基层医院急诊科低年资护士综合素质的培训方法及效果评价

目的探讨基层医院急诊科低年资护士的培训方法。方法采用理论与实践相结合,一对一带教,通过案例分析、现场指导、情景模拟和观看录像等方法对低年资护士进行培训,考核合格后独立上岗。结果 20名低年资护士接受培训后急诊护理理论考试和急救技能考核成绩明显高于培训前,前后比较差异具有统计学意义（P〈0.001）。培训前理论考试、技能考核合格率分别为80%、85%,培训后理论考试、技能考核合格率均达100%。结论通过有计划的不同方式的培训,可提高低年资护士的抢救技能以及基础技术,提高其综合素质,避免了护理纠纷的发生。     

快速康复理念在胃癌围手术期中的应用

目的研究快速康复外科理念（fast track surgery,FTS）在胃癌围手术期治疗中的安全性和有效性。方法 选择120例同期住院胃癌手术患者随机分为FTS组（观察组）和传统方法治疗组（对照组）,比较两组患者的手术及术后恢复相关评价指标。结果 FTS组与对照组相比在手术时间（73.02±10.94min vs100.12±8.00min,P=0.001）、术中出血量（160.17±10.28ml vs441.75±25.55ml,P=0.000）等手术相关指标和术后首次排气时间（29.05±7.33h vs63.53±22.10h,P=0.000）、首次排便时间（44.33±6.59h vs143.43±9.08h,P=0.000）、肠内营养并发症发生率（8.33%vs31.67%,P=0.001）、住院时间（9.97±1.12d vs12.65±2.08d,P=0.000）等术后恢复相关指标方面的差异均有统计学意义。结论 运用FTS理念可明显加速胃癌患者术后康复进程,在胃癌围手术期中的应用是安全可行的。     

阿托伐他汀对ApoE基因敲除小鼠血清白细胞三烯浓度及动脉粥样硬化斑块的影响

目的研究阿托伐他汀对ApoE（-/-）动脉硬化模型小鼠血清白细胞三烯浓度的影响,探讨阿托伐他汀的抗动脉硬化机制。方法将ApoE（-/-）小鼠分为对照组（n=12）、动脉硬化模型组（n=12）、阿托伐他汀干预组（n=12）。检测3组ApoE（-/-）小鼠血清的白细胞三烯B4和白细胞三烯D4浓度、测量主动脉斑块校正面积并进行比较。结果对照组主动脉未见动脉硬化病变;动脉硬化模型组建模成功,见不稳定斑块;阿托伐他汀干预组较动脉硬化模型组动脉硬化病变显著减轻,斑块校正面积显著下降,差异有统计学意义（13.24%±3.08%vs.29.08%±6.46%,P〈0.001）。动脉硬化模型组的血清白细胞三烯B4、白细胞三烯D4浓度显著高于对照组,差异有统计学意义[（34.79±4.47）ng.mL-1vs.（12.07±2.35）ng.mL-1,P〈0.001;（2 862.48±48.77）n.L-1vs.（2 357.10±53.57）ng.L-1,P〈0.001）]。阿托伐他汀干预组血清白细胞三烯B4、白细胞三烯D4浓度显著低于动脉硬化模型组,差异有统计学意义[（20.93±2.19）ng.mL-1vs.（34.79±4.47）ng.mL-1,P〈0.001;（2 592.06±22.45）ng.L-1vs.（2 862.48±48.77）ng.L-1,P〈0.001）]。结论阿托伐他汀可能通过降低血清白细胞三烯B4和白细胞三烯D4浓度,减轻炎症反应,稳定斑块,发挥抗动脉硬化作用。     

