研究和实施DRGs时应考虑的若干问题

研究和实施结合我国国情的疾病诊断相关分组（DRGs），对控制我国医疗费用不合理增长具有重要的现实意义。作者简要介绍了DRGs的概念和原理、国内外的发展和应用情况以及国外实施DRGs的成效和不足之处，并结合我国医院的现状及运行特点，提出在我国现阶段研究和实施结合我国国情的DRGs需要考虑的若干因素：即信息系统的统一完善、医疗资源消耗的度量、疾病严重程度的度量、统计学方法的选择、支付标准的制定及临床诊疗规范的建立等因素。     

Percutaneous absorption of anthracene in the rat: comparison of in vivo and in vitro results

The present study was conducted to evaluate the applicability of in vitro percutaneous absorption techniques to estimate in vivo absorption of polynuclear aromatic (PNA) compounds commonly found in mineral oils. The percutaneous absorption of 14C-labeled anthracene, a three-ring PNA, was compared in a six-day in vivo and in vitro experiment with female Sprague-Dawley rats following a single topical dose (9.3 micrograms/cm2). In vivo absorption was measured by the presence of 14C radioactivity in urine, feces and tissues and in vitro absorption by penetration of radioactivity through excised skin into the receptor fluid of Franz-type diffusion cells. Several modifications of standard diffusion cell techniques were used which are known to enhance the absorption of lipophilic compounds. Anthracene was observed to readily penetrate the skin in both experiments and the total amounts absorbed in vivo and in vitro were seen to gradually coalesce over time. Within six days after application, 52.3 and 55.9% of the administered anthracene was absorbed in vivo and in vitro, respectively.     

Competitive binding comparison of endocrine-disrupting compounds to recombinant androgen receptor from fathead minnow, rainbow trout, and human

Typically, in vitro hazard assessments for the identification of endocrine-disrupting compounds (EDCs), including those outlined in the Endocrine Disruptor Screening and Testing Advisory Committee (EDSTAC) Tier 1 Screening protocols, utilize mammalian receptors. Evidence, however, exists that fish sex steroid hormone receptors differ from mammalian receptors both structurally and in their binding affinities for some steroids and environmental chemicals. Most of the binding studies to date have been conducted using cytosolic preparations from various tissues. In the present study, we compare competitive binding of a set of compounds to full-length recombinant rainbow trout androgen receptor alpha (rtAR), fathead minnow androgen receptor (fhAR), and human androgen receptor (hAR), each expressed in COS cells. Saturation binding and subsequent Scatchard analysis using [3H]R1881, a high-affinity synthetic androgen, revealed an equilibrium dissociation constant (Kd) of 0.11 nM for the rtAR, 1.8 nM for the fhAR, and 0.84 nM for the hAR. Compounds, including endogenous and synthetic steroids, known mammalian antiandrogens, and environmental compounds, were tested for competitive binding to each of the three receptors. Overall, agreement existed across receptors as to binding versus nonbinding for all compounds tested in this study. Minor differences, however, were found in the relative order of binding of the compounds to the individual receptors. Studies such as these will facilitate the identification of EDCs that may differentially affect specific species and aid in the development and support of future risk assessment protocols.     

Use of viral pathogens and indicators to differentiate between human and non-human fecal contamination in a microbial source tracking comparison study

Assays for the detection and typing of adenoviruses, enteroviruses and F+ specific coliphages were performed on samples created as part of a national microbial source tracking methods comparison study. The samples were created blind to the researchers, and were inoculated with a variety of types of fecal contamination source (human, sewage, dog, seagull and cow) and mixtures of sources. Viral tracer and pathogen assays demonstrated a general ability to discriminate human from non-human fecal contamination. For example, samples inoculated with sewage were correctly identified as containing human fecal contamination because they contained human adenovirus or human enterovirus. In samples containing fecal material from individual humans, human pathogen analysis yielded negative results probably because the stool samples were taken from healthy individuals. False positive rates for the virus-based methods (0-8%) were among the lowest observed during the methods comparison study. It is suggested that virus-based source tracking methods are useful for identification of sewage contamination, and that these methods may also be useful as an indication of the public health risk associated with viral pathogens. Overall, virus-based source tracking methods are an important approach to include in the microbial source tracking 'toolbox'.     

