均约为67%);处方量排名第一的化学药品和生物制品类基本药物均为阿司匹林肠溶片,中成药均为百令胶囊。随机抽取的门诊处方中未发现无正当理由不首选国家基本药物的处方。结论该院西药门诊药房基本药物(除中药饮片外)的整体配备率尚未达标,应继续调整药品目录结构,尤其要增加中成药类基本药物的品种数,进一步提高基本药物占比。

门诊经验沟通与GLTC沟通对门诊医生情绪状态及沟通细节影响的比较研究

背景门诊医生是医院诊疗活动主要提供者,门诊医生的积极情绪及有效的医患沟通方式是优质医疗服务的保证。目的比较门诊医生经验性沟通与GLTC沟通的医生情绪状态和沟通细节完成情况,为今后提高医生沟通技巧、改善医生情绪状态提供参考。方法于2021年7月—2022年1月,在江苏省南京市随机抽取4家三级综合医院中6个科室的24名门诊医生为研究对象,并选取符合患者纳入标准的门诊医患沟通场景作为沟通细节完成情况的观察场景。对所有纳入的同一批次门诊医生先开展个人经验式沟通方案(记为经验沟通组),然后开展门诊GLTC医患沟通方案培训,一周后开展门诊GLTC沟通方案(记为GLTC组),比较经验沟通组、GLTC组沟通前后简明心境量表(BPOMS)各维度的得分情况及沟通细节要点完成率情况。结果经验沟通组医生沟通后BPOMS的疲劳维度得分高于沟通前(P<0.05);沟通后GLTC组医生BPOMS的疲劳、困惑维度得分低于经验沟通组(P<0.05);GLTC组的和蔼注视(接待)、礼貌语言(接待)、微笑(接待)、不轻易打断患者、适时点头回应、安抚、告知必要性、耐心(实验检查)、征询患者意见、耐心(诊疗与交流)、通俗讲解、语言安慰、态度友善、起身(结束与交代)、和蔼注视(结束与交代)、礼貌语言(结束与交代)、微笑(结束与交代)等沟通细节要点的完成率高于经验沟通组(P<0.05)。结论和门诊经验性沟通相比,门诊GLTC沟通更能改善医生情绪状态,缓解医生疲劳,同时相应沟通细节完成率提高,部分沟通细节完成率仍有提升空间。

门诊高危妊娠孕妇的产前护理管理效果

目的针对门诊高危妊娠孕妇实施产前护理管理,探讨其临床应用效果。方法研究时间为2021年1月至2022年12月,研究对象为我院门诊收治的高危妊娠孕妇100例,按照护理方法不同分为观察组50例与对照组50例,分别实施产前护理管理(包括宫内转诊风险评估管理、门诊健康教育、产前心理弹性支持、延续护理)与常规护理。比较两组孕妇对保健知识的掌握情况、高危妊娠评分情况、妊娠结局以及产后抑郁情况[采用爱丁堡产后抑郁量表(EPDS)评估]。结果观察组孕妇对保健知识的掌握情况优于对照组,心理弹性总分高于对照组,差异有统计学意义(P<0.05);观察组产妇的中转剖宫产率、产后2 h出血量、首次泌乳时间及新生儿窒息率均低于对照组,产后24 h泌乳量评分、新生儿1周存活率均高于对照组(P<0.05)。干预后,两组高危妊娠评分、EPDS评分均低于干预前,且观察组2个指标评分均低于对照组,差异有统计学意义(P<0.05)。结论对门诊高危妊娠孕妇实施产前护理管理,可明显提高孕妇对保健知识的掌握度和心理弹性,降低母婴不良的妊娠结局,改善产妇的抑郁状态。