BACKGROUND & AIMS: :Epilepsy affects a larger number of individuals than previously thought-up to 2% of the population-and its effects reach further. Yet epilepsy, with its associated lingering stigma and fear, has remained in the background in terms of services and research. Traditional quantitative research often falls short when trying to describe the impact of epilepsy on the lives of individuals and their families. In the present study, focus groups were held throughout South Carolina to discuss individuals' experiences with accessing epilepsy-related services and health care, and what life with epilepsy is like. Following qualitative data analysis, findings included two themes. One theme focuses on the ongoing search for services and help. The second theme concerns the experiences of living life with epilepsy. Also highlighted are recommendations for potential improvements in public awareness and professional training, and helpful interventions.

背景与目标： : 癫痫影响的个体数量比以前想象的要多-达到2% 的人口-其影响进一步扩大。然而，癫痫，伴随着挥之不去的耻辱和恐惧，在服务和研究方面仍然是背景。在试图描述癫痫对个人及其家庭生活的影响时，传统的定量研究往往不足。在本研究中，在南卡罗来纳州举行了焦点小组讨论个人获得与癫痫相关的服务和医疗保健的经验，以及癫痫的生活是什么样的。在定性数据分析之后，调查结果包括两个主题。一个主题侧重于正在进行的服务和帮助搜索。第二个主题涉及癫痫生活的经历。还强调了有关提高公众意识和专业培训以及有益干预措施的建议。

BACKGROUND & AIMS: :Egyptian medical papyri date the Santorini eruption, and reconcile the hitherto perceived dichotomy between archaeological/historical and scientific data. The medical documentation describes ailments, which can only have arisen from a volcanic source: ash fallout, rain acidified by ash, and a plume. Furthermore, the Egypt described by the medical texts matches the one in the series of so-called biblical plagues. This match in turn provides the length of time, 19 months, between the initial and final phases of the eruption, each phase contributing to the otherwise odd accumulation of sulfates spread over two consecutive biennia (1603-1600 BC) in Greenland's ice core. As a result, the initial phase of the eruption can be dated to August 21, 1603 BC, and the final one to March 1601 BC, in full agreement with the radiocarbon data (1627-1600 BC) based on the outermost ring on the branch of an olive tree killed by the eruption.

背景与目标： : 埃及医学纸莎草纸可以追溯圣托里尼喷发，并调和迄今认为的考古/历史和科学数据之间的二分法。医学文件描述了只能由火山来源引起的疾病: 灰烬沉降物，被灰烬酸化的雨水和羽流。此外，医学文献所描述的埃及与所谓的圣经瘟疫系列中的埃及相匹配。此匹配又提供了喷发的初始阶段和最终阶段之间的19个月的时间长度，每个阶段都导致了格陵兰岛冰核中连续两个两年期 (公元前1603-1600年) 散布的硫酸盐的奇数积累。结果，喷发的初始阶段可以追溯到公元前1603年8月21日，最后一个可以追溯到公元前1601年3月，这与放射性碳数据 (公元前1627-1600年) 完全一致。橄榄树被喷发杀死。

BACKGROUND & AIMS: We report the response to risperidone in seven hospitalized, adult patients who presented psychotic symptoms etiologically related to a general medical condition. The conditions included brain surgery in two, and anticardiolipin syndrome, renal failure, epilepsy, lupus, and metastatic carcinoma in one each. Four patients had failed previous treatment with at least one typical antipsychotic agent. Response to risperidone was assessed by the Brief Psychiatric Rating Scale (BPRS). Serum was collected for measurement of steady-state trough risperidone and 9-hydroxyrisperidone concentrations at effective doses in three patients. Amelioration of psychotic symptoms was noted in all seven patients. Mean (+/- SD) BPRS scores were reduced significantly from baseline (63.0 +/- 15.1) to endpoint (27.0 +/- 3.5; p < 0.01). The mean effective daily dose of risperidone was 3.1 +/- .7 mg and time to response was 4.7 +/- 2.4 days. Risperidone was not present at detectable concentrations in the three patients studied. The mean steady-state trough serum concentration of 9-hydroxyrisperidone in the three patients assessed was 20.3 +/- 9.8 ng/ml. These preliminary findings, which suggest that risperidone is a safe and effective agent in patients with psychotic symptoms due to various medical conditions, need to be confirmed by randomized, antipsychotic comparison trials involving a larger number of patients.

