加速康复外科在肾移植术后静脉补液中的应用

目的探讨加速康复外科(ERAS)在肾移植术后静脉补液中的应用。 方法回顾性分析陆军军医大学第一附属医院124例肾移植受者临床资料。根据肾移植术后多尿期每24小时静脉补液量分为3组，A组每24小时静脉补液量2 500～<4 000 mL，术后6 h进食流质；B组每24小时补液量4 000～6 000 mL，肛门排气后进食；C组每24小时补液量>6 000 mL，肛门排气后进食。采用单因素方差分析比较3组受者术后1周中心静脉压(CVP)、心率、血压、尿量和血糖以及平均特护时间、平均住院日和术后1个月血清肌酐。采用χ²检验比较3组受者性别、供肾类型以及术后高血糖、伤口延迟愈合和移植肾功能延迟恢复(DGF)发生率。P<0.05为差异有统计学意义。 结果A、B和C组受者术后1个月血清肌酐分别为(110±23)、(114±22)和(118±22)μmol/L，差异无统计学意义(F＝1.19，P>0.05)。A组受者术后1周CVP、收缩压、尿量和血糖均低于B、C组(P均<0.05)，平均特护时间和平均住院日均短于B、C组(P均<0.05)。3组受者术后高血糖和DGF发生率差异均无统计学意义(χ²＝4.581和0.404，P均>0.05)，A组受者伤口愈合延迟发生率低于C组(χ²＝7.303，P<0.017)。仅C组1例受者因心力衰竭和肺水肿死亡。 结论ERAS适用于肾移植受者术后静脉补液策略，鼓励受者尽早饮水进食，在保证血压正常或偏高的情况下，适当减少静脉补液量，有利于减少并发症，促进受者恢复。     

医科达数字化电子直线加速器控制软件IPV基本原理与应用解读

目的 介绍医科达数字化医用电子直线加速器控制软件里子项目和项目成分值(IPV)的工作原理,并具体说明控制软件通过三类子项目及其项目分项实时监测、控制子系统的运行状态。方法 首先介绍医科达数字化医用电子直线加速器的控制系统组成,然后介绍控制软件里子项目和项目分项的定义和分类,以及各类子项目的基本原理,最后通过分析高功率移相器的运动控制具体说明控制软件的子项目在实时监测、控制子系统运行状态的应用。结果 通过分析原理和举例详细、具体说明了控制软件IPV的工作原理及其应用,使用户尤其是维修人员能掌握相应理论知识,在日常使用和维修时能通过软件快速准确地查找运行参数,并根据相关子系统的控制原理分析问题和解决故障。结论 用户尤其是维修人员掌握这些子项目及其项目分项的工作原理,就能在日常使用或维修、校准时,快速准确地通过控制软件查看、校准运行参数,解决设备故障,并避免错误操作引起事故。     

Derivation and Validation of a Model to Predict 30-Day Readmission in Surgical Patients Discharged to Skilled Nursing Facility

ObjectivesTo identify factors associated with 30-day all-cause readmission rates in surgical patients discharged to skilled nursing facilities (SNFs), and derive and validate a risk score.DesignRetrospective cohort.Setting and participantsPatients admitted to 1 tertiary hospital's surgical services between January 1, 2011, and December 31, 2014 and subsequently discharged to 110 SNFs within a 25-mile radius of the hospital. The first 2 years were used for the derivation set and the last 2 for validation.MethodsData were collected on 30-day all cause readmissions, patient demographics, procedure and surgical service, comorbidities, laboratory tests, and prior health care utilization. Multivariate regression was used to identify risk factors for readmission.ResultsDuring the study period, 2405 surgical patients were discharged to 110 SNFs, and 519 (21.6%) of these patients experienced readmission within 30 days. In a multivariable regression model, hospital length of stay [odds ratio (OR) per day: 1.03, 95% confidence interval (CI) 1.02-1.04], number of hospitalizations in past year (OR 1.24 per hospitalization, 95% CI 1.18-1.31), nonelective surgery (OR 1.33, 95% CI 1.18-1.65), low-risk service (orthopedic/spine service) (OR 0.32, 95% CI 0.25-0.42), and intermediate-risk service (cardiothoracic surgery/urology/gynecology/ear, nose, throat) (OR 0.69, 95% CI 0.53-0.88) were associated with all-cause readmissions. The model had a C index of 0.71 in the validation set. Using the following risk score [0.8 × (hospital length of stay) + 7 × (number of hospitalizations in past year) +10 for nonelective surgery, +36 for high-risk surgery, and +20 for intermediate-risk surgery], a score of >40 identified patients at high risk of 30-day readmission (35.8% vs 12.6%, P < .001).Conclusions/ImplicationsAmong surgical patients discharged to an SNF, a simple risk score with 4 parameters can accurately predict the risk of 30-day readmission.     

