Mobile technology:Usage and perspective of patients and caregivers presenting to a tertiary care emergency department

BACKGROUND:Developments in information technology(IT)have driven a push in healthcare innovation in the emergency department(ED).Many of these applications rely on mobile technology(MT)such as smartphones but not everyone is comfortable with MT usage.Our study aims to characterize the technology usage behavior of users in the ED so as to guide the implementation of IT interventions in the ED.METHODS:A cross-sectional survey was conducted in the emergency department of a tertiary hospital.Patients and their caregivers aged 21 and above were recruited.The survey collected demographic information,technology usage patterns,and participant reported comfort level in the usage of MT.We performed descriptive statistics and multivariate logistic regression to identify factors differentially associated with comfort in usage of MT.RESULTS:A total of 498 participants were recruited,and 299(60%)were patients.English was the most commonly written and read language(66.9%)and 64.2%reported a comfort level of 3/5 or more in using MT.Factors that were associated with being comfortable in using MT include having a tertiary education,being able to read and write English,as well as being a frequent user of IT.Caregivers were more likely to display these characteristics.CONCLUSION:A large proportion of ED patients are not comfortable in the usage of MT.Factors that predicted comfort level in the usage of MT were common amongst caregivers.Future interventions should take this into consideration in the design of MT interventions.

patients with inflammatory bowel disease:Mechanisms and possible clinical impact

BACKGROUND High-dose intravenous iron is an effective treatment option for iron deficiency(ID)or ID anaemia(IDA)in inflammatory bowel disease(IBD).However,treatment with ferric carboxymaltose(FCM)has been associated with the development of hypophosphatemia.AIM To investigate mechanisms behind the development of hypophosphatemia after intravenous iron treatment,and disclose symptoms and clinical manifestations related to hypophosphatemia short-term.METHODS A prospective observational study of adult IBD patients with ID or IDA was conducted between February 1,2017 and July 1,2018 at two separate university hospitals in the southeast region of Norway.Patients received one dose of 1000 mg of either FCM or ferric derisomaltose(FDI)and were followed for an observation period of at least 7 wk.Blood and urine samples were collected for relevant analyses at baseline,week 2 and at week 6.Clinical symptoms were assessed at the same timepoints using a respiratory function test,a visual analogue scale,and a health-related quality of life questionnaire.RESULTS A total of 106 patients was available for analysis in this study.The FCM treatment group consisted of 52 patients and hypophosphatemia was present in 72.5%of the patients at week 2,and in 21.6%at week 6.In comparison,the FDI treatment group consisted of 54 patients and 11.3%of the patients had hypophosphatemia at week 2,and 3.7%at week 6.The difference in incidence was highly significant at both week 2 and 6(P<0.001 and P<0.013,respectively).We observed a significantly higher mean concentration of intact fibroblast growth factor 23(P<0.001),a significant rise in mean urine fractional excretion of phosphate(P=0.004),a significant decrease of 1,25-dihydroxyvitamin D(P<0.001)and of ionised calcium levels(P<0.012)in the FCM-treated patients compared with patients who received FDI.No clinical symptoms could with certainty be related to hypophosphatemia,since neither the respiratory function test,SF-36(36-item short form health survey)or the visual analogue scale scores resulted in significant differences between patients who developed hypophosphatemia or not.CONCLUSION Fibroblast growth factor 23 has a key role in FCM induced hypophosphatemia,probably by inducing loss of phosphate in the urine.Short-term clinical impact of hypophosphatemia was not demonstrated.

Clinical Predictors for Reduced Long-Term Survival and Cause of Death after Curative Resection for Rectal Cancer