背景与目标： 我们报告了7名住院成年患者对利培酮的反应，这些患者表现出与一般医疗状况相关的精神病症状。疾病包括两种脑部手术，以及抗心磷脂综合征，肾衰竭，癫痫，狼疮和转移性癌各一种。四名患者先前使用至少一种典型的抗精神病药治疗失败。通过简明精神病评定量表 (BPRS) 评估对利培酮的反应。在三名患者中以有效剂量收集血清以测量稳态谷利培酮和9-羟基利培酮浓度。所有7例患者的精神病症状均得到改善。平均 (+/- SD) BPRS评分从基线 (63.0 +/- 15.1) 到终点 (27.0 +/- 3.5; p < 0.01) 显著降低。利培酮的平均有效日剂量为3.1 +/- .7 mg，反应时间为4.7 +/- 2.4天。在研究的三名患者中，利培酮不存在可检测的浓度。在评估的三名患者中，9-羟基利培酮的平均稳态谷血清浓度为20.3/- 9.8 ng/ml。这些初步发现表明，利培酮是一种安全有效的药物，用于由于各种医疗条件引起的精神病症状的患者，需要通过涉及更多患者的随机抗精神病比较试验来证实。

BACKGROUND & AIMS: :"First responders" are people trained in advanced first aid who can respond at the same time as, and often more quickly than, ambulance services to suspected medical emergencies. Hatzolah is a volunteer First Responder group, based on halakhic (Jewish legal) principles, in a localised area of metropolitan Melbourne with the highest density of Holocaust survivors outside Israel. Low numbers of "call-outs" to Victoria's Metropolitan Ambulance Service (MAS) from this community suggested that many were reluctant to make contact with a "uniformed" external agency. Hatzolah is an autonomous organisation operating under adapted MAS clinical practice guidelines and clinical governance processes. Hatzolah responders undergo an 18-month MAS training course comprising first aid, cardiopulmonary resuscitation, the use of semiautomated defibrillators, and oxygen therapy. We describe the first 11 years (1995-2005) of the Hatzolah service. The number of patients attended to annually has risen steadily, peaking at 867 in 2005. The most frequent reasons for call-outs were falls (19.4%), chest pain (9.7%), or respiratory distress (7.6%). Hatzolah's median response times were 2 or 3 min for all cases. They attended 35 patients with cardiac arrest (median response time, 2 min), and arrived before the MAS to 29 call-outs (83%). Nineteen patients (54%) with cardiac arrest were resuscitated and transported from the scene alive. Among those transported, significantly more had a shockable cardiac rhythm (50% v 13%, P = 0.03). Five (14%) survived to hospital discharge. Hatzolah has evolved into an organisation providing a complementary service to the MAS. It serves as a model for the establishment of other metropolitan community First Responder groups.

