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室连续12个月进行了前瞻性抗菌药物阳性培养。在528例入院病例中，总共记录了144例感染和163种病原体。肺，尿，耳鼻喉（耳，鼻和喉）感染和菌血症的记录最频繁。葡萄球菌，链球菌，大肠杆菌，克雷伯菌和假单胞菌是最常见的病原体。革兰氏阳性菌株主要在单微生物菌血症期间观察到（48.9％）。分别在58％和92％的分离菌株中发现了耐甲氧西林的金黄色葡萄球菌（MRSA）和表皮葡萄球菌（MRSE）。没有发现特定的爆发。有必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: :Few well-constructed studies have systematically evaluated medical investigation protocols for children with autistic spectrum disorders. This is in large part due to the heterogeneous nature of the population and changing diagnostic frameworks. This review outlines the studies that have directed investigation strategies to date, and discusses how these might be applied in the clinical situation. The importance of listing the conditions that may be present on the basis of the specific clinical presentation, and using a thorough history and examination to generate a pre-test probability of the target disorders is emphasized if tests are to be useful in directing therapy or broader management approaches.

背景与目标： ：很少有结构完善的研究能够系统地评估自闭症谱系障碍儿童的医学研究方案。这在很大程度上是由于人群的异质性和不断变化的诊断框架。这篇综述概述了迄今为止指导研究策略的研究，并讨论了如何将这些策略应用于临床。如果测试对指导治疗或更广泛有用，则强调列出根据具体临床表现可能出现的疾病，并使用详尽的病史和检查以产生目标疾病的预测试概率的重要性。管理方法。

BACKGROUND & AIMS: BACKGROUND:Several case reports have raised serious concerns about the safety of shoulder surgery in the beach-chair position, related to global cerebral hypoperfusion. We summarize our experiences with 15,014 cases of shoulder arthroscopy over an 11-year period. Our primary aim was to evaluate the incidence of intraoperative or immediate postoperative neurologic events and secondarily to relate other perioperative complications. METHODS:We searched our online deidentified departmental quality improvement and patient safety database for adverse outcomes associated with arthroscopic shoulder surgery performed in the beach-chair position for the 11-year period between April 2001 and November 2011, as well as our hospital-system database and a statewide database. This was compared with the total number of such cases, available from our department billing database. RESULTS:The total rate of adverse events was 0.37%. Neurologic abnormalities suggestive of acute cerebral ischemia or hemorrhage did not occur in the immediate perioperative period. One new neurologic deficit was reported, secondary to ischemic stroke, which occurred 24 hours after the surgery. The most frequent complications detected were unplanned return to care (0.067%), local anesthetic systemic toxicity (0.053%), and airway compromise requiring unplanned intubation (0.033%). Complications were infrequent and did not vary in incidence over the course of the study. CONCLUSIONS:This retrospective study suggests that intraoperative or immediate postoperative stroke is rare when surgery is conducted in beach-chair position in conjunction with regional anesthesia, propofol sedation, and spontaneous respiration via natural airway.

背景与目标： 背景：几例病例报告引起了人们对与整体脑灌注不足有关的在沙滩椅位置进行肩部手术的安全性的严重关注。我们总结了我们在11年中共15014例肩关节镜检查的经验。我们的主要目的是评估术中或术后立即发生的神经系统事件的发生率，其次是与其他围手术期并发症相关。
方法：我们在2001年4月至2011年11月的11年期间，通过在线不确定的部门质量改善和患者安全性数据库搜索了在沙滩椅位置进行的关节镜肩部手术相关的不良结局，以及医院系统数据库和全州数据库。将其与此类案件的总数进行了比较，可从我们的部门账单数据库中获得该案件的总数。
结果：不良反应总发生率为0.37％。围手术期未发生提示急性脑缺血或出血的神经系统异常。据报道，继缺血性中风之后，又出现了新的神经系统缺陷，这种情况发生在手术后24小时。发现的最常见并发症是计划外恢复治疗（0.067％），局部麻醉剂全身毒性（0.053％）和需要计划外插管的气道损害（0.033％）。在研究过程中，并发症很少见，发生率也没有变化。
结论：这项回顾性研究表明，当在沙滩椅位置进行手术并伴有区域麻醉，异丙酚镇静和通过自然气道自发呼吸时，很少发生术中或术后中风。

