BMJ (Clinical research ed.)最新文献

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Obamacare lives on as Republicans fail to agree replacement. 由于共和党未能就替代方案达成一致，奥巴马医改得以延续。

IF 105.7

BMJ (Clinical research ed.)

Pub Date : 2017-09-28 DOI: 10.1136/bmj.j4514

Owen Dyer

Republican leaders in the US Senate have decided against a vote on their party’s latest attempt to repeal and replace the Affordable Care Act, otherwise known as Obamacare.Defections by Republican senators John McCain and Ted Cruz over the weekend of 23 and 24 September doomed the bill’s chances. And on 26 September, within minutes of the independent Congressional Budget Office releasing its analysis of the repeal bill, the Republican senator Susan Collins confirmed that she too would vote against it, leaving the party at least two votes short of the 50 needed.At a …

引用次数: 1

An atypical, non-healing perioral lesion. 一种非典型的、不愈合的口周病变。

IF 105.7

BMJ (Clinical research ed.)

Pub Date : 2017-09-28 DOI: 10.1136/bmj.j3823

Vinay Naresh Mistry, Mohamed Imran Suida, Deborah Kirkham, Michael Wing Sung Ho

A 57 year old man was referred urgently to the oral and maxillofacial surgery clinic. He described a three month history of fatigue, recurrent sore throats, and a persistent “cold sore.” An irregular and indurated ulcer was present on the right oral commissure (fig 1⇓), and an ipsilateral swelling was palpable in the submandibular triangle (fig 2⇓). He had no relevant medical history. He drank little alcohol and was a non-smoker.Fig 1 Irregular and indurated ulcer present on the right oral commissureFig 2 Ipsilateral swelling palpable in the submandibular triangle### 1. What are the most important differential diagnoses to consider?#### Short answerThe most important differential diagnoses to consider include herpes labialis, primary syphilis, and squamous cell carcinoma.#### DiscussionPrimary syphilis should be considered alongside herpes simplex labialis if the symptoms do not resolve in 10-14 days.1 Association with other red flags such as induration, bleeding, and concurrent cervical lymphadenopathy should prompt fast track referral to the local head and neck oncology clinic. Malaise is a common feature of syphilis that would not normally be seen at an early stage of squamous cell carcinoma.Cases of syphilis have risen dramatically in recent years. In the UK, USA, and other Western countries, this rise has been most marked in men who have sex with men, so taking a targeted sexual history is essential.2 Syphilis is classified …

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引用次数: 3

Diagnosis and management of postpartum haemorrhage. 产后出血的诊断与处理。

IF 105.7

BMJ (Clinical research ed.)

Pub Date : 2017-09-27 DOI: 10.1136/bmj.j3875

Edwin Chandraharan, Archana Krishna

#### What you need to knowPostpartum haemorrhage is a major cause of death during pregnancy and early motherhood, accounting for 25% of maternal deaths worldwide,1 and is the second leading direct cause of maternal deaths in the UK.2 It is defined as blood loss of more than 500 mL from the female genital tract after delivery of the fetus (or >1000 mL after a caesarean section). Primary postpartum haemorrhage occurs within the first 24 hours of delivery, whereas secondary postpartum haemorrhage occurs between 24 hours and 12 weeks after delivery and is less common.1 For every maternal death due to postpartum haemorrhage, there are at least 10 “near-misses.” Serious maternal morbidities include multiorgan failure, multiple blood transfusion, and peripartum hysterectomy.1 There have been recent advances in the management of postpartum haemorrhage secondary to coagulopathy and abnormal invasion of the placenta.3This review highlights the causes, diagnosis, and management of postpartum haemorrhage and is aimed at those involved in obstetric and postnatal care.#### Sources and selection criteriaWe searched PubMed using the key words “postpartum haemorrhage,” “balloon tamponade,” “uterine compression suture,” “embolization,” and “obstetric haemorrhage” from 1981 to 2016. We also considered review articles from 2001 to 2016 …

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引用次数: 48

Multiple choice questions: general surgery. 选择题:普外科。

IF 105.7

BMJ (Clinical research ed.)

Pub Date : 2017-09-27 DOI: 10.1136/sbmj.j3072

引用次数: 0

Telephone first consultations in primary care. 初级保健第一次电话咨询。

BMJ (Clinical research ed.)

Pub Date : 2017-09-27 DOI: 10.1136/bmj.j4345

Brian McKinstry, John Campbell, Chris Salisbury

引用次数: 0

Five minutes with . . . Tom Treasure. 五分钟……汤姆的宝藏。

IF 105.7

BMJ (Clinical research ed.)

Pub Date : 2017-09-27 DOI: 10.1136/bmj.j4472

Anne Gulland

The cardiothoracic surgeon describes the birth of heart surgery

引用次数: 1

Should we welcome plans to sell off NHS land? 我们应该欢迎出售NHS土地的计划吗?

IF 105.7

BMJ (Clinical research ed.)