背景与目标： : “急救人员” 是接受过高级急救培训的人员，他们可以与救护车服务同时做出反应，并且通常比救护车服务更快地应对可疑的医疗紧急情况。Hatzolah是一个基于halakhic (犹太法律) 原则的志愿第一响应者小组，位于墨尔本大都市的局部地区，以色列以外的大屠杀幸存者密度最高。来自该社区的维多利亚州大都会救护车服务 (MAS) 的 “呼叫” 数量很少，这表明许多人不愿与 “穿制服的” 外部机构联系。Hatzolah是一个自治组织，根据适应的MAS临床实践指南和临床治理流程运作。Hatzolah响应者接受为期18个月的MAS培训课程，包括急救，心肺复苏，半自动除颤器的使用和氧气治疗。我们描述了Hatzolah服务的前11年 (1995-2005年)。每年就诊的患者数量稳步上升，达到867 2005年的峰值。最常见的呼叫原因是跌倒 (19.4%)，胸痛 (9.7%) 或呼吸窘迫 (7.6%)。对于所有病例，Hatzolah的中位反应时间为2或3分钟。他们参加了35例心脏骤停患者 (中位反应时间为2分钟)，并在MAS之前到达29个呼叫 (83%)。19例 (54% 例) 心脏骤停患者被复苏并活着从现场转移。在运输的那些中，明显更多的具有可电击的心律 (50% v 13%，P = 0.03)。五 (14%) 幸存下来出院。Hatzolah已发展成为一个为MAS提供补充服务的组织。它是建立其他大都会社区急救小组的典范。

BACKGROUND & AIMS: PURPOSE:There has been little radiation oncologist (RO)-specific research in continuing medical education (CME) or quality improvement (QI) program efficacy. Our aim was to evaluate a CME/QI program for changes in RO behavior, performance, and adherence to department protocols/studies over the first 12 months of the program. METHODS AND MATERIALS:The CME/QI program combined chart audit with feedback (C-AWF), simulation review AWF (SR-AWF), reminder checklists, and targeted CME tutorials. Between April 2003 and March 2004, management of 75 patients was evaluated by chart audit with feedback (C-AWF) and 178 patients via simulation review audit (SR-AWF) using a validated instrument. Scores were presented, and case management was discussed with individualized educational feedback. RO behavior and performance was compared over the first year of the program. RESULTS:Comparing the first and second 6 months, there was a significant improvement in mean behavior (12.7-13.6 of 14, p = 0.0005) and RO performance (7.6-7.9 of 8, p = 0.018) scores. Protocol/study adherence significantly improved from 90.3% to 96.6% (p = 0.005). A total of 50 actions were generated, including the identification of learning needs to direct CME tutorials, the systematic change of suboptimal RO practice, and the alteration of deficient management of 3% of patients audited during the program. CONCLUSION:An integrated CME/QI program combining C-AWF, SR-AWF, QI reminders, and targeted CME tutorials effectively improved targeted RO behavior and performance over a 12-month period. There was a corresponding increase in departmental protocol and study adherence.

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BACKGROUND & AIMS: BACKGROUND:A growing body of literature shows that many universities and colleges are making educational portfolios part of their faculty assessment and student's learning plan for both undergraduate and graduate programs. We provide an outline for the development of a medical educator's portfolio, including an electronic version. DESCRIPTION:Guidelines for the development of an educational portfolio focusing on medical education are provided, including design, format, and content. An electronic version of the portfolio, which combines flexibility and ease of revision, is also described, including formats for publication and distribution. Student reflections on the e-portfolio are presented, and potential applications of the e-portfolio in medical education are described. CONCLUSION:We believe that portfolio development is a valuable application that provides rich documentation of participants' educational history, accomplishments, and intellectual property as related to their professional learning and growth.

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BACKGROUND & AIMS: -2

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BACKGROUND & AIMS: OBJECTIVES:To examine the long-term relationships between costs, utilization, and patient-centered medical home (PCMH) clinical practice systems. STUDY DESIGN:Clinical practice systems were evaluated at baseline by the Physician Practice Connections-Research Survey (PPC-RS). Annual costs and utilization of a retrospectively constructed cohort of 58,391 persons receiving primary care at 1 of 22 medical groups over a 5-year period (2005-2009) were compared. METHODS:Multivariate regressions adjusting for patient demographics, health status, and autoregressive errors compared PPC-RS scores and study outcomes for the entire cohort and 3 subcohorts defined by medical complexity (medication count 0-2 [n = 29,657], 2-6 [n = 19,505], >7 [n = 9229]). Outcomes (adjusted to 2005 dollars) were total costs, outpatient costs, inpatient costs, inpatient days, and emergency department (ED) use. RESULTS:For the entire cohort, a 10% increase in PPC-RS scores was associated with 3.9 (medication count: 0-2), 6 (3-6), and 11.6 (>7) fewer ED visits per 1000 in 2005; and 5.1, 7.6, and 13.6 fewer ED visits in 2009. That 10% increase was not associated with the 0-2 medication subcohort's total (-$22/person in 2005; $184/person in 2009), outpatient (-$11/person in 2005; $42/person in 2009), or inpatient ($26/person in 2005; $29/person in 2009) costs. However, it was associated with significantly decreased total (-$446/person in 2005; -$184/person in 2009) and outpatient (-$241/person in 2005; -$54/person in 2009) costs for the most medically complex subcohort (>7 medications). CONCLUSIONS:Association of PCMH clinical practice systems with reduced costs appears limited to the most medically complex patients.