BACKGROUND & AIMS: PROBLEM:Nurses are crucial members of the team caring for the acutely injured trauma patient. Until recently, nurses and physicians gained an understanding of leadership and supportive roles separately. With the advent of a multidisciplinary team approach to trauma care, formal team training and simulation has transpired. METHODS:Since 2007, our Level I trauma system has integrated TeamSTEPPS (Team Strategies & Tools to Enhance Performance & Patient Safety; Agency for Healthcare Research and Quality, Rockville, MD) into our clinical care, joint training of nurses and physicians, using simulations with participation of all health care providers. With the increased expectations of a well-orchestrated team and larger number of emergency nurses, our program created the Trauma Nurse Academy. This academy provides a core of experienced nurses with an advanced level of training while decreasing the variability of personnel in the trauma bay. Components of the academy include multidisciplinary didactic education, the Essentials of TeamSTEPPS, and interactive trauma bay learning, to include both equipment and drug use. Once completed, academy graduates participate in the orientation and training of General Surgery and Emergency Medicine residents' trauma bay experience and injury prevention activities. RESULTS:Internal and published data have demonstrated growing evidence linking trauma teamwork training to knowledge and self-confidence in clinical judgment to team performance, patient outcomes, and quality of care. IMPLICATIONS FOR PRACTICE:Although trauma resuscitations are stressful, high risk, dynamic, and a prime environment for error, new methods of teamwork training and collaboration among trauma team members have become essential.

背景与目标： 问题：护士是护理严重受伤的创伤患者的团队的关键成员。直到最近，护士和医师还分别了解领导和支持角色。随着多学科团队创伤治疗方法的问世，正式的团队培训和模拟已经出现。
方法：自2007年以来，我们的I级创伤系统已将TeamSTEPPS（提高绩效和患者安全的团队策略和工具；医疗研究与质量局，马里兰州罗克维尔）集成到我们的临床护理中，使用模拟对护士和医生进行联合培训在所有医疗保健提供者的参与下。随着团队的精心安排和急诊护士人数的增加，我们的计划创建了创伤护士学院。该学院为经验丰富的护士提供了高级培训，同时又减少了外伤部位人员的变异性。该学院的组成部分包括多学科的教学教育，TeamSTEPPS的基础知识和交互式创伤学，包括设备和药物使用。完成后，学院的毕业生将参加普通外科和急诊科住院医师的创伤湾经验和伤害预防活动的指导和培训。
结果：内部和公开的数据表明，越来越多的证据将创伤团队合作训练与临床判断的知识和自信心与团队绩效，患者结果和护理质量联系起来。
实践的意义：尽管创伤复苏具有压力，高风险，动态且是错误的主要环境，但创伤团队成员之间进行团队合作培训和协作的新方法已变得至关重要。

BACKGROUND & AIMS: :Suicide and violence are significant problems in a subset of Iraq/Afghanistan-era veterans. This study investigates how posttraumatic stress disorder (PTSD) and resilience in veterans are associated with suicidal ideation and violent impulses while controlling for known covariates of both adverse outcomes. Structured clinical interviews were conducted of N = 2,543 Iraq/Afghanistan-era U.S. veterans. Compared with veterans denying suicidal ideation or violent impulses (n = 1,927), veterans endorsing both (n = 171) were more likely to meet diagnostic criteria for PTSD, report childhood abuse, combat exposure, physical pain symptoms, and drug misuse, and less likely to endorse self-direction/life purpose. Veterans reporting concurrent suicidal ideation and violent impulses had higher odds of misusing drugs and reporting pain symptoms relative to veterans reporting suicidal ideation only (n = 186) and had lower odds of endorsing self-direction/life purpose compared with veterans reporting violent impulses only (n = 259). The findings underscore the importance of examining drug abuse, physical pain symptoms, and self-direction/life purpose, as well as PTSD and history of trauma, in the context of clinical assessment and empirical research aimed at optimizing risk management of suicide and violence in military veterans. (PsycINFO Database Record

