颅脑外伤患者的呼吸道护理干预研究

呼吸道护理干预能够有效地控制脑外伤患者的肺部感染,改善呼吸功能。文章通过分析总结大量颅脑外伤患者的临床资料,探讨了颅脑外伤患者呼吸道护理的方法和经验。     

Modeling economic implications of alternative treatment strategies for acute bacterial skin and skin structure infections

Objective:

The economic implications from the US Medicare perspective of adopting alternative treatment strategies for acute bacterial skin and skin structure infections (ABSSSIs) are substantial. The objective of this study is to describe a modeling framework that explores the impact of decisions related to both the location of care and switching to different antibiotics at discharge.

Methods:

A discrete event simulation (DES) was developed to model the treatment pathway of each patient through various locations (emergency department [ED], inpatient, and outpatient) and the treatments prescribed (empiric antibiotic, switching to a different antibiotic at discharge, or a second antibiotic). Costs are reported in 2012 USD.

Results:

The mean number of days on antibiotic in a cohort assigned to a full course of vancomycin was 11.2 days, with 64% of the treatment course being administered in the outpatient setting. Mean total costs per patient were $8671, with inpatient care accounting for 58% of the costs accrued. The majority of outpatient costs were associated with parenteral administration rather than drug acquisition or monitoring. Scenarios modifying the treatment pathway to increase the proportion of patients receiving the first dose in the ED, and then managing them in the outpatient setting or prescribing an oral antibiotic at discharge to avoid the cost associated with administering parenteral therapy, therefore have a major impact and lower the typical cost per patient by 11–20%. Since vancomycin is commonly used as empiric therapy in clinical practice, based on these analyses, a shift in treatment practice could result in substantial savings from the Medicare perspective.

Conclusions:

The choice of antibiotic and location of care influence the costs and resource use associated with the management of ABSSSIs. The DES framework presented here can provide insight into the potential economic implications of decisions that modify the treatment pathway.     

生大黄联合乌司他汀治疗重症急性胰腺炎临床疗效观察

目的观察生大黄联合乌司他汀治疗重症急性胰腺炎的临床疗效。方法入选济宁市附属医院住院确诊的重症急性胰腺炎患者88例,随机分成治疗组、对照组两组。对照组给予禁饮食、胃肠减压、抑酸、抗生素、补充血容等对症支持治疗,治疗组在上述治疗基础上加用生大黄粉及乌司他汀。结果生大黄联合乌司他汀治疗后,治疗组CRP浓度、血尿淀粉酶、白细胞数均较对照组显著降低,肝功能损害较入院时明显好转。结论生大黄联合乌司他汀治疗重症急性胰腺炎疗效好。     

Cost-effectiveness of mechanical thrombectomy for acute ischemic stroke: an Australian payer perspective

Aims: The goal of this study was to assess the cost-effectiveness of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) from an Australian payer perspective.

Methods: This study used a Markov model that employed a life-time time horizon, modeling patients from symptom onset of stroke until end of life. Clinical efficacy and safety data were taken from an individual patient level data (IPD) meta-analysis of clinical studies. The treatment effect of MT compared to usual care was measured by changes in modified Rankin Score (mRS). Post-treatment mRS scores were used to determine short- and long-term stroke care costs. Treatment costs were modeled, with health state utility values determined by literature review. All analyses were conducted using Microsoft Excel.

Results: In comparison to usual care, MT is associated with higher costs ($10,666 per patient) and additional quality-adjusted life years (QALYs) (0.8281 per patient), resulting in an incremental cost per QALY of $12,880. Sensitivity analyses demonstrated the reliability of the base case results across a range of assumptions. The higher cost associated with MT is, to an extent, offset by the cost savings resulting from lower stroke care costs due to improved patient outcomes. The life-time cost savings in terms of stroke care costs are estimated to be more than $8,000 per patient for patients who had received MT in combination with usual care.

Limitations: Stroke care costs based on patient disability/functional level were not available and were derived. As a consequence, long-term care costs for patients with poorer outcomes may be under-estimated. Patient outcomes at 90 days were extrapolated to a lifetime horizon, but this approach was supported by long-term evidence on stroke survival.

Conclusions: Mechanical thrombectomy is a cost-effective treatment option for AIS, with clinical benefits translating to short- and long-term cost benefits. This analysis supports rapid update of stroke care pathways to incorporate this therapy as a treatment option.     

Cost-effectiveness of blinatumomab versus salvage chemotherapy in relapsed or refractory Philadelphia-chromosome-negative B-precursor acute lymphoblastic leukemia from a US payer perspective

Objective: To evaluate the cost-effectiveness of blinatumomab (Blincyto) vs standard of care (SOC) chemotherapy in adults with relapsed or refractory (R/R) Philadelphia-chromosome-negative (Ph?) B-precursor acute lymphoblastic leukemia (ALL) based on the results of the phase 3 TOWER study from a US healthcare payer perspective.

Methods: The Blincyto Global Economic Model (B-GEM), a partitioned survival model, was used to estimate the incremental cost-effectiveness ratio (ICER) of blinatumomab vs SOC. Response rates, event-free survival (EFS), overall survival (OS), numbers of cycles of blinatumomab and SOC, and transplant rates were estimated from TOWER. EFS and OS were estimated by fitting parametric survival distributions to failure-time data from TOWER. Utility values were based on EORTC-8D derived from EORTC QLQ-C30 assessments in TOWER. A 50-year lifetime horizon and US payer perspective were employed. Costs and outcomes were discounted at 3% per year.

