Advance directives in the primary care setting

Advance directives have been available for more than 20 years, yet only 2% of patients report having had a discussion about them with their physician. Physicians and patients appear to be reluctant to bring up the subject despite evidence that patients not only want help with advance directives, but report more satisfaction with their health care when the topic is addressed. The primary care setting is particularly well-suited to the establishment of advance directives. A clearer understanding of the benefits of advance directives to physicians and their patients can hopefully increase the use of this important health care resource.     

Working in a ‘third space’: a closer look at the hybridity,identity and agency of nurse practitioners

Nurse practitioners (NPs), as advanced practice nurses, have evolved over the years to become recognized as an important and growing trend in Canada and worldwide. In spite of sound evidence as to the effectiveness of NPs in primary care and other care settings, role implementation and integration continue to pose significant challenges. This article utilizes postcolonial theory, as articulated by Homi Bhabha, to examine and challenge traditional ideologies and structures that have shaped the development, implementation and integration of the NP role to this day. Specifically, we utilize Bhabha's concepts of third space, hybridity, identity and agency in order to further conceptualize the nurse practitioner role, to examine how the role challenges some of the inherent assumptions within the healthcare system and to explore how development of each to these concepts may prove useful in integration of nurse practitioners within the healthcare system. Our analysis casts light on the importance of a broader, power structure analysis and illustrates how colonial assumptions operating within our current healthcare system entrench, expand and re‐invent, as well as mask the structures and practices that serve to impede nurse practitioner full integration and contributions. Suggestions are made for future analysis and research.     

经尿道等离子血供预断式前列腺三分区法剜切术的临床观察*

目的观察经尿道等离子血供预断式前列腺三分区法剜切术(PKERPDPB)治疗前列腺增生(BPH)的安全性和疗效。方法 158例患者,随机分成两组,观察组81例采用PKERPDPB,对照组77例采用经尿道等离子电切术(PKRP),比较两组手术时间、切除前列腺组织重量、术中出血量、术后导尿管留置时间、住院时间及术中并发症。术后随访12个月,比较两组患者国际前列腺症状评分(IPSS)、生活质量评分(QOL)、最大尿流率(Qmax)、膀胱残余尿量(PVR)及远期手术并发症等指标的变化。结果两组患者平均年龄、术前前列腺体积、IPSS、QOL及PVR差异均无统计学意(P0.05),观察组及对照组切除前列腺组织重量分别为(61.8±10.5)和(32.5±12.6)g;术中出血量分别为(98.7±15.8)和(160.5±16.5)ml;术后导尿管留置时间分别为(5.3±0.8)和(7.5±1.2)d;住院时间分别为(5.8±1.6)和(8.8±1.5)d,差异均有统计学意义(P0.05)。随访至12个月时,两组IPSS、QOL和Qmax术后较术前明显改善,差异有统计学意义(P0.01)。两组之间术后IPSS、QOL、Qmax及PVR相比差异无统计学意义(P0.05)。结论 PKERPDPB相比传统PKRP,疗效相似,但切除组织更彻底,术中出血更少,术后导尿管留置时间及住院时间更短,安全有效。     

一枝蒿提取物对小鼠胃肠运动的影响

目的观察一枝蒿水提物对小鼠胃肠运动的影响,探讨其作用机制。方法将小鼠随机分为正常对照组、多潘立酮组及一枝蒿水提物高、中、低剂量组。灌胃给药5d后,以葡聚糖蓝2000为标记物,观察色素在5组小鼠胃内的残留比,以及幽门括约肌至色素最前端及至盲肠的距离比。结果一枝蒿高剂量组及多潘立酮组的胃残留率、肠推进率与对照组比较,差异有统计学意义（P〈0．05,P〈0．01）,2组之间差异无统计学意义（P〉0．05）。结论一枝蒿水提物能有效改善小鼠的胃肠动力。     

国内医学信息素质教育的研究进展

信息素质作为一种获取、评价和利用信息的潜在能力,已日益成为社会高度关注的重要问题,信息素质教育也是国内外高等教育十分重视的热点。本文从医学信息素质教育的基本内涵及意义、方法及模式、现状及存在问题和加强医学信息素质教育的途径与措施进行综述。     