对分课堂在《中医诊断学》教学中的应用及探索

探讨对分课堂在《中医诊断学》教学中的应用。将对分课堂授课模式引入《中医诊断学》教学过程中，通过学生的课堂表现及课后对学生的问卷调查，评价对分课堂教学模式对《中医诊断学》教学效果的影响。学生普遍认可对分课堂教学模式，学生课堂活跃程度提高、主观能动性增加，自主学习能力增加，学习效率提高。通过对分课堂教学，有助于提高学生对《中医诊断学》的学习热情，提高学习成绩，提升教学质量。具有一定的推广意义。     

Clinical and pathological features of immunoglobulin A nephropathy patients with nephrotic syndrome

Clinical and Experimental Medicine - IgA nephropathy (IgAN) is the most common glomerulonephritis worldwide. The classic manifestation of IgAN is episodic hematuria and proteinuria. Nephrotic...     

Skewed B cell receptor repertoire and reduced antibody avidity in patients with DOCK8 deficiency

DOCK8 immunodeficiency syndrome (DIDS) is a combined immunodeficiency characterized by recurrent viral infections, severe atopy and early onset malignancy. Immunological abnormalities include lymphopenia, CD8⁺ T‐cell cytoskeleton dysfunction, defective B cell memory and variable serum immunoglobulin levels. Here, we analyse the B cell receptor repertoire (BCR) characteristics and antibody avidity of four DIDS patients, attempt to understand the dysregulated humoral immunity in DIDS patients with a normal antibody titre and suggest a scientific basis for intravenous immunoglobulin (IVIG) replacement therapy for these patients. We analysed BCR characteristics, including somatic hypermutation (SHM) frequency, using deep sequencing of multiplex PCR products derived from BCR heavy chain CDR3 regions from DIDS patients and controls. The antibody avidity of human tetanus and hemophilus influenza B antibodies was determined by ELISA using thiocyanate elution. IVIG replacement treatment and infection conditions were investigated retrospectively. We found skewing of the BCR repertoire and decreased antibody avidity in patients with DIDS. DIDS patients had fewer negatively charged amino acids than healthy controls. The SHM frequency of the IGHV3 gene was lower in patients with DIDS. Patients received regular IVIG therapy, resulting in fewer and less severe infections. We conclude that although IgG levels are normal in most DIDS patients, IVIG replacement therapy is still necessary.     

一种诊断脑室-腹腔分流装置梗阻的方法

目的 介绍一种诊断脑室腹腔分流装置梗阻的方法。方法 选择2014年8月至2018年3月收治的腹腔分流术后病人32例，其中分流装置梗阻16例（梗阻组），分流装置通畅16例（对照组）。病人先平躺1 h后改坐位，将0.1 ml 5%葡萄糖溶液注射入贮液囊，20 min后抽0.1 ml，用生理盐水将其稀释1倍后应用血糖仪检测葡萄糖浓度。结果 对照组贮液囊内葡萄糖浓度[（6.6±1.6）mmol/L]较梗阻组[（31.9±2.8）mmol/L]明显下降（P<0.05）。梗阻组病人入院后均行脑室-腹腔分流管调整术，手术证实分流装置梗阻，术后病人颅内压增高症状消失，术后3 d复查头颅CT结果显示脑室体积较术前减小11例，无明显变化5例。结论 此方法可检测分流管内脑脊液的流动情况，为诊断分流装置梗阻提供一种新的方法。