Crossing the Implementation Chasm: A Proposal for Bold Action

As health care organizations dramatically increase investment in information technology (IT) and the scope of their IT projects, implementation failures become critical events. Implementation failures cause stress on clinical units, increase risk to patients, and result in massive costs that are often not recoverable. At an estimated 28% success rate, the current level of investment defies management logic. This paper asserts that there are “chasms” in IT implementations that represent risky stages in the process. Contributors to the chasms are classified into four categories: design, management, organization, and assessment. The American College of Medical Informatics symposium participants recommend bold action to better understand problems and challenges in implementation and to improve the ability of organizations to bridge these implementation chasms. The bold action includes the creation of a Team Science for Implementation strategy that allows for participation from multiple institutions to address the long standing and costly implementation issues. The outcomes of this endeavor will include a new focus on interdisciplinary research and an inter-organizational knowledge base of strategies and methods to optimize implementations and subsequent achievement of organizational objectives.     

搭建多学科对话的桥梁

2004年4月12日下午,导报在中华医学会召开了一次具有特殊意义的专家策划会,此次会议的主旨在于邀请临床不同学科的专家,共同探讨交叉学科的话题。会议特别邀请了胡大一教授做会议主持,参会者是来自北京各大医院各个学科的专家:中国中医研究院西苑医院李连达院士、北京协和医院神经科李舜伟教授、北大人民医院消化科刘玉兰教授、北大一院心内科许玉韵教授、北大人民医院内分泌科纪立农教授、北京阜外心血管病医院内科荆志成副教授、北京同仁医院心内科史旭波副教授、北京同仁医院心内科李莉副教授。 编辑部的同事们一直在努力,希望在多学科的交叉领域内做一些有深度的报道。经过长时间的酝酿,终于在各位专家的支持下,才有了这次特别的策划会,希望以心血管疾病和其他相关科室疾病的讨论作为开始,隆重推出导报《对话》栏目。我们衷心地希望《对话》栏目成为一个各科医生互动的园地,您只需要登陆导报的网站:www.cmednews.com,就可以和天南海北的医生广泛地交换意见,可以发表自己的独到见解,也可以为我们出谋划策提出值得关注的话题(请发电子邮件至 hefang@cma.org.cn)。总之,在我们辛勤耕耘这一亩田的时候,也希望田里有您洒下的汗水,希望丰收的果实由我们共同来收获！     

新型粘结固定桥临床应用初步观察

目的 观察一种用于牙列缺损永久修复的新型粘结固定桥的临床效果。方法 选择有单个或多个牙缺失的病人，进行固定桥基牙的牙周和特定的牙体预备。然后制作固定桥并试戴，用4－META／MMA－TBB树脂粘结剂粘结固定桥。结果 267例（304个）固定桥病人经二年以上随访，发现192个前牙桥中只有1个，112个后牙桥中只有2个脱落，其余固定桥稳定、功能良好。结论 采用树脂粘接技术，结合基牙的机械预备，能较好地克服3／4冠桥、桩冠桥和嵌体桥的缺陷，使之成为良好永久的修复体。     

The Clinical Outcomes Assessment Toolkit: A Framework to Support Automated Clinical Records–based Outcomes Assessment and Performance Measurement Research

The Clinical Outcomes Assessment Toolkit (COAT) was created through a collaboration between the University of California, Los Angeles and Brigham and Women''s Hospital to address the challenge of gathering, formatting, and abstracting data for clinical outcomes and performance measurement research. COAT provides a framework for the development of information pipelines to transform clinical data from its original structured, semi-structured, and unstructured forms to a standardized format amenable to statistical analysis. This system includes a collection of clinical data structures, reusable utilities for information analysis and transformation, and a graphical user interface through which pipelines can be controlled and their results audited by nontechnical users. The COAT architecture is presented, as well as two case studies of current implementations in the domain of prostate cancer outcomes assessment.     