表象训练在虚拟现实内镜模拟器培训胃镜初学者中的应用

目的:探讨表象训练在胃镜技能获得中的作用.方法:分层抽样法抽取我校08级临床医学专业男学员30人,随机分为3组.A组(n=10)在常规模拟器练习过程中加入表象训练,B组(n=10)进行常规模拟器练习,C组(n=10)不做任何练习.完成培训结束时所有学员操作病例1,模拟器给出的评分,比较3组间的考核评分.所有学员接受培训前、后心理测评,评价心理状态是否稳定.结果:比较3组考核成绩显示,3组间总分差异有统计学意义,3组组间两两比较显示差异有统计学意义,其中A组优于B组,A组优于C组,B组优于C组.进一步分析差异原因,结果表明,安全性评分和准确性评分、残气量评分、患者痛苦指数评分、操作时间评分A、B、C3组间差异均有统计学意义;而A、B组两组之间比较,只有残气量评分、操作时间评分差异有统计学意义.结论:表象训练可提高使用虚拟现实内镜模拟器培训胃镜技能的效果,教学方法容易实施,学员容易掌握,是一种可行性较高的教学辅助方法.     

血清同型半胱氨酸水平与冠状动脉病变程度的相关性研究

目的：探讨同型半胱氨酸（Hcy）水平与冠状动脉病变狭窄程度的影响。方法收集冠心病患者269例,以酶法测定 Hcy≥10μmol/L为标准,将患者分为高 Hcy血症组（HHcy组）和 Hcy水平正常组（非 HHcy组）,比较两组患者的一般资料、生化水平、冠脉病变严重程度、Gensini冠脉病变积分。结果 HHcy 组三酰甘油（TG）水平高于非 HHcy 组,合并2型糖尿病比例也高于非HHcy组（33.3% vs 24.4%,2.16±1.07vs1.52±0.79）,差异有统计学意义（χ2=9.73,P〈0.05;t=3.018,P〈0.01）。2支病变组及多支病变组Hcy水平较单支病变组增高（22.1±10.10vs27.31±13.89vs13.40±6.76）,差异具有统计学意义（t=2.9、6.95, P〈0.01）;HHcy组Gensini评分高于非 HHcy组（47.65±23.12 vs 36.49±18.34）,差异有统计学意义（t=3.85,P〈0.001）。结论Hcy 水平与冠状动脉狭窄程度有关。     

两种胆道探查术后患者生存质量分析

目的探讨两种胆道探查手术前后患者生存质量的变化。方法采用GIQLI生存质量指标测定156例胆道探查手术患者术前及术后2,8,12,16周的生存质量值。结果腹腔镜胆道手术组和开腹胆道手术组术前GIQLI指数无明显差异,腹腔镜胆道患者术后2,8,12周平均GIQLI指数高于开腹胆道手术组（P〈0.05）（106.2±14.1 vs 96.3±11.1,P〈0.05;117.6±12.3 vs 106.7±11.6,P〈0.05;122.1±10.2 vs 115.6±13.8,P〈0.05）。结论腹腔镜胆道探查术后较开腹胆道术后生存质量高。     

手术直播演示结合分级腹腔镜模拟器训练法在普外科腹腔镜培训中的研究

目的手术直播演示结合分级腹腔镜模拟器训练法在普外科腹腔镜培训中的应用效果。 方法首都医科大学附属北京中医医院参加住院医师规范化培训基地第1阶段普外科、泌尿外科及妇科专业住院医师和本院纳入第1阶段住院医师规范化培训的普外科、泌尿外科及妇科专业研究生组成，共120名。腹腔镜基本技能培训为期1个月，内容包括3部分：手术直播演示每周2台；理论授课每周2次，每次1 h；模拟训练4周，操作每天4 h，包括（初级模块——基本技能训练；中级模块——简单及高级缝合训练；进阶模块——腹腔镜必要技巧训练；高级模块——模拟手术培训）。随机分为3组，其中试验组采用手术演示＋理论授课＋腹腔镜模拟训练；对照组采用理论授课＋手术演示；空白组采用仅进行理论授课，不参与其他培训，安排下一期参加培训。 结果培训后腹腔镜理论考核成绩试验组为（82.00±6.72）分，对照组为（83.40±6.51）分，空白组（83.20±5.72）分，均较培训前提高，但差异均无统计学意义（P＞0.05），且3组间培训前后理论成绩差异不显著，差异无统计学意义（P＞0.05）。腹腔镜操作技能考核成绩试验组培训后初级模块——基本技能训练、中级模块——简单及高级缝合训练、进阶模块——腹腔镜必要技巧训练、高级模块——模拟手术培训各项操作技能成绩分别为（86.00±5.98）、（86.00±5.98）、（85.00±5.13）和（82.50±6.38）分，较试验组培训前的（37.00±10.81）、（18.00±7.68）、（16.00±8.21）和（10.50±10.50）分显著提高，差异有统计学意义（P＜0.05）；明显高于对照组（46.00±9.95）、（44.00±9.40）、（39.00±7.18）和（35.00±7.18）分，差异均有统计学意义（P＜0.05）；明显高于空白组（36.00±8.21）、（18.50±6.71）、（16.50±9.44）和（11.00±9.68）分，差异均有统计学意义（P＜0.05）。 结论腹腔镜技能模拟训练能有效提高临床医学生的腹腔镜操作技能。     