Purpose: To identify clinical predictors for reduced long-term survival and describe the cause of death after surgical treatment for rectal cancer. Methods: A retrospective follow-up study of 442 consecutive, unselected patients treated for rectal cancer at a tertiary centre from 1990 until 2000 and followed for 17 years or until death. Predictors for death were assessed by Cox regression analysis. The cause of death was obtained from the Norwegian Cause of Death Registry. Results: 254 men and 188 women with a median age of 71 years (21 - 95 years) were resected for rectal cancer with low anterior resection (n = 266), abdominoperineal resection (n = 125), Hartmann’s procedure (n = 19) or diverting stoma only (n = 32). Median follow-up was 5 years (0 - 17 years). The relative five-year survival rates for stages I, II, III and IV was 83.9%, 65.2%, 41.1% and 9.3%, respectively. The proportion of deaths due to recurrence from colorectal cancer in stages I, II, III and IV was 23.5%, 55.8%, 72.3% and 98.0%, respectively. Heart, lung and cerebrovascular disease and other malignancies were the cause of death in the other patients. Higher age, abdominoperineal resection compared to low anterior resection, lack of lymph node dissection compared to total mesorectal excision (TME), postoperative reoperations, TNM stages II and III compared to stage I and residual tumours after surgery were all significant independent predictors of reduced survival in the adjusted Cox regression model. Conclusions: Age, tumour stage, type of surgery, lymph node dissection, residual tumour after surgery and reoperations are predictors for survival after surgery for rectal cancer. In the patients who died, the cause of death was due to a condition other than colorectal cancer recurrence in 32.3% of the patients. The five-year relative survival rate was related to tumour stage.

Cause of Death and Clinical Predictors of Survival after Curative Resection for Colon Cancer

Background: Clinical predictors of death and survival in surgical treatment of colon cancer are easily confounded by the modern adjuvant and neo-adjuvant chemotherapy. This study focuses on lethality and survival during implementation of ultra-radical surgery for colonic cancer prior to multimodal therapy. Methods: Retrospective observational follow-up study of 824 consecutive, unselected patients resected for Stage I, II, III and IV colon cancer from 1990 until 2000 at one tertiary centre, with a median follow-up of 45 months (0 - 202 months). Predictors for death were assessed by Cox regression analyses and log-rank test. The cause of death was obtained from the Norwegian Cause of Death Registry. Results: The relative survival rates were 86.3%, 71.9%, 50.3% and 6.6% in Stage I, II, III and IV, respectively. In 28.7% of the patients, the cause of death was other than colorectal cancer recurrence. The adjusted Cox regression model showed that higher age (1.04 (95% CI: 1.03;1.05)), male gender (1.37 (1.14;1.66)), emergency surgery (1.52 (1.21;1.93)), left vs. right hemicolectomy (1.39 (1.03;1.87)), and perioperative blood transfusion (1.25 (1.01;1.55)) were predictors of reduced survival. Health without known comorbidity (0.71 (0.58;0.88)), D2 versus D1 lymph node dissection (0.66 (0.53;0.83)) and tumour Stage I, II, III versus Stage IV 0.10 (0.06;0.16), 0.14 (0.11;0.19), 0.23 (0.18;0.30) were associated with prolonged survival. Conclusions: In 28.7% of the patients, the cause of death was other than colorectal cancer recurrence. Age, sex, comorbidity, emergency resection, lack of lymph node dissection, tumour stage, and preoperative blood transfusions are all significant predictors for reduced survival after surgery for colon cancer.

一项关于产后大小便失禁保守处理的随机对照6年随访试验

Objective: To determine the long term effects of a conservative nurse- led i ntervention for postnatal urinary incontinence. Design: Randomised controlled tr ial. Setting:Community based intervention in three centres in the United Kingdom and New Zealand. Participants:747 women with urinary incontinence at three mont hs after childbirth, of whom 516 were followed up again at six years (69% ). In tervention: Active conservative treatment (pelvic floor muscle training and blad der training) at five, seven, and nine months after delivery or standard care. M ain outcome measures: Urinary and faecal incontinence, performance of pelvic flo or muscle training. Results: Of 2632 women with urinary incontinence, 747 partic ipated in the original trial. The significant improvements relative to controls in urinary (60% v 69% ) and faecal (4% v 11% ) incontinence at one year we re not found at six year follow up (76% v 79% (95% confidence interval for difference in means - 10.2% to 4.1% ) for urinary incontinence, 12% v 13 % (- 6.4% to 5.1% ) for faecal incontinence)irrespective of subsequent obs tetric events. In the short term the intervention had motivated more women to pe rform pelvic floor muscle training (83% v 55% ) but this fell to 50% in bot h groups in the long term. Both urinary and faecal incontinence increased in pre valence in both groups during the study period. Conclusions: The moderate short term benefits of a brief nurse- led conservative treatment of postnatal urinary incontinence may not persist, even among women with no further deliveries. Abou t three quarters of women with urinary incontinence three months after childbirt h still have this six years later.

