教学督导会诊在超声医学科住院医师规范化培训中的应用

目的总结住院医师规范化培训阶段的会诊需求概况，评价教学督导会诊在住院医师规范化培训阶段的作用。 方法回顾性收集2015年8月至2017年8月间于北京协和医院超声医学科参加北京市住院医师规范化培训的住院医师43名及其于2017年11月至2018年8月申请教学督导会诊的病例，随访申请教学督导会诊的病例，总结会诊原因和部位，参照病理或临床诊断，对会诊医师作出教学评价（技术操作、定位、定性）。采用χ²检验比较不同年资、不同学历住院医师申请会诊原因和部位的差异，并采用t检验比较应用教学督导会诊前、后3年以下住院医师客观结构化临床考试（OSCE）阶段考核平均成绩的差异。 结果43名住院医师共随访1727份会诊病例。第一、二、三年住院医师申请会诊次数占比分别为53.0%（915/1727）、42.9%（741/1727）、4.1%（71/1727）。住院医师申请会诊原因：定性70.9%（1224/1727）、技术操作22.7%（392/1727）、定位6.4%（111/1727）。第一、二、三年住院医师因技术操作原因申请会诊比例分别为26.9%（246/915）、18.6%（138/741）、11.3%（8/71）；因定位原因申请会诊比例分别为7.8%（71/915）、4.5%（33/741）、9.8%（7/71）；因定性原因申请会诊比例分别为65.3%（598/915）、76.9%（570/741）、78.9%（56/71），不同年资住院医师申请会诊的原因不同，差异具有统计学意义（χ²=33.293，P＜0.001）。申请会诊的检查部位前三位为妇科27.9%（482/1727）、浅表器官23.3%（402/1727）和腹部20.1%（347/1727），共占71.3%，不同年资住院医师申请会诊的部位不同，差异具有统计学意义（χ²=167.583，P＜0.001）。第一、二年住院医师申请会诊主要为腹盆腔脏器技术操作和定性，第三年住院医师申请会诊集中在浅表器官病变的定性。不同学历住院医师申请会诊部位分布不同，差异具有统计学意义（χ²=64.942，P＜0.001），申请会诊原因分布差异无统计学意义（χ²=8.131，P=0.087），平均申请会诊次数相近。97.7%（383/392）的技术操作问题通过教学督导会诊得到解决；教学督导会诊定位正确率73.0%（81/111）；定性正确率92.7%（1135/1224）。应用教学督导会诊后的住院医师OSCE成绩高于应用前［（85.7±6.6）分vs（75.7±7.5）分］，差异具有统计学意义（t=-2.426，P=0.036）。 结论随着住院医师年资增加，申请会诊次数减少。不同年资住院医师申请会诊的部位和原因不同。住院医师因技术操作原因申请会诊次数逐年下降，定性需求逐年增加。教学督导会诊能有效帮助住院医师解决技术操作难点、定位和定性，提升住院医师临床胜任力。     

Radiomics signature as a new biomarker for preoperative prediction of neoadjuvant chemoradiotherapy response in locally advanced rectal cancer

PURPOSEWhether radiomics methods are useful in prediction of therapeutic response to neoadjuvant chemoradiotherapy (nCRT) is unclear. This study aimed to investigate multiple magnetic resonance imaging (MRI) sequence-based radiomics methods in evaluating therapeutic response to nCRT in patients with locally advanced rectal cancer (LARC).METHODSThis retrospective study enrolled patients with LARC (06/2014–08/2017) and divided them into nCRT-sensitive and nCRT-resistant groups according to postoperative tumor regression grading results. Radiomics features from preoperative MRI were extracted, followed by dimension reduction using the minimum redundancy maximum relevance filter. Three machine-learning classifiers and an ensemble classifier were used for therapeutic response prediction. Radiomics nomogram incorporating clinical parameters were constructed using logistic regression. The receiver operating characteristic (ROC), decision curves analysis (DCA) and calibration curves were also plotted to evaluate the prediction performance.RESULTSThe machine learning classifiers showed good prediction performance for therapeutic responses in LARC patients (n=189). The ROC curve showed satisfying performance (area under the curve [AUC], 0.830; specificity, 0.794; sensitivity, 0.815) in the validation group. The radiomics signature included 30 imaging features derived from axial T1-weighted imaging with contrast and sagittal T2-weighted imaging and exhibited good predictive power for nCRT. A radiomics nomogram integrating carcinoembryonic antigen levels and tumor diameter showed excellent performance with an AUC of 0.949 (95% confidence interval, 0.892–0.997; specificity, 0.909; sensitivity, 0.879) in the validation group. DCA confirmed the clinical usefulness of the nomogram model.CONCLUSIONThe radiomics method using multiple MRI sequences can be used to achieve individualized prediction of nCRT in patients with LARC before treatment.