伴有抑郁症状急性冠脉综合征早期应用氟哌噻吨美利曲辛疗效观察

目的探讨药物干预对伴有抑郁症状的急性冠脉综合征（ACS）患者的临床疗效。方法将入选的94例合并抑郁ACS患者随机分为干预组（n=48）和对照组（n=46）。干预组在冠心病常规治疗上给予氟哌噻吨美利曲辛。两组治疗前后HAMD评分、临床症状和超敏C反应蛋白（hs-CRP）进行比较。结果干预组治疗后HAMD评分明显低于对照组[（13±7）vs（26±7）,P〈0.05]。干预组治疗后临床症状改善率明显优于对照组（P〈0.05）。干预组治疗在观察中期和结束时hs-CRP水平下降优于对照组[6周时（12.7±4.7）vs（21.3±5.3）mg/L;12周时（8.2±2.2）vs（17.5±4.4）mg/L,P〈0.05]。结论对合并抑郁的ACS患者早期使用氟哌噻吨美利曲辛不仅可以改善抑郁症状,并有助于提早改善冠心病临床症状,降低hs-CRP水平,对ACS患者早期康复及近期预后有重要意义。     

抑郁对自发性高血压大鼠水通道蛋白-2的影响

目的探讨抑郁对自发性高血压大鼠水通道蛋白2（aquaporin2,AQP2）的影响,并探讨AQP2在高血压中的病理生理作用。方法60只SHR大鼠分为对照组（n=30）和抑郁组（n=30）,两组又各分为两个亚组：对照组非药物治疗亚组（n=15）、对照组贝那普利治疗亚组（n=15）;抑郁组非药物治疗亚组（n=15）、抑郁组贝那普利治疗亚组（n=15）。另外,选取Wistar Kyoto（WKY）大鼠20只作为正常组大鼠。药物治疗亚组大鼠予贝那普利10 mg.d-1.kg-1灌胃。抑郁组大鼠采用慢性不可预计温和应激（CUMS）结合行为学指标建立自发性高血压大鼠并抑郁动物模型。对照组、正常组大鼠动物正常饲养。检测并比较各组大鼠间血压的变化及血管加压素和肾脏AQP2表达的差异。结果 （1）抑郁组非药物治疗亚组血压（175±14）mm Hg高于对照组非药物治疗亚组（160±11）mm Hg及正常组（112±9）mm Hg,差异有统计学意义（P〈0.05）;贝那普利治疗后,抑郁组治疗亚组血压（136±15）mm Hg、对照组治疗亚组（113±12）mm Hg均低于各自非药物治疗组（P〈0.05）。（2）抑郁组非药物治疗亚组与正常组、对照组非药物治疗亚组及对照组贝那普利治疗亚组比较,糖水偏爱性均减低（P〈0.05）,体质量和旷场实验评分均明显下降（P〈0.05）,血浆血管加压素浓度升高[（9.31±0.42）pg/mL vs.（1.6±0.67）pg/mL、（3.04±0.97）pg/mL、（2.34±0.91）pg/mL,P〈0.05],AQP2蛋白表达增加（0.95±0.12 vs.0.12±0.07、0.44±0.06、0.24±0.06,P〈0.05）。（3）抑郁组贝那普利治疗亚组与对照组非药物治疗亚组、对照组贝那普利治疗亚组比较,糖水偏爱性均减低（P〈0.05）,体质量和旷场实验评分均明显下降（P〈0.05）,血浆血管加压素浓度升高[（4.55±0.69）pg/mL vs.（3.04±0.97）pg/mL、（2.34±0.91）pg/mL,P〈0.05],AQP2蛋白表达增加（0.62±0.17 vs.0.12±0.07、0.44±0.06,P〈0.05）。（4）对照组贝那普利治疗亚组与抑郁组非药物治疗亚组比较,糖水偏爱性亦增加（P〈0.05）,体质量和旷场实验评分升高（P〈0.05）,血浆AVP浓度下降[（4.55±0.69）pg/mL vs.（9.31±0.42）pg/mL,P〈0.05],AQP2蛋白表达减少（0.62±0.17 vs.0.95±0.12,P〈0.05）。结论抑郁可以促进自发性高血压大鼠血管加压素的分泌及肾脏AQP2的表达。抑郁可能通过促进血管加压素的分泌及肾脏AQP2的表达影响高血压的发展。     