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BACKGROUND & AIMS: BACKGROUND:The economic consequences of environmental tobacco smoke (ETS) have been simulated using models. We examined the individual-level association between ETS exposure and medical costs among Japanese nonsmoking women. METHODS:This population-based cohort study enrolled women aged 40 to 79 years living in a rural community. ETS exposure in homes at baseline was assessed with a self-administered questionnaire. We then collected health insurance claims data on direct medical expenditures from 1995 through 2007. Using generalized linear models with interaction between ETS exposure level and age stratum, average total monthly expenditure (inpatient plus outpatient care) per capita for nonsmoking women highly exposed and moderately exposed to ETS were compared with expenditures for unexposed women. We performed separate analyses for survivors and nonsurvivors. RESULTS:We analyzed data from 4870 women. After adjustment for potential confounding factors, survivors aged 70 to 79 who were highly exposed to ETS incurred higher expenditures than those who were not exposed. We found no significant difference in expenditures between moderately exposed and unexposed women. Total expenditures were not significantly associated with ETS exposure among survivors aged 40 to 69 or nonsurvivors of any age stratum. CONCLUSIONS:We calculated individual-level excess medical expenditures attributable to household exposure to ETS among surviving older women. The findings provide direct evidence of the economic burden of ETS, which is helpful for policymakers who seek to achieve the economically attractive goal of eliminating ETS.

背景与目标：

BACKGROUND & AIMS: :Human choline dehydrogenase (CHD) is located in the inner membrane of mitochondria primarily in liver and kidney and catalyzes the oxidation of choline to glycine betaine. Its physiological role is to regulate the concentrations of choline and glycine betaine in the blood and cells. Choline is important for regulation of gene expression, the biosynthesis of lipoproteins and membrane phospholipids and for the biosynthesis of the neurotransmitter acetylcholine; glycine betaine plays important roles as a primary intracellular osmoprotectant and as methyl donor for the biosynthesis of methionine from homocysteine, a required step for the synthesis of the ubiquitous methyl donor S-adenosyl methionine. Recently, CHD has generated considerable medical attention due to its association with various human pathologies, including male infertility, homocysteinuria, breast cancer and metabolic syndrome. Despite the renewed interest, the biochemical characterization of the enzyme has lagged behind due to difficulties in the obtainment of purified, active and stable enzyme. This review article summarizes the medical relevance and the physiological roles of human CHD, highlights the biochemical knowledge on the enzyme, and provides an analysis based on the comparison of the protein sequence with that of bacterial choline oxidase, for which structural and biochemical information is available.

