Physician-Rated Utility of Procedure Videos for Teaching Procedures in the Emergency Department, Overall and during Emergency Department Crowding

Background: Real-time use of procedure videos as educational tools has not been studied. We sought to determine whether viewing a video of a medical procedure prior to procedure performance in the emergency department improves the quality of teaching of procedures, and whether videos are particularly beneficial during periods of emergency department crowding. Methods: In this single-centre, prospective, before and after study standardized data collection forms were completed by both trainees and supervising emergency physicians (EPs) at the end of each emergency department shift in the before (August 2008-March 2009) and after (August 2009-March 2010) phase. Online procedure videos were introduced on emergency department computers in the after phase. The primary outcome measure was EP rating of the quality of teaching provided (5-point Likert scale). The interaction between crowding and videos was also assessed, to determine whether videos provide a specific additional benefit during periods of emergency department crowding. Results: There were 1159 procedures performed by 192 trainees. Median procedures performed per shift was 1.0 (IQR 0 - 2.0). Mean EP rating of teaching provided was significantly higher in the group that viewed videos, at 4.2 versus 3.7 (p 0.001). In the adjusted analysis, EP ratings increased by 0.5 with a video (p 0.001), while the odds of a score of 5.0 were 2.2 times greater if a video was viewed (p = 0.03). The interaction of crowding and procedure videos was not significant (the use of videos increased the average score by 0.24 in times of crowding compared to times of non-crowding, p = 0.19). Conclusions: Use of procedural videos was associated with EP perception of improved quality of teaching provided around procedures. While EPs rated the quality of their teaching as improved overall, the effect of videos on teaching quality was the same in crowded settings as it was in non-crowded setting.

亲缘关系与布氏田鼠双亲行为和杀婴行为关系的初探

根据幼仔发育的 5个阶段 :新生 (1～ 5日龄 )、耳立 (6～ 9日龄 )、睁眼 (10～14日龄 )、出巢 (15～ 2 0日龄 )和断奶 (2 1～2 4日龄 ) ,通过观察布氏田鼠对自己幼仔 (r=0 5 0 )和非亲缘幼仔 (r <0 12 5 )的行为反应 ,研究亲缘关系对布氏田鼠双亲和杀婴行为的影响。结果表明 :1)新生阶段 ,雄鼠抚育亲仔的时间显著多于非亲缘幼仔 ;断奶阶段 ,雄鼠与亲仔相触及在巢内活动的时间也显著多于非亲缘幼仔 ;雄鼠在耳立、出巢和断奶阶段嗅闻非亲缘幼仔 ,以及在新生和睁眼阶段修饰非亲缘幼仔的时间都显著多于亲仔。 2 )断奶阶段 ,雌鼠与亲仔相触的时间显著多于非亲缘幼仔 ,但在睁眼阶段修饰非亲缘幼仔 ,以及在新生、耳立和出巢阶段嗅闻非亲缘幼仔的时间显著多于亲仔。 3)雌雄鼠在15日龄前没有杀婴行为 ,15日龄后 ,开始对非亲缘幼仔发生杀婴行为 ;雌鼠杀婴行为受幼仔发育的显著影响 ,且杀婴频次显著高于雄鼠 ;雌鼠在断奶阶段对非亲缘幼仔的杀婴频次显著高于亲仔。综上所述 ,亲缘关系对布氏田鼠的双亲和杀婴行为有显著影响 ,这可能与个体间的已往经历 (熟悉性等 )或表现性匹配等辨别机制有关。

提高实效性临床试验报告的质量——《CONSORT声明》的扩展

近年来实效性临床试验受到更多重视,尤其在传统医学临床评价研究领域。为了提高实效性临床试验报告的质量,CONSORT声明组和医疗保健体系中的实效性随机对照临床试验(pragmatic randomized controlled trials in health care systems,PRACTIHC)小组对《CONSORT声明》进行了修改,以帮助读者评估试验质量和结果的可靠性。实效性试验报告指南,作为《CONSORT声明》的一个特殊扩展,能在报告、评价和应用实效性试验方面帮助编辑、系统评价者、试验设计者和决策者评估实效性试验报告中的信息,判定其结论是否适用,以及干预措施是否可行、可否被接受。2005年1月和2008年3月,在加拿大多伦多分别举行了为期两天的会议来探讨提高随机对照试验对卫生保健决策贡献的方法,焦点集中于实效性试验。2005年会,后扩展版草案修订清单发送至编写组成员,经过几次修订,编写组起草了一份摘要草案。在2008年讨论并修改了这一草案。这份草案发给CONSORT声明组以供修改并发表。这份声明的扩展版提出了对8个条目的补充。及时向国内读者和临床试验研究人员介绍该指南有重要的现实意义和学术价值。北京中医药大学循证医学中心刘建平教授等在短时间内翻译了该指南。本刊希望通过介绍中文版"提高实效性临床试验报告的质量——《CONSORT声明》的扩展"以提高国内实效性临床试验报告的质量,相信也有助于改进试验设计的方法学质量。

Antecedents and sex/gender differences in youth suicidal behavior

Suicide is the second leading cause of death in youth globally; however, there is uncertainty about how best to intervene. Suicide rates are typically higher in males than females, while the converse is true for suicide attempts. We review this "gender paradox" in youth, and in particular, the age-dependency of these sex/gender differences and the developmental mechanisms that may explain them. Epidemiologic, genetic,neurodevelopmental and psychopathological research have identified suicidal behaviour risks arising from genetic vulnerabilities and sex/gender differences in early adverse environments, neurodevelopment, mental disorder and their complex interconnections. Further, evolving sex-/gender-defined social expectations and norms have been thought to influence suicide risk. In particular, how youth perceive and cope with threats and losses(including conforming to others' or one's own expectations of sex/gender identity) and adapt to pain(through substance use and helpseeking behaviours). Taken together, considering brain plasticity over the lifespan, these proposed antecedents to youth suicide highlight the importance of interventions that alter early environment(s)(e.g., childhood maltreatment) and/or one's ability to adapt to them. Further, such interventions may have more enduring protective effects, for the individual and for future generations, if implemented in youth.