背景与目标： 自杀和暴力是伊拉克/阿富汗时代退伍军人中一个重要的问题。这项研究调查了创伤后应激障碍（PTSD）和退伍军人的适应力如何与自杀意念和暴力冲动相关联，同时控制了两种不良结局的已知协变量。对N = 2,543名伊拉克/阿富汗时代的美国退伍军人进行了结构化的临床采访。与否认自杀意念或暴力冲动的退伍军人相比（n = 1,927），同时支持这两种方式的退伍军人（n = 171）更可能符合PTSD的诊断标准，并报告了儿童期虐待，战斗暴露，身体疼痛症状和滥用药物的情况，且更少可能认同自我指导/人生目标。与仅报告有自杀倾向的退伍军人相比，报告同时发生自杀意念和暴力冲动的退伍军人比仅报告有自杀意念的退伍军人滥用药物和报告疼痛症状的几率更高（n = 186），并且认可自我指导/人生目标的几率比仅报告暴力冲动的退伍军人低（ n = 259）。这些发现强调了在临床评估和实证研究的背景下，检查药物滥用，身体疼痛症状和自我指导/生活目的，以及创伤后应激障碍和创伤史的重要性，旨在优化自杀和暴力行为的风险管理。退伍军人。 （PsycINFO数据库记录

BACKGROUND & AIMS: OBJECTIVE:Polyarteritis nodosa (PAN) is a necrotizing vasculitis of medium/small arteries. We aimed to examine the characteristics of adult- and childhood-onset PAN. METHODS:Fifteen pediatric (˂ 18 years) and 22 adult PAN patients who fulfilled the Ankara 2008 and American College of Rheumatology 1990 criteria, respectively, were included in the study. RESULTS:Five children had cutaneous and all the rest of the patients had systemic PAN. Weight loss was more common (59.1% vs. 20%, P = 0.041) and presence of an angiography at diagnosis was more frequent (81.8% vs. 33.3%, P = 0.003) in adults than children. Arthralgia/arthritis and skin involvement were more common in children (86.7% vs. 59.1%; 93.3% vs. 72.7%, respectively) while renal and neurologic involvement were more frequently observed in adult patients (50% vs. 20%; 59.1% vs. 40%, respectively) (P > 0.05 for all). Cutaneous PAN patients were treated with corticosteroids only. All but one adult patient received cyclophosphamide while mycophenolate mofetil was used in five and cyclophosphamide was used in four children as induction treatment. The median duration of induction treatment was longer in adults than children (12 vs. 3 months, respectively; P = 0.004). The most common maintenance drug was mycophenolate mofetil in children and azathioprine in adults. The mortality rate was 13.6% (n = 3) and 0% in adults and children, respectively. CONCLUSION:To our knowledge, this is the first study comparing characteristics of adult and childhood onset PAN. Our results have suggested that juvenile PAN had a more benign course (with less renal and neurologic involvement, shorter duration of induction treatment) than adult onset PAN.

背景与目标： 目的：结节性多发性动脉炎（PAN）是一种中/小动脉的坏死性血管炎。我们旨在检查成人和儿童期PAN的特征。
方法：本研究纳入了分别符合Ankara 2008年和1990年美国风湿病学会标准的15例儿科（˂18岁）和22例成年PAN患者。
结果：5名儿童皮肤皮肤，其余患者均患有全身性PAN。与儿童相比，成人的体重减轻更为普遍（59.1％vs. 20％，P = 0.041），并且在诊断时出现血管造影的频率更高（81.8％vs. 33.3％，P = 0.003）。儿童的关节痛/关节炎和皮肤受累更为常见（分别为86.7％和59.1％； 93.3％和72.7％），而成年患者更经常观察到肾脏和神经系统受累（50％和20％； 59.1％）分别为40％）（所有P均> 0.05）。皮肤PAN患者仅接受皮质类固醇激素治疗。除一名成年患者外，其余所有患者均接受环磷酰胺治疗，其中5例使用了霉酚酸酯，四例儿童使用了环磷酰胺作为诱导治疗。成人的中位诱导治疗时间比儿童长（分别为12个月和3个月； P = 0.004）。最常见的维持性药物是儿童用霉酚酸酯和成人用硫唑嘌呤。成人和儿童的死亡率分别为13.6％（n = 3）和0％。
结论：据我们所知，这是第一项比较成人和儿童发病PAN的特征的研究。我们的结果表明，与成人发作的PAN相比，未成年人PAN的病程更佳（肾脏和神经系统受累较少，诱导治疗的时间更短）。

BACKGROUND & AIMS: :Transforming small independent practices to patient-centered medical homes is widely believed to be a critical step in reforming the US health care system. Our team has conducted research on improving primary care practices for more than fifteen years. We have found four characteristics of small primary care practices that seriously inhibit their ability to make the transformation to this new care model. We found that small practices were extremely physician-centric, lacked meaningful communication among physicians, were dominated by authoritarian leadership behavior, and were underserved by midlevel clinicians who had been cast into unimaginative roles. Our analysis suggests that in addition to payment reform, a shift in the mind-set of primary care physicians is needed. Unless primary care physicians can adopt new mental models and think in new ways about themselves and their practices, it will be very difficult for them and their practices to create innovative care teams, become learning organizations, and act as good citizens within the health care neighborhood.