背景与目标： : 人胆碱脱氢酶 (CHD) 位于线粒体的内膜中，主要位于肝脏和肾脏中，并催化胆碱氧化为甘氨酸甜菜碱。它的生理作用是调节血液和细胞中胆碱和甘氨酸甜菜碱的浓度。胆碱对于调节基因表达，脂蛋白和膜磷脂的生物合成以及神经递质乙酰胆碱的生物合成很重要; 甘氨酸甜菜碱作为主要的细胞内渗透保护剂和甲基供体，从高半胱氨酸生物合成蛋氨酸，合成无处不在的甲基供体S-腺苷甲硫氨酸所需的步骤。最近，由于CHD与各种人类疾病有关，包括男性不育，同型半胱氨酸尿症，乳腺癌和代谢综合征，引起了广泛的医学关注。尽管重新引起了人们的兴趣，但由于难以获得纯化，活性和稳定的酶，该酶的生化特性仍然落后。本文综述了人类CHD的医学相关性和生理作用，重点介绍了该酶的生化知识，并根据蛋白质序列与细菌胆碱氧化酶的序列进行了比较，提供了结构和生化信息。

BACKGROUND & AIMS: OBJECTIVE:To describe the timing of cardiac arrest detection in relation to episodes of Medical Emergency Team (MET) review and routine nursing observations. DESIGN AND SETTING:Retrospective observational study in a university-affiliated hospital. PATIENTS:279 cardiac arrests involving ward patients MEASUREMENTS AND RESULTS:Cardiac arrests were allocated to one of 24 1-h intervals (24:00-00:59, 01:00-01:59, etc.). The actual hourly rate of cardiac arrests was related to the expected average hourly rate. Peak levels of cardiac arrest detection occurred during times of routine overnight nursing clinical observations between 02:00 and 03:00 (OR 3.06) and 06:00-07:00 (OR 1.95). The lowest level of cardiac arrest detection occurred between 20:00 and 21:00 (OR 0.42). After introduction of the MET there were 162 cardiac arrests, 28% of which occurred shortly after an initial MET call. The odds ratio for risk of cardiac arrest during periods of lowest MET activation (24:00-08:00) when compared with periods of highest MET activation (16:00-24:00) was 2.26. CONCLUSIONS:Cardiac arrest detection in our hospital is episodic with peak levels corresponding to periods of overnight routine nursing observations following a period when patient review is likely to be low. After the introduction of the MET there was an inverse link between detection of cardiac arrests and levels of MET activation over the 24-h period. Increased overnight utilization and earlier MET activation may further reduce the incidence of cardiac arrests at our hospital.

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BACKGROUND & AIMS: OBJECTIVES:The objectives of the study were (1) to assess similarities and differences between breast cancer patients and their husbands in terms of doctor-patient/spouse relationships and shared decision making; and (2) to investigate the association between breast cancer patients and husbands in terms of preference of type of doctor, doctor-patient relationship, and shared decision making regarding medical treatment. METHOD:Fifty-seven women with breast cancer, and their husbands, completed questionnaires measuring doctor-patient/spouse relationships (paternalism, autonomy), and decision making regarding medical treatment. RESULTS:Patients believe they have a key role in the medical decision-making process (93%) and that the participation of their husbands, and their agreement with the decision, is important (84% and 89%, respectively). Both breast cancer patients and their husbands prefer a shared decision-making process to paternalistic or autonomy-based approaches. CONCLUSION:In contrast to legal and bioethical approaches, which focus on the patient as the primary decision maker, this study reflects a practical recognition of the role of the breast cancer patient's husband in the decision-making process. It also reflects a relational rather than an individualistic perception of patient autonomy.

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BACKGROUND & AIMS: BACKGROUND:Limited data are available in our region on out-of-hospital treatment of cardiac arrest. The aim of this study is to evaluate whether the changes implemented in the emergency system (i.e. an increased number of basic life support and advance life support crews that were dispatched) produced the expected outcome improvements. METHODS:(a) EXPERIMENTAL DESIGN:data were prospectively collected on patients with sudden out-of-hospital cardiac arrest in three emergency dispatch centers for 3 months during two study periods, year 2000 and year 2003, differentiated only by the increase of qualified crews. Outcomes and survival were evaluated at 24 h and 1 month after the event. (b) SETTING:out-of-hospital treatment. (c) PATIENTS:352 (174 in the second study period) patients suffering cardiac arrest. (d) INTERVENTIONS:the study was observational. RESULTS:We could document, between the two study periods, stable 24 h (12.6 vs 9.1%) and 1 month survival (3.4 vs 5.8%, NS). Nevertheless, arrival time on site was significantly higher in the second period (from 8.3+/-3.3 to 10.1+/-5.4 min, P<0.05). CONCLUSIONS:The strengthening of only one link of the chain-of-survival did not improve 1 month survival.

