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儿童无症状性血尿分级诊疗模式的探讨
Study of hierarchical diagnosis and treatment model of asymptomatic hematuria in Children
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DOI:
作者:
龚一女,徐虹,沈茜,李正秀,谢岳林,蒋慧芬,陆文,翟亦晖,方晓燕
GONG Yinv, XU Hong, SHEN Qian, LI Zhengxiu, XIE Yuelin, JIANG Huifen, LU Wen, ZHAI Yihui, FANG Xiaoyan
作者单位:
1 复旦大学附属儿科医院肾脏风湿科 2上海市嘉定区中心医院儿科 3上海市嘉定区卫生和计划生育委员会医政科 4上海市宝山区疾病预防控制中心学校卫生科 5上海市宝山区中西医结合医院肾内科
1 Department of Nephrology and Rheumatology, Children’s Hospital of Fudan University, Shanghai, 201102, China 2 Department of Pediatrics, Jiading Central Hospital, Shanghai, 201800, China 3 Medical Affairs Section, Municipal Commission of Health and family planning, Jiading District, Shainghai, 201800, China 4 School Health Section, The Center for Disease Prevention and Control, Baoshan District, Shanghai, 201901, China 5 Department of Nephrology, Baoshan Integrated traditional Chinese and Western Medicine Hospital, Shanghai, 201901, China
关键词:
分级诊疗;儿童;无症状性血尿;学校尿液筛查
hierarchical diagnosis and treatment; children; asymptomatic hematuria; school urine screening
摘要:
背景:无症状性血尿病因复杂,大部分预后良好,仍有少数会出现蛋白尿,甚至肾功能损害,长期随访非常重要。本项目拟通过在上海市嘉定区和宝山区构建分级诊疗模式并进行无症状性血尿分级诊疗实践性研究,探索和完善“上海市学校尿液筛查网络化建设”的有效模式。 方法:2013年~2015年,由复旦大学附属儿科医院牵头,通过疾病筛查监测网络构建、相关临床数据信息化管理、人才队伍建设与区级医院开设专病门诊等三方面在嘉定区和宝山区试点建立分级诊疗模式,并对这两个区学校尿液筛查发现的隐血/蛋白尿学生实践无症状性血尿分级诊疗。 结果:1. 分级诊疗的构建1)形成由嘉定区、宝山区学校尿液筛查机构(一级)-嘉定区中心医院和宝山区中西医结合医院(二级)-复旦大学附属儿科医院(三级)的疾病筛查监测网络。2)开发并应用互联网尿液筛查数据库,对区级医院和儿童专科医院就诊/随访学生的临床资料进行信息化管理,并定期质控。3)协助区级医院组建儿童肾脏病诊疗队伍以及开设尿液筛查专病门诊。2. 分级诊疗的实践 1)共筛查嘉定区和宝山区20所初中4930名学生,发现隐血和/或蛋白尿70例(1.42%,70/4930)。2)区级医院首诊69例(首诊率为98.6%,69/70);复旦大学附属儿科医院转诊1例(50%,1/2),评估后为单纯性镜下血尿转回区级医院随访;区级医院单纯性镜下血尿随访20例(100%,20/20)。3.信息化管理嘉定区中心医院及宝山区中西医结合医院的相关临床数据。综合数据登记系统及电子登记表,信息化管理达100%。 结论:无症状性血尿分级诊疗可行性强,能提高学校尿液筛查阳性者的就诊率和随访率,是实现上海市学校尿液筛查网络化建设的有效模式,有望成为儿童慢性肾脏病二级预防的有力手段。区级医院儿科经过专科培训后可以承担当地儿童肾脏疾病常见症状的诊疗,在分级诊疗实行中发挥重要作用。
Backgrounds Childhood asymptomatic hematuria was extremely common according to screening study of chronic kidney disease (CKD), most cases with good prognosis, whereas there were still a few would develop proteinuria, even renal impairment, so long-term follow-up is very necessary. This project intends to establish the hierarchical diagnosis and treatment model in Jiading and Baoshan district of Shanghai, combined with practical studies of asymptomatic hematuria management in children to explore the effective mode of School urine screening network in Shanghai. Methods From 2013 to 2015, led by Children’s Hospital of Fudan University, we established the hierarchical diagnosis and treatment model in Jiading and Baoshan District through building disease screening and monitoring network, information management system for clinical data, and talent teams and sub-specialty outpatient service in district hospitals. Then we implemented the model to practice asymptomatic hematuria management among students with urine occult blood and/or proteinuria found in school urine screening in these two areas. Results 1. Model building 1) Disease screening and monitoring network consisted of Jiading and Baoshan district school urine screening agency (level 1) -District hospitals (level 2)- Children’s Hospital of Fudan University(level 3). 2) We developed a database based on Internet for registering related clinical data of cases with asymptomatic hematuria consulted in district hospitals and children's hospital, as well as carrying on quality control regularly. 3) We assisted district hospitals in building talent teams capable of diagnosing and managing children with kidney diseases by training and opening urine screening outpatient service in district hospitals. 2. Practical Study 1) Screening data: 4930 students from 20 primary schools in Jiading and Baoshan district were screened in this project, 70 students (1.42%, 70/4930) with urine occult blood and/or proteinuria was found. 2) Referral and follow-up situation: 69 students of 70 went to district hospitals (the first referral rate was 98.6%, 69/70) and 20 got a diagnosis of asymptomatic hematuria. 2 cases were evaluated as severe and should be transferred to Children’s Hospital of Fudan University, while 1 case (50%, 1/2) completed referral, who was microscopic haematuria after the assessment, transferred back to the district hospital for follow-up. All the 20 cases with microscopic haematuria followed up in district hospitals (100%, 20/20). 3. Data management: All the relevant clinical data in Jiading and Baoshan district hospital were registered in our database and uniform charts. Conclusions Hierarchical diagnosis and treatment model of asymptomatic hematuria was feasible, improving the management of students with positive findings found in school urine screening, making it possible for the construction of Shanghai school urine screening network. It would become powerful tool for secondary prevention of chronic kidney disease (CKD) in children. And district hospitals played an important role in hierarchical diagnosis and treatment model.
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