Responsabilidad por pérdida de oportunidad asistencial en patología oncológica maligna en la medicina pública española

ObjectiveThe loss of chance in healthcare has been forcibly introduced in the adjudications pronounced in recent years. Our objective was to analyse the verdicts of guilt resulting from the loss of chance ordered by the Contentious-Administrative Court (i.e., in the public healthcare system), in which both the origin of the disease to be treated and the sequelae were oncological processes.MethodWe analysed 137 cancer-related court judgments from the Contentious-Administrative Court, which referred to the concept of loss of chance, issued in Spain up to May 2014.ResultsOf the 137 sentences, 119 (86.9%), were pronounced due to diagnostic error and 14 (10.2%) due to inadequate treatment. Since 2010, 100 sentences have been passed (73.0%), representing an increase of more than 170% with respect to the 37 (27.0%) ordered in the first six years of the study (from 2004 to 2009). Most of the patients (68.6%) died, predominantly from breast cancer and gynaecological cancer (24.1%), and gastrointestinal cancers (21.1%). These malignancies were the ones most often involved in the sentences.ConclusionsThe litigant activity due to loss of chance in oncological processes in the public health care has significantly increased in the last years. The judgments were mainly given because of diagnostic error or inadequate treatment.     

踇甲皮瓣联合腓动脉穿支皮瓣游离移植再造拇指并修复足部供区 15 例

目的总结应用踇甲皮瓣再造拇指及腓动脉穿支皮瓣游离移植修复足部供区的手术方法及临床效果。方法2016 年 6 月—2018 年 5 月，应用踇甲皮瓣联合腓动脉穿支皮瓣游离移植再造拇指并修复足部供区 15 例。男 10 例，女 5 例；年龄 21～48 岁，平均 34.6 岁。致伤原因：重物压砸伤 7 例，机器绞伤 5 例，电锯切割伤 3 例。Ⅰ度缺损 9 例，Ⅱ度缺损 6 例。入院至皮瓣手术时间 4～7 d，平均 5.2 d。结果术后踇甲皮瓣及腓动脉穿支皮瓣全部成活，切口均Ⅰ期愈合。患者均获随访，随访时间 8～24 个月，平均 16.4 个月。末次随访时，再造拇指指甲生长平整，有光泽，指腹饱满；足部皮瓣外形良好，颜色及质地接近受区。根据中华医学会手外科学会拇手指再造功能评定标准，获优 9 例、良 6 例；根据 Maryland 足功能评分标准，获优 10 例、良 5 例。患者行走步态正常，无跛行及疼痛不适。结论踇甲皮瓣修复拇指Ⅰ、Ⅱ度缺损，再造拇指可获得良好外观及功能；腓动脉穿支皮瓣具有血供可靠、血管恒定、易切取等优点，可有效修复足部供区。     

脊椎错位引起的代偿及其临床意义

脊柱的平衡在发生病理性变化时会打破，但人体有保持自我平衡的能力，脊柱必会发生一系列代偿性变化来重新建立平衡，这就是人体平衡系统作用的结果。当脊椎发生错位，即推拿医生最关心的脊椎错位时，脊柱内部将会发生怎样的代偿性变化及具有什么样的临床意义，下文将给予阐述。     

古代日耳曼和阿拉伯律法与唐律中法医学内容的比较

本文详细介绍了古代日耳曼和阿拉伯律法中与法医学有关的内容及其对法医学发生发展的影响。认为以赎罪金代替原始的血亲复仇法是日耳曼法的一个进步；两法对非致命损伤的赔偿规定都取得了令人瞩目的成就。本文还就大致同时代的唐律对杀人及伤害案件的有关规定，比较了东西方法规的异同，探讨了差别的原因。     

1996-2000年某医院五种恶性肿瘤例均住院费用分析

恶性肿瘤是给群众带来严重健康损害的经济负担的疾病之一,已经列居我国城市 疾病死亡原因的第一位。本研究利用医院为基础的五种恶性肿瘤住院患者的费用数据,分析1996-2000年五种恶性肿瘤患者例均住院费用的变化趋势,比较自费患者和公费患者之间的例均费用差异。根据恶性肿瘤费用水平高、增长幅度快,且公费患者费用明显高于自费患者的情况,提出在医疗保障制度改革的社会环境下,医院必须加强病种费用管理,主动控制医疗费用水平。     

岗位业绩导向的医院薪酬设计

基于现代管理理论和医院的实际情况，设计了一种以岗位和业绩为导向的医院薪酬制度。该设计的主要特点是：①薪酬结构以岗位工资和绩效工资为主体，同时兼顾稳定和逐步过渡原则，原档案工资的固定部分(约占档案工资的60％)保留。②岗位工资采用全院统一的等级薪酬结构，等级的评定基于全院统一的指标体系和权重，岗位工资每年随绩效考核结果在工资带宽中升降；③绩效工资与岗位等级和绩效考核紧密挂钩，考核的依据是全院统一模式的岗位绩效合同；④整个薪酬设计建立在岗位调查、岗位评价和岗位说明书等的科学规范的工作基础之上。     