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BACKGROUND & AIMS: AIMS:The aim of the present study was to compare the levels of stress, depression, and intention to leave among clinical nurses employed in different medical units in relation to their demographic characteristics under the National Health Insurance (NHI) System in Taiwan. METHODS:Cross-sectional Spearman's correlation, one-way ANOVA with Scheffe post hoc analysis tests, and multiple regression analyses were conducted. Several self-report questionnaires, such as the Center for Epidemiological Studies Depression Scale, the Perceived Stress Scale and Intention to Leave Scale, were administered. A total of 314 research participants were surveyed, all of whom came from regional hospitals in Northern Taiwan. RESULTS:Marital status and working tenure were significant predictors to the levels of stress, depression, and intention to leave among nurses before taking the medical units into consideration. However, with adding medical units as predictors, the effect of marital status and working tenure were insignificant except for the stress model, indicating medical units were showing dominant effect over other variables. In particular, internal medical ward (IMW) nurses experienced a higher prevalence of depression than emergency room (ER) nurses and professional nursing practitioners. External medical ward (EMW) nurses also experienced greater depression than emergency room (ER) nurses. Both IMW and EMW nurses perceived significantly greater stress than ER and dialysis center. Moreover, IMW nurses also perceived greater stress than operating room (OR) nurses and showed stronger intention to leave than their counterparts in the outpatient service departments. CONCLUSIONS:The results indicated that significant differences existed among various medical units with regards to nurses' stress, depression, and intention to leave. Nurses working in internal and external medical wards, especially the inexperienced and married ones, experienced greater depression and stress, thereby developing stronger intention to leave their job.

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BACKGROUND & AIMS: CONTEXT:Improved survival of children with cancer has been accompanied by multiple treatment-related complications. However, most studies in survivors of childhood cancer focused on only 1 late effect. OBJECTIVE:To assess the total burden of adverse health outcomes (clinical or subclinical disorders ["adverse events"]) following childhood cancer in a large cohort of childhood cancer survivors with long-term and complete medical follow-up. DESIGN, SETTING, AND POPULATION:Retrospective cohort study of 1362 five-year survivors of childhood cancer treated in a single institution in the Netherlands between 1966 and 1996. All survivors were invited to a late-effects clinic for medical assessment of adverse events. Adverse events occurring before January 2004 were graded for severity in a standardized manner. MAIN OUTCOME MEASURES:Treatment-specific prevalence of adverse events (according to severity) at end of follow-up and relative risk of high or severe burden of disease (> or =2 severe or > or =1 life-threatening or disabling adverse events) associated with various treatments. RESULTS:Medical follow-up was complete for 94.3% of survivors (median follow-up, 17.0 years). The median attained age at end of follow-up was 24.4 years. Almost 75% of survivors had 1 or more adverse events, and 24.6% had 5 or more adverse events. Furthermore, 40% of survivors had at least 1 severe or life-threatening or disabling adverse event. A high or severe burden of adverse events was observed in 55% of survivors who received radiotherapy only and 15% of survivors treated with chemotherapy only, compared with 25% of survivors who had surgery only (adjusted relative risks, 2.18 [95% confidence interval, 1.62-2.95] and 0.65 [95% confidence interval, 0.46-0.90], respectively). A high or severe burden of adverse events was most often observed in survivors of bone tumors (64%) and least often in survivors of leukemia or Wilms tumor (12% each). CONCLUSIONS:In young adulthood, a substantial proportion of childhood cancer survivors already has a high or severe burden of disease, particularly after radiotherapy. This underscores the need for lifelong risk-stratified medical surveillance of childhood cancer survivors.

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