运用PDCA循环持续推进科室质量规范化建设

为了探讨PDCA在科室质量规范化建设中的应用,本研究以科室质量小组为抓手,科学开展Plan、Do、Check、Action阶段管理,通过现状分析进行工作筹划,采用加强管理机制、细化质量活动范畴、加强质量管理宣贯、规范质量改进项目、创新信息化管理等措施,开展质量持续改进工作。以质量监管"大环"运作,带动科室质量"小环"运转。通过一系列整改,医疗质量指标稳步提升,科室规范化发展,形成了一系列制度、流程和规范,安全文化氛围日渐浓厚。医院构建专业化质量管理模式,深化质量管理教育,加大质控信息化建设,可推动医疗质量持续改进。     

Demise of the stethoscope

Medical practice has undergone a massive drift over the past several years. With the advent of modernization and technical advancements in both diagnostic and therapeutic fields, bedside clinical skills have suffered a setback. Increasing patient load in the hospitals, administrative commitments of the physicians, and need to get superspecialty fellowships are some of the factors which preclude resident teaching, which, in-turn hamper their long-term clinical skills and influence the patient–doctor relationship. In this perspective, I narrate my own experience regarding changing attitude of the younger generation of doctors toward patient care and also describe the role of a mentor in shaping the believes and practices of his medical students. Using real-world examples, I further discuss the obstacles which hamper good medical practice and suggest possible ways to overcome some of them.     

Lessons Learned from the Reimbursement Profile of a Mature Private Medical Toxicology Practice: Office-Based Practice Pays

We previously reported the financial data for the first 5 years of one of the author’s medical toxicology practice. The practice has matured; changes have been made. The practice is increasing its focus on office-based encounters and reducing hospital-based acute care encounters. We report the reimbursement rates and other financial metrics of the current practice. Financial records from October 2009 through September 2013 were reviewed. This is a period of 4 fiscal years and represents the currently available financial data. Charges, payments, and reimbursement rates were recorded according to the type and setting of the medical toxicology encounter: forensic consultations, outpatient clinic encounters, nonpsychiatric inpatient consultations, emergency department (ED) consultations, and inpatient psychiatric consultations. All patients were seen regardless of ability to pay or insurance status. The number of billed Current Procedural Terminology (CPT) codes for office-based encounters increased over the study period; the number of billed CPT codes for inpatient and ED consultations reduced. Office-based encounters demonstrate a higher reimbursement rate and higher payments. In the fiscal year (FY) of 2012, office-based revenue exceeded hospital-based acute care revenue by over $140,000 despite a higher number of billed CPT encounters in acute care settings, and outpatient payments were 2.39 times higher than inpatient, inpatient psychiatry, observation unit, and ED payments combined. The average payment per CPT code was higher for outpatient clinic encounters than inpatient encounters for each fiscal year studied. There was an overall reduction in CPT billing volume between FY 2010 and FY 2013. Despite this, there was an increase in total practice revenue. There was no change in payor mix, practice logistics, or billing/collection service company. In this medical toxicology practice, office-based encounters demonstrate higher reimbursement rates and overall payments compared to inpatient and ED consultations. While consistent with our previous studies, these differences have been accentuated. This study demonstrates the results of changes to the practice—reduced inpatient/ED consultations and increased outpatient encounters. These practice changes resulted in higher overall revenue despite a lower patient volume. In this analysis, the office-based practice of medical toxicology has higher reimbursement rates, nearly 2.5 times higher, when compared to hospital-based acute care consultations.     

现状与未来：论我国综合性大学医学教育

在不同历史阶段,我国综合性大学医学教育经历了不同的发展模式。文章简要回顾了我国综合性大学医学教育的基本办学现状;结合我国高等教育事业的总体改革与发展思路,厘清综合性大学医学教育的办学定位和人才培养模式;重点分析和论述了综合性大学医学教育的人才培养目标以及基于此目标的预期教学效果。     

Evaluation of ventricular septal defects using high pitch computed tomography angiography of the chest in children with complex congenital heart defects below one year of age