两种不同的氧气浓度对人类未成熟卵子体外成熟培养、受精及早期胚胎发育的影响

目的探讨两种不同的氧气浓度对人类未成熟卵子体外成熟培养(IVM)及受精和早期胚胎发育的影响,为临床辅助生殖技术治疗提供参考依据。方法将收集的未成熟卵子随机分为低浓度氧气(低氧组)和高浓度氧气(高氧组)条件进行IVM,将成熟卵子进行卵胞质内单精子显微注射(ICSI)并行体外胚胎培养,分析两种不同的氧气浓度培养对人类未成熟卵子的成熟率、受精率、卵裂率以及优质胚胎率的影响。结果对于有生发泡(GV)期卵子,低氧组的成熟率高于高氧组(84. 40%vs. 69. 81%),差异有统计学意义(P<0. 05);低氧组的受精率和优质胚胎率都高于高氧组(65. 22%vs. 64. 86%;20. 51%vs. 12. 50%),低氧组的卵裂率低于高氧组(65. 00%vs. 66. 67%),但差异无统计学意义(均P>0. 05)。对于减数分裂I (MI)期卵子,低氧组的成熟率高于高氧组(90. 84%vs. 78. 29%),差异有统计学意义(P<0. 05);低氧组的卵裂率低于高氧组(62. 34%vs. 65. 08%),但差异无统计学意义(P>0. 05);低氧组的受精率和优胚率都高于高氧组(64. 70%vs. 62. 38%;18. 75%vs. 17. 07%),但差异无统计学意义(均P>0. 05)。结论低浓度氧气培养相对高浓度氧气可以提高卵子的体外成熟率,但不能改善其受精和早期胚胎发育。     

The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study

BACKGROUND: A report by the Institute of Medicine suggests that changing the culture of health care organizations may improve patient safety. Research in this area, however, is modest and inconclusive. Because culture powerfully affects providers, and providers are a key determinant of care quality, the MEMO study (Minimizing Error, Maximizing Outcome) introduces a new model explaining how physician work attitudes may mediate the relationship between culture and patient safety. RESEARCH QUESTIONS: (1) Which cultural conditions affect physician stress, dissatisfaction, and burnout? and (2) Do stressed, dissatisfied, and burned out physicians deliver poorer quality care? METHODS: A conceptual model incorporating the research questions was analyzed via structural equation modeling using a sample of 426 primary care physicians participating in MEMO. FINDINGS: Culture, overall, played a lesser role than hypothesized. However, a cultural emphasis on quality played a key role in both quality outcomes. Further, we found that stressed, burned out, and dissatisfied physicians do report a greater likelihood of making errors and more frequent instance of suboptimal patient care. PRACTICE IMPLICATIONS: Creating and sustaining a cultural emphasis on quality is not an easy task, but is worthwhile for patients, physicians, and health care organizations. Further, having clinicians who are satisfied and not burned out or stressed contributes substantially to the delivery of quality care.     

Doses of levonorgestrel comparable to that delivered by the levonorgestrel-releasing intrauterine system can modify the in vitro expression of zona binding sites of human spermatozoa

