BACKGROUND & AIMS: OBJECTIVE:Both physicians and patients view advance directives as important, yet discussions occur infrequently. We assessed differences and correlations between physicians' and their patients' desires for end-of-life care for themselves.

MEASUREMENTS AND MAIN RESULTS:Study physicians (n = 78) were residents and faculty practicing in an inner-city, academic primary care general internal medicine practice. Patients (n = 831) received primary care from these physicians and were either at least 75 or between 50 and 74 years of age, with selected morbid conditions. Physicians and patients completed identical questionnaires that included an assessment of their preferences for six specific treatments if they were terminally ill. There were significant differences between physicians' and patients' preferences for all six treatments (p < .0001), with physicians wanting less treatment than their patients for five of them. Patients desiring more care (p < .01) were more often male (odds ratio [OR] 1.7). African-American (OR 1.6), and older (OR 1.02 per year). There were no such correlates with physicians' preferences. A treatment preference score was calculated from respondents' desires to receive or refuse the six treatments. Physicians' scores were highly correlated with those of their enrolled primary care patients (r = .51, p < .0001).

CONCLUSIONS:Although patients and physicians as groups differ substantially in their preferences for end-of-life care, there was significant correlation between individual academic physicians' preferences and those of their primary care patients. Reasons for this correlation are unknown.

背景与目标： 目标 : 医生和患者都认为预先指示很重要，但讨论很少发生。我们评估了医生和患者对自己临终关怀的渴望之间的差异和相关性。
测量和主要结果 : 研究医生 (n = 78) 是在市中心执业的居民和教师，学术初级保健普通内科实践。患者 (n = 831) 接受了这些医生的初级护理，年龄至少为75岁或50至74岁，有一定的病态。医生和患者完成了相同的问卷调查，其中包括评估他们对六种特定治疗方法的偏好 (如果他们患有绝症)。医生和患者对所有六种治疗方法的偏好之间存在显着差异 (p <.0001)，医生对其中五种治疗的治疗要少于患者。希望更多护理的患者 (p < .01) 更多的是男性 (优势比 [或] 1.7)。非裔美国人 (或1.6) 和年龄较大 (或每年1.02)。与医生的喜好没有这种相关性。根据受访者接受或拒绝这六种治疗的愿望计算出治疗偏好评分。医生的得分与他们登记的初级保健患者的得分高度相关 (r = .51，p <.0001)。
结论 : 尽管患者和医生作为一组在他们对临终关怀的偏好上有很大的不同，个别学术医师的偏好与其初级保健患者的偏好之间存在显着相关性。这种相关性的原因尚不清楚。

BACKGROUND & AIMS: :Health care workers' perceptions of patient suffering have not been well studied. Patients and health care workers were invited to answer a single, open-ended question. To develop a survey tool that could be validated and used for future research, what health care workers thought causes or caused the most suffering for patients was compared with what patients actually identified as the cause of their worst suffering. Health care workers underestimated loss and significantly underestimated physical nonpainful symptoms as causes of maximal suffering. Communication, emotional, and systems issues were often overestimated by health care workers. Health care workers may not accurately perceive what causes the worst suffering for patients. More studies are needed.

背景与目标： : 医护人员对病人痛苦的看法没有得到很好的研究。邀请患者和医护人员回答一个开放式的问题。为了开发一种可以验证并用于未来研究的调查工具，将医护人员认为导致或导致患者最痛苦的原因与患者实际确定的最痛苦原因进行了比较。医护人员低估了损失，并大大低估了身体上的无痛苦症状，这是造成最大痛苦的原因。医护人员经常高估沟通，情感和系统问题。医护人员可能无法准确理解是什么导致了患者最严重的痛苦。需要更多的研究。