背景与目标： ：人们普遍认为，将小规模的独立实践转变为以患者为中心的医疗之家，是改革美国医疗保健体系的关键步骤。我们的团队针对改善初级保健实践进行了十五年的研究。我们发现小型初级保健实践的四个特征严重阻碍了他们向这种新的保健模式转变的能力。我们发现，小规模的实践非常以医师为中心，在医师之间缺乏有意义的沟通，被专制的领导行为所主导，并且被中庸的临床医师所忽视，而这些医师被赋予了难以想象的作用。我们的分析表明，除了支付改革之外，还需要改变基层医疗医生的思维方式。除非初级保健医生可以采用新的心理模式并以新的方式思考自己和他们的做法，否则他们和他们的做法将很难创建创新的保健团队，成为学习型组织并在保健邻里中扮演好公民的角色。 。

BACKGROUND & AIMS: :Improvements in health care are slow, in part because doctors and nurses lack skills in quality improvement, patient safety, and interprofessional teamwork. This article reports on the Retooling for Quality and Safety initiative of the Josiah Macy Jr. Foundation and the Institute for Healthcare Improvement, which sought to integrate improvement and patient safety into medical and nursing school curricula. In one academic year, 2009-10, the initiative supported new learning activities (87 percent of which were interprofessional, involving both medical and nursing students) in classrooms, simulation centers, and clinical care settings that involved 1,374 student encounters at six universities. The work generated insights-described in this article-into which learning goals require interprofessional education; how to create clinically based improvement learning for all students; and how to demonstrate the effects on students' behavior, organizational practice, and benefits to patients. A commonly encountered limiting factor for the programs was the lack of a critical mass of clinically based faculty members who were ready to teach about the improvement of care. What's more, the paucity of robust evaluation strategies for such programs suggests a future research agenda that deserves to be funded.

背景与目标： ：医疗保健方面的改进缓慢，部分原因是医生和护士缺乏提高质量，患者安全和跨专业团队合作的技能。本文报道了Josiah Macy Jr. Foundation和医疗保健改善研究所的“质量与安全重组”倡议，该倡议旨在将改善和患者安全纳入医疗和护理学校课程。在2009-10学年的一个学年中，该计划支持了教室，模拟中心和临床护理环境中的新学习活动（其中87％是跨专业的，涉及医学和护理学的学生），涉及六所大学的1,374名学生。这项工作产生了本文中介绍的见解，其中的学习目标需要跨专业的教育；如何为所有学生创建基于临床的改进学习；以及如何证明对学生的行为，组织实践和对患者的好处的影响。该计划的一个普遍遇到的限制因素是缺乏足够数量的临床教师来准备教授改善护理的知识。而且，此类计划缺乏强有力的评估策略，这表明未来的研究议程值得资助。

BACKGROUND & AIMS: OBJECTIVE:Provoked deep venous thrombosis (DVT) is precipitated by a specific event. This paper compares the characteristics of provoked DVT in patients with transient risk (TR) factors and patients with continuous risk (CR) factors. METHODS:A retrospective review of records of all consecutive patients diagnosed with DVT between January 2013 and August 2014 was performed. Patients with provoked DVT were included in the TR group if the provoking event resolved in 2 weeks and they did not have ongoing risk of thrombosis. Patients in the CR group had a provoked DVT with ongoing risk of thrombosis due to individual factors deemed to be ongoing risks of thrombosis, such as cancer, hypercoagulable disorder, and prolonged immobilization. Demographics, risk factors, association with pulmonary embolism (PE) and its severity, risk of recurrent venous thromboembolism (VTE), and mortality were compared between the two groups. RESULTS:A total of 838 patients were diagnosed with DVT, and 50.7% (425) were provoked. There were 127 (29.9%) patients with TR and 298 (70.1%) with CR. TR patients were younger (60.4 ± 16.3 vs 65.9 ± 16.0; P = .001). TR was more likely to be provoked by surgery (70.9% vs 55.4%; P = .003), whereas CR was more likely to be provoked by immobilization (21.5% vs 12.6%; P = .032). CR patients were affected by cancer (48.7%) and hypercoagulable disorders (4.4%). TR patients were more likely to have calf DVTs (36.2% vs 26.2%; P = .047). There was a trend toward lower association with PE on presentation in TR (17.3% vs 21.1%; P = .072), but that did not reach statistical significance. However, TR factors were more likely to be associated with low-risk PE compared with CR factors (30.2% vs 54.6%; P = .040). After mean follow-up of 7.2 months, CR had higher risk of recurrent VTE (14.0% vs 6.8%; P = .045) and mortality (23.5% vs 7.1%; P < .0001). CONCLUSIONS:Provoked DVT with CR factors affects older patients and is associated with high recurrence of VTE and mortality compared with provoked DVT with TR factors.