乙型肝炎肝硬化肝性骨营养不良的临床研究

目的探讨乙型肝炎肝硬化与肝性骨营养不良和骨质疏松的关系。方法收集自2008年3月~2009年3月在我院住院的乙型肝炎肝硬化患者43例,健康对照组21例,采用双能X线骨密度仪测定股骨颈、尺桡骨骨密度,空腹抽血测定血钙、血磷、甲状旁腺素、降钙素、白细胞介素-6。结果肝硬化组骨质疏松发生率显著高于对照组（P=0.003）;两组股骨颈骨密度[（-0.860±0.705）g/cm2vs（0.125±0.715）g/cm2,P〈0.001]、尺桡骨骨密度[（-0.702±0.666）g/cm2vs（0.279±0.709）g/cm2,P〈0.001）]、血钙[（2.151±0.168）mmol/Lvs（2.336±0.170）mmol/L,P〈0.001）]比较,肝硬化组显著低于对照组;血磷[（1.051±0.077）mmol/Lvs（0.961±0.069）mmol/L,P〈0.001）]、甲状旁腺素[（412.674±22.779）ng/Lvs（386.000±30.223）ng/L,P〈0.001）]、降钙素[（45.358±3.900）pg/Lvs（30.667±3.120）pg/L,P〈0.001）]、IL-6[（41.795±14.988）pg/mlvs（4.077±1.555）pg/mL,P〈0.001]比较,肝硬化组显著高于对照组;肝硬化组股骨颈骨密度与IL-6呈负相关。结论肝性骨营养不良是乙型肝炎肝硬化严重并发症之一,以骨质疏松为常见表现,应监测骨密度预防肝性骨营养不良。     

卒中专病门诊贯彻卒中二级预防指南的研究

目的观察医师培训和专病门诊对缩小临床实践与缺血性卒中二级预防指南差距的影响。方法选择在卒中专病门诊就诊的305例缺血性卒中患者,比较其在医师规范培训前后及出院与在专病门诊随访期间抗栓药、他汀类药物、不规范用药和降压药的使用情况。结果医师经培训后提高了二级预防用药的规范性,患者出院的抗栓药（79．3％比93．1％,P〈0．01）和他汀类药（19．5％对59．2％,P〈0．01）使用率显著提高,不规范用药（47．1％比27．5％,P=0．001）显著降低。高血压的治疗率（88．4％比94．0％）差异无统计学意义。与出院时相比,专病门诊随访患者的抗栓药和他汀类药使用率进一步提高,不规范用药进一步降低。出院带药规范者随访期的用药依从性高。结论医师培训能提高缺血性卒中二级预防处方的规范性,专病门诊能进一步提高患者出院带药及随访期用药的依从性。     