BACKGROUND & AIMS: BACKGROUND:Somatizing patients have maladaptive and increased rates of medical care utilization. If there were a way of routinely identifying such patients, one that did not require intensive, case-by-case review, they could be targeted for specific interventions to improve their use of medical care. OBJECTIVE:We sought to identify patterns of medical care utilization that would distinguish somatizing and nonsomatizing medical outpatients with acceptable sensitivity and specificity. DESIGN:Subjects completed questionnaires assessing somatization and sociodemographic characteristics. Their medical care utilization was obtained for the 12 months preceding the index visit. We then used multivariable logistic regression and recursive partitioning to identify patients with a provisional diagnosis of somatoform disorder. These exploratory models used various patterns of medical care utilization and sociodemographic characteristics as the independent variables. SUBJECTS:We studied consecutive adults attending 2 primary care practices on randomly chosen days. MEASURES:The provisional diagnosis of a somatoform disorder was assessed with a 15-item self-report questionnaire. The number of primary care visits, specialty visits, mental health visits, emergency visits, and inpatient and outpatient costs were obtained for the 12 months preceding the index visit from our hospital's automated medical records, which also provided a rating of aggregate medical morbidity. Self-reported utilization outside our hospital system was obtained from a subsample of patients. RESULTS:Complete data were obtained on 1440 patients. Somatizing patients had more specialty care than primary care visits, higher outpatient than inpatient costs, and more emergency visits than nonsomatizing patients. A regression model containing 7 measures of utilization and 4 sociodemographic characteristics distinguished somatizing and nonsomatizing patients with a c-statistic = 0.73. Recursive partitioning identified 10 terminal nodes with a very high specificity (99%) but a very low sensitivity (15%). CONCLUSIONS:We identified 7 discrete patterns of medical care utilization that distinguished somatizing and nonsomatizing patients. However, they did so with only modest specificity and sensitivity. This algorithm might be used effectively as the first step in a 2-step screening procedure whose second step would entail more intensive screening or individual, case-by-case review to identify somatizing patients in primary care practice.

背景与目标：

BACKGROUND & AIMS: :This study aimed to clarify the effectiveness of post-operative oral care, including tooth brushing, denture cleaning and tongue cleaning, after digestive tract surgery. Subjects included 30 elderly patients aged 60-98 years (74.9 +/- 7.8 years) who underwent digestive tract surgery. Subjects were randomly divided into an intervention group and a control group. In the intervention group, the following oral care was provided daily over a 5-min period in the morning starting at baseline (day of surgery) and continued for 5 days: gargling with povidone iodine, tooth brushing, denture cleaning using a special brush and tongue cleaning using a tongue brush. In the control group, the subjects only gargled with povidone iodine. We compared the following variables between the two groups at baseline and 5 days later: the sensation of dry mouth, intra-oral gas concentration, pulmonary sounds, body temperature and bacterial flora. The number of patients with abnormal pulmonary sounds (dry or moist rales) increased from 1 to 2 in the intervention group and from 0 to 4 in the control group (P < 0.05). The average number of bacterial species per subject for the control group was 3.64 +/- 1.34 pre-operatively and 3.50 +/- 1.74 post-operatively, whereas that for the intervention group was 3.08 +/- 0.95 pre-operatively and 2.62 +/- 0.65 post-operatively. In the intervention group, there was a significant decrease in the number of bacterial species (P < 0.05). These findings indicate that post-operative oral care in elderly patients undergoing digestive tract surgery lowers the number of bacterial species found in the oral cavity. This effect, in turn, might improve respiratory function.

背景与目标： : 本研究旨在阐明消化道手术后口腔护理的有效性，包括刷牙，义齿清洁和舌头清洁。受试者包括30名60-98岁 (74.9 +/- 7.8岁) 接受消化道手术的老年患者。受试者随机分为干预组和对照组。在干预组中，从基线 (手术当天) 开始，在早晨的5分钟内每天提供以下口腔护理，并持续5天: 用聚维酮碘漱口，刷牙，使用特殊刷子清洁义齿和使用舌头刷子清洁舌头。在对照组中，受试者仅用聚维酮碘漱液。我们在基线和5天后比较了两组之间的以下变量: 口干感，口内气体浓度，肺音，体温和细菌菌群。肺音异常 (干或湿啰音) 的患者数量在干预组从1增加到2，在对照组从0增加到4 (P <0.05)。对照组每个受试者的平均细菌种类数术前为3.64 +/- 1.34，术后为3.50 +/- 1.74，而干预组的平均细菌种类数术前为3.08 +/- 0.95，术后为2.62 +/- 0.65。干预组细菌种类显著减少 (P <0.05)。这些发现表明，接受消化道手术的老年患者的术后口腔护理降低了口腔中发现的细菌种类的数量。反过来，这种作用可能会改善呼吸功能。