Colorectal cancer is one of the most common malignancies. It ranks fourth for morbidity and third for mortality among malignant tumors, among which the proportion of rectal cancer with poor prognosis is over 60% (1, 2). Neoadjuvant therapy, combined with total mesorectal excision, has become a common strategy for rectal cancer (3). Response to neoadjuvant chemoradiotherapy (nCRT) is a marker of good prognosis in patients with locally advanced rectal cancer (LARC) (4). Tumor regression grading (TRG) is a reliable biomarker for evaluating the efficacy of nCRT (5, 6). TRG reflects the treatment effect of nCRT by evaluating fibrosis and the ratio of residual tumor cells (4). The accurate nCRT evaluation can only be achieved by postoperative histopathological TRG (3, 4), and there is still no technology that can noninvasively evaluate the therapeutic response.Magnetic resonance imaging (MRI) is commonly used in the diagnosis, preoperative staging, and therapeutic efficacy evaluation of rectal cancer. Prediction of the efficacy of nCRT by MRI has been rarely reported, partly due to the heterogeneity of the tumor combined with the prevalence of fibrosis and edema of lesions and surrounding tissue after nCRT. Over the recent years, a magnetic resonance TRG system was proposed for the evaluation of nCRT efficacy by using MRI and evaluating residual tumor and fibrosis. Nevertheless, the magnetic resonance TRG method has a low predictive value for pathological TRG and poor consistency, which hinders its clinical applications (7, 8).In recent years, radiomics has drawn increasing attention in oncology. Radiomics features selected from medical images have shown to be highly associated with the diagnosis and prognosis of cancers, and even with gene expression patterns (9). Studies highlighted the value of radiomics approaches in determining tumor status, preoperative staging, and efficacy evaluation (9, 10). Nevertheless, the application of the radiomics methods in evaluating therapeutic responses to nCRT is limited (11).Accordingly, the aim of the present study was to establish an nCRT prediction model based on multiple MRI sequences combined with tumor anatomy and biological characteristics so as to achieve a comprehensive preliminary prediction of nCRT efficacy for rectal cancer before treatment, to provide an essential basis for the rational formulation of clinical diagnosis and treatment decisions, and to avoid unnecessary exposure to radiotherapy and chemotherapy and the related risks such as toxicity and delayed definitive surgery.     

宫颈癌患者治疗后性功能状况变化的临床调查分析

目的:探讨宫颈癌患者治疗后性功能状况及其影响因素,以期提高临床治疗水平。方法:回顾性分析2011年1月至2013年1月我院收治的130例宫颈癌患者,采用性功能指数进行性功能状况评定,并总结影响因素。结果:治疗后患者在围绝经期症状方面无症状66.94%,轻度占18.18%,中度占9.09%,重度占5.79%;主要表现为性欲望、性兴奋、阴道润滑、性高潮、满意度下降,疼痛感增强。影响因素有年龄(≥45岁)、文化程度低(初中以下)、肿瘤晚期(Ⅳ期)、手术+放化疗、病情严重、心理障碍、配偶配合差、悲观(P均0.05)。其中年龄、文化程度、治疗方法、心理因素、肿瘤分期、性格、病情、配偶态度是宫颈癌治疗后性功能独立危险因素(P均0.05)。结论:宫颈癌患者治疗后会出现性功能障碍,在临床上要注重对性功能康复治疗,并注重防范影响因素,从而提高性生活质量。     