伴ModicI型改变的腰椎间盘突出症的手术疗效分析

目的探讨腰椎终板Modic I型改变对伴下腰痛的腰椎间盘突出症患者手术疗效的影响。方法回顾性分析2008年3月至2012年l1月收治的伴下腰痛的腰椎间盘突出症患者63例,分为两组:A组伴终板Modic I型改变,B组无终板Modic改变,均行单节段开窗减压髓核摘除术。采用疼痛视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)评估两组患者手术后的临床效果,评价终板Modic I型改变对患者术后下腰痛改善的影响。结果术前A、B两组的VAS、ODI评分差异均无统计学意义(P>0.05)。术后两组患者坐骨神经痛症状均明显缓解或完全消除。术后随访VAS及ODI评分两组差异均有统计学意义(P<0.05)。结论腰椎间盘突出症术后下腰痛的改善与终板Modic I型改变存在相关性。     

腹腔镜阴道/子宫骶骨固定术疗效及术后性功能的评价

目的:探讨腹腔镜阴道/子宫骶骨固定术对盆腔器官脱垂(POP)患者的疗效及术后性功能的评价。方法:分析2008年1月至2012年12月间武汉大学人民医院经盆腔器官脱垂定量分度法(POP-Q)分度证实为Ⅲ度及以上POP、且已完成生育的52例患者,23例行腹腔镜阴道骶骨固定术(HY+CSP子宫切除),29例行子宫骶骨固定术(HSP子宫保留),分别在术后1,6,12个月以及此后每年1次随诊,应用POP-Q评估、尿失禁影响问卷(ⅡQ-7)、泌尿生殖系影响量表(UDI-6)、视觉模拟满意度评分法(VAS)评估患者术后疗效。采用女性性功能指标量表(FSFI)问卷调查,评估患者术前、术后1年性生活质量。结果:腹腔镜阴道/子宫骶骨固定术后以POP-QⅡ度为复发的客观标准,患者术前、术后进行POP-Q分度评估、UDI-6、IIQ-7问卷、VAS满意度评分比较差异有统计学意义(P<0.05)。子宫骶骨固定术及阴道骶骨固定术患者术前FSFI中位数得分相似,而手术前后FSFI评分差异有统计学意义(P<0.05),且术后子宫骶骨固定组的性欲望、性兴奋和高潮程度中位数得分明显高于阴道骶骨固定组。结论:阴道/子宫骶骨固定术是治疗盆腔器官脱垂疗效良好的手术方式之一,子宫骶骨固定术的子宫保留与患者术后性生活质量密切相关。     

Crossing over to the other side

What happened when a doctor on duty in the emergency department suddenly made the transition to "patient in Resus 2"?     

Anesthesia Management at Fuwai Hospital: Practice,Evidence and Outcomes

Fuwai Hospital was established in 1956 and the Anesthesia Department of Fuwai Hospital was one of the earliest anesthesia departments then in China. Under the leadership of several department directors and with the concerted efforts of all generations of colleagues, the Anesthesia Department of Fuwai Hospital has dramatically transformed, upgraded and modernized. For more than six decades, the Anesthesia Department has been providing high-quality peri-operative anesthesia care for cardiovascular surgeries, conducting innovative experimental and clinical researches, and offering comprehensive training on cardiovascular anesthesiology for professionals across China. Currently, Fuwai Hospital is the National Center for Cardiovascular Diseases of China and one of the largest cardiovascular centers in the world. The present review introduces the Anesthesia Department of Fuwai Hospital, summarizes its current practice of anesthesia management, the outcomes of cardiovascular surgeries at Fuwai Hospital, accumulates relevant evidence, and provides prospects for future development of cardiovascular anesthesiology.     