BACKGROUND: The levonorgestrel-releasing intrauterine system (LNG-IUS) exerts its contraceptive effect by interfering with sperm transport through the female genital tract and with ovulation. However, the possibility cannot be discarded that the device exerts a direct effect on sperm function, thus, helping prevent fertilization. OBJECTIVES: The purpose of this study is to evaluate whether LNG at doses comparable to that measured in the uterus during the use of the LNG-IUS affects the detection of D-mannose binding sites or zona pellucida (ZP) receptors on human spermatozoa. The association with acrosomal status was also investigated. METHODS: Seventeen semen samples from fertile men were used, and spermatozoa were separated using a Percoll gradient and incubated for 22 h at 37 degrees C under 5% CO(2) in air. Capacitated spermatozoa were exposed for 30 min to 1,000 or 10,000 ng/mL of LNG or control medium. D-Mannose binding sites were detected using commercial D-mannosylated bovine serum albumin conjugated with fluorescein isothiocyanate, and the percentage of specific patterns (II and III) was recorded. The acrosome reaction was evaluated using the Pisum sativum technique. RESULTS: Levonorgestrel releasing significantly increased (p < .001) the percentage of spermatozoa with D-mannose receptors localized in pattern III, and this increase was dose dependent and a significant increase (p < .001) in the percentage of acrosome-reacted spermatozoa. Double staining confirmed an association between the location of the zona receptor and acrosomal status. RESULTS: The in vitro exposure of capacitated spermatozoa to the assayed doses of LNG increased the proportion of spermatozoa with fewer chances of interacting with the ZP. Further studies should be carried out to confirm whether this mechanism is part of the contraceptive action of the LNG-IUS.     

The SYNCAN project: goals, set-up, first results and settings of the human intervention study

Experimental evidence on the anticancer properties of dietary prebiotics such as chicory inulin and oligofructose and dietary probiotics has accumulated in recent years. Various experimental models ranging from chemoprevention studies, tumour implantation models to genetically modified mice models, etc. have systematically shown the protective effects of these food ingredients. In some studies it appeared that synbiotics (combination of pre- and probiotics) exerted synergistic activity against processes of carcinogenesis. The logical next step in research was to find out if these observations also would be valid for human volunteers. This was the principal goal of the EU-sponsored SYNCAN project (QLK1-1999-346) which involved the integration of an in vitro study to select the most suitable synbiotic preparation, the application of this synbiotic in an in vivo rat model of chemically induced colon cancer, and, as the heart of the project, the investigation of the synbiotic effects in a human intervention study. The in vitro tests consisted of fermentation studies where the interaction of pre- and probiotics was studied. Cell-free supernatants were generated from various synbiotic combinations fermented by faecal slurry, which were then used to optimise a series of bioassays. In the rat study the anticarcinogenic effect of prebiotics and synbiotics but not of probiotics was demonstrated. Using tissue samples generated in this model, attempts were made to gain a better insight into the mechanisms underlying cancer development. The human intervention study consisted of two groups of volunteers. One group was composed of people at high risk (polypectomised subjects) for colon cancer and the other of volunteers (colon cancer subjects) who had previously undergone 'curative resection' for colon cancer but were not currently receiving treatment. The present paper describes the experimental design of the SYNCAN study, and demonstrates a functional effect of the synbiotic preparation (probiotic survival during gastrointestinal transit and modification of the intestinal flora). Detailed experimental outcome of the human intervention study will be reported elsewhere.     

The milk of human kindness: environmental and human interactions in a WIC clinic that influence infant-feeding decisions of Black women

In this ethnographic study, the author explores the context of Black women's infant-feeding decisions in an urban WIC clinic. Data were obtained from 319 people (130 Black women enrolled in WIC [BWEW], 189 relatives and friends) with close follow-up of 11 primiparous key informants during pregnancy and the first year postpartum. The major findings include (a) the WIC clinic environment set a positive tone for service, (b) WIC employees treated the women with caring and respect, (c) BWEW believed that WIC was a source of support in time of need, and (d) WIC influenced infant-feeding decisions. The availability of free formula facilitated bottle feeding, but personalized breast-feeding promotion with trusting relationships with WIC providers encouraged breast-feeding decisions for almost half of the key informants.     