加速康复策略的麻醉管理在胃食管反流病手术治疗中应用的效果评价

目的探讨加速康复策略对采用腹腔镜手术治疗的胃食管反流病患者术后胃肠功能恢复、疼痛及应激反应因子的影响。 方法选择2017年9月至2018年6月在新疆自治区人民医院进行腹腔镜手术的胃食管反流病患者62例。按照随机数字表法分为加速康复组与对照组2组,每组各31例。加速康复组患者围手术期应用加速康复策略进行麻醉管理,对照组患者行传统麻醉处理措施。观察并记录2组患者胃肠功能恢复时间（包括肠鸣音恢复时间、肛门排气时间）、术后疼痛视觉模拟评分（VAS）、术后应激性指标［包括C-反应蛋白（CRP）、皮质醇水平及白细胞（WBC）计数］、下床活动时间、术后住院时间、患者满意度及术后并发症等,并采用t检验进行比较。 结果加速康复组患者肛门排气时间、肠鸣音恢复时间、下床活动时间均短于对照组患者,且差异均有统计学意义（t=14.95、16.39、14.94,P均<0.001）。但2组患者术后住院时间、满意度评分差异均无统计学意义。加速康复组患者术后疼痛VAS评分低于对照组患者,且差异有统计学意义（t=5.942,P<0.001）。加速康复组患者术后CRP水平、WBC计数均较术前升高,而皮质醇水平较术前降低,但差异均无统计学意义。对照组患者术后CRP水平、WBC计数均较术前升高,但差异均无统计学意义;皮质醇水平也较术前升高,但差异有统计学意义（t=13.15,P=0.048）。术前2组患者CRP、皮质醇水平及手术前后WBC计数差异均无统计学意义,术后加速康复组CRP、皮质醇水平均低于对照组患者,且差异均有统计学意义（t=0.60,P=0.001;t=4.640,P<0.001）。2组患者术后均无严重并发症发生。 结论在胃食管反流病患者腹腔镜手术围手术期应用加速康复策略进行麻醉管理可以明显促进胃肠功能恢复,缓解术后疼痛,降低术后炎性反应,且安全性高。     

Using Medical Mannequins to Train Nurses in Stroke Swallowing Screening

Screening patients admitted with stroke symptoms for risk of aspiration is often the responsibility of registered nurses (RNs). Simulation technology has become a widely used evidence-based form of training for healthcare professionals. The purpose of this study was to determine if the use of medical simulation mannequins as a training component is feasible when training and evaluating nurses administering swallowing screenings to stroke patients. A total of 32 RNs were divided into one of two training groups: didactic training only or didactic training plus simulation. Acquisition of skills was assessed immediately post-training and compared between the groups revealing significant differences between simulation group and didactic-only group for interpretation (p = 0.01) and administration (p = 0.05) accuracies. Following training to 100 % accuracy for post-training baseline competency, maintenance of skills across participants was assessed three more times over 6 weeks with the third follow-up screening completed with a standardized patient (live patient actor). While interpretation performance at each subsequent trial never equaled the baseline 100 % post-training accuracy (p = 0.001), steady improvement in performance was observed with each follow-up assessment. For screening administration, no significant differences in skills were evident between post-training baseline competency and the 6-week follow-up (p = 0.269) further confirming improvement in skills over time. Extension of screening administration and interpretation skills to the standardized patient was evident. Findings indicate that simulation training using medical mannequins can be used to train and evaluate nurses for obtainment and maintenance of swallowing screening competency.     

Increased mortality of women in coronary artery bypass surgery: evidence for referral bias