组合式推移皮瓣修复多发性褥疮

目的探讨组合式推移皮瓣修复骶尾、粗隆、坐骨结节多处巨大褥疮的临床方法。方法用组合式推移皮瓣修复骶尾、粗隆、坐骨结节多处巨大褥疮13例,其中骶尾部6例;股骨粗隆4例;坐骨结节3例。均为四度褥疮。手术彻底扩创后,根据创面及潜在腔隙的大小、皮瓣张力情况选择皮瓣的组合方式,将皮瓣覆盖整个创面。所有病例均获随访1～6年。结果术后皮瓣全部成活。其中2例伤口窦道形成,经二次？刮后痊愈。结论组合式推移皮瓣可修复骶尾、粗隆、坐骨结节多处褥疮,一次性消灭创面。皮瓣设计组合灵活,手术操作简单,是修复多处褥疮较大软组织缺损的一种有效方法。     

中医“四诊”在急诊预检分诊中的应用

目的探讨中医四诊法在急诊预检分诊中的应用效果及中医诊断思维与西医临床的结合。方法选取我院2008年1月-2010年12月急诊预检分诊中采用中医四诊法的患者382例,分析预检分诊时中医四诊的具体应用及分诊效果,探讨临床价值。结果382急诊患者分诊时间平均为（3．5±1．5）min,初步诊断与最终诊断符合率达到96．07％（367／382）。达到急诊预检分诊目的,符合分诊要求。结论中医四诊在急诊预检分诊中具有快速、简便的特点,有较高的诊断符合率,具有积极的临床应用价值。     

Role of a rapid response system and code status discussion as determinants of prognosis for critical inpatients: An observational study in a Japanese urban hospital

Rapid response systems (RRS) have been introduced worldwide to reduce unpredicted in-hospital cardiac arrest (IHCA) and in-hospital mortality. The role of advance care planning (ACP) in the management of critical patients has not yet been fully determined in Japan.We retrospectively assessed the characteristics of all inpatients with unpredicted IHCA in our hospital between 2016 and 2018. Yearly changes in the number of RRS activations and the incidence of unpredicted IHCA with or without code status discussion were evaluated from 2014 to 2018. Hospital standardized mortality ratios were assessed from the data reported in the annual reports by the National Hospital Organization.A total of 81 patients (age: 70.9 ± 13.3 years) suffered an unpredicted IHCA and had multiple background diseases, including heart disease (75.3%), chronic kidney disease (25.9%), and postoperative status (cardiovascular surgery, 18.5%). Most of the patients manifested non-shockable rhythms (69.1%); survival to hospital discharge rate was markedly lower than that with shockable rhythms (26.8% vs 72.0%, P < .001). The hospital standardized mortality ratios was maintained nearly constant at approximately 50.0% for 3 consecutive years. The number of cases of RRS activation markedly increased from 75 in 2014 to 274 patients in 2018; conversely, the number of unpredicted IHCA cases was reduced from 40 in 2014 to 18 in 2018 (P < .001). Considering the data obtained in 2014 and 2015 as references, the RRS led to a reduction in the relative risk of unpredicted IHCA from 2016 to 2018 (ie, 0.618, 95% confidence interval 0.453–0.843). The reduction in unpredicted IHCA was attributed partly to the increased number of patients who had discussed the code status, and a significant correlation was observed between these parameters (R² = 0.992, P < .001). The reduction in the number of patients with end-stage disease, including congestive heart failure and chronic renal failure, paralleled the incidence of unpredicted IHCA.Both RRS and ACP reduced the incidence of unpredicted IHCA; RRS prevents progression to unpredicted IHCA, whereas ACP decreases the number of patients with no code status discussion and thus potentially reducing the patient subgroup progressing to an unpredicted IHCA.     

Advances of radiation oncology in China

Radiation therapy is one of the main treatment .modalities used in cancer management. It is the primary curative modality for about 30% of patients with cancer, and more than half of all cancer patients received radiation therapy sometime during the course of their disease. It is estimated that 70% of the patients with cancer required radiation therapy in China.1 Radiation oncology is based on the development of radiological physics, radiological biology and clinical oncology.