Results: The B-GEM projected blinatumomab to yield 1.92 additional life years and 1.64 additional quality-adjusted life years (QALYs) compared with SOC at an incremental cost of $180,642. The ICER for blinatumomab vs SOC was estimated to be $110,108/QALY gained in the base case. Cost-effectiveness was sensitive to the number and cost of inpatient days for administration of blinatumomab and SOC, and was more favorable in the sub-group of patients who had received no prior salvage therapy. At an ICER threshold of $150,000/QALY gained, the probability that blinatumomab is cost-effective was estimated to be 74%.

Limitations: The study does not explicitly consider the impact of adverse events of the treatment; no adjustments for long-term transplant rates were made.

Conclusions: Compared with SOC, blinatumomab is a cost-effective treatment option for adults with R/R Ph???B-precursor ALL from the US healthcare perspective at an ICER threshold of $150,000 per QALY gained. The value of blinatumomab is derived from its incremental survival and health-related quality-of-life (HRQoL) benefit over SOC.     

PBL教学法在呼吸内科临床见习教学中的应用实践

目的:探讨PBL教学模式在呼吸内科临床教学中的应用效果。方法:选取2012年临床专业毕业在我院实习的200名学生,将学生随机分为两组,观察组学生100名,对照组学生100名。对照组学生接受传统教学。观察组学生在传统教学方法的基础上接受PBL教学。结果:观察组基础成绩和对照组基础成绩比较(P>0.05)无统计学意义,而观察组综合成绩明显优于对照组,(P<0.05)有统计学意义。结论:PBL教学模式在呼吸内科临床教学中能取得较好的教学效果,值得推广应用。     

急性脑梗死患者早期血清C-反应蛋白测定及临床意义

为了探讨血清C-反应蛋白（CRP）测定在急性脑梗死早期的临床价值 ,采用透射比浊法测定158例急性脑梗死患者入院后48小时内血清标本和30例体检健康者的血清标本中CRP水平,以CRP＞8mg/L为阳性,按临床及CT扫描结果分组比较.结果发现急性脑梗死患者轻、中、重各组血清CRP水平均明显升高,均显著高于正常对照组.在轻、中、重各组中,CRP水平也存在明显不同,随临床神经功能缺损程度的加重,CRP水平升高;急性脑梗死患者发病早期血清CRP阳性率为53.8%,而正常对照组中无1例阳性;急性脑梗死患者发病早期血清CRP阳性者其病死率显著高于CRP阴性者.认为可通过临床上检测急性脑梗死患者血清CRP的变化来判断病情及评估预后.     

Hospital costs associated with intraoperative hypotension among non-cardiac surgical patients in the US: a simulation model

Objective: Recent studies indicate intraoperative hypotension, common in non-cardiac surgical patients, is associated with myocardial injury, acute kidney injury, and mortality. This study extends on these findings by quantifying the association between intraoperative hypotension and hospital expenditures in the US.

Methods: Monte Carlo simulations (10,000 trial per simulation) based on current epidemiological and cost outcomes literature were developed for both acute kidney injury (AKI) and myocardial injury in non-cardiac surgery (MINS). For AKI, three models with different epidemiological assumptions (two models based on observational studies and one model based on a randomized control trial [RCT]) estimate the marginal probability of AKI conditional on intraoperative hypotension status. Similar models are also developed for MINS (except for the RCT case). Marginal probabilities of AKI and MINS sequelae (myocardial infarction, congestive heart failure, stroke, cardiac catheterization, and percutaneous coronary intervention) are multiplied by marginal cost estimates for each outcome to evaluate costs associated with intraoperative hypotension.

Results: The unadjusted (adjusted) model found hypotension control lowers the absolute probability of AKI by 2.2% (0.7%). Multiplying these probabilities by the marginal cost of AKI, the unadjusted (adjusted) AKI model estimated a cost reduction of $272 [95% CI?=?$223–$321] ($86 [95% CI?=?$47–$127]) per patient. The AKI model based on relative risks from the RCT had a mean cost reduction estimate of $281 (95% CI?=?–$346–$750). The unadjusted (adjusted) MINS model yielded a cost reduction of $186 [95% CI?=?$73–$393] ($33 [95% CI?=?$10–$77]) per patient.

Conclusions: The model results suggest improved intraoperative hypotension control in a hospital with an annual volume of 10,000 non-cardiac surgical patients is associated with mean cost reductions ranging from $1.2–$4.6 million per year. Since the magnitude of the RCT mean estimate is similar to the unadjusted observational model, the institutional costs are likely at the upper end of this range.     

喜炎平治疗小儿呼吸道合胞病毒感染性肺炎的临床疗效

目的探讨喜炎平治疗小儿呼吸道合胞病毒感染性肺炎的临床疗效。方法选取2012年1月至2013年12月我院收治的小儿呼吸道合胞病毒感染性肺炎患儿128例,随机将其分为对照组和治疗组,各64例。对照组患儿给予利巴韦林注射液静脉滴注治疗;治疗组患儿给予喜炎平注射液静脉滴注治疗。观察并比较两组患儿的临床疗效及咳喘消失时间、肺部啰音消失时间、退热时间、住院时间。结果治疗组患儿总有效率为98.4%,明显优于对照组的85.9%,差异有统计学意义(P<0.05);治疗组患儿咳喘消失时间、肺部啰音消失时间、退热时间及住院时间均明显短于对照组,差异有统计学意义(P<0.05)。结论采用喜炎平注射液治疗小儿呼吸道合胞病毒感染性肺炎疾病,疗效明显,安全性高,且不良反应少。