Randomized study of immune responses to two Tdap vaccines among adolescents primed with DTaP and comparison with results among adolescents primed with DTwP

BackgroundIt has been reported that persons primed with acellular (DTaP) pertussis vaccines have reduced duration of pertussis protection compared with those primed with whole-cell (DTwP) vaccines. However, due to the rapid transition to acellular vaccines, studies attempting directly to compare protection among DTaP-primed vs DTwP-primed individuals are subject to confounding by age and other limitations of ecological studies. Using validated assay results and stored sera from multiple Tdap studies, we evaluated two licensed Tdap vaccines among DTaP-primed adolescents to allow comparison with results obtained in the same laboratory from earlier studies involving DTwP-primed adolescents.MethodsParticipants 11–12 years of age who had received exactly 5 doses of DTaP vaccine prior to 7 years of age were randomly assigned in 2012 to receive one of two licensed Tdap vaccines. Serum specimens obtained pre- and post-vaccination were assayed for responses to the vaccines. Current results were then compared to results obtained in the same laboratory from prior randomized Tdap studies conducted among adolescents primed with DTwP or DTaP.ResultsBoth Tdap vaccines produced strong antibody responses to diphtheria and tetanus; responses to contained pertussis antigens were consistent with the differing levels of those antigens in each Tdap vaccine. However, postvaccination pertussis antibody responses were as much as 71% lower in these DTaP-primed adolescents compared with responses among DTwP-primed adolescents in a prior study of the same two Tdap vaccines. In contrast, results from the present study were similar to those seen in another study of Tdap among DTaP-primed adolescents.DiscussionTaken together, these results from randomized clinical trials provide direct evidence of reduced antibody responses to both licensed Tdap vaccines among adolescents primed with DTaP vaccine, compared with adolescents primed with DTwP vaccine.Clinical trial registry number: ClinicalTrials.gov, NCT01629589.     

The relationship between use of oral contraceptives and myocardial infarction in young women with fatal outcome, compared to those who survive: results from the MICA case-control study

To examine the relationship between use of oral contraceptives and the risk of dying from myocardial infarction, we made a comparison of deceased patients and live patients (women aged less than 45) identified for the Myocardial Infarction Causality case-control study, using data obtained from general practice medical notes. There were 422 live patients and 110 deceased patients of women with a myocardial infarction with data available. The adjusted odds ratio for exposure to second generation oral contraceptives and risk of death within 28 days of a myocardial infarction compared with no oral contraceptive use was raised (2.88, 95% confidence interval 1.22-6.77), and this effect was not seen for other types of oral contraceptives including third generation oral contraceptive formulations. In absolute terms, between 47,000 and 71,000 women would have to be exposed to a second generation pill for one year to result in one extra death from myocardial infarction, and this risk applies mainly to smokers. The results suggest a slightly increased relative risk of death among those having a myocardial infarction associated with exposure to second generation oral contraceptives, but this represents a small absolute risk. Further work is required before any change in contraceptive practice should be advocated.     

Need for a gender-sensitive human security framework: results of a quantitative study of human security and sexual violence in Djohong District,Cameroon

Background

Human security shifts traditional concepts of security from interstate conflict and the absence of war to the security of the individual. Broad definitions of human security include livelihoods and food security, health, psychosocial well-being, enjoyment of civil and political rights and freedom from oppression, and personal safety, in addition to absence of conflict.

Methods

In March 2010, we undertook a population-based health and livelihood study of female refugees from conflict-affected Central African Republic living in Djohong District, Cameroon and their female counterparts within the Cameroonian host community. Embedded within the survey instrument were indicators of human security derived from the Leaning-Arie model that defined three domains of psychosocial stability suggesting individuals and communities are most stable when their core attachments to home, community and the future are intact.

Results

While the female refugee human security outcomes describe a population successfully assimilated and thriving in their new environments based on these three domains, the ability of human security indicators to predict the presence or absence of lifetime and six-month sexual violence was inadequate. Using receiver operating characteristic (ROC) analysis, the study demonstrates that common human security indicators do not uncover either lifetime or recent prevalence of sexual violence.

Conclusions

These data suggest that current gender-blind approaches of describing human security are missing serious threats to the safety of one half of the population and that efforts to develop robust human security indicators should include those that specifically measure violence against women.

     

Comparative in vitro study of nonoxynol-9: effects on human, bull and boar spermatozoa.

Spermicidal activity of different dilutions of nonoxynol-9 (nonyl-phenoxy-polyethoxy-ethanol) on human, bull and boar spermatozoa was studied using the modified Sander-Cramer method. The results obtained showed that differences in spermatozoal resistance among the mentioned species to nonoxynol-9 were statistically very significant (P much less than 0.0005): bull greater than man greater than boar. The results obtained were compared to available literature results.     