银屑病住院患者的年龄、性别、生活质量和心理压力

Background: Psoriasis has a great impact on the quality of life of patients, and the ageing population is an important public health issue. Objectives: To investigate whether older patients with psoriasis have a different impairment in quality of life compared with younger patients, considering level of severity, duration of disease, gender and psychological distress. Methods: The study was performed between February 2000 and February 2002 at the inpatient wards of the Dermatological Institute IDI-IRCCS, Rome, Italy, in the framework of a large project on clinical, epidemiological, emotional and quality of life aspects of psoriasis (IMPROVE study). This is a hospital-based cross-sectional study, with measures of quality of life (Skindex-29, Dermatology Life Quality Index and Psoriasis Disability Index) and of psychological distress, generic (12-item General Health Questionnaire) and psoriasis-related (Psoriasis Life Stress Inventory), all self-asses- sed by patients. We compared the mean scores of each quality of life instrument in patients aged < 65 years and ≥65 years, in subsets of patients based on clinical and sociodemographic characteristics. Results: We analysed 936 patients hospitalized at IDI-IRCCS with a diagnosis of psoriasis. Quality of life was significantly more impaired in the older group for all the Skindex-29 scales, and psychological distress was higher in older patients. In particular, older women suffering from anxiety or depression had the greatest impairment in quality of life. The results were somewhat different using the other quality of life instruments. Conclusions: These results should alert dermatologists that similar levels of clinical severity in psoriasis may be associated with different levels of quality of life and psychological distress of patients. Particular attention should be devoted to older patients, and especially to older women.

保守治疗产后大、小便失禁的随机对照试验:6年随访研究

Objective: To determine the long term effects of a conservative nurse- led intervention for postnatal urinary incontinence. Design: Randomised controlled trial. Setting: Community based intervention in three centres in the United Kingdom and New Zealand. Participants: 747 women with urinary incontinence at three months after childbirth, of whom 516 were followed up again at six years (69% ). Intervention: Active conservative treatment (pelvic floor muscle training and bladder training) at five, seven, and nine months after delivery or standard care. Main outcome measures: Urinary and faecal incontinence, performance of pelvic floor muscle training. Results: Of 2632 women with urinary incontinence, 747 participated in the original trial. The significant improvements relative to controls in urinary (60% v 69% ) and faecal (4% v 11% ) incontinence at one year were not found at six year follow up (76% v 79% (95% confidence interval for differencein means- 10.2% to 4.1% ) for urinary incontinence, 12% v 13% (- 6.4% to 5.1% ) for faecal incontinence) irrespective of subsequent obstetric events. In the short term the intervention had motivated more women to perform pelvic floor muscle training (83% v 55% ) but this fell to 50% in both groups in the long term. Both urinary and faecal incontinence increased in prevalence in both groups during the study period. Conclusions: The moderate short term benefits of a brief nurse- led conservative treatment of postnatal urinary incontinence may not persist, even among women with no further deliveries. About three quarters of women with urinary incontinence three months after childbirth still have this six years later.

Clinical Predictors for Recurrence after Curative Resection for Colorectal Cancer

Purpose: To identify clinical predictors of recurrence of colorectal cancer after curative surgical treatment. Methods: Retrospective follow-up-study of 925 consecutive patients treated with R0-resection for colorectal cancer Stage I, II and III from 1990 until 2000 with a mean follow-up of 60 ± 37 months. Predictors for cancer recurrence were identified in a pilot-sample of these patients, followed by analyses of the rest of the patients (test-sample), and finally with a concluding analyses of the entire patient group. Data were analyzed with Pearson Chi-square test (χ2), Cox regression analyses and log rank test. Results: Tumor stage (Stage I: HR 0.10 (0.05;0.19), Stage II: HR 0.31 (0.24;0.41)) and postoperative reoperations due to complications due to other causes than anastomotic leakage (HR 2.02 (1.21;3.36)) were significant predictors of cancer recurrence in the multivariate Cox regression model. The association between reoperations and recurrence was strongest for the patients with the best prognosis: Stage I and Stage II-cancers. Long duration of surgery, strongly associated with blood-loss and infusions of liquid and blood-products, reoperation due to anastomotic leakage as well as right colon/transversum localization were significant at a trend-level (10%). Conclusions: Tumor stage and reoperations due to postoperative complications other than anastomotic leakage are significant predictors for recurrence after curative surgery for colorectal cancer.