Gender differences in mental health service utilization among respondents reporting depression in a national health survey

This study examined whether people who self-reported depression sought mental health treatment in the year after being interviewed, and how gender affected utilization. Depression data were obtained from the Canadian Community Health Survey (2000-01), and linked to medical records in Ontario (n = 24,677). Overall, women had higher rates of mental health service utilization, but there were no gender differences in rates of specialist care. The gender difference in mental health contact was greater for those without depression, as opposed to those with depression. Among those without depression, women were significantly more likely than men to use mental health services;however, rates were similar for women and men with depression. This finding suggests that men may be more likely than women to delay seeing a doctor for minor mental health concerns, but will seek help once a problem reaches a threshold.

老年高危病人的他汀降脂治疗：治疗与危险的矛盾

背景：心血管治疗（如他汀治疗）对二级预防的益处已被充分证明，但是在最有可能从中获益的病人中并未获得最佳应用。从理论上讲，积极应用这些有效治疗应该与基线心血管危险相关。目的：研究医生治疗积极性与患者基线心血管危险的关系。设计、地点及参试者：使用多个互联的保健管理数据库进行回顾性队列研究，这些数据库覆盖了安大略140余万老年居民。研究共包括396077例年龄≥66岁，正在接受内科治疗，截至1998年4月1日仍然存活的有心脏病史或糖尿病史韵病人。基线心血管危险用危险校正指数推导产生，据此模拟3年随访死亡概率。主要观察指标：应用他汀的可能性，在校正年龄、性别、社会经济状况及城乡居住状况后，按基线心血管危险进行分层。结果：在该二级预防队列中，仅有75617例病人（19．1％）曾予他汀处方。66～74岁的病人按基线低危、中危和高危进行分组，校正后给予他汀处方的概率分别为37．7％、26．7％和23．4％。年龄每增加1岁，预期3年死亡危险增加1％，而处方他汀类药物的可能性降低6．4％（校正后优势比，0．94；95％可信区间，0．93～0．95）。年龄与基线危险共同影响他汀类处方的概率（P〈0．001）。结论：我们发现，随着基线心血管危险以及预期死亡概率的增加，他汀类药物的处方逐渐减少。因为治疗的获益取决于基线危险性，所以他汀类药物的最大获益只有纳入了最高危的病人后才可能被充分认识。

心脏性和非心脏性病症对除颤器植入后存活率的影响

目的:调查接受埋藏式心脏复律除颤器(ICD)患者的预后以及年龄、性别和并存病对存活率的影响。背景:年龄、性别和并存病可能显著影响ICD植入者的预后。方法:利用加拿大安大略省全省数据库。

改进实效型试验的报告质量：CONSORT声明的扩充（1）

实效型试验旨在为临床实践决策提供依据，但报告得不好会降低其实用性。CONSORT和Practihc小组描述了对CONSORT指南的修改，帮助读者评估研究结果的适用性。

社区专业姑息治疗团队对患者临终时住院、急诊以及选择在医院内死亡的影响：一项汇总分析

目的汇总11个开展家庭医疗服务的专业姑息治疗团队效应。设计进行一项回顾性队列研究的汇总分析。地点加拿大，安大略省。参与者3109名在2009-2011年接受专业姑息治疗团队医疗服务的患者（暴露组）及3109名在此期间接受常规医疗服务的患者（非暴露组）。干预措施虽然这些姑息治疗团队所在地区和规模不同，但包含了相同的核心团队成员和角色分配，即能够为患者在其家中提供综合姑息治疗的姑息治疗专科医师、护士和家庭医生，团队任务包括全天候的管理症状、给予医疗信息和治疗措施以及协调服务。主要结局测量指标患者（a）在死亡前最后2周在医院度过；（b）死亡前最后2周有过急诊；（c）在医院内死亡。结果暴露组和非暴露组中癌症患者约占80％，且78％患者接受临终家庭医疗护理服务的平均时间相同。在所有姑息治疗团队中，暴露组中分别有970（31．2％）和896（28．9％）名患者在生命最后2周住院治疗和有急诊经历，而在非暴露组，分别为1219（39．3％）和1070（34．5％）名患者（P〈0．001）。暴露组与非暴露组患者在生命终期住院和经历急诊的汇总相对危险度分别为0．68[95％可信区间（CI，0．61～0．76）]和0．77[95％CI（0．69～0．86）]。与非暴露组相比，暴露组患者选择院内死亡的更少[503（16．2％）比887（28．6％），P〈0．01]，且在医院内濒死的汇总相对危险度为0．46（0．40-0．52）。结论尽管社区专业姑息治疗团队的组成和地区不同，但均能有效降低患者临终时急诊及选择在医院内死亡比例。