背景与目标： 目的：诱发深静脉血栓形成（DVT）是由特定事件引起的。本文比较了短暂风险（TR）因子和持续风险（CR）因子引起的DVT的特征。
方法：回顾性分析2013年1月至2014年8月间所有诊断为DVT的连续患者的病历。如果挑衅事件在2周内解决并且他们没有持续的血栓形成风险，则将挑衅性DVT的患者纳入TR组。 CR组的患者患有诱发性DVT，具有持续的血栓形成风险，原因是被认为是持续的血栓形成风险的个体因素，例如癌症，高凝性疾病和长时间的固定。比较了两组的人口统计学，危险因素，与肺栓塞（PE）的关联及其严重性，复发性静脉血栓栓塞（VTE）的风险和死亡率。
结果：总共诊断为DVT的838例患者，引起了50.7％（425）的挑衅。有127名（29.9％）的TR患者和298名（70.1％）的CR患者。 TR患者较年轻（60.4±16.3 vs 65.9±16.0; P = .001）。 TR更有可能由手术引起（70.9％vs 55.4％; P = .003），而CR更有可能由固定引起（21.5％vs 12.6％; P = .032）。 CR患者受癌症（48.7％）和高凝性疾病（4.4％）的影响。 TR患者更有可能患有小腿深静脉血栓（36.2％vs 26.2％; P = .047）。在TR中出现与PE的关联性较低的趋势（17.3％对21.1％; P = .072），但这没有统计学意义。然而，与CR因子相比，TR因子更可能与低风险PE相关（30.2％vs 54.6％; P = .040）。平均随访7.2个月后，CR复发VTE（14.0％vs 6.8％; P = .045）和死亡率（23.5％vs 7.1％; P <.0001）的风险更高。
结论：诱发性DVT伴CR因素会影响老年患者，与诱发性DVT伴TR因素相比具有较高的VTE复发率和死亡率。

BACKGROUND & AIMS: :Tufted capuchin monkeys are known to use both quadrupedalism and bipedalism in their natural environments. Although previous studies have investigated limb kinematics and metabolic costs, their ground reaction forces (GRFs) and center of mass (CoM) mechanics during two and four-legged locomotion are unknown. Here, we determine the hind limb GRFs and CoM energy, work, and power during bipedalism and quadrupedalism over a range of speeds and gaits to investigate the effect of differential limb number on locomotor performance. Our results indicate that capuchin monkeys use a "grounded run" during bipedalism (0.83-1.43 ms(-1)) and primarily ambling and galloping gaits during quadrupedalism (0.91-6.0 ms(-1)). CoM energy recoveries are quite low during bipedalism (2-17%), and in general higher during quadrupedalism (4-72%). Consistent with this, hind limb vertical GRFs as well as CoM work, power, and collisional losses are higher in bipedalism than quadrupedalism. The positive CoM work is 2.04 ± 0.40 Jkg(-1) m(-1) (bipedalism) and 0.70 ± 0.29 Jkg(-1) m(-1) (quadrupedalism), which is within the range of published values for two and four-legged terrestrial animals. The results of this study confirm that facultative bipedalism in capuchins and other nonhuman primates need not be restricted to a pendulum-like walking gait, but rather can include running, albeit without an aerial phase. Based on these results and similar studies of other facultative bipeds, we suggest that important transitions in the evolution of hominin locomotor performance were the emergences of an obligate, pendulum-like walking gait and a bouncy running gait that included a whole-body aerial phase.