BACKGROUND & AIMS: BACKGROUND:Despite increasing numbers of morbidly obese patients admitted to acute care facilities for surgery or treatment of nonsurgical conditions, there is little evidence of the problems nurses face in providing care to these patients. Anecdotal evidence suggests that the care of these patients is more demanding than the care of nonobese patients. The objective of this study was to describe nurses' perceptions of the challenges that they face when caring for morbidly obese patients. METHODS:Focus groups of nurses from a tertiary care facility were convened. A trained facilitator posed questions to the group concerning various aspects of care for morbidly obese patients. Comments of respondents were categorized using NVIVO software. RESULTS:Nurses reported concerns about the increased staffing needs required for care of these patients and the particular challenges of the physical care. Concerns also included the availability, placement, and use of specialized equipment. Room size and the absence of some equipment were also problematic. Finally, nurses perceived safety issues, both for themselves and their patients. CONCLUSIONS:Morbidly obese patients in the acute care setting require specialized nursing care in terms of techniques, levels of staffing required, and the use of specialized equipment.

背景与目标：

BACKGROUND & AIMS: PURPOSE:Making good consumer decisions requires having good information. This study compared long-term-care recommendations among various types of health professionals. DESIGN AND METHODS:We gave randomly varied scenarios to a convenience national sample of 211 professionals from varying disciplines and work locations. For each scenario, we asked the professional to recommend the appropriate forms of long-term care. RESULTS:Although the professional respondents used the full spectrum of options offered to them, some professionals tended to favor the sector they worked in. Advanced practice nurses recommended day care and homemaking more and adult foster care less. Gerontologists used skilled nursing-facility placement more actively and rehabilitation, homemaking, and home health care less actively. Geriatricians and primary care physicians both favored rehabilitation and skilled nursing-facility care and were both less enthusiastic about assisted living, homemaking, and informal care, but the geriatricians favored day care more than did the primary care physicians. Registered nurses were highly supportive of assisted living, adult foster care, homemaking, and home health care, and they opposed skilled nursing-facility care. Social workers were less likely than other participants to endorse rehabilitation and adult foster care. IMPLICATIONS:Because consumer preference should be a major factor in making long-term-care decisions, many consumers need information about what options may best fit their situation. In the absence of empirical data on which types of long-term care work best for whom, consumers have to rely on expert judgment-but that judgment varies. Clients should be aware that an expert's background (as defined by discipline and work situation) may affect his or her recommendations. Each discipline appears to have its own set of experiences and beliefs that may influence recommendations.

背景与目标：

BACKGROUND & AIMS: :Clubfoot (talipes equinovarus) is a common orthopaedic malformation that can be accurately diagnosed prenatally. The study was conducted to investigate possible in utero visualization of transient and late-onset clubfoot. Early (13-16 weeks' gestation) prenatal transvaginal sonographic diagnosis of clubfoot deformity was made in 36 cases during the study period. Only those cases where follow-up examination revealed different sonographic findings were considered. The results showed that seven cases of transient (as well as relapsing) clubfoot were identified. In 4 of 7 cases, the clubfoot resolved (all after more than 10 min of observation) during the same examination. In the fifth and sixth cases, it initially resolved, later reappearing in follow-up examinations (20 and 22 weeks' gestation). In the seventh case, the clubfoot persisted for two consecutive examinations (2 weeks apart each) and later disappeared. In addition, six late-onset (22-24 weeks' gestation) clubfoot cases were identified during the study period. Although infrequent, in utero clubfoot can be both a transient and a late-onset phenomenon. Over- and under-diagnosis are potential hazards in these situations.

背景与目标： : 马蹄内翻足 (马蹄内翻足) 是一种常见的矫形畸形，可以在产前准确诊断。进行这项研究是为了研究子宫内短暂性和迟发性马蹄内翻足的可能性。在研究期间，对36例马蹄内翻足畸形进行了早期 (妊娠13-16周) 产前经阴道超声诊断。仅考虑那些随访检查显示超声检查结果不同的情况。结果表明，发现了7例短暂性 (以及复发性) 马蹄内翻足。在7例中的4例中，在同一检查中，马蹄内翻足消退 (所有观察超过10分钟后)。在第五和第六例中，它最初得到解决，后来在后续检查中再次出现 (妊娠20和22周)。在第七例中，马蹄内翻足持续进行了两次连续检查 (每次间隔2周)，后来消失了。此外，在研究期间还发现了6例迟发性 (妊娠22-24周) 马蹄内翻足病例。尽管很少出现，但子宫内的马蹄内翻足既可以是短暂现象，也可以是迟发现象。在这些情况下，过度诊断和诊断不足是潜在的危险。