Neck proprioception compensates for age-related deterioration of vestibular self-motion perception

Vestibular functions are known to show some deterioration with age. Vestibular deterioration is often thought to be compensated for by an increase in neck proprioceptive gain. We studied this presumed compensatory mechanism by measuring psychophysical responses to vestibular (horizontal canal), neck and combined stimuli in 50 healthy human subjects as a function of age (range 15–76 years). After passive horizontal rotations of head and/or trunk (torso) in complete darkness (dominant frequencies 0.05, 0.1, and 0.4 Hz), subjects readjusted a visual target to its remembered prerotational location in space. (1) Vestibular-only stimulus (whole-body rotation); subjects' responses were shifted towards postrotatory body position, this only slightly at 0.4 Hz and pronounced at 0.1 and 0.05 Hz. These errors reflect the known physiological drop of vestibular gain at low rotational frequency. They exhibited a slight but significant increase with age. (2) Neck-only stimulus (trunk rotated, head stationary); the responses showed errors similar to those upon vestibular stimulation (with offset towards postrotatory trunk position) and this again slightly more with increasing age. (3) Vestibular-neck stimulus combination during head rotation on stationary trunk; the errors were close to zero, independent of stimulus frequency and the subjects' age. (4) Opposite stimulus combination (trunk rotated in the same direction as the head, but with double amplitude); the errors were clearly enhanced, essentially reflecting the sum of those with vestibular-only and neck-only stimulation. Taken together, we find a parallel increase in neck- and vestibular-related errors with age, in seeming contrast to previous studies. We explain our and the previous findings by a vestibular-neck interaction model in which two different neck signals are involved. One neck signal is used, in combination with the vestibular signal, for estimating trunk-in-space rotation. It is internally shaped to always match the vestibular signal, so that these two signals cancel each other out when summed during head rotation on stationary trunk. Because of this matching, perceived trunk stationariness during head rotation on the stationary trunk is independent of vestibular deterioration (related to stimulus frequency, age, ototoxic medication, etc.). The other neck proprioceptive signal, coding head-on-trunk rotation, is superimposed on the estimate of trunk-in-space rotation, thereby yielding a notion of head-in-space. This neck signal remains essentially unchanged with vestibular deterioration. Generally, we hold that the transformation of the vestibular signal from the head down to the trunk proceeds further to include the hip and the legs as well as the haptically perceived body support surface; by this, subjects yield a notion of support kinematics in space. As a consequence, spatial orientation is impaired by chronic vestibular deterioration only to the extent that the body support is moving in space, while it is unimpaired (determined by proprioception alone) during body motion with respect to a stationary support. Electronic Publication     

The role of the monkey sensory cortex in the recovery from cerebellar injury

Summary The aim of the study was to investigate the contribution of the primary sensory cortex in the compensation of cerebellar deficits during self-paced movements. For this purpose, monkeys were trained on motor tasks which required goal-reaching and independent finger movements. The intermediate and lateral deep cerebellar nuclei and the sensory cortex were lesioned in isolation and in sequence and the course of motor recovery was studied on the test performances. The deep nuclei were lesioned by kainic acid injections, the sensory cortex was removed by ablation. Cerebellar lesions in isolation produced obvious deficits at proximal and distal joints, affecting both slow and fast motor adjustments. Only lesions of the anterior portions of the intermediate and lateral deep nuclear complexes produced deficiencies in voluntary movements. Lesions of the posterior portions produced postural disturbances. The process of recovery following cerebellar lesions was slow and, depending on the nature of the task, was found to be differentially disruptive for motor performances requiring fast and slow motor adjustments. The deficits at distal joints appeared to be more enduring than those at proximal joints. Sensory cortical lesions in isolation produced much less severe and more transient motor deficits. They consisted of hand clumsiness and their recovery was fast and reached higher levels of performance than following cerebellar lesions. When the sensory cortex was removed secondarily to a cerebellar lesion and after recovery from the cerebellar deficits, the initially recovered motor performance became much worse again (decompensation). Removal of the sensory cortex prior to a cerebellar lesion exaggerated the cerebellar deficits and severely limited their recovery. Slow and fast motor performances were completely abolished for three weeks following sequential lesions. Signs of recovery subsequently appeared and stabilized at low levels of performance by five to seven weeks. The effects of combined, sequential cerebellar and sensory cortical lesions were much worse than expected if the effects from the two lesions were merely additive. This indicates that there is some functional interrelationship between the sensory cortex and the cerebellum, which promotes compensation. The somatosensory cortex appears to play a crucial role in the process of recovery from cerebellar motor deficits and it is likely that sensation is an important component in the process of recovery. It is suggested that the sensory cortex exerts its compensatory actions via a structure or structures which receives convergent cerebellar and sensory cortical inputs.