背景与目标： ：簇绒的卷尾猴在其自然环境中同时使用四足动物和两足动物。尽管先前的研究已经研究了肢体运动学和代谢成本，但是在两腿和四腿运动过程中它们的地面反作用力（GRF）和质心（CoM）力学仍然未知。在这里，我们确定了双足和四足运动在各种速度和步态下的后肢GRF和CoM的能量，功和功率，以研究差异肢数对运动性能的影响。我们的研究结果表明，卷尾猴在两足动物（0.83-1.43 ms（-1））期间使用“地面跑步”，而在四足动物（0.91-6.0 ms（-1））期间主要使用步态和奔腾步态。在两足动物中，CoM能量回收率非常低（2-17％），而在四足动物中，CoM能量回收率通常较高（4-72％）。与此相一致，两足动物的后肢垂直GRF以及CoM功，功率和碰撞损失要比四足动物的高。 CoM的正功是2.04±0.40 Jkg（-1）m（-1）（双足）和0.70±0.29 Jkg（-1）m（-1）（四足），在两个和两个的已发布值范围内。四足陆生动物。这项研究的结果证实，卷尾猴和其他非人类灵长类动物的兼性两足动物运动不必局限于像摆一样的步行步态，而可以包括奔跑，尽管没有空中阶段。基于这些结果以及对其他兼性两足动物的类似研究，我们建议，人的自发运动能力进化的重要转变是专心的，像摆的步行步态和有弹性的奔跑步态的出现，其中包括整个身体的空中阶段。

BACKGROUND & AIMS: :Venous thromboembolism (VTE) is a potentially serious complication occurring in 1%-2% of hospitalized medical patients. Despite this low absolute risk, as many as 82% of medical patients are considered to be at increased risk of developing VTE and are eligible for medical thromboprophylaxis. In this commentary, The author will discuss the main findings of a recent paper published in Clinical Epidemiology that questions the large proportion of individuals who are eligible for medical thromboprophylaxis, and also discuss the potential implications for the prevention of VTE. The recent paper demonstrated that when a population is divided into high- and low-risk groups, the maximum absolute risk depends on the inverse of the proportion of patients that is considered to be high risk. Consequently, even an effective treatment will only result in a small reduction in the absolute risk when the high-risk group comprises the largest proportion of this population. For medical thromboprophylaxis, this implies that even patients considered to be at high-risk for developing VTE have a maximum absolute VTE risk of 2% when the overall risk is 1.6%. Therefore, even an effective preventive initiative will only result in a small risk reduction. This small potential benefit should be weighed against potential harms associated with prophylaxis, mainly bleeding events. Still, there may be a reasonable overall balance between prevention of pulmonary embolism and major bleeding, mainly because major bleeding events are rare. Nonetheless, this discussion underscores that future risk prediction models should aim to predict the benefits and harms in individual patients in order to provide optimal care for the right patients.

背景与目标： ：静脉血栓栓塞症（VTE）是潜在的严重并发症，发生在1％-2％的住院医疗患者中。尽管绝对风险较低，但仍有多达82％的医疗患者罹患VTE的风险增加，并且有资格进行医疗血栓预防。在这篇评论中，作者将讨论《临床流行病学》上发表的一篇最新论文的主要发现，该论文质疑有资格进行医学血栓预防的大部分个人，并讨论了预防VTE的潜在意义。最近的论文表明，当将人群分为高风险和低风险组时，最大绝对风险取决于被认为是高风险的患者比例的倒数。因此，当高危人群占该人群的最大比例时，即使是有效的治疗也只会导致绝对风险的少量降低。对于医学上的血栓预防，这意味着即使总风险为1.6％，即使被认为是发生VTE的高风险患者，其绝对VTE的最大绝对风险也为2％。因此，即使是有效的预防措施也只能减少很小的风险。应当权衡这种小的潜在益处，以预防相关的潜在危害，主要是出血事件。仍然，在预防肺栓塞和大出血之间可能存在合理的总体平衡，这主要是因为很少发生大出血事件。尽管如此，本讨论强调指出，未来的风险预测模型应旨在预测个别患者的利弊，以便为​​合适的患者提供最佳护理。