Candidate gene association study of the radiosensitivity of human chromosomes with candidate gene polymorphisms upon exposure to gamma-irradiation in vitro and in vitro

The genotypic associations of the frequencies of spontaneous and radiation-induced chromosome aberrations in human lymphocytes were studied to develop genetic tests for elevated and reduced radiosensitivity. Cytogenetic analysis and genotyping (19 sites of detoxification and DNA repair genes) were carried out for a sample of Chernobyl cleanup workers (n = 83) and for a homogenous control sample of volunteers (n = 99). In both groups, the frequency of chromosome-type aberrations proved to be elevated in carriers of minor alleles in the XPD gene (sites T2251G (Lys751Gln) and G862A (Asp312Asn)) and a combination of GSTM1-GSTT1-positive genotypes. The polymorphism of these gene did not affect the frequency of gamma-radiation-induced aberrations in the controls (1 Gy in vitro), which was associated with the alleles of the OGG1, XRCC1, and CYP1A1 genes. Thus, the frequencies of spontaneous and in vitro induced chromosome-type aberrations are associated with the alleles of different xenobiotic detoxification and DNA repair genes. At the same time, among the cleanup workers (irradiated in vivo), the elevated frequency of aberrations was observed in the carriers of the genotypes associated with the higher rate of spontaneous (but not induced in vitro) cytogenetic damages in the controls.     

Equol: a comparison of the effects of the racemic compound with that of the purified S-enantiomer on the growth, invasion, and DNA integrity of breast and prostate cells in vitro

It has been postulated that the R- and S-equol enantiomers have different biological properties given their different binding affinities for the estrogen receptor. S-(-)equol is produced via the bacterial conversion of the soy isoflavone daidzein in the gut. We have compared the biological effects of purified S-equol to that of racemic (R and S) equol on breast and prostate cancer cells of varying receptor status in vitro. Both racemic and S-equol inhibited the growth of the breast cancer cell line MDA-MB-231 (> or = 10 microM) and the prostate cancer cell lines LNCaP (> or = 5 microM) and LAPC-4 (> or = 2.5 microM). The compounds also showed equipotent effects in inhibiting the invasion of MDA-MB-231 and PC-3 cancer cells through matrigel. S-equol (1, 10, 30 microM) was unable to prevent DNA damage in MCF-7 or MCF-10A breast cells following exposure to 2-hydroxy-4-nonenal, menadione, or benzo(a)pyrene-7,8-dihydrodiol-9,10-epoxide. In contrast, racemic equol (10, 30 microM) prevented DNA damage in MCF-10A cells following exposure to 2-hydroxy-4-nonenal or menadione. These findings suggest that racemic equol has strong antigenotoxic activity in contrast to the purified S-equol enantiomer implicating the R-, rather than the S-enantiomer as being responsible for the antioxidant effects of equol, a finding that may have implications for the in vivo chemoprotective properties of equol.     

TRH test in alcoholics: relationship of the endocrine results with neuroradiological and neuropsychological findings.

Neuroradiological, neuropsychological and neuroendocrine parameters were evaluated in 20 non-depressed alcoholic men after 4 weeks (N = 11) or after at least 1 year (N = 9) of abstinence from alcohol and in normal men (N = 9). With regard to normal controls, 4-week abstinent alcoholics showed larger lateral and third ventricles, without modification in the number of cerebral sulci, and altered scores of tests evaluating subcortical and frontal function. Furthermore, in these patients the TSH (thyroid stimulating hormone) and PRL (prolactin) responses to thyrotropin releasing hormone were higher than in controls, suggesting a reduced hypothalamic control of TSH and PRL secretion. Taken together, these findings suggest the presence of a frontal-subcortical disorder in alcoholics. Patients who had been abstinent from alcohol for at least 1 year were not distinguishable from controls for neuroradiological, neuropsychological and neuroendocrine findings, suggesting that the alcohol-related brain alterations are reversible after a long period of abstinence.