Pub Date : 2017-09-27 DOI: 10.1136/bmj.j4290

Robert Naylor, Kailash Chand

The government seems likely to back the recommendations of Robert Naylor to raise capital by selling off inefficiently used assets, but Kailash Chand worries that services could be threatened and that public consultation is lacking

引用次数: 3

When the only reasonable response is to be unreasonable. 唯一合理的回应就是不讲理。

IF 105.7

BMJ (Clinical research ed.)

Pub Date : 2017-09-27 DOI: 10.1136/bmj.j4206

Michael O'Donnell

Like Oliver, I’m uneasy with medical committees making the assumption that all progress will come through consensus.1Consensus is a commendable way to stabilise established positions but is no way to seek ideas. As the full quote from Bernard Shaw’s Man and Superman …

引用次数: 0

Evaluation of telephone first approach to demand management in English general practice: observational study. 电话第一方法在英语全科医疗需求管理中的评价：观察研究。

BMJ (Clinical research ed.)

Pub Date : 2017-09-27 DOI: 10.1136/bmj.j4197

Jennifer Newbould, Gary Abel, Sarah Ball, Jennie Corbett, Marc Elliott, Josephine Exley, Adam Martin, Catherine Saunders, Edward Wilson, Eleanor Winpenny, Miaoqing Yang, Martin Roland

Objective To evaluate a "telephone first" approach, in which all patients wanting to see a general practitioner (GP) are asked to speak to a GP on the phone before being given an appointment for a face to face consultation.Design Time series and cross sectional analysis of routine healthcare data, data from national surveys, and primary survey data.Participants 147 general practices adopting the telephone first approach compared with a 10% random sample of other practices in England.Intervention Management support for workload planning and introduction of the telephone first approach provided by two commercial companies.Main outcome measures Number of consultations, total time consulting (59 telephone first practices, no controls). Patient experience (GP Patient Survey, telephone first practices plus controls). Use and costs of secondary care (hospital episode statistics, telephone first practices plus controls). The main analysis was intention to treat, with sensitivity analyses restricted to practices thought to be closely following the companies' protocols.Results After the introduction of the telephone first approach, face to face consultations decreased considerably (adjusted change within practices -38%, 95% confidence interval -45% to -29%; P<0.001). An average practice experienced a 12-fold increase in telephone consultations (1204%, 633% to 2290%; P<0.001). The average duration of both telephone and face to face consultations decreased, but there was an overall increase of 8% in the mean time spent consulting by GPs, albeit with large uncertainty on this estimate (95% confidence interval -1% to 17%; P=0.088). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase. Compared with other English practices in the national GP Patient Survey, in practices using the telephone first approach there was a large (20.0 percentage points, 95% confidence interval 18.2 to 21.9; P<0.001) improvement in length of time to be seen. In contrast, other scores on the GP Patient Survey were slightly more negative. Introduction of the telephone first approach was followed by a small (2.0%) increase in hospital admissions (95% confidence interval 1% to 3%; P=0.006), no initial change in emergency department attendance, but a small (2% per year) decrease in the subsequent rate of rise of emergency department attendance (1% to 3%; P=0.005). There was a small net increase in secondary care costs.Conclusions The telephone first approach shows that many problems in general practice can be dealt with over the phone. The approach does not suit all patients or practices and is not a panacea for meeting demand. There was no evidence to support claims that the approach would, on average, save costs or reduce use of secondary care.

目的评估一种“电话优先”的方法，在这种方法中，所有想要看全科医生（GP）的患者都被要求在电话上与全科医生交谈，然后再预约面对面的咨询。设计对常规医疗保健数据、国家调查数据和主要调查数据进行时间序列和横断面分析。参与者采用电话第一方法的147个一般做法与英国10%的其他做法随机抽样进行比较。两家商业公司为工作量规划和采用电话优先方法提供干预管理支助。主要结果测量就诊次数，总就诊时间（59次电话首次就诊，无对照）。患者体验（全科医生患者调查，电话首次实践加对照）。二级保健的使用和费用（医院事件统计，电话首次实践加上对照）。主要分析是治疗意向，敏感性分析仅限于被认为密切遵循公司协议的做法。结果采用电话优先就诊方式后，就诊人数明显减少(调整后实践内变化-38%，95%置信区间-45% ~ -29%；结论电话优先的方法表明，在一般实践中许多问题可以通过电话处理。该方法并不适合所有患者或实践，也不是满足需求的灵丹妙药。没有证据支持这样的说法，即平均而言，这种方法会节省成本或减少二级保健的使用。

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引用次数: 0

Whistleblowing: a word of warning from an unreasonable man. 告密:一个不讲理的人发出的警告。

IF 105.7

BMJ (Clinical research ed.)

Pub Date : 2017-09-27 DOI: 10.1136/bmj.j4205

Hendrik J Beerstecher

Oliver points to the moral, ethical, and professional guidance for blowing the whistle on systematic problems in the NHS.1 This is all well and good if you want to be investigated by the NHS and the General Medical Council (GMC). But if you want to keep your job and registration and to avoid years of …

引用次数: 0

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