BACKGROUND & AIMS: OBJECTIVES:Bevacizumab has been approved by the US Food and Drug Administration as a first-line therapy for metastatic non-small-cell lung cancer (NSCLC), in combination with carboplatin and paclitaxel. A single Latin American center experience was reviewed to determine the safety and efficacy of adding bevacizumab to first-line chemotherapy in a local population. METHODS:We retrospectively identified patients with non-squamous NSCLC treated with bevacizumab plus chemotherapy combinations as first-line chemotherapy between July 1, 2006, and January 30, 2011, at Sirio Libanes Hospital in Sao Paulo, Brazil. We collected data on patient characteristics, treatment combinations, toxicities, response to treatment, and survival. Overall survival (OS) and progression-free survival (PFS) were calculated by Kaplan-Meier analysis, and prognostic factors were identified by the Cox regression model. RESULTS:A total of 56 patients were included in the final analysis (median age 62.4 years; 70% male). In 35 patients (62.5%), bevacizumab was combined with carboplatin and paclitaxel, and in 16 patients (28.6%), it was combined with pemetrexed and carboplatin. The response rate evaluated by the reference clinical team reached 74.5%, the median PFS was 5.3 months, and the median OS was 14.8 months. In multivariate analysis, use of maintenance therapy was the only predictive factor for OS (hazard ratio 6.85, 95% confidence interval 2.94-15.22). No treatment-related deaths were identified, and the overall incidence of grade 3-4 non-hematologic toxicities was 16%. CONCLUSION:Our results confirm the efficacy and safety data of bevacizumab first-line combinations for NSCLC in a Brazilian population.

背景与目标： 目的：贝伐单抗已被美国食品和药物管理局批准作为转移性非小细胞肺癌（NSCLC）与卡铂和紫杉醇联合治疗的一线治疗药物。回顾了一个拉丁美洲中心的经验，以确定在当地人群中将贝伐单抗添加到一线化疗中的安全性和有效性。
方法：我们回顾性分析了2006年7月1日至2011年1月30日期间在巴西圣保罗的Sirio Libanes医院接受贝伐单抗联合化疗联合治疗的非鳞状非小细胞肺癌的患者作为一线化疗的方法。我们收集了有关患者特征，治疗组合，毒性，治疗反应和生存率的数据。通过Kaplan-Meier分析计算总生存期（OS）和无进展生存期（PFS），并通过Cox回归模型确定预后因素。
结果：最终分析共纳入56例患者（中位年龄62.4岁；男性占70％）。贝伐珠单抗联合卡铂和紫杉醇治疗35例患者（占62.5％），培美曲塞和卡铂联合治疗16例患者（占28.6％）。参考临床团队评估的缓解率为74.5％，中位PFS为5.3个月，中位OS​​为14.8个月。在多因素分析中，维持治疗是OS的唯一预测因素（危险比6.85，95％置信区间2.94-15.22）。没有发现与治疗相关的死亡，并且3-4级非血液学毒性的总发生率为16％。
结论：我们的结果证实了贝伐单抗一线联合治疗NSCLC在巴西人群中的疗效和安全性数据。

BACKGROUND & AIMS: OBJECTIVES:There is paucity of data on Primary immunodeficiency disorders (PID) from India. Here we describe the frequency of different primary immunodeficiency disorders, their clinical features and disease complications of 159 patients with PID diagnosed in a tertiary care center from India over the last 3 years. METHODS:We retrospectively reviewed the records of all the patients identified to have specific PID from 2008 to 2011. The diagnosed patients were classified according to guidelines of International Union of Immunological Society (IUIS) into eight different sub groups. RESULTS:The distribution pattern was as follows: diseases of immune dysregulation (29 %), phagocytic defects (29 %), predominant antibody deficiency (13 %), combined T and B cell deficiency (19 %) and other well defined diseases (10 %). CONCLUSION:The distribution pattern of PID varied significantly from those reported by western studies. This study highlights the need for development of more advanced facilities for diagnosis and management of PID in India and also the need for establishing population and hospital based registries.