BACKGROUND & AIMS: :A prospective collection of positive antimicrobial cultures was performed over 12 consecutive months in the medical intensive care unit of a cancer hospital. In all, 144 infections and 163 pathogens were documented during 87 of the 528 admissions. Lung, urinary, ENT (ear, nose and throat) infections and bacteraemia were the most frequently documented. Staphylococcus species, Streptococcus species, Escherichia coli, Klebsiella species and Pseudomonas species were the most common pathogens. Gram-positive strains were observed predominantly during monomicrobial bacteraemia (48.9%). Methicillin-resistant Staphylococcus aureus (MRSA) and Staphylococcus epidermidis (MRSE) were found in 58% and 92% of the isolated strains respectively. No particular outbreak was identified. A further prospective study will be necessary to evaluate the impact of the antibiotic use on the selection of resistant strains in our ICU.

背景与目标： : 在癌症医院的医疗重症监护病房中连续12个月进行了阳性抗菌培养的前瞻性收集。在528的87例入院期间，共记录了144例感染和163例病原体。肺，泌尿，耳鼻喉科 (耳，鼻和喉) 感染和菌血症是最常见的记录。最常见的病原体是葡萄球菌，链球菌，大肠杆菌，克雷伯菌和假单胞菌。革兰氏阳性菌株主要在单株菌血症期间观察到 (48.9%)。分离株的58% 和92% 中分别发现了耐甲氧西林金黄色葡萄球菌 (MRSA) 和表皮葡萄球菌 (MRSE)。没有发现特别的爆发。需要进行进一步的前瞻性研究，以评估抗生素使用对我们ICU中耐药菌株选择的影响。

BACKGROUND & AIMS: :Spiritual issues arise frequently in the care of dying patients, yet health care professionals may not recognize them, may not believe they have a duty to address these issues, and may not understand how best to respond to their patients' spiritual needs. The case of a patient with a strong religious belief in a miraculous cure of metastatic pancreatic cancer is used to explore how better understanding of this belief and more explicitly spiritual conversation with the patient by his treating team might have provided opportunities for an improved plan of care. This article distinguishes spirituality from religion; describes the salient spiritual needs of patients at the end of life as encompassing questions of meaning, value, and relationship; delineates the role physicians ought to play in ascertaining and responding to those needs; and discusses the particular issue of miracles, arguing that expectations of miraculous cure ought not preclude referral to hospice care.

背景与目标： : 精神问题经常出现在临终病人的护理中，然而医疗保健专业人员可能不认识他们，可能不相信他们有责任解决这些问题，也可能不了解如何最好地应对患者的精神需求。对转移性胰腺癌的奇迹般治愈具有强烈宗教信仰的患者的案例被用来探索如何更好地理解这种信仰以及他的治疗团队与患者进行更明确的精神对话可能会为改善护理计划提供机会。本文将灵性与宗教区分开来; 描述了生命末期患者的显着精神需求，包括意义，价值和关系问题; 描述了医生在确定和应对这些需求时应扮演的角色; 并讨论了奇迹的特殊问题，认为对奇迹般的治愈的期望不应排除转诊至临终关怀。

BACKGROUND & AIMS: INTRODUCTION:Since 2003, Iraq has struggled to build a single national health system administered by the Iraqi Ministry of Health, but politics, lack of leadership, and a cultural bias against treating soldiers in civilian hospitals have hindered access to care for members of Iraq's armed forces who are wounded in combat. METHODS:U.S. surgeons are providing trauma care for Iraqi soldiers in American field hospitals, with more than 80% of hospital bed days occupied by Iraqis. At the same time, Iraqi hospitals have been treating the many civilian casualties of violence, and the Ministry of Health has greatly improved its emergency response and management capabilities over the past year. RESULTS:Ministry of Health hospitals have adequate surgical capabilities and bed capacity to care for both civilian and security forces casualties. Faltering attempts to develop a national health policy that provides comprehensive care for Iraqi Security Forces will jeopardize Iraq's ability to assume responsibilities for the country's national defense, and could delay the withdrawal of Coalition military forces from Iraq. CONCLUSIONS:It is imperative that leadership of the new government of Iraq and the international surgical community strongly endorse the implementation of a single health care system for all Iraqis.