成年人有必要补充维生素D预防疾病吗？

美国预防医疗项目工作组（The US Preventive Services Task Force）建议健康的绝经后妇女补充维生素D和钙剂预防骨折。尽管有高质量的系统性综述说明此举无效，许多指南依然继续推荐补充维生素D（或者联合钙剂）预防跌倒或骨折。最近，英国公共卫生组织（Public Health England）推荐人均维生素D摄取量为每天10μg（400IU）以保护骨骼和肌肉健康。

获取患者反馈，改进全科医疗服务质量 各种方法混杂，且未经充分评估，患者感到失望，医生也未觉受益

要想确保服务能够满足目标人群的需求，最好的办法是获得体验反馈，并鼓励服务提供方采取措施解决其中发现的问题。多年来，这一直体现在健康政策中，但在初级医疗保健中贯彻得如何呢？

多维效用指数及其在亚洲的应用

个人对健康状态或治疗结果的偏好(preference)可以用经济学上的价值(value)和效用(utility)来描述。在每一个健康状态或结果的价值和,或效用确定后,我们就为整个系统(即目标人群可能出现的所有健康状态或经过某一医疗卫生项目和技术治疗后病人可能出现的所有结果)建立了一个指数系统。该指数系统可以用来比较不同目标人群的健康状态或者用来评估不同医疗卫生项目和技术。

教育程度对健康效用测量有影响吗——一项针对新加坡华人的研究

共有95名新加坡华人参加了面谈。总体来看,大多数受访者能够完全集中精神回答问题,也能够完全理解视觉尺度法和标准博弈法中的问题。大多数受访者认为视觉尺度法(66．3％)和标准博弈法容易或非常容易完成(70．5％),但是这些比例在高教育程度的受访者中均显著(或以接近显著水平)高于低教育程度的受访者。通过视觉尺度法和标准博弈法测得的4个健康状态(即MA、MB、MC、AW)的效用值,高教育程度的受访者要高于低教育程度的受访者,但二者没有统计学意义。总体来说,不同教育程度受访者的健康效用值是合理的,即随着健康状态变差(从MA、MB、MC到AW),效用值呈下降趋势。

Development of a heart rate variability and complexity model in predicting the need for life-saving interventions amongst trauma patients

Background:Triage trauma scores are utilised to determine patient disposition,interventions and prognostication in the care of trauma patients.Heart rate variability(HRV)and heart rate complexity(HRC)reflect the autonomic nervous system and are derived from electrocardiogram(ECG)analysis.In this study,we aimed to develop a model incorporating HRV and HRC,to predict the need for life-saving interventions(LSI)in trauma patients,within 24 h of emergency department presentation.Methods:We included adult trauma patients(≥18 years of age)presenting at the emergency department of Singapore General Hospital between October 2014 and October 2015.We excluded patients who had non-sinus rhythms and larger proportions of artefacts and/or ectopics in ECG analysis.We obtained patient demographics,laboratory results,vital signs and outcomes from electronic health records.We conducted univariate and multivariate analyses for predictive model building.Results:Two hundred and twenty-five patients met inclusion criteria,in which 49 patients required LSIs.The LSI group had a higher proportion of deaths(10,20.41%vs 1,0.57%,p<0.001).In the LSI group,the mean of detrended fluctuation analysis(DFA)-α1(1.24 vs 1.12,p=0.045)and the median of DFA-α2(1.09 vs 1.00,p=0.027)were significantly higher.Multivariate stepwise logistic regression analysis determined that a lower Glasgow Coma Scale,a higher DFA-α1 and higher DFA-α2 were independent predictors of requiring LSIs.The area under the curve(AUC)for our model(0.75,95%confidence interval,0.66–0.83)was higher than other scoring systems and selected vital signs.Conclusions:An HRV/HRC model outperforms other triage trauma scores and selected vital signs in predicting the need for LSIs but needs to be validated in larger patient populations.

肥胖基础知识(三) 治疗:第一部分——改变生活方式、饮食及活动

目前，英国有超过22％的成人患肥胖症，并伴多种相关健康问题，其体重指数（体重／身高^2，kg／m^2）t〉30。英格兰的国家糖尿病和冠心病保健机构对帮助肥胖患者控制体重十分重视。由于体重会随年龄的增加而持续增加，所以30％-40％的老年人到了五、六十岁就开始变胖，同时出现慢性病、行动不便以及抑郁加重。

制定临床指南:现行方法面临挑战

以前人们很少考虑如何将研究证据转变为治疗指南制定指南时达成共识的正规方法仍缺乏足够的透明度和可信性,并且过程过于繁琐、可持续性差我们提出了一个新方法,可以使目标。