STUDY OBJECTIVE: To determine whether differences in referral reasons explain the higher operative mortality of women in coronary artery bypass surgery. DESIGN: Case series. SETTING: A tertiary care, private teaching hospital. PATIENTS: Consecutive patients who had isolated coronary artery bypass surgery between 1982 and 1987 (total, 2297; 79% male and 21% female). MEASUREMENTS AND MAIN RESULTS: The inhospital mortality rate was significantly higher for women than for men (4.6% compared with 2.6%; P = 0.036; 95% CI for difference in mortality, 0% to 4.0%). Women were older than men (mean, 68.2 and 64.0 years, respectively; P less than 0.001), and a higher percentage of women were referred with unstable angina (P = 0.007), postmyocardial infarction angina (P = 0.029), congestive heart failure (P less than 0.001), and New York Heart Association class IV symptoms (66% compared with 45%, P less than 0.001). More men were referred with a history of an abnormal exercise test (P less than 0.001), and patients referred because of a positive exercise test had a lower mortality (P less than 0.001). Using multivariate analysis, adjustment for the higher preoperative functional class of women and for age accounted for all of the difference in mortality between men and women (odds ratio, 1.04; CI, 0.60 to 1.79; P = 0.89). After correction for functional class alone, there continued to be no significant difference in mortality between men and women (P = 0.40). CONCLUSIONS: Differences in functional class and age account for the higher operative mortality of women in coronary bypass surgery. Women are referred for coronary bypass surgery later in the course of their disease than men, and later referral may increase their changes of operative death.     

An evaluation of a refresher training intervention for HIV lay counsellors in Chongwe District,Zambia

To address a severe shortage of human resources for health, the Zambian Ministry of Health has begun to make use of lay counsellors for HIV counselling and testing. However, their skills and knowledge rarely have been reviewed or refreshed. We conducted a two-day refresher workshop for lay counsellors to review their performance and refresh their skills and knowledge. The objective of this study was to evaluate the refresher training intervention for HIV lay counsellors in the rural district of Chongwe in Zambia. The two-day refreshertraining workshop was held in November 2009. Twenty-five lay counsellors were selected by District Health Office and participated in the workshop. The workshop included: the opening, a pre-training exercise, lectures on quality assurance with regard to testing and safety precautions, lectures on counselling, filling the gap/Q&A session, and a post-training exercise. In both the pre- and post-training exercise, participants answered 25 true/false questions and tested 10 blood panel samples to demonstrate their knowledge and skill on HIV counselling and testing. The average overall knowledge test score increased from 79% to 95% (p<0.001). At the baseline, knowledge test scores in topic of standard precaution and post-exposure prophylaxis were relatively low (58%) but rose to 95% after the training (p<0.001). The per cent agreement of HIV testing by lay counsellors with reference laboratory was 99.2%. Participants' knowledge was improved during the workshop and skill at HIV testing was found to remain at a high level of accuracy. Relatively weak knowledge of standard precautions and post-exposure prophylaxis suggests that lay counsellors are at risk of nosocomial infections, particularly in the absence of refresher training interventions. We conclude that the refresher training was effective for improving the knowledge and skills of lay counsellors and provided an opportunity to monitor their performance.     

Severity of cardiac conduction involvement and arrhythmias in myotonic dystrophy type 1 correlates with age and CTG repeat length

INTRODUCTION: Cardiac myopathy manifesting with conduction disturbances and arrhythmias is common in the neurologic disease myotonic dystrophy. We studied whether the severity of cardiac involvement in myotonic dystrophy correlates with the severity of the genetic abnormality cytosine-thymine-guanine (CTG) repeat expansion. METHODS AND RESULTS: History, physical examination, ECG evaluation, and genetic testing were performed in patients with a clinical diagnosis of myotonic dystrophy. In 342 of 385 patients, the diagnosis was confirmed by CTG repeat expansion. In these patients, the muscular disability severity correlated with age and CTG repeat length (r = 0.44, P < 0.001). An arrhythmia diagnosis was present in 19 (5.6%) patients with a likelihood of diagnosis correlating with age (relative risk [RR] 2.2 per decade, 95% confidence intervals [CI] 1.4 to 3.4, P = 0.001) and CTG repeat length (RR 2.9 per 500 repeats, 95% CI 1.5 to 5.4, P = 0.001). ECGs were abnormal in 222 (64.9%) of the patients. Age, CTG repeat length, and male gender were factors found to correlate with ECG conduction abnormalities quantitated by the PR interval (r = 0.43, P < 0.001) and QRS duration (r = 0.32, P < 0.001). A 24-hour ambulatory ECG was abnormal in 95 (29.6%) of 321 recordings. The presence of an abnormality correlated with age (RR 1.5 per decade, 95% CI 1.2 to 1.9, P < 0.001) and CTG repeat length (RR 1.6 per 500 repeats, 95% confidence intervals 1.1 to 2.2, P = 0.01). CONCLUSION: The severity of skeletal and cardiac myopathy in myotonic dystrophy correlates with age and CTG repeat length, suggesting a similar mechanism causing a time-dependent degenerative process.     