临床医学导论组织教学探析

为临床医疗本科学生开设“临床医学导论”，在我校实属首次，我们开设此门课程的目的旨在引领医学生早期进入医生角色，明晰人类社会对该职业的期望和要求。使医学生在学习初期就能了解医学相关理论与知识，以现代医学观为指导开展今后的学习。全面的培养和提高自身素质。在参阅大量相关文献的基础上，制作了相关的教学课件并采用多种方法向学生讲述，取得了较好的效果。我们于     

乙烯裂解焦炭在燃烧过程中的微观形态变化

对乙烯裂解焦炭的性质进行了分析，并对乙烯裂解焦炭在未加助燃剂和添加助燃剂情况下的燃烧过程中微观形态的变化进行了研究。研究结果表明，乙烯裂解焦炭在燃烧后期的燃烧速率比前期小很多，而且有5％左右的烧焦残余物很难燃尽。加入了助燃剂后，焦炭原有的微观形态被破坏，这不仅提高了焦炭的燃烧速率，而且也增加了焦炭的燃尽率。     

原子力显微镜观察间充质干细胞向成骨细胞系分化过程中的表征变化

目的 通过对骨髓间充质干细胞(mesenchymal stcm cell，MSC)向成骨细胞系转化过程中表征变化进行观察，以期更全面地了解MSC在体外的成骨分化过程。方法 将羊MSC进行体外诱导分化，进行组织学、免疫组化、X线衍射分析等检测及原子力显微镜观察。结果 诱导后的MSC碱性磷酸酶染色阳性率达90％以上，Ⅰ型胶原免疫组化和钙结节染色均呈阳性；诱导后细胞形成的结节样物中主要由羟基磷灰石组成；原子力显微镜观察见诱导后的MSC具有成熟的成骨细胞特性。结论 体外培养的MSC能被诱导成骨；运用原子力显微镜可以清晰地看到MSC在向成骨细胞分化过程中表征的变化。     

多胺在动脉粥样硬化发生发展过程中的变化

目的：探讨动脉粥样硬化的发病机制。方法：采用雄性日本鹌鹑喂饲高胆固醇膳食,造成动脉粥样硬化动物模型,动脉观察主动脉壁的中内膜的多胺变化。结果：血浆胆固醇和分类胆固醇提示高脂血症,结合病理切片,说明本实验动脉粥样硬化模型可靠。结论：1．多胺对动脉粥样硬化的发生起着重要作用;2．多胺在动脉粥样硬化发生（病理标准）前升高,后又依次降低的特殊现象。     

即刻临时固定桥修复后牙周情况观察

目的:观察、研究拔牙后即刻临时固定桥修复后基牙牙周组织情况及对永久修复体的影响.方法:选择25例患者,予常规牙周洁治后,基牙牙体预备(龈上边缘)取印模,拔牙,纱团压迫止血,此时制作即可固定桥,40分钟后即可戴临时固定桥,Relyx Temp NE 临时粘结剂(3M ESPE)粘固,2～3月后再次牙体预备(龈下边缘)永久固定桥修复.并重新制作临床时固定桥.观察、研究即刻临时固定桥修复后基牙牙周组织情况及对永久修复体的影响.结果:即刻临时固定桥对拔牙创面具有保护作用,利于自洁和愈合.即刻临时固定桥,因是龈上设计,故对基牙牙周组织不产生不利影响,不影响永久固定桥修复.结论:拔牙后即刻临时固定桥(采用龈上边缘设计)修复,对基牙牙周组织及永久修复体无不利影响,是满足患者的舒适、美观和功能的理想修复方法.     

Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation

While some cases of sexual exploitation involve predatory doctors, many other cases represent the culmination of a series of boundary crossings (non-exploitative departures from usual practice). The deliberate move to reduce formality in medicine has increased the likelihood of boundary crossings and violations. There are also individual doctor risk factors; boundary violations appear more likely when doctors are under stress, with insufficient emotional support. Preventive strategies include continuing education about ethics and the management of professional boundaries, along with appropriate psychological support structures for doctors. Doctors are often involved in other professional relationships as teachers, supervisors and team leaders; inappropriate sexual behaviour in these relationships is harassment. Public pressure for more punitive responses is likely if the profession is not seen to be doing all it can to deal with these issues effectively, and to be cooperating with other responsible agencies.