背景与目标： 目的：印度缺乏有关原发性免疫缺陷疾病（PID）的数据。在这里，我们描述了过去3年间在印度三级护理中心诊断的159例PID的不同原发性免疫缺陷疾病的发生率，其临床特征和疾病并发症。
方法：我们回顾性回顾了2008年至2011年所有被鉴定为具有特定PID的患者的记录。根据国际免疫学会联合会（IUIS）的指南，将诊断出的患者分为八个不同的亚组。
结果：分布模式如下：免疫失调疾病（29％），吞噬缺陷（29％），主要抗体缺乏症（13％），T和B细胞联合缺乏症（19％）和其他明确疾病（10） ％）。
结论：PID的分布模式与西方研究报道的存在显着差异。这项研究突出了在印度开发用于PID诊断和管理的更先进设施的需求，以及建立以人口和医院为基础的注册表的需求。

BACKGROUND & AIMS: :Diagnostic accuracy for radiologists is above that expected by chance when they are exposed to a chest radiograph for only one-fifth of a second, a period too brief for more than a single voluntary eye movement. How do radiologists glean information from a first glance at an image? It is thought that this expert impression of the gestalt of an image is related to the everyday, immediate visual understanding of the gist of a scene. Several high-speed mechanisms guide our search of complex images. Guidance by basic features (such as color) requires no learning, whereas guidance by complex scene properties is learned. It is probable that both hardwired guidance by basic features and learned guidance by scene structure become part of radiologists' expertise. Search in scenes may be best explained by a two-pathway model: Object recognition is performed via a selective pathway in which candidate targets must be individually selected for recognition. A second, nonselective pathway extracts information from global or statistical information without selecting specific objects. An appreciation of the role of nonselective processing may be particularly useful for understanding what separates novice from expert radiologists and could help establish new methods of physician training based on medical image perception.

背景与目标： ：放射科医生的诊断准确性高于他们在接受胸部X射线照片仅五分之一秒的机会时所期望的准确性，这个时期太短，无法进行多次自愿的眼球运动。放射科医生如何从乍一看就可以收集信息？可以认为，对图像的格式像的这种专家印象与场景要点的日常，直观的视觉理解有关。几种高速机制可指导我们搜索复杂的图像。基本功能（例如颜色）的指导不需要学习，而复杂场景属性的指导则是学习的。基本功能的硬线指导和场景结构的习得性指导都可能成为放射科医生专业知识的一部分。场景搜索最好用两种途径来解释：对象识别是通过选择性途径进行的，在该途径中必须单独选择候选目标进行识别。第二种非选择性途径可从全局或统计信息中提取信息，而无需选择特定对象。理解非选择性处理的作用对于了解什么将新手与放射线专家区分开来尤其有用，并且可以帮助建立基于医学图像感知的医师培训新方法。

BACKGROUND & AIMS: BACKGROUND:Optimal burn care is provided at specialized burn centers. Given the geographic location of these centers, many burn patients receive initial treatment at local emergency departments prior to transfer. The purpose of this study was to determine whether patients transferred from other facilities have worse outcomes than those admitted directly from the field. STUDY DESIGN:A retrospective cohort study was performed comparing the outcomes of patients admitted to our burn center directly from the field with patients requiring transfer from a preliminary care facility. The outcomes of interest were mortality, length of stay, length of stay/TBSA burned, number of operations and hospital charges. Poisson regression or Cox proportional hazards model was used to evaluate differences in outcomes after adjusting for potential confounders. RESULTS:From 2000 to 2003 a total of 1877 patients were admitted to our burn center and 953 (51%) were transferred from a preliminary care facility. No difference (p<0.05) was found in length of stay, number of operations, hospital charges and mortality between the two cohorts. CONCLUSIONS:This study demonstrates that patients transferred to a regional burn center from local hospitals have equivalent mortality, length of stay and hospital charges as those admitted directly from the field.

背景与目标： 背景：在专门的烧伤中心提供最佳烧伤护理。考虑到这些中心的地理位置，许多烧伤患者在转移之前会先在当地急诊科接受初步治疗。这项研究的目的是确定从其他机构转移来的患者是否比直接从现场接受的患者具有更差的结局。
研究设计：进行了一项回顾性队列研究，比较了直接从现场进入我们烧伤中心的患者与需要从初级保健机构转诊的患者的结局。感兴趣的结果是死亡率，住院时间，住院时间/ TBSA烧伤，手术次数和医院费用。泊松回归或Cox比例风险模型用于评估潜在混杂因素后评估结局的差异。
结果：从2000年到2003年，共有1877名患者被收录到我们的烧伤中心，其中953名（51％）从初级护理机构转入了治疗。两组的住院时间，手术次数，住院费用和死亡率均无差异（p <0.05）。
结论：这项研究表明，从当地医院转移到区域烧伤中心的患者的死亡率，住院时间和住院费用与直接从现场住院的患者相同。