Illness behavior and laparoscopic antireflux surgery: tailoring the wrap to suit the patient

Psychological factors are believed to play a role in gastroesophageal reflux disease. It has previously been shown that preoperative illness behavior influences the outcome after laparoscopic Nissen fundoplication. Between August 2001 and June 2004 we considered a partly subjective assessment of illness behavior when selecting patients with gastroesophageal reflux disease for laparoscopic anterior partial (n = 77) or total fundoplication (n = 90). A prospective questionnaire study of illness behavior was also undertaken and the results were correlated with clinical follow up after 12 months. There was a statistically significant difference in age (P < 0.001), primary esophageal peristalsis on manometry (P = 0.037) and two illness behavior category scores related to hypochondriasis (P = 0.041 and P = 0.025) between laparoscopic anterior partial fundoplication and Nissen total fundoplication groups. Despite these differences, there was no significant correlation between preoperative illness behavior score and patient satisfaction in either group. There was a statistically significant negative correlation between the ability to express personal feelings and postoperative heartburn score in those who had a laparoscopic anterior partial fundoplication (P = 0.048). The clinical outcome in both groups was good to excellent in terms of postoperative heartburn and satisfaction scores. A tailored approach in the choice of wrap, taking into account psychological factors preoperatively, is an appropriate strategy for laparoscopic fundoplication.     

腹腔镜模拟培训在微创外科研究生临床教学中的应用

目的探讨腹腔镜模拟培训在微创外科专业学位研究生临床教学中的应用效果。 方法采用腹腔镜模拟训练结合临床教学模式对我科24名微创外科专业学位研究生进行临床教学，教学结束时考核教学效果，调查教学满意度，比较考核前后的成绩。 结果培训后学生出科平均成绩、合格率、优秀率、主观对自己基本操作熟练程度评分、满意度评分等均高于培训前，且差异有统计学意义（P<0.001）。 结论微创外科研究生临床教学理论与腹腔镜模拟培训相结合，可有效提高微创外科研究生对腹腔镜基本操作及视觉能力，提高腹腔镜操作者的基本技能，取得良好的教学效果，但考核标准仍需要完善。     

Using verbal autopsy to ascertain perinatal cause of death: are trained non‐physicians adequate?

Objectives  To develop a standardized verbal autopsy (VA) training program and evaluate whether its implementation resulted in comparable knowledge required to classify perinatal cause of death (COD) by physicians and non-physicians.
Methods  Training materials, case studies, and written and mock scenarios for this VA program were developed using conventional VA and ICD-10 guidelines. This program was used to instruct physicians and non-physicians in VA methodology using a train-the-trainer model. Written tests of cognitive and applied knowledge required to classify perinatal COD were administered before and after training to evaluate the effect of the VA training program.
Results  Fifty-three physicians and non-physicians (nurse-midwives/nurses and Community Health Workers [CHW]) from Pakistan, Zambia, the Democratic Republic of Congo, and Guatemala were trained. Cognitive and applied knowledge mean scores among all trainees improved significantly (12.8 and 28.8% respectively, P  < 0.001). Cognitive and applied knowledge post-training test scores of nurse-midwives/nurses were comparable to those of physicians. CHW (high-school graduates with 15 months or less formal health/nursing training) had the largest improvements in post-training applied knowledge with scores comparable to those of physicians and nurse-midwives/nurses. However, CHW cognitive knowledge post-training scores were significantly lower than those of physicians and nurses.
Conclusions  With appropriate training in VA, cognitive and applied knowledge required to determine perinatal COD is similar for physicians and nurses-midwives/nurses. This suggests that midwives and nurses may play a useful role in determining COD at the community level, which may be a practical way to improve the accuracy of COD data in rural, remote, geographic areas.