BackgroundAim of this study was to assess the accuracy of ventricular septal defects (VSD) using high pitch computed tomography angiography (CTA) of the chest in children below 1 year of age, compared to the intraoperative findings and echocardiography.MethodsOut of 154 patients that underwent Dual-Source CTA of the chest using a high-pitch protocol at low tube voltages (70–80 kV), 55 underwent surgical repair of a VSD (median age 8 days, range 1–348 days). The margins of the VSDs and their relation to the surrounding structures were reproduced by en-face views using multiplanar reformations (MPR). Absolute diameter, normalized area and relative area compared to the aortic valve annulus were used for discrimination between restrictive and non-restrictive defects. Localization was classified into four subtypes. The results were compared to two-dimensional echocardiography and intraoperative findings.ResultsMedian absolute size of VSDs did not differ significantly between CTA-measurements (10.8 mm, range 2.8–18.1 mm) and intraoperative findings (12.0 mm, 3.0–25.0 mm, p = 0.09). Echocardiographic values were significantly lower (9.6 mm, 3.0–18.5 mm, both p < 0.01). The classification of the location and orientation matched the intraoperative situs in 96.4% of all cases using CT and in 87.3% using echocardiography. Echocardiography missed the relation to valves in 11% of all cases. Pre-interventional sensitivity and specificity for detection of a VSD were 97.2/98.9% compared to echocardiography. Median radiation dose was 0.32 mSv (range 0.12–2.00 mSv) and differed significantly between second and third generation Dual-Source CT (0.43 vs. 0.22 mSv, p = 0.003).ConclusionSize and subtype of VSDs can be accurately assessed by CTA of the chest in patients with complex congenital heart defects at a very low radiation dose.     

Trochanteric bursitis information on the internet; can we trust the information presented?

Trochanteric bursitis is one of the most common causes of lateral hip pain in adults. The prevalence of unilateral trochanteric bursitis is 15.0% in women and 8.5% in men. Access to internet based information has increased dramatically and health related information is now one of the most popular searches in online activity, despite this the quality of information can vary. The objective of this paper is to examine the quality and readability of internet based information of trochanteric bursitis. Overall, we have found a high variability among not only the quality but also the readability of information published. Websites that appeared first on each search engine for trochanteric bursitis did not necessarily score better, demonstrating the importance of providing patients with high quality resources. Future articles should use more critical appraisal tools in order to provide the reader with more high quality and readable information.     

芒针对脊髓损伤大鼠运动功能和炎症水平的影响

目的探究芒针深刺秩边穴对大鼠脊髓损伤后运动功能的影响及可能作用机制。方法选择健康雄性Wister大鼠81只,随机分为正常组、模型组和芒针组(正常组9只,其余两组各36只),采用改良Allen's造模法制备大鼠脊髓中度损伤模型,模型组不做特殊处理,芒针组采用芒针深刺秩边穴,每日1次,每次30 min。分别于术后1 d、3 d、5 d、7 d行BBB(Basso-Beattie-Bresnahan)运动功能评分;术后1 d、3 d、5 d、7 d取受损段脊髓组织行酶联免疫吸附测定(ELISA)、实时荧光定量PCR(RT-qPCR)和苏木素-伊红染色(HE染色)。结果术后5 d和7 d,芒针组大鼠BBB评分高于模型组,差异有统计学意义(P<0.01);脊髓损伤后,模型组和芒针组大鼠脊髓组织中高迁移率族蛋白B1(HMGB1)、核转录因子kB(NF-kB)、白介素-6(IL-6)含量及HMGB1mRNA、NF-kBmRNA、IL-6mRNA水平显著升高(P<0.05);受损的脊髓组织松散,灰质中有许多空洞形成,伴有炎性细胞浸润。芒针治疗后,芒针组大鼠脊髓组织中HMGB1、NF-kB、IL-6含量及HMGB1mRNA、NF-kBmRNA、IL-6mRNA水平较模型组降低,且在3 d、5 d、7 d差异有统计学意义(P<0.05);受损部位的空洞及炎性细胞逐渐减少。结论脊髓损伤后,炎症因子的大量聚集引起级联性炎症反应,影响大鼠运动功能的恢复。芒针的抗炎机制可能包括抑制HMGB1的表达,降低NF-kB信号通路的传导,下调促炎因子IL-6的分泌。