护士职业价值观、工作满意度、工作绩效的关系研究

目的 采用结构方程模型探讨护士工作满意度在职业价值观与工作绩效间的中介作用.方法 采用横断面现况研究于2018年9月至12月采用便利抽样的方法在陕西省6所医院抽取548名一线在职护士作为研究对象.采用护士职业价值观量表(NPVS-R)、护士工作满意度量表(NJSS)、护理行为六维度量表(6-D)进行研究,并分析其相关性.结果 护士职业价值观评分为(92.14±15.74)分,工作满意度评分为(48.87±9.24)分,工作绩效评分为(141.47±25.61)分.护士职业价值观与工作满意度和工作绩效呈正相关,工作满意度与工作绩效呈正相关(P<0.01).结构方程模型显示,直接路径职业价值观对工作绩效有直接正向预测效果,标准化路径系数为0.37;间接路径职业价值观通过工作满意度间接正向预测工作绩效,标准化路径系数为0.18.护士工作满意度在职业价值观与工作绩效间有部分中介作用.结论 护理管理者应关注和提高护士职业价值观水平,从而提高工作满意度及工作绩效.     

围术期新型冠状病毒肺炎患者感染防控相关建议解读

由2019新型冠状病毒(2019-nCoV)引起的新型冠状病毒肺炎(COVID-19)是一种传染性极强的感染性疾病。多数新型冠状病毒肺炎患者症状较轻,表现为发热、乏力和干咳等症状,但重症患者可迅速发展为急性呼吸窘迫综合征(ARDS)、感染性休克、严重的酸中毒和凝血功能紊乱。此类重症患者往往需要行气管插管和机械通气,且部分非重症患者也可能因急诊手术需行全身麻醉。2019-nCoV可通过飞沫、接触和气溶胶等途径在人与人之间进行传播。而气道管理过程中,医务人员可能接触病毒载量很高的呼吸道飞沫和气溶胶,所以具有极高的职业暴露风险。加强围术期医护人员和手术室的感染防控对于预防院内聚集性感染非常重要。中华医学会麻醉学分会和中国医师协会麻醉学医师分会先后制定了《新型冠状病毒肺炎危重型患者气管插管术的专家建议(1.0版)》和《新型冠状病毒肺炎患者围术期麻醉工作指导及感染防控建议》,对围术期和围插管期的感染防控提出了原则性的指导。本文结合这两个建议,以及《新型冠状病毒肺炎防控指南(第五版)》和《普通物体表面消毒剂的卫生要求》,对围术期新型冠状病毒肺炎患者感染防控提出详细的操作性建议,供基层医务人员参考。     

Notch ligand Delta-like1 enhances degranulation and cytokine production through a novel Notch/Dok-1/MAPKs pathway in vitro

Food allergy includes sensitization phase and effect phase, and effect cells degranulate and secrete cytokines in the effect phase, causing allergic clinical symptoms. We have demonstrated that Notch signaling plays an important role in the sensitization phase, but its role in effect phases still remains unclear. In this study, we investigated the role of Notch signaling in degranulation and cytokine production of the effect phase response. A RBL-2H3 cell model was used and Notch signaling was induced by priming with Notch ligands. Our results showed after priming with Notch ligand, Delta-like1(Dll1)-Fc, β-hexosaminidase release, and cytokines production, including TGF-β, IL-1β, IL-4, IL-6, and IL-13, were increased significantly, and the enhancement was abolished after DAPT treatment, a γ-secretase inhibitor, indicating that Dll1 Notch signaling enhanced RBL-2H3 cell degranulation and cytokine production. Western blot analysis showed that Dll1 Notch signaling augmented high-affinity IgE receptors-mediated phosphorylation of MAPKs through suppressing the expression of downstream tyrosine kinases 1 (Dok-1). Besides, a passive systemic anaphylaxis mouse model was used to confirm the role of Notch signaling. And our data showed that allergic clinical features of mice were alleviated, and the level of degranulation was decreased significantly after inhibiting Notch signaling in vivo. Therefore, we demonstrated Notch ligand Dll1 enhanced RBL-2H3 cell degranulation and cytokine production through a novel Notch/Dok-1/MAPKs pathway, suggesting Notch signaling played a key role in the effect phase of food allergy.     