背景与目标：

BACKGROUND & AIMS: INTRODUCTION:To obtain strict glucose regulation, an accurate and feasible bedside glucometry method is essential. We evaluated three different types of point-of-care glucometry in seriously ill intensive care unit (ICU) patients. The study was performed as a single-centre, prospective, observational study in a 12-bed medical ICU of a university hospital. METHODS:Patients with an expected ICU stay of more than 48 hours were included. Because the reference laboratory delivers glucose values after approximately 30 to 60 minutes, which is too slow to use in a glucose regulation protocol and for calibration of the subcutaneous continuous glucose monitoring system (CGMS) (CGMS System Gold), we first validated the ICU-based blood gas/glucose analyser ABL715 (part 1 of the study). Subsequently, part 2 was performed: after inserting (and calibrating) the subcutaneous CGMS, heparinised arterial blood samples were drawn from an arterial line every 6 hours and analysed on both the Precision PCx point-of-care meter using test strips and on the blood gas/glucose analyser ABL715. CGMS glucose data were downloaded after 24 to 72 hours. The results of the paired measurements were analysed as a scatter plot by the method of Bland and Altman and were expressed as a correlation coefficient. RESULTS:Part 1: Four hundred and twenty-four blood samples were drawn from 45 critically ill ICU patients. The ICU-based blood gas/glucose analyser ABL715 provided a good estimate of conventional laboratory glucose assessment: the correlation coefficient was 0.95. In the Clarke error grid, 96.8% of the paired measurements were in the clinically acceptable zones A and B. Part 2: One hundred sixty-five paired samples were drawn from 19 ICU patients. The Precision PCx point-of-care meter showed a correlation coefficient of 0.89. Ninety-eight point seven percent of measurements were within zones A and B. The correlation coefficient for the subcutaneous CGMS System Gold was 0.89. One hundred percent of measurements were within zones A and B. CONCLUSION:The ICU-based blood glucose analyser ABL715 is a rapid and accurate alternative for laboratory glucose determination and can serve as a standard for ICU blood glucose measurements. The Precision PCx is a good alternative, but feasibility may be limited because of the blood sample handling. The subcutaneous CGMS System Gold is promising, but real-time glucose level reporting is necessary before it can be of clinical use in the ICU. When implementing a glucose-insulin algorithm in patient care or research, one should realise that the absolute glucose level may differ systematically among various measuring methods, influencing targeted glucose levels.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:Surveys of the population are commonly used to obtain information on health status. Increasingly, researchers are linking self-reported health status information to primary care consultation data. However, it is not known how participating in a health-related survey affects consultation behaviour. The objective of this study was to assess whether completion of a health-related questionnaire changes primary care consultation behaviour. METHODS:Participants were 3402 adults aged 50 and over from the general population in North Staffordshire, UK, who completed a health-related postal survey received in April 2003. The survey was predominantly about occurrence and severity of knee pain in the last year. Primary care attendance for the three months following response was compared to three control periods: i) the three months prior to the survey, ii) the same time period in the previous year and iii) the same time period in the following year. Comparisons were made on consultations for any problem, consultations for musculoskeletal disorders and consultations for knee problems. RESULTS:The percentage of subjects consulting for any condition was marginally higher for the three months directly after receipt of the questionnaire but the difference was only statistically significant in comparison to the three months before the survey (64% v. 62%, p = 0.05). There was little difference in consultation prevalence for musculoskeletal problems immediately after the survey compared to the three control periods. There was an increase of 37% in knee disorder consultations for the three months after the survey compared to the three months directly before the survey (p = 0.02). However, consultation prevalence for knee problems was identical for the three months after the survey to the same time periods in the years prior to and following the survey (both p = 0.94). CONCLUSION:The results from this study suggests that questionnaires related to physical health do not affect the standard consulting behaviour of patients, even for the symptom under investigation. This should reassure researchers who wish to link self-reported health status and medical care utilisation and clinicians whose patients are involved in such research.