阅读疗法对抑郁症患者生活质量的影响

目的探讨阅读疗法对抑郁症患者生活质量的影响。方法将92例抑郁症患者随机分为观察组和对照组各46例,两组均给予抗抑郁药物治疗和一般康复治疗,观察组在此基础上联合阅读疗法,疗程3个月。干预前后采用汉密顿抑郁量表(HRSD)、生存质量测定量表(QOL-100)对两组患者进行评定。结果两组HRSD评分干预后较干预前均有下降,观察组下降值显著大于对照组(均P<0.01);干预后观察组QOL-100总评及各因子(除精神信仰外)评分较干预前显著提高(均P<0.01)。结论阅读疗法对抑郁症患者的康复治疗有较好的辅助作用,能显著改善其抑郁症状和生活质量。     

Impact of bibliotherapy on quality of life of patients with depression

目的 探讨阅读疗法对抑郁症患者生活质量的影响.方法 将92例抑郁症患者随机分为观察组和对照组各46例,两组均给予抗抑郁药物治疗和一般康复治疗,观察组在此基础上联合阅读疗法,疗程3个月.干预前后采用汉密顿抑郁量表(HRSD)、生存质量测定量表(QOL-100)对两组患者进行评定.结果 两组HRSD评分干预后较干预前均有下降,观察组下降值显著大于对照组(均P＜0.01);干预后观察组QOL-100总评及各因子(除精神信仰外)评分较于预前显著提高(均P＜0.01).结论 阅读疗法对抑郁症患者的康复治疗有较好的辅助作用,能显著改善其抑郁症状和生活质量.     

超声弹性成像不同切面应变比值法诊断甲状腺结节的价值比较

目的探讨不同切面超声弹性成像应变比值法在诊断甲状腺结节良恶性方面的价值区别。方法选取2012年11月至2013年5月因甲状腺结节疾病在解放军总医院超声科就诊的患者118例,共有153个结节,患者术前均行弹性成像检查,从纵切和横切面分别获得弹性应变率面积比值,采用ROC曲线评价其诊断价值,将结节分为临近峡部组、非临近峡部组两组,并将诊断结果与病理结果对照。结果纵切面与横切面面积应变比值法在鉴别甲状腺良恶性结节的ROC曲线下面积(AUC)分别为0.906、0.844,二者无显著性差异(Z=1.54,P>0.05);最佳诊断界点分别为:3.65、3.58;纵切面、横切面应变比值法的敏感度、特异度、准确性、阳性预测值、阴性预测值分别为:81.2%、80.8%、81.0%、87.2%、71.2%;77.2%、76.9%、77.1%、84.4%、63.4%。临近峡部组纵切面与横切面面积应变比值法在鉴别甲状腺良恶性结节的ROC曲线下面积(AUC)分别为0.903、0.830,二者无显著性差异(Z=1.125,P>0.05);最佳诊断点分别为:3.30、3.28;纵切面、横切面应变比值法的敏感度、特异度、准确性、阳性预测值、阴性预测值分别为:86.2%、68.8%、80.0%、83.3%、73.3%;78.6%、58.8%、71.1%、75.9%、62.5%。非临近峡部组纵切面与横切面面积应变比值法在鉴别甲状腺良恶性结节的AUC分别为0.906、0.852,二者无显著性差异(Z=0.936,P>0.05);最佳诊断界点分别为:3.33、3.71;纵切面、横切面应变比值法的敏感度、特异度、准确性、阳性预测值、阴性预测值分别为:90.1%、75.7%、85.2%、87.7%、80.0%;84.7%、70.3%、80.6%、83.6%、72.2%。结论超声弹性成像有助于甲状腺结节的鉴别诊断,但横切面与纵切面的诊断效果无统计学差异。     

中医针刺治疗对COPD模型大鼠外周血HDAC2活性的影响

目的：观察针刺对COPD模型大鼠的治疗效果及对外周血中HDAC2活性的影响。方法：连续3周对熏烟法建立COPD模型大鼠进行针刺治疗,仪器检测大鼠肺的通气能力。3周后抽取大鼠外周静脉血,用活性荧光分析技术测定其中HDAC2酶活性;用ELISA法检测外周血中IL-10、IL-8和TNF-α的表达含量。结果：针刺治疗的大鼠,与模型组的大鼠相比,肺通气水平明显上升（P<0.05）,外周血的HDAC2活性亦明显上升（P<0.05）,但是炎症因子IL-10、IL-8和TNF-α的表达含量明显降低（P<0.05）。结论：针刺治疗对于COPD模型大鼠具有疗效,结果也提示针刺疗效可能是通过调节HDAC2活性,从而消除炎症而起作用。