背景与目标：

BACKGROUND & AIMS: :Bedside duplex/color Doppler sonography is used for a wide gamut of abnormalities encountered in the neonatal intensive care unit. This article emphasizes the use of bedside sonography for evaluation of infants with necrotizing enterocolitis, infants requiring line placement, and those in whom a diaphragmatic abnormality is suspected. Although the assessment of those infants requires excellent operator skills, learning to do so is a definite benefit to these babies who would otherwise be exposed to ionizing radiation.

背景与目标： : 床边双工/彩色多普勒超声检查用于新生儿重症监护病房中遇到的各种异常情况。本文强调使用床旁超声检查评估坏死性小肠结肠炎婴儿，需要行放置的婴儿以及怀疑diaphragm肌异常的婴儿。尽管对这些婴儿的评估需要出色的操作员技能，但学习这样做对这些原本会受到电离辐射的婴儿来说是绝对的好处。

BACKGROUND & AIMS: :In the present pilot study, the feasibility of a site-of-care cervicovaginal self-sampling methodology for HPV-based screening was tested in 346 women residing in underserved rural areas of Northern Greece. These women provided self-collected cervicovaginal sample along with a study questionnaire. Following molecular testing, using the cobas® HPV Test, Roche®, HPV positive women, were referred to colposcopy and upon abnormal findings, to biopsy and treatment. Participation rate was 100%. Regular pap-test examination was reported for 17.1%. Among hrHPV testing, 11.9% were positive and colposcopy/biopsy revealed 2 CIN3 cases. Non-compliance was the most prevalent reason for no previous attendance. Most women reported non-difficulty and non-discomfort in self-sampling (77.6% and 82.4%, respectively). They would choose self-sampling over clinician-sampling (86.2%), and should self-sampling being available, they would test themselves more regularly (92.3%). In conclusion, self-sampling is feasible and well-accepted for HPV-based screening, and could increase population coverage in underserved areas, helping towards successful prevention.

背景与目标： : 在本试点研究中，对居住在希腊北部服务不足的农村地区的346名妇女进行了基于HPV筛查的护理现场宫颈阴道自采样方法的可行性进行了测试。这些妇女提供了自我收集的宫颈阴道样本以及研究问卷。在分子测试之后，使用cobas®罗氏HPV检测®HPV阳性女性被转诊至阴道镜检查和异常发现后，进行活检和治疗。参与率为100%。报告定期进行17.1% 巴氏试验检查。在hrHPV检测中，11.9% 例为阳性，阴道镜/活检显示2例CIN3。不遵守是以前没有出席的最普遍原因。大多数妇女报告说，自我取样没有困难，也没有不适 (分别为77.6% 和82.4%)。他们将选择自采样而不是临床医生采样 (86.2%)，并且如果自采样可用，他们将更定期地测试自己 (92.3%)。总之，自我采样对于基于HPV的筛查是可行的且被广泛接受，并且可以增加服务不足地区的人口覆盖率，从而有助于成功预防。

BACKGROUND & AIMS: INTRODUCTION:The aim of this article is to report, from their own perspective, the attitudes and believes towards vaccination, with special emphasis on the influence of sources of information to make the decision to get vaccinated, of health care workers (HCWs), considered as a specific risk group for immunization strategy against A (H1N1) influenza. METHODS:Cross-sectional observational study focused on active health workers in the province of Alicante. Made by face to face questionnaires to a stratified random sample based on occupational categories in hospitals and health care centres. RESULTS:The sources of information differ between subgroups; physicians used journals and/or conferences, nurses obtained information through the Ministry of Health and other nurses, and the remaining workers opted for television and/or the family physician. Of the three studied groups, physicians felt minor concern about the influenza A (H1N1) pandemic (59.4%), had the most confidence in the vaccine (42.3%), were the ones who recommended the vaccine the most (44.4%), who best followed the recommendations to avoid infection (93%), and were the most vaccinated (18.3%). Around three-quarters (75.5%) of the HCWs assessed the provided information as fair, poor or very poor. All HCWs admitted that a social alarm was created. DISCUSSION:The success of future immunization campaigns against influenza in HCWs could increase if information activities were designed to focus on each subgroup of HCWs, by adapting the strategy and improving the quality of information.

背景与目标：